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Gary L. Clayman, MD, DMD, FACS

• Alando J. Ballantyne Distinguished Chair of Head and Neck Surgery
• Professor of Surgery and Cancer Biology
• Director of Interdisciplinary Program in Head and Neck Oncology
• Chief, Section of Head and Neck Endocrine Surgery
• Deputy Head Division of Surgery
• University of Texas MD Anderson Cancer Center
• Houston, Texas

Today medications like zoloft purchase actonel 35mg with visa, greater numbers of adopted children are older treatment writing buy actonel with a mastercard, have spent some time in foster care symptoms of a stranger generic 35 mg actonel with mastercard, are of other races symptoms after flu shot generic actonel 35 mg visa, have special needs treatment multiple sclerosis cheap 35 mg actonel with mastercard, and were born in other countries D medications resembling percocet 512 order actonel 35 mg on-line. If we receive a Y sex chromosome (named after its Y shape) from our fathers, we develop into males. If one parent carries genes for only brown eyes, and the other for only blue eyes, the children would have brown eyes. Sperm with Y sex chromosomes appear to swim faster than sperm with X sex chromosomes. This is one of the reasons why between 120 and 150 boys are conceived for every 100 girls. Overheating of the testes, which happens now and then among athletes, such as longdistance runners, and pressure, which can be caused by certain bicycle seats, are two causes of male infertility. Students often assume that if twins look alike, they are identical (monozygotic) twins. If an ultrasound reveals that twins are sharing an amniotic sac and a placenta in utero, they must be identical. Yet separate amniotic sacs do not always indicate fraternal twins, although twin fetuses of different sexes always indicate fraternal twins. Consider using this website as a springboard for classroom discussions regarding methodology in studying twins, what is known about monozygotic and dizygotic twins, and what type of research is continuing. Conduct an inclass discussion on what traits are primarily due to genetics and what are primarily due to environment. Also included is a segment about two brothers who both have children with TaySachs disease. This video may also be viewed online through the interactive companion website. Extensive presentation of genetic science using historical footage and interviews and including information on the Human Genome Project and cloning, and a discussion of the discriminatory practices of insurance companies in paying for prenatal testing and infertility treatments. Thus, these ultrasounds do not provide any medical information about the health or gestational age of the baby; they just provide pretty pictures that cost a pretty penny! Many companies offering this service, including Prenatal Peek and Fetal Fotos, operate informative and slickly marketed websites. Classroom Activities and Demonstrations Video Suggestions All in the Genes (1998, Filmakers Library, 52 minutes). Overview of cloning the new science of genetics, with a discussion of the implications for children with genetic disorders. Genetic Translation (1996, Films for the Humanities and Social Sciences, 15 minutes). Prenatal Testing: A Mixed Blessing (1995, Films for the Humanities and Social Sciences, 51 minutes). Follows four couples through prenatal testing and counseling, including a discussion of Down syndrome. Gene Research: Promises and Dilemmas (Films for the Humanities and Social Sciences, 33 minutes). Covers difficulty of advising families about results of prenatal testing for diseases for which there is no cure. Student Projects Genetic Counseling Have students contact a genetic counselor and interview that person regarding his/her role in helping parents who are expecting a child or considering conceiving a child. Prior to contacting a genetic counselor, have students find information online regarding this profession. Have them view the videos and information written for both mothers and professionals. How useful do they think this information would be if they were an expectant mother (or father) or a professionalfi Ask students to find other similar websites and compare and contrast each of them in terms of validity of the information provided and the usefulness for expectant parents. Below are the video narration and the application questions with answers on Prenatal Assessment. Video Narration: During a routine prenatal visit, ultrasound is used to estimate fetal age, determine the position and growth of the baby, and determine the health of the placenta. The ultrasound uses sound waves to produce an image of the unborn child for analysis. In highrisk pregnancies, the ultrasound is used to check for fetal abnormalities. Women approaching or beyond the age of 35 have a higher risk of having a baby with Down syndrome and other chromosomal abnormalities. While the ultrasound cannot diagnose chromosomal or other abnormalities, it is a useful screen for estimating risk and the need for additional diagnostic tests such as amniocentesis. Cohen, 1/270 pregnancies in women over the age of 35 What is the relationship between maternal age and the risk of having a baby with this disorderfi Cohen explains how multiple prenatal assessment measures can be used together to make decisions regarding whether further medical monitoring procedures, such as amniocentesis, are necessary. Cohen states that 95% of the time the baby will turn around by the time the pregnancy is full term What structures does Dr. Describe two structural abnormalities and/or markers of chromosomal abnormalities discussed by Dr. Eleanor began taking prenatal vitamins three months prior to conception, and she stopped consuming alcohol in the month prior to conception. Lecture Expanders GenotypeEnvironment Effects the textbook briefly points out that expressed traits represent an interaction of heredity and environment. These authors propose three genotypeenvironmental interactions: passive, evocative, and active. Each of these interactions influences the expression of phenotypes in developing children. For example, parents who are talented musicians may pass down genes that allow a child to develop perfect pitch and an environment with high levels of exposure to music. People will seek out environments they are comfortable in and that are consistent with their traits. This child may choose to try out for the school basketball team and actively seek out opportunities to practice this sport. This influence becomes more prominent as a child matures and is able to make his or her own choices in life. How people make their own environments: a theory of genotype greater than environment effects. The notion is that genetics sets upper and lower limits on environmental influences. One way to help your students grasp this concept is to have them generate examples of how multiple phenotypes are possible from one genotype in the areas of physical, cognitive, and