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Wilson (1985) states: I have observed this feature in the drawings of children from other countries with Islamic populations—Saudi Arabia order 160mg kamagra super free shipping impotence causes and cures, Qatar discount 160 mg kamagra super overnight delivery homemade erectile dysfunction pump, Turkey, Iran, India, and Kenya (although I have not determined the percentages). The feature oc- curs with such regularity that I have called it the Islamic torso. Thus, I took this into account when scor- ing and interpreting the final art product (Figure 3. Qualitative Analysis: Details House: (1) There is no chimney on either drawing, and this is in keep- ing with the patient’s culture, as homes in India do not possess chimneys; (2) the patient places a barlike emphasis on the door of the home in the second figure only (feelings of entrapment, inability to escape present liv- ing situation). Tree: A ground line exists under both trees, with the first being longer and bolder (insecurity in the environment). Person: (1) The first rendering contains a mouth, which is omitted in the second drawing. The omission could suggest the patient’s ongoing dif- ficulty in relating to others due to the language barrier rather than intel- lectual deterioration. Qualitative Analysis: Proportion House: The home is the smallest item in the first drawing and is even smaller in the second (sees, feels, views his family connections as far away in relation to his present environment). Tree: The tree is very large in comparison to the page in the second drawing (feels constricted by and in the environment). Person: The person is drawn large in both drawings but is further away (spatial distance) from the home in the second rendering and devoid of a 140 Interpreting the Art mouth (feelings of helplessness and frustration produced by a restricting environment and physical distance from his home and family). Qualitative Analysis: Perspective House: The house in the second drawing is shown from a bird’s-eye view and appears far away (rejection of the home situation; however, due to bars on door, may instead indicate a rejection of his present circum- stances). Qualitative Analysis: Comments, Postdrawing Inquiry Rather than asking the formal questions designed by Buck, I adminis- tered the shortened version (for the second drawing only) and requested that the client tell me "what’s going on in this picture? When questioned about the man’s age, he said he is 43 years old and that his fam- ily lives in the house. When asked to give the drawing a title or name, he decided to title it "Village Town," which I wrote out (on the left) and which he copied in his own hand. Qualitative Analysis: Concepts House: The perspective and spatial distance of the house from the per- son indicates that in the first rendering the patient may have had more hope for a return to his community and family, while in the second draw- ing the home is obviously dwarfed by the present circumstances and literal distances. Tree: In the second drawing the tree is extremely large as well as sepa- rating home and person. Person: Assigning the role of doctor to the person in the second draw- ing is an interesting mixture of hope for renewal (the doctor has always provided well for the client in the past) and trepidation as the client’s pres- ent circumstances place him in the position of having to trust unknown professionals. The lack of mouth may symbolize not only the client’s grow- ing frustration due to the language barrier but also the family doctor’s lack of input into the patient’s treatment. In addition, a row of buttons is nor- mal in drawings by Western children until the age of 7 or 8 but afterwards comes to symbolize feelings of inadequacy or dependency. Additionally, the midline that separates the trunk vertically "is frequently seen in schiz- 141 Reading Between the Lines oid or schizophrenic individuals whose physical inferiority and mother dependence are in the forefront" (Machover, 1949, p. Although the meaning of this may differ in other cultures, it is interesting to note that it is the second drawing that contains references to dependency and not the first. Story: The title of the drawing, "Village Town," may represent a combi- nation of two cultures, with the village suggesting India and the town in- dicating America. It is apparent from this titling that the traditional bonds of family and community remain strong. Qualitative Analysis: Summary As noted under cultural considerations, the art of select Islamic coun- tries is typically different from its Western counterpart. In addition, due to the patient’s initial drawing of the mouth, I gave him credit despite its subse- quent omission, as I consider the exclusion to be due to his increased frus- tration with his inability to communicate and therefore not an indication of pathology. His good IQ score correlates to an IQ of 85 and represents his abil- ity to interact in his environment, with a flaw IQ score of 85. An overview of his detail, proportion, and perspective scores represents an overall stability of functioning with the exception of his perspective good score, which is a measure of insight. This low score coupled with the low score in the proportion flaw indicates difficulty surrounding critical judg- ment in the more basic problems presented within the environment. The patient’s lowest overall scores appear in the drawing of the person, which expresses a significantly low degree of functioning with regard to interper- sonal relationships. Evaluation of his HTP reveals the presence of the following character- istics: (1) feelings of entrapment, helplessness, frustration, and insecurity produced by a restricting environment; (2) a conviction that his family connections are far away and possibly unattainable in relation to his pres- ent environment; (3) a growing despondency and dependency. In conclusion, the patient, estranged from the traditional systems of se- curity previously rooted in his family system, is experiencing increased feelings of inadequacy, despondency, and helplessness. However, as outlined earlier, this modified version can still yield accurate data when combined with Buck’s scoring system for ap- titude and intelligence.

