Sanjeev Bhalla, MD

• Associate Professor of Radiology
• Washington University
• Mallinckrodt Institute of Radiology
• Chief, Cardiothoracic Imaging Section
• Barnes Jewish Hospital
• St. Louis, Missouri

Impairment of function Any anatomic or functional loss erectile dysfunction drugs kamagra purchase caverta 50 mg with visa, lessening impotence versus erectile dysfunction order caverta overnight, or weakening of the capacity of the body erectile dysfunction protocol free discount caverta american express, or any of its parts do erectile dysfunction pumps work buy discount caverta 100mg on-line, to perform that which is considered by accepted medical principles to be the normal activity in the body economy erectile dysfunction cures over the counter buy generic caverta 100 mg on line. Latent impairment Impairment of function that is not accompanied by signs and/or symptoms but is of such a nature that there is reasonable and moral certainty www.erectile dysfunction treatment cheap caverta 100mg line, according to accepted medical principles, that signs and/or symptoms will appear within a reasonable period of time or upon change of environment. Manifest impairment Impairment of function that is accompanied by signs and/or symptoms. The presence of physical disability does not necessarily require a finding of unfitness for duty. Physician A doctor of medicine or doctor of osteopathy legally qualified to prescribe and administer all drugs and to perform all surgical procedures. Sedentary duties Tasks to which military personnel are assigned that are primarily sitting in nature, do not involve any strenuous physical efforts, and permit the individual to have relatively regular eating and sleeping habits. Each note has a different definition for use but they are both similar in that they indicate that codes excluded from each other are independent of each other. An excludes2 note indicates that the condition excluded is not part of the condition it is excluded from but a patient may have both conditions at the same time. When an Excludes2 note appears under a code it is acceptable to use both the code and the excluded code together. Code First/Use Additional Code notes (etiology/manifestation paired codes) Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. The "sequelae" include conditions specified as such; they also include residuals of diseases classifiable to the above categories if there is evidence that the disease itself is no longer present. Primary malignant neoplasms overlapping site boundaries A primary malignant neoplasm that overlaps two or more contiguous (next to each other) sites should be classified to the subcategory/code. D35 Benign neoplasm of other and unspecified endocrine glands Use additional code to identify any functional activity. The dysfunction may be primary, as in diseases, injuries, and insults that affect the brain directly and selectively; or secondary, as in systemic diseases and disorders that attack the brain only as one of the multiple organs or systems of the body that are involved. The category is also for use in multiple coding to identify these conditions resulting from any cause Excludes1:congenital cerebral palsy (G80. Pupillary occlusion Pupillary seclusion Excludes1:congenital pupillary membranes (Q13. The "sequelae" include conditions specified as such or as residuals which may occur at any time after the onset of the causal condition Excludes1:personal history of cerebral infarction without residual deficit (Z86. Use additional code, where applicable, to identify: exposure to environmental tobacco smoke (Z77. Excludes2: chronic (childhood) granulomatous disease (D71) dermatitis gangrenosa (L88) dermatitis herpetiformis (L13. If one of the underlying conditions listed below is documented with a lower extremity ulcer a causal condition should be assumed. N11 Chronic tubulo-interstitial nephritis Includes: chronic infectious interstitial nephritis chronic pyelitis chronic pyelonephritis Use additional code (B95-B97), to identify infectious agent. The appropriate code from category O30, Multiple gestation, must also be assigned when assigning a code from category O36 that has a 7th character of 1 through 9. The appropriate code from category O30, Multiple gestation, must also be assigned when assigning a code from category O41 that has a 7th character of 1 through 9. The appropriate code from category O30, Multiple gestation, must also be assigned when assigning a code from category O69 that has a 7th character of 1 through 9. This code must be accompanied by a delivery code from the appropriate procedure classification. Practically all categories in the chapter could be designated "not otherwise specified", "unknown etiology" or "transient". The Alphabetical Index should be consulted to determine which symptoms and signs are to be allocated here and which to other chapters. The conditions and signs or symptoms included in categories R00-R94 consist of: (a) cases for which no more specific diagnosis can be made even after all the facts bearing on the case have been investigated: (b) signs or symptoms existing at the time of initial encounter that proved to be transient and whose causes could not be determined; (c) provisional diagnosis in a patient who failed to return for further investigation or care;(d) cases referred elsewhere for investigation or treatment before the diagnosis was made; (e) cases in which a more precise diagnosis was not available for any other reason; (f) certain symptoms, for which supplementary information is provided, that represent important problems in medical care in their own right. A13 Poisoning by pertussis vaccine, including combinations with a pertussis component, assault T50. A23 Poisoning by mixed bacterial vaccines without a pertussis component, assault T50. Z92 Poisoning by other vaccines and biological substances, intentional self-harm T50. Most often, the condition will be classifiable to Chapter 19, Injury, poisoning and certain other consequences of external causes (S00-T98). A transport accident is one in which the vehicle involved must be moving or running or in use for transport purposes at the time of the accident. A car [automobile] is a four-wheeled motor vehicle designed primarily for carrying up to 7 persons. A special vehicle mainly used in agriculture is a motor vehicle designed specifically for use in farming and agriculture (horticulture), to work the land, tend and harvest crops and transport materials on the farm. W67 Accidental drowning and submersion while in swimming pool Excludes1:accidental drowning and submersion due to fall into swimming pool (W16. See category X08 Contact with heat and hot substances (X10-X19) Excludes1: exposure to excessive natural heat (X30) exposure to fire and flames (X00-X09) X10 Contact with hot drinks, food, fats and cooking oils the appropriate 7th character is to be added to each code from category X10 A initial encounter D subsequent encounter S sequela X10. See category T71 Y21 Drowning and submersion, undetermined intent the appropriate 7th character is to be added to each code from category Y21 A initial encounter D subsequent encounter S sequela Y21. Categories Z00-Z99 are provided for occasions when circumstances other than a disease, injury or external cause classifiable to categories A00-Y89 are recorded as "diagnoses" or "problems". They are for use in conjunction with other aftercare codes to fully explain the aftercare encounter. Relevant issues emphasized include an emphasis on Evidence Based Practice in Psychology, the needs and preferences of a rapidly diversifying society, and the increasing focus on health promotion, wellness, spirituality, and many non-Western traditions that are consistent with this approach. Keywords: complementary, alternative, medicine, practice, ethics the profession of psychology is