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By: John Walter Krakauer, M.A., M.D.

  • Director, the Center for the Study of Motor Learning and Brain Repair
  • Professor of Neurology

https://www.hopkinsmedicine.org/profiles/results/directory/profile/9121870/john-krakauer

Certainly a simple guilty plea would expiate this feeling Mahoney warned would be recurrent depression glass ebay buy cheap geodon on-line, the ceaseless self-interrogation about a death he could have prevented depression definition uk cheap geodon 80mg mastercard. Nightingale hadn’t sued bipolar depression 40 discount 80mg geodon overnight delivery, and suddenly he came to depression market definition order geodon master card a conclusion at which even the omniscient Mahoney hadn’t arrived America wasn’t such a litigious society! The doctor-patient rela tionship used to be viewed by the courts as a contract between two people, but the law soon realized the relationship was not a simple contract. If the patient was wronged because of the doctor, the law had to provide an adequate remedy. So malpractice was no longer a subject in the books of contract law, but moved to the textbook of the Rape of Emergency Medicine Page 266 tort law, now found in the chapters on negligence. She sued, but couldn’t find a physician willing to break the conspiracy of silence. Her attorney changed the action from a malpractice or negligence issue to a consent issue, saying the woman never consented to have the good leg cut off. The courts agreed, awarding her damages, and since it was a consent case, and not a malpractice case, the courts didn’t require an expert witness. There has never been a suc cessful consent action won by a plaintiff against a physician for tak ing emergency action that has ever been upheld by the appeals courts. The appellate the Rape of Emergency Medicine Page 267 court is well aware they don’t want to provide a disincentive to any physician, anywhere, even within the hospital, for taking emergency actions. A twelve-membered jury will forgive the so-called ‘four D’s’ the dumb, dedicated, documented doctor. They’re not likely to forgive some doctor who thinks he’s a legal beagle, withholding treatment on a literal technicality. One can see in any legal journal scores of companies offering physicians to testify in medical-malpractice cases. There’s actually a glut of expert witnesses today, ready and willing, if not fully able, to testify against other doctors. One of the cases we had in a class involved a woman who appeared in the emergency room at three a. The emergency physician was asleep, and told the nurses to give her a diet, and went back to sleep, and saw the woman four hours later, but this time in a full cardiac arrest. Because she couldn’t pump blood through her vessels adequately, she accumulated fluid in her extremities. Instead she was sent home to drown in her own bed in her own fluids (the ‘go home and drown in your own fluids’ patient). So he indeed breached his duty the Rape of Emergency Medicine Page 268 to the patient. Emergency department physicians are not allowed to choose which patients they will see. Uncle Hershel was again astonished at the ignorance of physicians regarding even the most fundamental principles or law, saying, “Philip, I’ve told you repeatedly in the past, civil cases are decided by a ‘preponderance of the evidence,’ fifty-one percent of the tilt, and not by the heavier weight of ‘beyond a reasonable doubt. Do you realize all attorneys in the United States of America know that there are seven cervical ver tebral bodies, and yet physicians can’t even distinguish between the civil and the criminal law? We went over a case involving a psychiatrist who was confronted by a patient with a gun. The two of them were alone in the doctor’s office when the patient told the psychiatrist he had homicidal ideations and wanted to kill someone, anyone. The psychiatrist conducted the interview with complete imperturbability, even though the gun was pointed straight at him, until about thirty minutes into the session when the patient agreed with the therapist that he had lost his homicidal feel ings, and handed his gun over to the shrink. The shrink continued the session, and when the timer buzzed, signaling the end of the forty-five minute session, the psychiatrist, believe it or not, gave the patient back his gun. The patient went out,” while Uncle Hershel waited a minute for the uproarious laughter to abate, “the patient went out to the bathroom and shot himself,” which made everyone in the room howl even louder. A conservative Southern jury said the entire event was unforeseeable,” causing an immediate standing ovation by all, no one quite certain if the joyous applause was due to Philip Mahoney’s being wrong again or because the doctor beat the rap. Uncle Hershel then changed the subject, saying to Steinerman, “Elaborate more