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The role of colchicine in pericarditis: a systematic review and meta-analysis of randomized trials purchase red viagra 200mg otc. Biventricular mechanics in constrictive pericarditis comparison with restrictive cardiomyopathy and impact of pericardiectomy discount red viagra 200mg on-line. Genetic abnormalities have been associated with all types of cardiovascular disease buy discount red viagra on-line, including coronary atherosclerosis discount red viagra 200mg visa, rhythm disorders, aortic disease, and structural heart disease. The ability to efficiently scour through the massive amount of genomic information is improving our understanding of the contributions of genetics to cardiovascular disease. This understanding would potentially lead to an improved ability to accurately diagnose disease, prevent progression, and risk stratify at the individual level. The pharmacogenomic profiles developed may provide a refined approach to treatment with less toxicity. A more comprehensive assessment of future risk for both patient and potentially affected family members would also be feasible. As opposed to Mendelian disorders, which are deterministic, complex traits are probabilistic. It will require extensive time and effort to be able to define all the variations in all the genes that contribute to the susceptibility to or protection from a complex trait. Furthermore, the simple identification of genes involved does not address the issue of gene–gene and gene–environment interactions influencing complex traits. There have been extensive recent reports of genomic variants associated with risk of diseases. These variants are common, often accounting for 20% to 30% of the population attributable risk, but with an odds ratio of 1. The hunt to find rare variants that induce susceptibility to common diseases with high risk (or protection) will be more challenging, but eminently feasible with sequencing technology and ultra high– throughput genotyping. At some point in the future, the major genomic underpinnings for most cardiovascular diseases will be known. Furthermore, the integration of all of the genomic variants for any cardiovascular disease has not been undertaken. What follows is a brief overview of what is known today about the genetic basis for a sampling of disease entities within cardiovascular medicine. The process of discovering relevant genetic underpinnings of generally complex traits requires an extensive analysis of genetic information in large populations. Complex traits without simple Mendelian patterns of inheritance are difficult to analyze, given that there are often multiple genes involved, with many gene interactions being important. However, even before attempting this task, perhaps the single most significant goal is to accurately and concisely define the phenotype in question. The ability to clearly define cases and controls is paramount to obtaining accurate and reproducible information. Using genes of interest in a particular disease phenotype, scans are conducted in areas of interest in both cases and controls to compare haplotype frequency to determine if a statistically significant difference between the two groups in the region of interest exists. The breakdown of the genome into bins via the International Haplotype map was critical in making current genome-wide association studies possible. Using this method the researcher has the opportunity to discover if rare genetic variants in the coding region of any of the genes in the loci may be related. These new technologies have increased the speed and lowered the cost of sequencing thereby increasing access to many more researchers and accelerating discovery. Linkage analysis is another tool used to identify genes that are possibly involved in the pathogenesis of complex traits. The use of linkage analysis begins without any assumptions as to the potential involvement of various genes. It is based on the idea that during the process of meiosis when recombination events occur, they tend to involve loci on a particular chromosome that are closer together than farther apart. By following the inheritance of certain known loci, assumptions can be made about the presence of alleles that cosegregate with them. Using linkage analysis, the potential exists to identify these known loci as markers and determine the transmission through a pedigree and its relationship to the phenotype in question. In doing so, it may be possible to suggest that an allele in proximity to known loci may be associated with a particular phenotype. The identification of certain disease alleles or loci associated with disease-causing genes provides valuable information but remains limited in its scope. The statistical association of genes and disease does not prove causation or even involvementin disease. Gene expression profiling takes this concept one step forward in trying to delineate gene expression. The presence of transcription profiles may provide more useful information in terms of relevance of findings made in gene association studies or linkage analysis. Technology now permits the evaluation of large genomes in a rapid fashion to derive expression profiles, which can then be compared between diseased and healthy individuals to draw conclusions about which genes are transcriptionally active in certain phenotypes. Coronary atherothrombosis and atherosclerosis remain significant causes of morbidity and mortality in the population as a whole. The presence of atherosclerosis is necessary but not sufficient for atherothrombosis. There are separate factors involved that predispose to plaque rupture and thrombosis. Even within the category of plaque rupture, the clinical phenotypes vary significantly, as reflected by the spectrum of diseases that constitute the acute coronary syndromes. Inflammation, endothelial dysfunction, and dyslipidemias are only a few of the pathways influencing the development of atherothrombosis and atherosclerosis. Delineating the genetic basis of specific pathophysiological mechanisms, in most cases, is a work in progress, but it may help to broaden our understanding of the disease. Often, these patients can develop atherosclerotic disease between 20 and 30 years of age. The majority of individuals are heterozygous, and those with homozygous patterns of inheritance are more severely affected and are more likely to be diagnosed during childhood. The cellular mechanisms involved in cholesterol metabolism are complex, and there are many potential targets where mutations can significantly affect phenotype. These results indicate the complexity of the genetic picture for dyslipidemia and the power of whole-genome sequencing in detecting rare variants in large global samples. T 21-bp deletion has not been conclusively found in any family apart from that in the original study. This particular mutation may be a “private mutation” for the family in the original study and therefore extremely difficult to replicate. It is worthy to note that the HapK is very rare in an African population and evidence of HapK in African-American cohorts may be due to European genetic influence. Genetic mutations affecting the connective tissue and extracellular matrix typically affect multiple organ systems, but often the most devastating and lethal effects arise from those upon the cardiovascular system. Aortic dissection and rupture are often the consequences of such abnormalities, and what follows is a brief description of three such disorders. This disorder is inherited in an autosomal dominant fashion with variable penetrance, and it affects the connective tissue, leading to abnormalities of organs of the cardiovascular, skeletal, and ocular systems. The classic features of tall stature, arachnodactyly, dolichostenomelia, pectus excavatum, ectopia lentis, and a positive family history all support a diagnosis of Marfan syndrome. The cardiovascular system is affected, and the most common cause of death in these patients is from aortic dissection and aortic rupture. When patients with Marfan syndrome present with dissection, they are typically younger and do not have hypertension. Ehlers–Danlos syndrome is a group of connective tissue disorders caused by defects in proteins that are involved in the formation of collagen. It is uncommon and usually has an autosomal dominant pattern of inheritance but recessive inheritance pattern is seen also. In 1997, Villefranche Nosology classified six distinct subtypes of Ehlers–Danlos syndrome. For the most part these subtypes were based on clinical features and linked to mutations in collagen-related genes.

