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By J. Grok. Vanderbilt University. 2018.

What these male movie stars portrayed for us was not the healthiest model for couples and relationships discount 50mg nizagara overnight delivery. On the other hand purchase nizagara 25mg amex, Elizabeth Taylor and Greta Garbo did not offer the greatest models of women in rela- tionships either nizagara 50 mg online. PERSPECTIVE IN REWRITING LOVE STORIES On a more applied note: Another useful book on couples is The Dance Away Lover (Goldstein order nizagara 25 mg line, Larner discount nizagara 100 mg line, Zuckerman, & Goldstein, 1977). This book is par- ticularly valuable in helping people understand the predictable stages in relationships. The concept of The Dance Away Lover accounts for a person’s "interpersonal valence. However, this quality is not so helpful as the relationship moves past the glow of the first stage in love. The therapist working with older couples (as with any couple) must strike a balance of joining couples in a way that helps collaboration, yet can be forceful and clear when difficult issues must be addressed. The first stage shows up in popular music, movies, and hero worship in our culture. Beauty, humor, perceived success, sex, and a host of other qualities often win the day. The second stage involves the realizations that a relationship gets tougher when the qualities that attract us to another become the same ones that annoy us or cause conflict. The romantic first stage of love seeks excitement, rapture, and immersion in another. Some of our students (when intro- duced to the concept of Stage 1 as worshipped in popular music) jokingly suggest that the second stage may be more like country and western songs where "somebody does somebody wrong. Actually, this stage is an opportunity to explore what is each partner’s responsibility for foiling continued love and growth. Then, the couple may reform and balance a mature appreciation of commitment and responsibility to strengthen the relationship. If there is a real commitment, this is when both partners take stock of their own foibles, irritating habits, or unfinished business. Each person in the couple can work to enrich their relationship, by knowing their blind spots, and their strengths. Some of the funny dyads the authors describe include: The Dance-Away Lover, The Anxious Ingenue, The Disarmer, The Provider, The Prizewinner, The Fragile, The Pleaser, The Victim, The Ragabash and The Tough-Fragile. The stages are elaborated along with perspectives on sex, affairs, and risks of splitting up. The book offers an entertaining yet informative way of looking at enduring patterns. They like the book and grasp the pre- dictable emotional undertow that the therapist authors describe in funny, yet clear examples. The therapy with a senior couple, Bob and Helen, may help clarify the process of forming and reforming each of their identities, as well as revis- ing the story of their relationship together. Bob came with symptoms of agi- tated depression, a strong conviction that he needed a divorce in order to Therapy with Older Couples: Love Stories 93 get relief from various frustrations, and an unnamed anger that was cur- rently haunting him. The referral from the physician also asked to consider whether there was a dementing neurological disease. He usually could get a new per- spective on himself in response to firm confrontation. He carried a strong part of his identity in the traditional pride and rig- ors of standing up for what he believed in. After his retirement from the military, he was able to make the transition into civilian life as an engineer involved in the NASA space program. Now in retirement, he and his wife are financially stable and comfortable, but his ego engine runs high. At times, he shared with the therapist articles he had written on topics from revamping the IRS to a touching and insightful look at his experience with prostate cancer and surgery. There was little contact with his ex-wife, but his sons who lived three hours away were a low-level stressor or anxiety for him.

