Louis S. Constine, MD, FASTRO

• Professor of Radiation Oncology and Pediatrics
• Section Chief, Pediatric Radiation Oncology
• Vice Chairman, Department of Radiation Oncology
• James P. Wilmot Cancer Center
• University of Rochester Medical Center
• Rochester, New York

Thus the liver and intestine erectile dysfunction facts and figures cheap suhagra online american express, despite their rather small contribution to the total protein content of the body erectile dysfunction treatment houston buy 100 mg suhagra, are together believed to contribute as much as 50 percent of whole body protein turnover (McNurlan and Garlick erectile dysfunction los angeles cheapest generic suhagra uk, 1980; Waterlow erectile dysfunction causes mayo proven suhagra 50 mg, 1984) erectile dysfunction drugs compared suhagra 100 mg on line. Con versely erectile dysfunction treatment herbs buy suhagra 50mg, skeletal muscle is the largest single component of body protein mass (43 percent), but contributes only about 25 percent to total body protein turnover (Reeds and Garlick, 1984; Waterlow, 1984). At the tissue level, proteins are continually being synthesized and degraded as a sensitive means of regulating the amount of each separate enzyme or structural component. Other proteins may be secreted from the cell after synthesis and subsequently degraded at a distant site. Examples of such proteins are serum albumin synthesized in the liver, antibodies in the Blymphocytes, digestive enzymes in the pancreas, and peptide hor mones formed in the endocrine glands. Amino Acid Catabolism Nitrogen Metabolism About 11 to 15 g of nitrogen are excreted each day in the urine of a healthy adult consuming 70 to 100 g of protein, mostly in the form of urea, with smaller contributions from ammonia, uric acid, creatinine, and some free amino acids (Table 104). These are the end products of protein metabolism, with urea and ammonia arising from the partial oxidation of amino acids. The removal of nitrogen from the individual amino acids and its con version to a form that can be excreted by the kidney can be considered as a twopart process. Transamination is a reversible reaction that uses ketoacid intermediates of glucose metabolism. Most amino acids can take part in these reactions, with the result that their amino nitrogen is transferred to just three amino acids: alanine from pyruvate, aspartate from oxaloacetate, and glutamate from ketoglutarate. Unlike many amino acids, branchedchain amino acid transamination occurs throughout the body, particularly in skeletal muscle. Here the main recipients of amino nitrogen are alanine and glutamine (from pyruvate and glutamate, respectively), which then pass into the circulation. These serve as important carriers of nitrogen from the periphery (skeletal muscle) to the intestine and liver. In the small intestine, glutamine is extracted and metabolized to ammonia, alanine, and citrulline, which are then conveyed to the liver via the portal circulation (Harper et al. Nitrogen is also removed from amino acids by deamination reactions, which result in the formation of ammonia. A number of amino acids can be deaminated, either directly (histidine), by dehydration (serine, threonine), by way of the purine nucleotide cycle (aspartate), or by oxida tive deamination (glutamate). These latter two processes are important because glutamate and aspartate are recipients of nitrogen by transamination from other amino acids, including alanine. Glutamate is also formed in the specific degradation pathways of arginine and lysine. Thus, nitrogen from any amino acid can be funneled into the two precursors of urea synthesis, ammonia and aspartate. Urea synthesis takes place in the liver by the cyclic pathway known as the KrebsHenseleit cycle. The remaining part of the cycle involves the resynthesis of arginine using nitrogen from ammonia and aspartate. Thus, although arginine is the direct precursor of urea, it is not consumed in the process, as the nitrogen excreted as urea is all derived from ammonia and aspartate. After synthesis, the urea is carried by the circulation from the liver to the kidney, where it is excreted into the urine. Although the excretion of urea dominates nitrogen excretion as a whole, significant quantities of ammonium ions are also excreted. There are some metabolic pathways, notably the purine nucleotide cycle, whereby purine nitrogen is converted to ammonium ions. It is generally believed that much of the ammonia produced by this cycle in skeletal muscle is transported in the blood as glutamine. Some of this glutamine is metabolized in the kidneys, where the enzyme glutaminase leads to the release of ammonium ions and glutamate. This glutamate, after losing its amino group, is then utilized in the synthesis of glucose in the kidney. Carbon Metabolism For most amino acids, removal of the amino nitrogen group generates their ketoacid analogues. Many of these are already in a form for entry into the pathways of oxidative metabolism ure 103). All the others have specific degradation systems that give rise to intermediates that can be metabolized in these oxidative pathways. This is particularly true in nongrowing adults, who on average consume, and therefore oxidize, about 10 to 15 percent of their dietary energy as protein (Appendix Table E17). Protein oxidation also has been shown to rise considerably in highly traumatized or septic individuals, which results in large amounts of body protein loss; this loss can compro mise recovery or even lead to death (see below) (Klein, 1990). It is much less in periods of chronic starvation because of various metabolic adaptations related to ketone utilization, or on proteinrestricted diets. Whether glucose or fat is formed from the carbon skeleton of an amino acid depends on its point of entry into these two pathways. The carbon skeletons of other amino acids can, however, enter the pathways in such a way that their carbons can be used for gluco neogenesis. This is the basis for the classical nutritional description of amino acids as either ketogenic or glucogenic. Some amino acids produce both products upon degradation and so are considered both ketogenic and glucogenic ure 103). It has been argued that the majority of hepatic amino acid catabolism is directed in an obligatory fashion to glucose synthesis (Jungas et al. This cycle also involves the peripheral synthesis of glutamine, an amino acid that is utilized in substantial quantities by the intestinal cells in which it is used for energy and for the synthesis of proline, citrulline, and nucleic acids. A significant proportion of the glucose synthesized in the liver is due to recapture and recycling via the liver of 3carbon units in the form of lactate derived from anaerobic glucose breakdown in muscle (the Cori cycle). Since the nitrogen donors may be either glucogenic or ketogenic amino acids, these cycles function as mechanisms for transporting nitrogen from the periphery to the liver as well as for glucose production. The cycle involving glutamine transport from the periphery to the gastrointestinal tract is also vital to the synthesis of arginine and proline and is critical to the preven tion of the build up of excessive ammonia in the circulation. Nonprotein Pathways of Amino Acid Nitrogen Utilization Although in general the utilization of dietary amino acids is dominated by their incorporation into protein and their role in energy metabolism, amino acids are also involved in the synthesis of other nitrogenous com pounds important to physiological viability as shown in Table 105. Some pathways have the potential for exerting a substantial impact on the utili zation of certain amino acids, and may be of potential significance for the requirements for these amino acids. This is particularly true for glycine, which is a precursor for six nitrogenous compounds, as shown in Table 