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This purchase red viagra australia, like the newer peristaltic pumps generic red viagra 200 mg online, is driven by a stepper motor con- Anvil plate ‘Pinched off’ volumes trolled directly by a microprocessor order red viagra with a mastercard. The volume of the cassette is typically about 5 ml generic 200mg red viagra overnight delivery, with the dedicated dispos- Figure 19. A valve operating in harmony with the piston directs fow from the infusate bag to the reservoir or from there to the patient. Precision silicone tubing is drawn rapidly from the reservoir bag into the cassette in often used in this section of the giving set. The valve is then actuated such that on the Rotary peristaltic pumps are now more often seen in use piston upstroke the contents are expelled at the required for the less demanding requirements of enteral feeding rate into the patient, and the cycle is repeated. The driving force is again a These are seen much less frequently now owing to the stepper motor. The rotary motion from the motor is trans- expense of the disposables and the feasibility of getting lated into a linear peristalsis by the use of cams and cam good accuracy using simple intravenous giving sets in followers as shown in Fig. Because such infusion pumps have the theoretical capacity to inject limitless quantities of air into a patient Peristaltic pumps should air ingress occur upstream of the pump (for The principle of the peristaltic infusion pump is shown in example due to an empty infusion bottle), these devices Fig. The tubing of a giving set is compressed by a incorporate sophisticated ultrasonics (Fig. These are usually mechanism must be hard wearing, of known and consist- placed downstream of the pump mechanism. Further pro- ent internal volume, and have no memory after compres- tection is conferred by setting target delivery volumes sion so that it easily flls on being released. Thus, each pulse applied to the stepper 0 10 20 30 40 50 60mm motor causes the advancement of the syringe plunger by Set rate 10 bleeps mm per (24 h) day a known amount. Syringe pumps (the term is synonymous with syringe of the pressure generated in the infusion line beyond the drivers) are now designed to automatically recognize a device. Peristaltic intravenous pumps, therefore, use a variety of syringes by virtue of the calibre of the barrel sensing piston pressing on the infusion line immediately using some form of spring-loaded arm; some manufactur- downstream of the pumping chamber. This is calibrated ers’ models nonetheless require manual confrmation of to indirectly measure line pressure and can be programmed the detector. Infusion line pressure (and empty syringe to alarm for occlusion at different pre-set levels. This Syringe drivers is a more popular option than the use of specialized infu- There continues to be a range of small simple battery- sion sets with in-built diaphragm and corresponding operated syringe drivers (Fig. The off intermittently and drives a screw-threaded rod (lead facility in some devices to also alarm for low infusion line screw), which is linked to the syringe plunger, causing its pressures is intended to allow recognition of disconnec- advancement. They may have a variable rate that is altered tion of an infusion line (with the aim of, for example, by adjusting a recessed control using a small screwdriver. These pumps are small and light enough to be worn in a holster by an ambulant patient and are now used chiefy Rechargeable batteries for narcotic infusions for the relief of cancer pain. Great care must be taken in calculating drug dilutions and to Although mains-driven, electrical infusion devices must ascertain that the correct units are used for setting the have battery back-up both to cover mains failure and for infusion rates, as the pumps are available in different patient transfer and emergency situations. The perform- models with rates set either as mm per 24 h or mm per h ance of the in-built rechargeable batteries is an important of plunger movement (Fig. Lead acid batteries, also called ‘sealed lead acid’ to designate portability and to differentiate from the fooded type used in cars, have no ‘memory’, are cheap and reliable, but have long charging times. They are most often found on portable equipment such as ventilators and other heavy devices (e. Lead acid batteries, conversely, suffer by being allowed to fully discharge and must not be stored in this Figure 19. The distortion (invisible to the eye) of the steel energy density and no memory but are very expensive. The plate caused by the force acting on the lead screw causes technology is currently confned largely to portable per- a change in resistance which can be calibrated to be read sonal electronic equipment such as mobile telephones. Medical device batteries obviously cannot be safely run render otherwise excellent devices unreliable and unusa- down whilst in use. Pumps should be kept connected to the mains when discharge of a battery decreases the safety margins in the not in use and batteries should be replaced appropriately. Safety In common with many rechargeable batteries, nickel- cadmium (NiCd) rechargeable batteries should be periodi- Microprocessor-driven infusion devices are used for cally run down completely to prevent the development of the administration of many potent drugs with narrow 405 Ward’s Anaesthetic Equipment therapeutic