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He drew the female first (possible difficulty in establishing a mascu- line identity) purchase viagra plus 400mg with mastercard erectile dysfunction after radiation treatment for prostate cancer. The female was drawn in nine colors and the male in six colors (inability to exercise self-control and restraint over emotional impulses) 400mg viagra plus with amex erectile dysfunction zyprexa. Although both heads have overemphasized hair (overthinking, anxiety, fantasy), the female drawing has multiple reinforcements with regard to color and aggressive line quality. The female has tiny half-moon eyes, a squiggly mouth, and bushy eyebrows (uninhibited), with no neck (body drives threaten to overwhelm, regressive). The body is multicolored 120 Interpreting the Art with an exceptionally heavy trunk (confusion of physical power, mater- nal symbol), a small waistline, long arms, oversized hands (hostility), tiny sticklike legs with knobby knees or joints (faulty and uncertain sense of body integrity), feet drawn like hands, and a transparency in the feet (pathological aggressiveness) with large clunky shoes that feature aggres- sive detailing. The client drew squiggles that look like knife slashes on the forearms, thighs, and chest area, as well as the bottom of the dress leading toward the genitalia. He worked quickly on this image and drew the head and face last (disturbance in interpersonal relation- ships). The image is drawn with angular strokes (masculine), as compared to the first image, which is rounded. The hair is again prolific (virility striv- ings), the eyes are closed (not wanting to see), the mouth is drawn in a heavy slash like a "V" (verbally aggressive, sadistic personality), and the nose is drawn in the same manner. There is no neck; the trunk is large (un- satisfied drives) and the hands are in proportion, but the left has pointy fin- gers (aggressive) and the arms are excessively long and thin (weakness and futility). He has drawn pockets on the pants and shirt front (dependency issues, infantile, maternal deprivation). The legs are exceedingly thin, with long feet (striving for virility) and no transparency; the shoes are decorated high-tops (impotence). The "knife slash" squiggles appear on the male also, but not in such proliferation. The lack of postdrawing inquiry, though unfortunate, does not hin- der the interpretation: The clinical interview that preceded the art projec- tive will serve as a guide. From a structural perspective this patient exhibits not only a sense of grandiosity and egocentricity but poor inner controls and restraint over his impulses. His initial reluctance to complete the task (evident in the stick figure) with concomitant redirecting yielded a hostile response in the drawing of his initial figure (female) with a much less regressive rendering for his male figure. In addition, the drawings show excessive diffi- culty in coping with environmental stressors. From a formal perspective this patient both denigrates women and yearns for a maternal figure that will meet his needs. This infantile de- pendency takes the form of hostile reactions when he feels deprived or dis- missed. His multiple assaults revolve around not only these dependency is- sues but also his confused sense of manhood, his virility strivings, and power, which is tied into maternal symbols. He feels futile and weak when 121 Reading Between the Lines compared to females and attempts to stave this off through verbal aggres- sion and intellectual defenses. His history shows that he became excessively hostile after the birth of his first child and was verbally threatening toward a mother and her children. These issues, coupled with his emotional dependence on women and his mental illness, make him pathologically aggressive toward others (espe- cially women) whom he views as thwarting his needs. In addition, signifi- cant signs of psychotic decompensation appear in the regressive features, joint emphasis, transparency, unusual coloring, and distorted body parts. In the final analysis, due to this patient’s propensity toward coping with environmental stress with either ambivalence or violence together with psychotic decompensation, the prognosis for this patient is poor. When discussing his family, he spoke briefly of the loss of his father and mentioned a younger sister. The patient was charged with making terrorist threats after having made multiple phone calls to his girlfriend. Since early adulthood he has been treated for Bipo- lar disorder, and he describes his illness as follows: "I believe I have a par- tial mental illness. He spoke in a ram- bling manner about his extensive substance use and his prison terms and verified that his relationship with his mother was symbiotic in nature. His appearance was neat, his attitude was friendly and cooperative, his motor activity was restless, and his affect was mood congruent. The men- tal status exam showed concrete thinking in response to similarities, with a fair fund of knowledge. To the proverb "Even a dragon that walks along the river has small fish biting its tail" he replied, "Even the poor little folks are trying to keep up with the big folks. He drew both figures on the lower left side of the page (seeks immediate and emotional satisfaction, over-concern with self and past). The male stands five and one-quarter inches high (normal height) while the female stands four and three-quarters inches high (environment experienced as overwhelming).

