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Children In approximately 50% of patients with migraines buy cheap viagra plus 400mg line erectile dysfunction questions, the headache disorder starts before the age of 20 years (4) best viagra plus 400 mg erectile dysfunction by age. A primary concern in children with headache is the possibility of a brain tumor (8,9). Although brain tumors constitute the largest group of solid neoplasms in children and are second only to leukemia in overall fre- quency of childhood cancers, the annual incidence is low at 3 in 100,000 (9). Primary brain neoplasms are far more prevalent in children than they are in adults (10). They account for almost 20% of all cancers in children but only 1% of cancers in adults (4). Central nervous system (CNS) tumors are the second cause of cancer-related deaths in patients younger than 15 years (11). Overall Cost to Society The prevalence of migraine is highest in the peak productive years of life between the ages of 25 and 55 years (12,13). The direct and indirect annual cost of migraine has been estimated at more than $5. Suggested guidelines for neuroimaging in adult patients with new-onset headache First or worst headache Increased frequency and increased severity of headache New-onset headache after age 50 New-onset headache with history of cancer or immunodeficiency Headache with fever, neck stiffness, and meningeal signs Headache with abnormal neurologic examination Methodology A Medline search was conducted using Ovid (Wolters Kluwer, New York, New York) and PubMed (National Library of Medicine, Bethesda, Mary- land). Keywords included (1) headache, (2) cephalgia, (3) diagnostic imaging, (4) clinical examination, (5) practice guidelines, and (6) surgery. Summary of Evidence: The most common causes of secondary headache in adults are brain neoplasms, aneurysms, arteriovenous malformations, intracranial infections, and sinus disease. Several history and physical examination findings may increase the yield of the diagnostic study dis- covering an intracranial space-occupying lesion in adults. Summary of Evidence: The data reviewed demonstrate that 11% to 21% of patients presenting with new-onset headache have serious intracranial pathology (moderate and limited evidence) (4,16,17). Computed tomogra- phy (CT) examination has been the standard of care for the initial evalua- tion of new-onset headache because CT is faster, more readily available, less costly than magnetic resonance imaging (MRI), and less invasive than lumber puncture (4). In addition, CT has a higher sensitivity than MRI for subarachnoid hemorrhage (SAH) (18,19). Unless further data become available that demonstrate higher sensitivity of MRI, CT is recommended in the assessment of all patients who present with new-onset headache (limited evidence) (4). Lumbar puncture is recommended in those patients in which the CT scan is nondiagnostic and the clinical evaluation reveals abnormal neurologic findings, or in those patients in whom SAH is strongly suspected (limited evidence) (4). Supporting Evidence for Clinical Guidelines and Neuroimaging in New-Onset Headache: Duarte and colleagues (16) studied 100 consecutive patients over 184 L. For patients who do not meet these criteria or those with negative diagnostic workup, clinical observation with periodic reassessment is recom- mended. If CT is positive, further workup with CT angiography or magnetic reso- nance imaging (MRI) plus MR angiography is recommended. In selected case, conventional angiography and endovascular treatment may be warranted. In patients with suspected metastatic brain disease, contrast-enhanced MRI is recommended. In patients with suspected intracranial aneurysm, further assessment with CT angiography or MR angiogra- phy is warranted. Inclusion criteria included patients admitted to the neurology unit with recent onset of headache. Recent onset of headache was defined by the authors as persistent headache of less than 1 year’s duration. Tumors were identified in 21% of the patients, which com- prised 16% of the patients with a negative neurologic examination. A smaller-scale prospective study examined the association of acute headache and SAH (limited evidence) (20). Of the 27 patients studied, 20 had a negative CT and four were diagnosed with SAH. Among the remaining three patients, one had a frontal meningioma, another had a hematoma associ- ated with SAH, and the other had diffuse meningeal enhancement caused by bacterial meningitis. Lumbar puncture was performed in 19 of the patients with negative CT, yielding five additional cases of SAH. A retrospective study of 1111 patients with acute headache who had CT evaluation found 120 (10. There were statistical dif- ferences in the percentage of intracranial lesions based on the setting in which the CT was ordered. One study in the outpatient setting that studied 726 patients with new headaches found no serious intracranial disease (limited evidence) (6). The difference in prevalence of disease among emergency patients, inpatients, and outpatients is probably related to patient selection bias. Summary of Evidence: Most of the available literature (moderate and limited evidence) suggests that there is no need for neuroimaging in patients with migraine and normal neurologic examination.