windows where maladministration can have automatically senses the drug in the preflled syringe lethal consequences. The drugs are used in a variety of and hence does not have this problem but this may dilutions and dosed in units that can vary by several orders now predispose doctors to errors when using other of magnitude (ηg/ml, µg/ml, µg/kg/min, mg/kg/h). Software changes across generations of potential for user error with disastrous consequences. Though rare, glitches in the uncontrolled fow of fuid from a syringe into software may under certain circumstances cause over- or the patient under gravity. Software issues are more commonly seen the plunger and have a detector or mechanism built as a stopped infusion when the processor receives appar- in to protect against incorrectly mounting the syringe ently conficting messages from different sources in the plunger. It is best, even with modern designs, to not device, which then is made to fail safe with appropriate have the syringe driver higher than the patient, as alarms and error codes. Anti- sion can be equally dangerous – if, for example, the siphon valves – essentially a one-way valve with a patient’s circulation is dependent on vasoactive drugs. In spite of this, they remain high-risk devices capable being properly clamped off when the pump is not in ultimately of delivering drugs dangerously: they have a operation or when the infusion set has not loaded recognized associated morbidity and mortality. In at least into the device properly still exists but should be 27% of the 1495 incidents involving infusion pumps largely designed out in new devices. Where multiple infusion lines are connected 1990 and 2000, the cause was found to be user error to a single intravascular device and there is a distal (including failure to maintain the device appropriately). It is such as performance, degradation, quality assurance and imperative that such lines have anti-refux valves design and labelling. It is worth was established it is likely that a very large number repre- stating that this fault situation can and does also sent user error. Where more than one infusion cannula has ‘tissued’ or become extravascular are not pump is used particularly when they are controlled prevented by the use of low infusion line pressure through a common interface it is relatively easy to limits. The Diprifusor system These can produce a wholly new machine within the 406 Infusion equipment and intravenous anaesthesia Chapter | 19 | familiar appearance of the old. Although features may be added or improved, there is also the possibility of introducing new problems and errors, particularly for those familiar with previous versions. Manufacturers should treat all but the most trivial software revisions as new devices and issue new instruction and training/maintenance manuals. Because of the huge fexibility of microprocessor- controlled infusion devices, it is increasingly important for users of these devices to have familiarized themselves specifcally with the features and functions of each model before clinical application. Programming errors are very common and may potentially result in lethal overdosage. These devices are not always entirely intuitive to use, errors are commonplace with, for example, the ‘hands free bolus’ facility (a pre-programmable bolus dose that does not require the button to be kept depressed during delivery), which may give the option of a variety of unexpected units Figure 19. For number of drugs to prevent confusion example, pumps left switched on with infusion rates or not cause systematic and institution wide doses programmed, but where the infusion is not started forced errors, e. An audible signal • They need careful delineation of responsibility spanning the delivery of a ‘hands free’ bolus is common for maintenance, e. These limits may be as both a soft limit (where • They do inherently decrease fexibility of infusion a confrmatory key press after a warning message allows devices. Users in anaesthetic areas often programme the higher values) and a hard limit where higher values in a series of ‘unnamed’ drugs administered in a cannot be chosen. Clearly these limits are specifc to the number of differing mass units per unit patient weight drug in use. For this reason it has become standard to have per units of time to allow for unexpected eventualities. In conjunction with connection to automated record • They must be set up with great thought and keeping systems such a set-up also allows high-quality attention to detail so as to: record keeping with obvious associations between 407 Ward’s Anaesthetic Equipment interference even in standby mode and must, therefore, be fully switched off to be considered safe. Cordless tele- phones and wireless computer local area networks do not appear to cause signifcant interference. Although most hospitals have policies demanding that mobile phones be switched off in clinical areas, clinicians must always bear in mind the potential for such malfunc- tion, given the ubiquitous nature of mobile telephones and the increased risk of problems with the two-way radios used in hospitals. Limits must be set such Although the drugs used for intravenously maintained that nuisance alarms do not occur due to the resistance of anaesthesia are of rapid onset and have short half-lives the giving set or ‘stiction’ at the syringe barrel/plunger and durations of action, in order to rapidly achieve and interface.