social development. First have them propose traits that they think are very heavily influenced by heredity and traits they think have very little genetic influence. You might even have students generate graphs of their examples as a way to highlight the way heredity and environment are said to interact in this model. What overlap do they see between themselves and these individuals and among these individualsfi One interesting way to gather and understand this information is provided on the University of Utah website, learn. Have students try out several of these activities and report back to the class on their findings. This method, currently used in clinical trials, sorts sperm before conception to increase the proportion of either sperm containing either an X or Y chromosome, depending on the desired sex. According to the information on the website, MicroSort is effective in the number of babies born of the desired gender from this technology that raises the percentages to 93% for girls and 82% for boys. This technology is the center of an ethical debate that you can discuss with your students. Classroom Activities and Demonstrations Folk Wisdom Perhaps no other period of life generates as much fascination and misinformation as the gestation and delivery of a new baby. Some are based on fact and observation; others are derived from fears or a cultural belief. Ask students to share some folk wisdom they have heard about determining the sex of the fetus. While relatives are a good source, you can also make this a crosscultural study and suggest that students do some research into the folk wisdom or specific cultures in regards to determining the sex of the fetus before this class discussion. Discuss how the folk wisdom presented relates (or does not relate) to the science of conception. Student Projects Determining Ovulation When couples are trying to conceive, they may use many methods to determine when the woman is ovulating in order to appropriately time sexual intercourse to her most fertile time. Have students write a report presenting at least three methods that can be used to determine ovulation and a discussion of the pros and cons of each method. There are many web resources that will be helpful to students in completing this project, including the American Pregnancy Association and FertilityFriend. You may expect students to include charting basal body temperature, the presence and consistency of cervical mucus, and ovulation prediction kits that indicate the presence of luteinizing hormone. However, higher order multiple pregnancy is undesirable because of the many risks to both the mother and the fetuses. Many countries have laws that restrict the number of embyos that can be transferred. It actually recommends that women under the age of 35 with a favorable prognosis should only have a single embyo transferred. Frontline program on reproductive medicine and the questions regarding safety, commercialization, and the changing face of the family. Louise Brown, born in 1978, was the first baby conceived outside the womb and since that time, reproductive science has moved forward in ways you may not have thought about. At least 18 ways are discussed, including the baby with five parents, and a report on Arceli Keh, who gave birth at 63 after she lied about her age to participate in an egg donation program. Reproduction: Designer Babies (1995, Films for the Humanities and Social Sciences, 20 minutes). Examines the practice of female infanticide in India (resulting from dowry rules) and the attempts to eradicate it. Have them create a report showing the financial coverage that their health insurance provides for infertility treatments and/or adoption costs. Next, have students investigate the costs of these infertility treatments and the fees associated with private adoptions. Finally, have students discuss these findings in terms of social policy on healthcare. Have them evaluate those options in terms of fesibility, affordability and availability. If a gay couple chooses to use surrogacy as an option in choosing to have children, what legal considerations must they face that heterosexual couples do notfi

Ando S medicine 2632 35 mg actonel sale, Rubens R and Rottiers R: Androgen Studying the effect of type 2 diabetes mellitus plasma levels in male diabetics symptoms 9dpo actonel 35mg without a prescription. Atlantis E symptoms genital warts purchase actonel 35 mg free shipping, Fahey P treatment nerve damage cheap 35 mg actonel amex, Martin S et al: Predictive insulindependent diabetes mellitus in men 714x treatment for cancer order actonel us. Tibblin G treatment breast cancer discount actonel 35 mg free shipping, Adlerberth A, Lindstedt G et al: the hormonebinding globulin as an independent pituitarygonadal axis and health in elderly predictor of incident type 2 diabetes mellitus in men: a study of men born in 1913. Li J, Lai H, Chen S et al: Interaction of sex Steroids in adult men with type 1 diabetes: a steroid hormones and obesity on insulin tendency to hypogonadism. Svartberg J, Jenssen T, Sundsfjord J et al: the type 2 diabetic men and its relation with lipid associations of endogenous testosterone and profile. Nord C, Bjoro T, Ellingsen D et al: Gonadal hormones and the risk of type 2 diabetes hormones in longterm survivors 10 years after mellitus: a 9year follow up among elderly men treatment for unilateral testicular cancer. J Clin Endocrinol Metab Comparison of screening questionnaires for the 1998; 83: 3155. J Clin Endocrinol Metab with testosterone administration in older men 1999; 84: 3469. J Clin Polycythemia as a complication of testosterone Endocrinol Metab 1997; 82: 1661. Aversa A, Bruzziches R, Francomano D et al: al: Effects of testosterone on muscle strength, Effects of testosterone undecanoate on physical function, body composition, and quality cardiovascular risk factors and atherosclerosis of life in intermediatefrail and frail elderly in middleaged men with lateonset men: a randomized, doubleblind, placebo hypogonadism and metabolic syndrome: results controlled study. Huang G, Travison T, Maggio M et al: Effects of prostate tissue in men with lateonset testosterone replacement on metabolic and hypogonadism: a randomized controlled trial. Am J Alzheimers Dis Other Demen 2015; and efficacy of testosterone gel 1% 30: 421. J Geriatr of testosterone and progressive resistance Psychiatry Neurol 2005; 18: 20. J Clin Restorative increases in serum testosterone Endocrinol Metab 2013; 98: 1891. Svartberg J, Agledahl I, enschau Y et al: J Clin Endocrinol Metab 2011; 96: 3007. J Clin diabetes: retrospective consideration of the Endocrinol Metab 2008; 93: 3870. Akishita M, Hashimoto M, Ohike Y et al: Low dysfunction is associated with low total serum testosterone level as a predictor of testosterone levels and impaired flowmediated cardiovascular events in Japanese men with vasodilation in intermediate risk men according coronary risk factors. Nephrol Dial Transplant 