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This next section focuses more closely on the setting of target zones or exercise heart rates (Table 3 buy 400mg viagra plus amex erectile dysfunction causes relationship problems. The effective threshold for attaining beneficial physiological adaptations cheap 400mg viagra plus free shipping erectile dysfunction icd 9 2014, which is linked to the patient’s training status. The training status influences the heart rate relationship with both %VO2max and the ‘lactate threshold’. THE SAFE HEART RATE Before considering the target heart rate from a physiological training per- spective, the safe exercise HR has to be regarded as the prime governor to the upper limit of exercise (Coplan, et al. This specifically refers to the heart rate at which medically significant myocardial events can occur (e. Based on evidence for individuals with silent myocardial ischaemia (Hoberg, et al. Recommended aerobic exercise intensities relative to the percentage of maximal oxygen uptake (%VO2max), maximal heart rate reserve (%HRRmax) and maximal heart rate (%HRmax) Guideline ACSM (1994, 2000) BACR (1995), SIGN (2002) %VO2max* 40%–85% 40%–60%** %HRRmax 40%–85% 40%–60%** %HRmax 55%–90% 60%–75%** *The term VO2max is used in this case for reasons of simplicity but it must be noted that guidelines vary in the use of VO2peak or maximal VO2reserve. Exercise Physiology and Monitoring of Exercise 55 the upper HR limit should be set at least 10 beats·min-1 below the level asso- ciated with myocardial dysfunction. In patients who do get typical symptoms that relate to ischaemia or cardiac output dysfunction (angina and breath- lessness, respectively), it is possible that these symptoms could arise at a point higher than the actual onset of the clinically measured significant change. Hence, it would be unwise to use these symptoms as a reference point for determining the upper HR training limit. It is therefore important first to acknowledge the safe heart rate limit, relative to the effective physiological training HR limits, as outlined in Table 3. The beneficial target heart rate Beneficial HR target selection and progression assumes that the patient has developed the skill and confidence to exercise at these recommended intensi- ties. The target range for the recommended physiologically effective heart rate, as summarised in Table 3. The more training an individual has done, from the perspective of frequency (times per week) and longevity (>4 weeks), the greater the per- centage of maximum (HR, HRR or VO2) at which that individual will need to work in order to gain further benefits (Ekblom, et al. This leads to the concept of considering intensity progression relative to both work rate and heart rate. Progression of exercise intensity and heart rate This section provides the rationale for using the recommended target heart rates summarised in Table 3. The sedentary patient is thus prescribed exercise starting at the low end of the recommended heart rate range. Over the course of the first three to six months of exercise the patient should progress the intensity to elicit heart rates in the middle of the range. In the longer term, if the patient continues to exercise regularly, they could progress to the higher end of the target heart rate zone. All of this assumes that these targets are 10 beats·min-1 below the clinically significant heart rate as described in the section on the safe heart rate. The need for later progres- sions in exercise intensity provides an important rationale for having qualified exercise advisors available to patients in phase IV CR. This type of exercise leader is available to discuss with the patient appropriate changes to their exercise regime in the longer term. Exercise leaders should be aware that target heart rates can be adjusted in the future. It is not incorrect to assume that the progression of intensity will automatically occur if the patient exercises to the same given heart rate; the work rate for a given heart rate will increase as fitness improves. However, this assumption only reflects 56 Exercise Leadership in Cardiac Rehabilitation one of the two main training adaptations to regular aerobic exercise: an increase in VO2max. The other physiological adaptation, as shown clearly in three studies involving cardiac patients, is that with training, individuals can sustain exercise at a higher proportion (percentage) of their VO2max (Sullivan, et al. In these three studies, this phenomenon was closely allied to the amount of lactic acid pro- duced at a given VO2,aphenomenon which has been known for many years (Edwards, et al. The importance of this is that improvements in aerobic power (VO2max) and endurance capacity (the inten- sity at the lactate threshold) in cardiac patients, compared to healthy individ- uals, is mostly due to the adaptations of skeletal muscle and not of the myocardium (Hiatt, 1991). Because the key agent in increasing VO2max in cardiac patients is skeletal muscle, it is important to ensure that this tissue is challenged as effectively as possible. This is even more apparent in the train- ing adaptations of the older or heart failure patient (Sullivan, et al. HEART RATE, MYOCARDIAL STRAIN AND PERFORMANCE There is a direct link between HR and myocardial strain, performance and dysfunction. However, the contractility of the myocardium is also a function of the stroke volume that results from the heart wall tension produced during diastole and the force of contraction during systole. It is both the rate and force of contraction of the myocardium that determine the oxygen demand or uptake (MVO2) of the heart (Froelicher and Myers, 2000).