a vibrant one, with a history of 2006). Yet, one area of innovation and one vision for the future of consistently moving forward and integrating new innovations into psychological practice involves looking back to the history existing practice. In their ongoing efforts to better meet the clinical of health care and mental health care, tapping into the wisdom of needs of clients, practicing psychologists engage in lifelong learn many hundreds of years of clinical experience. This vision of the ing, endeavoring to continually enhance their clinical competence future of the practice of psychology involves integrating Comple (Barnett, Doll, Younggren, & Rubin, 2007). This article is one of 11 in this special section on Visions for the Future of We propose that each practicing psychologist should possess a Professional Psychology. She is currently a fifth year graduate student in the profession of psychology and how many individuals conceptualize doctoral program in clinical psychology at Loyola University Maryland health care and how they choose to live their lives. Presently, there are several different forms of meditation, in a large national survey conducted for the National Institutes of each of which falls into one of two categories: mindfulness med Health (Barnes, Bloom, & Nahin, 2008): dietary supplements, itation and concentrative meditation. Meditation is used to treat a variety of symptoms such as elevated blood pressure, anxiety, stress, pain, and insomnia, as well as to promote overall health and wellbeing (Grossman, Ni Dietary Supplements emann, Schmidt, & Walach, 2007; Rainforth et al. There are risks associated with aroma are a variety of organizations that offer certification in specific therapy use related to toxicity, skin irritation, and dosing regula forms of meditation such as mindfulness-based meditation and tions that competent professionals will be aware of. Psychologists looking to integrate med itation into their practice will want to first assess the legitimacy of Massage Therapy particular organizations before seeking certification through them. Chiropractic is used by reported to have used massage therapy in the past year (Barnes et 8. However, this integra To practice chiropractic, one must obtain a doctor of chiroprac tion must be done by referral to qualified massage therapists even tic degree, which takes several years of graduate work to earn. The regulations for practicing mas doctor of chiropractic degree, it is important to recognize that even sage vary from state to state. Clinical aromatherapy focuses on relieving Anusara, Bikram, Kundalini, and Viniyoga. In recent years, yoga symptoms that are typically addressed in psychotherapy, such as has been increasingly studied and it has been shown to be effective stress and anxiety. Holistic aromatherapy focuses on the whole at treating numerous symptoms including anxiety, depression, and person, aiming to improve overall well-being and quality of life. With such a wide range of uses, it is not surprising that in traditionally used in skin care (Metcalfe, 1989). In recent years aromatherapy has been increas of yoga does not require any physical manipulation of the client by ingly studied and has shown positive results when used to treat a the psychologist, it is an area that may be integrated into ongoing variety of symptoms to include pain, anxiety, and agitation specific treatment as appropriately trained psychologists may choose to to dementia (Han, Hur, Buckle, Choi, & Lee, 2006; Lehrner, begin a session by utilizing various poses to promote relaxation. Marwinski, Lehr, Johren, & Deecke, 2005; Lin, Chan, Ng, & Lam, Additionally, clients who might benefit from yoga in addition to 2007). Dance/movement therapists believe beneficial for clients who are experiencing anxiety, tension, or that the mind and the body do not function separately and that by stress-related symptoms. Typically, acu puncture involves penetrating the skin with needles, which are then According to the U. Clients may sicians who have completed additional training, acupuncturists, identify themselves as only spiritual or religious, and not both. Addi Spirituality, religion, and prayer are three areas that have been tionally, in some states, licensure is required to practice acupunc difficult to study. However, competence about the religion or Additionally, in some states, it is illegal for psychologists to faith-based practices being addressed is essential. Thus, psychologists will want to educate clients about the Reiki practitioner utilizes a series of established hand positions as utility of hypnosis, while emphasizing that the purpose is not to a means for allowing the energy to move freely between the gain control over another human being. Despite this, Reiki has been shown to help with stress As an example, hypnosis is commonly used to treat pain and and pain management, as well as promoting relaxation (Bowden, fatigue, as well as nausea and vomiting that occur as a side effect Goddard, & Gruzelier, 2010; Olson, Hanson, & Michaud, 2003). Hypnosis can be integrated made for Reiki services, as opposed to integrating into ongoing into ongoing practice and one must obtain certification although practice, as the hand positions will likely result in a boundary this is not standardized. Many immigrant (the hypnotist) to respond to suggestions for changes in subjective communities have brought with them their beliefs and practices experience, alterations in perception, sensation, emotion, thought relevant to health promotion and health care. But, spirituality and religi health care are part of a larger movement in the United States (and osity, for example, are harder to operationalize and measure and, other Western nations) that focuses on more integrative and ho therefore, conducting research in this area is more challenging. Many individuals now seek the use of these modalities However, it is important to remember that a lack of studies, and either instead of or in addition to modern industrialized medicine therefore a lack of support, does not mean that a particular mo and are making known these preferences to health care practitio dality is not useful. While this is quite promising, ensure that needed support for research, to include funding, is psychologists should be cognizant of the potential limitations received. An additional area of concern is the lack of no-treatment condi Further, Eisenberg et al. Essential components of to provide the highest quality of care psychologists will find it the informed consent process include a review of reasonably important to be educated on various forms of treatment, both those available options and alternatives along with a discussion of the that many clients may already be using when they enter a psy potential risks and benefits of each. Additionally, we must be aware of when clients should or sion of reasonably available treatment options. Thus, ethical psychologists will know about ments, contraindications, and its potential benefits. Not all skills to be able to practice effectively and to not practice outside psychologists will wish to become licensed or certified in each areas of demonstrated competence. A randomised controlled others, additional training in the form of continuing education single-blind trial of the effects of Reiki and positive imagery on well courses will be needed. What is diversifying population, in the future, we hope that all training music therapy The Duke encyclo References pedia of new medicine: Conventional & alternative medicine for all ages. Complementary careers/ctindex/ and alternative therapy use by psychotherapy clients. Kava treatment in patients with CertificationInformation/LevelsofCertification/tabid/171/Default anxiety. Fatigue during breast cancer treatment of pain associated with endometriosis: Preliminary findings.