2011; the high prevalence of testosterone deficiency 26: 184. Dhindsa S, Upadhyay M, Viswanathan P et al: Polish men with lateonset hypogonadism. J Clin Endocrinol Metab of testosterone level is associated with reduced 2004; 89: 5462. Vlachopoulos C, Ioakeimidis N, Miner M et al: Journal of Diabetes and Vascular Disease 2009; Testosterone deficiency: a determinant of aortic 9: 226. Zheng R, Cao L, Cao W et al: Risk factors for with type 2 diabetes and their relationship with hypogonadism in male patients with type 2 cardiovascular risk factors and cardiovascular diabetes. J Clin Endocrinol Association between serum total testosterone Metab 2005; 90: 712. Am J Respir Crit Care Med 2005; 171: life in men diagnosed with prostate cancer on 728. Wang N, Han B, Li Q et al: Vitamin D is finasteride increases bone mineral density in associated with testosterone and hypogonadism older men with low serum testosterone. J Clin in Chinese men: results from a crosssectional Endocrinol Metab 2004; 89: 503. Zitzmann M, Brune M, Vieth V et al: Monitoring increased erythropoietin and suppressed bone density in hypogonadal men by hepcidin: evidence for a new erythropoietin/ quantitative phalangeal ultrasound. Basurto L, Zarate A, Gomez R et al: Effect of of testosterone treatment on constitutional and testosterone therapy on lumbar spine and hip sexual symptoms in men with type 2 diabetes mineral density in elderly men. Guo C, Gu W, Liu M et al: Efficacy and safety of Testosterone supplementation and body testosterone replacement therapy in men with composition: results from a metaanalysis of hypogonadism: a metaanalysis study of observational studies. The effect of castration, of estrogen replacement therapy in hypogonadal men at and androgen injection on serum phosphatases high risk for prostate cancer: results of 1 year in metastatic carcinoma of the prostate. BoonchayaAnant P, Laichuthai N, two prepubertal children exposed to topical Suwannasrisuk P et al: Changes in testosterone androgen. J Pediatr Endocrinol Metab 2013; 26: levels and sex hormonebinding globulin levels 981. Oshakbayev K, Dukenbayeva B, Togizbayeva G the combination of testosterone undecanoate et al: Weight loss technology for people with with tamoxifen citrate enhances the effects of treated type 2 diabetes: a randomized each agent given independently on seminal controlled trial. Taylor F and Levine L: Clomiphene citrate and steadystate pharmacokinetics, metabolism, testosterone gel replacement therapy for male and variability of a transdermal testosterone hypogonadism: efficacy and treatment cost. Helo S, Ellen J, Mechlin C et al: A randomized changing testosterone gel preparations prospective doubleblind comparison trial of (Androgel or Testim) among suboptimally clomiphene citrate and anastrozole in raising responsive hypogonadal men. Distribution in bile, blood, feces and of testosterone on sexual function in men: urine. Miller J, Britto M, Fitzpatrick S et al: major 17ketosteroid metabolites in plasma: Pharmacokinetics and relative bioavailability of relation to thyroid states. J Clin Endocrinol absorbed testosterone after administration of a Metab 1974; 38: 424. J Steroid Biochem Mol Biol Complications of injectable testosterone 2008; 109: 168. Wang C, Swerdloff R, Kipnes M et al: New multiinstitutional observational study of testosterone buccal system (Striant) delivers testosterone levels after testosterone pellet physiological testosterone levels: (Testopel ) insertion. Schubert M, Minnemann T, Hubler D et al: Intramuscular testosterone undecanoate: pharmacokinetic aspects of a novel testosterone formulation during longterm treatment of men with hypogonadism. The development of Study populations in individual trials included in any the evidence report was particularly challenging in the metaanalysis have a significant impact on the testosterone space due to the heterogeneity in the reliability of outcomes. Differences in age, geography, literature resulting in difficulties comparing data across date of initial testing (testosterone immunoassay studies. As the reader delves into this guideline, and testing was more commonly used before 2005), more importantly reads the literature, it should be comorbid conditions, and baseline and therapeutic borne in mind that studies have varied significantly in testosterone levels across studies introduce areas, such as patient age, failure to control for heterogeneity in the pooled population. Readers should concomitant comorbidities associated with low recognize that guideline statements have been testosterone levels, use of total versus free generalized in an attempt to provide a clinically useful testosterone, and the testosterone cutoffs used to document with the understanding that certain define low levels. This is further complicated by populations and clinical scenarios will fall outside of the laboratory methodology issues, such as time of day for initial criteria upon which the studies were based. It also Thousands of articles on testosterone deficiency and highlights that treating clinicians should have specific testosterone therapy have been published over the past endpoints for treatment in mind, with regular several decades. To accurately interpret the published monitoring of these outcomes to assure that ongoing testosterone literature, it is important to critically therapy is warranted and effective. The current guideline only included duration of followup, primary endpoints, adverse event studies in the metaanalysis that used morning total reporting, statistical reporting, and clinical relevance of testosterone <350 ng/dL as an inclusion criterion. The mean testosterone in the important aspects of any investigation because it patient population across all the studies was 249 ng/dL defines the reliability of outcomes and the extent to but this does not take into account that there were which they may be extrapolated to other groups. Testosterone dependent on the quality of the weakest study included therapy likely yields rapid improvements in some in the analysis. This is Primary Endpoints, Adverse Events, and particularly relevant for the current guideline as it Statistical Measures. Studies are often specifically powered and designed to address a key efficacy endpoint, such as a particular symptom improvement, and not to address secondary symptom improvement or adverse events. Although one objective of metaanalyses is to increase study power to identify significant results, this often results in an amalgamation of studies that may have different primary and secondary endpoints, thereby reducing the reliability of the outcomes. In analyzing the literature, it is imperative to determine whether or not statistically significant results are clinically meaningful. The matrix separated from the skin by a microporous unique pharmacokinetic profiles of transdermal membrane. Initial studies of testosterone patches testosterone preparations relate to several factors, demonstrated increases