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By: Bertram G. Katzung MD, PhD

  • Professor Emeritus, Department of Cellular & Molecular Pharmacology, University of California, San Francisco

Repositioning (anterior transposition) of the inferior oblique is used in the treatment of dissociated vertical deviations order suhagra 100mg otc erectile dysfunction drugs least side effects. Muscle force redirection—In addition to generic suhagra 100mg without prescription erectile dysfunction treatment san diego simple strengthening or weakening 100mg suhagra visa does gnc sell erectile dysfunction pills, the point of attachment of the muscle can be shifted to safe 100mg suhagra impotence natural food give the muscle a rotational action it did not previously have. In sixth cranial nerve (abducens) palsy, surgically moving the insertions of both vertical rectus muscles of the same eye toward the insertion of the lateral rectus will passively reduce the inward rotation of the eye in primary gaze and slightly improve abduction. Surgically moving the insertions of horizontal rectus muscles affects the horizontal eye position in upgaze and downgaze. This is used for A or V patterns (see later section in chapter), in which the horizontal deviation is more eso (or less exo) in upgaze or downgaze, respectively. In the Harada-Ito procedure, the anterior fibers of the superior oblique tendon are tightened to increase its incyclotorsional action. Faden procedure—A special operation for muscle weakening is the posterior fixation (Faden) procedure (retroequatorial myopexy) (Figure 12–7), in which a new insertion is created by suturing the muscle well behind the original insertion. This causes mechanical weakening of the muscle as the eye rotates into its field of action without significant alteration of the primary position of the eye. This prevents unwrapping of the muscle as the eye turns into the muscle’s field of action. If this procedure is combined with recession, the alignment in primary position is also affected. Choice of Muscles for Surgery Deciding which muscles to operate on is based on several factors. Modifications are made for significant differences in distance and near measurements. The medial rectus muscles have more effect on the angle of deviation for near and the lateral rectus muscles more effect for distance. For exotropia greater at distance, both lateral rectus muscles should be weakened. For deviations approximately the same at distance and near, bilateral weakening procedures or unilateral recession/resection procedures are equally effective. The suture is placed on the sclera at any point that will be accessible to the surgeon. The development of adjustable sutures offers an advantage in muscle surgery for reoperations and incomitant deviations. During the operation, the muscle is reattached to the sclera with a slip knot placed so that it is later accessible to the surgeon. After the patient has recovered from the anesthesia to cooperate in the adjustment process, a topical anesthetic drop is placed in the eye and the suture can be tightened or loosened to change the eye position as indicated by cover testing. Adjustable sutures can be used on rectus muscles for recessions or resections and on superior oblique muscle procedures. Although any patient willing to cooperate is suitable, the method is usually not applicable for children under age 12. It is divided into two types: nonparetic (comitant) and paretic (due to paresis or paralysis of one or both lateral rectus muscles). Nonparetic esotropia is the most common type in infants and children; it may be accommodative, nonaccommodative, or partially accommodative. Most cases of childhood nonaccommodative esotropia are classified as infantile esotropia, with onset by age 6 months. Others occur after age 6 months and are classified as acquired nonaccommodative esotropia. An accommodative element is sometimes superimposed upon comitant esotropia (partially accommodative). At least half of children with infantile esotropia will later develop an accommodative esotropia as preschoolers, despite successful surgical alignment as infants. Paretic strabismus is uncommon in childhood but accounts for most new cases of strabismus in adults. Infantile Esotropia Infantile esotropia usually begins by age 6 months, but may present later in the first year. The deviation is comitant, with the angle of deviation being approximately the same in all directions of gaze and usually not affected by accommodation. It is likely that the majority of cases are due to faulty innervational control, involving the supranuclear pathways for convergence and divergence and their neural connections to the medial longitudinal fasciculus. A small 576 number are due to anatomic variations such as anomalous insertions of horizontally acting muscles, abnormal check ligaments, or various other fascial abnormalities. Abduction may be limited but can be demonstrated with oculocephalic (doll’s head) maneuvers. Almost without exception, it is the eye with better vision or lower refractive error (or both). If at various times either eye is used for fixation, the patient is said to show spontaneous alternation of fixation, in which case, vision will be equal or nearly equal in both eyes. In large-angle esotropia, the eye preference may be determined by the direction of gaze, with the right eye being used for fixation on left gaze and the left eye on right gaze (cross fixation). Preliminary nonsurgical treatment may be indicated to ensure the best possible result. Glasses should be tried if there are more than 3 diopters (D) of hyperopia to determine if reducing accommodation has a favorable effect on the deviation. Once reproducible measurements are obtained, surgery should be scheduled as early as reasonably possible since there is ample evidence that sensory results are better the sooner the eyes are aligned. Many procedures have been recommended, but the two most popular are (1) recession of both medial rectus muscles and (2) recession of the medial rectus and resection of the lateral rectus on the same eye. Acquired Nonaccommodative Esotropia this type of nonparetic esotropia develops in childhood, usually after the age of 2 years.

