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    The language used in naming problems comes directly from the partners consulting with the therapist buy 400 mg indinavir with amex. The fol- lowing questions illustrate how the therapist and couple can engage in an externalizing conversation: "You mentioned feeling guilty discount 400 mg indinavir with visa. Would Guilt be a good name for the prob- lem that has you avoiding each other at home? Here discount indinavir 400mg mastercard, we invite inquiry into the knowledge that each partner carries about how the problem first gained access to their relationship and how it has managed to gain control over time. We are looking for specific examples of the problem’s real effects and the methods it uses to exert its influence. Mapping events through time is necessary to help couples perceive differences that may lead to new possi- bilities for action (Bateson, 1972), as evidenced by the following questions: "What is the earliest recollection you have of Defensiveness infiltrating your relationship? Will they continue to submit to the requirements of problematic practices or do they want to take a different stance? The following questions aim to help couples evaluate the real effects of problems that are influencing their relationship: "Is it acceptable that Suspicion has co-opted your relationship in this way? This provides an opening for therapists to explore new perspectives and hopes for helping the couple to move forward with their relationship, as seen by the following questions: "Can you tell me a story that illustrates why this problem of Withdrawal is important to you? By exploring the history and effects of these unique experiences, we reconnect the couple to resources that often have become dormant due to the escalating strength of the problem. The following questions seek to make visible unique experiences that contradict problematic ways of relating: "I understand that Sorrow is currently in the driver’s seat for your rela- tionship. What would you call this quality that enabled you to sidestep Manipulation’s influence? How do these new descriptions alter the stories the couple holds about their partnership? We also look for evidence of experiences, intentions, and people that support the couple’s new path. Identifying this evidence from the past and imagining how it might evolve into the future adds density to the emerging story, as evidenced by the following questions: "You mentioned Collaboration as a recent re-discovery. Is Collaboration more indicative of your preferred way of relating with your partner? This may take the form of letter writing or having outside members of the couple’s community par- ticipate in a therapy session. We also create communities of support by invit- ing others to share their past successes (in taking their lives back from certain problems) with couples currently struggling with similar problems. The following questions invite the couple to consider ways of expanding their community of support: "Would you be interested in hearing about strategies that other couples have used in coping with Suicide? If you could carry your grandmother with you as you risk having this conversation with Bill, what difference might that make? Partners often come into our offices engaged in monologue or in ways of relating that restrain genuine listening. Clinical theories tend to focus on improving speaking skills, while paying less at- tention to forces that restrain the listening process. Like the construction of music, dialogue exists in a space that allows for the participation of many voices. This requires openness to expressions from the other, which transports the conversation to a place it hasn’t been before. When restraints to listening dominate, new perspectives are not in- tegrated into the conversations. Or one might be fitting the partner’s ex- pressions into a framework that’s congruent with one’s own beliefs, ideas, and assumptions. Conversations can open space and generate possibilities or close down space and limit options for moving the dialogue forward (Chasin et al.

    However 400 mg indinavir free shipping, colonoscopy") discount 400 mg indinavir visa, impotence ("There’s nothing I can do for expressing understanding must be done cautiously to her") indinavir 400 mg for sale, failure ("I messed up, I’m a bad doctor"), loss prevent a response such as,"How can you possibly under- ("I’m really going to miss this person"), resentment stand what I’m going through—have you ever had a ("This patient is going to keep me in the hospital all stroke? For example, feelings of failure may motivate one what they are doing and how they are managing with a to avoid the patient, while feelings of loss may make dis- difficult situation. The first step toward and makes people feel good about themselves and more managing such feelings is to acknowledge that they exist. A useful statement might The next step is to discuss them with colleagues or con- be, "I am so impressed with how you’ve continued to fidants. In most cases, however, patients do not benefit provide excellent care for your mother as her dementia from hearing such thoughts. Simple statements, such as "I will be there with If the answer is truly the latter, then it may be appropri- you throughout this illness," can be tremendously com- ate to share. Health care providers ought not feel the entire support burden on their shoulders—support offered can include other members of a team. For example, "We will Emotion-Handling Skills send a nurse to your home to check in on you in a couple One barrier to eliciting patient affect is the fear of being of days, and if you’d like, I could ask the chaplain to pay unable to manage the patient’s emotional response. The primary goal of emotion handling say, "After you gave me the results of the test, I thought is to convey a sense of empathy. Tulsky concerns about cancer that will be helpful in planning patient’s specific fears and concerns are. Here is how the physician might approach the patient41: Communicating Bad News MD: Is there anything that you are particularly worried that this might be? Communicating bad news draws upon the skills discussed PT: I guess anyone would be scared that it is cancer. Many protocols exist for the delivery of bad