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Video conferencing 400mg viagra plus erectile dysfunction young, which allows the presentation of many types of visual and audio information via videocameras quality viagra plus 400mg erectile dysfunction frequency age, microphones, and display stations. Pictorial information can be sent as an image, for example, a digital x-ray is displayed on a screen and imaged by the camera rather than being transmitted in its native format. There are re®nements, including digitizing whiteboards whose contents may be transmitted at the touch of a button. High-quality videoconferencing requires dedicated high bandwidth links, whereas slow-scan video can work satisfactorily over two 64 Kb/s ISDN B-channel links. Data conferencing allows participants to manipulate shared data in real time, typically in conjunction with voice conferencing. Each has control of a cursor, which moves simultaneously on both the local and remote displays. Document conferencing assumes that all participants are supplied with a copy of the conference documents (e. Telecollaboration could be thought of as conferencing using basic Web- based tools such as e-mail, newsgroups, and links to educational databases (Fig. However, the real bene®t of telemedicine is that more that one practitioner can telecollaborate (e. Cooltalk has a shared whiteboard, has talk facilities, and can even be combined with videoconferencing facilities. The shared whiteboard can be used to view and annotate the same image simultaneously on two Web-connected workstations, facilitating the tele-aspect of telemedicine (Fig. Java could also be used to manipulate the VRML models, performing tasks such as intersection and measurement analysis, as shown in Figure 3. Java is platform independent; therefore, the developed applets could run on any 86 VIRTUAL REALITY AND ITS INTEGRATION INTO A TWENTY-FIRST CENTURY Figure 3. An example of the same applet, a region-growing algorithm, running on two di¨erent platforms is shown in Figures 3. A Java applet could be used to reconstruct the VRML representation from MRI images, as shown in Figure 3. These models could be fused to produce a new model whereby the movement of the endocardium is denoted by color (Fig. The 3-D and 4-D models generated by the Java programs should be augmented so they can be viewed by VR techniques. The interaction could be in the form of surgery planning and surgery assistance, making use of VR techniques, such as VRASP developed at the Mayo Clinic. The prediction aspect includes medical physics for determining blood ¯ow analysis and tumor growth. This should be provided either by a connection from a hospital to a computing site or by using the hospital computers in a collaborative network. It is envisaged that a meta-computing environment will be made available for a variety of medical applications. The idea of 88 VIRTUAL REALITY AND ITS INTEGRATION INTO A TWENTY-FIRST CENTURY Figure 3. Generally, this is much longer than can be cost- e¨ectively supported by the technologies used in the on-line storage system. If a PACS should provide digital archival it must be decided how many images should be made accessible. Since any archive system will in principle over¯ow in time most systems provide for an on-line and an o¨-line archive. In terms of an optical disk jukebox, on-line pallets are those located on a shelf in a storeroom, ready to be manually inserted in the jukebox on request. Studies have shown that `10% of images are accessed ever again after the ®rst year. The example study showed the storage requirements in a general hospital over a 1-year period. Taking into consideration time depth and storage capacity, the requirements of an archival system might read as follows: 3. Average annual Storage Requirements MB/year Annual Images/ KB/ MB/ without Modality Procedure Volume Study Image Study Compression Radiography Chest 1 view 37,500 1 7,500 7. Diagnostic Requests per Image for Seriously Ill Patients Timing First 3 days of hospital stay 10 Next 6 days of hospital stay 4 Rest of ®rst year 3 Outpatient studies 2 PACS operational load Initial acquisition 1 QC/examination veri®cation 1 Initial archival 1 Dearchivals 5 Total number of request per image 27 1. The system shall include su½cient on-line archive storage to provide ac- cess to at least 2 years of image production without manual intervention by a human operator. Accessibility can be satis®ed by requiring a human operator to inset storage media into the system. If a human operator is requested to upload an archival system, it shall automatically provide instructions identifying the location of the media involved and the action to be performed.