Additional imaging studies may be performed to further characterize indeterminate results discount nizagara 50mg fast delivery. The ulti- mate goal that radiologists should strive for is nonoperative reduction for all children with idiopathic intussusception (approximately 95% cases) order nizagara 25 mg on-line. A Medline search was performed using PubMed (National Library of Med- icine buy 25mg nizagara overnight delivery, Bethesda generic nizagara 100mg without prescription, Maryland) for original research publications discussing the diagnostic performance and effectiveness of imaging strategies in intus- susception nizagara 100mg free shipping. Clinical predictors of intussusception were also included in the literature search. The search strategy employed different combinations of the following terms: (1) , (2) , , (3) , and (4) or or. Additional articles were identified by review- ing the reference lists of relevant papers, identifying appropriate authors, and use of citation indices for MeSH terms. The author performed an initial review of the titles and abstracts of the identified articles followed by review of the full text in articles that were relevant. Determination of which children should undergo imaging, and which should not undergo imaging, has not been studied in formal prospective trials. Ideally, children with intussusception should be diagnosed early to avoid bowel necrosis and surgery. One report found that only 50% of children were correctly diagnosed at initial presentation to a health care provider (20). The classic triad of colicky abdominal pain (58% to 100% cases), vomiting (up to 85% cases), and bloody stools is present in only 7% to 20% of children (6,8,22). Kuppermann and colleagues (24) published a cross-sectional study that evaluated the clinical factors that might predict intussusception in 115 children (limited evidence). Using mul- tivariate logistic regression and bootstrap sample analysis, they found that 484 K. Pracros JP, Tran-Minh VA, Morin de Finfe CH, Deffrenne-Pracros P, Louis D, Basset T. Accuracy of ultrasonography compared with cholescintigra- phy in the diagnosis of acute cholecystitis Cholescintigraphy Ultrasonography Sensitivity/specificity Sensitivity/specificity Investigator (%) (%) Zeman et al. However, not all authors have found this test to be specific (61), or to correlate with histologic findings (62). Some have found reduced ejection fractions in control groups (61), and others have found spontaneous resolution of symptoms in patients with an abnormal study (63). However, the overall evidence remains strong that cholecystokinin-stimulated cholescintigraphy is highly predictive for CAC and relief of symptoms after cholecystectomy. These workers correctly identified patients with sphincter of Oddi dysfunction before papillotomy and showed functional improvement in the majority of patients following papillotomy. Further more, a recent direct comparison between cho- lescintigraphy and manometry found that cholescintigraphy was a better predictor of symptom relief after sphincterotomy than clinical symptoms or even manometry (65). However, others have found sensitivities ranging from only 69% to 83%, and specificities ranging from 60% to 88% in the cholangiographic diagnosis of sphincter of Oddi dysfunction (66–70). For these reasons, quantitative cho- lescintigraphy is not widely used and its clinical utility yet remains to be determined. Although technically challenging, ERCP with manometry is useful in the diagnosis of sphincter of Oddi dysfunction. At ERCP, pressures can be measured in the lower bile duct and sphincter zones by standard mano- metric techniques. A resting sphincter pressure of 40mmHg is taken to be abnormal and predictive of patients likely to benefit from a therapeutic sphincterotomy (65,72,73). In patients without gallstones and persisting chronic biliary symptoms, cholescintigraphy should be used to select patients with CAC that may benefit from cholecystectomy. In the remaining patients, MRCP is indicated to exclude mechanical lesions of the bile duct. In patients with suspected functional disorders of the bile duct, the relative merits of quantitative cho- lescintigraphy versus ERCP with manometry have not been fully estab- lished. An evidence-based algorithm for imaging of patients with chronic biliary symptoms is given in Figure 27. However, MRCP and EUS are superior to ultrasonography in visualizing the whole of the bile duct, and establishing the level of bile duct obstruction (strong evidence). This easy to follow, self-paced workbook includes worked examples from real clinical scenarios to help health professionals find the Evidence-based best available evidence for any clinical question. Contents include: • Introduction to evidence-based medicine: What is evidence-based medicine? Medicine Workbook • The steps in EBM • Resources and further reading Finding and applying the best research evidence to improve patient care This attractive, full colour workbook provides a clear explanation of evidence-based medicine skills and concepts.