in total testosterone from a including the delivery system (alcohols or other baseline 167 ng/dL to a peak of 1, 154 ng/dL at 5. Following removal, the observed testosterone drug solubility has been variably estimated, with most 425, 426 halflife was 116 minutes. A multicenter, open studies reporting systemic absorption rates ranging 413415 label study confirmed mirroring of the circadian rhythm from 1320%. Repeated application to the same when the patch is applied in the evening with a morning site (after washing) does not reduce uptake, and the peak of 740 ng/dL and a nighttime trough of 213 ng/ use of an occlusive dressing has been shown to 427 415, 416 dL. When applied to the abdomen, the patch exhibits Topical gels and liquids generally demonstrate less slightly lower minimum testosterone values (over 24 variability in absorption uptake when compared to other 417 hours) compared to other methods of delivery and therapies. After application, steady state levels are some gels, with bioequivalence noted for average and achieved within 2472 hours, with testosterone levels 428 maximum testosterone values. Liquids and gels should be applied values within normal physiologic levels and closer to clean, dry skin, and the treatment site should not be representation of the natural circadian rhythm. If insufficient testosterone levels are achieved comparisons of any one modality to another are with one topical agent, including with dose dependent on the dosing and schedule of adjustments, substitution with another topical agent is administration. Topical liquid and gel formulations are able to achieve testosterone levels in the normal range in 74 Dosing Strategies. Patches are currently available in 87% of men and are relatively similar among the 2 and 4 mg formulations, with a 4mg starting dose various preparations. Patches are able to achieve testosterone may be required to achieve appropriate therapeutic levels within normal physiologic ranges (2 patches delivery. There is no consistent data at this time that every 2448 hours) in 77100% of individuals with demonstrate that one agent achieves higher serum 181, 429 >85% achieving values >300 ng/dL. Adverse effects specific to topical with patches is application site reactions, which have preparations include application site reactions (316% 181 been historically reported in up to 60% of patients. Patients Other adverse effects include pruritus, application site should be particularly cautioned against contact with 431 vesicles, and back pain. Compared to topical gels and women and children after application of the gel to limit solutions, the rate of transference is likely minimal. Transference may be mitigated by washing hands, covering the application site with clothing, and washing the region prior to anticipated direct contact with others. One of the oral alternatives for testosterone therapy is the 30 mg sustainedrelease mucoadhesive buccal Efficacy. In a 90day open label trial of 306 pellet applied to the upper gums above the incisor teeth testosterone deficient men using two actuations (11mg) twice daily. Absorption through the oral (90%) had an average testosterone concentration mucosa avoids liver deactivation that is experienced by within the specified normal range for the study (300 other formulations. The mean testosterone concentration tablet in a manner similar to the normal daily rhythm of 436 was 421 ng/dL. It restores the approval, side effects related to nasal delivery included circulating testosterone level to the physiological range. The progressive hydration tablet with a matrix Injectable testosterone is available in several forms, containing 30 mg of testosterone is placed in position including short acting and longacting preparations. Following application, testosterone administrations to limit the duration of time spent is absorbed through the nasal mucosa to achieve outside (above or below) the normal reference range. These data are notable as they demonstrate far levels have been measured midcycle (day three to less variability between peak and trough levels four); however, such a measurement protocol misses compared to shorteracting preparations. Likewise, there might be value in undenaconate (1, 000 mg every 9 weeks, a dosage that defining the trough level (measured prior to injection 440 is only available outside the United States). The dosing at 0 and 4 weeks represents the percentage of men have difficulty achieving therapeutic loading period followed by regular dosing is every 10 levels within standard dosing ranges, injectable weeks. Further individualization may be considered testosterone preparations are able to achieve based on trough testosterone levels at the end of a 10 therapeutic levels in almost any clinical scenario. For trough total testosterone However, compared to other agents, shortacting values <300 ng/dL, the interval may be decreased by 1 injections can result in longer times in the supra week (9 weeks) until values >300 ng/dL are achieved therapeutic and subtherapeutic ranges, which may at the end of an injection period. No men experienced maximal values <300 ng/dL, and only 5% Injectable Agents (LongActing) had mean concentrations <300 ng/dL during the 10 weeks. Mean peak levels were 890 ng/dL, with 92% of Testosterone undecanoate is the only currently men remaining below 1, 500 ng/dL. Peak that providers be risk evaluation and mitigation concentrations were achieved at a mean 7 days after strategy certified to administer the therapy. These findings conservatively in the clinic, with no supplemental are supported by a multiinstitutional study that oxygen required. It is notable that similar findings have also been observed with other oilbased testosterone Based on these initial data, Kaminetsky and colleagues preparations that are currently most often self performed a followup redosing study with 2 fewer administered at home (typically with lower volumes of pellets administered if peak testosterone levels were injection). The adjustment of future pellet number: peak level >1, 000 unique pharmacokinetic profile of testosterone pellets is ng/dL, reduce by 2 pellets at next insertion; <500 ng/ due to their crystalline structure, which dissolves slowly dL, increase by 2 pellets. Individual pellets consist of 75 mg of levels should be assessed around three months after testosterone and may be combined to deliver variable implantation and rechecked every two to four weeks doses of testosterone therapy. Although no consensus exists, it is reasonable to Initial pharmacokinetic data were provided by 446 perform reimplantation when total testosterone levels Kaminetsky et al. Of the using varied protocols (inserted pellet number ranged 30 patients enrolled, none met criteria for 6 pellets, and from 6 to >10 pellets), demonstrated therapeutic levels a median of 10 pellets were implanted. Peak total in 100% of men at 4 weeks and maintained levels >300 testosterone levels were achieved 1 week after ng/dL at 4 months.

