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The relative impact of health education for low- and high-risk pa- tients with hypertension cheap fluconazole 150mg without prescription. Treating difficult couples: Helping clients with coexisting mental and relation- ship disorders purchase 200 mg fluconazole. Treating difficult couples: Helping clients with coexisting mental and relationship disorders. Connectedness versus separateness: Applicability of family therapy to Japanese families. Ex- ercise testing to enhance wives’ confidence in their husbands’ cardiac capabil- ity soon after clinically uncomplicated acute myocardial infarction. Working with couples in a diabetes clinic: The role of the ther- apist in a medical setting. CHAPTER 16 Treating Couples with Sexual Abuse Issues Michele Harway and Ellen Faulk ARIA ELENA (35) AND Jose (37) have been married for 10 years and have two children, Rob (9) and Sylvia (7). Maria Elena is an ele- Mmentary school teacher and Jose is a state government employee in a managerial position. Jose complains that Maria Elena has not enjoyed sex during the entire time they have been married. Maria Elena says she is always busy with her work and the children and sex just is not that important to her. During an early session, Jose admits that lately he has been having problems with pre- mature ejaculation, commenting that before marriage "I could go all night. If you are the therapist who is treating Maria Elena and Jose, what is your initial assessment of the presenting problem? Or do you determine that the best course of treatment would be to focus on the couple’s mismatched sexual drives? In each instance, without an appropriate exploration of the possibility of sexual abuse, the treatment would most likely NOT focus on the most impor- tant issue that is affecting Jose and Maria Elena—the fact that Maria Elena was sexually abused when she was 9, and how it has impacted her individu- ally and in her relationships with others. While most psychotherapists do receive training on child abuse, the focus of such training is on the identifica- tion of currently occurring abuse in families with children (and the conse- quent legal/ethical and treatment issues this raises). Psychotherapists are 272 Treating Couples with Sexual Abuse Issues 273 seldom trained to identify adults who were molested as children, particu- larly when they present with relationship problems. The focus of this chapter is on couples who present for psychotherapy, where one member of the couple has experienced sexual abuse as a child. Working with these couples requires special understanding of the impact of sexual abuse on the survivor and consideration of how the coping mech- anisms the survivor develops to live through her abuse experience might impact her relationship with her partner. Because the issue of sexual abuse is extremely complex, this chapter nec- essarily is limited to certain types of sexual abuse. Thus, although as many as 16% of men are sexually abused (Wurtele & Miller Perrin, 1992), this chapter focuses on couples where the abuse survivor is female (studies summarized by the same authors indicate 7% to 62% of women have a sex- ual abuse history). The impact of sexual abuse on men is as deleterious as it is on women and some would say that it impacts men’s relationships at least as much as it does those of women. Others, however, would argue that given the importance of relationships to women’s sense of self, sexual abuse is likely to have a greater impact on women’s relationships than on men’s. Gilligan (1982) and Erikson (1968) suggest that in gaining a sense of themselves, young women rely more on interpersonal relationships than do young men, thus women who were abused by someone of a close famil- ial nature may have difficulties developing a healthy self-identity. In either case, however, a focus on male survivors and their partners is beyond the scope of this chapter. Because most perpetrators of sexual abuse are likely to be men, the impact of having been sexually abused on a later ro- mantic relationship is different when the partner is female (as in a lesbian relationship) than when the partner is male. However, to limit the scope of issues to be considered in this chapter, we focus exclusively on heterosex- ual relationships. Prior to discussing how couples therapists might proceed in treating a couple such as Maria Elena and Jose, and before meeting other couples with similar histories, this chapter includes an overview of the impact and nature of sexual abuse and considers the experience of the sexual abuse survivor’s partner. We next discuss assessment issues looking at the case of Maria Elena and Jose in more detail.