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She lists common integrative elements of contemporary approaches (Johnson & Denton discount 400mg viagra plus amex erectile dysfunction at the age of 18, 2002) generic viagra plus 400 mg free shipping erectile dysfunction va disability rating. Scholars stress that contemporary approaches must move beyond a bag of tricks mentality (Lid- dle et al. Absent from these observa- tions are the messianic tendencies that in the past have been part of the couple and family therapy field (Johnson, 2001). In contrast to the next new way of thinking mentality, these authors describe a field desiring to use knowledge from expanding areas of psychology and break bread with other treatment approaches and disciplines historically viewed as existing outside of MFT circles. EFT (Greenberg & Johnson, 1988; Johnson, 1996) fits with the present zeitgeist of the field in that it’s well suited for integration and cross- fertilization with other therapy approaches and academic disciplines be- cause it is essentially integrative. In EFT, collaborative client-centered, gestalt, and systemic approaches are intertwined with constructivist think- ing, a passion and commitment to research, and a vision of love relation- ships best captured in attachment theory. The focus on the regulating role of emotion and attachment needs and fears allows the EFT therapist to ad- dress universal elements of couple relationships, while the humanistic stance and focus on the process of interaction finds it sensitive to unique in- dividual differences. Since its inception 17 years ago, EFT has emphasized how emotional bonds are of primary concern in conceptualizing and creating change in inti- mate relationships (Johnson, 1986). Emotion is viewed in EFT as an adaptive relational action tendency—a natural part of systems theory (Johnson, 1998). EFT has established itself as an empirically validated approach to couple therapy (Baucom, Shoham, Mueser, Daiuto, & Stickle, 1998; Johnson, Hun- sley, Greenberg, & Schindler, 1999) and has demonstrated efficacy apart from the originators of the approach (Denton, Burleson, Clark, Rodriguez, & Hobbs, 2000). Recognized as one of only about five empirically supported EFT: An Integrative Contemporary Approach 181 (EST) marital and family treatment approaches, EFT is a meta-analytically supported treatment (MAST; Sprenkle, 2002). The targets of the EFT change processes and the theory of relatedness are also supported by empirical re- search (Gottman, 1994; Simpson, Rholes, & Phillips, 1996). In terms of out- come, a meta-analysis of the four most rigorous EFT outcome studies yielded a 70% to 73% recovery rate for relationship distress and a 90% significant im- provement over controls (Johnson et al. Positive changes made in treat- ment also appear to be stable with little evidence of relapse (Clothier, Manion, Gordon-Walker, & Johnson, 2002). EFT continues to evolve and expand, as evidenced in the newer constructs of attachment injuries (Johnson, Makinen, & Millikin, 2001) and the out- lining of key therapist interventions utilized in softening change events (B. There is a growing base of treatment applica- tions with diverse populations such as families with a bulimic child (John- son, Maddeaux, & Blouin, 1998), couples suffering from trauma (Johnson, 2002), depression (Dessaulles, Johnson, & Denton, 2003; Whiffen & Johnson, 1998), and chronic illness such as heart disease (Kowal, Johnson, & Lee, 2003), older (M. EFT’s collaborative and affirming stance makes it particularly well suited to value the spiritual beliefs of clients and families (B. An in- dividual version of EFT has been repeatedly tested (Elliott & Greenberg, 2001). Keiley (2002) reports the usefulness of EFT with incarcerated adolescents and their parents. The approach has also been integrated within feminist (Vatcher & Bogo, 2001) and life-cycle (Dankoski, 2001) perspectives. With the couple in the vignette, EFT is specific enough to help the