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Generally it is not possible to decide prior to a 177 Reading Between the Lines session whether to use specific directives during the therapeutic hour; in- stead generic nizagara 50mg online, directives develop out of the unique requirements of the individual and his or her interaction in the here-and-now cheap nizagara 100 mg on-line. For this reason generic 50mg nizagara visa, these cat- egories should be utilized as a starting point for intervention rather than as a comprehensive guide generic nizagara 25mg with visa. The Introduction Not unlike the stage theory of development order 100mg nizagara with visa, the phases of therapy can be distinguished by the progression of growth toward a mature identity. In this fashion, the initial encounter, with its need to join and build trust where mistrust often resides, is as important to the relationship as the stage of closure. For it is the introduction, the initial meetings that impart the tone for the relationship. In this stage, as Erikson (1963) noted in a dis- cussion of the infant’s social achievement goals, "the constant tasting and testing of the relationship between inside and outside meets its crucial test" (p. Although Erikson’s focus is infants, this statement easily ap- plies to the client’s first steps toward social relatedness regardless of age. Characterized by a struggle surrounding dependency (reliance upon an- other) and power (testing the environment), the initial stages of therapy seek an integration of inside and outside. The following illustrations typify directives that are useful in the early stages of therapy. Once this is done, cut out the hand and glue it to the mural pa- per" (which was taped to the wall). In this first meeting the task of forming connections was completed through not only the drawing phase but also the discussion that followed. Each group member explained the symbols that he had produced and how it related to the self. From verbal descriptions of faith (second from the left) and sobriety (fourth from the left) to the unconscious rendering of jagged lines framing the fingers of a male who the evening before had put his hand through a window (first on the left), these institutionalized men focused on the basics of their personality as they interacted beyond material needs. Additionally, the group prominently labeled their hands with their names (digitally changed); rather than using their hands to symbolize the self, they preferred to affirm the connection physically with a name. This may be due in large part to the unspoken credo of the institutionalized that physical contact is always to be avoided, since in an institution even an innocent bump can create a dangerous situation. Consequently, while the adolescent females seek a connection, often in- trusively, the institutionalized male distances himself for protection and safety. Yet the objective of both groups remains the same: the provision of a safe haven where individuals can share, express, and build a foundation for improved trust that breaks down the division of internal wants and ex- ternal needs. In much the same way, a collage directive, with its prefabricated im- agery, offers the individual a nonthreatening medium with which he or she can clarify interests and provide information in an atmosphere of support 4. In the early stages of therapy, the clinician is responsible for providing an environment of supportive safety as well as outer control. These condi- tions are necessary if the new client is to learn productive methods of com- munication within the environment. Yet for some clients the intensity of such a personal interaction creates a sense of fear and vulnerability, which is often juxtaposed with the use of defense mechanisms to protect from en- suing anxiety. The process for this directive (although many adaptations can be utilized) was that I quickly scribbled random lines and asked the client to help me find a "picture" within the scribbles. She identified the bunny, and I colored in the disparate areas to flesh out the image. Understanding her issue with control and her frequent forays into destructiveness, I commented aloud, "he looks out of control," to which she responded, "turn it away, don’t look at it. Along these lines, a directive that I make use of not only to facilitate trust but also to assess the level of identity formation is one I call the initial game. The procedure for this directive is to instruct the client to "draw your initials as large as you want on the drawing paper. Feel free to remain within or outside the lines, and use as much color as you desire. Instead of using his initials he used a combination of his first and last names (digitally changed). From an interpretive standpoint, the client’s verbal explanation is as important as the visceral response of the viewer examining the drawn-form items.