105. Its utilization in the synthesis of creatine (muscle function), heme (oxygen transport and oxidative phosphorylation), and glutathione (protective reactions which are limited by the amount of available cysteine) is not only of physiological importance, but can also involve substantial quantities of the amino acid. For example, in the absence of a dietary source of creatine, adults require at least 1. In premature infants, mainly fed human milk, there is evidence that the glycine supply may be a primary nutritional limitation to growth (Jackson, 1991). These may be important nutritional con siderations in individuals consuming marginal amounts of proteins of plant origin and undoubtedly have an impact on overall amino acid utilization when protein intake is very low. Clinical Effects of Inadequate Protein Intake As outlined above, protein is the fundamental component necessary for cellular and organ function. Not only must sufficient protein be pro vided, but also sufficient nonprotein energy. Hypoalbuminemic malnutrition has been described in hospitalized adults (Bistrian, 1990) and has also been called adult kwashiorkor (Hill, 1992). Clearly, protein deficiency has adverse effects on all organs (Corish and Kennedy, 2000). Furthermore, protein deficiency has been shown to have adverse effects on the immune system, resulting in a higher risk of infections (Bistrian, 1990). It also affects gut mucosal function and permeability, which, in turn, affects absorption and makes possible bacterial invasion from the gut, which can result in septicemia (Reynolds et al. Protein deficiency has also been shown to adversely affect kidney function, where it has adverse effects on both glomerular and tubular function (Benabe and MartinezMoldonado, 1998). Total starvation will result in death in initially normalweight adults in 60 to 70 days (Allison, 1992). For comparison, protein and energy reserves are much smaller in premature infants, and survival of 1, 000g neonates is only about 5 days (Heird et al. Clinical Assessment of Protein Nutritional Status No single parameter is completely reliable to assess protein nutritional status. Borderline inadequate protein intakes in infants and children are reflected in failure to grow as estimated by length or height (Jelliffe, 1966; Pencharz, 1985). However, weightheight relationships can be distorted by edema and ascites (Corish and Kennedy, 2000). Midupper arm parameters such as arm muscle circumference have been used to measure protein status (Young et al. The triceps skinfold is reflective of energy nutritional status while the arm muscle circumference (or diameter) is reflective of protein nutritional status (unless a myopathy or neuropathy is present) (Patrick et al. In addition, urinary creatinine excretion has been used as a reflection of muscle mass (Corish and Kennedy, 2000; Forbes, 1987; Young et al. The most commonly used methods to clinically evaluate protein status measure serum proteins; the strengths and weaknesses of these indicators are summarized in Table 106. In practical terms, acute protein depletion is not clinically important as it is rare, while chronic deficiency is important. Serum proteins as shown in Table 106 are useful, especially albumin and transferrin (an ironbinding protein). Due to their very short halflives, prealbumin and retinol binding protein (apart from their dependence on vitamin A status) may reflect more acute protein intake than risk of protein malnutrition (which is a process with an onset of period of 7 to 10 days (Ramsey et al. Hence, albumin and transferrin remain the best measures of protein mal nutrition, but with all of the caveats listed in Table 106. In protein malnutrition, the skin becomes thinner and appears dull; the hair first does not grow, then it may fall out or show color changes (Pencharz, 1985). Over a longer period of time, assessment of changes in lean body mass reflects protein nutritional status. The clinical tools most available to assess lean mass are dual emission xray absorptiometry and bioelectrical impedance (Pencharz and Azcue, 1996). This section reviews some of the possible indicators used or proposed for use in analyses estimating human protein requirements. Factorial Method the factorial method is based on estimating the nitrogen (obligatory) losses that occur when a person is fed a diet that meets energy needs but is essentially protein free and, when appropriate, also relies on estimates of the amount of nitrogen that is accreted during periods of growth or lost to mothers during lactation. The major losses of nitrogen under most con ditions are in urine and feces, but also include sweat and miscellaneous losses, such as nasal secretions, menstrual losses, or seminal fluid. This is where the factorial method has its greatest weakness, since the relationship between protein intake and nitrogen retention is somewhat curvilinear; the efficiency of nitrogen retention becomes less as the zero balance point is approached (Rand and Young, 1999; Young et al. Additionally, in order to utilize the factorial approach when determining the protein requirement for infants and children, their needs for protein accreted as a result of growth must be added to their maintenance needs. Nitrogen Balance Method this classical method has been viewed by many as theoretically the most satisfactory way of determining the protein requirement. Nitrogen balance is the difference between nitrogen intake and the amount excreted in urine, feces, skin, and miscellaneous losses. As discussed below, nitro gen balance remains the only method that has generated sufficient data for the determination of the total protein (nitrogen) requirement. It is assumed that when needs are met or exceeded adults come into nitrogen balance; when intakes are inadequate, negative nitrogen balance results. In determining total protein (nitrogen) needs, highquality proteins are utilized as test proteins to prevent negative nitrogen balance resulting from the inadequate intake of a limiting indispensable amino acid. A significant literature exists regarding the methods and procedures to use in deter mining nitrogen balance amount (Manatt and Garcia, 1992; Rand et al. Limitations of the Method the nitrogen balance method does have substantial practical limita tions and problems. First, the rate of urea turnover in adults is slow, so several days of adaptation are required for each level of dietary protein tested to attain a new steady state of nitrogen excretion (Meakins and Jackson, 1996; Rand et al. Second, the execution of accurate nitro gen balance measurements requires very careful attention to all the details of the procedures involved. Since it is easy to overestimate intake and underestimate excretion, falsely positive nitrogen balances may be obtained (Hegsted, 1976). Indeed, an overestimate of nitrogen balance seems con sistent throughout the literature because there are many observations of quite considerable apparent retention of nitrogen in adults (Oddoye and Margen, 1979). A third limitation of the nitrogen balance method is that since the requirement is defined for the individual, and studies rarely provide exactly the amount of protein necessary to produce zero balance, individuals must be studied at several levels of protein intake in the region of the requirement so that estimates of individual requirements can be interpolated (Rand et al. Finally, dermal and miscellaneous losses of nitro gen must be included in the calculation. These are inordinately difficult to measure, and vary with the environmental conditions. In fact, the literature indicates marked (at least twofold) differ ences between studies (Calloway et al. The inclusion of dermal and miscellaneous nitrogen losses can have a significant effect on estimates of amino acid requirements via nitrogen balance, especially in adults (Calloway et al.

