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    By O. Oelk. New Jersey City University. 2018.

    A sense of agency is increased through enhanced ability to observe self and be increasingly responsible for one’s own emotional func- tioning rizatriptan 10mg on line. A sense of communion is increased through an improved ability to be more fully present to self while also being more fully present to others buy 10mg rizatriptan mastercard. This ability to be present to self and others is an especially important factor in establishing meaning and experiencing support in the context of the many challenges that illness presents buy rizatriptan 10mg mastercard. COUPLES, ILLNESS, AND CULTURE In working with couples facing a serious physical or chronic illness, under- standing the cultural context in which the illness occurs is as important as understanding the couple’s particular illness story and the family history of experience with illness. There are wide cultural variations in how illness is expressed, in the meaning attributed to illness and disability, in the defini- tion of the role of the patient, in the understanding of the patient-provider relationship, and in the role expectations for the family and community car- ing for the patient (Kleiman, Eisenberg, & Good, 1978; Loustaunau & Sobo, 1997; Mechanic, 1986). Filipino women, for example, have been found more likely to attribute the cause of illnesses to spiritual-social explanations than American women (Edman & Kameoka, 1997). Pantilat (1996) describes how 268 SPECIAL ISSUES FACED BY COUPLES patients from different ethnic groups have differing attitudes toward auton- omy and medical decision making, including whether and how the patient (or family) should be given news of illness. These issues highlight the need for the therapist to be sensitive to the wider ethnic and sociocultural factors influencing emotional reactivity, in addition to the more immediate "culture" of a particular family group. This will be particularly germane when the members of a couple come from dif- ferent cultural or ethnic backgrounds. In such cases, spouses or partners may misinterpret culturally based behavior as personal attack, setting off a cycle of intensifying reactivity. It can be helpful to clarify such dynamics by asking the couple about how their respective cultures would view the concerns they present. Where relevant, it can be useful to explore their cul- tures’ concepts about the meaning of illness, how sick people are to behave, and the role expectations for family members. The relationship each member of the couple has with his or her own cul- tural background may shed light on the impasses that illness has created for them. For example, a couple who has moved to the United States from an- other country five years ago may be experiencing different rates of assimila- tion, which in turn leaves them speaking a different language from each other (Landau-Stanton, 1982). In such a context, the development of a seri- ous illness in one spouse may cause a smoldering resentment to burst into open conflict as they struggle with their now-different expectations for management of the illness. These differences, in turn, may bring up compli- cated feelings relating to immigration and the dilemma of assimilation to the new culture versus maintenance of traditional values. Unresolved fam- ily of origin issues may serve to further intensify the struggle with cultural transition. For example, if one partner has significant guilt about leaving family in the home country, significant unresolved and unexpressed guilt about betrayal of family and cultural loyalties may function as a source of emotional reactivity in their current conflict over management of illness (McDaniel, Harkness, & Epstein, 2001). BOWEN THEORY AND CULTURE Western culture places particular stress on the individual over the group, on self-assertion over self-sacrifice, nonconformity over conformity, intel- lect over affect, novelty over tradition, youth over age, and doing over being. Many other cultures, especially those with collectivist traditions, emphasize the opposite of each of these polarities. Bowen theory has been criticized from a feminist perspective for valuing thinking and devaluing feeling, and emphasizing the differentiation side of the differentiation- togetherness pole in emotional functioning (Bograd, 1988; Lerner, 1985; Luepnitz, 1988). Cautions regarding Bowen theory and its implementation have also been offered from a cultural perspective for similar reasons. For example, Managing Emotional Reactivity in Couples Facing Illness 269 Tamura and Lau (1992), note that "the preferred direction of change for Japanese families in therapy is toward a process of integration—how a person can be effectively integrated into the given system—rather than a process of differentiation. This discussion of differentiation from the perspective of Japanese culture illustrates that the interpretation of healthy relatedness is heavily influenced by cultural values. As therapists, it is important to be mindful of our own cultural biases and the cultural values of the couples with whom we work, just as it is important to be aware of our own areas of reac- tivity as we help couples address theirs.