Itm igh tcom e in h andy to h ave th is inform ation in yourm edical ch artsom eday in th e future medicine world order 35mg actonel visa. The content was developed by the Integrative Medicine Program medicine you can take while pregnant discount actonel 35mg online, Department of Family Medicine symptoms neck pain purchase line actonel, University of WisconsinMadison School of Medicine and Public Health in cooperation with Pacific Institute for Research and Evaluation medicine ads order on line actonel, under contract to the Office of Patient Centered Care and Cultural Transformation treatment trichomonas actonel 35mg discount, Veterans Health Administration treatment 21 hydroxylase deficiency purchase actonel 35 mg with visa. Information is organized according to the diagram above, the Components of Proactive Health and WellBeing. While conventional treatments may be covered to some degree, the focus is on other areas of Whole Health that are less likely to be covered elsewhere and may be less familiar to most readers. Rather, you are encouraged to learn more about other approaches and how they may be used to complement conventional care. The ultimate decision to use a given approach should be based on many factors, including patient preferences, clinician comfort level, efficacy data, safety, and accessibility. No one approach is right for everyone; personalizing care is of fundamental importance. Although low testosterone ("low T") is a diagnosis being promoted by the makers of testosterone medications, it is not as simple as just prescribing hormone replacement. Testosterone supplementation is also not without risks, and in terms of longterm use, there is much about safety that we do not yet know. Key factors in optimizing male hormones Maintain ideal body weight this is probably the most important thing a man can do. As belly fat increases, there is an increase in activity of the enzyme "aromatase" which converts testosterone in the fat cells to estrogen. This reduces testosterone and increases estrogen, which can increase fat deposition in typical female areas (breast, hips, thighs) and increase the risk of enlargement of the prostate and even prostate cancer. In fact, management of obesity may prevent declining total testosterone in the aging male. Avoid developing diabetes Developing diabetes increases the risk of having a total testosterone level of less than what is considered normal. Over a ten year period, the risk for developing abnormally low testosterone levels more than doubles in diabetic individuals. Exercise A combination of aerobic (increase in heart rate) and resistance (weight lifting) training has been found to increase the production of testosterone. This also helps prevent the most common diseases that men are moste likely to die from, heart disease and cancer. Avoid excessive alcohol Alcohol (more than two drinks a day), increases the conversion of testosterone to estrogen. This can go on for months to years while a person is being treated with opioid medications. It appears that the higher the dose of opioids, the greater the risk of low testosterone. Fortunately, this side effect should be reversible after stopping the pain medication. Of course, do not stop or change pain medication suddenly without consulting with the prescribing provider. Research has shown that the average testosterone level in men has gradually dropped over the years. This may be in part due to all the environmental toxins that have accumulated over the years. Avoid plastic containers with the numbers 3, 6, or 7 engraved in the triangle on the product. Avoid excessive stress Cortisol levels in the blood are indicators of stress level. This steroid hormone can increase fat deposition, resulting in more conversion of testosterone to estrogen. Eat well Poor nutrition is at the root of many diseases and can also create an imbalance of male hormones. Supplements are not regulated with the same degree of oversight as medications, and it is important that clinicians keep this in mind. Products vary greatly in terms of accuracy of labeling, presence of adulterants, and the legitimacy of claims made by the manufacturer. To maintain healthy testosterone levels, the changes discussed above will trump any supplement, but the nutrients below have been found to inhibit aromatase and may be additive benefits. You can get all these nutrients by eating nuts, fruits (grapes and citrus) and vegetables. Whole Health: Change the Conversation Website Interested in learning more about Whole Healthfi It is a period of frequent change and exploration that covers many aspects of their life: home, family, work, school, resources, and role. Young people take longer to achieve economic and psychological autonomy Where do they livefi For abstract ideas and create systems for establishing values about sexual behavior; example, early in the process youth are organizing abstract thoughts. What diversity of people (and their perspectives) hypothetically; can discern the underlying kind of person would suit me best as a and appreciate that there may be many principles and apply them to new partnerfi They learn struggle to identify a true self amid seeming especially for those who live at home the skills necessary for these roles and contradictions in the way they feel and (nearly half of all U. This is important as commitment to family, community and n Firmer sense of identity, although still a residential change is highest in late citizenship. They question combined with work and periods of non adults and in supervised activity. As networks with peers advantaged households find it harder to guide decisions and behavior). Able to see multiple viewpoints, value the in peer relationships: diversity of people and perspectives and n Work experiences become more focused appreciate that there can be many right 1. Reorientation of friendships from activity on laying foundation for adult occupation answers to a problem. Teipel of the State Adolescent Health Resource Center, Konopka Institute, University of Minnesota. If the patient is unable to make medical decisions, the orders should reflect patient wishes, as best understood by the health care agent or surrogate. All health care professionals must follow these medical orders as the patient moves from one location to another, unless a physician or nurse practitioner examines the patient, reviews the orders, and changes them. It usually involves electric shock (defibrillation) and a plastic tube down the throat into the windpipe to assist breathing (intubation). It means that all medical treatments will be done to prolong life when the heart stops or breathing stops, including being placed on a breathing machine and being transferred to the hospital. If a lifesustaining treatment is started, but turns out not to be helpful, the treatment can be stopped. Before stopping treatment, additional procedures may be needed as indicated on page 4. Treatment Guidelines No matter what else is chosen, the patient will be treated with dignity and respect, and health care providers will offer comfort measures. Check one: Comfort measures only Comfort measures are medical care and treatment provided with the primary goal of relieving pain and other symptoms and reducing suffering. Medication, turning in bed, wound care and other measures will be used to relieve pain and suffering. Oxygen, suctioning and manual treatment of airway obstruction will be used as needed for comfort. No limitations on medical interventions the patient will receive all needed treatments. Treatments are available for symptoms of shortness of breath, such as