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Nevertheless order red viagra, the disease generic red viagra 200mg fast delivery, which has proved to be refractory to medical decision to treat as streptococcal disease was justified buy 200mg red viagra with visa, management buy discount red viagra 200mg on-line. The standard treatment consists of dietary given the degree of illness, even though the streptococcal salt restriction, elimination of xanthines (caffeine and screen was negative. Rapid screening tests are only 80% to chocolate), and smoking cessation for prevention and 87% sensitive. Not mentioned is that this patient, if he has prescription of diuretics as well as judicious use of valium infectious mononucleosis, would have greater than a 90% during attacks. Meclizine, helpful in most vertiginous chance of developing a maculopapular or sometimes a states, does not appear to be effective in Meniere’s disease. The patient may be logically, given the pathophysiology of infectious mono- a candidate for surgical relief, the most common approach nucleosis, is often not appreciable. If the procedure must be thy is frequently notable posteriorly rather than anteriorly repeated, the most definitive operation is vestibular nerve as is found in streptococcal disease, but this is not a section. For that reason, References patients must be cautioned to avoid sports for at least 6 weeks. Which of the follow- (A) Onset of headaches over the age of 50 years ing would be the least indicative of serious pathology (B) Seizures associated underlying the cause of the headache? Of the many 6 A 35-year-old woman complains of headaches that contraindications to their usage, which of the follow- are throbbing and frontal or occipital in distribution. These have been occurring for most of her adult life (A) Presence of ischemic heart disease but have become more severe over the last several (B) Taking within 24 hours of another triptan days, lasting the whole day, several times per week. Neurological history (including inquiry regarding visual and other neurological 3 All of the following are commonly found in cluster symptoms accompanying the headaches) and exami- headache except for which one? Which of the following is most likely as the (B) Tearing and rhinorrhea diagnosis of the headaches? Which of headaches associated with rhinorrhea and tearing for the following is acceptable and safe for relief of her the past several weeks. He been no rash and this is the first time the patient has had never before experienced a headache. The pain is lancinating, reported drug use, and he denies taking any prescrip- and it is precipitated by touching the skin of the tion medication. Vital signs are normal, except for affected areas, by chewing, and sometimes by talking. The patient’s head Which of the following is possibly associated with shows no ecchymosis, and stethoscopy reveals no this syndrome? There is resistance to flexing and rotation in (C) Vascular compression of the gasserian ganglion the neck. He can move all extrem- ities, and sensation to touch is intact in all extremi- 9 A patient presents exactly as the person in Question 5 ties. Deep tendon reflexes are normally reactive and except that she complains also of disturbed vision symmetrical. Examination reveals tenderness of over the right side of the occipital scalp at the ridge, the right temporal artery. Dental examination is neg- and tapping the area produces a shocklike pain in the ative. She does note an increase in her headaches cheeks when she is under stress or anticipates stress. Which (E) Fever of the following characteristics is most commonly associated with this type of headache? Recently, she has begun hearing her own pulsation in (B) There is nausea and emesis. When you (E) They are frequently brought on by oral move the scope to the mastoid areas, you hear on the contraceptive usage. They last 1 to 2 hours and are carotid artery associated with erythema of the face and rhinorrhea. He suffered a concussion (D) Cluster headache 2 years ago and had headaches for several months (E) Temporal arteritis afterward, but he has had none since until the recur- rent headaches a year ago. Which of the following 16 A 28-year-old woman complains of a 10-year history does this patient have? These headaches are fronto-occipital in (A) Allergic rhinitis location and are noted often at the end of workdays; (B) Classic migraine they are more likely when sleep has been poor or (C) Cluster headache short and they are generally relieved by sleep. Vomiting with nausea is not a solid analgesics may result in this phenomenon, including the indication for neuroimaging during management of a triptans. Although some have said that vomit- headache is common in tension-type (sometimes called ing with or without nausea is an indication for neuroim- vascular) headaches, rapid onset may be a sign of an aging, actually nausea and vomiting associated with intracranial vascular phenomenon or cervical spine syn- migraine is relatively common and not of great concern dromes. Headache that awakens the patient in the night is except when there is no history of these symptoms being unlikely to have a benign cause unless there are associated associated with headaches or if there be anything “differ- migraine features or in the case of cluster headache. Certain indications for neuroimaging with in the mornings or associated with nausea, must be evalu- migraine include seizures, prolonged aura, onset of head- ated for intracranial pathology. The description is typical of tension any neurological signs that were not present at baseline. Ischemic heart disease that is relative sleep deprivation, onset of anxiety or depression, active (e. Intrac- process, could result in prolonged cerebral ischemia and ranial hemorrhage is unlikely, given the overall chronicity. Ninety percent of patients who complain of “sinus head- ache” have identifiable forms of headache. Each of the characteristics or paired factors given is associated with cluster headaches except 7. Tempo- edema and ptosis; cluster headache has an abrupt onset ral arteritis is associated with tenderness of the temporal and short period of duration, generally a maximum of artery. It appears that all types of vascular head- aches are treated with the same battery of medications, 4. This patient has typical trigeminal trimesters, but not the first trimester of pregnancy; the neuralgia (“tic douloureux”). Valproate in pregnancy can be teratogenic, ity of these cases are now thought to be caused by ana- resulting especially in neural tube defects. Vitamin B2 is tomic aberrations, including posterior fossa tumors, also said to be contraindicated in pregnancy. Acceptable meningioma, schwannoma, epidermoid cyst, and basilar drugs for migraine relief in pregnancy include