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Its activity m ay be due to purchase 100 mg suhagra with mastercard erectile dysfunction weight loss selective inhibition of cyclo-oxygenase in the central nervous system rather than in peripheral tissues 100 mg suhagra with amex diabetes and erectile dysfunction health, but there is evidence that paracetam ol also acts peripherally at pain chem oreceptors order suhagra 100 mg overnight delivery erectile dysfunction causes heart disease. Aspirin Because of its m ore pronounced adverse reaction profile order suhagra 100mg with visa erectile dysfunction causes relationship problems, aspirin has now been largely superseded in proprietary products in favour of paracetam ol and ibuprofen. Aspirin is also associated w ith Reye’s syndrom e, a rare but potentially fatal encephalopathy of infants and children, and it is not licensed for use in children under the age of 16. Ibuprofen Ibuprofen m ay also cause gastric side-effects, although they are generally less serious than w ith aspirin. Hypersensitivity reactions are also less likely, no interaction norm ally occurs w ith anticoagulants in norm al doses, and there is no association w ith Reye’s syndrom. Paracetam ol is m etabolised in the liver w here it is converted to a highly reactive toxic interm ediate, w hich is norm ally detoxified by conjugation w ith glutathione. The free toxic m etabolite then com bines w ith hepatic m acrom olecules causing hepatitis and necrosis, w hich often proves fatal. The toxic level of paracetam ol need not be greatly above the therapeutic level (4 g daily for adults and children over 12 years) and sym ptom s of overdose m ay not appear for 2 days or m ore. It is therefore extrem ely im portant to ensure that patients do not exceed the recom m ended dosage or use m ore than one product containing paracetam ol at a tim. Ancillary analgesics Opioids Codeine and dihydrocodeine are w eak narcotic opioid analgesics useful for the treatm ent of m ild to m oderate pain. Codeine is com bined w ith paracetam ol in co-codam ol tablets and w ith aspirin in co-codaprin tablets. It has also been claim ed that caffeine facilitates absorption of analgesics and enhances their action, but this is disputed. Caffeine is habit-form ing, can add to gastrointestinal adverse effects and m ay itself induce headache in large doses or on w ithdraw al. Other constituents Som e analgesic preparations also contain sedating antihistam ines, such as diphenhydram ine and doxylam ine, for their claim ed sedative and m uscle relaxant effects. They m ay also have som e value as antiem etics in patients w ho experience nausea or vom iting am ong their dysm enorrhoea sym ptom s. Additional advice Sym ptom atic treatm ent w ith a w arm bath or locally applied heat (such as hot w ater bottle) m ay provide relief. Dysmenorrhoea 201 Exercise decreases the severity of m enstrual cram ps through generation of endorphins, ‘the body’s ow n painkillers’. Avoid sm oking, as this has been associated w ith increased m enstrual pain and heavier bleeding. Self-assessm ent Case study A teenage girl asks if she can discuss something with you in private. Once there, she tells you