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Scalp psoriasis Causes Psoriasis is a chronic skin disease characterised by inflam m ation of the skin and hyperproliferation of skin cells diabetes mellitus results in quizlet forxiga 5mg without prescription. Epidem iology Scalp psoriasis affects about 3% of the population and both sexes equally diabetes definition medical forxiga 10mg line. Onset is m ost com m on betw een 15 and 40 years of age diabetes diet honey cheap forxiga amex, and is rare under 10 years diabetes mellitus homeostatic imbalance purchase forxiga 10 mg mastercard. Signs and sym ptom s Lesions are characteristically w ell defined diabetes diet menu pdf discount 10mg forxiga fast delivery, raised diabetes symptoms feet tingling forxiga 10mg with visa, erythem atous and scaly, and salm on pink or full rich red in colour. There is a surface silvery scale w hich m ay be easily rem oved, often leading to pinpoint capillary bleeding. Scalp psoriasis often extends just below the scalp m argin, leaving an inflam ed, scaly border. Sym ptom s and circum stances for referral Patients w ith m oderate to severe psoriasis m ay require treatm ent under the supervision of a derm atologist. Scalp ringworm (tinea capitis) Causes Tinea capitis is a fungal infection of the scalp that is often acquired from cats and dogs. Sym ptom s and circum stances for referral In severe cases a kerion, a sw ollen m ass discharging pus, w ill appear on the scalp. The lym ph nodes of the neck m ay also becom e sw ollen and tender, and in rare cases there m ay also be a fever. Self-assessm ent Case study A young man asks you for advice about his severe dandruff, which seems to be getting worse. If you have time at the end of the exam, you can then check answers in the reference texts. The fem ale urethra is very short (about 3 cm) and infecting organism s are readily transferred from the perineum and anus to the bladder. Epidem iology Cystitis is very com m on in wom en, affecting over 2 m illion per year and 50% of wom en have at least one attack in their lifetim. Urethral syndrom e, which affects 20–30% of adult wom en and m ay have one of several functional or psychogenic causes, has sim ilar sym ptom s to cystitis caused by infection (lower urinary tract infection). Cystitis is uncom m on in young m en; as well as the urethra being longer than in wom en, prostatic fluid is thought to possess antibacterial properties. Cystitis is m ore frequent in older m en, where it m ay be due to prostatic disease or bladder neoplasm s. Signs and sym ptom s abrupt onset; attacks often begin w ith an itching or pricking sensation in the urethra frequent desire to urinate, although only a few drops m ay be passed dysuria – burning or stinging w hen passing w ater urine m ay be dark and cloudy, and have an unpleasant ‘fishy’ odour m ay be raised tem perature or fever m ay be pain in the suprapubic area or low er back. Differential diagnosis Pyelonephritis: infection of the upper urinary tract – ureter and kidney. Parasitic infection – schistosom iasis and bilharzia – usually contracted in the 193 194 Managing Symptoms in the Pharmacy M iddle East or North Africa. This leads to thinning of the endom etrial tissue w ith increased susceptibility to irritation and traum a and cystitis-like sym ptom s. Sym ptom s and circum stances for referral all m ales pregnant w om en children haem aturia (although this does not necessarily have serious im plications) vaginal discharge (indicates vaginal infection of fungal or bacterial origin) loin pain and tenderness (m ay indicate infection in the kidneys or ureters) fever sym ptom s persisting for m ore than 2 days recurrent attacks. Treatm ent Sym ptom atic dilution of urine and ‘flushing through’ of any causative organism s by drinking large quantities of fluids – w ater, soft drinks and barley w ater alkalinisation of acidic urine, w hich causes irritation, w ith over-the-counter preparations. Alkalinising agents Alkalinising agents are the only treatm ents available specifically for cystitis w ithout prescription. They act by neutralising the urine w hich becom es acidic, particularly w hen there is bacterial infection, causing irritation of the bladder. They are supplied as 2-day courses of single-dose sachets, taken three tim es daily in a large glass of w ater. Sodium bicarbonate, 3 g (a level teaspoonful) in w ater every 2 hours until sym ptom s subside, can also be used. If sym ptom s persist after 2 days of treatm ent the patient should be referred to a doctor. Cautions: – Sodium -containing preparations can lead to fluid retention and raised blood pressure and should be avoided in patients w ith hypertension, cardiovascular Cystitis 195 disease, diabetes and im paired renal function and during pregnancy. They should also be avoided by patients taking lithium, as the effectiveness of lithium m ay be reduced. Such preparations should be avoided in patients taking potassium -sparing diuretics, spironolactone and angiotensin-converting enzym e inhibitors, and in patients w ith heart or kidney disease. Antibacterials A short course of trim ethoprim, am oxicillin or nitrofurantoin can be prescribed. Additional advice To reduce the possibility of attacks: Void the bladder com pletely w hen urinating: w ait for 20 seconds once the bladder feels em pty, then strain to squeeze out the final drops. After bow el m otions, w ipe from front to back to m inim ise transfer of faecal organism s to the vagina and urethra. If this seem s to be a trigger, w ash the perianal skin beforehand and em pty the bladder before and after. Reduce intake of coffee and alcohol as these act as bladder irritants in som e people. There is evidence that drinking cranberry juice regularly (300 m l/day) is prophylactic. Self-assessm ent Case study A young woman is referred to you by your medicines counter assistant, as she has picked up a General Sales List alkalinising treatment for cystitis but she tells your assistant she has not used such a product before. The client says that she thinks she has cystitis, but when you ask her if she has had cystitis before she says no, but she has talked about her symptoms to a friend who has had cystitis, and her friend thinks that this is what it is. In response to your questions, the symptoms she describes are: urine not being passed more frequently than normal, but dark with an unpleasant smell; pain about halfway up her back on both sides, and she has been feeling feverish since she woke up this morning. Second statem ent: Alkalinising agents containing sodium or potassium salts m ay cause fluid retention and raise blood pressure. Tips For exams, try to memorise the four or five most important symptoms and referral factors for each minor ailment. It generally starts a year or so after m enarche (the first period), once ovulatory cycles are established. This m ay result from : overproduction of prostaglandins, w hich cause the contractions that shed and expel the endom etrium together w ith the unfertilised ovum increased sensitivity of endom etrial m uscle to prostaglandins. Other possible causative factors are: ischaem ia – increased contraction of the m yom etrium m ay reduce blood flow, causing ‘uterine angina’ and cram py pain increased production of vasopressin, w hich increases both the synthesis of prostaglandins and m yom etrial activity. Fragm ents of endom etrial tissue becom e detached, find their w ay and adhere to abdom inal and pelvic structures outside the uterus. Each piece undergoes the m onthly cycle of thickening, shedding and bleeding, causing severe pain. This is norm al, but in som e cases the pain is very severe and the cycle is shortened, w ith m id-cycle pain im m ediately follow ed by prem enstrual and then m enstrual pain. Intrauterine devices, as w ell as som etim es causing discom fort and heavier periods, can also cause infection. They are often sym ptom less but can cause severe pain associated w ith m enstruation and heavy m enstrual bleeding. Analgesic preparations are all based on one of three drugs – aspirin, paracetam ol and ibuprofen – som etim es in com bination w ith the ancillary analgesics codeine or dihydrocodeine, or w ith other constituents that are claim ed to increase effectiveness. The m echanism of action of paracetam ol is not w ell understood; it has little anti-inflam m atory activity but is an effective analgesic and antipyretic. Its activity m ay be due to selective inhibition of cyclo-oxygenase in the central nervous system rather than in peripheral tissues, but there is evidence that paracetam ol also acts peripherally at pain chem oreceptors. Aspirin Because of its m ore pronounced adverse reaction profile, 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. She brandishes an empty packet of the ‘morning-after pill’ at you and says she found it when she was cleaning her 15-year-old daughter’s bedroom, and it has been dispensed at your pharmacy. She says that the general practitioner who prescribed it had no right to do so and you had no right to dispense it without asking her permission, as her daughter is still a child and is her responsibility and under her parental control. She says she is going to report both you and the general practitioner to ‘the authorities’. Overall, it prevents about 85% of expected pregnancies if used w ithin 72 hours of unprotected intercourse. You should recom m end it if intercourse has taken place w ithin 7 days of the follow ing: a tw o or m ore pills m issed from the first seven pills in a pack b.

