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The long-term stability of dos- ing in the cancer population has also been documented elsewhere cheap 30gm v-gel free shipping herbals outperform antibiotics in treatment of lyme disease. It is probable that about 5 to 10% of those in the cancer pain popula- tion are candidates for an implantable pump system using the selec- tion criteria noted earlier 30gm v-gel otc herbals postums perses 16. Non-Cancer-Related Pain The use of intrathecal opioids for pain not due to cancer has burgeoned in recent years in spite of a lack of prospective studies. The most de- finitive data to date supporting such an increase in use are provided by the survey of physicians in the United States by Paice, Penn, and Shortt,17 cited in connection with cancer-related pain and including data on pain not related to cancer, and in the retrospective study by European authors Winkelmuller and Winkelmuller. Doses for neuropathic pain tended to be higher at 6 months than for somatic or visceral pain. These patients exhibited a linear in- crease in dose over time, eventually reaching stable levels by one year at 9. The best ini- tial response was seen in the nociceptive pain group, with a 77% ini- tial reduction in pain intensity that declined to 48% at last follow-up. Deafferentation and neuropathic pain groups benefited from therapy and in fact over the long term showed the best results, with 68 and 62% pain reduction as measured by VAS, respectively. While these results are impressive in a population of patients unre- sponsive to more conventional methods, prospective studies compar- ing this and alternative therapies would more rigorously establish in- trathecal infusion of medication as a treatment of choice. The current acceptance in clinical practice empirically validates the technique but also makes prospective and certainly randomized studies difficult to implement. Complications Any technique involving a surgical procedure, prosthetic device, and the infusion of medication will have complications. With implantable drug administration systems, complications may be divided into three categories: surgical complications, device-related complications, and drug-related complications. Surgical Complications In the perioperative period, bleeding with the subsequent development of a pocket hematoma is perhaps the most troublesome and prevent- able problem. Meticulous attention to hemostasis during pump pocket formation will avoid this problem. An additional aid in prevention is the placement of an abdominal binder, such as a 6 in. Ace wrap, around the abdomen and lightly compressing the fresh pump pocket for 24 to 48 hours. This compression dressing helps to avoid the accumulation of blood or fluid in the pocket. The possibility of epidural and intrathecal hemorrhage is frequently mentioned, with the obvious risk of neurological injury. This compli- cation, unfortunately, tends to occur at the time of catheter implant. Pre- operatively, care should be taken to discontinue nonsteroidal anti- inflammatory drugs and reverse any anticoagulation. Signs of a devel- oping hematoma are usually a sudden increase in focal back pain as- sociated with tenderness, progressing numbness and/or weakness in the lower extremities, and loss of bowel or bladder control (in the form of retention/constipation or incontinence). This clinical presentation warrants immediate imaging with MRI or CT/myelogram and emer- gent neurosurgical intervention if there is neurological deterioration. With implantable devices, one of the most feared complications is Complications 287 wound infection. The use of prophylactic antibiotics has been contro- versial, but a consensus seems to have developed around the practice of using some preoperative antibiosis. One method is to use a cephalosporin intravenously an hour prior to surgery without subse- quent antibiosis. Some clinics use daily prophylaxis while an exter- nalized screening electrode trial is under way. Attention on the part of surgical personnel to handle all sterile parts with care, avoiding unnecessary contact with any, even prepped, skin may reduce contamination. While not all wound infections require removal of the device, gen- eral experience with foreign bodies implanted in the body (e. Implantable pumps contain an internal filter that guards against direct contamination re- sulting in meningitis. However, with infection tracking along the in- trathecal catheter, either an epidural abscess or meningitis may result.