MultiSite Evaluation of Batterer Intervention Systems: A 30Month Follow Up of CourtMandated Batterers in Four Cities finasteride erectile dysfunction treatment order suhagra amex. Violence by Intimates: Analysis of Data on Crimes by Current or Former Spouses blood pressure drugs erectile dysfunction cheap suhagra 50mg online, Boyfriends best erectile dysfunction pills treatment cheap suhagra 50 mg mastercard, and Girlfriends erectile dysfunction caused by vasectomy discount suhagra 100 mg otc. Department of Health and Human Services erectile dysfunction natural treatment options generic suhagra 50 mg otc, Substance Abuse and Mental Health Services Association erectile dysfunction treatment ayurveda order suhagra from india, 2009, available online at. Court Processing and the Effects of Restraining Orders for Domestic Violence Victims. Department of Justice, National Institute of Justice, and the Urban Institute, April 2006, available online at. A Typology of Domestic Violence: Intimate Terrorism, Violent Resistance, and Situational Couple Violence. Department of Health and Human Services, Centers for Disease Control and Prevention, May 14, 2010, available online at. A Victim Survey on the Effects of a CourtMandated Batterer Intervention Program in Rhode Island. New York: Center for Court Innovation, National Institute of Justice, November 2005, available online at. Intimate Partner Violence and Social Isolation Across the Rural/Urban Divide, Journal on Violence Against Women, 15 (11), 13111330 482. Domestic Violence: Keeping the Promise, Victim Safety and Batterer Accountability. Report to the California Attorney General from the Task Force on Local Criminal Justice Response to Domestic Violence. The Crime Control Effects of Criminal Sanctions for Intimate Partner Violence: A Systematic Review of 31 Studies. The Effects of Arrest on Intimate Partner Violence: New Evidence From the Spouse Assault Replication Program. For information about the intervention, contact Futures Without Violence in San Francisco. Partner violence before and after couplesbased alcoholism treatment for male alcoholic patients. Violence risk factors in stalking and obsessional harassment: A review and preliminary metaanalysis. Association between exposure to violence and objectively measured sleep characteristics: a pilot longitudinal study in Cleveland, Ohio. Violence Against Women in Families and Relationships: Volume 3, Criminal Justice and the Law. If I Had One More DayFindings and Recommendations from the Washington State Coalition Against Domestic Violence. Health Policy Institute of Ohio, Ohio State University College of Public Health, October 2010, available online at a5e8c023c8899218225edfa4b02e4d9734e01a28. Physical Violence in American Families: Risk Factors and Adaptations to Violence in 8, 145 Families. Applied Research Forum, National Electronic Network on Violence Against Women, National Resource Center Domestic Violence, the Pennsylvania Coalition Against Domestic Violence, 1999. Department of Health and Human Services, Administration for Children and Families, Administration on Aging, September 1998, available online at. Measuring Intimate Partner Violence Victimization and Perpetration: A Compendium of Assessment Tools. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Prevalence, Incidence, and Consequences of Violence Against Women: Findings From the National Violence Against Women Survey. Office of Community Planning and Development, 2011, available online at. Domestic Violence: Prevalence and Implications for Employment Among Welfare Recipients. Borderline but not antipersonality disorder symptoms are related to selfreported partner aggression in late middleage. States, 1997: Exploring the Incidence and Risk for Hospitalized Assaults Against Women During Pregnancy. The Violence and Addiction Equation: Theoretical and Clinical Issues in Substance Abuse and Relationship Violence. Reconsidering Domestic Violence Recidivism: Individual and Contextual Effects of Court Dispositions and Stake in Conformity in Hamilton County, Ohio, 1993 1998. The Link Between Intimate Partner Violence, Substance Abuse and Mental Health in California. He is author of the Criminal Justice Response to Domestic Violence (Thomson/Wadsworth). His Practical Implications of Current Domestic Violence Research for Law Enforcement, Prosecutors and Judges was released as a Special Report by the National Institute of Justice. Her work includes public policy development, training, and technical assistance on a broad range of issues such as: advocacy; economic justice and security for survivors; systems to monitor batterer intervention programs; implementation of coordinated community intervention systems; development and critique of legislation; construction of court procedures and standards; consultation on impact litigation; development of fatality review processes; and design of training curricula. She has served as a leader in the national efforts to implement the Violence Against Women Act. Hart hosts a series of national/international webinars designed to create discourse between prominent researchers and expert practitioners. Several treatises suggest that the abuse experienced by male victims of female intimates is contextually different than that experienced by women victims of male intimates. It is a distinct philosophy and science which strengthens the ageold faith in the correction of bodily disorders and restoration and main tenance of health through elements freely available in nature. It brings home the basic fact that healing is brought about by the inherent curative powers of the body. A news item appear in newspapers recently about a famous French folk singer, Rike Zarai, who had never practised naturopathy but her faith, based on her personal experience, turned her into an authority on herbs and nature cure. At the Height of her career as a singer, Rika met with an accident, when her car went off the road, due to poor visibility on account of fog and she was taken from the wreckage with four broken vertebrae, one of which was pulverised. The attending doctors indicated that she might not be able to walk again without crutches. Clay compresses were smuggled into the hospital and she applied them regularly to her back. Her surgeon was outraged when she attributed her remarkable recovery not to his skill but to the clay. With the zeal of a convert, she applied herself to the wider study of natural medicine. This book offers a way which, if followed, will