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My “favourite” colleagues Gunn Johansson and Elisabeth Logander for your very sensible and down-to-earth comments and for your showing me that you care diabetes mellitus case study forxiga 5 mg with visa. Andreas diabetes diet snacks discount forxiga, Martin diabetes symptoms of the feet buy forxiga 5mg without prescription, August and Olle for your valuable help with handling of the question naires diabetes test during pregnancy buy 5mg forxiga mastercard. Jenny Betsmark and Magdalena Öström diabetes symptoms vertigo proven 10mg forxiga, staff at the Medical Library managing diabetes type one cheap forxiga generic, Faculty of Health Sciences in Linköping for quick support with the references. My parents Kerstin and Thore who during my entire life have always been there whenever I needed them. To my sister Annika and her husband Peter with their families for love and support and for assisting me with the “big party”. Andreas, Daniel and Therese, my wonderful “children” who, all of you, have given me en ergy during these years and forced me to sometimes focus on other things than science. Most of all, to Mats, my ♥ husband who in spite of hard work is always there to encourage me and stand by my side. The studies were supported by grants from the Country Council of Östergötland, the Swedish Medical Research Council, the Research Council of the South East of Sweden, the Swedish Society of Obstetrics and Gynecology and, Lions Forskningsfond mot Folksjukdomar vid Hälsouniversitetet i Linköping. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. National use of postmenopausal hormone therapy: annual trends and response to recent evidence. Replacing hormone therapy-is the decline in prescribing sustained, and are nonhormonal drugs substituted? Recommendations from a multi-study evaluation of proposed criteria for staging reproductive aging. Defining menopause status: creation of a new definition to identify the early changes of the menopausal transition. Factors associated with age at natural menopause in a multiethnic sample of midlife women. World Health Organization Collaborative Study of Neoplasia and Steroid Contraceptives. Evidence for a secular trend in menopausal age: a population study of women in Gothenburg. Current smoking at menopause rather than duration determines the onset of natural menopause. Frequency and severity of hot flashes and sleep disturbance in postmenopausal women with hot flashes. Symptoms associated with menopausal transition and reproductive hormones in midlife women. National Institutes of Health State-of-the-Science Conference statement: management of menopause-related symptoms. Reproductive health, use of estrogen and experience of symptoms in perimenopausal women: a population-based study. Risk factors for low bone mass in healthy 40 60 year old women: a systematic review of the literature. Determinants and qualification of quality of life after the menopause: the Utian Menopause QoL score. Well-being during the menopausal transition and early postmenopause: a longitudinal analysis. Psychosocial factors associated with the use of hormonal replacement therapy in a longitudinal follow-up of Swedish women. Benefits and harms associated with hormone replacement therapy: clinical decision analysis. Health related quality of life after combined hormone replacement therapy: randomised controlled trial. A longitudinal population study of climacteric symptoms and their treatment in a random sample of Swedish women. Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause. Gradual discontinuation of hormone therapy does not prevent the reappearance of climacteric symptoms: a randomized prospective study. Vasomotor symptoms usually reappear after cessation of postmenopausal hormone therapy: a Swedish population-based study. Duration not severity of the climacteric syndrome predicts resumption of hormone therapy after discontinuation: a prospective cohort study. Meanings of menopause: cultural influences on perception and management of menopause. Belief, attitude, intention, and behavior : an introduction to theory and research. Psychosocial factors, attitude to menopause and symptoms in Swedish perimenopausal women. Physicians as well as patients need more information about postmenopausal hormone therapy]. Discourses on menopause-Part I: Menopause described in texts addressed to Danish women 1996-2004. Associations between attitudes toward hormone therapy and current use of it in middle-aged women. Changes in attitudes, knowledge and hormone replacement therapy use: a comparative study in two random samples with 6 year interval. A new methodological approach to the evaluation of quality of life in postmenopausal women. Declaration of Helsinki Ethical Principles for Medical Research Involving Human Subjects. Risk communication in consultations about hormone therapy in the menopause: concordance in risk assessment and framing due to the context. Representations of menopause and their health care implications: a qualitative study. Attitudes toward menopause and hormone therapy among women with access to health care. Relation of demographic and lifestyle factors to symptoms in a multi-racial/ethnic population of women 40-55 years of age. Scientific evidence changes prescribing practice-a comparison of the management of the climacteric and use of hormone replacement therapy among Swedish gynaecologists in 1996 and 2003. Physician specialty is significantly associated with hormone replacement therapy use. Hormone replacement therapy: knowledge, attitudes, self-reported use and sales figures in Nordic women. Declining socioeconomic differences in the use of menopausal and postmenopausal hormone therapy in Finland. Accuracy of subjective hot flush reports compared with continuous sternal skin conductance monitoring. Discontinuing postmenopausal hormone therapy: an observational study of tapering versus quitting cold turkey: is there a difference in recurrence of menopausal symptoms? Relevance of norm values as part of the documentation of quality of life instruments for use in upper gastrointestinal disease. Effects of estrogen therapy on well-being in postmenopausal women without vasomotor complaints. Om Du ändrar Dig, fyll då i hela rutan med färg och sätt ett tydligt kryss i den ruta som är den rätta. Sedan följer några kunskapsfrågor om övergångsåldern och slutligen kommer frågor om kunskaper om hormonbehandling mot övergångsbesvär. Grundskola, folkskola Gymnasieutbildning Universitets eller högskoleutbildning 2. Förvärvsarbetande, hel eller deltid Hemarbetande Sjukskriven/sjukpensionär Studerar/arbetssökande 7. Ja, jag har regelbunden ”naturlig” mens (= blödning ungefär varje månad) eller blödningar p. Nej, jag har inte haft