MD: I’m afraid that it might be cancer. There are other news; however, the behaviors tend to be grouped into things that it might be too, however. That’s why several key domains that include preparation, content we are going to do the biopsy—to find out. What of message, dealing with patient responses, and ending 40,41 worries you most about cancer? She suffered preparation (getting the setting right, getting needed terribly with it. Content of Message At the end of this exchange, note how the physician Knowledge of what the patient already knows or believes begins to find out what the patient’s fears are in an effort is extremely valuable to have before revealing bad news to to anticipate the patient’s reactions to the news if the test a patient. One might ask, One should avoid spending any time "beating around the "Is there anything that you are particularly concerned bush" before sharing the news. Find out what patient knows and believes The clinician should remain silent and allow the patient Find out what patient wants to know an opportunity for the news to sink in. One can strike an Suggest a supportive person accompany the patient Learn about the patient’s condition empathic stance, maintain comfortable eye contact, and Arrange the encounter in a private place with enough time perhaps use a nonverbal gesture, such as reaching out and Content touching the patient’s hand. However, silence is impera- Get to the point quickly tive to allow the patient an opportunity to process the Fire "warning shot" (example: "I have bad news") information, formulate a response. The clinician who feels uncomfortable Avoid false reassurance during this silent phase needs to appreciate that the dis- Make truthful, hopeful statements comfort is rarely shared by the patient, who is engrossed Provide information in small chunks in thought about the meaning of the news and thoughts Handle patient’s reactions about the future. Furthermore, very little that is said by Inquire about meaning of the condition for the patient NURSE (Name, Understand, Respect, Support, Explore) expressed the physician at this time will be remembered by the emotions patient, so it is best not to say it at all. If the patient makes Assure continued support no verbal response after perhaps 2 minutes, it can be Wrap-up useful to check in: "I just told you some pretty serious Set up a meeting within the next few days news. Do you feel comfortable sharing your thoughts Offer to talk to relatives/friends Suggest that patients write down questions about this? It is also important to explore the Ending the Encounter meaning the news has for the patient and to achieve a The clinician must end the encounter in a way that leaves shared understanding of the disease and its implications.

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    During the pump filling discount indinavir 400 mg on-line, care must be exercised to avoid al- lowing air to enter the reservoir discount 400mg indinavir with visa, since air in the reservoir chamber could lead to overpressurization and faulty volume estimates buy 400mg indinavir. Using the pump programmer, the implant assistant programs a purge of the reservoir while it is still in the sterile container or on the sterile field after it has been removed. The pump has been placed on the sterile field, the catheter port cover is removed and the port is ob- served for flow. If after several minutes a drop of fluid is visualized, the pump is submerged in warm saline until the internal purge is com- pleted, about 15 minutes. Surgical Implantation Technique The implantation procedure may be accomplished under general or lo- cal anesthesia with anesthesia monitoring. The latter technique is of- Surgical Implantation Technique 283 ten preferred in an outpatient setting because it lends itself to rapid re- covery following the procedure. Prior to implantation, some time should be spent with the patient to optimize the side and location of the pump. About the only area amenable to the implantation of these generally large devices is the right or left lower quadrant of the abdomen. Some time should be spent with the patient preoperatively discussing which side and where the pump will be placed. The anatomical constraints tend to be the iliac crest, the symphysis pubis, the ilioinguinal ligament, and the costal margin. These structures should not contact the pump with the patient in the seated position. The task is easier in more obese patients and can be very difficult in cachectic cancer patients. The patient is positioned on the operating table in the lateral decu- bitis position, with the implantation side upward. At this stage C-arm fluoroscopy may be necessary if a new intrathecal catheter is to be placed. The instrument is positioned to allow an anterior–posterior view for an easy lumbar puncture and identification of the catheter tip level. A 5 cm incision is made in the skin, down to the lumbar fascia, and then the catheter is implanted through a paraspinous approach. A good flow of spinal fluid is documented, the catheter is clamped to the drape to prevent CSF loss, and the incision is packed with an antibi- otic-soaked sponge. If the existing catheter is to be used as the permanent delivery catheter, the patient is positioned on the operating table in the decu- bitis position with the implant side upward and the exiting screening extension catheter downward. The previous back incision is reopened and the disposable extension catheter is disconnected from the permanent in- trathecal catheter and pulled from under the patient by the circulating nurse. The intrathecal catheter is then clamped to prevent CSF loss, and the implantation proceeds in the usual manner. Attention is then turned to the lower quadrant of the abdomen, where a 10 cm incision is made down to the underlying subcutaneous fat layer. A subcutaneous pocket large enough to admit the particular pump be- ing used is then fashioned. Generally, if all four fingers can be admitted to the metacarpal phalangeal joints in the pocket, it is large enough. The upper side of the incision is undermined roughly as the width of the pump, or about 2. The eccentric location of the pocket allows the pump to be placed so that the refill port is clear of the incisional scar and easier to locate.