that she has started to get crampy abdominal pains around the start of her periods and wants to know if you can recommend any effective treatment. In response to your questions she tell you she is 16, has been having periods since she was 13, but they have been getting painful in the last few months. The pains usually begin about 12 hours before a period starts and have gone by about 12 hours afterwards, but they can be very painful while they last. Her periods have always been regular and there has been no change in regularity lately. She has tried paracetamol tablets, which have helped a bit, but wonders if there is anything better. W hich of the follow ing inform ation that she gives you w ould m ake you decide that she should be referred to a doctor? The pain is cram py and colicky, in the low er abdom en and radiating dow n the back of her legs. The pains start about a day before the start of bleeding and last until about a day after. Tips In multiple choice question examinations, watch out carefully for negatives in questions. M ode of action Levonorgestrel is thought to act in one of several w ays, depending on the point in the m enstrual cycle at w hich it is used: – Before ovulation it m ay prevent ovulation by delaying or inhibiting the release of the ovum from the ovary. All m echanism s are considered to be contraceptive rather than abortifacient, as clinically conception and the start of the pregnancy are not considered to have occurred until a fertilised ovum is im planted in the endom etrium. It is: – 95% effective if the first dose is taken w ithin 24 hours – 85% effective if used w ithin 24–48 hours – 58% effective if used w ithin 48–72 hours. Dosage the tablet is taken as soon as possible after unprotected sexual intercourse, preferably w ithin 12 hours and not m ore than 72 hours after. Unprotected intercourse m ay have occurred because part of a course of an 203 204 Managing Symptoms in the Pharmacy oral contraceptive has been m issed. In all m issed-pill situations, additional contraceptive precautions should be taken until consecutive daily pill-taking at the correct tim e has been resum ed for at least 7 days. The only contraindications are: hypersensitivity to levonorgestrel pregnancy, because it w ill be ineffective, although there is no evidence that the fetus w ill be harm ed severe hepatic dysfunction conditions such as severe diarrhoea or Crohn’s disease, w here there is a high risk that the m edication w ill not be absorbed. A relative contraindication is breast cancer, although the risk to a sufferer from the m edication is m uch less than that of pregnancy. Breastfeeding is not a contraindication as only very sm all am ounts of levonorgestrel appear in breast m ilk. The m ain undesirable effect is nausea, w hich affects about one-quarter of subjects, w ith vom iting occurring in about 5%. If vom iting occurs w ithin 3 hours of a dose, absorption is im paired and another dose m ust be taken as soon as possible. A dose m ust be kept dow n for at least 3 hours w ithin 84 hours of intercourse to ensure effectiveness. Levonorgestrel inhibits the m etabolism of ciclosporin, raising plasm a levels and increasing the risk of toxicity.