provide renewed energy, increased vitality and greater satisfaction that comes from living a full and useful life. The author has advocated that the right food could work wonders and has tremendous curative power. One can enjoy perfect health by proper regulation of eating, drinking, breathing, bathing, dressing, working, thinking, and other social activities on a normal and natural basis. More importantly, in my own case, I suffered immen sely, for many years, largely due to the shortcomings of the modern medical system. In my despair, I earnestly began my study of natural methods of treatment and cure of disease, as also the ways and means of maintaining good health. Putting the timetested nature cure methods into practice proved so beneficial in my own case, that I took to studying their application for several other diseases as well. What began as mere jottings was gradually expanded into fulllength articles on the subject " Cure Without Drugs ", several of which were published in "The Economic Times. This book as well as my second book titled " Diet Cure For Common Ailments " published three years laters, was well received by the press and the public. This fact coupled with the immense popularity of my articles on health, nutrition and nature cure being published in several leading newspapers and magazines, have prompted me to write a comprehensive book on nature cure under the present title for the benefit of the general public. Experience, they say, is the most convincing teacher, and I would like to begin with details of my own case history as a means of indicating the major health problems that nature cure can overcome. While doing my intermediate arts, at the age of 16, I contracted two serious illness pleurisy and typhoid fever simultaneously. Having run their course for about 45 days, both ailments left me so debilitated that I had to dis continue my studies for one year, on medical advice. My recovery was gradually but not complete, as I developed heartburn and breathing problems. At 28 came the worst crisis, when I suffered a stroke in the early hours of an extremely hot day in May after acute heartburn throughout the night. The stroke made the left side of my body extremely heavy and weak, and the attending physician referred my case to a well known neurosurgeon, suspecting a brain tumour. For nearly two months I lay helpless in the special ward of a reputed hospital, undergoing several tests and at the same time observing around me frequent deaths following unsuccessful brain surgery. Finally, having twice failed to inject air through the spinal cord for taking Xrays of the brain, the specialist decided to make holes in my skull for that purpose and even operate if necessary. Fortunately for me, the specialist had to attend a medical conference elsewhere and, therefore, instructed his assistant to try the newlyintroduced method of cerebral angiography, which involved injecting dye through an exposed vein in the neck to enable Xraying of veins in the brain. When these Xrays did not reveal anything abnormal, I was allowed to go, but not before the harrowing experience had left me a complete nervous wreck. I underwent a barium meal examination which indicated " Chronic doudenitis, may be chronic duodenal ulcer. I endured this for three years, until the pain and heaviness of the left side was miraculously cured by an astrologer: But nothing could rid me of the heartburn, abdominal pain and occasional severe stomach upsets, which continued to necessiate the use of several drugs. Investigations, from time to time, confirmed the diagnosis of duodenitis or chronic duodenal ulcer. A barium meal examination, done when I was 39, revealed hiatus hernia with peptic oesophegal ulcers. To add to all of this, at 45, an eminent heart specialist declared me a heart patient, following a checkup due to pain on the left side of my chest. Consulting another eminent heart specialist two years later, I was informed that there was no evidence whatsoever of heart trouble, but he confirmed the presence of hiatus hernia and stomach trouble. God alone knows which diagnosis was correct: Then came a host of diseases in rapid succession spondylosis, myalgia, backache and prostate enlargement, in treating all of which the modern medical system failed to give me any relief, despite taking huge quantities of drugs, especially painkillers, antacid tablets and tranquillisers. All this time, I was aware of the natural methods of treatment which I had studied from the age of 30 and a few of which I had practised occassionally. I, however, dared not adopt them wholeheartedly because of my heavy dependence on drugs. Rather late in the day, at the age of 55, I made a determined bid to do away with all drugs and take recourse to natural methods. I began collecting and studying a greater deal of data on the subject and also consulted naturopaths. I made drastic changes in my diet and lifestyle and started rigidly observing the laws of nature. I was rewarded sooner than expected so much so, that for one who narrowly escaped death at the age of 28, when my son was a year old, I can proudly say that today, at 64, when I have a nineyearold grandson, I feel healthier, thanks mainly to my taking recourse to nature cure methods. But I do maintain that I have been able to control them substantially and have obtained a lot of relief without resorting to drugs. I am certain that my own success in controlling several dreaded disabilities will serve as inspiration to those readers who are suffering from various ailments and hold out the hope of their deriving real benefits from the natural methods of treatment outlined in this book. Bolar, an eminent naturopath and Executive Director, Indian Institute of Drugless Therapy, Churchgate, Bombay, for his foreword. I am also grateful to my wife, Draupadi, for her painstaking efforts in going through the typescript of the book and carry out corrections of typographical errors a task which I possiblly could not undertake due to sharp deterioration in my eyesight on account of degeneration of retina of both the eyes. It is not only a system of healing, but also a way of life, in tune with the internal vital forces or natural elements comprising the human body. India, it appears, was much further advanced in older days in natural healing system than other countries of the world. The Great Baths of the Indus Valley civilisation as discovered at Mohenjodaro in old Sind testifies to the use of water for curative purposes in ancient India.

