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Overemphasis on the right side: avoidance of emotional satis- faction; looks toward intellectual satisfaction B malegra dxt plus 160 mg amex. Branches loop and curve in at ends: strong ruminative tenden- cies buy malegra dxt plus 160mg amex, introversion F purchase malegra dxt plus 160mg free shipping. Apples (very common in young children): dependency and oral needs 313 Appendix D H buy malegra dxt plus 160 mg. One-dimensional branches: possible organicity buy discount malegra dxt plus 160mg online, impotence, fu- tility, poor ego strength, inadequacy J. Small animal inside (common in children): ambivalence sur- rounding childbearing; obsessive guilt 314 315 316 APPENDIX F Sample Directives Introductory 1. Close your eyes and relax; when you are ready, open your eyes and look at your colors; now let a color pick you and draw on your paper. Draw or use clay to make a picture you feel strongly about (a person, place, or thing). Close your eyes and visualize a chasm, and design a way of crossing it, considering that you have every means at your disposal. Suppose that while you sleep tonight a miracle happens and all of your problems are completely solved. Hang up a piece of poster board and have the group choose one pic- ture to place in the center. Using the media, create a piece of work that shows how you see the group and your place in it. Have each person make a sym- bol for the self (game piece) and set a personal goal (treasure). As a team, the group decides on the obstacles for the game (mountains, rivers, monsters, etc. A sheet of butcher paper and cardboard are given to the entire group, and they create a game board and the 3-D obstacles. As the game begins, each group uses the same game board but responds to the other team’s questions when they encounter an obstacle. They move their game pieces individually, and the first person to arrive at an obstacle must wait for the team members to join him or her be- fore answering the question as a group. Once the question is an- swered properly, the group must decide how to overcome the obsta- cles and create solutions by using art supplies and building a way around/over. Variations: (1) Have questions already prepared; (2) Have the group earn or lose building materials in the quest to surmount ob- stacles; (3) Give the group building materials at the beginning of the game to use as a team; they must continue to use only these to surmount obstacles. Members pass the drawing and on another sheet of paper draw a friend for the animal. The drawings go back to original owner, who adds anything he or she wishes to the cut-out drawings. Create the face you present to new people you meet on one side of the bag and the face you would like to present on the other side. Variations: (1) The "me" others see and (on other side) the real "me"; (2) how the world sees you/how you see yourself. Use collage to depict family, friends, and others with whom you have left something unsaid. Select and paste pictures of people, then write down what they are thinking and saying. On one side draw what peace looks like, on the next draw a trouble, on the third draw trust, and on the last draw anything you please. Give each group member a box and have them decorate the outside 320 Sample Directives showing "who you are. Make three separate drawings: one of you at the beginning of group or before group started; one of you during the group; and one of you presently. Make a drawing that represents another group member at the be- ginning and ending of the group. Draw what you’ve liked most about this group, what you’ve liked least about this group, or one final gift you’d like to give to someone in this group. Draw something that you would like to give to [name of person leav- ing] to help him or her be successful. Working together, combine your efforts to make a visual tribute to someone who is leaving (or has left). Offer each group member a sheet of butcher paper; have them pro- duce a cartoon strip showing significant events in their lives. Variation: Write a continuous piece of prose about your life, and se- lect a significant image from your writing and draw it.