någon blödning de senaste 12 månaderna och mensen slutade ”naturligt”. Nej, jag har inte haft någon blödning de senaste 12 månaderna eftersom jag opererat bort livmodern. Nej, jag har inte haft någon blödning de senaste 12 månaderna eftersom jag använder hormonspiral eller annat preventivmedel som tar bort mensen. Ja, jag använder eller har använt östrogen huvudsakligen för att förebygga benskörhet. Hade Du övergångsbesvär i form av svettningar/värmevallningar innan Du började med östrogen? Ja, lika mycket besvär som när jag började med östrogen Ja, mer besvär än i när jag började med östrogen Nej, besvären med svettningar/värmevallningar kom inte tillbaka. Oönskade blödningar Bröstspänningar Viktökning Svullnadskänsla Påverkan på humöret Blodpropp Bröstcancer Kärlkramp eller hjärtinfarkt Annan biverkan, i så fall vad? Det finns också alternativ till traditionell hormonbehandling och lokalbehandling mot slemhinnebesvär. Ange nedan om Du har provat någon/några av dessa och om Du tyckte att de hade effekt på värmevallningar och svettningar. Aldrig provat Provat men Använder Effekt Ej effekt slutat idag Naturläkemedel Vagitorier/kräm (Vagifem, Dienoestrol, Ovesterin, Estring) Ovesterintabletter Akupunktur Del 2 Kunskaper om övergångsåldern. Hur stor är sannolikheten för en kvinna i övergångsåldern att uppleva värmevallningar eller svettningar? Sätt ett kryss i den ruta som bäst överensstämmer med din åsikt Ingen Mycket Liten Ganska Måttlig Ganska Stor Mycket Alla drabbas liten liten stor stor drabbas 22. Sätt ett kryss i den ruta som bäst överensstämmer med din åsikt Ingen Mycket Liten Ganska Måttlig Ganska Stor Mycket Alla drabbas liten liten stor stor drabbas 23. Kvinnor i övergångsåldern upplever ofta värmevallningar och/eller svettningar Ja Nej Vet ej 24. Sätt ett kryss i den ruta som bäst överensstämmer med din åsikt I huvudsak V arken I huvudsak nackdelar bra eller fördelar dåligt 29. Sätt ett kryss i den ruta som bäst överensstämmer med din åsikt Obefintlig Mycket Liten Ganska Måttlig Ganska Stor Mycket nytta liten liten stor stor nytta 30. Sätt ett kryss i den ruta som bäst överensstämmer med din åsikt Obefintlig Mycket Liten Ganska Måttlig Ganska Stor Mycket risk liten liten stor stor risk 31. Hur bedömer Du att risken är för en kvinna i övergångsåldern, som använder östrogenbehandling, att drabbas av bröstcancer jämfört med en kvinna utan östrogenbehandling? Hur bedömer Du att risken är för en kvinna i övergångsåldern, som använder östrogenbehandling, att drabbas av blodpropp jämfört med en kvinna utan östrogenbehandling? Hur bedömer Du att risken är för en kvinna i övergångsåldern, som använder östrogenbehandling, att drabbas av hjärtinfarkt jämfört med en kvinna utan östrogenbehandling? Hur bedömer Du att risken är för en kvinna i övergångsåldern, som använder östrogenbehandling, att drabbas av benskörhet jämfört med en kvinna utan östrogenbehandling? Gulkroppshormoner används tillsammans med östrogenbehandling i övergångsåldern för att förstärka östrogenets effekt på värmevallningar och svettningar. Gulkroppshormoner används tillsammans med östrogenbehandling för att motverka att östrogenet stimulerar livmoderslemhinnan för kraftigt. Ja Nej Vet ej Har Du det senaste året fått ny kunskap om östrogenbehandling i övergångsåldern? Sätt ett kryss i den ruta som bäst överensstämmer med hur du uppfattade rapporteringen I huvudsak Varken I huvudsak Ingen nackdelar bra eller fördelar uppfattning dåligt 48. Har rapportering i massmedia kring östrogenbehandlingen det senaste året påverkat Din syn på östrogenbehandling i övergångsåldern? Ja, till det sämre Nej, inte alls påverkat mig Ja, till det bättre Ej sett någon rapportering i massmedia 49. Har rapportering i massmedia kring östrogenbehandling i övergångsåldern det senaste året gjort att Du valt att börja med östrogenbehandling. Psykologiska besvär i övergångsåldern beror mer på livsförändringar (t ex barn flyttar hemifrån) än på hormonförändringar. Skicka in formuläret i det bifogade svarskuvertet till avdelningen för Obstetrik & Gynekologi, Hälsouniversitetet, Universitetssjukhuset, 581 85 Linköping. Menopause is a signal event in a woman’s life that marks the end of reproductive competence. Although the age-related loss of vaginal bleeding in women has been described throughout history, the studies of Block,1 published in 1952, documented the dramatic decrease in the number of follicles within the ovary as a function of age, demonstrating that the loss of both germ cells and the hormone-producing cells that support them is key to the loss of menstrual function in women. In this article these 3 phases of reproductive aging are discussed on the background of a discus sion of normal reproductive cycle function and the changes that occur at all levels of the reproductive axis with aging. Normal menstrual cycle function requires tightly integrated interactions between the hypothalamus, pituitary, and ovary whereas the endometrium serves as a gonadal ste roid end organ and clinical marker of reproductive cycles (Fig. Estradiol secretion from developing follicles causes follicular phase proliferation of the endometrium. After ovulation, the combination of progesterone and estrodial produces the secretory changes that prepare the endometrium for implantation if conception occurs. In the absence of pregnancy, the function of the corpus luteum declines, hormonal support of the endometrium is lost, and menses results (for review see Hall4). The hormonal, follicular, and endometrial (Endo) dynamics of the normal menstrual cycle from the late luteal phase through menses and the beginning of a new cycle of follicle development, ovulation, and corpus luteum function and decline. Thereafter, there is a steady decline due to atresia such that, at birth, only 1 million follicles remain, with a further reduction to 250,000 by the time of puberty (for review see Gougeon10). During and after puberty, follicles leave the pool of resting follicles by activation of further growth or by degeneration. Between the ages of 30 and 35, however, the percentage of growing follicles increases12–14 and the tra jectory of follicle loss is accelerated until the pool of resting follicles is reduced to be tween 100 and 1000, when there is cessation of reproductive cycles. Chemotherapy, radiation, and smoking are all factors that accelerate follicle loss through damage to the oocyte and/or dividing granulosa cells. Studies in younger and older postmenopausal women suggest that there are effects of aging on the hypothalamus and pituitary that are independent of the loss of steroid feedback. Studies of these new ovarian factors not only has contributed to fertility prognosis but also has provided important insights into the integrated changes that occur with reproduc tive aging.