Orgasm Orgasms is a brain event impotence of organic nature order caverta from india, typically triggered by genital stimulation that can occur during sleep or from stimulation of other body parts including the breast and nipple or by fantasy erectile dysfunction freedom book purchase caverta 100mg free shipping, occasionally by medication impotence underwear buy caverta with visa, and in spinal cord injured women by vibrostimulation of the cervix erectile dysfunction rings for pump buy caverta 50 mg amex. In able-body women erectile dysfunction causes treatment buy caverta pills in toronto, it involves a myotonic response of smooth and striated muscle associated with feelings of sudden release of the sexual tension built up during arousal erectile dysfunction injections australia cheap caverta 50mg with mastercard. Some women may subjectively perceive uterine contractions during orgasm and some may report a difference in their perception of orgasm after hysterectomy, but this is not objectively documented. An objective quantitative measure was established that shows strong correspondence with the subjective experience of orgasm. Analysis of rectal pressure data while volunteers imitated orgasm, tried to achieve orgasm and failed, or experienced orgasm showed a significant and important difference in this analysis between orgasm and both control tasks (29). Brain imaging studies of women during orgasm showed brain activations and deactivations similar but not identical to those found in men (30). This area is activated when experiences are particularly hedonic, with further activation increasing satiation and deactivated with feelings of satiety. The latter is deactivated during the genital stimulation and arousal and remains deactivated during orgasm. The subjective description of orgasm is very much in keeping with this depiction (31). The majority of women most easily experience orgasm from direct clitoral stimulation. More direct contact with the clitoris is possible from contact of pubis to pubis after the man has ejaculated and penile size is reduced, if the man maintains contact. The bodies are more closely approximated and the woman can move her pelvis on his at a rate that is most conducive to her orgasm. Breast stimulation, kissing, and clitoral stimulation during intercourse are other commons means of experiencing orgasm. Women are potentially multiorgasmic, capable of experiencing a number of orgasms close together during one sex response cycle and of resuming sexual activity without any refractory period. Resolution Following the sudden release of sexual tension brought about by orgasm, women experience a feeling of relaxation and well-being. The gradual lessening of pelvic engorgement contrasts with the quicker loss of penile firmness in men. Nongenital changes that took place during arousal are reversed, and the body can return to a resting state after some 5 to 10 minutes. With further stimulation, the response can resume before or after this resting state is reached. Women who enjoy arousal without orgasm and without any sense that orgasm is very close but frustratingly absent report a similar sense of well-being and relaxation. These factors include mood; age; relationship duration and quality; personal psychological factors stemming from relationships in childhood with parental figures; previous losses, traumas, and ways of coping with emotions; illness; and use of medication, alcohol, and illicit drugs. One study of women, where a diagnosis of clinical depression was excluded, showed a strong association between decreased sexual interest and self-reporting of negative emotional and psychological feelings, including low self-esteem, feelings of insecurity, and lost femininity (18). Impaired sexual desire is noted in most studies of women with depression, even before the administration of antidepressants with sexually negative side effects (35). Paradoxically, depressed women may masturbate more frequently than women who are not depressed, despite an increased prevalence of dyspareunia and difficulties with arousal and orgasm in partnered sex (38). Self stimulation may cause calmness, relaxation, and improved sleep and in women is often not a consequence of sexual urge or desire. Some studies showned little increase in sexual problems with age, whereas in others almost 40% of the sample reported reductions in responsiveness and an increased desire for nongenital sexual expression (13, 39, 40). In one study, the prevalence of reduced desire increased significantly as a function of both menopause status and age, from 22% in the premenopausal group to 32% in the postmenopausal group (41). Low levels of desire were strongly associated with other sexual problems, including difficulties with arousal and orgasm. One large cohort of women studied over 10 years from peri to postmenopause showed a decline in desire and responsiveness as a function of both age and menopause (42). The number of menopausal symptoms experienced influenced well-being, which in turn affected sexual responsiveness and sexual desire and interest. Many studies of sexuality and aging show that older women report less distress about lack of desire when compared with younger women (17, 18, 43). In a nonclinical study of 102 women, the determinants of sexual satisfaction in those younger than 45 years of age were compared with those of women older than 45 years of age (18). There was no difference in sexual satisfaction achieved either by intercourse or noncoital sexual activities. Older women reported lower frequency of orgasm and different ratings on certain dimensions of sexual satisfaction. For the older women, the dominant qualities important to their satisfaction were those related to an emotional sense of calm and to factors such as feeling secure with their partner, whereas for younger women the subjective physical experience was more important. Despite reports of reduced sexual interest and desire by some older women, most retain some interest and maintain the potential for sexual pleasure for their entire lives. In older women, a strong predictor of continued sexual interest is sexual behavior and enjoyment at an earlier age. A discrepancy between sexual interest and actual sexual activity occurs in many cases because an adequate partner is no longer available. In other instances, the cessation of sexual activity with age is more an expression of emotional problems resulting from lack of tenderness, communication, and attraction. If intercourse is perceived as a necessary component of sexual activity with a partner, some older women will lose motivation and interest as a result of discomfort and dyspareunia associated with lack of estrogen. Although the increase in vaginal congestion in response to visual sexual stimulation is similar in women with and without estrogen, baseline vaginal blood flow is lower in estrogen-deficient women (23). There may be loss of elasticity and thinning of the vaginal epithelium, which becomes vulnerable to damage from intercourse. Estrogen depletion predisposes women to vulvar vaginitis and urinary tract infections, both of which contribute to dyspareunia and reduce sexual self-image. Women who remain sexually active, alone or with a partner, may have less vulvar and vaginal atrophy than sexually inactive women but may still be symptomatic (47). Adrenal production of testosterone precursors gradually decreases with age, beginning in the late 30s. Available assays were not sufficiently sensitive in the female range of serum testosterone to detect particularly low levels. When mass spectroscopy was used: serum testosterone levels were similar in 121 women carefully assessed and diagnosed with disorders of low desire and arousability to levels in 125 women similarly carefully assessed but to exclude any sexual dysfunction (50). The association is weaker than that between male erectile dysfunction and hypertension, hyperlipidemia, diabetes, and coronary artery disease. Depression is the major factor influencing sexual function in women with chronic illness including end-stage renal disease (51), multiple sclerosis (52), or diabetes (53). Personality Factors Studies show that, compared with functional women, those who have concerns about low levels of desire and arousability are characterized as having vulnerable self-esteem, high levels of anxiety and guilt, negative body image, introversion, and somatization (18). The clinical impression of women with orgasmic disorder is that many are extremely uncomfortable in conditions in which they are not in control of circumstances or their bodily reactions. For many women with vaginismus, there is a phobic quality to the fear of vaginal penetration. Many women with provoked vestibulodynia show a marked fear of negative evaluation by others, ultra conscientiousness, and self-criticism, as well as an increase in somatization and anxiety (54). Relationships Most women who report loss of desire and arousability to physicians