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Page headers and their text and link buttons with anchors for accessing any resources can be entered buy 160mg malegra dxt plus with amex. The Lesson Editor generates an ASCII ®le that can also be further modi®ed using any text editor malegra dxt plus 160mg amex. An expanding list of Xresources can be used to specify changes to user interface characteristics such as color buy malegra dxt plus 160mg without a prescription, size discount malegra dxt plus 160mg without a prescription, position order malegra dxt plus 160mg on line, device baud rate, and communications port without the need to recompile the application. Facet can also be extended to support any type of input/output (I/O) devices and their associated device drivers via shared objects loaded at run time. This simple ASCII ®le speci®es user-interface commands as event de®nitions associated with command-to-action mappings. Commands global to the appli- cation may therefore be implemented equivalently by several distinct device drivers. Device drivers are well encapsulated so that the addition of new devices as well as modi®cations to existing device commands are easily made. Another means of extending Facet is through the addition of customized blocks and tools, which inherit core Block and tool functionality as prescribed by Facet. These new blocks and tools are also created as dynamically shared objects that are loaded into the application at run time, freeing the need to recompile the application when any changes or additions are made. Using blocks with events allows VisualizeR to ¯exibly associate contextually appropriate interaction, display characteristics, and behaviors with extensible lesson content, while letting Facet maintain control of the visual display. This approach has been successful in providing core capabilities while allowing the application to evolve both functional capabilities and layout organization. Faster hardware con®gurations support higher frame rates and greater numbers of concurrently loaded 3-D models. Dual processors available on some of these con®gurations have been found to signi®cantly enhance performance by en- 216 ANATOMIC VISUALIZER abling the separate device I/O and graphics rendering threads to be processed in parallel. Speci®c frame rates depend on multiple factors, including the number of polygons in models and model sets and the choice of monoscopic or stereo- scopic display. Currently, three visual display con®gurations are supported: monoscopic CRT, stereoscopic CRT using StereoGraphics CrystalEyes eye- wear, and stereoscopic Virtual Research V6 or nVision Datavisor VGA head- mounted displays (HMDs). Hand- and head-motion tracking is provided using Ascension Flock of Birds trackers. Hand position information from the Ascen- sion trackers, when combined with hand pinches or gestures allow the user to grab any block and move it within the VE. Application menu bars that appear in the VE organize interface options for user interaction. Location of menu bars as well as di¨erent gestures and motions are being evaluated for their ease of use. Consequently its primary curricular use has been as a teaching/visualization tool in lecture. In 1999, a lecture on the anatomy of the human ear was also delivered to the UCSD medical students using this application. On each of these occa- sions, the corresponding Anatomic VisualizeR±based learning module was made available for individual and small group sessions on a voluntary basis and was used by more than 50% of the class. Anatomic VisualizeR made its curricular debut outside UCSD in fall 1999 when it was used for the teaching of two graduate-level nursing anatomy lec- tures at the Uniformed Services University of the Health Sciences (USUHS), in Bethesda, Maryland. USUHS is currently running the only — version of Visu- alizeR outside of the LRC and will be jointly developing other VR-based anatomy lessons. Anatomic VisualizeR has also been used to develop anatomy learning modules aimed at a high school student population. This pilot project, undertaken in 1998±1999, brought more than 30 senior high school students to the LRC for two half-day sessions using a lesson co-authored by their anatomy teacher. Both the USUHS and high school experiences have reinforced the necessity of porting the VisualizeR application to a platform (e. This is a necessary next step in the evolution of VisualizeR from a research project to application capable of running on student workstations. To do so, the issues that are being addressed include the development environment, the 3-D graphics API, the Unix operating behaviors (e. Other near-term e¨orts are being directed at the development of new VR-based learning modules for use at USUHS and UCSD. In addition, UCSD is also working with the USUHS faculty to explore the pedagogical issues pertaining to teaching and learning with virtual environments.

The manufacturing process used for the commercial products is more rigorous than that used at most blood bank facilities in preparation of nonautologous cryoprecipitate discount malegra dxt plus 160 mg amex. The disadvantage of Fibrin Glue Patch 329 the commercial product is the higher cost if a large amount of fibrin glue is needed buy cheap malegra dxt plus 160 mg on line. Both blood-banked cryoprecipitate and the commercial fibrin glue have been administered percutaneously for treatment of postoperative dural tears and for treatment of PDPS and SIH generic malegra dxt plus 160 mg on line. Fibrin glue has been reported in a single case report to be successful in treating SIH that was unresponsive to two epidural blood patches buy 160 mg malegra dxt plus mastercard. The fibrin patch may be used in patients with CSF hypo- volemia who have concurrent HIV infection purchase malegra dxt plus 160mg with visa, leukemia, severe anemia, or lack of venous access. A fibrin glue patch can also be considered in patients who have persistent CSF hypovolemia symptoms despite epidural blood patching. Fibrin glue has greater adhesive strength than a blood patch, and there is no risk of injecting blood into the sub- arachnoid space. Fibrin glue is probably a better treatment for post- surgical dural tears than EBP. Transient fever and headache after fibrin patch were described in one patient and may be indicative of aseptic meningitis. The pa- tient should be informed that he or she will be receiving a blood prod- uct. Some hospitals may have a separate consent form for patients who are about to receive blood products. There is a rare potential risk of vi- ral transmission, although this has not been reported in connection with fibrin