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Regularly clean all working surfaces with an appropriate cleaning solution following manufacturers’ guidelines who diabetes definition 1999 order forxiga canada. Prevent the risk of cross infection by checking for contraindications during the consultation First Platform to Permanent Make Up diabetes mellitus type 2 cure forxiga 5mg line. All gowns and towels should be washed at a minimum of 60 °C and clean towels and gowns provided for each client diabetes test journal purchase forxiga 5mg with amex. Waste should be placed in correct bags or sharps containers depending on their nature and disposed of in accordance with local government legislation diabetes etymology order forxiga 10 mg mastercard. Pigment caps and all contaminated usable items diabetes type 2 patho generic 10 mg forxiga with amex, including the barrier film wrapping should be disposed of in the yellow waste bags 6 diabetes service dogs new york forxiga 10mg fast delivery. First Aid It is imperative that as a semi-permanent make up practitioner, you know basic first aid techniques acquired through a relevant course (such as those run by St. You should know how to deal with fainting and blackouts, panic attacks, heart palpitations and anaphylaxis, as well as cuts, burns and sprains. You should remove your gloves and squeeze the injured area hard so that it bleeds, and then run the area under cold water. You should apply a disinfectant such as neat Dettol and put a plaster on the broken skin. You may wish to carry out a risk-assessment on your client and visit the doctor if you feel you need. All practitioners should have had a Tetanus and Hepatitis B vaccination prior to entering the industry. Preliminary Consultation the preliminary consultation is used to understand what your client wants to achieve and to determine whether they are a suitable candidate for Micropigmentation. Their colourings will be assessed as well as any contraindications they may have that will prohibit them from having the treatment. It is during this consultation that you should be able to answer any questions that your client has and they should be given a patch test. Either at this point, or at the beginning of their procedure the client should be given a consent form to sign, giving you permission to carry out the treatment. Patch Test A patch test should be given to the client at least 24 hours prior to them having their treatment to help determine whether they have an allergy to either the pigment or anaesthetic. If the client comes to the clinic, a small dot of pigment and anaesthetic should be applied to an inconspicuous part of their body, for example behind the ear. If you are posting their patch test to them, you may wish to send a cotton bud that has some of the pigment and anaesthetic on it which they can rehydrate and apply to themselves. Contraindications As has previously been mentioned, a contraindication to micropigmentation is a condition that serves as a purpose for a person not undergoing the semi-permanent make up treatment. If your client admits to having one of these conditions, you should not carry out the treatment. This list below is not exhaustive, but these are the most common contraindications preventing a client from having treatment. You should also check with your insurance company as they may put exclusion clauses in your public and product liability insurance relating to certain conditions. Consent Forms and Eligibility Your client must declare their medical history and give their signed consent to you carrying out the treatment before you begin. Client Questions Here are typical answers that we give to our clients frequently asked questions: How long will my Permanent Make up last? The majority of clients require 2 initial permanent make-up treatments after which you will require at least one treatment per year to ensure that your make-up stays fresh and fabulous looking for the whole year. Pigment implantation is partially affected by differing skin types and by the following. Depending on the treatment, we recommend at least 2 hours for each new procedure to ensure that the client receives a detailed and personalized consultation and treatment. However, it cannot be truly classed in the same category as a tattoo for in many cases the pigment will fade and may even disappear completely. If the procedure was classed as semi-permanent this would imply that the skin will return to its pre-tattooed stage at some point (this usually would not be the case). The procedure would only be truly classed as semi-permanent if the penetration of pigment only affected the epidermal layers. The layers of the epidermis are constantly renewing themselves so therefore any pigmentation implantation to this level only, would be desquamated out of the skin within a 4 -6 week period. Traditional tattooing procedures are practiced using inks and dyes which are dissolved in a wetting agent and implanted at a deeper level into the lower reticular layer of the dermis. Micro-pigmentation procedures implant iron oxides into the upper reticular layer of the dermis, therefore there may be a degree of colour visible in the skin for a lifetime. However the degree of colour will usually fade and maintenance procedures are required every 12-18 months to ensure clarity of colour and design. Clients should be informed that the procedure will leave a degree of pigmentation in the skin that is likely to fade over time. There is an exception to this rule when discussing lip tissue type 1 in comparison to the vermilion border or peri-oral skin. Due to the vascular nature of lip tissue type 1, infused pigment will usually only last about 2-3 years maximum before they need re-treating. The vermilion border and peri-oral skin are more likely to retain pigment and therefore a definite lip line may become apparent as the body of the lip tissue pigment colour fades. Any area of enhancement can have colour changes as the pigments fade over time, although this is more obvious in eye and eyebrow procedures. Reviewing the clarity and colour every 12 -18 months will ensure the client is satisfied with the overall results and allow for any changes that need to be made. Remember that pain is experienced at differing levels with each individual client and that it is felt as a result of causing damage to the tissues of the body. During the permanent cosmetic procedure, pain can be derived in a number of ways. The continuous rapid needle penetration damages the tissue and may present itself as a sharp/scratchy pain. While it is necessary to stretch the skin for good practice, it could cause the client some discomfort, especially as the tissue has been damaged. The anaesthetics and cleansers used are chemical irritants and can cause what some may consider to be a painful sensation, especially when used around the eyes for example. It is likely that your client will experience some level of pain, and while you should use anaesthetics to minimize this, your client should not be deluded into thinking that this is a pain-free procedure, nor should they be made to worry that this painful sensation is abnormal. You may wish to mention to your client that she will be more sensitive during her period and also that it is normal to experience pain more on one side of the body than the other because of the positioning of our nerve endings. Application of anaesthetic (although by law the client must by their own anaesthetic and apply it themselves). Pre-Procedural Advice First Platform to Permanent Make Up See Appendix B for standard document of pre-procedural advice. Contra-actions and Allergic Reactions Certain contra-actions are expected in the first week following micro-pigmentation procedures. Inflammation erythema, swelling and increased skin temperature on and around the treatment site is expected for the first 72 hours post treatment. Severe swelling and blistering within in this timescale would indicate allergic reaction to the healing balm. Pain lips are the most sensitive regarding pain and this symptom can last up to 2 weeks post procedure. Eyelid procedures can cause discomfort for around 72 hours post treatment in line with the normal inflammatory response period. Eyebrows are usually a little tender post procedure but are not generally painful. Peeling/Flaking Skiniii increased shedding of the skin will occur following trauma, this is all part of the natural healing process. Lips can require the application of moisture balm for up to a month post procedure as they do not contain sweat or sebaceous glands to provide natural lubrication to the area. Bruising this can commonly affect the eyelids and lips but is only superficial and normally subsides within 3-5 days First Platform to Permanent Make Up. Herpes Simplex Type 1iv herpes outbreak will only occur if the client is already carrying the virus. The client should be advised to use topical anti-viral creams as a precautionary method for a week following micro-pigmentation enhancement to the lips. It slows the growth and spread of the herpes virus so that the body can fight off the infection. Impetigov impetigo is a skin infection caused by the bacterium Staphylococcus aureus or Streptococcus pyogenes and causes fluid-filled spots or blisters. The bacterium enters into a cut or opening in the skin and is a common secondary infection following on from herpes simplex. Good hygiene and aftercare practice can minimise the chances of contracting this infection It is not possible to predict whether a client is likely to be allergic to pigments which may be Organic, Inorganic, Synthetic Organic or Synthetic Inorganic. You should always ask for the safety data sheets on any pigment range which you are using from the manufacturer to prove that the pigment is from a sterile source and the ingredients are safe to be introduced into the human body. However it does not guarantee that a reaction will not take place at a later date even if the result is negative. There have been reports of delayed reactions occurring up to 2 years following the procedure. First Platform to Permanent Make Up True allergic reaction symptoms to iron oxide pigments would not usually manifest themselves until 3 months and up to 2 years post procedure. The following symptoms on the treatment site following several years could be observed. Oozing lymphvi Allergic reaction of this nature is rare however if you suspect your client has pigment allergy they should be referred to a dermatologist immediately. Note: All British insurance companies covering micro-pigmentation presently insist on sensitivity testing for pigment prior to treatment. Anatomy As a permanent make up practitioner, it is essential that you have an in depth knowledge of the anatomy of the face, the way certain parts of the face will typically and atypically react to treatment and also conditions and disorders that are known to affect it. You must have an understanding of this before you can learn the main theories of permanent make up. The Skin Skin is made up of 3 main layers a thin epidermis at the surface a thicker dermis beneath, and below that a fatty layer known as the subcutaneous layer. The epidermis is made up of 5 layers of cells, these are structured like a brick wall. New cells are constantly being formed in the bottom most layer and they push the older cells towards the surface. As the cells get pushed upwards, they become flat, hard and eventually die (keratinisation), forming a dead layer at the surface. The cells on the surface of the epidermis are like overlapping tiles and are constantly being shed (desquamation). The epidermis contains a dark pigment called melanin, ethnic skins contain higher levels of melanin than Caucasian skins. Oriental skins have an additional pigment called carotene which gives their skin a yellowish tone. Although Caucasian skins do not have such high levels of melanin, the amount is increased by the action of ultra-violet light on the skin stimulating the pigment producing cells melanocytes into producing more protective pigment. The dermis is composed of a network of tough connective tissue fibres, blood, lymph capillaries and sense organs. Towards the bottom of the dermis there are sweat glands from which narrow sweat ducts run to the surface of the skin. First Platform to Permanent Make Up Projecting out of the skin are hairs, each hair projects from a hair follicle, and its root is situated deep in the dermis. Opening into the hair follicles are glands which produce oil, they are known as sebaceous glands, the oil they produce is known as sebum, this keeps the hair supple and helps make the skin waterproof. A muscle runs from the side of each hair follicle to the base of the epidermis, when this muscle contracts it causes the hair to stand upright, when it relaxes the hair lies flat, it is known as the erector pili muscle and is important in temperature control. Below the dermis is a layer of cells containing fat which varies in thickness from one part of the body to another. This layer is known as the subcutaneous layer, the fat in this layer acts as insulation to preserve body heat and acts as a cushion to protect underlying bones and organs. The 5 layers of the epidermis are known as: Stratum Germinativum (Germinating Layer) this is a single layer of soft cuboid cells. These cells divide to form new cells which push the adjacent ones nearer the surface. Smaller cells called melonocytes are also present in this layer, they produce granules or melanosomes. These contain the yellow, brown or black pigment melanin which is the main pigment agent in skins. Stratum Spinosum (Prickle Cell Layer) this layer contains living cells with spiny outgrowths which form bridges between the cells. This layer receives the pigmentation caused by melanin production from the melanocytes situated within the germinating layer. The Stratum Germinativum and the Stratum Spinosum together form the living layer of the epidermis known as the Malpighian layer. Stratum Granulosum (Granular Layer) this is an area where a lot of change takes place in the cells. Stratum Lucidium (Clear Layer) this is a very shallow layer in facial skin but is thicker on the soles of feet and palms of the hands. The Stratum lucidium will increase in these areas to First Platform to Permanent Make Up form protection against friction. The flattened cells in this layer are completely filled with keratin and are translucent in appearance. Stratum Corneum (Horny Layer) this is the outer layer of the epidermis and consists of flat dead cells of keratin. The Dermisviii the average thickness of the dermis is 3 mm and it is made up of 2 regions: the Papillary Layer this region interlocks with the epidermis in series of ridges sometimes referred to as the dermal papillae. This layer is continuous around each hair follicle forming a connective tissue sheath.

