Clinical supervision: Its influence on client-rated working alliance and client symptom reduction in the brief treatment of major depression

Supervision of psychotherapists and counselors, especially in the early years of practice, is widely accepted as being important for professional development and to ensure optimal client outcomes. Although the process of clinical supervision has been extensively studied, less is known about the impact of supervision on psychotherapy practice and client symptom outcome. This study evaluated the impact of clinical supervision on client working alliance and symptom reduction in the brief treatment of major depression. The authors randomly assigned 127 clients with a diagnosis of major depression to 127 supervised or unsupervised therapists to receive eight sessions of problems-solving treatment. Supervised therapists were randomly assigned to either alliance skill- or alliance process-focused supervision and received eight supervision sessions. Before beginning treatment, therapists received one supervision session for brief training in the working alliance supervision approach and in specific characteristics of each case. Standard measures of therapeutic alliance and symptom change were used as dependent variables. The results showed a significant effect for both supervision conditions on working alliance from the first session of therapy, symptom reduction, and treatment retention and evaluation but no effect differences between supervision conditions. It was not possible to separate the effects of supervision from the single pretreatment session and is possible that allegiance effects might have inflated results. The scientific and clinical relevance of these findings is discussed.

Clinical features and management of tumors affecting the lacrimal drainage apparatus

Purpose: To report the clinical features of a series of patients with lacrimal drainage apparatus tumors and present guidelines for management based on histopathology. Methods: A noncomparative retrospective chart review of the clinical, imaging, and pathologic findings of 37 patients presenting to four regional orbital Surgery departments with tumors affecting the lacrimal drainage apparatus between 1990 and 2004. Results: There were 37 patients, of whom 62% were male. The mean age at referral was 54 years. Epiphora, a palpable mass, and dacryocystitis were the most common presentations. Two thirds of the tumors were epithelial. with carcinomas being the most frequent (38%). followed by papillomas (27%). Lymphomas were the most common nonepithelial malignancy (30%). Epithelial tumors were more common in men (87%), whereas lymphomas were more common in women (57%). Treatment modalities included surgery, in addition to radiotherapy and/or chemotherapy and immunotherapy. Mean follow-up was 38 months. Thirty-three patients (89%) remain alive without evidence of disease and 4 patients died of recurrence and/or metastases. Conclusions: Lacrimal drainage apparatus tumors require careful initial management to ensure adequate local and systemic disease control. Atypical mucosa encountered during dacryocystorhinostomy should be biopsied and small papillomas or pedunculated tumors excised and analyzed with frozen sections. If a diffuse or infiltrative mass is encountered, it should be biopsied and managed on the basis of histopathology and extent of disease. Lymphomas should be treated according to protocols. whereas noninvasive carcinoma and extensive papillomas require complete excision of the system. Invasive disease requires en bloc excision. Long-term follow-up is essential for early detection of recurrence.

En bloc excision in malignant tumors of the lacrimal drainage apparatus

Purpose: To describe the surgical technique and results of en bloc excision in a series of patients with extensive malignant tumors of the lacrimal drainage apparatus (LDA). Methods: This was a noncomparative, retrospective chart review of the clinical and pathologic findings of 11 patients presenting with a malignant tumor affecting the LDA who underwent en bloc excision of the lacrimal system. Results: Of the 11 patients, 7 were male. The mean age at presentation was 58 years (range, 39 to 81 years), and all cases were unilateral. Histopathology revealed 4 squamous cell carcinomas, 3 transitional cell carcinomas, 2 mucoepidermoid carcinomas, and 2 melanomas. Epiphora and a mass were the most common presentations. An external lesion could be identified in 4 cases. Irrigation of the lacrimal system revealed nasolacrimal duct obstruction in 2 cases and common canaliculus obstruction in another 2 patients. The entire LDA and surrounding bony tissues were excised through a lateral rhinotomy approach. Adjuvant radiotherapy was given in 4 cases. Nine patients remain alive and well after a mean follow-up of 2 years (range, 6 months to 7 years). Three cases showed distant disease and 2 patients died of metastatic melanoma involvement. Conclusions: The use of en bloc excision as a radical treatment to remove the complete LDA and surrounding bony structures affords good local tumor control and may provide the best opportunity for enhanced patient survival.

