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Studies are also traditionally divided into retrospective and prospective (Table 1 purchase paxil 20mg visa. These terms refer more to the way the data are gathered than to the specific type of study design purchase 20 mg paxil free shipping. In retrospective studies order 20 mg paxil with visa, the events of interest have occurred before study onset. Retrospective studies are usually done to assess rare disorders, for pilot studies, and when prospec- tive investigations are not possible. If the disease process is considered rare, retrospective studies facilitate the collection of enough subjects to have meaningful data. For a pilot project, retrospective studies facilitate the col- lection of preliminary data that can be used to improve the study design in future prospective studies. For example, in a case-control study, subjects in the case group (patients with hemorrhagic brain aneurysms) are compared with subjects in a control group (nonhemorrhagic brain aneurysms) to determine a pos- sible cause of bleed (e. Prospective studies, therefore, are the preferred mode of study design, as they facilitate better control of the design and the quality of the data acquired (6). Prospective studies, even large studies, can be performed effi- ciently and in a timely fashion if done on common diseases at major insti- tutions, as multicenter trials with adequate study populations (11). The major drawback of a prospective study is the need to make sure that the institution and personnel comply with strict rules concerning consents, protocols, and data acquisition (10). Persistence, to the point of irritation, is crucial to completing a prospective study. For example, a cohort study could be per- formed in which the risk factor of brain aneurysm size is correlated with the outcome of intracranial hemorrhage morbidity and mortality, as the patients are followed prospectively over time (9). The strongest study design is the prospective randomized, blinded clin- ical trial (Table 1. Blackmore known and unknown confounding factors, and blinding helps to prevent observer bias from affecting the results (6,7). However, there are often cir- cumstances in which it is not ethical or practical to randomize and follow patients prospectively. This is particularly true in rare conditions, and in studies to determine causes or predictors of a particular condition (8). Finally, randomized clinical trials are expensive and may require many years of follow-up. For example, the currently ongoing randomized clini- cal trial of lung cancer CT screening will require 10 years for completion, with costs estimated at $200 million. The evidence that supports much of radiology practice is derived from cohort and other observational studies. More randomized clinical trials are necessary in radiology to provide sound data to use for EBI practice (3). What Is the Diagnostic Performance of a Test: Sensitivity, Specificity, and Receiver Operating Characteristic (ROC) Curve? While a perfect stan- dard of reference or so-called gold standard can never be obtained, careful attention should be paid to the selection of the standard that should be widely believed to offer the best approximation to the truth (12). In evaluating diagnostic tests, we rely on the statistical calculations of sensitivity and specificity (see Appendix 1 at the end of this chapter). Sen- sitivity and specificity of a diagnostic test is based on the two-way (2 ¥ 2) table (Table 1. Sensitivity refers to the proportion of subjects with the disease who have a positive test and is referred to as the true positive rate (Fig. Sensitivity, therefore, indicates how well a test identifies the sub- jects with disease (6,13). Specificity is defined as the proportion of subjects without the disease who have a negative index test (Fig. Specificity, therefore, indicates how well a test identifies the sub- jects with no disease (6,10). It is important to note that the sensitivity and specificity are characteristics of the test being evaluated and are therefore usually independent of the prevalence (proportion of individuals in a pop- ulation who have disease at a specific instant) because the sensitivity only deals with the diseased subjects, whereas the specificity only deals with the nondiseased subjects.