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Analytical approach for study 3 Objectives: the purpose of study 3 was to explore how women’s beliefs about menopause are located within their social context and to relate this to uptake of biomedical and non-biomedical treatments Comparison of volunteers and non-volunteers blood glucose 300 treatment discount 10mg forxiga with amex. One hundred and ninety-four women (53% of the participants at stage 1) from study 2 volunteered for study 3 diabetes insipidus 3 year old trusted forxiga 10mg. Ninety-six women declined to participate and 54 women did not complete this question diabetes type 1 vs 2 5mg forxiga otc. Volunteers were more likely to have sought more treatments for menopause-related symptoms on average blood glucose 236 cheap forxiga online visa. Thus homa diabetes definition generic forxiga 5mg on-line, volunteers for study 3 had used more treatments (though had not necessarily experienced more intense symptoms) diabetes readings discount forxiga amex. A coding audit was performed with another researcher, and differences were debated and codes amended after discussion. Families of codes were identified using measures of ‘groundedness’ and were further integrated to identify higher order concepts. Constant comparison was used to identify inconsistencies in the data and the findings from study 3 were reviewed in the context of results from study 2. Most of the studies were qualitative and few specifically asked women about their beliefs and, as Ayers et al (2010) noted, there were few studies that explicitly investigated the relationships between attitudes and symptoms. To develop new measures of belief about menopause based upon the existing literature 2. To describe women’s beliefs about the menopause Sample and recruitment Women aged between 40 and 60 years of age were recruited between May and June 2011. Participants were recruited from women’s groups, volunteer staff at museums in Cambridge, the Minority Ethnic Network for the East of England, Housing Association staff, gyms, leafleting at Race for Life meetings, leaflets in places where women congregate (public lavatories, pubs, supermarkets) in Cambridge, Stevenage, and London. One hundred and sixty women responded to the questionnaire, of which 155 were completed online. Incomplete surveys, where a large proportion (50% or more) of the questionnaire was not filled in were removed, leaving 149 responses. Despite efforts to reach a more diverse audience, the sample was predominantly white, well-educated and married with children (Table 7. In addition, items were added to represent concerns about aging and feelings of being invisible in society as identified in research by Rubinstein and Foster (2012). All the items were measured on a Likert scale from 1 (strongly disbelieve) to 7 (strongly believe). Symptom severity: Prevalence and intensity of symptoms were determined using the Menopause Rating Scale. Comparison of symptom ratings between pre-, peri and postmenopausal women with one way analysis of variance. Descriptive statistics were used to describe women’s beliefs about the menopause 3. Results Eighteen per cent of the sample was premenopausal (either using contraception or having regular periods), 24% were perimenopausal (experiencing irregular or heavy periods), 47 % were postmenopausal (not menstruated for more than 12 months) and 11% had surgical menopause. Only 3% of this sample reported no symptoms at all, with 27% reporting 1-2 symptoms, 25% reporting 3-4 symptoms, 35% reporting 6-7 symptoms, and 11% reported 8-9 symptoms. Sleep problems, physical and mental exhaustion, and vasomotor symptoms were reported as being the most severe and apart from irritability, all these symptoms were more prevalent among postmenopausal women (Figure 7. There was some indication that premenopausal women also reported some symptoms associated with menopause including hot flushes and night sweats and dryness of the vagina. Nonetheless, in keeping with previous research, incidences of reporting these symptoms are higher in the peri and postmenopausal groups. Premenopause = 27, perimenopause = 36, postmenopause = 86 86 the mean intensity of symptoms was higher in the peri and postmenopause groups compared with premenopausal women. The intensity of sleep problems, exhaustion, anxiety, bladder problems, joint & muscular discomfort and vasomotor symptoms were significantly higher among postmenopausal women though women in perimenopause reported higher mean symptoms for irritability, dryness of the vagina and sexual problems. The differences with respect to sleep problems and exhaustion may be related to the experience of vasomotor symptoms as night sweats could affect sleeping patterns that results in tiredness during the day (Table 7. Post hoc comparisons indicated the following: differences in sleep problems were significant between pre and postmenopausal women (p<0. Thus, women depicted menopause as a natural but significant developmental phase (Table 7. For example, 84% believed that ‘women should consider changing their diet and exercise more at menopause’ and 83% believed that ‘every woman experiences menopause in a different way and there is no one expert to go to’. This reflects the discourse that focuses on self-management and personal responsibility for one’s own health during menopause. Women did not believe that ‘health professionals think that menopause is an illness because they want to control women’ (73% disagreed) but were divided in their opinion as to whether or not doctors are experts; 41% believed and 35% did not believe that doctors are ‘experts when it comes to offering good advice about menopause’. Seventy percent of women believed that ‘there are lots of natural remedies that women can use to help them get through the menopause’ suggesting that they may prefer to find their own solutions to problematic symptoms. There was some indication that women were unsure about who is authoritative about menopause; 83% believed that ‘doctors don’t know everything about menopause’ Table 7. In contrast, almost one-third (29%) believed that ‘Hormone replacement therapy is too dangerous for women to take for menopausal symptoms’ Data reduction to identify social constructions of menopause A principal components analysis was run using a Varimax rotation, selecting for components of > 0. Components 1 to 4 reached reasonable scale reliability levels but component 5 was well below the acceptable level for a robust scale. Component 1 achieved a high reliability and represented a construction of menopause as rendering menopausal women as invisible and unvalued by society. Component 2 also achieved scale reliability and represented a construction that represented menopause as a big change that makes women ill. However, the item ‘It is changes to women’s hormones that cause all the problems and there is nothing they can do about it’ did not load onto the component in study 2 and was not used in the final Illness belief scale. Component 3 had a slightly lower reliability score and was the opposite of component 2 in that it represented a construction of menopause as a natural phenomenon. Items in this component included 90 ‘Women make too much of a fuss about menopause, it is nothing out of the ordinary’ and ‘Sexual interest and comfort increase following the menopause because women don’t have to worry about contraception’. The items in this scale were similar, but not identical to the final Postmenopausal Recovery scale used in study 2 (see Chapter 8 for detail). One item did not load onto this scale in study 2; this was ‘Women should consider changing their diet and do more exercise when they reach menopause’ and hence this was omitted in the final scale. Component 5 failed to achieve reliability, though it did incorporate some of the questions that reflected confusion. For example, ‘Even doctors don’t know everything about menopause so women should do whatever they think is right’ and ‘Women don’t know what to believe because there are so many conflicting views’. Items which failed to load onto any component were removed: these included ‘Women often find that their memory gets worse during menopause’, ‘Women get fat and change their shape when they go through menopause’, and ‘Health professionals think that the menopause is an illness because they want to control women. New items were added to reflect previous research by Neugarten et al (1964) and in particular to ensure that positive attitudes to menopause could be reflected. These included ‘Menopause is a mysterious thing which women don’t understand’, ‘Life is more interesting for women after the menopause’ and ‘A woman has more confidence in herself after the menopause’. A Pearson’s product moment correlation was conducted between the symptom sub-groups of the menopause rating scale and the four most