for me on this pork-barrel ‘management’ and other aspects of emergency medicine mountebankery. The Rape of Emergency Medicine Page 270 “Criminal lawyers, product-liability lawyers, divorce lawyers, and bankruptcy lawyers don’t diversify, but now you’re telling me about hair transplants? Between cardiac arrests and the Swine flu, these doctors Monk and Walsh can transplant tufts of hair? Steinerman and Mahoney (along with eleven thousand other very fine physicians) simply stated they be longed to the organization without ever explaining why. Uncle Hershel replied, “I don’t belong to non-obligatory clubs, es pecially ones that would have me so easily as a member. Also, it doesn’t hire Rheumatologists in a nation wide, centralized plan to go out and see the crippled patients, and then send ‘management’ residuals to the ‘suit’ who established the beachhead first. Steiner man mentioned it was Goldman who’d given the lecture on con tracts, publicly claiming he was losing money on Braintree Chil dren’s, but decided for the good of emergency medicine everywhere to enforce the noncompete clause which Uncle Hershel had instinc tively known at this point was unenforceable. But they sure can shut you up for the time being with the specter of pro longed, complicated, and costly litigation. It’s a simple vendetta, and a well-known ploy of well-heeled companies to fight their critics, usually the honest critics. These lawsuits are known within the legal community as ‘intimidation suits,’ designed to punish people in a war of attrition, making everyone think twice about speaking out against the empire. It’s certainly not the interpretation Oliver Wendell Holmes or Justice Brandeis might give it. You guys are doctors, see ing patients, and the spirit of the law doesn’t restrain from good medical care. The Rape of Emergency Medicine Page 272 Uncle Hershel listened more closely to the cheap, petty, sordid, mean-spirited, spoil-sport thing that was happening to Philip Ma honey in the name of a medical specialty with their own unholy alliance with the law, and he did something that no one in the fam ily outside of Doctor had ever seen before. Doctor Steinerman remembered it from a long time ago when he was twelve years old and had borrowed, without authorization, Un cle Hershel’s baseball glove. Uncle Hershel became completely glan dular, his face reddened, sweat poured out, and all of a sudden he flew into a rage. The family was stunned, but it was refreshing for Doctor to see his brother as his old self. Early the next day Mahoney and Steinerman saw Uncle Hershel and the family off, and both Mahoney and Steinerman went to join many of the medical families of Boston for the great festive event that morning. It was time for everyone to rush over to Boston Uni versity’s Death and Doughnuts conference, now Bagels, Cream Cheese, Death and Doughnuts. Everyone knew it would be crowded because Sheila Schultz’s head was on the chopping block. Schultz had managed to piss off everyone in Boston and beyond, and therefore, a big, hostile crowd was expected. Riley was the visiting surgeon from Indiana in charge of today’s Death and Doughnuts, and to everyone’s delight, Doctor Schultz would be sitting on the stool by herself for two cases: one a missed appendicitis; and the other a botched, abdominal gunshot wound. The Rape of Emergency Medicine Page 273 the eminently distinguished statesman of surgery, the silver-haired Doctor Riley, read the first case, looking splendid in his long white coat. He delivered the reading of the first case like a man of letters, but wasn’t quite prepared for Schultz, and before he could even fin ish, she snapped, “Why didn’t the surgical resident who saw her first perform a rectal exam, or is that not part of the abdominal examina tion from Boston any more? Riley could hardly be heard over the roar of the engines as she screamed, “I don’t understand exactly what you’re saying about our gunshot-wound statistics in Boston, Doctor Riley. Are you people in Indiana just better surgeons, or are our citizens in Boston better marksmen? Schultz put the six-ton monster on full throttle and flattened Riley right there in front of everyone. People coughed from the diesel the Rape of Emergency Medicine Page 274 fumes, and the male doctors in the front row threw their hands up to avoid being splattered with the raspberry filling. The males were furious while the vicious Schultz kept gleefully juggling with the controls, backing over Riley, who muttered something about sewing the omentum over the liver in bad cases, but it only annoyed her more. She blew the whistle on the big yellow steamroller, letting it rip, “That’s frosting on the cake and you know it. The trauma sur geons don’t waste their time on that here in Boston,” as she kept it up, back and forth, back and forth and Oh, the horror, the horror as Riley kept getting flatter and flatter.