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    Unfortunately order 10mg rizatriptan overnight delivery, microscopic invasion of structures immediately outside the capsule is crucial discount 10 mg rizatriptan amex, and microscopic changes cannot be detected by CT at all; high accuracy has never been possible (77) generic rizatriptan 10 mg with mastercard. A careful study with appro- priate blinding of observers yielded a sensitivity of only 50% in predicting intracapsular disease; errors were found in analysis of seminal vesicle images and other regions immediately surrounding the prostate (78). Since CT can demonstrate only morphologic changes of the seminal vesicles, and since tumor may invade these structures without changing their gross con- figuration, CT frequently misses such invasion; MRI, which is discussed later, may demonstrate similar abnormalities and thus be more sensitive (79). A larger study of CT, in which CT interpretation results were com- pared with surgical-pathologic findings, showed the accuracy of CT was only 24% for capsular extension and 59% for seminal vesicle invasion (80). Due to these discouraging results, and to the higher accuracy of MRI in revealing the local extent of disease, CT has been largely abandoned as an initial test for evaluating local disease. Computed tomography may still have a role, however, in evaluating lymphatic metastases. Metastases may enlarge nodes, and since CT can evaluate nodal size well, it has become the primary modality for search- ing for nodal disease. It is well recognized that patients may have metasta- tic nodal disease from prostate cancer in which individual nodal deposits are sufficiently small that the overall node size is not enlarged, so that the sensitivity of the CT is considerably less than 100%. The studies of false- negative rates for CT in detecting nodal metastasis have reported sensi- tivities of only 0% to 7% (76,81,82). Careful dissection studies (83) have confirmed that this is due to the relatively small size of many tumor- bearing nodes. Large nodes are felt to be a more accurate CT sign of metastatic disease than small ones are of disease without metastases; still, enlarged nodes (77,83) may occasionally be found in patients without metastatic disease. The occasional false-positive case notwithstanding, def- initely enlarged nodes seen on CT are usually regarded as reliable evidence Chapter 7 Imaging in the Evaluation of Patients with Prostate Cancer 127 of metastatic disease, especially if local tumor volume and grade suggest that metastases are likely, and if the location of the enlarged nodes is com- patible with metastatic prostate cancer. This disease tends to spread to and enlarge nodes in the pelvic retroperitoneum before causing enlargement of nodes in the abdomen or elsewhere (84). It has been well known for a long time that clinical stage, PSA, and Gleason score are independent predictors of the likelihood that metastases will be found in surgically resected lymph nodes. It seemed logical that these factors might be useful in predicting which CT scans are likely to show enlarged nodes, and, indeed, all three factors have been found to be independent predictors of CT-demonstrated lymphadenopathy (85). These find- ings have been substantiated by another study (86), and still others (87,88) corroborate the importance of PSA; all studies suggest that in patients with an initial PSA below 20, a positive CT scan is extremely unlikely. These findings have primarily been interpreted as indicators that for these patients at low risk, CT need not be performed; they may also be useful for radiologists confronted with CT scans with marginal nodal findings; in these cases, investigation of the PSA and Gleason score may aid in reach- ing radiologic decisions. Magnetic Resonance Imaging Early in the development of body MRI it became apparent that the prostate could be visualized, and even that the zones within it could be distin- guished. Although little success was met in screening for prostate cancer, a series of publications investigated the technique as a staging technique for recently diagnosed prostate cancer. Most of these relied on external coils (89–93), which continued to be used in a later series as well (94). Staging of the local extent of disease, rather than detecting metastatic disease, was the task at hand, and the external coil was not highly accurate. Accuracy percents tended to be in the low 60’s, and many studies found no improve- ment over simply using PSA or DRE. A few investigators managed to achieve higher accuracy with body coil MRI (95,96), finding that MRI was superior to sonography and CT for evaluating seminal vesicle invasion (95) and achieving high specificities in predicting capsular penetration (80%) and seminal vesicle invasion (86%) with a moderately high sensitivity for capsular penetration (62%) (96). With the introduction of the intrarectal surface coil, the higher spatial resolution that the technique permitted improved accuracy of staging (92,97–102). Various levels of sensitivity, specificity, PPV, and NPV have been reported; overall staging accuracy ranges from 62% to 84%. Even with the rectal coil techniques, however, not all authors were enthusiastic (103,104). Detection of metastatic disease in pelvic and abdominal lymph nodes by body coil MRI suffers from the same problem as CT, which is that size is the only parameter that can be accurately measured, and that tumor is often found in nonenlarged nodes.