robust constructs (table 7. Believing in postmenopausal recovery has a significant negative association with psychological symptoms and somatic symptoms but not urogenital symptoms Discussion Symptom reporting was prevalent across all menopausal statuses with higher levels of severity reported by postmenopausal women for most symptoms. Women’s beliefs about menopause are multi faceted and contradictory with a degree of confusion and uncertainty apparent. However, the principal components analysis indicated the presence of four constructs and one emergent construct. The four constructs portrayed menopause as rendering women invisible and unvalued, as an illness, as a period of change after which there is recovery and as amenable to treatment. A possible emergent construct related to menopause as a time confusion and confliction was also evident. The preliminary survey did not support all the constructions identified in the literature and some discourses were rejected by women. For example, the feminist discourse which portrays doctors as oppressing and controlling women was not supported. A discourse where doctors are the experts was not evident and the discourse of menopause as confusion was indicated but did not result in a robust construct. Most women agreed that menopause is natural but views about hormone therapy were mixed. There was some indication that the confusion discourse is embryonic and Component 5 appeared to reflect this. However, it did not emerge as a reliable latent variable despite the fact that a majority of women (67%) of respondents believed that ‘women don’t know what to believe because there are too many different and conflicting views about the menopause’. Thus, there were four prevalent social constructions of menopause among this sample as follows: 94 Construct 1 represented menopause as a symbol of being unvalued and invisible. Menopause, which is symbolic of aging, is constructed as a time when women become invisible, unvalued and less desirable. Our society routinely undervalues older people (Cuddy, Norton & Fiske 2005) and if these associations trigger negative schema of aging there may be an impact on women’s perceptions of symptoms. This was reflected in the significant correlations between this construct and all three symptom domains. Construct 2 represented menopause as an illness that changes women and a time when women should expect to feel unwell. Thus, perceiving menopause as an illness is associated with perceived higher severity of psychological, somatic and urogenital symptoms. However, the direction of this association is unclear as experiencing more severe symptoms could contribute to a stronger belief that menopause is an illness. Construct 3 represented menopause as being amenable to treatment with hormone therapy. This construction incorporates the idea that replacing lost estrogen will delay the signs of aging, have a positive effect on osteoporosis, and help to maintain a healthy sex life. This construction did not correlate significantly with symptom experiences in study 1. Construct 4 construed menopause more positively suggesting a postmenopausal recovery: items included ‘after menopause women have more time to do what they always want to do’, ‘menopause is nothing out of the ordinary’, and ‘sexual interest and comfort increase’. Nevertheless, the construction of menopause as a period of declining estrogen which leads to illness is deeply embedded in how women think about this transition, regardless of menopausal stage. Both the illness and treatment constructs were supportive of the dominant biomedical view. The social constructions described above, indicate that the label ‘menopause’, for some (though not all) women, contains an expectation of being unwell and is associated with a series of anticipated symptoms such as hot flushes, tiredness and irritability. Individual differences in terms of the cognitive schema which women hold about menopause (the beliefs contained in each of the constructs) are likely to contribute to their perception of symptom severity. Two of the constructs in this study were sub-optimal with Cronbach Alpha scores below the threshold of 0. As described in chapter 6, the changes that were made in study 2 resulted in four robust components (Cronbach Alpha above 0. There appeared to be one emergent construct which might represent the confusion discourse. To explore the pathways to treatment Specific treatment utilisation hypotheses were: 1. Women who rate higher for treatment utilisation for menopause symptoms will be more likely to construct menopause as pathological and to associate menopause as a symbol of aging. Women who rate higher for treatment utilisation will have fewer coping strategies, score lower on emotional stability and higher on the measure of cognitive inflexibility. The rationale for the selection of measurement instruments is described in detail in Chapter 5: Methods. Validated scales were selected, the social construction scales were developed and piloted in study 2 and the outcome measure, treatment utilisation was specifically developed for this study. The data were analysed in the following ways: i) Descriptive statistics to describe general health wellbeing, symptom prevalence, attribution of symptoms to menopause and to compare women of different menopausal status ii) Logistic regression was used to identify predictors of being in the clinical sample iii) Bivariate and multivariate hierarchical regression were used assess which factors were predictive of symptom severity and of treatment utilisation iv) Structural equation modelling was used to explore the pathways to treatment mediation and moderation analysis Recruitment of participants: the recruitment process is described in detail in Chapter 5. Questionnaires which were more than 50% incomplete were excluded from the analysis. The sample has a bias towards the higher income groups and 42% had a degree or higher degree. This may reflect the sample locations: income levels are higher in the south of England and Cambridge is a university town. Despite recruiting from Nottingham, which has a higher level of working class and ethnic populations, the sample was predominantly white, and biased towards the better educated and households with higher income levels. One practice manager reported that she ‘had tried many times to get Asian women to fill in questionnaires at the surgery’ but either their English was poor or they preferred not to participate. It is known that there are cultural differences with respect to symptom reporting and attitudes to menopause (Avis & Crawford, 2008) but there were too few women of different ethnicities to be able to conduct analysis of these groups separately. Two hundred and ninety five peri and postmenopausal answered questions on sociodemographics, lifestyle and general health, menopause experience and attitudes, and social and cognitive factors. Twenty-nine per cent were in perimenopause, 53% were postmenopause and 18% had a surgical menopause as a result of a hysterectomy or treatment for cancer. Sample by Category and Source Population Clinical Total Perimenopausal 69 16 85 Postmenopausal 95 60 155 Surgical menopause 25 28 53 Total 189 104 295 A Chi-squared test indicated that there were significantly fewer women who were perimenopausal in the clinical sample than expected (17 observed compared with an expected count of 31) and significantly more of the clinical sample had surgical menopause (28 observed compared with an expected count of 19) χ2 (2) = 16. It has been reported elsewhere that women who experience surgical menopause often experience higher levels of symptom reporting than those who experience natural menopause and this may account for their greater representation in the clinic (Avis et al. Descriptive statistics the main areas of interest were general levels of health and wellbeing, prevalence and severity of reporting menopausal symptoms, the extent to which these were attributed to menopause, usage of hormone therapy and an understanding of the main attitudes to the menopause transition. In addition, it was important to understand whether there were any significant differences on these measures between women of different menopausal status. General health and wellbeing: the Health wellbeing variable was a composite score of self-rated general health, life satisfaction and the four wellbeing items of the Women’s Health Questionnaire. The distribution indicated a slight negative skew as most people reported good levels of health and satisfaction: skew –0. One-quarter of women in perimenopause reported an illness that might impact on their experience of menopause compared with 46% of women at postmenopause. By definition, women who had undergone surgical menopause had had an operation that could induce symptoms or could exacerbate existing menopause symptoms.