fluoxetine, artery aneurysm. Another surgically approachable cause propranolol, amitriptyline, gabapentin, and topiramate. Daily use of medication commonly ods of destruction of the ganglion or the root, such as results in rebound headache. Conversely, daily use of radio frequency, glycerol, or balloon compression, all analgesics often fails to respond to preventive therapy. Sedimentation rate eleva- joint syndrome nor maxillary sinusitis has sensory stimu- tion is sensitive for temporal arteritis, which occurs in latory precipitation. The common pathological pathway medical urgency because it can be the cause of blindness, of trigeminal neuralgia includes demyelination of the based on occlusion of the ophthalmic artery. The jaw pain nerve root near the ganglion, which may be on a mechan- is the ischemic pain of claudication. The diagnosis is con- ical basis as described in Question 5 or by the mechanism firmed by biopsy of the temporal artery. Sepsis could not explain the can affect many other parts of the arterial vascularity, symptoms described without having more than one focus. Mechanical causes of compres- matically to systemic glucocorticoids, and these do not sion of the ganglion would not explain the urinary and have to be continued indefinitely. Occipital neuralgia is caused by the facial cheeks is not known to be associated with tem- compression of the greater occipital nerve, by underlying poral arteritis. Temporal arteritis may lead to the symp- entities such as posterior head trauma or compression of toms of polymyalgia rheumatica (or the symptoms of the occipital nerves by muscle tension (a possible cause in both may develop simultaneously). Tapping to is present in only about 7% of patients at the time of pre- stimulate electric shocklike pain is here called the Tinel’s sentation, but it will develop in about 44% of patients if sign, just as it is in relationship to carpal tunnel syndrome. Temporal arteritis is characterized by Such muscle tension can be secondary to osteoarthritis of a strikingly elevated sedimentation rate. Temporal arteri- the cervical spine, and on occasion, the cause cannot be tis must be considered as a potential source of fever in found. Tension headache is not characterized by local ten- those patients who are older than 50 years.

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Individuals with narcissistic personalities spend considerable energy evaluating their status relative to that of others order 200mg red viagra free shipping. They tend to defend their wounded self-esteem through a combination of idealizing and devaluing others (Bradley buy red viagra 200 mg with amex, Heim order generic red viagra canada, & Westen buy red viagra 200 mg online, 2005). When they idealize someone, they feel more special or important by virtue of their association with that person; when they devalue someone, they feel superior. Therapists who work with such individuals tend to feel unreasonably idealized, unrea- sonably devalued, or simply disregarded. Effects on the therapists may include bore- dom, detachment, distraction (daydreaming, inability to focus attention or to track therapeutic dialogue), mild irritation, impatience, and the feeling that they are invisible (Colli et al. They may also, especially if the wounds to these patients’ self- esteem are apparent, have parental feelings (Gazzillo et al. Gabbard (2009b) noted that a narcissistic patient, especially one of the grandiose and overt type, can be experienced “as speaking ‘at’ instead of ‘to’ the therapist, leaving him/her unable to emotionally invest in the therapeutic relationship and to be a real ‘participant observer’” (p. The clinical literature on narcissistic personality disorder includes diverse specu- lations about etiology and consequently diverse treatment recommendations. Kohut (1971, 1977) emphasized empathic attunement and exploration of the therapist’s inev- itable empathic failures, and described periods in treatment when the patient ideal- izes the analyst, treating him or her as a perfect and all-powerful parent figure (the “idealizing transference”). He felt that during these times, the primary challenge for the therapist is to resist the temptation to confront this pattern too quickly. Kernberg (1975, 1984), on the other hand, has recommended the tactful but systematic exposure 48 I. Contemporary practitio- ners are more likely to adopt an integrated approach to working with narcissistic individuals—confronting defenses when they are salient, and empathically attuning to underlying hurt and vulnerability when those feelings are accessible. Narcissistic envy can create a subtle fear of progress in therapy (because improve- ment would reveal that there was originally something to improve), whereas the ideal- ization puts pressure on the therapist to be brilliant (but not so brilliant as to threaten the patient’s intelligence by comparison). Progress may thus be slow, but any improve- ment for a patient with a narcissistic psychology is valuable for both the patient and those who relate to him or her. Like persons whose character structure is more psy- chopathic, narcissistic people may be easier to help in therapy in midlife or later, when their investments in beauty, fame, wealth, and power have been disappointed, and when they have run into realistic limits on their grandiosity. Paranoid Personalities Individuals who are so recurrently or chronically paranoid that they have a diagnos- able personality disorder are found mainly in the borderline and psychotic ranges. Paranoid psychologies are characterized by unbearable affects, impulses, and ideas that are disavowed and attributed to others, and are then viewed with fear and/or outrage. They occupy the introjective, self-definition end of Blatt’s continuum from relatedness to self-definition. Projected feelings may include hostility, as in the common paranoid conviction that one is being persecuted by hostile others; dependency, as in the sense of being deliberately rendered humiliatingly dependent by others; and attraction, as in the belief that others have sexual designs on the self or on the people to whom one is attached (e. Other painful affects, such as hatred, envy, shame, contempt, disgust, and fear, may also be disowned and projected. Because pathologically paranoid individuals tend to have histories marked by felt shame and humiliation (Gilbert, Boxall, Cheung, & Irons, 2005; Meissner, 1978), they expect to be humiliated by others and may attack first in order to spare them- selves the agony of waiting for the inevitable attack from outside. Their expectation of Personality Syndromes—P Axis 49 mistreatment creates the suspiciousness and hypervigilance for which they are noted— attitudes that tend to evoke the hostile and humiliating responses they fear. Their