indicate that their partnerships are stable and satisfactory. The loss of sexual spontaneity resulting from the goal-oriented approach to sex while trying to conceive with scheduled intercourse (coinciding with ovulation naturally or after hormonal stimulation) may lead to sexual dysfunction and is considered a major problem for many women (57). The stress of testing and waiting for results may disrupt emotional intimacy, causing further damage to sexual function. Often there are unresolved feelings of guilt over personal responsibility for the infertility and feelings of resentment of the multiple procedures required for women compared with one semen analysis for men. Drugs Prescription and nonprescription medications, including alcohol and illicit drugs, can alter the normal sexual response (Table 11. A Cochrane review could make no recommendations for women but did note that bupropion may be effective based on the results of one of two randomized controlled trials (43, 59). Chronic Pelvic Inflammatory Disease and Endometriosis Chronic dyspareunia, remitting temporarily or not at all with surgical or medical therapy, typically is associated with loss of sexual motivation or interest. The limited data suggest that lower satisfaction is related to obesity and cosmetic androgen-related effects of hirsutism and acne. One small case study showed desire to increase in six women with antiandrogen treatment and to decrease in 13 women (61). A recognized difficulty with recurrent herpes is viral shedding despite lack of skin lesions and uncertainty whether long-term antiviral therapy prevents shedding. Lichen Sclerosis Tethering of the clitoral hood, which occurs with lichen sclerosis, may cause pain with clitoral stimulation. When this skin disorder involves the introitus, it may cause dyspareunia or prevent entry of penis, dildo, or fingers. Topical corticosteroid administration is the primary treatment, although topical testosterone cream may be beneficial when loss of sexual sensitivity occurs. Breast Cancer Sexual dysfunction following breast cancer treatment is likely to persist more than 1 year after diagnosis of breast cancer (63). Chemotherapy appears to be responsible for most of the resulting sexual difficulties, including loss of desire, subjective arousal, vaginal dryness, and dyspareunia (64). A small study of women with past breast cancer and complex endocrine status resulting from ongoing antiestrogen therapy found that, whereas relationship factors predicted desire, history of chemotherapy predicted disorders of arousal lubrication, orgasm, and dyspareunia but there was no connection between sexual function and androgen levels including androgen metabolites (65). A model for predicting sexual interest, function, and satisfaction after breast cancer has evolved from two large independent groups of breast cancer survivors (64). The most important predictors of sexual health were absence of vaginal dryness, presence of emotional well-being, positive body image, better quality of relationship, and lack of partner sexual problems. Use of tamoxifen does not consistently alter sexual function, but use of aromatase inhibitors is often associated with severe dyspareunia from the profoundly estrogen-depleted state (67, 68). The optimal management of ongoing dyspareunia from the estrogen deficient state, especially when the woman is on aromatase inhibitors, is unclear. Zero systemic absorption of estrogen from vaginally administered preparations is the goal, and formulations are under investigation for efficacy at lower dosages than are currently available. Some oncologists will permit the use of local estrogen via a Silastic ring that does cause brief, but detectable (although not to premenopausal estrogen levels), systemic absorption. For most of the 3 months that the ring is in place systemic absorption is not detectable. Vaginal moisturizers can allow some benefit but do not restore the full elasticity. Fertility preservation is considered along with the overall treatment plan for younger women, and a number of options are emerging. One is to delay treatment to undergo a cycle of hormone stimulation and oocyte retrieval, providing the growth of the tumor is not expected to be promoted by exogenous estrogen. Other techniques can avoid exposure to exogenous hormones by retrieving ovarian tissue and either aspirating the oocytes or reserving ovarian tissue strips and then using cryopreservation. An even newer technique called in follicle maturation involves obtaining immature follicles from the cryopreserved ovarian tissue, maturing them in vitro, to be followed by in vitro fertilization procedures (20). Diabetes the majority of studies clearly identified a strong link between sexual dysfunction and comorbid depression but not with diabetic controls, duration of diabetes, or its complications.

Prader stage V defines virilization resulting in complete labioscrotal fusion erectile dysfunction when drugs don't work cheap caverta 50 mg with mastercard, a penile phallus with the urethra opening on the glans erectile dysfunction with age cheap caverta 100 mg. Teratogens It is important to recognize that ambiguous genitalia can result from the maternal ingestion of various teratogens impotence in diabetics buy 100mg caverta visa, most of which are synthetic steroids (Table 29 erectile dysfunction at the age of 17 buy caverta with a mastercard. Exposure to the teratogen must occur early in pregnancy impotence losartan order caverta 100mg line, during genital organogenesis erectile dysfunction causes std cheap caverta 100 mg without prescription. Not all exposed fetuses manifest the same anomalies or even the presence of any anomalies. In principle, most synthetic steroids with androgenic properties, including weakly androgenic progestins, can affect female genital differentiation. The doses required to produce genital ambiguity are generally so great that the concern is only theoretical. The one agent that can lead to genital ambiguity when ingested in clinically used quantities is danazol. There is no evidence that inadvertent ingestion of oral contraceptives, which contain relatively low doses of either mestranol or ethinyl estradiol and a 19-nor-steroid, results in virilization (105, 106). Increased risk of precocious puberty in internationally adopted children in Denmark. The timing of normal puberty and the age limits of sexual precocity: variations around the world, secular trends, and changes after migration. Body fat mass, body fat distribution, and pubertal development: a longitudinal study of physical and hormonal sexual maturation of girls. The role of estrogen in bone growth and maturation during childhood and adolescence. Tables for predicting adult height from skeletal age: revised for use with the Greulich-Pyle hand standards. The ontogeny of pituitary hormones and hypothalamic factors in the human fetus: maturation of central nervous system regulation of anterior pituitary function. A diphasic pattern of gonadotropin secretion in patients with the syndrome of gonadal dysgenesis. Synchronization of augmented luteinizing hormone secretion with sleep during puberty. Simultaneous augmented secretion of luteinizing hormone and testosterone during sleep. Episodic fluctuations of serum gonadotropins in pre and post-pubertal girls and boys. Serum androgens in normal prepubertal and pubertal children and in children with precocious adrenarche. Puberty in girls: correlation of serum levels of gonadotropins, prolactin, androgens, estrogens and progestin with physical changes. The significance of incomplete fusion of the mullerian ducts in pregnancy and parturition with a report on 35 cases. Reproductive and gynecological surgical experience in diethylstilbestrol-exposed daughters. Localizing ovarian determinants through phenotypic-karyotypic deductions: progress and pitfalls. Ullrich-Turner syndrome with a small ring X chromosome and the presence of mental retardation. Germ cell tumors in the intersex gonad: old paths, new directions, moving frontiers. Risk of death in pregnancy achieved through oocyte donation in patients with Turner syndrome: a national survey. Six-year results of a randomized prospective trial of human growth hormone and oxandrolone in Turner syndrome. Normalization of height in girls with Turner syndrome after long-term growth hormone treatment: results of a randomized dose-response trial. Body proportions during long-term growth hormone treatment in girls with Turner syndrome participating in a randomized dose-response trial. Growth hormone therapy of Turner syndrome: the impact of age of estrogen replacement on final height. Importance of estrogen on bone health in Turner syndrome: a cross-sectional and longitudinal study using dual-energy x-ray absorptiometry. Biology of normal luteinizing hormone-releasing hormone neurons during and after their migration from olfactory placode. Clinical counterpoint: gonadotropin-releasing hormone deficiency: perspectives