thera- pist see through the smoke of such a hot session to pinpoint relationship- defining elements and focus the therapist on key issues and processes. In this chapter, we offer a snapshot of an ever-evolving approach to couple therapy that we call emotionally focused therapy. We highlight the specifics of the approach and try to take the reader in-session as the couple begins to share moments of happiness and despair. EMOTIONALLY FOCUSED COUPLES THERAPY Essentially, EFT offers a brief systemic approach to changing distressed couples’ rigid interaction patterns and emotional responses and enhancing the development of a secure bond (Johnson, 1996; Johnson & Denton, 2002). This approach targets absorbing affect states that organize stuck patterns of interaction in distressed relationships (Gottman, Driver, & Tabares, 2002; Heavey, Christensen, & Malamuth, 1995). These patterns become self- reinforcing, often taking the form of critical pursuit followed by distance and defensiveness; EFT combines an experiential, intrapsychic focus on inner experience with a systemic focus on cyclical interactional responses and ensuing patterns. It is a constructivist approach in which clients are 182 THEORETICAL PERSPECTIVES ON WORKING WITH COUPLES seen as the experts on their experience. Key elements of experience, such as attachment needs and fears, are unfolded and crystallized in therapy ses- sions. Rather, they are viewed as struggling with problems arising from a particular social context that would likely be just as problematic for the therapist to deal with if she found her- self there (Neimeyer, 1993). To achieve these goals, EFT integrates key elements of client-centered therapy (e. Attachment theory (Bowlby, 1969, 1988) provides EFT with a developmental nonpathologizing theoretical context for understand- ing the importance of emotional bonds, interdependency, and adult love and intimacy. A brief overview of principles from these theories that have im- pacted EFT follows. SYSTEMS THEORY ROOTS Systems theory places an emphasis on the power of present interactions, especially patterned sequences and feedback loops, to direct and prohibit individual behavior (Watzlawick, Beavin, & Jackson, 1967). Systemic thera- pists make in-session process assessments based on present sequences of interactional behavior. The therapist is active and directive, using such in- terventions as reframing and creating enactments between family mem- bers (Butler & Gardner, 2003).

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VR2 has also been identified and this is activated by noxious Adenosine Triphosphate (ATP) heat (threshold of 52°C) proven 400mg viagra plus erectile dysfunction treatment hyderabad. A VR-like (VRL-1) receptor ATP is an important intracellular messenger viagra plus 400mg on-line erectile dysfunction support groups, now also has also been postulated to exist on nociceptors. Following Since anandamide (AEA, see later), an endocannabi- release from secretory vesicles or lysed cells, it can noid, is structurally related to capsaicin (with amide modulate ion channel activity. This is achieved bonds and aliphatic side chains) it has been postulated through specific receptors, found peripherally in the to act at VR1. Indeed, AEA induces vasodilation via skin and centrally on second-order neurones located VR1, accompanied by the release of calcitonin gene- in the DH. Adenosine then acts at P1 (A1- or A2-types) receptors, further modulating pain transmission both peripher- ally and centrally (though the effects observed are usu- Nerve Growth Factor (NGF) ally opposing). Poly- ATP and other adenosine nucleotides activate puriner- modal C-fibre neurones can be classified depending gic G-protein-coupled (P2Y) or ionotropic (P2X) on their need for neurotropic mediators: receptor subtypes. Seven subtypes, P2X1–P2X7 have NGF-dependent nerves are also known as tyrosine been cloned so far. Of these, at least six (P2X1–P2X6) • kinase A (TrkA)-positive neurones, since they are