The "precipice" may be any clinically evident marker such as death cheap 10 mg paxil, confusion generic paxil 10mg with amex, or cardiac arrest order 40mg paxil visa. Physiologic Reserves Increasing Age tion as well as those from a younger person5; of course, physiologic reserves have not "disappeared," as sug- others function poorly, and it is the relative ratio of the gested in Figure 3. I focus on examples from opposed to the pediatrician who can within a few weeks the cardiovascular system, such as heart rate, cardiac anticipate when a baby will start to walk, the geriatrician hypertrophy, and diastolic function, because the data in has a much harder time predicting when senescent this area provide an ample molecular, biochemical, and changes will become clinically evident. Baltimore ogists describe the growing rate of obesity, especially Longitudinal Study data, obtained from healthy, highly among older men, as an increasingly sedentary existence screened individuals, give a regression equation of of most people beyond 30 years of age. Some, such as the decrease in maximum heart rate attained with exercise, appear to be more predictable. Data from the cardiovascular system are expanded here because the data in this area provide ample rationale to justify the necessity to reinterpret the traditional approach to homeostenosis. This reinterpre- tation helps one understand the phenomenon of frailty, a central concern of geriatrics. Frailty is the state when physiologic reserves are reduced to the point at which susceptibility to disability is increased. Frailty is, there- fore, the clinical manifestation of the later stages of homeostenosis, an intolerance of homeostatic challenges. Additionally, the reinterpretation of homeostenosis makes those caring for the elderly appreciate and under- stand the complexities they face. In the elderly, as in youth, maintaining homeostasis is a dynamic, active process. Acute physiologic assess- persons are actively employing some of their physiologic ment (APA) scores (from the APACHE II severity of illness reserves just to maintain homeostasis. Their available scale) are shown from patients who subsequently experienced reserves appear depleted because they in are already in cardiac arrest and a resuscitation attempt. The data show the use by the old heart (or other organ or system) to com- APA scores were significantly higher in the younger patients pensate for primary age-related or other changes. Endocrine system Impaired glucose tolerance (fasting glucose increased 1 mg/dl/decade; postprandial increased 10 mg/dl/decade) Increased serum insulin and increased HgbA1C nocturnal growth hormone peaks lost, decreased 1GF-1 Marked decrease in dehydroepiandrosterone (DHEA) Decreased free and bioavailable testosterone Decreased T3 Increased parathyroid hormone (PTH) Decreased production of vitamin D by skin Ovarian failure, decreased ovarian hormones Increased serum homocysteine levels Cardiovascular Unchanged resting heart rate (HR), decreased maximum HR Impaired left ventricular filling Marked dropout of pacemaker cells in SA node Increased contribution of atrial systole to ventricular filling Left atrial hypertrophy Prolonged contraction and relaxation of left ventricle Decreased inotropic, chronotropic, lusitropic response to beta-adrenergic stimulation Decreased maximum cardiac output Decreased hypertrophy in response to volume or pressure overload Increased serum atrial natriuretic peptide (ANP) Large arteries increase in wall thickness, lumen, and length, become less distensible, and compliance decreases Subendothelial layer thickened with connective tissue Irregularities in size and shape of endothelial cells Fragmentation of elastin in media of arterial wall Peripheral vascular resistance increases Blood pressure Increased systolic blood pressure (BP), unchanged diastolic BP Beta-adrenergic-mediated vasodilatation decreased Alpha-adrenergic-mediated vasoconstriction unchanged Brain autoregulation of perfusion impaired Pulmonary Decreased FEV1 and FVC Increased residual volume Cough less effective Ciliary action less effective Ventilation–perfusion mismatching causes PaO2 to decrease with age: 100 - (0. Continued Genitourinary (GU) Prolonged refractory period for erections for men Reduced intensity of orgasm for men and women Incomplete bladder emptying and increased postvoid residuals Decreased prostatic secretions in urine Decreased concentrations of antiadherence factor Tamm–Horsfall protein Temperature Impaired shivering Regulation Decreased cutaneous vasoconstriction and vasodilation Decreased sweat production Increased core temperature to start sweating Muscle Marked decrease in muscle mass (sarcopenia) due to loss of muscle fibers Aging effects smallest in diaphragm (role of activity), more in legs than arms Decreased myosin heavy chain synthesis Small if any decrease in specific force Decreased innervation, increased number of myofibrils per motor unit Infiltration of fat into muscle bundles Increased fatigability Decrease in basal metabolic rate (decrease 4%/decade after age 50) parallels loss of muscle Bone Slower healing of fractures Decreasing bone mass in men and women, both trabecular and cortical bone Decreased osteoclast bone formation Joints Disordered cartilage