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Clinically diabetes definition glucose level order forxiga 10mg without prescription, the regulatory defect in bone turnover Surgical intervention with stapedectomy to improve con results in pathologic fractures and hearing loss diabetes mellitus 2 order 10mg forxiga amex. There is Clinical Findings a greater tendency for bleeding and difficult footplate mobilization diabetes mellitus zuckerkrankheit symptome generic forxiga 10 mg amex. Alternately diabetic diet includes purchase genuine forxiga online, patients may choose to improve thus affects multiple organ systems diabetes type 2 aafp 10 mg forxiga free shipping, producing a broad hearing with an amplification device jenis diabetes insipidus discount forxiga 5mg mastercard. Hearing loss in osteogenesis imperfecta Aharinejad S, Grossschmidt K, Streicher J et al. Auditory ossicle tarda can be audiometrically indistinguishable from oto abnormalities and hearing loss in the toothless mutation in sclerosis. However, osteogenesis imperfecta has an earlier the rat and their improvement after treatment with colony stimulating factor 1. Syndrome character an otospongiosis-like focus, as seen in early otosclerosis, or ized by osteitis fibrosa disseminata, areas of pigmentation and diffuse changes within the otic capsule. Osteogenesis imperfecta: otologic and maxillofacial plication of osteogenesis imperfecta. Autosomal dominant os teopetrosis: an otoneurologic investigation of the two radio have substantial overlap with those found in otosclerosis. Osteodystrophia fibrosa: report of a case rosteosis of the temporal bone: a histopathologic study. Comparison of a single infusion of view of 26 patients to determine the etiology of conductive hear zoledronic acid with risedronate for Paget’s disease. Occasionally, clival junction and petrous apex require either a middle an asymptomatic tumor may be diagnosed when a mid fossa-transpetrous approach with removal of the petrous dle ear mass is noted during routine otoscopic examina apex bone (Kawase triangle, Figure 65–2) or a combined tion of the ear. Unfortunately, it is all too common for subtemporal-retrolabyrinthine approach (Figure 65–3). Surgical strategies are chosen by to have the diagnosis of a skull base tumor delayed the skull base surgeon based on approaching the tumor because of an incomplete work-up. By far, the majority with enough exposure to perform a complete and safe of skull base tumors are benign and can be successfully resection while minimizing neurologic morbidity. Table 65–1 lists the various skull base neoplasms and their imaging characteristics. Tumors of the cerebellopontine angle and Meckel cave are not considered in this chapter General Considerations (see Chapter 61, Nonacoustic Lesions of the Cerebel lopontine Angle). Surgical approaches to these three areas Paragangliomas (or glomus tumors) are tumors of paragan are numerous, and the nomenclature is confusing. To glionic tissue, which originally derive from the migration remove a lesion of the middle ear or mastoid, a mas of neural crest cells during fetal development. These tissue toidectomy through a postauricular incision or a middle rests are distributed predominantly throughout the middle ear exploration through the ear canal is usually adequate. These cell clusters are innervated by toidectomy is performed along with skeletonization of the parasympathetic nervous system and function as the facial nerve, the sigmoid sinus, and the jugular bulb. One classic approach to the jugular foramen is the Fisch the most common paraganglioma is the carotid Type A approach (Figure 65–1). A well-known, but rare, paraganglioma is the facial nerve out of its bony canal and rerouting it the pheochromocytoma. Permanent facial paresis or synkinesis can there are two main types of paraganglioma: glomus tym occur. Glomus tympanicum Type A approach, which leaves the patient with a maxi tumors arise within the middle ear, from paraganglionic 794 Copyright © 2008 by the McGraw-Hill Companies, Inc. Surgical resection of a large jugulotympanic paraganglioma (Fisch Type A approach). Although the classic Fisch Type A approach involves closure of the external auditory canal and rerouting of the facial nerve, these proce dures are not often required to resect even large jugular foramen tumors as shown in this example. Fisch Type B and C approaches (not shown) are not used to approach the jugular foramen, but in stead are used to approach tumors of the in fratemporal fossa, petroclival junction, and na F sopharynx. Good visualiza tion of the petroclival junction, as well as the anterior brainstem, is obtained by this approach. Combined subtemporal Labbe retrolabyrinthine approach for resection of tumors of the petroclival junction. Excellent exposure of the Sigmoid entire brainstem from the posterior circle sinus of Willis to the jugular foramen is obtained. Together these bilateral glomus jugulare tumors and a 7% incidence of nerves are called the tympanic plexus, which consists of an associated carotid body tumor. In addition, another form of the disease has an autosomal dominant mode of transmission, and the Pathogenesis causative genetic defect has been localized to two sepa rate loci: 11q13. Paragangliomas Paragangliomas are also associated with phakoma are slow-growing tumors, and metastases are extremely toses (neurologic diseases with cutaneous manifesta rare. Within the skull base, they tend to extend through matosis, Sturge-Weber syndrome, tuberous sclerosis, fissures and foramina, vascular channels, and air cell tract and von Hippel-Lindau disease. Classification Approximately 1% of paragangliomas display function ally significant catecholamine secretion similar to a pheo There are two main classification schemes for paraganglio chromocytoma. Pathologically, the chief cell is the cell of mas of the temporal bone: Fisch and Glasscock-Jackson. Classic findings are clusters of chief cells, termed Zellballen, with a rich vascular plexus through the Fisch classification includes four main categories: out the entire tumor. Indeed, these tumors are highly vas (1) Type A (tumors limited to the middle ear), (2) Type cular and may bleed substantially during surgical excision. If the inner ear is invaded, a senso the classification scheme of Glasscock and Jackson dif rineural hearing loss will be found. Impedance audiome ferentiates between glomus tympanicum and glomus try will reveal a flat tympanogram if a middle ear mass is jugulare tumors. Glomus tympanicum neoplasms—For glomus tym panicum neoplasms, this staging system includes (1) Type C. Glomus jugulare neoplasms—For glomus jugulare lar foramen is involved with the tumor. If the tumor is a glomus jugulare tumor that has extended the two most common presenting symptoms of a into the middle ear cavity, this bone will be eroded. In patient with a paraganglioma of the temporal bone are contrast, if the tumor is a glomus tympanicum tumor, conductive hearing loss and pulsatile tinnitus. There may be a semicircular canal fistula or the symptoms of sympathetic discharge, which may repre tumor may be in close proximity to the fallopian canal, sent a functionally secreting tumor, such as tachycardia, particularly along the vertical segment. Moreover, extend anterior to the internal auditory canal or along the patient should be queried about any symptoms of the petrous portion of the internal carotid artery. These dysphagia or hoarseness, which may represent palsy of findings may affect the planned surgical approach. Both may demonstrate a sign is the blanching of the mass with manual compres speckled pattern within the tumor, termed a “salt and sion of the ipsilateral carotid artery. This pattern is due to flow voids from tion of the cranial nerves is indicated, with particular the large number of intratumoral blood vessels. This may occur directly if the tumor is usually done 1 or 2 days before surgical excision. This contacts the ossicular chain or indirectly if the tumor permits definitive diagnosis of the tumor by visualizing the blocks the eustachian tube, producing a serous middle tumor blush characteristic of such highly vascular tumors. Sensorineural