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Chapter 539 also be helpful and may be considered impotence vacuum device buy 100mg suhagra fast delivery, particularly for girls Chapter 38 who need contraception erectile dysfunction family doctor discount suhagra 100mg overnight delivery. Onset of symptoms with menarche when cycles are usually 4 anovulatory may be due to mullerian tract abnormalities History should include onset of symptoms and whether 1 with partial outfow obstruction impotence yoga poses order 100 mg suhagra overnight delivery. It is important to obtain a history of cyclic dysmenorrhea with accumulation of menstrual fuid erectile dysfunction drugs viagra discount 100 mg suhagra mastercard, re disruption of daily activity and response to medications to de sulting in hematocolpos erectile dysfunction young male causes purchase 100mg suhagra amex, hematometra erectile dysfunction treatment in ayurveda discount suhagra 50mg overnight delivery, or hematosalpinx, de termine the extent of investigation and treatment required. Endometriosis is the presence of endometrial tissue outside the normal intrauterine cavity. Unlike in adults, in adolescents the Primary dysmenorrhea has no clinically detected pelvic 2 pelvic examination may be normal or there may be minimal pathology. It begins with the Psychogenic dysmenorrhea may be related to negative 6 onset of the menstrual period and lasts from a few hours to sexual experiences, such as child abuse or rape. The pelvic examination is normal but is Bibliography usually not clinically indicated. At puberty, breasts develop owing to gonadal estrogens; axillary and pubic hair is absent. Hypothalamic dysfunction leading to amenorrhea is a diagno Amenorrhea is the absence of menstrual periods. It is caused by suppression of gonadotropin orrhea occurs when there is no menstrual period by age 15 years, releasing hormone pulsatile secretion and is most commonly or no signs of puberty as well as menses by age 13 years. Secondary associated with chronic illness associated with undernutrition amenorrhea occurs when a previously menstruating female has (Crohn disease, celiac disease), stress, excessive exercise, or no menstrual bleeding for at least 3 to 6 months. The female athlete triad is when there is more than 6 weeks between menstrual cycles or consists of disordered eating, amenorrhea, and low bone mass. Withdrawal bleeding may occur with a progestin challenge (see History should include pubertal development and menstrual note 9). Pregnancy is the frst consideration in an adolescent with secondary amenorrhea, but Polycystic ovary syndrome is characterized by oligomen 5 should always be considered as a possible cause even in primary orrhea or amenorrhea and evidence of hyperandrogenism, amenorrhea. Information on sexual history including sexual abuse either clinical or laboratory. Laboratory evidence may include and use of hormonal contraceptives should be carefully elicited. Diag participation, and abnormal eating patterns (anorexia, bulimia) is nostic criteria vary among experts. Family history should include gynecologic problems, age at common cause (see note 9). On physical examination, it is impor is also known as hypergonadotropic hypogonadism. Galactorrhea is ofen associated with amenorrhea; acne, palate, low hairline, shield chest, ptosis, cutis laxa, pterygium hirsutism, and other signs of possible virilization should be identi colli, shortened fourth metacarpals, cubitus valgus, heart mur fed. A Autoimmune disease may cause primary ovarian insuf careful examination of the reproductive tract is useful in identify ciency. Other associated conditions include myasthenia gravis, ing anatomic defects and assessing sexual maturity. Ovarian failure may Congenital structural abnormalities such as imperforate hy 2 result from chemotherapy or from irradiation. Gonadotropin men and transverse vaginal septum may obstruct menstrual secreting adenomas are not associated with amenorrhea. A history of cyclic pain may be present, and a midline lower abdominal mass (hematocolpos/hematometra) may be If there is history of contraceptive use (birth control pills 7 palpated. Mullerian agenesis (MayerRokitanskyKusterHauser or longacting implantable or injectable progestins), syndrome) is characterized by an absent or shallow vagina with amenorrhea may be attributed to the suppression of ovulation an absent cervix and uterus. Menstrual sexual development are normal, but urinary tract and skeletal cycles should revert to normal within 6 months of stopping anomalies may be present. Chapter 69 142 Part V u Genitourinary System Adolescent girls with hyperprolactinemia may present occurs within 2 weeks of treatment, it implies a functional 8 with amenorrhea or delayed puberty and ofen with uterus and outfow tract and an endometrium that has been galactorrhea. The amount of bleeding is roughly propor evaluate for pituitary or hypothalamic tumors or disease (cra tional to the amount and duration of prior estrogen exposure. Galactorrhea If there is no bleeding, it usually implies a lowestrogen with normal or mildly elevated prolactin levels may be second 10 state or hypoestrogenic amenorrhea. Rarely, it may be that ary to nipple stimulation and chest wall irritation or trauma. If there is any question, the pregnancy test Estrogen status may be evaluated by progestin challenge, must be repeated. Estrogen status may also be confrmed by vaginal smear or the presence Bibliography of abundant watery cervical mucus. Infectious vulvovaginitis usually appears as a discharge, 4 but bleeding may be present. Periodic men isms obtained on culture are group A streptococci, Shigella, and strual bleeding occurring more frequently than every 21 days, mixed organisms. The presence of gonococci, Chlamydia, or greater than every 45 days, or lasting longer than 7 days requires Trichomonas should prompt evaluation for sexual abuse. With excessive blood loss, iron defciency anemia may Vulvovaginal trauma is usually caused by straddle injuries develop. Variations in menstrual cycles may include menorrhagia 5 and less commonly by vaginal penetration and tearing (normal intervals, excessive fow and duration of bleeding), metror from forced leg abduction; always consider the possibility of rhagia (irregular intervals), polymenorrhea (intervals # 21 days), sexual abuse. The age of the patient is important, as well as any history of If a mass is visualized, consider urethral prolapse, which 1 6 abuse or trauma, including sexual abuse. A history of any for appears as red, friable, ofen necrotic tissue at the urethra. In girls who have reached menarche, a 7 parchmentlike (classically in an hourglass pattern around detailed menstrual history including date of menarche and men the introitus and anus) and therefore susceptible to bleeding strual pattern should be obtained. A sexual history (sexually transmitted disease, sexual partners) is important, as well as any use of hormonal contraception. Neoplasms include hemangiomas, polyps, and sarcoma 8 Exposure to medications, including exogenous estrogens, anticoagu botryoides (a grapelike mass protruding from the va lants, and platelet inhibitors, may be a cause of bleeding. Malignancies are uncommon (adenocarcinoma and pain or vaginal discharge may indicate infections. An ex Exogenous exposures to estrogens may occur from inges 9 amination of external genitalia must be done (vaginal digital exam if tion of birth control pills, foods, and beauty products. It possible) to identify anatomic abnormalities, and a pelvic examina has been hypothesized that plastics may contain estrogenlike tion performed when indicated for sexually