glue patches. Prophylactic fibrin glue injection for prevention of CSF leak has been studied in an animal and an in vitro model, but there are no published human studies. Fibrin Patch Technique A CT-guided fibrin patch may be successful in treating postlaminec- tomy headache secondary to dural tear (Figure 17. MRI may be help- ful to help identify and characterize the site of the tear and the extent of pseudomeningocele formation (Figure 17. CT guidance can then be used to drain the pseudomeningocele and patch the tear at the same time, thereby saving the patient from a major repeat surgery. Most spine surgeons dread such a complication and are grateful for this serv- ice. The fibrin patch can also be administered under fluoroscopic guid- ance by means of the same technique described for EBP. If frozen cryoprecipitate is to be used, the blood bank will need 30 minutes’ notice to allow time for thawing. Twenty thousand (20,000) units of thrombin is reconstituted in 10 mL of 10% calcium chloride solution and 0. The thrombin solution and cryoprecipitate are drawn up into sep- arate 3 mL Luer syringes. Equal volumes of thrombin and fibrinogen are then injected simultaneously by means of a three-way stopcock, through an 18-gauge spinal needle placed at the site of the suspected 330 Chapter 17 Epidural Blood and Fibrin Patches FIGURE 17. Axial image after percutaneous aspiration of the pseudomeningocele through an 18-gauge needle and application of fibrin glue patch through the same nee- dle. The commercial fibrin glue is usually stocked in hospital operating rooms, not in the hospital pharmacy. Tisseel and Hemaseel are actually the same product but packaged under the two different names by dif- ferent distributors. The commercial glue is available in vials of 2 or 5 mL, both of which reconstitute to make a slightly larger volume. The commercial glue comes as a kit comprising sealer protein concentrate (the main component is pooled human cryoprecipitate), fibrinolysis in- hibitor (bovine aprotinin) solution, thrombin (human), calcium chloride solution, and a double-barreled syringe with a common plunger. This plunger ensures that equal volumes of the two main components (fib- rinogen and thrombin) are drawn up separately but can be fed through a common needle for administration. Once the kit has been opened, the product must be used within 4 hours following reconstitution. By demon- strating the site of laminectomy and pseudomeningocele, MRI may be helpful in characterizing a postoperative CSF leak prior to intervention.

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Upon completion of the report for each disc studied generic malegra dxt plus 160mg mastercard, we add a state- ment regarding the patient’s general cooperation and pain tolerance observed during the procedure purchase malegra dxt plus 160 mg with amex. We also state whether malegra dxt plus 160mg amex, in our opin- ion 160 mg malegra dxt plus for sale, results of the study are or are not valid cheap 160 mg malegra dxt plus otc. Conclusion Discography has become an indispensable assessment tool to evaluate pain of spinal origin; no longer is it reserved for those who are fusion candidates. With the continuous evolution of spinal interventions and the growing recognition of discogenic pain as a major clinical problem, the demand for this procedure is certain to increase. Our experience has been that when discography is performed with appropriate clini- cal indication(s) by skilled, knowledgeable, and experienced procedu- ralists, it leads to improved clinical outcomes. Discography is a proce- dure ideally suited for interventional neuroradiologists, especially those who also interpret spinal imaging studies. High-intensity zone: a diagnostic sign of painful lum- bar disc on magnetic resonance imaging. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects: a prospective investigation. Vertebral end-plate (Modic) changes on lumbar spine MRI: correlation with pain reproduction at lum- bar discography. Normal magnetic resonance imaging and abnormal discography in lumbar disc disruption. The symptomatic lumbar disc in patients with low-back pain: magnetic resonance imaging appearances in both sympto- matic and control population. Predictive signs of discogenic lumbar pain on magnetic resonance imaging with discography correlation. Differentiating lumbar disc pro- trusions, disc bulges, and discs with normal contour but abnormal signal intensity. A correlation of cervical magnetic resonance imaging and discography/computed tomographic discograms. The value of lumbar spine mag- netic resonance imaging in the demonstration of annular tears. Lumbar disc high-intensity zone: correlation of magnetic resonance imaging and discography. Cervical discogenic pain: prospective correlation of magnetic resonance imaging and discography in asymptomatic subjects and pain sufferers. Schellhas KP, Garvey TA, Johnson BA, et al: Cervical diskography: analy- sis of provoked responses at C2-C3, C3-C4, and C4-C5. Interobserver reliability of de- tecting lumbar intervertebral disc high-intensity zone on magnetic reso- References 119 nance imaging and association of high-intensity zone with pain and an- nular disruption. Painful lumbar disc derangement: relevance of endplate abnormalities at MR imaging. Cervical discogenic syndrome: results of op- erative intervention in patients with positive discography. Thoracic discography in healthy individuals: a controlled prospective study of magnetic resonance imag- ing and discography in asymptomatic and symptomatic individuals. Painful adult thoracic Scheuermann’s disease: di- agnosis by discography and treatment by combined arthrodesis. The ability of pressure-controlled discography to predict surgical and nonsurgical outcomes. Position statement from the North American Spine Society Diagnostic and Therapeutic Committee. Reported pain during lumbar discography as a function of annular ruptures and disc degeneration: a re- analysis of 833 discograms. The association between pain drawings and computed tomographic/discographic pain responses. Relation between pain location and disc pathology: a study of pain drawings and CT/discography. Effects on the vertebral end-plate of un- complicated lumbar discography: an MRI study. The prevalence and clinical fea- tures of internal disc disruption in patients with chronic low back pain. Dallas discogram description: a new classification of CT/discography in low back disorders. Four-year follow-up results of lumbar spine arthrodesis using the Bagby and Kuslich lumbar fusion cage. Eckel Back pain is the most common pain complaint resulting in physician of- fice visits.