personality is defensively organized around the themes of danger and power (either the persecutory power of others or the megalomanic power of the self). Paranoid patients tend to have more or less mild thought disorders and trou- ble conceiving that thoughts are different from actions—a belief that may stem from childhoods in which they were (or felt) criticized for their real or presumed attitudes, as if feelings are equivalent to action. Some clinical reports (Bonime, 1979; Stern, 1989) suggest that they have experienced a parent as seductive or manipulative and are consequently alert to the danger of being seduced and exploited by the therapist and others. They may exist in anxious conflict between feeling panicky when alone (afraid that they will be damaged by an unexpected attack, and/or afraid that their destructive fantasies will damage or have already damaged others) and anxious in relationships (afraid that they will be used and destroyed by the agendas of others). Finally, paranoid people have severe difficulties putting themselves in others’ shoes and examining experiences from such a perspective; that is, they have problems in “cognitive decentration” (Dimaggio & Semerari, 2004). Clinical experience attests to the rigidity of the pathologically paranoid person (Shapiro, 1981). A therapist’s countertransference may be strong, mirroring feelings that the paranoid person disowns and projects, such as helplessness, fright, and a sense of being criticized when the patient expresses only the angry aspects of his or her emo- tional reaction and shows no fear or vulnerability. The clinical literature emphasizes the importance of maintaining a patient, matter-of-factly respectful attitude; the communication of a sense of strength (lest a paranoid patient worry unconsciously that his or her negative affects could destroy the therapist); a willingness to respond with factual information when the patient raises questions (lest the patient feel evaded or toyed with); and attending to the patient’s private conviction that aggression, dependency, and sexual desire—and the verbal expressions of any of these strivings—are inherently dangerous. It is best not to be too warm and solicitous, as such attitudes may stimulate a terror of regression and fuel suspicions about why the therapist is “really” being so nice. Central tension/preoccupation: Attacking versus being attacked by humiliating others. In fact, many people with psychopathic personalities are able to pursue their agendas in contexts of social approval and even admiration. Although many psychopathic individuals run into trouble with authorities, some are quite adept at evading accountability for the damage they do to others. Once referred to as having “moral insanity” (Prichard, 1835), individuals with psychopathic personalities are commonly found in the borderline to the psychotic range of severity (Gacano & Meloy, 1994). Deutsch’s (1955) classic concept of the “impostor” fits within the psy- chopathic realm. Although the stereotype of antisocial personality involves aggression and violence, clinical writings over many decades (beginning with Henderson, 1939) have also noted more passive, parasitic versions of psychopathy, such as the person who operates a scam or Ponzi scheme within a relational matrix. Psychopathic people feel anxiety less frequently and intensely than others (Ogloff & Wong, 1990; Zuckerman, 1999). People with diagnosed antisocial personality dis- order have a higher-than-normal craving for stimulation and may seek it addictively (Raine, Venables, & Williams, 1990; Vitacco & Rogers, 2001). Psychopathic individ- uals lack the empathy and the moral center of gravity that, in people of other person- ality types, tames the striving for power and directs it toward socially valuable ends. Psychopathic individuals may be charming and even charismatic, and they may read others’ emotional states with great accuracy (Dolan & Fullam, 2004). They may be hyperacutely aware of their surroundings, but think and act from a self-referential stance and for egoistic purposes. Their own emotional life tends to be impoverished, and their expressed affect is often insincere and intended to manipulate. Their affec- tive connection to others is minimal; they typically lose interest in people they see as no longer useful. Their indifference to the feelings and needs of others, including their char- acteristic lack of remorse after harming others, may reflect a grave disorder of early attachment. Neglect, abuse, addiction, chaotic undependability in caregivers, and pro- foundly bad fits between a child’s temperament and those of responsible adults have been associated with later psychopathy, but there also appear to be temperamental contributing factors. Therapists working with psychopathic individuals may find themselves feeling initially charmed and then deeply disturbed. They lack the usual sense of emotional connection and may find themselves feeling uncharacteristically apprehensive, jittery, or even “under the thumb” of their psychopathic patients—all countertransferences that are highly informative. Recent empirical studies have identified clinicians’ emo- tional reactions of being criticized and overwhelmed while working with psychopathic patients (Colli et al. Any known history of violence in a patient that coexists with these distressing emotional reactions should impel a thera- pist to give first consideration to issues of his or her own safety. Personality Syndromes—P Axis 51 Treatment in which therapists persistently try to reach out sympathetically may come to grief with psychopathic patients, who regard kindness as signs of weakness. It is possible, however, to have a therapeutic influence on many psychopathic individu- als if their clinicians convey a powerful presence, behave with scrupulous integrity, and recognize that these patients’ motivations revolve primarily around the desire for power. The prospects for any therapeutic influence are better if a psychopathic indi- vidual has reached midlife or later, and has thus felt a decline in physical power and encountered limits to omnipotent strivings. Sadistic Personalities Sadistic personality organization is found mainly at the borderline or psychotic level and is organized around the theme of domination. Internally, the sadistic person may experience deadness and affective sterility, which are relieved by inflicting pain and humiliation—in fantasy and often in reality. Yet, despite the fact that sadism and psy- chopathy are highly related (Holt, Meloy, & Strack, 1999), they are not identical. Not all psychopathic people are notably sadistic, nor are all sadistic people psycho- pathic. Except for studies of criminal sexual sadism, there has been very little empirical research on sadistic personality patterns or disorders.