matrix Modified proteoglycans and glycosaminoglycans Peripheral nervous system Loss of spinal motor neurons Decreased vibratory sensation, especially in feet Decreased thermal sensitivity (warm–cool) Decreased sensory nerve action potential amplitude Decreased size of large myelinated fibers Increased heterogeneity of axon myelin sheaths Central nervous system Small decrease in brain mass Decreased brain blood flow and impaired autoregulation of perfusion Nonrandom loss of neurons to modest extents Proliferation of astrocytes Decreased density of dendritic connections Increased numbers of scattered neurofibrillary tangles Increased numbers of scattered senile plaques Decreased myelin and total brain lipid Altered neurotransmitters, including dopamine and serotonin Increased monoamine oxidase activity Decrease in hippocampal glucocorticoid receptors Decline in fluid intelligence Slowed central processing and reaction time Gastrointestinal (GI) Decreased liver size and blood flow Impaired clearance by liver of drugs that require extensive phase I metabolism Reduced inducibility of liver mixed-function oxidase enzymes Mild decrease in bilirubin Hepatocytes accumulate secondary lysosomes, residual bodies, and lipofuscin Mild decrease in stomach acid production, probably due to nonautoimmune loss of parietal cells Impaired response to gastric mucosal injury Decreased pancreatic mass and enzymatic reserves Decrease in effective colonic contractions Decreased calcium absorption Decrease in gut-associated lymphoid tissue 3. Continued Vision Impaired dark adaptation Yellowing of lens Inability to focus on near items (presbyopia) Minimal decrease in static acuity, profound decrease in dynamic acuity (moving target) Decreased contrast sensitivity Decreased lacrimation Smell Detection decreased by 50% Thirst Decreased thirst drive Impaired control of thirst by endorphins Balance Increased threshold vestibular responses Reduced number of organ of Corti hair cells Audition Bilateral loss of high-frequency tones Central processing deficit Difficulty discriminating source of sound Impaired discrimination of target from noise Adipose Increased aromatase activity Increased tendency to lipolysis Immune system Decreased cell-mediated immunity Lower affinity antibody production Increased autoantibodies Facilitated production of anti-idiotype antibodies Increased occurrence of MGUS (monoclonal gammopathy of unknown significance) More nonresponders to vaccines Decreased delayed-type hypersensitivity Impaired macrophage function (Interferon-gamma, TGF-beta, TNF, IL-6, IL-1 release increased with age) Decreased cell proliferative response to mitogens Atrophy of thymus and loss of thymic hormones Accumulation of memory T cells (CD-45+) Increased circulating IL-6 Decreased IL-2 release and IL-2 responsiveness Decreased production of B cells by bone marrow 208 - (0. It is likely that women have lower maximum parasympathetic stimulation), as well as invokes heart rates at age 30 and a more gentle fall with aging reserves just to maintain resting heart rate. Data from Jose,6 although regretfully including only a modest than this equation predicts. This decrease in maximum heart rate responsiveness results from a combination of number of elders, show a decrease in intrinsic heart rate factors. First, primary aging decreases the intrinsic heart from 120–130/min to less than 80. Physiologic The older person employs or consumes physiologic Reserves reserves just to maintain homeostasis, and therefore Already In Use there are fewer reserves available for meeting new challenges. Taffett in resting heart rate with age, so the extent of parasym- pathetic tone, slowing heart rate at rest, is decreased. Sympathetic Stimulation Removal of parasympathetic tone, the first mechanism invoked to increase heart rate with exercise, is then less effective for the elderly because vagal tone is already diminished at rest; this is consistent with the attenuated Intrinsic Heart Rate heart rate response of healthy elders to administration of atropine. The decreased yield from lysis of parasympa- thetic tone is added to decreased beta-adrenergic chronotropic responsiveness to contribute to the overall decreased maximal heart rate in response to exercise Vagal Tone (Fig. Importantly, the same limitation in maximum heart Age 20 Age 80 rate with exercise applies to that in response to other Resting Heart Rate stimuli, such as infection or anemia. Therefore, an 80- year-old man with a sinus tachycardia of 120, mounting Figure 3. There are no dif- close to a maximum heart rate response, could be con- ferences in resting heart rate between the older and young sidered as a young man who had a heart rate of 170. In person, but the extent of the resting vagal tone, slowing heart rate (dark gray bar),is decreased in the older person. With exer- the setting of an infection, although a 120 heart rate tion, the removal of the vagal tone results in smaller increment would hardly raise eyebrows, a 170 would surely provoke in heart rate and the beta-adrenergic chronotropic responsive- serious concern. For their respective age groups, both ness is also decreased (light gray bar), all contributing to the values roughly represent an equivalent of 75% of decreased maximum heart rate in the old.