As a conse- colon buy discount kamagra super 160 mg online erectile dysfunction medication options, and rectum increased more rapidly among patients quence discount kamagra super 160 mg online erectile dysfunction at 25, emergency surgery may become necessary at over age 75 than in those younger than 55 (Fig. For some point in the future when reserves are further com- cancers that required extensive surgery and for those promised. Operative mortality and morbidity increase at from which survival is poor even with surgery, there was least threefold when surgery is performed under emer- less of a change, even for early-stage disease (Fig. In a series of 42 operative proce- appropriate decision making based on the overall health dures in 31 men and women over age 100 years, all the of the patient and the patient’s preference for treatment perioperative deaths occurred in patients requiring emer- or a consequence of unfounded age bias. With age 65 has increased, attitudes toward surgery in older the question of "can we operate? To answer this question, we must understand the portion of all operations performed in which the patient goals and expectations of treatment in the context of the is over age 65 has increased from 19% in 1980 to 36% in individual patient. Common operations performed on elderly be provided with excellent results in a cost-effective patients. Total patients Patients Percent In the recent debates over containing rising health care Operation (¥1000) of age >65 (%) costs, this latter consideration has gained attention. The Coronary bypass 553 304 55 efficacy and cost-efficiency of major surgery as a treat- Total joint replacement 426 286 67 ment modality for the elderly is demonstrated in a recent Open reduction and 416 184 44 study of coronary artery bypass surgery versus medical Internal fixation management in octogenarians. Outcome was assessed in Cholecystectomy 438 165 38 4 terms of cost and quality life-year survival. The cost of Large bowel resection 242 146 60 Lysis of adhesions 310 87 27 surgical care per quality life-year saved was only $10,424, Appendectomy 278 16 5 less than the cost for many common procedures such 2 as screening mammography. Using a validated health status assessment Mortality and Morbidity 5 tool, the EurQol Questionnaire, the authors assessed the For surgeons, the traditional measures of outcome have quality of life in five domains: pain, activity, mobility, self- always been postoperative mortality and morbidity, with care, and depression/anxiety. In all areas, quality of life mortality used as the endpoint in the determination was better in the surgically treated than in the medically of "operative risk. Quality of life in the group of 80-year-old restoration of functional capacity to at least the preoper- patients who selected Coronary Artery Bypass Grafting ative level and quality of life may be far more important (CABG) was found to be equal to that of an average considerations than survival alone. However, when a complication improve functional outcome, as are coronary revascular- occurs, the elderly are far less able to muster the reserves ization and joint replacement, are not yet abundant. Strategies to improve surgical care for the traditional data on operative outcomes of mortality and elderly, therefore, should be designed to identify and morbidity. Chapter 20 details the essential ative mortality over the past several decades, from 10% to 25% in the 1960s to less than 5% in 1990s. Series of this kind are primarily retro- tion to the details described therein, surgical care can spective with a wide variety of procedures from a wide Figure 22. Temporal and regional variations in the percent of 1986–1991; squares, patients over 75 years of age; circles, patients treated surgically for rectal cancer (left) and breast patients under 55 years of age. Surgical Approaches to the Geriatric Patient 241 100 90 80 70 Colon 73–78 Colon 86–91 60 Stomach 73–78 Stomach 86–91 Lung 73–78 50 Lung 86–91 Pancreas 73–78 40 Pancreas 86–91 Breast 73–78 30 Breast 86–91 20 10 0 <55 55–64 65–74 75–84 >85 AGE IN YEARS Figure 22. Temporal variation in the percent of patient treated surgically for local stage cancer, with age. In one such study examining the results of open ology to allow comparison among of the patient groups cholecystectomy in the prelaparoscopic era in 21,000 for comorbidity and severity of illness. However, increasing imposed by comorbidity and other pre- and intraopera- comorbidity with age, rather than chronologic age alone, tive factors, can be found in the National VA Surgical was shown to be responsible for this effect. The study was Pathophysiologic Considerations designed to provide risk-adjusted mortality and morbidity figures for the comparison of surgical care across institu- Aging influences surgical outcome in two major ways: tions in the VA Hospital system. At present,there are more first, because of the increased incidence of comorbid than 1 million cases enrolled in the database. Although this disease, and second, because of changes in the presenta- study was not designed to look at older patients specifi- cally,nearly half the patients are over age 65 because of the nature of the VA population. Effect of age and comorbidity on mortality from to obtain age-specific data are presently underway. From 1991 to 1999, overall postoperative mortality in Mortality (%) the NSQIP population has fallen from 3. Risk-adjusted complications rates as a function of Comorbid index age are not yet available; however, it is likely that this 0 1. Inactivity 70 was defined in this study as the inability to leave the home by one’s own effort at least twice 60 at week.

