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When a course or workshop is not immediately available extra super viagra 200 mg with visa, the PTP may counsel premarital couples in need of more training via OFFICE PAIRS until they can participate in a PAIRS program discount 200mg extra super viagra free shipping. The PTP selects concepts buy extra super viagra 200 mg online, exercises discount 200mg extra super viagra overnight delivery, and experiences thought to be most cogent to their missing competencies and then teaches these in a series of 90-minute sessions purchase extra super viagra 200mg without prescription. In locations where there are no available PAIRS courses or workshops and when a couple cannot travel to one in another location, the PTP may contract to lead the couple through the content of one of the shorter PAIRS curriculums in a defined se- ries of 90-minute sessions. When engaging a PAIRS curriculum, each pur- chases a participant’s handbook for the selected course and a copy of The Passage to Intimacy book, which provides a deeper presentation of the ideas, skills, or attitudes under study. In such OFFICE PAIRS activities, couples re- ceive homework assignments and are expected to practice daily the skills they are learning. Teaching these skills is usually easier and more natural in a group setting than in the office. THE PAIRS RELATIONSHIP MASTERY COURSE The full PAIRS curriculum is divided into six main sections: 1. The following summary highlights specific PAIRS exercises and key con- cepts in italic. Premarital Counseling from the PAIRS Perspective 15 COMMUNICATION AND PROBLEM SOLVING PAIRS begins with a presentation of the Relationship Roadmap, the basic PAIRS model of how relationships succeed or become stuck and fail. Couples learn of the essential role of confiding in intimacy and then how to listen and speak in ways that deepen their level of confiding. They are taught the Daily Tempera- ture Reading, in which they are expected to confide in one another each day sharing Appreciations, New Information, Puzzles, Complaints with Request for Change, and Wishes, Hopes, and Dreams. Participants then read and practice Virginia Satir’s (1988) The New Peoplemaking and discover how the style one uses can be a far greater problem than the actual issue under dis- cussion. When stressed and communicating in stress styles (Blaming, Placat- ing, Computing, and Distracting), the underlying problem goes unresolved. Couples are then taught the Leveling Style of Communication practiced in the congruent position (face to face, hands in hands), which is a foundation for the subsequent confiding work in the course. They cultivate the skill to slow down communication using Empathic Shared Meaning, taking turns being the speaker and the listener with feedback to assure understanding. They next learn how to confide a negative reaction to their partner’s behavior all the way through in safety using the PAIRS Dialogue Guide. The Dialogue Guide leads the speaker through a sequence of 18 "I-Statement" sentence stems re- garding this negative reaction. Maintaining eye contact, holding hands while they speak, giving verbatim feedback, and not answering the complaint or introjecting defensiveness helps couples to stay connected to one another and avoid misunderstandings. They discover how to speak so that the other person really wants to listen, and how to listen with empathy so that the other feels deeply heard and understood. One of the many paradoxes of PAIRS is how direct and skillful engage- ment of conflict builds greater closeness, trust, and confidence in the rela- tionship. Couples are taught safe and structured ways to move into the intense emotion regarding a conflict as a first step toward resolving an issue. When emotions are cut off or suppressed, it is as if they are poured into a jug and stopped up with a cork—a cork that becomes the "stiff upper lip" of indifference. This process can occur relatively quickly when couples master the tools and are not fearful of each other’s emotions. By learning how to express fully one’s fear, pain, and anger in safe and non- destructive ways, and to do so in the arms of their beloved, and/or with the support of peers, the bond between intimate partners powerfully deepens. The Emptying the Jug Exercise is also taught as a prenegotiation release and as an emotional confiding tool that may be used like the Daily Temperature Reading. They include the Anger Rituals (the Haircut, and the Vesuvius) in which one partner asks permission of the other to vent in a time-limited fashion with as much intensity as is present. The Anger Rituals help to contain anger in those who explode or speak caustically and to give permission to be angry and assertive to those who rarely allow themselves to do this. Once suppressed emotions around an issue are released, couples can then productively engage the Fair Fight for Change, another Bach ritual adapted by PAIRS for use as a structured negoti- ation. Here, couples learn to fight for the relationship, rather than against their partner. Peer couple coaches guide the partners through the fight for- mat, prohibit dirty fighting, and enable reflective evaluation of the partners’ emerging healthy fight styles.