If the primary cause of your decreasing sexual drive lies in primary neurological damage v-gel 30gm fast delivery herbals on deck review, then this is harder to deal with directly discount v-gel 30gm with mastercard herbals and supplements. You and your partner could consider first sensual activity experiences, without you feeling the immediate pressure for sexual intercourse. Ensure that you make time to enjoy the experiences with each other without feeling hurried or under pressure. As in other relationships where circumstances SEXUAL RELATIONSHIPS 65 change, new, and possibly exciting and stimulating, patterns of mutual exploration may need to be learnt or re-learnt. Problems during intercourse Incontinence If you haven’t had one already, visit your doctor for an assessment of the problems you have with incontinence. Try and ensure that you have no urinary infections, which can make your bladder problems worse if left untreated. The following advice can help reduce the risk of ‘accidents’ during intercourse: • Reduce your intake of fluids for an hour or two beforehand. If the woman has problems with spasticity in her legs, then such a position is likely to reduce the possibility of annoying cramps and rigidity. Sometimes lubrication can be helped by direct stimulation of the genital area; or try to set up an environment which is relaxing and conducive to sexual thoughts and experiences. As far as additional lubrication is concerned, K-Y Jelly or a similar water-soluble substance can be very helpful. Substances like Vaseline are not recommended because they do not dissolve in water, and they are likely to leave residues which could give rise to infections. Spasticity Check with your doctor that the general control of your spasticity is as good as it can be. Try and keep your muscles as well toned as possible through regular exercises (see Chapter 8), and use appropriate drugs such as baclofen as necessary to give additional control. There are also certain positions for sexual activity that appear to make the muscular spasms less likely, although it is important that you explore other possibilities than those mentioned below, for you may find another position that suits you both very well. For a man who may have difficulty with spasms or rigidity in his legs, then sitting in an appropriate chair (without arms) would allow his partner to sit on his penis either facing him or with her back to him. For a woman, lying on her side may help, perhaps with a towel or other material between your legs for more comfort. Another possibility is to lie on your back towards the edge of your bed with the lower part of your legs hanging loosely off the bed. Fatigue As with other symptoms associated with MS, it is important to discuss this with your doctor who will assess the best means of managing it. Although there are one or two drugs which may help (for example amantadine or pemoline) and which – if prescribed for you – might be taken a few minutes before sexual activity, currently the best help is through various appropriate lifestyle changes. The use of various techniques to assist with fatigue is discussed in more detail in Chapter 7. Although this may not necessarily be the time when you feel that you should be having sex – such as in the morning, or during the day, rather than at a more conventional time – you may be less tired and enjoy it more. Rather than thinking of sexual intercourse as the major element, you could agree with your partner to engage in some other less energetic sexual activities – such as gentle stroking or foreplay – that you could participate in more frequently. As with so many other aspects of living with MS, it is a question of finding ways to adapt to the situation through experimentation. When you visit your doctor, particularly your GP, you may find that he or she puts virtually all your symptoms down to MS itself. Whilst statistically it is probably correct that most of your symptoms will be related to the MS, many will not. It is easy for both of you to say ‘Oh, that’s another symptom of MS’ and not realize that, like other people, you can have other everyday problems. It is important that both are recognized in relation to pain as well as other symptoms. If GPs do confuse MS and non-MS symptoms, this is not through incompetence – even specialists sometimes have similar problems.