On the other hand generic kamagra super 160mg overnight delivery erectile dysfunction fertility treatment, all of the findings could be explained by something interfering with normal function of the right sciatic nerve kamagra super 160 mg visa erectile dysfunction treatment in mumbai, as commonly seen with TMS. That nerve receives branches from spinal nerves lumbar 3, lumbar 4, lumbar 5, sacral 1 and sacral 2. Therefore, anything that disturbs the sciatic nerve may affect the parts of the leg supplied by any or all of those nerves, which was clearly the case with this patient. Her examination also revealed tenderness on pressure over The Traditional (Conventional) Diagnoses 103 all the muscles of the right buttock, which is where the sciatic nerve is located. This and other characteristic findings on physical testing established the diagnosis of TMS involving the right buttock and sciatic nerve; the herniated disc was an incidental finding of no significance. Such clinical discrepancies are common and make one wonder why they are not routinely discovered. So fixed are physicians on the herniated disc, the diagnosis is sometimes made solely on the basis of a history of simultaneous low back, buttock and leg pain, or even in the absence of leg pain, without benefit of a CT scan or MRI study. The diagnosis of herniated disc cannot be made clinically or even with plain X rays. If the latter are done, what is usually seen is narrowing of an intervertebral disc space, most frequently of the last two intervertebral spaces. At the last space this abnormality is almost universal beyond the age of twenty, as stated earlier. It means the disc has degenerated, and it is a perfectly normal part of the aging process. It may be tempting but is inadvisable to attribute symptoms to normal aging phenomena. In my experience, disc degeneration is no more pathological than graying hair or wrinkling skin. In recent years there have been numerous reports in the medical literature of herniated discs in patients with no history of back pain. They were discovered inadvertently on CT or MRI studies done to investigate other parts of the body. In fairness to an objective evaluation of the problem, it should be noted that in one statistical study there was a higher incidence of back pain historically in people with evidence of disc abnormalities. I have tried to reconcile this with the clear observation that it is TMS and not disc pathology that causes the pain and can only conclude that in the mysterious process by which the brain chooses a site for TMS it selects an area of “abnormality” (like disc herniation) even though the anatomical aberration may not be pathological. One hundred and nine patients were interviewed by telephone by a research assistant. Their names were selected randomly from a large population of patients who were seen and treated from one to three years previously. In each case pain was attributed to a herniated disc that could be seen on CT scan. Based on history and physical examination, the diagnosis was TMS; all went through the usual treatment program. The results were as follows: Free, or nearly free of pain, unrestricted physical activity................................... Yet each of these patients had been told that this was the reason for the pain; thirty-nine had been advised to have surgery; three had already had such surgery; and most of the rest had been told that surgery might be necessary if conservative measures failed. The patient was a twenty-five- year-old man with a history of low back and right leg pain; he had had a lumbar myelogram showing a herniated disc two months before I saw him in consultation. He was advised to stop all physical activity and surgery was recommended, both appropriate recommendations if the disc was the cause of the pain. A dedicated athlete (basketball and squash were his favorites), he was devastated by the diagnosis. He was further upset by the fact that he would no longer be able to “burn off” his tension through vigorous sports, and he saw himself as a very tense fellow. The Traditional (Conventional) Diagnoses 105 He decided against surgery and, with great trepidation, continued to work out in the gymnasium; he even played basketball occasionally. Though he got neither better nor worse, he lived in constant fear that he might really hurt himself.