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Viscum album in Aesculus compositum, Arteria-Heel, Ginseng compositum, Procainum compositum, Rauwolfia compositum, Thalamus compositum, Thyreoidea compositum, Viscum compositum (mite, medium, forte). Zincum metallicum in Discus compositum, Echinacea compositum (forte) S, Testis compositum. Biotherapeutic Index Ordinatio Antihomotoxica et Materia Medica Biotherapeutic Index. These Objectives do not define a medical curriculum and should be used to identify the domains of cognitive and clinical skills evaluated by this national examination. Baumber, then as Chair of the Education Committee, and a group of co-authors from the University of Calgary, were involved in upgrading the examination and the development of the first edition of the Objectives. The second edition was the result of revisions undertaken by a Task Force in 1997-98. Now in 2003, we publish the third edition, following a major collaborative effort involving the faculties of medicine, public members of Council, panels of practicing physicians, all headed by Dr. However, this edition will be web based, with better indexing, making for easier use. Although several significant steps beyond the 1999 edition of these objectives have been accomplished, it is a certainty that the next edition will provide additional improvements. Perhaps since perfection may never be attained, it is more advantageous that each edition be an advance on the previous one. We hope that this format will enable readers to locate the required set of objectives with greater ease. One of the recommendations made by physicians from across Canada who reviewed the second edition was to translate and apply the generic objectives in the Legal, Ethical and Organizational domains of medicine to actual clinical situations. In the current edition, we selected a number of appropriate clinical presentations and after referring to the generic Legal, Ethical, and Organizational objective, applied these to the specific presentation. No attempt was made to translate all of the generic objectives to all of the clinical presentations. It was considered desirable to provide a number of examples without attempting to be comprehensive. In the belief that a true understanding of clinical situations requires in many instances the application of scientific concepts that underpin clinical medicine, an attempt was made to identify such concepts. These concepts are included in the hope that they will assist candidates with their comprehension of the various clinical presentations.

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Clinical and Demographic Characteristics by Study Groups Women without Women with Women with diabetes diabetes (HbA1c £ 7%) diabetes (HbA1c > 7%) (n = 90) (n = 135) (n = 102) p a Age in years 53 cheap suhagra 100 mg with visa erectile dysfunction treatment clinics. Muscle and joint aches buy suhagra 100 mg on line impotence cream, hot fla Symptom prevalence rates in our sample were higher than shes suhagra 100mg discount cheap erectile dysfunction pills online uk, and sad mood were reported at rates up to purchase 100 mg suhagra erectile dysfunction medications over the counter 79%, 75%, and rates documented in cohort studies of healthy women. Type of Menopause by Study Group Entire Women without Women with Women with sample diabetes diabetes HbA1c £ 7% diabetes HbA1c > 7% a (n = 325) (n = 90) (n = 133) (n = 102) p Type of menopause 0. Menopause Symptom Prevalence by Study Groups Entire Women without Women with Women with sample diabetes diabetes (HbA1c £ 7%) diabetes (HbA1c > 7%) (n = 313) (n = 87) (n = 129) (n = 97) p Muscle/joint aches 245 (78. Collectively, these clinical factors, along with the high observed in the few postmenopausal studies of women with rates of hysterectomy, have been linked to higher rates of chronic illness. Two-thirds of the participants had diabetes as vasomotor, sleep, somatic, genitourinary, and mood symp part of a set of five chronic health conditions; the nondiabetic 23,26,39–42,45 toms in the postmenopause. In addition reporting has also been associated with African American to diabetes, the most prevalent comorbidities were hyperten 26,39,43–44 and Hispanic ethnicity, groups well represented in sion (n = 234; 73%), hyperlipidemia (n = 208; 65%), and os this sample. Among post-polio survivors, 46 5 menopause symptoms, and although not assessed in this Kalpakjian et al. Menopause Symptom Severity by Study Group Women without Women with Women with diabetes diabetes (HbA1c £ 7%) diabetes (HbA1c > 7%) (n = 87) (n = 129) (n = 97) p Muscle/joint aches 1. For example, were described in postmenopausal women with the metabolic somatic symptoms such as fatigue, cognitive complaints of 50 syndrome. These data suggest that comorbid, chronic con impaired concentration and psychological concerns of emo ditions may be an important contributor to increased symptom tional lability are symptoms associated with all three condi reporting with menopause. Evidence from meta-analyses is conflicting, showing We also report for the first time that glucose control was a that depression increases diabetes risk and worsens glucose 58 key correlate of menopause symptom severity in women