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As the relationship evolves beyond the ro- mantic first stage of love best viagra plus 400mg erectile dysfunction at age 26, problems can appear cheap viagra plus 400 mg online impotence aids. She has written an excellent book called The Ageless Self (1986), which gives valuable guidelines on how to understand people and the difference between a clinical history and a life story. One strategy she emphasizes (in improving people’s lives) is the concept of the minimal inter- ference principle. This principle says that a good therapist (who works with individuals, families, or couples) listens to a life story (or life episodes) in a personal way. The wise therapist needs to understand: • Who they have been • Who they feel they are now • How they have navigated their life’s journey • Who they have become in their relationship Kaufman also developed an interview format that emphasizes a life story in contrast to a clinical history. The life story may be a better reflection of the self than a clinical conceptualization. A crucial principle is that intimacy is a balance of control and vulnerability in a committed relationship. Both partners need to influence the relationship; to be able to get their own needs met, yet still sustain a climate where it is safe to be vulnerable. Intimacy is a balance of commitment, influence, and the safety to make one’s needs known and honored. A poignant quote by George Bernard Shaw sug- gests, "If two people agree on everything, one of them is unnecessary. The psychologist Rollo May in The Courage to Create (1975), suggested that cre- ativity in art, literature, and music is also a balance of form and passion. Loving relationships must balance form and passion (guided by sincere commitment) in order for a relationship to stay vital. When counseling cou- ples, relationships may need change if a relationship has become stagnant. In a way, relationships (or movies that portray them) are another example of Rollo May’s notion (1975) that creativity is a balance of form and passion. The fascinating parallel is that re- lationships (like art) are a balance of passion, form, and commitment. The form of a loving relationship, and the ingredients of commitment and pas- sion, parallel the core of creativity. Each person in a loving relationship con- tributes to make the couple vital as well as committed. Once again, this principle of growth, commitment, and passion provides a background in which both people continue to shape and influence the relationship. Other experts on life stages have built on Erikson’s work to give more in- sight into ways women’s development may vary from men’s. Building on her earlier explanations, Josselson and Lieblich (1993) have described the narra- tive study of lives. In addition, they offer techniques on how to listen to, and understand people’s life stories. The fabric of these life stories merge (or sometimes collide) in loving relationships. However, as relationships evolve, they go through periods of tension, which can lead to change or accommo- dation. The tough task for an artist, a couple, or a therapist is knowing when to stabilize and when to change. With older couples this may involve the evolution (or in bad times, devolution) of their relationship. THERAPY APPLICATION, UNDERCURRENTS, AND STRATEGIES What considerations are important for therapists working with older adults? Older adults have much to tell us as we help them navigate both their past and future. Add the request of "What have been your experiences—good and bad—in past relations? The couple’s individual or shared history of life challenges, losses, and growth are important to ad- dress. We only want to make the changes that are needed, while building on past strengths. A couple saw this quote in the author’s office and asked, "How’s one success out of three? Therapists with older adults must also understand health care sys- tems, insurance configurations, and interaction of medical problems with Therapy with Older Couples: Love Stories 83 psychological and spiritual dimensions. The reader is encouraged to read Setting Limits: Medical Goals in an Aging Society (Callahan, 1995). Callahan clarifies the forces that shape ethics (or lack thereof) and policy in health care.