oxygen and morphine. Future Hospitalization/Transfer Check one: Do not send to the hospital unless pain or severe symptoms cannot be otherwise controlled. Artificially Administered Fluids and Nutrition When a patient can no longer eat or drink, liquid food or fluids can be given by a tube inserted in the stomach or fluids can be given by a small plastic tube (catheter) inserted directly into the vein. Other Instructions about starting or stopping treatments discussed with the doctor or nurse practitioner or about other treatments not listed above (dialysis, transfusions, etc. Part of the difficulty is that there are different definitions of homelessness now in use. Department of Education (DoE) uses a broader definition that includes families who are doubledup with others due to economic necessity. Others are based on DoE data, and reflect the more expansive definition; these also are likely undercounts since not all homeless children are counted. Since then, indications are that the crisis has deepened: o the number of people who have lost their homes and are living doubledup with family or friends due to economic necessity remained at 7. In 2012, more than one out 10 of every four renters (27%) paid over 50% of their income in rent. In 2012, 27% of AfricanAmerican households paid over 50% of their incomes in rent, along with 24% of Hispanic households and 21% of Asian households; only 14% of White 13 households paid over 50% of their incomes in rent. Only one in four of those poor 14 enough to qualify for lowincome housing assistance receives it. Causes of homelessness fi Insufficient income and lack of affordable housing are the leading causes of homelessness: o In 2012, 10. Conference of Mayors, major cities across the country report that top causes of homelessness among families were: (1) lack of affordable 42 housing, (2) unemployment, (3) poverty, and (4) low wages, in that order. The same report found that the top four causes of homelessness among unaccompanied individuals were (1) lack of affordable housing, (2) unemployment, (3) poverty, (4) mental illness and the lack of needed 43 services, and (5) substance abuse and the lack of needed services. Aron, Edgar Lee, and Jesse Valente] and published in 2001 by the Urban Institute, [Martha R. This study found that, using a narrow definition of homelessness, about 1 million were homeless at any given point in time and about 3. Psychotherapist and Behavioral Health Consultant My Goal for Today M y only G oal of the day is to get you to Think and Think Critically Disrupt Your Current Thought Process. Thus, even family members who have not directly experienced the trauma can feel the effects of the event generations later. African Am ericans had alm ost tw ice the sudden infant death syndrom e m ortality rate as nonHispanic w hites, in 2013. A strong parentchild relationship, or, when such a relationship is not available, a surrogate caregiving figure who serves a mentoring role. Funding for the Monitoring the Future Study is provided by the National Institute on Drug Abuse. Kaiser Family Foundation, 2006 References & Resources 3 References Reid, Omar et al. Causes of Human Infertility Abagale Lee Cowden November 19, 2010 Many couples in the United States suffer from infertility each year. According to the National Survey of Family Growth 2002, the fiPercent of women ages 1544 with impaired fecundity is 11. According to the American Society for 3 Reproductive Medicine, fiInfertility affects men and women equally. This essay addresses the most common causes of infertility in both males and females. Some of the most common causes are age, polycystic ovaries, complications from being infected with sexually transmitted diseases, smoking, and being underweight or overweight. Although most occurrences of infertility result from these mentioned causes many times infertility results from a combination of issues from both the male and female side. So, as one can imagine, the older these follicles become, the more likely oocytes are to have genetic abnormalities. The meiotic spindle in the oocytes of older women frequently exhibits abnormalities in chromosome 5 alignment and microtubular matrix compositionfi. Polycystic ovary syndrome is a serious condition resulting in ovaries which cannot ovulate an oocyte.

Combination of the physical dependence on symptoms 3dpo discount 35mg actonel, behavioral manifestations of the use of treatment eating disorders purchase actonel, and subjective sense of need and craving for a psychoactive substance moroccanoil treatment 35 mg actonel overnight delivery, leading to compulsive use of the substance either for its positive effects or to avoid negative effects associated with abstinence from that substance symptoms parkinsons disease actonel 35 mg free shipping. Opioid analgesics are a class of compounds that bind to 283 specific receptors in the central nervous diazepam illness and treatment generic actonel 35mg line, chlordiazepoxide symptoms thyroid problems buy actonel overnight delivery, clonazepam, system to block the perception of pain or alprazolam, lorazepam). Methods deter tives, as well as a number of synthetic com mined, often by a consensus of experts, to pounds. Chronic administration or abuse be optimal for defined therapeutic situa of opioid analgesics may lead to addiction. Such guidelines usually are based on both an analysis of published research antagonist. Identifying evidence of opioid cise nature and extent of a patientis sub and other psychoactive substance use and stance use disorder and other medical, measuring the levels of substances or medi mental health, and social problems as a cations in the body by examining patient basis for treatment planning. Assessment blood specimens for the presence and con usually begins during program admission centrations of identifiable drugs and their and continues throughout treatment. Severity of disease often is assessed or maintenance treatment of opioid addic further in terms of physiologic dependence, tion and marketed under the trade names Subutexfi and Suboxonefi (the latter also organ system damage, and psychosocial morbidity. Legal process that per to measure patient progress and to track mits individuals to be confined against their patients through treatment. These determinations are used to assistance or referral to other experts and establish short and longterm treatment services as needed. Rules estab substancefree lifestyle and encourage lished by Federal and State agencies to abstinence from alcohol and other limit disclosure of information about a psychoactive substances. Urgent, seemingly overpowering Programs must notify patients of their desire to use a substance, which often is rights to confidentiality, provide a written associated with tension, anxiety, or other summary of these rights, and establish dysphoric, depressive, or negative affective written procedures regulating access to and states. Use of preestab and practices of persons from a given lished, mutually agreedon privileges. It includes the holding of loss of privileges) to motivate improvements knowledge, skills, and attitudes that allow in treatment outcomes. Much evidence supports a linear stance and/or administration of an antago relationship among the amount of medica nist. Examination of an individual term incorrectly suggests that opioid treat to determine the presence or absence of ment medications are toxic. Compare medi illicit or nonprescribed drugs or alcohol or cally supervised withdrawal. Release from or discontinuation of treatment medication effectively prevents enrollment in treatment when