Furtherm ore cheap kamagra super 160mg overnight delivery erectile dysfunction las vegas, a num ber of im portant m edical and param edical journals are not covered by M edline at all safe 160 mg kamagra super impotence uk. It is said that M edline lacks com prehensive references in the fields of psychology, m edical sociology, and non-clinical pharm acology. If you wish to broaden your search to other electronic databases, ask your local librarian where you could access the following. Available via a num ber of suppliers including Internet G rateful M ed (see below). Produced by the British Library, available from a num ber of suppliers including Silver Platter or OVID. Includes a range of com m issioned review topics for the U K N H S Research and D evelopm ent D irectorate. Available via a num ber of software suppliers including OVID (see reference list). It covers psychology, psychiatry and related subjects; journals are included from 1974 and books from 1987 (English language only). Available through several software com panies (see reference list) along with M edline. U seful for finding follow up work done on a key article and for tracking down the addresses of authors. Querying a num ber of key databases, such as M edline, Cochrane abstracts and D ARE (see above), SUM Search aim s to select the m ost appropriate source, form at the search query, m odify this query if too few or too m any hits are found, and return a single docum ent to the clinician. Covers a range of journals on health, health m anagem ent, health econom ics, and social sciences. This is indeed the case, and the Cochrane Library now boasts several hundred system atic reviews and hundreds of thousands of peer reviewed sum m aries of random ised controlled trials. In 1972, epidem iologist Archie Cochrane called for the establishm ent of a central international register of clinical trials. H is book Effectiveness and efficiency15 caused little reaction at the tim e but captures the essence of today’s evidence based m edicine m ovem ent. The Cochrane Library also includes two "m etadatabases" (the Cochrane D atabase of System atic Reviews and the D atabase of Abstracts of Reviews of Effectiveness) and a fourth database on the science of research synthesis (the Cochrane Review M ethodology D atabase). Published articles are entered on to the Cochrane databases by m em bers of the Cochrane Collaboration,16 an international network of (m ostly) m edically qualified volunteers who each take on the handsearching of a particular clinical journal back to the very first issue. U sing strict m ethodological criteria, the handsearchers classify each article according to publication type (random ised trial, other controlled clinical trial, epidem iological survey, and so on), and prepare structured abstracts in house style. The Collaboration has already identified around 60 000 trials that had not been appropriately tagged in M edline. All the Cochrane databases are in user friendly W indows style form at with a search facility very sim ilar to that used in the com m on M edline packages. N um erical data in overviews are presented in a standardised graphics way to allow busy clinicians to assess their relevance quickly and objectively. In 1997 som e of the founder m em bers of the Cochrane Collaboration published a com pilation of articles reflecting on Cochrane’s original vision and the projects that have em erged from it. G eneral practitioners’ perceptions of the route to evidence based m edicine: a questionnaire study. Cross sectional survey of cervical cancer screening in wom en with learning disability. Severity of osteopenia in estrogen- deficient wom en with anorexia nervosa and hypothalam ic am enorrhea. Com pleteness of reporting of trials published in languages other than English: im plications for conduct and reporting of system atic reviews. The Cochrane Collaboration: preparing, m aintaining, and dissem inating system atic reviews of the effects of health care. In 1979, the editor of the British Medical Journal, D r Stephen Lock, wrote "Few things are m ore dispiriting to a m edical editor than having to reject a paper based on a good idea but with irrem ediable flaws in the m ethods used". M ost papers appearing in m edical journals these days are presented m ore or less in standard IM RAD form at: Introduction (why the authors decided to do this particular piece of research), M ethods (how they did it and how they chose to analyse their results), Results (what they found), and D iscussion (what they think the results mean). If you are deciding whether a paper is worth reading, you should do so on the design of the m ethods section and not on the interest value of the hypothesis, the nature or potential im pact of the results or the speculation in the discussion.