Dural Arteriovenous Malformation (Dorsal Intradural AVM purchase 200 mg fluconazole with mastercard, or Type I) The type I AVF represents the most common type of spinal vascular malformation and should be in the differential diagnosis in an adult presenting with gradually worsening myelopathy purchase 150 mg fluconazole free shipping. C l a s s i f i c a t i o n A n g i o g r a p h i c / a n a t o m i c N e w c l a s s i f i c a t i o n P r e v a l e n t O t h e r c l a s s i f i c a t i o n ( S p e t z l e r e t a l. The most common location for these malformations is between T4 and L3, with the peak incidence between T7 and T12. This lesion is composed of a direct fistula between the dural branch of a radicular artery (only rarely of a radiculo- medullary artery) at the level of the proximal nerve root and a radicu- lomedullary vein (type A, Figure 16. The arterialized radiculomedullary vein then transmits the increased flow and pressure to the valveless coronal venous plexus and longitu- dinal spinal veins. The mean intraluminal venous pressure is increased to 74% of the systemic arterial pressure. In one series, the mean venous pres- sure in the coronal venous plexus was measured at 40 mmHg. The most common presenta- tion is progressive paraparesis of the lower extremities with sensory changes also. Although the pro- gression is usually continuous, it can also present in a stepwise fash- ion, or a waxing–waning course with gradual progression. The symp- toms can be exacerbated by any physical activity that increases intra- abdominal pressure, and thus central venous pressure, as well as by an upright posture (venous drainage hindered by gravity). Superselective angiogram of an intercostal artery (D, arrow) shows (E) the DAVF (curved arrow), the ret- rograde draining and congested radiculomedullary vein (open arrow), and the congested dorsal median vein (heavy black arrow). Almost all these patients (98%) exhibited myelopathy, with 96% displaying leg weakness and/or paraparesis. Ninety percent had sensory numbness or paresthesias, and 55% had pain either in the lower back or lower extremities. Eighty-two percent had urinary incontinence/retention, and 65% complained of bowel dysfunction. All the patients had lower extremity weakness with or without perineal or bowel/bladder dysfunction. Five patients also had upper extremity symptoms, all of whom had high T2 signal within the cervical cord. Eighty-eight patients reported sensory loss, and 61 patients had bowel/bladder dysfunction. A very interest- ing finding in this series was an essentially 50-50 split among patients with symmetric versus asymmetric lower extremity symptoms; in ad- dition, approximately 50% of patients demonstrated worsening of symp- toms with erect posture/Valsalva maneuver and improvement with re- cumbent position. This effect was not as prominent in the group of patients with the most severe symptoms. Eight of the patients included in this series had posterior fossa dural arteriovenous shunts with drainage into the medullary venous system, which is a well-described phenomenon and necessitates the injection of the posterior fossa and ex- ternal carotid arteries in completion of a total spinal angiogram. Therapy The surgical treatment for type I malformations has been well described and essentially consists of performing one or more laminectomies and surgical disconnection of the draining vein, just distal to the fistulous site. Before the availability of acrylate products ("glue"), treatment consisted of selective microcatheterization of the feeding artery, with particulate embolization of the fistula by means of polyvinyl alcohol (PVA) particles. Despite high rates of angiographic success immediately after treatment, this technique was associated with a high recurrence rate ( 83%), owing to recanalization of the arterial feeding pedicles. With the availability of acrylate products, the recurrence rate has significantly diminished. The consensus among interventional neuroradiologists at this time is that successful treatment of these malformations consists of penetration of the fistula and the proximal radicular draining vein to obviate the need for future surgery (Figure 16. The treatment protocol used in the series of patients presented by Van Dijk et al. Us- ing their endovascular treatment criteria, which included both the abil- Spinal Vascular Malformations 297 ity to penetrate the fistula and proximal portion of the draining vein, as well as the ability to treat the malformation in a single session, only 11 (25%) of the patients were treated via the endovascular route, all of whom demonstrated a clinical success rate and stability equivalent to that of surgery (mean follow-up of 32. Under less stringent criteria, other endovascular specialists using acrylate have reported success rates of up to 90%, but with recur- rence rates of up to 23%. Intradural (Pial) Arteriovenous Fistula (Ventral Intradural AVF, or Type IV) The type IV AVF represents a direct fistula from the anterior spinal ar- tery to the coronal venous plexus (Figure 16. Subtype A (also classified as Merland subtype I) represents a small shunt, with moderate venous hypertension. There is no enlargement of the anterior spinal artery (ASA) and only minimal dilatation of the ascending draining vein.

If test results were still posi- patient’s blood pressure again (this had to be done tive quality 150mg fluconazole, it looked as if the cascade of likely events would after every 10th student)—it was stable purchase 200 mg fluconazole with amex. And I tested the include ultrasonography, urine samples for malignant urine to check it was normal—it was not. I had time to think about not a problem as far as the examination was concerned adopting an evidence based approach. I tested Formulating the question my urine again a week later, and when I found it was still positive I sent a specimen to the laboratory. The report The most difficult part of adopting evidence in practice stated that urine culture was negative but confirmed the is formulating the question. The model that is the chance of having a serious condition with sprang to mind first is summarised in the table. Ideally, it would be huge study of general tuberculosis and schistosomiasis as causes of haema- turia. A textbook of medicine2 suggested further Causes and management of haematuria assessments, including checking my blood relatives for Site of bleeding Disease Management urine abnormality and carrying out haemoglobin elec- Generalised Bleeding diathesis Check bleeding and coagulation profiles; trophoresis and 24 hour urinary estimations of urate treat accordingly and calcium excretion. If all these investigations were Lower renal tract Prostate hypertrophy or cancer; Cystoscopy; treat accordingly negative, intravenous urography, cystoscopy, and renal urethral inflammation; bladder lesion computed tomography were proposed, with indefinite or cancer Ureteric lesions Transitional cell carcinoma; ureteric Ultrasonography or intravenous regular follow up thereafter. The