If a paid attendant is out of financial reach generic paxil 40 mg otc, other relatives could be asked to assist with time or with some of the money needed to pay for a part-time attendant 10 mg paxil amex. Sometimes adult children live at a great distance from their parents in another part of the state or the country order paxil 40mg visa. No matter where the children live, it’s important for them to communicate regularly, to visit, and to have their parents as guests if possible. Letters, phone calls, and little gifts help to keep up morale and help to maintain the good attitude that is so important to the well-being of a person with Parkinson’s. Children can look through a medical supply store for little things that will make the parent’s life easier. One busy man was surprised and delighted, for example, when his daughter gave him a small pocket pillbox with relationships with our adult children 129 a built-in timer. This thoughtful little gift enables him to take his medications on time as he moves from activity to activity. The person with Parkinson’s will experience a quicker emo- tional recovery if a sense of caring and support is extended by the children. At the same time, it’s important for adult children to refrain from pushing their advice too assertively on the parent who has Parkinson’s. Gayle Dakof of California, family members can best help a patient by showing concern and affection. But advice is taken better when it comes from doctors, other medical personnel, or other patients going through the same circumstances (see The Journal of Person- ality and Social Psychology, February 1990). Tay- lor, there is also a delicate balance between showing too much and too little concern about a patient’s condition. Be attentive, caring, and supportive of each other; keep the lines of communi- cation open; and educate yourselves as much as possible about Parkinson’s disease. In 1980, the first two of my grandchil- dren were born, and in the same year, my Parkinson’s manifested itself. The arrival of grandchildren brought pure delight; the arrival of Parkinson’s brought frustration and sorrow. When the time came to share the news, I received two very different mes- sages: Shout from the rooftops that you are a grandmother; keep quiet about the Parkinson’s. Everyone knew how much I had looked forward to being a grandmother, and soon they knew that I had attained that status. It’s about the grandpar- ent’s need to develop and enjoy that relationship, as well as to be open and honest with the grandchildren about Parkinson’s. Many people avoid discussing serious problems with children, problems such as an illness, a death in the family, or a change in family circumstances. They fear upsetting the children and, in a mistaken desire to protect them, delay such discussions "until the children are older. Today most psychologists support my position that children need to be told the truth (in an appropriate way) about circum- stances that arise. It’s easier to teach children positive attitudes in their early years than to change their attitudes when they are older. And it’s better to prevent the misinterpretations that develop when discussion is avoided. Children sense when something is being kept from them, and they are likely to build up in their minds whatever they imagine. In a recent instance, a seven-year-old whom we know was found crying while the adults in his family mourned the loss of a relative. When asked why he was crying, he said that he didn’t like to see everybody so sad. When he received assurance that this was a normal part of the process of grieving and saying good-bye, he was content to go off and play. When adults avoid the subject, children may begin to believe that something about the grandparent is so bad that it must not be talked about. Don’t be afraid to talk with your grandchildren and let them ex- press their fears, which will help them adjust to your Parkinson’s. My conviction about helping children to express their fears comes from my own childhood experience with fears, especially the fear of dying. I believe that this fear was caused by the deaths 132 living well with parkinson’s of people close to me, which no one discussed with me or helped me to accept.