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Revolutionary developments in computer graphics display hardware and software revolutionized airline safety in the form of real-time interactive ¯ight simulators discount extra super viagra 200 mg without a prescription. The real hype started in 1989 generic 200mg extra super viagra mastercard, when Jaron Lanier buy cheap extra super viagra 200mg line, who is often called the step-father of VEs discount extra super viagra 200 mg overnight delivery, generated business from VE technology order 200mg extra super viagra overnight delivery. He succeeded at that time in developing and selling sensor technology to interface the subject with the computer in such a way that a nearly natural communication with the system was possible. The historical experience with interactive ¯ight simulators and their revolutionary e¨ect on airline safety is used today as an argument to proceed with developing simulators for medical training and certi®cation. His e¨ort led Charles Dotter to start experi- menting with threading radio-opaque catheters through blood vessels under ¯uoroscopic-image guidance in the 1960s. Those experiments were a trigger point for the avalance of minimally invasive imaging procedures emerging today in clinical practice. Dotter was the ®rst to interact and intervene with a patient in an indirect way: He looked at shadow images in stead of the patient. This chapter advocates the use of VE technologies in the ®eld of medicine to render medical services in a virtual world: to bring medical care to the patient and to improve care by dedicated training and skills building. Therefore, I start with highlighting the technologies involved with VE and how these technologies create bene®ts for the medical community. The second part of the chapter illustrates that the combined e¨orts of the medical and computer societies have already created real products. VE is the term used by academic researchers to describe the form of computer±human interactionÐin which the human is 2. The term VE emphasizes the immersion of the subject in the virtual environment synthesized by the machine. Other terms are cyberspace, telepresence, mirror world, arti®cial reality, augmented reality, wraparound compuvision, and synthetic environment. In principle, all ®ve human senses (sight, hearing, touch, taste, and smell) are involved with the immersion in such a way that there is stimulation by the machine. The human responds to the system by actuating peripheral sensors and absorbs most information by sight. Motoric activation, speech, and head and eye movements are exploited when the subject responds to the presented information. At present, peripheral sensors are based on the DataSuit, DataGlove, SpaceBall and 3-D Mouse; sight and hearing are the most prominent of the senses involved. Stim- ulating the olfactory and gustatory senses with program-controllable sub- systems is still in the laboratory (4). Contrary to what the popular press wants us to believe, VE technology is not magical but rather a synergy of various technologies that by themselves have been around for some time. VE systems combine human interface technology, graphics technology, sensor and actuator technology, and high-performance computing and networking (HPCN) to allow the subject to explore and interact with computer-animated graphics. Various applications for VE simulations are currently the subject of research and development. The subject interacts with the real environment and the physically modeled environment, i. The actuator subsystem supports the subject in that experience, and the sensor subsystem enables the subject to interact with the environments. The control subsystem plays a central role in coordinating all tasks of the sensor and actuator subsystems. The subject stands or walks on a ¯oor, sits in a chair or hardware mock-up, and interacts with that environment through elementary laws of nature (gravity, momentum, etc. A physically modeled en- vironment consists of a description of the geometry of objects in the environ- 36 VES IN MEDICINE; MEDICINE IN VES Figure 2. In a medical application, the geometry of the objects is determined by human anat- omy and pathology, the functions of the objects and their interactions is deter- mined by physiology, and physical deformation is a function attributed to the objects. The objects can also be completely virtual (surgical) instruments or hand-held instruments that are visible in the VE. In the latter case, the objects are part of both the real and the virtual environments.