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    The microgliocytes and astrocytes in the DH are presently known to show up-regulated expression of acti- vation markers in response to different conditions that produce hyperalgesia 400 mg indinavir with amex, such as injury of the peripheral nerve (Colburn et al indinavir 400mg lowest price. Increases in NGF and BDNF mRNA occur in Schwann cells and satellite cells in SG during inflammation of peripheral tissues (Cho et al 400mg indinavir free shipping. Peripheral axotomy in- duces a significant increase in NGF mRNA in the SG satellite cells, enhancing the pathologic sympathetic sprouting (Zhou et al. Other satellite cell-derived substances that might have demonstrable effects consistent with enhanced pain include glial cell-derived neurotrophic factor (GDNF), BDNF, neurotrophin-3, and proinflammatory cytokines (Watkins and Maier 2002a). The endothelins are pep- tides that have a diverse array of functions mediated by two receptor subtypes, the endothelin A and B receptors (Pomonis et al. Endothelin A receptor expression may play a role in signaling acute pain or NP, whereas endothelin B receptor expression may be involved in the transmission of chronic inflammatory pain. These data indicate that the endothelins can have direct, nociceptive effects on the peripheral sensory nervous system and that peripheral glia may be directly involved in signaling nociceptive events in peripheral tissues. They foundthatFGF-2wasup-regulatedbothinPAneuronsandintheSCastrocytes, suggesting neurotrophic functions of this growth factor following peripheral nerve lesion and possibly in astrocyte-related maintenance of pain states. This suggests that spinal viral invasion, causing glial acti- vation and proinflammatory cytokine release, might potentially explain such pain. This highly contagious virus causes a relatively benign disease in childhood: varicella (chickenpox). CNS complications are estimated to occur in less than 1% of chickenpox cases, and even this low number may be an overestimate (Kleinschmidt-DeMasters and Gilden 2001). The most common abnormality is cerebellar ataxia; very rarely, transverse myelitis has been reported. After varicella resolves, VZV becomes latent in the SG and in the sensory ganglia of the cranial nerves and persists throughout the life of the host (Esiri and Tomlinson 1972; Gilden et al. Recent publications indicate that the virus is located predominantly in the pseudounipolar PA neurons, but the satellite cells are also implicated as a potential reservoir of latent VZV (Lungu et al. During latency, VZV is not infectious and does not transcribe most of its genetic material, thereby escaping detection and clearance of the virus by the immune system. The likelihood of viral reactivation to HZ increases with each advancing decade of age. HZ usually develops in elderly individuals and is eight to ten times more frequent after the age of 60 years than before (Kost and Straus 1996; Bowsher 1999c). Immunocompromised patients are at especially high risk (Kleinschmidt- DeMasters and Gilden 2001). With reactivation, the virus spreads transaxonally to the skin, causing a rash with a dermatomal distribution, and is associated with severe radicular pain. Any level of the neuraxis might be involved, but thoracic HZ is the most common one, affecting one to two, rarely more dermatomes, followed by the ophthalmic division of the 5th nerve (Hope-Simpson 1965; Portenoy et al. The involvement of the facial nerve results in HZ oticus, often combined with paresis of the ipsilateral muscles of facial expression: geniculate neuralgia, described as early as 1907 by Ramsay Hunt (Hunt 1907, 1937; Brodal 1981). Similar combination of painful dermatomal rash with myotomal motor weakness might be observed also in the spinal nerve HZ (Yaszay et al. In the majority of patients, a prodrome of dermatomal pain starts before the appearance of the characteristic rash (Dworkin and Portenoy 1996; Dworkin and Johnson 1999). Dermatomal pain without a rash (zoster sine herpete) occurs rarely (Lewis 1958; Gilden et al. HZ is monophasic with recurrence occurring in less than 5% of immunocompetent patients. In contrast, in immunocompromised patients (especially in AIDS patients) HZ is recurrent, protracted, and often accompanied with severe neurological complications (De La Blanchardiere et al. The neuropathological investigation of HZ was started by the monograph of Head and Campbell (1900), reviewed by Oaklander (1999). Also quite early, von Bokay (1909) postulated an infectious agent common to varicella and HZ. The basic pathologic substrate for HZ is ganglionic hemorrhage, necrosis, and inflammation (Ghatak and Zimmerman 1973; Nagashima et al.

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