from clinical investigation. The role of genomic imprinting in human developmental disorders: lessons from Prader-Willi syndrome. Abnormal hypothalamic-pituitary-adrenal function in anorexia nervosa: pathophysiologic mechanisms in underweight and weight-corrected patients. Hypothalamic dysfunction in secondary amenorrhea associated with simple weight loss. Natural history of premature thelarche in Olmsted County, Minnesota, 1940 to 1984. Pelvic ultrasonography: early differentiation between isolated premature thelarche and central precocious puberty. The luteinizing hormone-releasing hormone-secreting hypothalamic hamartoma is a congenital malformation: natural history. Reproductive axis after discontinuation of gonadotropin-releasing hormone analog treatment of girls with precocious puberty: a long term follow-up comparing girls with hypothalamic hamartoma and idiopathic precocious puberty. Consensus statement on the use of gonadotropin-releasing hormone analogs in children. Final height after long-term treatment with triptorelin slow-release for central precocious puberty: importance of statural growth after interruption of treatment. Activating mutations of the stimulatory G protein in the McCune-Albright syndrome. Tamoxifen treatment for precocious puberty in McCune-Albright syndrome: a multicenter trial. Height outcome in congenital adrenal hyperplasia caused by 21 hydroxylase deficiency: a meta-analysis. Long-term somatic follow-up of prenatally treated children with congenital adrenal hyperplasia. Extensive personal experience: prenatal diagnosis for congenital adrenal hyperplasia in 532 pregnancies. Revised 2003 concensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Early metabolic abnormalities in adolescent girls with polycystic ovarian syndrome. Adult manifestation of congenital hyperplasia due to incomplete 21-hydroxylase deficiency mimicking polycystic ovarian disease. Late-onset 21-hydroxylase deficiency mimicking idiopathic hirsutism or polycystic ovarian disease. Cyproterone acetate versus hydrocortisone treatment in late-onset adrenal hyperplasia. McClamrock Girls experienced menarche at increasingly younger ages during the past century. Primary amenorrhea is defined as absence of menses at age 13 years when there is no visible development of secondary sexual characteristics or age 15 years in the presence of normal secondary sexual characteristics. Absent or irregular menses may be an indication that a woman has a medical condition that can affect her overall health. When gonadal failure occurs in conjunction with primary amenorrhea, it is associated with a high incidence of abnormal karyotype. The anatomic causes of amenorrhea are relatively few, and the majority may be diagnosed by history and physical examination. Therapeutic measures may include specific therapies (medical or surgical) aimed at correcting the primary cause of amenorrhea, hormone therapy to initiate and maintain secondary sexual characteristics and provide symptomatic relief, treatments to maximize and maintain peak bone mass including hormone therapy, calcium, and vitamin D for cases where circulating estrogen levels are low, and ovulation induction for patients desiring pregnancy. A complex hormonal interaction must take place in order for normal menstruation to occur. A normally functioning ovarian follicle secretes estrogen; after ovulation, the follicle is converted to corpus luteum, and progesterone is secreted in addition to estrogen. If pregnancy does not occur, estrogen and progesterone secretion decrease and withdrawal bleeding begins. If any of the components (hypothalamus, pituitary, ovary, uterus, and outflow tract) are nonfunctional, bleeding cannot occur. Therefore, the definition of primary amenorrhea changed: Primary amenorrhea is defined as the absence of menses by 13 years of age when there is no visible development of secondary sexual characteristics or by 15 years of age in the presence of normal secondary sexual characteristics. The ages defining primary amenorrhea were decreased by 1 year to continue to represent two standard deviations above the mean age of developing secondary sexual characteristics and menses (1). A woman who previously menstruated can develop secondary amenorrhea, which is defined as absence of menstruation for three normal menstrual cycles (2). A woman with regular cycles and a delay of menses of even a week may warrant assessment with a pregnancy test. With a few exceptions, the causes of primary amenorrhea are similar to the causes of secondary amenorrhea. These patients may bleed excessively during menstruation because estrogen is unopposed. The etiologies of oligomenorrhea overlap with the etiologies of amenorrhea, with the exception that certain anatomic. To detect the cause of amenorrhea, it is useful to determine whether secondary sexual characteristics are present (Fig. The absence of secondary sexual characteristics indicates that a woman was never exposed to estrogen. Amenorrhea without Secondary Sexual Characteristics Although the diagnosis and treatment of disorders associated with hypogonadism were discussed in another chapter (see Chapter 29), they will be mentioned here because these conditions may present as primary amenorrhea. Because breast development is the first sign of estrogen exposure in puberty, patients without secondary sexual characteristics typically have primary, not secondary, amenorrhea (Fig 30. It is helpful to categorize the causes of amenorrhea in the absence of breast development on the basis of gonadotropin status. Causes of Primary Amenorrhea Hypergonadotropic Hypogonadism Associated with Absence of Secondary Sexual Characteristics Gonadal dysgenesis is a term typically used to describe abnormal development of the gonads, typically resulting in streak gonads. Karyotypic abnormalities are common in women with primary amenorrhea associated with gonadal failure (Table 30. In one series, approximately 30% of patients with primary amenorrhea had an associated karyotypic abnormality (3). Turner syndrome (45, X) and its variants represent the most common form of hypergonadotropic hypogonadism in women with primary amenorrhea. Other disorders associated with primary amenorrhea include structurally abnormal X chromosomes, mosaicism. Individuals with these conditions have gonadal failure and cannot synthesize ovarian steroids. Most patients with these conditions have primary amenorrhea and lack secondary sexual characteristics. It appears that patients with Turner syndrome initially have normal ovarian development in utero. In addition to gonadal failure, there are associated stigmata with Turner syndrome that include short stature, webbed neck, shield chest, cubitus valgus (increased carrying angle of the arms), low hair line, high arched palate, multiple pigmented nevi, and short fourth metacarpals (4). X inactivation is a process that inactivates most of the genes on one X chromosome. Of the genes on the X chromosome, 20% escape X inactivation, and it is believed that loss of the second copy of these genes in a 45, X patient causes the stigmata associated with Turner syndrome (5). After the diagnosis of Turner syndrome is confirmed by karyotype, studies should be performed to ensure that cardiac (30% have coarctation of the aorta), renal (especially horseshoe kidney), and autoimmune (thyroiditis) abnormalities are diagnosed and treated. Evaluation should be performed in childhood to identify potential attention-deficit or nonverbal learning disorders. Women with Turner syndrome should be screened for diabetes mellitus, aortic enlargement, hypertension, and hearing loss throughout their lives (6). Patients with a deletion of the long arm of the X chromosome (Xq) from Xq13 to Xq26 have sexual infantilism, normal stature, no somatic abnormalities, and streak gonads (7). Patients with a deletion of the short arm of the X chromosome (Xp) usually are phenotypically similar to individuals with Turner syndrome (8). Many genes on the Xp chromosome escape X inactivation and act similarly to genes on autosomes. The effective monosomy created by the deletion results in the phenotypic features of Turner syndrome (5). Most patients with a ring X have ovarian failure and phenotypes similar to Turner syndrome, although some are able to reproduce successfully. These patients differ from those with Turner syndrome in that they are more likely to have intellectual disability and have syndactyly. Half of the women with balanced translocations of the X chromosome to an autosome have gonadal failure. Typically, the normal X is inactivated to preserve the balance of autosomal genes. The gonadal failure can be caused by the chromosomal break occurring in a gene that is required for ovarian function, abnormal meiosis, or X inactivation of the translocated X and adjacent autosomal genes (5, 9). The gonads are usually streaks, but there may be some development of secondary sexual characteristics, and a few episodes of uterine bleeding.