Consuming a multivitamin monitored by frequent weight and intake and output with minerals containing the RDA for iron discount v-gel 30 gm without a prescription herbs chips, combined measurements v-gel 30 gm cheap herbals for ed. If current evidence confirms adverse effects of iron stores, the use of iron-containing supplements in the elderly may well be unwise. Numerous studies indicate that, for a wide variety of min- erals and vitamins, intake is significantly lower than the RDA for a large proportion of ambulatory elderly. The mineral may be involved in minimizing free Of most importance is the evidence that lifelong inade- radical accumulation, as it is essential for the normal quate intakes of calcium contribute to the high prev- function of glutathione peroxidase. It is generally deficiency has been reported frequently in the elderly, recommended that calcium intake in the elderly be although syndromes associated with selenium deficiency between 1. There is some evidence that selenium defi- ciency may contribute to a greater neoplastic risk and The prevalence of zinc deficiency is important because of declines in immune function. In elderly subjects with chronic debilitat- ing diseases, modest zinc deficiency may contribute to Aging generally is associated with increases in serum anorexia. Although not clinically proven, there is also evi- copper concentrations, although the significance of this dence that zinc supplementation aids in wound healing increase is unknown. Copper deficiency is very rare and in general and in the healing of pressure ulcers in par- has been reported only in total parenteral nutrition. Recent evidence has suggested an important role for chromium in carbohydrate metabolism. It In younger patients, iron deficiency is the most common is possible that chromium deficiency may contribute to cause of anemia and the most common global deficiency glucose intolerance in the elderly, although the thera- leading to widespread morbidity and decreased work peutic efficacy of chromium replacement is controversial. As a consequence, iron deficiency is rare in the elderly and invariably is caused by pathologic blood loss. It is important to empha- Studies have shown that dietary intake of many vitamins size that the anemia of chronic disease, which is associ- is inadequate in the elderly, including an intake of 50% ated with iron-deficient erythropoiesis, including a low or less for folic acid, thiamine, vitamin D, and vitamin E. Providing supplements such as drug use (digoxin, fluoxytene), thyrotoxicosis, with meals is not recommended, as total caloric intake and depression can usually result in weight gain if the will not be improved. The importance of a comprehen- underlying condition is corrected with appropriate sive rehabilitation program cannot be overemphasized. Other conditions that may well Recent evidence has shown that increased caloric intake contribute to weight loss that are potentially improvable can only be achieved when nutritional supplementation include social or economic isolation, difficulties with is accompanied by an aggressive and proactive program 10 cooking or feeding as a consequence of physical disabil- of exercise and physical therapy (Fig. Patients ity, dental or swallowing problems, and not provid- who fail to respond to treatment of their underlying ing palatable or preferred foods. Failure to identify a medical condition and fail to gain weight despite nutri- cause for weight loss is generally accompanied by a poor tional and physical rehabilitation carry a very poor prognosis despite aggressive medical and nutritional prognosis. Older persons who have experienced weight loss are consuming inadequate calories to meet their needs. This can be achieved by assuring the use of palatable meals, often recommending diets high in both protein and fats. All too frequently the underweight older person may, for apparent health reasons, be consuming a low-fat, low-protein diet that may well contribute to or minimize Figure 68. In these patients, risks of agement of nutritional problems in the acute care setting. For this reason, in underweight older ment is extremely important in deciding the appropriate persons we often recommend high-fat diets, including red time to commence nutritional support. In the acutely ill meats, pork, full cream milk, and ice cream, all of which patient, attention should first be directed at correcting the are dense in both calories and proteins. Thus, management of infec- meals should be recommended, using nutritional supple- tions, control of blood pressure, and the restoration of ments that are calorie dense and high in protein as meal metabolic, electrolyte, and fluid homeostasis must assume This page intentionally blank able 1034 T. Both devices are designed to enlarge the airway A related disorder that occurs during the relaxed, awake at the base of the tongue by advancing the tongue or the state often just before sleep onset is restless leg syndrome mandible forward. Patients report unpleasant sensations in their legs mated to range between 50% and 100%, success rates 42 and irresistible movement of the legs. Thus, able, sometimes painful leg sensations are alleviated by oral appliances are indicated for patients who do not rubbing or squeezing the legs or simply by walking. The respond to behavioral treatment such as weight loss or prevalence of RLS is not well defined. Most patients with body position, who are intolerant to CPAP, or who are 43 RLS also suffer from PLMS, suggesting that these disor- not candidates for surgery. Furthermore, many patients with on the severity of the apnea, the patient’s medical status, PLMS also suffer from other sleep disorders, including the level of urgency in treating the apnea, and the 46,47 SDB and REM sleep behavior disorder. PLMS is diagnosed in a full night sleep recording in the sleep clinic, which includes the recording of the anterior tibialis muscles to establish the MI.

