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Exactly how and when is an arduous and painful diagnostic and treatment course justified for any particular person? Are resources spent on major surgery for pets justified when they could be diverted to the care of people? How much does a cultural or psychological attitude toward death influence care at the end of life in any particular case? Should an aged Inuit be subjected to a medical or psychological evaluation if she feels ready to depart into the snow? Descriptions report and narratives explain but there are multiple possible levels and extensions of reporting buy 20mg female cialis, and many possible narratives for explaining meaning purchase 20mg female cialis with amex. One act can be assessed in terms of a narrow or a broad descriptive focus and also can be subsumed under several narratives discount 10mg female cialis mastercard. Thus the "preventing a lawsuit" narrative and the "making a living" narrative can diverge from the "giving the best care" JOHN DEWEY’S PERSPECTIVES ON MEANS AND ENDS 91 narrative cheap female cialis 20 mg with amex. Recipes for clinical care are supposed to dictate choices when doing so is really helpful, but they always involve assumptions about narrative and descriptive context which need, at the proper time, to be examined. The fact that rigidity and automaticity work sometimes does not mean that they work all the time. Even in the greatest emergencies conditions may arise which demand that we not be creatures of protocol. The two great pitfalls around context which Dewey identifies are failing to consider context and its particularities, so that our actions become inappropriate in the light of it, and discounting central concerns and priorities because considerations are too diffuse. There is a time to discount and ignore and a time to pay attention to some individual fact; a time to accept the obvious and a time to question it. There is a time to concentrate and a time to look around; a time to make a judgment and a time to withhold one. Bayesian reasoning, with its controversial concept of prior probability is one attempt to assess, semi-formally, the importance of context. In a nutshell, it offers a method for weighting the significance of an individual piece of data given certain aspects of the context in which it occurs. Informally, we do this all the time, for example when we decide to double check a laboratory value which makes no sense in light of what we know already about a case. When studies come out "proving" that penicillin does not shorten the course of streptococcal pharyngitis, that antibiotics do not help cat scratch disease, that triglycerides do not affect heart disease, that ibuprofen is as safe as acetaminophen in children over six months and that post-menopausal estrogen causes breast cancer (or does not), that a high fiber diet can (or cannot) prevent colon cancer or that personality does or does not affect heart attack risk, we take all with "a grain of salt. No matter how compelling the statistical evidence internal to one study may be, it does not exist in a contextual vacuum. For example, suppose that a serologic test for HIV is positive in 95% of people actually infected with HIV and in 1% of people who are not infected. When such a test is used in a population "previously known" to have a low incidence of HIV infection, say "worried well college students" who havea1in1,000 chance of being infected, a positive test has much less predictive value than it does in a population of 1,000 prisoners whose "prior probability" of being infected is, say, 10%. When prior probabilities are actually applicable to the group being tested, and in this lies the controversy, the predictive value of the test comes out as follows: For the 1,000 college students 92 CHAPTER 3 there is one who will likely have a true positive test result and there are 10 who will have false positive tests. After the test, the probability of anyone testing positive actually being infected is about. The predictive value of a negative test only improves the odds that one is not infected in this group from. In contrast, for the prisoners, out of the 100 actually infected, 95 will test positive and out of the 900 not infected, 9 will test positive. A test is most useful when it most strongly changes the odds that a disease is present, and that depends on the setting in which it is used. Bayesian theory is a wonderful way to improve the precision of informal reasoning about some contextual questions. But, as Dewey has shown, informal reasoning deals with much more than just weighing the significance of prior probabilities.

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Medical Therapies 47 Patients with major depressed mood order female cialis 20mg, anxiety cheap female cialis 10 mg visa, or other negative af- fective states report more pain with noxious stimuli than do controls with positive affective states female cialis 20 mg otc. We believe that emotionally depressed patients can be appropriate candidates for interventional therapies; it is simply necessary to be especially careful when offering them thera- pies that carry significant risks order female cialis 20mg free shipping. While it may be obvious that patients with severe pain caused by a peripheral pain generator will also ex- perience depression or anxiety, it is less obvious that the same nega- tive affective states actually increase the experience of pain itself. De- pressed affective states can also maintain pain and cause it to take on a life of its own by dramatically amplifying what would otherwise be a relatively minor pain generator. Frequently, a physician can determine the severity of emotional dys- function during an initial encounter. If the patient reports anhedonia, depressed or increased appetite, a history of major depression, or dif- ficulty sleeping, a physician should be alert to the possibility that de- pressed mood is an exacerbating component of the pain. When a ma- jor depression is suspected, it should be treated prior to initiating interventional techniques, directly or by referral to a competent physi- cian who can help with this aspect of pain. Pain Management To reiterate: in order to determine the most appropriate therapeutic strategy, it is vital to begin by making an accurate and comprehensive pain diagnosis. The treatment of neuropathic pain might be very dif- ferent from that of nociceptive pain. Likewise, the treatment of myo- fascial pain is very different from that of discogenic pain, and so forth. Frequently, the tools just discussed are sufficient to establish the diag- nosis, the severity of symptoms, and the prognosis of the patient with pain. Once the diagnosis has been established, it is important to de- sign the most appropriate strategy. This involves choosing the best strategy for the patient and selecting the appropriate patient for a given procedure. In other words, certain conditions may call for certain ther- apies, but for a specific patient suffering from one such condition, the usual therapies may be inappropriate. In addition, some therapies may fail in some patients and succeed in others with the same condition. It is, thus, important that the physician involved in interventional pain medicine be familiar with the full spectrum of diagnostic and ther- apeutic care and with ways to determine appropriate patient selection for any given procedure. They should be considered as tools in a toolbox, however, not as a list of medica- tions that must be tried prior to initiating interventional therapies. When applied to peripheral pain fibers, prostaglandins (PGE2 in particular) amplify the experience of pain. Nonsteroidals block the cyclooxygenase (COX) enzymes that oversee production of PGE2 and, thus decrease the amount of prostaglandin. These pharmaceuticals are commonly used to treat pain syndromes characterized by inflammation or by mild pain. Non- steroidals are also used to decrease the dosage of opioids required to control pain. Unfortunately, traditional nonselective prostaglandin inhibitors also block the production of the constitutive enzymes required to protect gastrointestinal mucosa and platelet function. For this reason, phar- maceutical companies developed newer classes of nonsteroidals that selectively block the COX-2 enzyme. These agents appear to have a similar efficacy to the traditional nonsteroidals and to offer a marked improvement in the safety profile. Antiepileptic or Membrane-Stabilizing Agents The class of agents most commonly used to treat neuropathic pain, antiepileptics and membrane stabilizers, has become the mainstay of therapy for neuropathic pain (see Table 3. Membrane-stabilizing agents have multiple mechanisms of action and should be tried con- secutively if a single agent fails. Gabapentin is the most commonly pre- scribed drug for neuropathic pain, even though it is indicated only for postherpetic neuralgia. Tricyclic Antidepressants Tricyclic antidepressants have multiple mechanisms of action and have been most thoroughly studied in the treatment of neuropathic pain. They function by decreasing depression and, thereby decreasing the amplification of pain. They also decrease the inhibitory neurotrans- mitters norepinephrine and serotonin, thereby amplifying the impact of the body’s own mechanisms to inhibit pain transmission. The anticholinergic effects of tricyclic antidepressant can cause prob- lems in patients with glaucoma, cardiac conduction abnormalities, or prostatic hypertrophy; thus, these pharmaceuticals must be used cau- tiously in elderly patients or in patients with these comorbid diseases.