essential feature of calculi urography; treat accordingly this model is that identifying the lesion anatomically or Renal lesions Cancer; calculi; vascular abnormalities; Check blood pressure; ultrasonography physiologically is the key to managing the problem. Neither exercise, recent sexual inter- course, nor flying were associated with microscopic Searching for evidence haematuria, although recall of a history of urethritis The standard textbooks on my shelf were no help in was. This would have been the most The clinical decision convenient source of data and is strong on evidence for different treatments, but unfortunately it does not yet What should I do now? I decided that the chance of include routinely collected data on the course of having an adverse outcome was not sufficiently high diseases and conditions. My search strat- adopt a management policy of "expectant observa- egy was simple,3 and probably sensitive at the expense tion. Inspection of titles helped me discard immediately I have applied my own values to the clinical about half the 230 hits, but reading through the printout decision. If, in similar circumstances, a patient of mine of abstracts of the remainder took an evening. There elected to proceed with further investigations, I would were no systematic reviews—the best form of evidence. This does not address matters of gatekeeping Two articles were clearly useful because they described (resource allocation), which probably should be dealt large studies with long term follow up of people with with away from the consultation. The The evidence main difference was the change in clinical thinking that In a British study, 2. Some a serious condition that was amenable to cure—two answers are difficult to find. We a prognosis of the outcome someone like me (my situ- also need a forum of peers and those skilled at ation being similar to screening) would expect. It evidence based medicine in which test out our ideas so suggested that I was unlikely to have a serious that we can reassure ourselves that we are not condition that was amenable to cure. If health authorities are serious this may be an overestimate of the benefits of about promoting evidence based medicine in clinical screening. Perhaps those three people would have practice, they may have to consider providing a service developed symptoms such as frank haematuria or (perhaps like pathology, radiology, or referred special- dysuria sufficiently early to negate the beneficial effect ist opinions) to help clinicians to take these steps. Paul Glasziou constructively read earlier drafts and checked, Another study was done in California. In: outcome of people whose dipstick test was not positive; Fauci AS, Braunwald E, Isselbacker KJ, Wilson JD, Martin JB, et al, eds. New York: McGraw Hill, their probability of developing urological cancer was 1998:258-62. Dipstick urinalysis screening, asymptomatic microhematuria, and subsequent urological cancers in a population- were probably the best match with my situation that I based sample. The second study, particularly, seemed 7 Froom P, Gross M, Froom J, Caine Y, Margaliot S, Benbassat J.

Stage One: Product Differentiation and the Consumer Mentality The postwar period witnessed the emergence of a wide variety of new prod- ucts fluconazole 150mg amex, particularly in the consumer-goods industries discount fluconazole 150 mg otc. Newly empowered con- sumers demanded a growing array of goods and services, even if existing goods and services had adequately served previous generations. This development contributed to the emergence of marketing for at least two reasons. First, consumers had to be introduced to and educated about these new goods and services. Second, new market entrants introduced a level of competition unknown in the prewar period. This meant that mecha- nisms had to be developed to both make the public aware of a new prod- uct and to distinguish that product from those of competitors’ in the eyes of potential customers. Consumers had to be made aware of purchase opportunities and then convinced to buy a certain brand. The standardization of existing products that occurred during this period further contributed to the need to convince newly empowered consumers to purchase a particular good or service. These developments resulted in a shift away from a seller’s market to a buyer’s market. Once the consumer market began to be tapped, it was realized that the demand for many types of goods was highly elastic. The prewar mentality had emphasized the meeting of consumer needs and assumed that a finite amount of goods and services could be purchased by a population. With the increase in discretionary income and the introduc- tion of consumer credit after World War II, consumers began to satisfy wants. Fledgling marketers found out that they could not only influence consumers’ decision-making processes but could even create demand for certain goods and services. The postwar period was marked by a growing empha- sis on consumption and acquisition. The frugality of the Depression era gave way to a degree of materialism that was shocking to older generations. The availability of consumer credit and a mind-set that emphasized "keep- The History of M arketing in Healthcare 5 ing up with the Joneses" generated a demand for a growing range of goods and services. America had given rise to the first generation of citizens with a consumer mentality. By the 1970s, there was a growing emphasis on self-actualization in American culture, often carried to the point of narcissism in the minds of many observers. Not only were individuals coming to be identified in terms of their material possessions, but the cultural environment encouraged peo- ple to "do their own thing. A growing consumer market with expand- ing needs, coupled with a proliferation of products, created a fertile field for the emergence of marketing. Underlying these developments was the growing emphasis being placed on change itself. Traditional societies (including the United States until World War II) emphasized stability; the status quo; and, as the name implies, tradition. A premium was placed on the old ways of doing things, and impending change engendered skepticism, if not outright resistance. Clearly, previous generations were oriented to the present (or even the past) in terms of their cultural moorings. The prospect of change had always threatened deep-seated convictions that had survived for generations. By the 1970s, not only had change become accepted as inevitable as society underwent major transformations, but change began to take on a pos- itive connotation. Individuals began switching jobs, residences, and even spouses at a rate that shocked their forefathers. It became a maxim that the American dream involved the advancement of each generation over the previous one. Stage Two: The Emerging Role of the Sales Representative The second stage of marketing evolution focused on sales. Under these conditions, sales representatives took orders from what was essentially a captive audience.