The development and implementation of an affect regulation and attachment intervention for incarcerated adolescents and their parents cheap paxil 10 mg with amex. Towards a developmental family therapy: The clinical utility of research on adolescence buy 10 mg paxil with visa. The feminist/emotionally focused therapy prac- tice model: An integrated approach for couple therapy paxil 20mg cheap. CHAPTER 12 Strategic and Solution-Focused Couples Therapy Stephen Cheung OUPLES THERAPY IS very complex. Couples therapy must be sensitive to and simultaneously address a myriad of variables, such as the Cfirst person’s unique life challenges, personal developmental stage, and interpersonal style vis-à-vis those of the second person; the couple’s collective challenges; the couple’s progress in their developmental life cycle; the interaction between the couple; and the interaction between the first person and/or the second person with another outside the couple re- lationship. These variables all impact the couples and the way they per- ceive their problems and their resources to solve their problems (Berg & de Shazer, 1993; Berg & Miller, 1992; Carter & McGoldrick, 1999; Haley, 1973, 1987, 1990, 1996; Madanes, 1981, 1990, 1991; O’Hanlon & Weiner- Davis, 1989). From the inception of psychotherapy until recently, many therapists had a one-size-fits-all mentality toward couples therapy and individual therapy in general. In other words, therapists tended to believe that one kind of therapy would be suitable for all couples and that one type of therapy would adequately address all problems between these couples. However, in the twenty-first century, therapists, informed by modern and postmodern schools of therapy, are more humble and realis- tic, and have rejected the one-size-fits-all approach. Instead, they realize their own limitations and those of their favorite therapy approaches (Cheung, 2001; Corey, 2004; Ivey, D’Andrea, Ivey, & Simek-Morgan, 2002; Prochaska & Norcross, 2003). They further respect the phenomenal world of the individual and trust his or her ability to solve problems. In 194 Strategic and Solution-Focused Couples Therapy 195 this zeitgeist, this chapter presents strategic and solution-focused couples therapy (SSCT) and discusses how SSCT can be beneficially applied to couples. SSCT selectively integrates principles from two therapy ap- proaches: namely, strategic couples therapy (SCT) and solution-focused therapy (SFT). A brief review of the existing theoretical and clinical literature on SCT is first described. Next comes a brief review of the existing theoretical and clinical literature on SFT. The methodology of SSCT that selectively inte- grates principles of SCT and techniques of SFT is then presented. After that, the methodology of SSCT is applied to a specific case to illustrate how it is utilized to address problems presenting in a couple. Last, the chapter explores how cultural and ethnic sensitivity in the application of SSCT can lead to beneficial results. REVIEW OF THEORETICAL AND CLINICAL LITERATURE SCT is based on Milton Erickson’s Strategic Therapy. Underlying Assumptions and Key Concepts Haley and Madanes concur with Erickson’s emphasis on tolerance of the idiosyncrasies of the indi- vidual. They also agree that it is the therapist’s responsibility to initiate what happens during therapy and to design a particular approach for solving each of the client’s problems (Haley, 1973, 1987, 1990, 1996; Madanes, 1981, 1991). Being highly practical, they deem it appropriate for the thera- pist to borrow any useful technique from other therapy models to address the presenting problem. They moreover espouse the epistemology of structuralism and a systemic perspective. The epistemology of structural- ism attempts to identify the objective truth of universals and structures and principles underlying and governing human behavior; it holds that symptoms result from some underlying psychic or structural problem, such as an enmeshed family boundary, incongruous family hierarchies, or psychotic family games (Haley, 1987, 1990; Madanes, 1981, 1990; Minuchin, 1974; Minuchin & Fishman, 1981; Selvini-Palazzoli, 1986; Selvini-Palazzoli, Boscolo, Cecchin, & Prata, 1978). A systemic perspec- tive assumes recursiveness or circular causality that views people and events in the context of mutual interaction and mutual influence. Instead of examining individuals and events in isolation, a systemic perspective examines the relationships between individuals and events, how each in- teracts with and influences the other. In other words, according to the systemic perspective, meaning is derived from the relationship between individuals and events, where each defines the other. There must be great tolerance of all the different ways cou- ples find to live together or apart. A more sensible focus would seem to be on the particular problem a couple is having within their type of marriage.

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