Glenda’s symptomology and her shame relative to sexual pleasure might necessitate a cessation of sexual contact while Glenda is able to ad- dress these feelings in her individual therapy buy v-gel 30gm online herbs n more. Over the long term order v-gel 30gm mastercard herbals a to z, a pro- gram of sex therapy might be initiated to gradually ease the couple from nonsexual touch to increasingly more intimate forms of touch, as they both feel comfortable. When Glenda feels safe to resume intercourse with James, the therapist can teach behavioral methods, such as relaxation and thought stopping, to minimize the chance of flashbacks. Communication between the couple during sex can be encouraged so that Glenda can let James know if she becomes frightened, allowing her to regain a sense of control over her body. Should she choose to stop during intercourse, other sexual stimula- tion techniques can be substituted. This process over time also helps to en- gender mutual trust and care within the couple relationship. SUMMARY The complexities of treating couples where one partner has experienced childhood sexual abuse have been explored through three cases demon- strating different aspects of the long-term impact of this abuse. Specific symptoms and a wide variety of disparate presenting problems, which may not in themselves be identified by the couple as related to child sex- ual abuse, may be the motivators for starting couples therapy. The well- trained clinician will do an assessment that includes identifying or ruling out sexual abuse whenever couples present for psychotherapy. Because the survivor and her partner have reacted to her sexual abuse history in a variety of ways, a one-size-fits-all approach has been difficult to docu- ment here, therefore several approaches are suggested. Knowledge of the impacts of sexual abuse on the survivor and on her partner are critical for appropriate treatment. Finally, couples therapy with these couples is 286 SPECIAL ISSUES FACED BY COUPLES ancillary to individual therapy for the survivor and in some cases for the partner as well. Couples therapy may need to be deferred until the survivor has made sufficient progress in her individual therapy to allow her to shift her focus and her emotional energy to the more interpersonally difficult work required in couples therapy. Paper presented at the annual meeting of the American Psychological Association, Washington, DC. Sexual abuse trauma among professional women: Validating the Trauma Symptom Checklist-40 (TSC-40). Sexual abuse in a na- tional survey of adult men and women: Prevalence, characteristics, and risk factors. Spouse abuse: Assessing and treating battered women, batterers, and their children. Spouse abuse: Assessing and treating battered women, batterers, and their children (2nd ed. Empirical development of an MMPI subscale for the assessment of combat-related posttraumatic stress dis- orders. Perpetrator-victim relationship: Long-term effects of sexual abuse for men and women. When the wife was sexually abused as a child: Marital relations be- fore and during her therapy for abuse. Rage and women’s sexuality after childhood sexual abuse: A phenomenological study. The developing mind: How relationships and the brain interact to shape who we are. Sexual traumata among eating disordered, psy- chiatric, and normal female groups: Comparison of prevalence and defensive styles. Long-term psychological sequelae of child sexual abuse: The Los Angeles Epi- demiologic Catchment Area Study. Childhood molestation: Vari- ables related to differential impact on psychosexual functioning in adult women. CHAPTER 17 Working with Couples Who Have Experienced Physical Aggression Amy Holtzworth-Munroe, Kahni Clements, and Coreen Farris HE QUESTION OF whether or not conjoint couples therapy is an appro- priate intervention for couples experiencing physical aggression is a Tcontroversial one. For reasons outlined later in this chapter, some ex- perts believe that it is never appropriate to offer violent couples conjoint therapy. In contrast, other experts, including ourselves, are willing to try such interventions cautiously and have experienced some clinical advan- tages in doing so. First, although many couples seeking couples ther- apy have experienced physical aggression, most will not report this aggres- sion during the therapy intake unless they are explicitly asked about it; thus, therapists should assess every couple for the possible occurrence of physical aggression. In doing so, they should use methods likely to increase the reporting of aggression (e.