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Couples acquire a style and identity in the early days before children that characterizes their relationship buy female cialis 20 mg without a prescription. Those who have bonded too tightly Couples with Young Children 47 may have difficulty expanding to include a child best female cialis 10mg, and those so loosely con- nected may find it challenging to reorganize around a new member generic female cialis 20mg mastercard. Rigidly structured relationships with clearly defined roles are especially challenged when a new baby arrives cheap 10mg female cialis free shipping, but among the most important skills couples bring to the childbearing years is their ability to problem solve. When a new baby enters the family circle, there is a decided shift in at- tention from the spouse to the newborn. Although having positive feelings toward their child, anger and resentment may simultaneously be directed at their partner. Fatigue from many sleepless nights, insecurity in handling the numerous childcare tasks, unmet expectations, and the loss of the undivided attention from one’s spouse all contribute to the confusion and turmoil young parents experience. The ground rules have changed, and although old patterns of relating are not always accessible, new pat- terns have not yet been clearly established (Wolfson & DeLuca, 1981). The history of how well they solve problems together influences how likely they are to make adjustments and compromises required in reorganizing their lives (Cox et al. RETURNING TO WORK When both partners are employed prior to a child’s birth, the assumption is often made that the mother will return to her former employment after maternity leave. Some couples may choose not to alter their lifestyle and make the ad- justments necessary to live on a single salary, while others are simply unable to survive on one income. Even when there is a choice as to whether or not the wife returns to work, the decision is often influenced by the availability of adequate childcare. In earlier times, when our society was less mobile, extended families of- fered a ready supply of babysitters, and mothers could reliably leave their infant in the care of a family member with little or no cost involved. With families increasingly living at greater distances from one another, this is not always an option. With the older generation living longer and healthier lives, extended family members who are geographically accessible are choosing to pursue their own personal or career interests rather than be- come full-time babysitters. Couples are forced to go outside the family circle for childcare and assess their comfort with a paid caregiver, understanding that the hired help may in fact hear their child’s first word or witness his first step. Full-time parenting and nurturing versus the stimulation of childcare opportunities has been argued for decades by vocal advocates in support of their positions. But the decision often comes down not to what others say, but to the mother’s choice of what works best for her and her family. Some 48 LIFE CYCLE STAGES women cannot imagine leaving their children in the care of another during these early years, while others are unwilling to remain home full-time with an infant, no matter how engaging its personality. When the mother has decided to return to work after finding suitable childcare, there is still the inevitable sick child or emergency. Although spouses agree in theory that their careers are of equal importance, there in- evitably arises the question of which spouse leaves work to retrieve a sick child or who remains home when communicable childhood illnesses prevent the child from attending the childcare center. The decision is often based on which spouse’s income is higher or whose employment offers the greatest potential for growth. Employers may pay lip service to the family-friendly workplace, but are less likely to promote the employee who prioritizes family over long hours and high productivity (Bradt, 1989). Additionally, contempo- rary society does not universally esteem mothers who forgo careers in order to parent full time. By applauding the hardworking father and devaluing the stay-at-home mom, there seems little in modern America that supports cou- ples’ efforts to prioritize family life. SEX AND INTIMACY Sexual intimacy is the emotional barometer of a relationship, and most couples are eager to return to their prechildbirth sexual activity after the customary six-week postnatal visit. But sex, like most activities after the birth of a baby, usually requires some adaptation, accommodation, and patience. Although women, in theory, may be eager for the physical affection and intimacy of sex, physiological and emotional issues may interfere, at least initially. Sex may be simply physically uncomfortable for her still-healing body, especially if there has been the added complication of caesarian sur- gery. Fatigue from lack of sleep and the stress of a demanding new role may diminish sexual desire.

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