with control, and likewise diabetes increases risk for depres 59 diabetes, independent of the well-described influence of sion. Women with worse glucose control had conditions was observed: depressed mood imposed a 60% higher symptom severity scores than their peers with better increased risk for type 2 diabetes, while diabetes incurred a 60 control who were of similar body size, years post menopause, 15% rise in depression risk. Moreover, menopause symptom characterize women using the stages of reproductive aging severity scores were similar between diabetic women with would help clarify these relationships. These and corroborate some, but not all, findings from inter data suggest that interventions targeting glucose control national studies in women with diabetes or the metabolic may improve the postmenopausal symptom experience for syndrome. Depressed mood occurs in 25%–45% of adults nondiabetic Swedish women showed no relationship between 51–52 63 with diabetes, and up to 40% of diabetic patients expe vasomotor symptoms and glucose values, while a longitu 53 52–53 rience anxiety, with women more affected than men. While the association of emerging evidence that vasomotor symptoms may be a sur 64 these symptoms with diabetes is well documented, few rogate marker for cardiovascular disease risk, more studies studies have specifically examined them in diabetic midlife are needed. With the known influence of the selective serotonin and With only cross-sectional data, it is difficult to determine if norepinephrine receptor inhibitors and gabapentin on the 65–67 the greater severity of psychological symptoms observed relief of vasomotor symptoms, it is possible that the here is related to menopause, diabetes, or an interaction be higher use rates of these medications in women with diabetes tween both conditions. The retrospective self-report of symptoms and age women using skin conductance devices to measure vaso of menopause are prone to bias. Without data regarding the motor events paired with glucose monitoring would more military service experience, or a detailed gynecological his accurately characterize these symptoms. Musculoske letal complaints are common and emerge differentially Conclusions across the menopause transition, reported by 20%–80% of 25,30,68–69,71 In summary, a number of high-risk health conditions (obe women. Although women with type 2 diabetes experience similar pain/stiffness, independent of aging and obesity. In the Framingham cohort, the prevalence of glucose control may improve the postmenopausal experience symptomatic degenerative changes of the knee and hand 75–76 of women with diabetes. Moreover, hormone therapy trials demonstrate ment of Veterans Affairs, Veterans Health Administration, evidence that exogenous estrogen improves muscle and joint Health Services Research and Development Service Quality symptoms. No funder had a role in the design and received estrogen alone, there was improvement in joint pain conduct of the study; collection, management, analysis, and 80 compared with controls. The views expressed in this article are those may also contribute to the rates of muscle and joint pain of the authors and do not necessarily reflect the position or symptoms. This research was conducted while 81–84 82,83 83 the knee, hip, and hand among both women and Dr. We are most 75 study, participants at baseline without knee osteoarthritis had grateful to the women who served as research participants. Increasing age has also been associated with a 10-fold of Nursing, University of Michigan Ann Arbor, Michigan for 82 increase in degenerative changes in the hand, knee, and hip. Military women have twice the injury rates of men; almost half sustain Author Disclosure Statement 87 a musculoskeletal injury in initial training. In addition, none of tudinal data, it is difficult to determine if the prevalence and the authors have commercial associations that might create a severity of muscle and joint symptoms are a function of conflict of interest in connection with this manuscript. Strengths of the study included access to an ethnically References diverse national sample and electronic health record data to accurately evaluate clinical features of diabetes. Human immuno distress and natural menopause: A multiethnic community deficiency virus and menopause. Increased hot flash midlife: the influence of the menopause, social factors and severity and related interference in perimenopausal human health in earlier life. A prospective without type 2 diabetes mellitus in the general population: population based study of menopausal symptoms. The epi graphic and lifestyle factors to symptoms in a multi-racial/ demiology of urinary incontinence in women with type 2 ethnic population of women 40–55 years of age. Sleep difficulty in reported sleep problems among people with diabetes in the women at midlife: A community survey of sleep and the United States, 2005–2008. Menopause Practice: pause: Prevalence, severity, trajectory and significance in th A Clinician’s Guide, 4 ed. Skin blood flow in adult human thermo late reproductive years: Risk factors for African Americans regulation: How it works, when it does not and why.

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