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A needle is in position just inferior to the inferior mar- gin of the third rib purchase red viagra with visa, ∼5cm from midline buy discount red viagra 200mg on line. One milliliter of radiographic contrast has been injected (iohexol 180 mg per mL) and spans the space between the third and the fourth ribs with a striated pattern extending in an inferior and lateral direction indicat- ing superficial placement within the external intercostal muscle order generic red viagra on line. Clavicle Transverse process of T1 1st rib Medial border of scapula 2nd rib 3rd rib Spinous 4th rib processes Contrast Needle in external tip intercostal m 200 mg red viagra with amex. A: Anterior-posterior radiograph of the chest during the second intercostal neurolysis. A needle is in position just inferior to the inferior margin of the second rib, ∼5 cm from mid- line. Three milliliters of radiographic contrast containing phenol have been injected (10% phenol in iohexol 180 mg per mL). The neurolytic solution has spread along the course of the intercostal nerve, extending medially to the paravertebral space and several centime- ters lateral from the point of injection. Chapter 14 Intercostal Nerve Block and Neurolysis 203 Clavicle Transverse process of T1 1st rib Medial border of scapula 2nd rib 3rd rib Spinous 4th rib processes 5th rib Contrast Contrast along course in external of intercostal nn. Anterior-posterior radiograph of the chest during the fifth intercostal neurolysis. A: A nee- dle is in position just inferior to the inferior margin of the fourth rib, ∼5cm from midline. Three milliliters of radiographic contrast containing phenol have been injected (10% phe- nol in iohexol 180 mg per mL). The neurolytic solution has spread along the course of the intercostal nerve, extending several centimeters medial and lateral from the point of injection. Thus, close attention must be paid to the total local Neurolysis of the intercostal nerves is carried out in the anesthetic dose delivered and to adequate monitoring, same manner described for intercostal nerve blocks using intravenous access, and ready availability of resuscitation local anesthetic. The use of 10% Centers with extensive experience using intercostal nerve phenol in radiographic contrast (e. Injection of 2 to 4 mL of neurolytic clinically insignificant, but radiographically demonstrable solution is usually sufficient to produce spread along a pneumothorax is somewhat higher (0. When intercostal neurol- mode (M-mode) ultrasound provides a sensitive and simple ysis is carried out close to the proximal portion of the rib, technique for detecting even the smallest pneumothoraces the contrast will often extend to the paravertebral space and (see Fig. Treatment of most pneumothoraces extend through the intervertebral foramen to the lateral epi- should be conservative, with observation and administra- dural space. Needle extension of the contrast into the epidural space is unlikely aspiration or chest tube drainage is rarely necessary and to cause adverse effects and may well improve the results of should be reserved only for patients with symptomatic neurolysis. Worsening of pain can arise during intercostal neuroly- sis and is likely the result of incomplete neurolysis of the Complications treated intercostal nerve. Such patients typically report Because of the close proximity of vascular structures to worsened pain in the distribution of the treated intercostal the intercostal nerves, there is a significant risk of direct nerve and may develop signs and symptoms of neuropathic 204 Atlas of Image-Guided Intervention in Pain Medicine pain, including burning or lancinating pain and allodynia in root for intercostal neurolysis: a case report. Phenol neurolysis for at least one case report of spinal cord injury following inter- severe chronic nonmalignant pain: is the old also obsolete? Intrathecal infusion of opioid, opioid and adjuvant analgesic combinations, or ziconotide may be used in selected patients with persistent, cancer-related pain unresponsive to more conservative treatments. Shared decision making regarding intrathecal infusion should include a specific discussion of potential complications. Neuraxial opioid trials should be performed before considering permanent implantation of intrathecal drug delivery systems. Intrathecal infusion of opioid, opioid and adjuvant analgesic combinations, or ziconotide may be used in selected patients with persistent, noncancer pain unresponsive to more conservative treatments. Shared decision making regarding intrathecal infusion should include a specific discussion of potential complications. Neuraxial opioid trials should be performed before considering permanent implantation of intrathecal drug delivery systems. The use of intrathecal morphine has been compared on Chronic Pain Management published a 2010 Prac- with maximum medical therapy in the treatment of patients tice Guideline, offering the following recommendations: with advanced cancer and shown to provide comparable pain “Ziconotide infusion may be used in the treatment of a relief with significantly fewer opioid-related adverse effects, select subset of patients with refractory chronic pain. Intrathecal ziconotide has “Intrathecal opioid injection or infusion may be used for been compared with placebo in the treatment of patients patients with neuropathic pain. Shared decision making with advanced illness and shown to provide marginally regarding intrathecal opioid injection or infusion should superior pain reduction with almost universal