It illustrates the difficulties inherent in trying to agree what we mean by the terms we use and that a classification that suits one purpose erectile dysfunction treatment injection purchase discount caverta on line, such as a diagnostic approach erectile dysfunction hypothyroidism generic 100mg caverta, may not always be ideal for others erectile dysfunction treatment fort lauderdale order line caverta, such as therapy issues erectile dysfunction young male causes discount caverta 50mg fast delivery. Bax M impotence cure cheap caverta online american express, Goldstein M erectile dysfunction young age treatment order caverta 50 mg with visa, Rosenbaum P, Leviton A, Paneth N, Dan B, Jacobsson B, Damiano D; Executive Committee for the Definition of Cerebral Palsy. Badawi N, Novak I, McIntyre S, Edwards K, Raye S, deLacy M, Bevis E, Flett P, van Essen P, Scott H, et al. However, the definition of a diagnosis identifies explicitly which cases the seminal work describing cerebral paralysis, and particu are to be recorded under that term and, by implication, which larly the related musculoskeletal issues, was elucidated by an are to be specifically excluded. The definition is the basis for English orthopaedic surgeon named William Little in one of a planning treatment and for counting cases in a population. Whilst his lectures focused on joint contractures and similar characteristics together and distinguishes those cases deformities resulting from long-standing spasticity and with diverse features apart. The design of a classification paralysis, Little clearly indicated that the cause of the spasticity system, for instance whether it is organized into nominal or and paralysis was often damage to the brain during infancy, ordinal categories, will vary depending on the concept being and specifically preterm birth and perinatal asphyxia (Little classified and intended purpose for which classification is 1843). The label does however encompass a variety of Heine, was reporting similar clinical syndromes as a result of syndromes and some, therefore, prefer the term cerebral infections such as scarlet fever and vaccinations (von Heine palsies. He cited the work of his compatriot Henoch, who had written his dissertation several years earlier, describing hemiple gia in children (Henoch 1842). However, Little was known to have spent some years studying in Germany during the 1830s and it is possible that there was some cross-fertilization of ideas, although this is not formally recorded. Little differentiated between the congeni tal deformities observed at the time of birth, such as falipes equinovarus, and the limb deformities that developed subse quent to preterm, difficult, or traumatic births, due to what he termed spastic rigidity. He demonstrated his familiarity with the work of French, German, and Irish pathologists in constructing his theory. Little grouped the clinical presenta tion of 47 cases as either: (1) hemiplegic rigidity affecting one side only, although lesser impairment of the apparently unin volved limb was frequently observed; (2) paraplegia affect ing both legs more than arms; and (3) generalized rigidity. Little showed careful consideration for his audience in the Historical Perspective Christopher Morris 3 published discussion by conceding to the President of the causes. He thought Sarah McNutt, an American physician, continued to raise the the task of separating congenital from acquired cases impos profile of the risks of long-term disability arising from birth sible in some cases and generally unhelpful. Notably, the American Neurological that children with ataxic symptoms might require a separate Association admitted her as their first female member; but group, as became the case after the work of Batten (1903), the content of her lectures apparently made her unpopular but at the time of his writing he had not seen enough cases of with some eminent obstetricians whilst she was on a tour in non-progressive ataxia to be sure. Nevertheless, his influ William Osler published articles in 1886 and 1888 before his ence was such that his lasting statements regarding the futili more notable monograph was published in London in 1889. Phelps gists Sachs and Peterson published their series of 140 cases acknowledged the need for a neurological classification sys (Sachs and Peterson 1890). They contrasted the comprehen tem for diagnostic purposes but preferred to use his own sive understanding that had then been achieved regarding classification system as a basis for treatment. Sachs and Peterson including both mental and physical ability, and that a social followed the convention of the time by using the same classi assessment should precede treatment. Freud recognized (American Academy for Cerebral Palsy and Developmental that, even with post-mortem examination, the pathological Medicine 2005). Thus, he suggested plegia, generalized congenital chorea, and generalized that a modular description using components from each cat athetosis. Minear conducted a survey with the Hammond, as involuntary writhing movements in adults members of the American Academy for Cerebral Palsy in 1953 affected by hemiplegia (Hammond 1871), and it would later and published the resulting classification system based on be more clearly differentiated from other movement disor their majority opinion (Minear 1956). A separate dimension for functional hypertonia (including stiffness, spasticity, and rigidity); (3) capacity with four levels is included in the classification but dyskinesia; and (4) ataxia (Evans et al. A decision was used undefined terms such as mild and moderate limitation made to record details of each limb and the head and neck sep of activity. Wyllie (1951) used a confusing combina tions, as well as genetic and other disorders. Some effort was tion of neurological and aetiological criteria to define cate made to validate this system, with repeated meetings showing gories which were: (1) congenital symmetrical diplegia; (2) videos to test inter and intraobserver, and within and between congenital paraplegia; (3) quadriplegia or bilateral hemiple patient variations. The selected category was supple ty of their classification were not widely disseminated. Notably this hemiplegia, double hemiplegia, and diplegia from ataxic annotation also included a revised Swedish classification sys and dyskinetic categories. Ingram grouped involuntary tem which, whilst still not perfect, offered simplicity as its movement disorders, such as dystonia, chorea, and atheto major asset. Ingram continued his aforementioned criticism ing, restricting lifestyle, functional but not fluent, or walks citing the changes observed in the series of 1821 patients by fluently (Evans and Alberman 1985). Children in Level I can perform all the activities of their health markers of perinatal and neonatal health care. The system has had good some of the correlations that are emerging between the tim uptake internationally and across the spectrum of health care ing and location of the lesion and functional, cognitive, and professions for use in research and clinical practice by provid sensory impairments. The definition was largely a reiteration of that development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred proposed by Mutch and colleagues (Mutch et al. Carr (2005) described how the proposed to aid classification into neurological and topographical cat definition and classification would affect clinical practice and egories including spastic (unilateral or bilateral), ataxic, dys the challenge of shifting from traditional modes of thinking; kinetic (dystonic or choreo-athetotic), or not classifiable. Clearly Blair and Love (2005) considered the precision of the definition defined symptoms and requirements are provided for each to be flawed in the same way as previous attempts, particularly neurological category. Historical Perspective Christopher Morris 7 Executive Committee used this information and additional A report: the definition comments from the international community to generate a report on the Definition and Classification of Cerebral Palsy, and classification April 2006. At the end of the 19th century, Centre for Childhood Disability Research, Hamilton, Ontario, Sigmund Freud and Sir William Osler both began to contribute Canada. Suggestions were made alies of the brain arising in the early stages of development. A Clinical Study lows) was to revisit and update the definition and classifica for the Infirmary for Nervous Diseases. The Definition and Classification but that