hearing loss is uncommon In addition, the feeding vessels can be identified and embo but can occur if the tumor erodes the dense otic capsule lized to reduce blood loss during surgery. Paragangliomas of the temporal bone may cause facial nerve palsy (21%) by invading the nerve within the Differential Diagnosis temporal bone. Even if nerve the differential diagnosis of a patient with a middle ear function is unaffected, most glomus jugulare tumors mass includes otitis media, cholesterol granuloma, other grow to wrap around the facial nerve and erode its bony types of middle ear neoplasms—including middle ear canal in this location. A microsurgical dissection of a adenoma or carcinoma—a vascular anomaly such as a dehiscent nerve surrounded by tumor is the norm and high-riding dehiscent jugular bulb, an aberrant carotid can be quite challenging. Other temporal which the bony canal surrounding the nerve has been bone neoplasms that might involve the middle ear space eroded. It should be noted that rather than an isolated tumors; however, it does not eliminate viable tumor recurrent laryngeal nerve injury that causes vocal cord cells within the mass. Tumors have been known to paralysis (such as with a Pancoast tumor), the jugular recur even more than a decade after radiation therapy. Radiation therapy for paragangliomas of the temporal this is much more severe because the combination of a bone can be useful as a treatment for elderly patients lack of sensation to the upper larynx and vocal cord with symptomatic tumors or for patients who are paralysis puts these patients at extremely high risk of unwilling to undergo a surgical resection. Patients with functionally hypoglossal foramen in the occipital bone, anteroinfe secreting tumors need to be alpha-blocked with phento rior to the jugular foramen. Large paragangliomas that lamine before and during surgical resection to prevent extend inferiorly may affect the hypoglossal nerve. The life-threatening hypertension as the alpha-adrenergic patient may complain of worsening articulation, and hormones are released with tumor manipulation. For a glomus tympanicum tumor that is limited to the middle ear cavity, a simple middle ear exploration through E. After raising the sympathetic nerves to the head run from the supe the tympanic membrane, the tumor can be visualized rior cervical ganglion up along the internal carotid on the promontory. If the tumor is larger and the petrous portion of the internal carotid artery may extends into the mastoid air cells, a tympanomastoidec cause an ipsilateral Horner syndrome with ptosis, mio tomy with an extended facial recess approach may be sis, and ipsilateral facial flushing and sweating. This is a standard mastoidectomy via a post auricular incision with sacrifice of the chorda tympani F. Intradural to the facial nerve (the retrofacial air cells) can be tumors can grow within the cerebellopontine angle, resected after exposing the facial nerve along its vertical producing cerebellar dysfunction and imbalance, brain segment to prevent injury to it. For glomus jugulare tumors, a larger surgical approach Tumors that grow superiorly or medially can affect is required. A tympanomastoid approach with Treatment an extended facial recess and complete skeletonization A. Observation—Observation with no treatment is tion of a thin layer of bone surrounding the facial nerve reasonable in patients with minimal symptoms, particu circumferentially is ideal to minimize risk to the facial larly if they are older. This approach is less acceptable for younger patients in the sternocleidomastoid and digastric muscles are sepa whom the tumor would be expected to grow substan rated from the mastoid tip so that the great vessels can tially during their life span. Radiation—The role of radiation therapy in the be controlled both proximally and distally to the tumor management of paragangliomas is controversial. Superiorly, the sigmoid sinus is treatment of paragangliomas needs to be individualized occluded in the mastoid cavity, inferior to the junction based on the patient, the disease, and the physician. In either case, patients can wall of the sigmoid sinus and the tumor filling the usually regain the ability to eat within the first few sinus) is dissected from the posterior fossa dura and cra weeks after surgery with swallowing therapy. There is usually substantial nerve palsy also can occur during tumor removal, bleeding from the entry point of the inferior petrosal although if the facial nerve is anatomically intact at the sinus to the jugular bulb during this process. After tumor removal, the mastoid nificant amounts of blood loss during the resection of cavity is often packed with fat harvested from the these tumors because of their highly vascular nature. Preoperative embolization is quite helpful in reducing Large glomus jugulare tumors, which extend anteri the amount of blood loss. Lateral skull base surgery for glomus tu the facial nerve from the geniculate ganglion to the pes mors: long-term control. Transjugular craniotomy for the management of jugular foramen tumors the jugular spine, the bone between the internal jugu with intracranial extension. Prognosis General Considerations Paragangliomas have a slow but relentless growth pat tern. For most patients, the treatment of choice is a com Primary tumors of the facial nerve can arise anywhere plete microsurgical removal to prevent worsening mor from the glial-Schwann cell junction in the cerebel bidity from tumor progression. These are very treatment can be performed if the patient is elderly and slow-growing tumors and tend to spread longitudinally has only minimal symptoms. The use of radiation ther along the course of the facial nerve within the temporal apy is limited to elderly patients with symptomatic bone (the fallopian canal). These tumors are histologi tumors, hopefully slowing the growth rate of an already cally similar to vestibular schwannomas (acoustic neu slow-growing tumor. The main question, however, is romas) except for the fact that they rise along a different whether this tumor will cause serious morbidity or mor cranial nerve. Patients with Bell’s palsy in whom facial nerve function was not of acute onset should be evaluated for a facial nerve schwan noma. Also, patients with facial palsy that does not begin to demonstrate the return of function within 6–9 months of onset should be evaluated for a facial nerve schwannoma. For facial nerve schwannomas that begin in the cerebellopontine angle or internal auditory canal, the most common clinical findings are sensorineural hearing loss, tinnitus, vestibular dysfunction, and balance. These find ings are precisely the same symptomatology as those of a patient with an acoustic neuroma. They can also present strates an enhancing tumor of the left internal auditory with conductive hearing loss if the mass impinges upon the canal (arrow) that extends anteriorly to the geniculate middle ear ossicles. For all locations, a common patient history is a slow onset of facial nerve palsy over 3–6 months, which has nerve within the middle ear. Usually, facial romas stop at the fundus, which is the distal portion of spasm is noted before the onset of facial paralysis. Audiometry—Audiometry often demonstrates con sents with facial palsy of rapid onset (over 1–2 days). The ipsilateral acoustic reflex may have these patients are diagnosed with idiopathic Bell’s elevated thresholds or show abnormal decay functions. Although ster oids may reduce tumor edema and initially lead to an Differential Diagnosis improvement in facial nerve function, the facial nerve palsy will return over the next few weeks as the effects the differential diagnosis of a facial nerve schwannoma wear off. If a parotid mass is palpable, all types of whether the tumor mass impinges upon the ossicles. For any patient with unilateral defining the extent of the tumor within the cerebel peripheral facial palsy, both idiopathic Bell’s palsy and lopontine angle and the parotid gland (Figure 65–5). Ramsey-Hunt syndrome should be included in the dif the tumor has an intermediate signal intensity on both ferential diagnoses.

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