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The relapse prevention model was developed to treat addic- tive behaviours buy viagra plus 400 mg on line latest advances in erectile dysfunction treatment, such as alcoholism and smoking (Marlatt and Gordon purchase 400 mg viagra plus otc erectile dysfunction doctor in philadelphia, 1985). The model proposes that relapse may result from an individual’s inability to cope with situations that pose a risk of return to the previous behaviour. For example, a former smoker finds himself or herself in a social situation with lots of smokers and is tempted to smoke. Thus, helping the individual to acquire strategies to cope with high-risk situations will both reduce the risk of an initial lapse and prevent any lapse from escalating into a total relapse. Simkin and Gross (1994) assessed coping responses to high-risk situations for exercise relapse (e. The study found that 66% of par- ticipants experienced a lapse (defined as not exercising for one week) and 41% experienced a relapse (defined as not exercising for three or more consecu- tive weeks) over the 14 monitored weeks. Participants who experienced a relapse reported significantly fewer behavioural and cognitive strategies to cope with high-risk situations, compared to participants who did not relapse. These findings suggest that acquiring effective strategies to cope with high-risk situations may prevent relapse. Relapse prevention training (Simkin and Gross, 1994) involves teaching individuals that a lapse from exercising (e. The individual is encouraged to identify situations that are likely to cause a lapse. Potential high-risk situations relevant to exercise can include bad weather, an increase in work commitments, change in routine, injury or illness. Individuals are encouraged to develop a plan to cope with these high- risk situations. For example, increased work commitments could be overcome by rescheduling an activity session or engaging in a shorter bout of activity. Studies have used relapse prevention strategies to improve exercise adher- ence in the general population (King and Fredrickson, 1984; Belisle, et al. Description of how each component of the TTM is addressed during exercise consultation Component of Exercise Consultation Description of Strategy TTM Strategy Decisional balance Decisional balance table Perceived pros and cons of being active Self-efficacy Exploring activity options Providing realistic and setting goals opportunities for success and achievement Experiential Processes Consciousness raising Decisional balance table Providing information about the benefits of physical activity and discuss the current physical activity recommendations Dramatic relief Decisional balance table Discussing the risks of inactivity Environmental Decisional balance table Emphasise the social and reevaluation environmental benefits of physical activity Self-reevaluation Review current physical Review current physical activity status and assess activity status and assess values related to physical values related to physical activity activity Social liberation Exploring suitable activity Raise awareness of options potential opportunities to be active and discuss how acceptable and available they are to the individual Behavioural Processes Counterconditioning Exploring suitable activity Discussion of how to options substitute inactivity for more active options (e. Another study evaluated the effect of relapse prevention techniques to maintain physical activity for six months after completion of a six-month home-based exercise programme (King, et al. Fifty-one sub- jects were randomised either to receive strategies for improving exercise adherence, including daily self-monitoring of activity and relapse prevention, or to a comparison group who underwent weekly self-monitoring of activity. The intervention group engaged in significantly more exercise sessions over the six-month period, relative to the comparison group. Therefore, daily self- monitoring of activity levels and relapse prevention training is associated with exercise adherence. Overall, these behaviour change models have been used to understand exer- cise behaviour change in non-clinical and, to a lesser extent, in clinical popu- lations. These theories have identified factors influencing physical activity participation: exercise self-efficacy, perceived pros and cons, use of cognitive and behavioural processes and ability to cope with high-risk situations. In addi- tion, evidence suggests that interventions based on these models are effective in increasing and maintaining physical activity. CONDUCTING AN EXERCISE CONSULTATION In 1995, Loughlan and Mutrie published guidelines for health professionals on conducting an exercise consultation (Loughlan and Mutrie, 1995). However, more recently it has been adapted for use with clinical populations, including people with Type II diabetes and CR participants (Hughes, et al. This section describes the components involved in delivering the exer- cise consultation to cardiac rehabilitation participants. Counselling skills A key element of the intervention is that the consultation is client-centred, which means that individuals should consider their own reasons for being active and should choose their own activity goals. In addition, the activ- ity goals should be tailored to the individuals’ needs and lifestyle. Good inter- personal skills are essential, which consist of communication (verbal and non-verbal), active listening and expressing empathy. Active listening shows the individual that the consultant has listened care- fully and understands what he or she has said. Empathy involves showing individuals that you understand what it is like to be in their world. Empathy can be expressed using examples of other patients who have been in a similar situation to the individual. As the exercise consultation is a client-centred approach, the consultant should try to avoid preaching, lecturing or providing solutions for the client. The consultant can offer suggestions, such as how to overcome a certain barrier to activity, but this is best achieved by using examples of how other individuals overcame this barrier. Further information on the client-centred approach and the interpersonal skills involved in behaviour change coun- selling is provided in guidelines on exercise consultation (Loughlan and Mutrie, 1995), and there is also a variety of books on this topic (Rollnick, et al. COMPONENTS OF AN EXERCISE CONSULTATION Assessing stage of exercise behaviour change The consultation should begin by assessing the individual’s stage of exercise behaviour change in order to select the most appropriate strategies to use in the consultation. Those who have recently completed a phase III exercise programme are likely to be either regularly physically active (i. Contemplation I am not regularly active but am thinking about starting in the next 6 months.

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