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Some actions need to be evaluated partly by how they affect this relationship cheap nizagara 50mg on line, because the efficacy of much subsequent work depends on its strength 50 mg nizagara fast delivery. This chapter has used the field of medical care to demonstrate how our everyday operational and common sense uses a deeply embedded yet informal semantic architecture buy nizagara 50mg online. The topography of categories buy nizagara 100mg with visa, the variety of image schemas discount 50 mg nizagara visa, the multi- plicity of metaphors and the plastic nature of scenarios and narratives provides a rich menu of possible alternatives for reasoning about means and ends. These cognitive structures, as opposed to those of formal logic, grow out of full-bodied experience not limited to the manipulation of numbers, symbol strings and propo- sitions. Informal reasoning (the lately despised "clinical judgment") picks and chooses, but not in an arbitrary way, among these structures to apply them in fluid situations. It is our job to appreciate the situations best understood by using a custom set of cognitive tools. The failure of a category, a metaphor, or a causal logic to give satisfaction when used in a given situation is not an adequate reason to strike that tool from our cognitive kit. We have in our culture and language several conceptual alternatives which are not understood or appreciated by those who would dispense with them in the name of "efficiency. See also the extensive discussion of symmetry in the various works of Mark Turner cited in the bibliography. CHAPTER 2 HEALTH AND DISEASE: FLUID CONCEPTS EVOLVED NON-LITERALLY "While there is no a priori standard of health with which the actual state of human beings can be compared so as to determine whether they are well or ill, or in what respect they are ill, there have developed, out of past experience, certain criteria which are operatively applicable in new cases as they arise. While symptoms are literally given in experience, diseases are constructs which attempt to relate and explain symptoms. The notion that all diseases ought to have a common essence, originating in the conviction that a category like "disease" must be either classical or incoherent, has motivated a search for the unifying principle or set of necessary and suffi- cient conditions to identify candidate syndromes as diseases. This chapter gives a preliminary sketch of unifying concepts, or models, which have been put forth as philosophical criteria of "disease" and also others, less explicitly discussed, on which common sense notions of health and disease seem to be based. I will argue that no one of these concepts is adequate to lay down a basis on which "disease" can be made into a classical category. Yet each of them has value as one of a cluster of models, often metaphorical, on which our understanding of disease is based. Some of the metaphors for causation described in Chapter One fit particular models of disease better than others. We will find that no one concept of causation can begin to be adequate universally when considering diseases and their treatments, just because of the diverse models which are more or less appropriate to the various categories of disease. Additionally, there is no privileged level of analysis on which the causation of disease must be described, nor is there a privileged choice for every purpose among causes of various remoteness or proximity to the targeted disease events. While no discrete principle unifies all diseases, they are linked to each other in such a way that a meaningful and useful, but radial category is generated. Not everything that is meaningful or useful is necessarily precise, as Wittgenstein pointed out when discussing the category of "games" united only by what he called "family resemblance. Each cognitive model of 41 42 CHAPTER 2 "disease" has its correlative version of health. And as we shall see, the relation between these "opposites" is not simple contradiction and mutual annihilation. The focus of the philosophical literature on the subject has been to judge the adequacy of the various concepts of disease and health. Rather than undertake such a task with the idea of settling on one best definition, we need to better understand how these concepts are generated and in what situations they seem to work. This survey should afford ample evidence that conventional ideas of "efficiency" provide little compass for action given the conceptual terrain. We will find no literal, univocal core concept of disease, although some concepts seem to have wider applications than others. And the array of what are called "diseases" is a non-classical, radial category having central exemplary examples and exhibiting prototype effects. Given the enormous complexity and dynamism of the main disease models which will be outlined, the projection of purposes in clinical care simply cannot be mechanized in rigorous fashion. The idea that "costs" and "benefits" or even "costs" and "effects" are well formed concepts usable in formulating logical rules for decision making is founded on a fictional view of both the disease category and the nature of value. The first part of this chapter focuses on how Western medicine and popular culture, at least, operationally assume diverse concepts of disease. The several concepts of disease form a complex "cluster" of what George Lakoff calls idealized cognitive models. His example of such a cluster is the concept mother: Individual models in this cluster are as follows: (a) The birth model – The person who gives birth is the mother. Nevertheless, some of the concepts are, in most contexts, more central than others.

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