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Effectiveness in health care: an initiative to evaluate and im prove m edical practice. Evidence based general practice: a retrospective study of interventions in one training practice. Evidence and expertise: the challenge of the outcom es m ovem ent to m edical professionalism. Practical issues of involving patients in decisions about health care technologies. You can apply all the rules for reading a paper correctly but if you’re reading the wrong paper you m ight as well be doing som ething else entirely. Every m onth, around 5000 m edical journals are published worldwide and the num ber of different journals which now exist solely to sum m arise the articles in the rem ainder probably exceeds 250. Only 10–15% of the m aterial which appears in print today will subsequently prove to be of lasting scientific value. A num ber of research studies have shown that m ost clinicians are unaware of the extent of the clinical literature and of how to go about accessing it. Browsing, in which we flick through books and journals looking for anything that m ight interest us. Reading for information, in which we approach the literature looking for answers to a specific question, usually related to a problem we have m et in real life. Reading for research, in which we seek to gain a com prehensive view of the existing state of knowledge, ignorance, and uncertainty in a defined area. In practice, m ost of us get m ost of our inform ation (and, let’s face it, a good deal of pleasure) from browsing. To overapply the rules for 15 H OW TO READ A PAPER critical appraisal which follow in the rest of this book would be to kill the enjoym ent of casual reading. Jewell warns us, however, to steer a path between the bland gullibility of believing everything and the strenuous intellectualism of form al critical appraisal. If reading for inform ation (focused searching) or research (system atic review), you will waste tim e and m iss m any valuable articles if you sim ply search at random. N ote that if you are looking for a system atic quality checked sum m ary of all the evidence on a particular topic you should probably start with the Cochrane database (see section 2. H owever, if you are relatively unfam iliar with both, M edline is probably easier to learn on. M edline is com piled by the N ational Library of M edicine of the U SA and indexes over 4000 journals published in over 70 countries. The M edline database is exactly the sam e, whichever com pany is selling it, but the com m ands you need to type in to access it differ according to the CD -ROM software. Com m ercial vendors of M edline on-line and/or on CD -ROM include Ovid Technologies (O VID ), Silver Platter Inform ation Ltd (W inSPIRS), Aries System s Inc (Knowledge Finder), and PubM ed. The best way to learn to use M edline is to book a session with a trained librarian, inform aticist or other experienced user. By any word listed on the database including words in the title, abstract, authors’ nam es, and the institution where the research was done (note: the abstract is a short sum m ary of what the article is all about, which you will find on the database as well as at the beginning of the printed article). By a restricted thesaurus of m edical titles, known as m edical subject heading (M eSH ) term s. To illustrate how M edline works, I have worked through som e com m on problem s in searching. The following scenarios have been drawn up using OVID software4 (because that’s what I personally use m ost often and because it is the version used by the dial up service of the BM A library, to which all BM A m em bers with a m odem have free access). I have included notes on W inSPIRS5 (which m any universities use as a preferred system ) and PubM ed (which is available free on the Internet, com es with ready m ade search filters which you can insert at the touch of a button, and throws in a search of PreM edline, the database of about to be published and just recently published articles6). All these system s (Ovid, W inSPIRS and PubM ed) are designed to be used with Boolean logic, i.

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