previous definitions had become unsatisfactory. Reservations were expressed about the exclu broad spectrum of audiences with a common conceptualiza sive focus on motor deficit, given that persons with neurode tion about cerebral palsy. As in the prior concept, it was agreed that of the development5 of movement and posture6 causing7 the motor disorder needed to be emphasized; however, activity limitation, 8 that are attributed to9 non-progressive10 recognition should be provided that other developmen disturbances11 that occurred in the developing fetal or infant12 tal disorders of performance and behaviour can and brain. As it relies essentially on clinical been identified and included in the revised definition. This inciting event(s) produce(s) a disruption of and warranted to serve different purposes. These groupings normal brain structure and function which may be associated may show overlap. It excludes motor disorders solely signs can appear throughout childhood or later. Thus, disorders of movement limitations that restrict learning and perceptual develop and posture that are not associated with activity limitations ment experiences. Where neuroimaging facilities, diag distribution, type of motor disorder and functional classification of cerebral palsy: how do they relate Classification often requires making difficult decisions about the motor disorders of cerebral palsy are often accompanied where to draw the boundaries within ordinal or quantitative by disturbances of sensation, perception, cognition, commu measures. Each is purpose of the classification, certain characteristics or com elaborated upon in the text that follows. Motor abnormalities for a specific type of tone abnormality, the nature of the motor 1. Providing strategy has been adopted by the classification system described such definitions is, however, beyond the scope of this docu in the Reference and Training Manual of the Surveillance of ment. Some use the term to describe children with spastic entiated into dystonia and choreoathetosis. However, determining the relative severity of each of the tone and or movement abnormalities may be of arm and leg involvement can be challenging since they of greater clinical and etiologic utility, as recommended by perform very different functions. Accompanying impairments evaluating the functional consequences of different health the presence or absence of later-developing musculoskeletal states. The functional consequences of involvement of problems and/or accompanying non-motor neurodevelopmental the upper and lower extremities should therefore be sep or sensory problems, such as seizures, hearing or vision arately classified using objective functional scales. A high research priority is the development rapid pace, particularly in the area of quantitative assessment of a scale for speech and pharyngeal activity limitation in cere of the neuro-imaging and clinical features of cerebral palsy. In the meantime, the presence and severity of bul these advances will continue to improve our ability to classify bar and oromotor involvement should be recorded. These ment on the opposite side and some children with primarily impairments may have resulted from the same or similar bilateral involvement may have appreciable asymmetry across pathophysiologic processes that led to the motor disorder, sides. This distinction should be considered as part of a mul but they nonetheless require separate enumeration. Examples tiaxial classification scheme, thus it should be coupled with a include seizure disorders, hearing and visual problems, cog description of the motor disorder and functional motor clas nitive and attentional deficits, emotional and behavioral issues, sification in both upper and lower extremities. It is increasingly apparent that cerebral palsy may result from the interaction of multiple risk factors, and in many cases, 3. It is possible that by look classification schemes included only the extremities and ing further downstream from putative cause to common required a subjective comparison of severity in the arms and mechanisms of injury, and by grouping cases on that basis, the legs. The inherent validity of making this comparison has a more salient method of classification may be developed. Notably missing from current anatom when reasonably firm evidence indicates that the ical classification schemes is description of truncal and bul causative agent, or a major component of the cause, was bar involvement. World Health Organization (2001) International Classification posture and flexibility for children with cerebral palsy. These could yield larger differences in apparent make the diagnosis, they should lead on classi cation but the rates over time or between places than any change in underly epidemiologist must temper such ideas so they are applicable ing rate. Where clinicians mild hemiplegia may never present or may present at a much want detailed sub-classi cation, this also needs epidemiologi older age and would not be counted by a register ascertain cal advice if we are to be con dent that different clinicians, ing up to 5 years of age. It would be more reliable to compare when using the same word, mean the same thing.

Morbidity and mortality associated with primary and repeat operations for ovarian cancer erectile dysfunction alcohol order on line caverta. Survival effect of maximal cytoreductive surgery for advanced ovarian carcinoma during the platinum era: a meta-analysis depression and erectile dysfunction causes safe caverta 100 mg. Systematic aortic and pelvic lymphadenectomy versus resection of bulky nodes only in optimally debulked advanced ovarian cancer: a randomized clinical trial erectile dysfunction treatment in singapore cheap caverta on line. The effect of debulking surgery after induction chemotherapy on the prognosis in advanced epithelial ovarian cancer erectile dysfunction drug generic caverta 50 mg on line. Specialist gynecologists and survival outcome in ovarian cancer: a Scottish National Study of 1966 patients erectile dysfunction vacuum pump india buy genuine caverta on line. The effect of centralization of primary surgery on survival in ovarian cancer patients erectile dysfunction pills don't work purchase generic caverta. Improved short-term survival for advanced ovarian, tubal, and peritoneal cancer patients operated at teaching hospitals. Surgery by consultant gynecologic oncologists improves survival in patients with ovarian carcinoma. Is stage I epithelial ovarian cancer overtreated both surgically and systemically Randomized trial comparing cisplatin with radioactive phosphorus or whole abdominal irradiation as adjuvant treatment of ovarian cancer. Platinum based chemotherapy of high risk stage I epithelial ovarian cancer following comprehensive surgical staging. Adjuvant treatment for early epithelial ovarian cancer: results of two randomized clinical trials comparing cisplatin to no further treatment or chromic phosphate (32P). Controversial issues in the management of early epithelial ovarian cancer: conservative surgery and the role of adjuvant therapy. Clinical trials in patients with epithelial ovarian cancer: past, present and future. Analysis of failure in patients with stage I ovarian cancer: an Italian multicenter study. Acute nonlymphocytic leukemia after therapy with alkylating agents for ovarian cancer. Impact of adjuvant chemotherapy and surgical staging in early-stage ovarian carcinoma: European Organisation for Research and Treatment of Cancer-Adjuvant Chemotherapy in Ovarian Neoplasm Trial. International collaborative ovarian neoplasm trial 1: a randomized trial of adjuvant chemotherapy in women with early-stage ovarian cancer. Carboplatin and paclitaxel in ovarian carcinoma: a phase I study of the Gynecologic Oncology Group. European-Canadian randomized trial of paclitaxel in relapsed ovarian cancer: high-dose versus low-dose and long versus short infusion. Long-term follow-up confirms a survival advantage of the paclitaxel cisplatin regimen over the cyclophosphamide-cisplatin combination in advanced ovarian cancer. Chemotherapy in advanced ovarian cancer: an overview of randomized clinical trials. Randomized trial of cyclophosphamide plus cisplatin with or without doxorubicin in ovarian carcinoma: a Gynecologic Oncology Group study. Cyclophosphamide plus cisplatin versus cyclophosphamide, doxorubicin, and cisplatin chemotherapy of ovarian carcinoma: a meta-analysis. A randomized clinical trial of cisplatin/paclitaxel versus carboplatin/paclitaxel as first-line treatment of ovarian