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A famous form 4 cluded that even if an immortal species had ever existed discount extra super viagra 200mg mastercard, of senescence is the death of the Pacific salmon extra super viagra 200 mg with visa. The question is buy 200 mg extra super viagra fast delivery, is Although the mathematical formulation of this death "merely" the result of entropy? It would be as Charlesworth is rigorous 200 mg extra super viagra amex, there are challenges to the accurate to posit that death caused by smallpox (or star- conclusions that may be drawn from this formulation vation or myocardial infarction) is due to entropy cheap 200mg extra super viagra with amex. Such because of the assumptions on which the analysis is a formulation might be formally true, but it is more based. For example, several species appear to exhibit informative to ascribe the mechanism of senescence to its extremely low, indeed virtually undetectable, rates of senescence. Finally, as discussed below, several individual difficult to determine the biologic substrate of the degen- genes have been found whose continuing activity is by erative changes. This difficulty has given rise to the sense itself limiting to life span; furthermore, across phyla, these that degenerative changes with age are essentially genes appear to be impinging on similar physiologic random, for example, a manifestation of entropy. If such a simple set of genes operated similarly view has been reinforced by the argument, developed in humans, it would be the object of great interest and 2. Molecular and Biologic Factors in Aging 17 22 perhaps a potential target for drug intervention. Furthermore, the fact that dietary restric- tence of such genes poses a stark challenge to evolution- tion increases maximum life span and also reduces blood ary analyses that imply that senescence could not be glucose and rate of glycation has continued to stimulate determined by the activity of a few genes or a develop- interest in the possible role glycation may play in the process of senescence. However, a major difficulty with the The bewildering diversity of age-related impairments has free radical and glycation theories, and indeed with all led many gerontologists to conclude that no general such theories, is that they are of little value in predicting mechanism is likely to underlie these changes. Further- the specific physiologic impairments that characterize the more, although there is a general sense that senescence senescence of each species. The two most popular has been a field characterized by a plethora of mecha- candidates for the weak link theories are the neuroen- nistic theories. Both the generally fall into two categories, which can broadly be neuroendocrine system and the immune system exhibit referred to "loose cannon" theories and "weak link" profound and specific functional impairments during theories. Failure of the neuroendocrine system would be The "loose cannon" theories posit that some entropy- expected to produce profound impairments in homeo- producing agent is slowly wearing away at cellular macro- static systems, including the loss of reproduction and molecular constituents. Considerable evidence suggests that oxidative damage increases with Similarly, failure of the immune system would be age. For example, it now appears in more, simultaneous overexpression of two different fact that, far from the expected relationship between enzymes that attenuate free radical damage, superoxide declining growth hormone and age-related mortality, dismutase and catalase, significantly increases the life mice with growth hormone deficiency exhibit increased span of fruit flies;20 no effect was seen when only one life span compared to wild-type mice, whereas mice with elevated growth hormone exhibit reduced life span. Similarly, exposure of nematodes to small molecules that mimic effects of superoxidase Similarly, although autoimmune processes cause type dismutase and catalse also increased life span. The major means by which glucose has been pro- roendocrine and immune systems do exhibit impairments posed to promote senescence is through nonenzymatic with age, little is known about the more primary mecha- attachment to proteins and nucleic acids through Schiff nisms that drive these changes. Therefore, in their current base formation, followed by an irreversible formation incarnations, none of the entropic theories of aging are of Amadori products, the same process that produces complete, and it cannot be said that considerable evi- glycated hemoglobin. Mobbs Physiology of Aging Although this derivation is far from accomplished, simply being able to formulate such a precisely quantitative As organisms age, they accrue functional impairments in question is evidence of the state of gerontology as a sci- virtually every physiologic system. Analysis suggests that at least the form Shock and his coworkers developed a general rule of of the Gompertz curve may arise from evolutionary thumb that many physiologic systems accrue impair- effects, involving a decline in the force of natural selec- 28 ments at a rate of about 5% to 10% per decade after the tion acting on age-specific mortality. In the top panel that a heart rate more than 80% of maximum attainable (A), the survival curve (fraction of initial population left during a stress test is dangerous, and that the maximum alive as age increases) of a typical ("normal") population heart rate attainable during a stress test reliably is compared with the survival curve of a genetically decreases by about 1 beat per minute each year during similar population placed into an optimum environment aging. The rate of this decline is reduced by about half ("enhanced environment") or a population modified in highly trained athletes, but even in such athletes, genetically or subject to dietary restriction. Note that an maximum heart rate and maximum oxygen consumption enhanced environment can increase average life span rate nevertheless decline with age. In contrast, genetic variance and dietary restriction can increase not only average life span but maximum life span as well. When these same data are plotted in terms The Gompertz Curve of rate of mortality (the number of individuals that have The essential feature of senescence, at least when applied died over an arbitrarily small unit of time), the mortality to mortality, is that the rate at which death occurs rate of all groups increases exponentially with age and increases with time. If the rate at which death occurred reaches the same high rate toward the end of life; the were constant (e. In most species, nential increase (although then the rate increases even senescence, manifest as an increase in the rate of mortal- faster toward the end of life), whereas genotype and ity with age, can be described by a remarkably simple dietary restriction can actually change the rate at which mathematical function. Because mortality rate increases species that have been studied, including flies, nematodes, exponentially with age, these effects are more easily and rodents, increases exponentially with time, first understood by subjecting the rate data to a logarithmic observed in humans by Benjamin Gompertz after observ- transform. After such a transform, log (mortality rate) ing actuarial statistics and reported in 1825. Normal and enhanced envi- pertz equation can be stated succinctly as Rm(t) =-(1/n) ronment groups have similar slopes.

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