active patients. Precocious menarche is a rare form of incomplete preco 10 In the newborn, a small amount of endometrial bleeding cious puberty with cyclic menstruation but no other sec 2 may occur secondary to withdrawal from relatively high ondary sexual characteristics. Chapter 69 146 Part V u Genitourinary System In pubertalage girls, frst exclude pregnancy. Complica disorders, factor defciencies, liver dysfunction, and vitamin K 11 tions of pregnancy such as miscarriage or ectopic preg defciency. Consultation with a hematologist may be needed for nancy may appear as abnormal bleeding. Infections causing vaginitis and cervicitis include chla Causes include Neisseria gonorrhoeae, Chlamydia trachomatis, 13 mydia, gonorrhea, and trichomoniasis, herpes simplex, and endogenous fora (streptococci, anaerobes, gramnegative and human papillomavirus. Constant levels of estrogen result in per sistent endometrial stimulation and irregular heavy bleeding Neoplasms include fbroids (submucous myoma), endo 21 when the endometrium cannot be sustained. Chronic diseases include diabetes, renal disease, and sys 15 22 Causes include idiopathic thrombocytopenic purpura temic lupus erythematosus. Foreign bodies (ofen retained toilet tissue) in the vagina 7 cause a foulsmelling brown or bloody discharge. If the foreign body cannot be visualized, examination using anesthe Vaginal discharge is a common but nonspecifc sign in female sia may be needed. It should prompt consideration of sexually trans Anal pruritus may indicate pinworms and can be diag mitted disease in sexually active girls. Pinworms are more common in Menstrual history, including changes in cycle or new onset younger children. A history of symptoms including odor, color, amount of discharge, and pruritus should Neoplasms are a rare cause of discharge. Sexual abuse should be consid ered, particularly in prepubertal girls with vaginal discharge. Mullerian anomalies may also present with vaginal dis 11 Most discharge in this age group is not sexually acquired. Pelvic examination (if necessary) in prepubertal girls may monas has a yellow frothy discharge. The Pederson speculum is with evidence of cervicitis may be seen with Chlamydia tracho slightly larger and may be used in an adolescent. Microscopic examination of secretions may help provide the Physiologic leukorrhea is a whitish mucoid discharge that diagnosis. Other causes of vaginitis include allergic vulvovaginitis 20 Herpes appears initially as vesicles and pustules associated caused by soaps, douches, contraceptive gels or creams, 17 with vaginal discharge and dysuria, followed by ulceration and (rarely) sperm. Tender Chronic discharge may be due to an intrauterine device inguinal lymphadenopathy may be present. Tese may include endometritis, salpingitis, 22 Crohn disease and rarely with obstetric trauma (more of tuboovarian abscess, and pelvic peritonitis, ofen in combina ten seen in developing countries with inadequate obstetric tion. If an efusion is present, joint aspiration is recommended to rule out a septic arthritis. Infection within the bone is osteomyelitis; secondary spread to involve the joint may accompany it. Both disorders An abnormal gait in a child may be due to pain, weakness, tor may present with localized pain and tenderness in an acutely ill sional deformity, or a musculoskeletal disorder. Osteomyelitis may also occur subacutely with prolonged A birth history and developmental history are particularly pain and limp but without fevers or systemic complaints. Bone 1 important for problems noticed early or around the time a changes on xray may not become evident for 7 to 10 days. Prematurity and birth complications are tissue changes may be evident earlier, plus flms are usually risk factors for hypoxic brain damage. Septic arthritis is a medical emergency requiring prompt 6 The musculoskeletal examination should include careful at diagnosis and treatment. The hip exam is particularly fever, malaise, refusal to walk, and localized joint pain, most important because hip problems are a common cause of limp commonly knee or hip. Examination reveals erythema, warmth, ing, plus hip pathology frequently causes referred pain to the swelling, and pain with passive motion. Careful observation of the gait, ideally over a distance gest the diagnosis by demonstrating an efusion, but joint aspi such as a long hallway, is critical. Having the child adequately ration is mandated to confrm (or rule out) the diagnosis. Congenital and neuromuscular disor limping in children, usually between 3 and 8 years of age. The ders are more likely to present with a painless (Trendelenburg) etiology is not well defned; it is described as a nonspecifc in gait, which indicates proximal muscle weakness or hip instabil fammatory condition, although viral, allergic, and traumatic ity. The stance phase is equal from side to side in these cases, but mechanisms have all been suggested. Children present with the child tends to shif their weight over the involved side for unilateral hip pain, a painful limp, and slightly restricted abduc balance. Fevers may be present, but rarely do Children are more at risk for epiphyseal fractures than liga patients present with the acute toxicity suggestive of septic ar 2 mentous sprains because their ligaments are generally stronger thritis. The diagnosis is one of exclusion; the most important than the adjacent growth plates. Several recent studies show only physeal widening, the diagnosis is ofen clinical. Consul have focused on identifying factors that help distinguish a sep tation should always be considered when in doubt. With transient (growth plate) leads to posterior displacement of the metaphy synovitis, laboratory results are usually normal or suggest a sis (femoral neck) relative to the epiphysis (femoral head). Xrays are usually normal or may many cases, an undiagnosed chronic slip is diagnosed afer it is show a slightly widened medial joint space or accentuated peri acutely worsened by trauma. Examination reveals limited internal rotation of pain and fever; children presenting afer 1 or 2 days of symp the afected hip and an outtoed, painful gait. Bilat sis of the femoral head resulting in a bony deformity of the eral views are recommended because the condition is bilateral femoral head. Children between 2 and 12 years of age are af in 25% of cases at initial presentation. Conditions like hypothy fected, with a peak incidence between 4 and 8 years of age; boys roidism, pituitary disorders, and renal osteodystrophy can im are afected more than girls. Pain complaints are usually as sociated with activity; the pain may be located in the groin or When infection or infammation is suspected, laboratory referred to the anteromedial thigh or knee. Afected children are delayed in crawling and walk usually suggest the diagnosis of benign bone tumors; intervention ing. The condition is characterized by toewalking and a pain (biopsy, removal, monitoring) will be required for many of them. Examination reveals in creased muscle tone, spasticity, hyperactive deep tendon If not diagnosed in infancy, developmental dysplasia of 10 refexes, tight heel cords, and persistent pathologic refexes. Blood cultures should be obtained if concerned Chapter 43 about a septic joint; testing for Neisseria gonorrhoeae (urine, rectal, throat) should be performed if the patient is sexually ac tive. Synovial fuid should be sent for Gram stain and culture, including inoculation on solid media and in aerobic blood culture bottles. The Gram stain is particularly important, thritis is joint swelling or the presence of two or more of the since synovial fuid cultures are ofen negative.