appearance include a specific discussion of potential complications. The use of ering permanent implantation of intrathecal drug delivery implanted drug delivery systems carries significant risk, systems. In addition, recent popu- Two recent guidelines were prepared by a multidisci- lation studies point to an increased risk of death in those plinary panel of experts in the use of intrathecal drug deliv- receiving intrathecal infusions; errors in programming and ery; one of the guidelines reviews the evidence regarding the misplacement of the drug into the subcutaneous pocket use of intrathecal drug delivery for patients with cancer pain during refill have been proposed as possible causative fac- (Deer, 2011) and the other for patients with noncancer pain tors. Consensus guidelines for the selection and implantation of patients with noncancer pain for intrathecal drug delivery. Although determined, mark the proposed skin incision with a perma- it is challenging to ascertain optimal timing for the initia- nent marker while the patient is in the sitting position. To optimize difficult to determine once the patient is lying on his or her clinical practice in the absence of evidence-based guidance or side. Performing the initial spinal catheter placement under Intrathecal drug delivery is an invasive and expensive general anesthesia carries concerns about neural injury that treatment modality that carries significant risk. The avail- are similar to performing any neuraxial technique under able evidence for long-term efficacy is modest and the general anesthesia. The avail- The patient is positioned on a radiolucent table in the able expert opinion from different consensus groups offers lateral decubitus position with the patient’s side for the imprecise guidance, highlighting the empiric nature of pump pocket nondependent (see Fig. The final recommendations put forth in are extended at the shoulders and secured in position so the table above represents a composite of the available rec- they are well away from the surgical field. Care must be taken to ensure that the x-ray Before the procedure, discuss with the patient the location view is not rotated by observing that the spinous pro- of the pocket for the intrathecal pump. Most devices are cesses are in the midline, halfway between the vertebral large, and the only region suitable for placement is the left pedicles (Fig. The L3/L4, L4/L5, or L5/S1 interspace is identified using A 5- to 8-cm incision parallel to the axis of the spine is fluoroscopy. The spinal needle supplied by the intrathecal extended from just cephalad to just caudad to the needle, device manufacturer must be used to ensure that the cath- extending directly through the needle’s skin entry point eter will advance through the needle without damage. The subcutaneous tissues are divided using needle is advanced using a paramedian approach starting blunt dissection until the lumbar paraspinous fascia is vis- 1 to 1. A purse-string suture to the superior margin of the lamina that forms the inferior is created within the fascia surrounding the needle shaft border of the interspace you plan to enter (see Fig. Using fluoro- needle and stylette are removed simultaneously, using care scopic guidance, the spinal catheter is advanced through not to dislodge the spinal catheter (Fig. The final catheter catheter and gentle aspiration used to ensure the catheter position can vary and there is no firm connection between remains within the thecal sac. The needle is then withdrawn slightly (∼1 to 2cm) a specific anchoring device supplied by the manufacturer but left in place around the catheter within the subcutane- (Fig. A 10- to 12-cm transverse 210 Atlas of Image-Guided Intervention in Pain Medicine A L3 Needle tip in midline Inferior at L4/L5 L4 margin of lamina of L4 Superior Spinous margin of process lamina of L5 of L5 Iliac crests B C Figure 15-2. B: Initial spinal needle placement via the L4/L5 interspace using a left parame- dian approach. Chapter 15 Implantable Spinal Drug Delivery System Placement 211 Tip of intrathecal L2 catheter L3 L4 L5 Figure 15-3. In many patients, the blunt dis- subcutaneous pocket is created using blunt dissection section can be accomplished using gentle but firm pressure (Fig. If the pocket is placed cephalad to the inci- small pair of surgical scissors to perform the blunt dissec- sion, the weight of the device on the suture line is likely to tion using repeated opening (not closing or cutting) motions Tip of intrathecal L2 catheter L3 L4 L5 Figure 15-4. Sagittal (A) and axial (B) computed tomography of the thorax in a patient with an intra- thecal drug delivery system that has been in place for more than 10 years and providing ongoing pain relief for a patient with chronic axial low back pain. The catheter tip can be seen in the left anterolateral aspect of the thecal sac at the T6/T7 level. Sagittal (C) and axial (D) computed tomography of the thorax in a patient with an intrathecal drug delivery system placed and providing pain relief for a patient with chest wall pain associated with metastatic lung cancer. The catheter tip can be seen in the midline in the posterior aspect of the thecal sac at the T9/T10 level. Reference line on the sagittal images corresponds with the level of the axial images shown. Note that both of the imaging studies shown here were obtained for diagnostic purposes related to each patient’s primary illness. They are shown here to demonstrate the variation in intrathecal catheter position that is commonly seen in practice.

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