cancer. Survival and prognostic factors of women with advanced ovarian cancer and complete response after a carboplatin-paclitaxel chemotherapy. An assessment of dose-intensive therapy in suboptimally debulked ovarian cancer: a Gynecologic Oncology Group study. Carboplatin dosage: prospective evaluation of a simple formula based on renal function. Docetaxel and cisplatin in combination as first-line chemotherapy for advanced epithelial ovarian cancer. Intraperitoneal chemotherapy for the initial management of primary epithelial ovarian cancer. Dose-dense paclitaxel once a week in combination with carboplatin every 3 weeks for advanced ovarian cancer: a phase 3, open-label, randomised controlled trial. Quality of life in women treated with neoadjuvant chemotherapy for advanced ovarian cancer: a prospective longitudinal study. Bevacizumab plus irinotecan, fluorouracil, and leucovorin for metastatic colorectal cancer. Maintenance therapy in advanced ovarian cancer: progression-free survival and clinical benefit. Randomized placebo-controlled study of oregovomab for consolidation of clinical remission in patients with advanced ovarian cancer. Oregovomab maintenance monoimmunotherapy does not improve outcomes in advanced ovarian cancer. Prognosis of surgically determined complete responders in advanced ovarian cancer. Second-look laparotomy after chemotherapy in the management of ovarian malignancy. Recurrence after negative second-look laparotomy for ovarian cancer: analysis of risk factors. Correlation of abdominal ultrasound and computed tomography scans with second or third-look laparotomy in patients with ovarian carcinoma. Influence of secondary cytoreduction at the time of second-look laparotomy on the survival of patients with epithelial ovarian carcinoma. Secondary surgical cytoreduction in advanced epithelial ovarian cancer: patient selection and review of the literature. The role of secondary cytoreductive surgery in the treatment of patients with recurrent epithelial ovarian carcinoma. Complete salvage surgical cytoreduction improves further survival of patients with late recurrent ovarian cancer. Secondary cytoreductive surgery for localized intra-abdominal recurrences in epithelial ovarian cancer. Guidelines and selection criteria for secondary cytoreductive surgery in patients with recurrent, platinum-sensitive epithelial ovarian carcinoma. Second-line platinum therapy in patients with ovarian cancer previously treated with cisplatin. Treatment of relapsed carcinoma of the ovary with cisplatin or carboplatin following initial treatment with these compounds. Duration of response to second-line, platinum-based chemotherapy for ovarian cancer: implications for patient management and clinical trial design. Second-line therapy for potentially platinum-sensitive recurrent ovarian cancer: what is optimal treatment Predictors of response to subsequent chemotherapy in platinum pretreated ovarian cancer: a multivariate analysis of 704 patients. Long-term survival advantage for women treated with pegylated liposomal doxorubicin compared with topotecan in a phase 3 randomized study of recurrent and refractory epithelial ovarian cancer. Paclitaxel by 3-hour infusion followed by 96-hour infusion on failure in patients with refractory malignant disease. Dose-intense taxol: high response rate in patients with platinum-resistant recurrent ovarian cancer. Weekly paclitaxel in patients with recurrent or persistent advanced ovarian cancer. Paclitaxel for platinum-refractory ovarian cancer: results from the first 1000 patients registered to National Cancer Institute Treatment Referral Center 9103. Topotecan versus paclitaxel for the treatment of recurrent epithelial ovarian cancer. Activity and pharmacodynamics of 21-day topotecan infusion in patients with ovarian cancer previously treated with platinum-based chemotherapy. The use of continuous infusion topotecan in persistent and recurrent ovarian cancer. Phase 2 evaluation of topotecan administered on a 3-day schedule in the treatment of platinum and paclitaxel-refractory ovarian cancer. Oral topotecan as single-agent second-line chemotherapy in patients with advanced ovarian cancer. Topotecan has substantial antitumor activity as first-line salvage therapy in platinum-sensitive epithelial ovarian carcinoma: a Gynecologic Oncology Group Study. Efficacy of low-dose topotecan in second-line treatment for patients with epithelial ovarian carcinoma. Three-consecutive-day topotecan is an active regimen for recurrent epithelial ovarian cancer. A randomised trial of oral versus intravenous topotecan in patients with relapsed epithelial ovarian cancer. A dose-escalating study of weekly bolus topotecan in previously treated ovarian cancer patients. Pegylated liposomal doxorubicin and carboplatin compared with paclitaxel and carboplatin for patients with platinum-sensitive ovarian cancer in late relapse. Weekly low-dose carboplatin and paclitaxel in the treatment of recurrent ovarian and peritoneal cancer. Docetaxel: an active new drug for treatment of advanced epithelial ovarian cancer. Activity of gemcitabine in patients with advanced ovarian cancer: responses seen following platinum and paclitaxel. Second-line chemotherapy with gemcitabine and carboplatin in paclitaxel-pretreated, platinum-sensitive ovarian cancer patients. Phase I feasibility trial of carboplatin, paclitaxel, and gemcitabine in patients with previously untreated epithelial ovarian or primary peritoneal cancer: a Gynecologic Oncology Group study. Phase 2 trial of single-agent gemcitabine in platinum-paclitaxel refractory ovarian cancer. Prolonged oral etoposide as second-line therapy for platinum-resistant and platinum-sensitive ovarian carcinoma: a Gynecologic Oncology Group study. Tamoxifen therapy for ovarian cancer in the adjuvant and advanced settings: systematic review of the literature and implications for future research. Responsiveness of patients with advanced ovarian carcinoma to tamoxifen: a Gynecologic Oncology Group study of second-line therapy in 105 patients. Combination therapy with leuprolide acetate and tamoxifen in refractory ovarian cancer. Quality of life evaluations in patients with ovarian cancer during chemotherapy treatment. Avoiding bevacizumab related gastrointestinal toxicity for recurrent ovarian cancer by careful patient screening. Intestinal obstruction in patients with ovarian cancer: variables associated with surgical complications and survival. Bowel obstruction in patients with ovarian cancer: a search for prognostic factors. Palliative surgery for bowel obstruction in recurrent ovarian cancer: an updated series. The utility of gastrojejunostomy in secondary cytoreduction and palliation of proximal intestinal obstruction in recurrent ovarian cancer. An analysis of surgical versus chemotherapeutic intervention for the management of intestinal obstruction in advanced ovarian cancer. Surgery for the resolution of symptoms in malignant bowel obstruction in advanced gynaecological and gastrointestinal cancer. Palliation of small bowel obstruction by percutaneous gastrostomy in patients with progressive ovarian carcinoma. Palliative treatment of upper intestinal obstruction by gynecologic malignancy: the usefulness of percutaneous endoscopic gastrostomy. Malignant germ cell tumors of the ovary and testis: an immunohistologic study of 69 cases. Ovarian and extragonadal malignant germ-cell tumors in females: a single-institution experience with 43 patients. Conservative surgery to preserve ovarian function in patients with malignant ovarian germ cell tumors: a review of 74 cases. Treatment of disseminated germ cell tumors with cisplatin, bleomycin and either vinblastine or etoposide. Chemotherapy of advanced ovarian dysgerminoma: trials of the Gynecologic Oncology Group. Cisplatin, vinblastine, and bleomycin in advanced and recurrent ovarian germ-cell tumors. Adjuvant therapy of ovarian germ cell tumors with cisplatin, etoposide, and bleomycin: a trial of the Gynecologic Oncology Group. Treatment of malignant germ cell tumors of the ovary with bleomycin, etoposide, and cisplatin. Combined modality treatment for malignant transformation of a benign ovarian teratoma. Adjuvant therapy of completely resected dysgerminoma with carboplatin and etoposide: a trial of the Gynecologic Oncology Group. Cisplatin-based chemotherapy in dysgerminoma of the ovary: thirteen-year experience at the Institut Gustave Roussy.

Quality 50 mg caverta. Hot actress Vidya Balan's superb chemistry with Thala Ajit in Nerkonda Paarvai തലയും വിദ്യയും കിടിലൻ.