Elicits symptoms in domains 12 to 17 y of oppositionality erectile dysfunction hypertension medications buy generic suhagra line, cognitive Self: 87 items for self problems/inattention erectile dysfunction medication injection buy suhagra with a mastercard, hyperactivity best erectile dysfunction pills review discount 100mg suhagra overnight delivery, anxietyshyness erectile dysfunction treatment in vijayawada 100 mg suhagra fast delivery, perfectionism erectile dysfunction neurological causes discount suhagra 100mg mastercard, social problems impotence 60784 purchase suhagra 50 mg online, psychosomatic problems. Elicits strengths and weaknesses in domains of attention, impulsivity/hyperactivity. Strengthbased rating scales have the potential to evaluate the normal distribution of behaviors and to provide reliable cutoff defning abnormal behavior. Norms were developed based on 644 representative individuals with a conduct disorder. Computerized structure interview 8item abbreviated version available generally high (0. As a screening, it is recommended that the results from the Intrusion and Avoidance scales only be used. Collateral Information Tools (Algorithm Steps A12a, B2b, B9) Rating Scales Vanderbilt73 See previous entry in table. American Academy of Pediatrics Council on Children With promoting mental health, identifying and addressing 9. Getting into adolescent heads: Disabilities, Section on Developmental and Behavioral mental health and substance use concerns in pediatric an essential update. Screening for dysfunction in the children children with developmental disorders in the medical Guidelines for Health Supervision of Infants, Children, of outpatients at a psychopharmacology clinic. Available at: to screen for psychosocial problems in pediatric primary Thomas; 1982. J factors related to positive screens and the contribution of Completed, ChildMonitoring System for SocialEmotional Affect Disord. Detecting and monitoring Somatoform Dissociation Questionnaire: a replication Spanish mothers. The Trauma Family Assessment Device: does it work with Chinese Assessment Resources, Inc Web site. Psychometric properties of the Multidimensional Scale of Perceived Social Support Accessed January 20, 2010 63. Strain Questionnaire: measuring the impact on the family Accessed January 20, 2010 of living with a child with serious emotional disturbance. The Global University of California at Los Angeles Posttraumatic Assessment Scale. A retrospective Vermont, Department of Psychiatry; 1991 hyperactivity disorder symptoms. Available at: evaluative properties over the course of an 8week Simmons T, Worley K. Accessed January 20, 2010 from previous versions, and reliability of some common htmfi Int J Methods Accessed January 6, 2012 disorders for adolescent psychiatric inpatients. Children and symptom and social functioning selfreport scales: patient health questionnaire for adolescents: validation War Foundation Web site. Technical analysis of father responses to BriefInfant Toddler Social and Emotional Assessment: technology to tailor wellchild care encounters. Center for Achenbach System of EmpiricallyBased Assessment Pearson Assessments Web site. A male factor is solely responsible in about 20% of infertile couples and contributory in another 1 3040%. If a male infertility factor is present, it is almost always defined by the finding of an abnormal semen analysis, although other male factors may play a role even when the semen analysis is normal. This review offers recommendations for the optimal diagnostic evaluation of the male partner of an infertile couple. Some of these conditions are identifiable and reversible, such as ductal obstruction and hypogonadotropic hypogonadism. Other conditions are identifiable but not reversible, such as bilateral testicular atrophy secondary to viral orchitis. When identification of the etiology of an abnormal semen analysis is not possible, as is the case in many patients, the condition is termed idiopathic. When the reason for infertility is not clear, with a normal semen analysis and partner evaluation, the infertility is termed unexplained. Rarely patients with normal semen analyses have sperm that do not function in a manner necessary for fertility. Even azoospermic patients may have active sperm production or could have sperm production induced with treatment. Detection of conditions for which there is no treatment will spare couples the distress of attempting ineffective therapies. Detection of certain genetic causes of male infertility allows couples to be informed about the potential to transmit genetic abnormalities that may affect the health of offspring. Thus, an appropriate male evaluation may allow the couple to better understand the basis of their infertility and to obtain genetic counseling when appropriate. Alternatively, such couples may consider therapeutic donor insemination or adoption. Finally, male infertility may occasionally be the presenting manifestation of an 2 underlying lifethreatening condition. Failure to identify diseases such as testicular cancer or pituitary tumors may have serious consequences, including, in rare cases, death. The goals of the optimal evaluation of the infertile male are to identify: potentially correctable conditions; irreversible conditions that are amenable to assisted reproductive techniques using the sperm of the male partner; irreversible conditions that are not amenable to the above, and for which donor insemination or adoption are possible options; life or healththreatening conditions that may underlie the infertility and require medical attention; and genetic abnormalities that may affect the health of offspring if assisted reproductive techniques are to be employed. Methodology this best practice statement, Optimal Evaluation of the Infertile Male, is part of an updated series on male infertility prepared by the Male Infertility Best Practice Statement Panel (Appendix 1). Other titles include: Best Practice Statement on Evaluation of the Azoospermic Male, Best Practice Statement on Management of Obstructive Azoospermia and Best Practice Statement on Varicocele and Infertility. The first editions (2001) of these 4 documents were prepared by the Male Infertility Best Practice Policy Committee of the American Urological Association, Inc. The two organizations had agreed to collaborate to prepare documents of importance in the field of male infertility. The evidence was generally of a low level, being derived overwhelmingly from nonrandomized studies. The Panel was charged with developing a best practice statement, based on the previous report, by employing published data in concert with expert opinion. The mission of the Panel was to develop recommendations, based on expert opinion, for optimal clinical