maximum withdrawal symptoms or craving. Duration benefit has been achieved or when a patient of action can be affected by many factors, is deemed no longer suitable for treatment. Sale or other unauthorized distri bution of a controlled substance, usually E for a purpose other than the prescribed and legitimate treatment of a medical or eligibility. Federal opioid duration of action of a substance or 286 Appendix C medication and can be influenced by intensity of treatm ent. Frequency and patient factors such as absorption rate, method of delivery for therapeutic services. Activity that increases can range from monitoring multidisci the likelihood that a recovering patient in plinary staff members to direct manage substance abuse treatment will relapse to ment of cases, depending on the severity of substance use or contract a substance patientsi problems. Treatment of tion) in which addiction professionals and opioid addiction and related complications clinicians provide therapeutic services to that requires patient residency for some clients who live at home or in special resi period in a hospital setting or outpatient dences. Treatment is delivered in two to treatment in a hospitallinked facility to five regularly scheduled sessions per week ensure that necessary services and levels of totaling 6 to 24 hours per week. The process of providing care macotherapy, usually during the acute to a patient or taking action to modify a phase of treatment, in which steadystate symptom, an effect, or a behavior. Types of M intervention can include crisis interven tion, brief intervention, and longterm m aintenance dosage. Medication sons related to program operations, safety, used for ongoing treatment of opioid or treatment complianceofor example, addiction. An opioid ago incident to withdrawal from the continuous nist medication derived from methadone or sustained use of opioid drugs. Type of fully or do not show an acceptable response addiction treatment, usually provided in to other addiction treatments. Program offering treatment services, including medical and the benefits of peer support to people who psychosocial services. Facility established as part TwelveStep programs are one type of of, but geographically separate from, an mutualhelp program. The most frequently used opioid displaces opioids from these receptors and agonist medication. Methadone is a synthet can precipitate withdrawal, but it does not ic opioid that binds to mu opiate receptors activate the mu receptors, nor does it cause and produces a range of mu agonist effects the euphoria and other effects associated similar to those of shortacting opioids such with opioid drugs. Some pro Dispensing of methadone at stable dosage grams use naloxone to evaluate an individ levels for more than 21 days in the super ualis level of opioid dependence. W ithdrawal comprehensive maintenance services (with symptoms evoked by naloxoneis antagonist medication and counseling in one or several interaction with opioids confirm an individ mobile units) to more limited care, usually ualis current dependence. Other substances com drawal from opioids to prevent drug monly used by people addicted to opioids relapse in selected, wellmotivated patients. Some drugsoin particular, highdose barbituratesoused in Glossary 289 O opioid agonist. Areas on cell surfaces in that normally are bound by opioid psy the central nervous system that are activat choactive substances and that blocks the ed by opioid molecules to produce the activity of opioids at these receptors with effects associated with opioid use, such as out producing the physiologic activity pro euphoria and analgesia. Drug that binds to , Mu and kappa opiate receptor groups prin but incompletely activates, opiate receptors cipally are involved in this activity. Natural derivative of opium or syn nist but, at increasing doses, does not pro thetic psychoactive substance that has duce as great an agonist effect as do effects similar to morphine or is capable of increased doses of a full agonist. Opioid trexone, of individuals who are addicted to addiction is characterized by repeated self opioids. Services may include medically supervised withdrawal and/or maintenance opioid addiction treatm ent. Dispensing treatment, along with various levels of of approved medication to prevent with medical, psychiatric, psychosocial, and drawal and craving during the elimination other types of supportive care. Method of identify and rehabilitation services or medication ing evidence of opioid and other psychoac prescribed when necessary to alleviate the tive substance use and measuring the levels adverse medical, psychological, or physical of substances or medications in the body by effects. This term encompasses medically examining patient saliva for the presence supervised withdrawal, maintenance treat and concentrations of identifiable drugs ment, comprehensive maintenance treat and their metabolites. In most States, patient excep withdrawal but not for ongoing mainte tions are contingent on the approval of the nance pharmacotherapy. OxyContin is one of several as well as rights and responsibilities of prescription opioids increasingly obtained patients and treatment providers. Term applied to two lev els of activity in addiction treatment: (1) a patient referral. Alternative to providing all social or political movement working for necessary treatment services and levels of changes in legislation, policy, and funding care at the program site by collaboratively to reflect patient concerns and protect their outsourcing some services to other settings rights. When a patient must obtain philosophy of substance abuse treatment comprehensive services in multiple settings, practice maintaining that patients should Glossary 291 treatment program staff members should psychotherapy. Treatment service provided arrange the referrals, monitor patient to patients in a comprehensive opioid treat progress, and coordinate care. Process of and treats patients for diagnosed psychi individualizing therapeutic resources to atric problems. Readmission usually is preceded by a (1) assessing, (2) selecting the most suitable review of the patientis records to determine treatment modality and site, and (3) identi whether and how the individualis treatment fying the most appropriate services. Treatment of disease treatment medication continue to eliminate with prescribed medications. Breakdown or setback in a personis attempt to change or modify a particular prevalence. Number of cases of a disease in a behavior; an unfolding process in which the population, either at a point in time (point resumption of compulsive substance use is prevalence) or over a period (period the last event in a series of maladaptive prevalence). Prevalence rate is the fraction responses to internal or external stressors of people in a population who have a or stimuli. State in which a mental or physi existing cases of the condition at a specified cal disorder has been overcome or a disease time and the denominator is the total process halted. Evaluation of within the context of a cooperative living program effectiveness based on compliance arrangement. A substance that affects combination of patient and program char the mind, thoughts, feelings, and sometimes acteristics. Process of determining whether a assigned by the governor to exercise the prospective patient has a substance use dis responsibility and authority within a State order before admission to treatment. Negative association attached to an observation of known presenting com activity or condition; a cause of shame or plaints and symptoms