expressed on sensory neurones. They do not identical subunits, which model a required structural express TrkA, but rather P X. Of greatest interest is P X , as this is the primary sub- 2 3 type expressed in small C-fibres. During inflamma- tion, an upregulation of P2X receptors is observed, Serotonin (5-HT) possibly due to the H sensitivity of the receptors. It is found majority of nociceptive information from peripheral in brain cells, platelets, enterochromaffin and mast ATP. There are many serotonergic pathways originat- at P2X receptors, the two being distinct populations ing in the raphe nuclei; paralleling those of norepi- with an apparent different subunit composition. ATP can also degranulation of mast cells, it is probable that 5-HT act pre-synaptically on nociceptors to increase glu- has a role in controlling NGF-mediated inflammatory tamate release. These are G-protein coupled, with the Primary nociceptive exception of 5-HT3 that is a member of the ligand- modulators gated ion channel family. Several subtypes of CGRP receptors have been identified, as well as a calcitonin- Tachykinins like receptor. These are all G-protein coupled and are localised in the nucleus accumbens, indicating a CNS SP an undecapeptide was the first neuropeptide role for CGRP in pain transmission. These neuropeptides are formed by the proteolytic cleavage of larger precursor GABA is the most widely distributed inhibitory trans- proteins (pre-protachykinins) in the spinal ganglia. At least three subtypes of GABA receptor of A -fibres, and not at all in A /A -fibres. It is a have been identified on GABAergic neurones: co-transmitter with other peptides and glutamate in GABA A is an ionotropic pentameric ligand-gated • response to both nociceptive and non-nociceptive Cl channel. Its actions are mediated through the with , , and being essential for receptor tachykinin receptor NK1. There are several isoforms of each sub- All NK receptor subtypes are G-protein coupled unit; hence at least 13 subclasses of this receptor (similar to BK1 and BK2 receptors) and act by increas- exist. The receptors are localised in culline (on - and -subunits) and also has binding the DH and bind to SP (NK1), NKA (NK2) and sites for barbiturates, ethanol and benzodiazepines. This receptor binds CGRP is a 37 amino acid neuropeptide, distributed GABA and the muscle relaxant, baclofen. It has an generally found on nerve terminals mediating pre- important role in inflammation and pain modulation. It is found in the majority of primary afferent nerves • GABA C receptors (recently discovered) are also (in approximately 50% of polymodal C-fibre afferents, ligand-gated Cl channels, found mainly in the 33% of A -fibres and 20% of A /A -fibre neur- retina. These bind GABA, muscimol and the agon- ones), after synthesis in the dorsal root ganglion ists, cis- and trans-4-aminocrotonic acid and are (DRG). It is released in the periphery where it can sensitive to picrotoxin, but not bicuculline. RECEPTOR MECHANISMS 55 GABAergic neurones involved in pain transmission within the post-synaptic cell. Long projec- posed that nitric oxide (NO) and prostanoids can also tions are found between the striatum and the substan- activate NMDA receptors. However, they are also found in the Opioid peptides spinal cord, mediating release of peptides. Several classification systems for the three classical opioid receptor subtypes have been proposed. The Glutamate more recent system uses DOP ( or OP1), KOP ( or OP2), MOP ( or OP3) nomenclature and is in line This is one of the most important transmitter path- with recent IUPHAR (International Union of ways modulating nociception. Glutamate, released types, such as , , , and , have been postulated, from central terminal afferents, is the major excitatory though are not generally accepted. Classical opioid output along: receptors belong to the G-protein-coupled receptor • Ascending nociceptive pathways from the DRG superfamily and couple to pertussis toxin-sensitive and lamina I.