Combined external-endonasal approach for complete excision of the lacrimal drainage apparatus

Purpose: The purpose of this study was to describe a new surgical technique for the complete excision of the lacrimal drainage apparatus (LDA) that combines external and endoscopic approaches. Methods: This study involved a noncomparative, retrospective chart review of the clinical and pathological findings of four patients presenting with LDA papillomas who underwent a combined open and endonasal excision of the lacrimal system. Results. Of the four patients, three were male. The mean age at referral was 41 years, and all cases were unilateral. Histopathology revealed two transitional cell papillomas, one squamous cell papilloma, and one combined transitional/squamous papilloma. Epiphora and an external lesion were the main complaints at presentation. Nasolacrimal duct obstruction was present in all four patients. Papilloma virus infection was suggested in two cases and was confirmed in the only patient who had recurrence. CT identified a solid enhancing mass in two cases. The surgical approach in all cases was performed with the patient under general anesthetic supplemented with infiltration of local anesthesia with vasoconstriction. The lacrimal sac was exposed as per an external dacryocystorhinostomy with biopsy collection from the lacrimal sac lumen to confirm the diagnosis prior LDA excision. The superior aspect of the LDA was isolated by using lacrimal probes in each canaliculus to stabilized parallel incisions and careful dissection toward the common canaliculus until they met the medial aspect of the lacrimal sac. The sac was then separated from the periosteum from the medial orbital wall, using sharp dissection. Finally, an endoscopic dissection of the lower end of the nasolacrimal duct released the most inferior aspect of the LDA, allowing the surgeon to pull and excise the complete system from the external wound. Conclusions: Extensive LDA papillomas required complete excision of the drainage system to prevent recurrence and/or malignant transformation. The use of a combined approach through an open excision of the superior part of the LDA in conjunction with the direct manipulation of the nasolacrimal duct guided by the nasal endoscope facilitates the complete excision of the system for extensive benign lesions.

A novel nucleation apparatus for regime separated granulation

A novel nucleation apparatus is presented for the production of narrow sized nuclei from various powder and binder liquid combinations. Mono-sized binder liquid droplets are produced by a specially designed mono-disperse droplet generator. The droplet generator is positioned above a conveyor belt, transporting a powder bed through the spray zone of the droplet generator. By nucleating powder on a conveyer belt, the nucleation mechanism is completely separated from all other granulation mechanisms due to the lack of relative motion between primary particles and/or formed nuclei. Nucleation tests were performed using chalcopyrite and limestone powders with water as the binder liquid. At all operating conditions, the formed nuclei were found to originate from multiplicities of drops that merged on the powder bed surface. Investigation of the dynamics of nuclei formation showed that powder-binder liquid combinations with fast penetration dynamics result in less variation in the number of droplets from which nuclei originate. Smaller and more narrowly distributed nuclei were also achieved by increasing powder speed through the spray zone.

The Future of the Australian-U.S. Security Relationship

Australia is an increasingly important ally for the United States. It is willing to be part of challenging global missions, and its strong economy and growing self-confi dence suggest a more prominent role in both global and regional affairs. Moreover, its government has worked hard to strengthen the link between Canberra and Washington. Political and strategic affi nities between the two countries have been refl ected in--and complemented by--practiced military interoperability, as the two allies have sustained a pattern of security cooperation in relation to East Timor, Afghanistan and Iraq in the last 4 years. This growing collaboration between the two countries suggests that a reinvention of the traditional bilateral security relationship is taking place. At the core of this process lies an agreement about the need for engaging in more proactive strategic behavior in the changing global security environment, and a mutual acceptance of looming military and technological interdependence. But this new alliance relationship is already testing the boundaries of bipartisan support for security policy within Australia. Issues of strategic doctrine, defense planning, and procurement are becoming topics of fi erce policy debate. Such discussion is likely to be sharpened in the years ahead as Australia’s security relationship with the United States settles into a new framework.

High-resolution bulk density images, using calibrated X-ray radiography of impregnated soil slices

Bulk density of undisturbed soil samples can be measured using computed tomography (CT) techniques with a spatial resolution of about 1 mm. However, this technique may not be readily accessible. On the other hand, x-ray radiographs have only been considered as qualitative images to describe morphological features. A calibration procedure was set up to generate two-dimensional, high-resolution bulk density images from x-ray radiographs made with a conventional x-ray diffraction apparatus. Test bricks were made to assess the accuracy of the method. Slices of impregnated soil samples were made using hardsetting seedbeds that had been gamma scanned at 5-mm depth increments in a previous study. The calibration procedure involved three stages: (i) calibration of the image grey levels in terms of glass thickness using a staircase made from glass cover slips, (ii) measurement of ratio between the soil and resin mass attenuation coefficients and the glass mass attenuation coefficient, using compacted bricks of known thickness and bulk density, and (iii) image correction accounting for the heterogeneity of the irradiation field. The procedure was simple, rapid, and the equipment was easily accessible. The accuracy of the bulk density determination was good (mean relative error 0.015), The bulk density images showed a good spatial resolution, so that many structural details could be observed. The depth functions were consistent with both the global shrinkage and the gamma probe data previously obtained. The suggested method would be easily applied to the new fuzzy set approach of soil structure, which requires generation of bulk density images. Also, it would be an invaluable tool for studies requiring high-resolution bulk density measurement, such as studies on soil surface crusts.