that are indicators of embarrassment. Agent, drug, or medication that system sedating and tranquilizing proper produces stimulation. An example is any of the benzodi lant usually refers to drugs that stimulate azepines. Medically unsanctioned use referred to as substance abuse or of drugs by a person to relieve any of a dependence). Consequence (especially an or it can occur regularly and be associated adverse result) other than that for which a with medical and mental problems, often drug is usedoespecially the result pro including tolerance and withdrawal. Process of provid substances and continue on maintenance ing immediate assistance (as with an opioid medication while receiving other types of agonist) to eliminate withdrawal symptoms intervention as needed to resume primary and drug craving. Opioid addiction problems, language difficulties, ethnic and treatment medication dispensed to patients social attitudes, logistics (caring for chil for unsupervised selfadministration. Joining of patients and their treatment providers in an effec treatm ent eligibility. Relative qualification tive collaboration to assess and treat of a prospective patient for admission to an patientsi substance use disorders. Consciously Federal guidelines are minimum require designed social environment or residential ments and restrict admission to individuals treatment setting in which social and group who have been demonstrably dependent on processes are harnessed with treatment opioids for 1 year; however, certain high intent. Treatment focuses on drug abstinence, coupled with social and treatm ent outcom es. Observable results of psychological change requiring a multidi therapy, including decreased use of illicit mensional effort along with intensive mutu psychoactive substances, improved physical al help and support. Combination of considered the best indicator of treatment amount of medication and frequency and program effectiveness. Therapeutic dosage levels that specifies the services to be provided should be determined by what each patient and their frequency and schedule (adapted needs to remain stable. Many addiction among the patient, program physician, and treatment programs use a 12Step structure treatment providers. Originally used symptoms after abrupt discontinuation of as a measure of program effectiveness, or rapid decrease in use of a substance that urine testing now is used to make program has been used consistently for a period. Fundam ental Ethical Principles Beneficence (Benefit) According to Beauchamp and Childress (2001), the medical principle of beneficence emphasizes that treatment providers should act for the benefit of patients by providing competent, timely care within the bounds of accepted treatment practice. The principle of beneficence is satisfied when treatment providers make proper diagnoses and offer evidencebased treatments, that is, treatments drawn from research that provides statistical data about outcomes or from consensusbased stan dards of care. Beneficence is compromised when diagnoses are question able or when outcome data do not validate a diagnosis or treatment. Autonom y Autonomy, like beneficence, springs from the ideal of promoting patientsi best interests. However, whereas beneficence emphasizes the application of provider knowledge and skills to improve patient health, autonomy emphasizes respect for patientsi rights to decide what treat ment is in their best interests (Beauchamp and Childress 2001). Usually, patientsi and physiciansi goals for treatment are identical, but, when they differ, physicians generally accord patients the right to make 297 their own choices and accept the fact that Justice patientsi values may differ from physiciansi the principle of justice emphasizes that treat values. For example, a physician might focus ment providers should act with fairness on extending a patientis life, whereas the (Beauchamp and Childress 2001). Sometimes patient might be more concerned with the this principle is expressed as the duty of quality of that life. Normally, standard medical prac Besides emphasizing that clinicians should act tice does not permit an exception when patients fairly toward patients, the principle of justice make the iwrongi choice and the physician imposes a responsibility to advocate politically iknows better. Nonm alfeasanceoiFirst, Do Ethics in Practice No Harm i the principle of nonmalfeasance emphasizes Conflict Betw een Beneficence that health care providers should not harm or injure patients (Beauchamp and Childress and Autonom y 2001). The risks associated with i W hat is the proper balance between respect injecting or otherwise ingesting substances of for a patientis autonomy and a provideris abuse produced under unknown conditions are responsibility for that patientis healthfi Patients come under the i Should the patient or the clinician decide care of professionals who monitor adverse drug what is in a patientis best interestsfi His position is that he has stopped his use of illicit opioids entirely, which was his goal entering treat ment. These strategies with provider views of what is in their best iare based on the assumption that patients interests risk administrative discharge or other have the necessary skills to produce drugfree sanctions. A working familiarity with their best interests such studies provides treatment providers with a reasonable basis to choose beneficence over i Disagreement about goals between patients autonomy when they conclude that they know and treatment providers better than patients what is in patientsi best i Attention to community concerns interest. These providers might draw on agents of conventional society (Hunt and lessons from physicians caring for patients with Rosenbaum 1998). Based on the complain because they have a sense of power disease model underlying comprehensive main lessness and do not want to jeopardize their tenance treatment, total abstinence may be treatment. Rather than assuming that the tilt the continuing but reduced presence of symp toward beneficence is always correct, treatment toms, they are not defining addiction as a dis providers and administrators should ask them ease. The longterm goal is always reducing or selves in each case whether they are striking eliminating the use of illicit opioids and other a proper balance between these two fundamen illicit drugs and the problematic use of pre tal principles. This dependence was particularly troubling to them because of the increasing insecurity of subsidized slots. Many users expressed concern about once having entered the system and accepting its lifestyle with little or no warning they would be ejected from it. Involuntary discharge ment, in most cases, will halt their recovery or appears to breach practitionersi duties to put precipitate relapse (Knight et al.

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References

• Mouchaers KT, et al. Fasudil reduces monocrotaline-induced pulmonary arterial hypertension: comparison with bosentan and sildenafil. Eur Respir J 2010;36:800-807.
• Kajiwara M, Inoue S, Kobayashi K, et al: Therapeutic efficacy of narrow band imaging-assisted transurethral electrocoagulation for ulcer-type interstitial cystitis/painful bladder syndrome, Int J Urol 21(Suppl 1):57n60, 2014.
• Hakim LS, Kulaksizoglu H, Hamill BK, et al: Guide to safe corporotomy incisions in the presence of underlying inflatable penile cylinders: results of in vitro and in vivo studies, J Urol 155:918n923, 1996.
• Takahashi Y, Shimizu S, Ishida T, et al. Plexiform angiomyxoid myofibroblastic tumor of the stomach. Am J Surg Pathol 2007; 31:724.