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Two reviews (11 buy discount viagra plus 400mg line erectile dysfunction in young guys,12) included studies that reported data on composite clinical examinations without specifying the precise examination maneu- vers that were used quality 400mg viagra plus erectile dysfunction 33 years old. In general, these composite examinations resulted in reasonable sensitivity and specificity for anterior cruciate ligament (82% and 94%, respectively), posterior cruciate ligament (91% and 98%), and meniscal (77% and 91%) injuries (12). However, it is very difficult to repli- cate or generalize these findings given the lack of detail about the indi- vidual components of the examination. To date, the majority of studies have been conducted by musculoskele- tal specialists skilled in physical examination techniques. Given the inevitable methodologic flaws in many of these studies, we conclude that there is limited evidence (level III) that the clinical examination can accu- rately select patients most likely to benefit from therapeutic arthroscopy. The rise in MRI utilization is probably due to increased availability of equipment and reluctance on the part of physicians to rely solely on the clinical examination to determine treatment. Furthermore, some legal judgments have criticized surgeons for operating without full information about the extent of the lesion(s). However, overreliance on advanced imaging technology might be counterproductive if MRI is not sufficiently accurate. In particular, age-related degeneration of the menisci might lead to false-positive MRI findings and unnecessary surgery (43). Demographic aspects also play a part: there may be much more reason for a professional athlete to undergo soft tissue imaging in the acute phase compared with a middle-aged sedentary person (Fig. Few surgeons relish inter- vening in the acute phase when there is a lot of hemorrhage still masking the operative field. Although MRI may show many unexpected lesions in the acute phase, the immediate clinical management of the patient rarely changes (44). We identified four reviews summarizing the accuracy of MRI compared to arthroscopy for soft tissue knee injuries (11,15,16,45). All reviewed a wealth of evidence, albeit from methodologically weak studies in many instances. Of these studies, only four (14%) had adequate blind- ing of the index test (MRI) when conducting arthroscopy, the reference standard. Three-dimensional (3D) gradient echo MRI of a soccer player follow- ing recent trauma. The intact anterior cruciate ligament has pulled off a small rind of cortex from the proximal tibia (arrow). Prompt surgery allowed this avulsion fracture, well shown on this preoperative roadmap, to be pinned back promptly. The pooled weighted sensitivity and specificity estimates from this review are reported in Table 15. The results suggest that the sensitivity of MRI is consistently lower in lateral meniscal tears than medial meniscal and cruciate injuries; conversely, specificity is higher. One explanation for this finding is that radiologists may have a lower threshold for reporting medial meniscal tears as opposed to lateral tears. Overall, there is moder- ate evidence (level II) that MRI of the knee is a highly accurate method of diagnosing soft tissue knee injuries. In actuality the accuracy of MRI might be higher than the figures indicated in Table 15. It is recognized that, while arthroscopy is the only viable reference standard, in particular Table 15. Diagnostic accuracy of MRI for soft tissue knee injuries Pooled weighted Pooled weighted Positive Negative Lesion sensitivity* specificity* likelihood ratio likelihood ratio Medial meniscal tear 93 (92–95) 88 (85–91) 7. The 3D gradient echo MRI shows a classical tear at the junction of the middle and posterior thirds of medial meniscus (arrow). Continuing symptoms led to clinicoradiologic discussion; a second arthroscopy confirmed the tear. Several observational studies have gone beyond the intermediate outcome of diagnostic accuracy to examine whether MRI can decrease the rate of arthroscopy (42,47–53). This lack of consensus is not surprising given the range of primary and secondary care settings examined, and varying definitions of what constitutes a purely diagnostic arthroscopy. Of these patients with negative MRI findings, 93 were ran- domly selected and received immediate arthroscopy. Ninety-one percent (85/93) of arthroscopies subsequently performed in these patients were purely diagnostic (86%) or had a minor therapeutic procedure (5%) on a lesion that, according to the study protocol, did not require surgical inter- vention. The remaining 9% (8/93) of negative MRI findings were genuine false negatives overlooking clinically important lesions. Most patients (200/221) with positive MRI findings had subsequent arthroscopy; only 11% (21/200) of these had a purely diagnostic arthroscopy. Based on the large proportion of diagnostic arthroscopies that could have been avoided, these authors concluded that a combination of a clinical examination and MRI was useful in selecting patients for arthroscopy. Cost-Effectiveness Analysis Two small randomized trials have analyzed the impact of knee MRI on costs and patient quality of life.

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