practices in the diagnosis and treatment of male infertility. It was not the intention of the Panel to produce a comprehensive treatise on male infertility. The Medline search spanning 1999 through October 2007 was supplemented by review of bibliographies and additional focused searches. In all, 341 articles were deemed by the Panel members to be suitable for scrutiny. Three of the four original 2001 reports were updated with new findings and are presented in the documents in colored font. This updated document was submitted for peer review, and comments from 21 physicians and researchers were considered by the Panel in making revisions. In addition, men who question their fertility status despite the absence of a current partner should have an evaluation of their fertility potential. The initial screening evaluation of the male partner of an infertile couple should include, at a minimum, a reproductive history and two semen analyses. If possible, the two semen analyses should be separated by a time period of at least one month. The reproductive history should include 1) coital frequency and timing; 2) duration of infertility and prior fertility; 3) childhood illnesses and developmental history; 4) systemic medical illnesses. Men with secondary infertility should be evaluated in the same way as men who have never initiated a pregnancy (primary infertility). Recommendations: An initial screening evaluation of the male partner of an infertile couple should be done if pregnancy has not occurred within one year of unprotected intercourse. An earlier evaluation may be warranted if a known male or female infertility risk factor exists or if a man questions his fertility potential. A full evaluation by a urologist or other specialist in male reproduction should be done if the initial screening evaluation demonstrates an abnormal male reproductive history or an abnormal semen analysis. Further evaluation of the male partner should also be considered in couples with unexplained infertility and in couples in whom there is a treated female factor and persistent infertility. When to do a full evaluation for infertility the full evaluation for male infertility should include a complete medical and reproductive history, a physical examination by a urologist or other specialist in male reproduction and at least two semen analyses. These tests may include additional semen analyses, endocrine evaluation, postejaculatory urinalysis, ultrasonography, specialized tests on semen and sperm, and genetic screening. The history should include all factors listed above for a reproductive history plus 1) a complete medical and surgical history; 2) a review of medications (prescription and non prescription) and allergies; 3) a review of lifestyle exposures and a review of systems; 4) family reproductive history; and 5) a survey of past infections such as sexually transmitted diseases and respiratory infections. In addition to the general physical examination, particular focus should be given to the genitalia including 1) examination of the penis; including the location of the urethral meatus; 2) palpation of the testes and measurement of their size; 3) presence and consistency of both the vasa and epididymides; 4) presence of a varicocele; 5) secondary sex characteristics including body habitus, hair distribution and breast development; and 6) digital rectal exam. Semen analysis Semen analysis is the cornerstone of the laboratory evaluation of the infertile male and helps to define the severity of the male factor. Physicians should provide patients with standard instructions for semen collection. These instructions should include a defined period of abstinence of two to three days. Semen can be collected by masturbation or by intercourse using special semen collection condoms that do not contain substances detrimental to sperm. The specimen should be kept at room or body temperature during transport and examined within one hour of collection. Azoospermia should not be diagnosed until the specimen is centrifuged at maximum speed (preferably 3000 x g) for 15 minutes, and the pellet is examined. Although the methods for routine measurement of sperm concentration and motility have changed little during the past two decades, sperm morphology assessment has evolved 3 considerably. When these criteria are applied to the evaluation of sperm morphology relatively few sperm are classified as having normal morphology, even in semen from fertile men. Values that fall outside these ranges suggest a male infertility factor and indicate the need for additional clinical and/or laboratory evaluation of the patient. It must be emphasized that the reference values for semen parameters are not the same as the minimum values needed for conception, and that men with semen variables outside the reference ranges may be fertile. Conversely, patients with values within the reference range may still be infertile. Recommendations: the minimum full evaluation for male infertility for every patient should include a complete medical history, physical examination by a urologist or other specialist in male reproduction and at least two semen analyses. Table 1: Semen Analysis: Reference Values On at least two occasions: Ejaculate volume 1. An endocrine evaluation should be performed if there is: 1) an abnormal semen analysis, especially if the sperm concentration is less than 10 million/ml; 2) impaired sexual function; or 3) other clinical findings suggestive of a specific endocrinopathy. Some experts believe that all infertile males should have an endocrine evaluation, but there is no consensus of opinion on this controversy. It should be performed if there is: (1) an abnormally low sperm concentration, especially if less than 10 million/ml; (2) impaired sexual function; or (3) other clinical findings suggestive of a specific endocrinopathy. In order to diagnose possible retrograde ejaculation, the physician should perform a postejaculatory urinalysis for any man whose ejaculate volume is less than 1. It is also important to assure that either incomplete collection or very short abstinence periods (less than 1 day) are not the causes of the lowvolume ejaculate. The postejaculatory urinalysis is performed by centrifuging the specimen for 10 minutes at a minimum of 300 x g, and microscopically inspecting the pellet at 400x magnification. The presence of any sperm in a postejaculatory urinalysis of a patient with azoospermia or aspermia is suggestive of the diagnosis of retrograde ejaculation. Significant numbers of sperm must be found in the urine of patients with low ejaculate volume oligospermia in order to suggest the diagnosis of retrograde ejaculation. Expert consensus on the definition of significant numbers of sperm in the urine does not exist.