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    This personal symbol (golf and croquet utilized interchangeably) appeared often in John’s verbal comments and art productions buy 10mg rizatriptan. Prior to this directive he had created a collage wherein a father and 4-year-old boy were depicted together in an attic; the two were getting ready to go to "the children’s golf course cheap 10mg rizatriptan amex. As the project continued and John became familiar with the repetitious directives and tasks buy 10 mg rizatriptan with visa, he took more initiative. Soon he was creating objects, experimenting with media, decorating, and detailing without any interven- tion. Thus, the dependency issues that John normally presented slowly abated as the gradual expansion of his own personality was given sway. At this juncture, I viewed my role as that of the "good parent": providing sup- 5. In short, I endeavored to enhance his adaptive func- tioning (by utilizing countertransference of the good parent) while offering a vehicle for his emotional expression regarding his early familial relation- ships (transference situation). However, it is interesting that it took John numerous sessions to build a house in response to the question "what does this family need? The house, with its symbolic representation of familial dynamics in John’s case, lies bare. If we refer to Appendix C and apply interpretation to the formal items, the small door, unidimensional roof (he had created many roofs that were triangular shaped in group three-dimensional projects), ab- sent chimney, and low-hanging windows point toward feelings of emotional constriction, distance, and the projection of these feelings both toward and from his family. This significance becomes even more pronounced when we look at the completed project (Figure 5. John had created his "background" for the family, providing them with a bounty of recreational items, yet the house seemed an afterthought, a nec- essary "evil" that was undertaken out of necessity rather than enjoyment. At this stage John pronounced his project complete, and I asked him to tell me "what was going on. They were a happy family, and the father never went to school, as he was a preacher (with his father), which is where he met his wife (who volunteered for the church). In John’s brief story we see the amalgamation of delusion, symbolism, and reality. He holds fast to being a preacher with his father yet reports accu- rately his meeting his wife in a church. Additionally, he appears to be uti- lizing the theme of golf or croquet to represent his sexuality and concomi- tant need for love, whether it is through intimacy or molestation. In subsequent sessions I provided a wide range of media choices and al- lowed John to choose among them as his needs dictated. However, in one session as he drew his rep- etitious "church in the Ozarks" he made a superfluous comment that led me to believe that his insight was growing. As he turned his attention to the church, I expected him to return to his fantasy, but that day he did not. The feelings of vulnerability and anxiety are countered only by the fantasy pro- ductions that lend order and structure to a world that tends to overwhelm the schizophrenic’s fragile sense of self. In successive sessions John’s insight faded as his delusional mind-set took precedence. As he oscillated between delusional functioning and moments of reality- based thought processing, I decided to introduce an ego-modifying directive into the session. John had grown accustomed to deciding on the direction of the thera- peutic hour and was taken aback at my suggestion for a topic. However, our relationship was such that in short order he drew as I had requested.

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    Open spina bifida is characterized by a dorsal herniation of all or part of the spinal content without full skin coverage discount 10 mg rizatriptan with amex. Closed or occult spinal dysraphism (OSD) is characterized by a spinal anomaly covered with skin and hence with no exposed neural tissue (2 buy discount rizatriptan 10 mg on line,3) rizatriptan 10mg discount. The OSD spectrum includes dorsal dermal sinus, thickened filum termi- nale, diastematomyelia, caudal regression syndrome, intradural lipoma, lipomyelocele, lipomyelomeningocele, anterior spinal meningocele and other forms of myelodysplasia (Figs. Scoliosis Scoliosis is defined as an abnormal spinal curvature most apparent in the coronal plane (4). Scoliosis can be classified as congenital, degenerative, neuromuscular, or idiopathic. Idiopathic scoliosis is further subdivided according to the age at which the disease presents: infantile (birth to 3 years), juvenile (4 to 9 years), and ado- lescent (10 years and beyond) (5). Congenital scoliosis is caused by verte- bral anomalies of embryologic etiology (6). Conus Medullaris Position Controversy has existed about the normal position of the conus medullaris. The normal level of the conus medullaris was thought to vary with the age of the child (7–9). Additional imaging studies, however, indicate that the normal conus medullaris position can vary from the middle of T11 to the bottom of L2 by age 2 months (7,9) and probably at birth (7,10). Although a spinal cord terminating at these normal levels can be tethered (8), the conus that terminates caudal to the L2-L3 disk space is at much higher of being tethered (7,9,11). Neuroimaging can define the anatomic location of the conus medullaris, but "tethered" is a neurophysiologic concept that requires clinical input (12). Five to six percent of normal individuals can have variable amounts of fat in the filum terminale (13,14). Epidemiology Spinal Dysraphism Three percent of neonates have major central nervous system or systemic malformations (15). Furthermore, 5% to 15% of pediatric neurology hospi- tal admissions are related to cerebrospinal anomalies (16). Occult spinal dys- raphism is the most prevalent spinal axis malformation (19) and the most common indication for spinal imaging in children (20). Occult spinal dys- raphic lesions are commonly associated with urinary tract anomalies (21). The clinical spectrum of occult dysraphism is broad, ranging from skin stigmata such as a dimple, sinus tract, hair patch, or hemangioma to motor, bladder, or bowel dysfunction (22–24). About 50% to 80% of occult spinal dysraphic cases exhibit a dermal lesion (25–28). Scoliosis Adolescent idiopathic scoliosis, by far the most common form, has a preva- lence between 0. In a United Kingdom study of 15,799 children and young adolescents, Stir- ling and colleagues (31) found that the prevalence ratio of girls to boys was 5. Infantile scoliosis constitutes approximately 8% of idio- pathic scoliosis whereas juvenile scoliosis represents 18% (34). Congenital scoliosis is caused by failure of segmentation of formation of spinal elements (4). In a series of 60 cases of congenital scoliosis, Shahcheraghi and Hobbi (6) found that the most common type of anomaly was a hemivertebra (failure of formation), and that the most severe deformity was associated with a unilateral unseg- mented bar (failure of segmentation) with a contralateral hemivertebra). Chapter 18 Imaging of Spine Disorders in Children 339 The etiology of adolescent scoliosis remains a mystery; however, some principles are generally agreed on (35): 1. The younger the onset and the greater the severity of the curve, the faster the progression.

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