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Fine-needle aspiration aids in diagnosis anxiety burning sensation buy geodon 40 mg low cost, showing histologic criteria depression jugendalter test discount geodon american express, a focus score of greater than 1 focus/ 2 acinar atrophy with diffuse lymphocytic infiltra 4 mm is diagnostic mood disorder nos dsm 4 cheap geodon 80 mg without a prescription. Characteristic histopathologic findings include a lymphocytic infiltrate in acinar units tion depression journal articles order 80 mg geodon, and foci of epimyoepithelial islands. Complications General Considerations Cases of progression to neoplastic disease can result, Benign lymphoepithelial lesions are also known as Godwin including lymphoepithelial carcinoma, low-grade B-cell tumor, Mikulicz syndrome, or punctate parotitis. Treatment & Prognosis Pathogenesis the treatment of benign lymphoepithelial lesion is A benign lymphoepithelial lesion is an inflammatory pro symptomatic unless the parotid enlargement is severe cess characterized by lymphocytic infiltration around sali enough to warrant a superficial parotidectomy. With submandibular excision is an adequate treatment of the increasing lymphocytic infiltration, progressive acinar rare benign lymphoepithelial cyst. Upon malignant transformation; however, careful observation further progression, the ductal epithelia proliferate and is warranted even after complete excision of the gland. Pathologic features of lymphoid proliferations of the Clinical Findings salivary glands: lymphoepithelial sialadenitis versus low-grade B-cell lymphoma of the malt type. Fine-needle thelial lesions of the salivary glands and low-grade B-cell lym phoma of mucosa-associated lymphoid tissues relies on evalu aspiration of the parotid mass is helpful. Chronic myoepi this condition often affects the parotid gland and thelial sialadenitis: symptomatology, clinical signs, differential rarely affects the submandibular gland; when it does diagnostics. Necrotizing sialometaplasia is a benign, self-healing inflammatory process mainly involving the minor sali-. Enlargement of gland accompanied by regional appearing, painless ulceration or swelling usually over lymphadenopathy. Histology shows the characteristic General Considerations pseudoepitheliomatous hyperplasia and squamous meta plasia. Care must be taken to avoid confusing the diag Kimura disease is a rare, benign chronic inflammatory nosis with squamous cell carcinoma or mucoepider disease mimicking a tumor in regions of the head and moid carcinoma; the main complication is misdiagnosis. It occurs predominantly in young Asian males in Lesions in necrotizing sialometaplasia are self-healing, their twenties and thirties. In the parotid and submandibular glands, this disease pre Adenomatoid hyperplasia is a rare swelling of the minor sents as painless superficial swellings often accompanied salivary glands that occurs most commonly in the palate. The formation of lym Local trauma, environmental irritation, and chronic phoid follicles and the aggregation of eosinophils in the inflammation are the proposed causes of this condition. Patients present with painless swellings that have been present for an indeterminate length of time. Adenomatoid hyper plasia must be distinguished from minor salivary gland the differential diagnoses of Kimura disease include the tumors. The differential diagnoses include benign and following: (1) angiolymphoid hyperplasia with eosin malignant tumors. Angiolymphoid general architecture of the gland and no evidence of hyperplasia with eosinophilia differs from Kimura disease neoplasia or atypia. Complete excision is the treat in the lack of lymphadenopathy and decreased eosin ment of choice. Rosai-Dorfman disease is an idiopathic benign malignant tumors within the hard palate, the key is to condition characterized by histiocytic proliferation and distinguish malignant tumors from benign adenoma massive lymphadenopathy, including involvement of the toid hyperplasia. Adenomatoid hyperplasia of the Treatment palate mimicking clinically as a salivary gland tumor. General Considerations True cysts of the parotid gland account for 2–5% of Sialadenosis, or sialosis, is a rare, noninflammatory parotid lesions. This condition may Classification also cause degenerative changes to the autonomic inner vation of the glands. Type I cysts—Type I cysts are a duplication anom medical conditions are associated with sialadenosis. The cyst include obesity, alcoholic cirrhosis, diabetes, hyperlipid may be located anteroinferior to the ear lobule. Dermoid cysts—A second type of congenital cyst the treatment of sialadenosis is directed at the underlying occurring in the parotid gland is a dermoid cyst. It contains keratinizing squa General Considerations mous epithelium, sweat glands, and other associated Mucoceles represent dilatations of the minor salivary skin appendages. Excision to prevent recurrent infec gland ducts due to both accumulated mucous secretions tions, with attention to the facial nerve, is the most suc and, often, mucous extravasations into the connective cessful treatment. When a mucocele appears in the Acquired cysts of the parotid gland may result from mouth floor, it is defined as a ranula (related to the other parotid disorders such as tumors, trauma, chronic Latin term for frog). Fine-needle aspiration of cystic pa Mucoceles are thought to arise from either a trauma to rotid gland lesions: an institutional review of 46 cases or a rupture of the minor salivary gland ducts with with histologic correlation. Ranulas, involving the sublingual or submandibu Congenital salivary fistulas and sinus tracts are exceed lar ducts, present as round, fluctuant masses in the ingly rare. They are usually unilateral and may affect vary gland tissue or aberrant gland formation during any age group with no gender preference. These fistula and ranula is a true cyst with an epithelial lining that sinus tracts may form cutaneous openings in the sub occurs intraorally with elevation of the mouth floor. Complete surgical excision cle, beyond the sublingual space, and involves the sub is the recommended treatment. Unlike a simple ranula, a plunging ranula does 10930638] (A case report and discussion of a rare case of a not have an epithelial lining and therefore is classified salivary gland sinus tract. An important differential diagnosis for a mucous reten tion cyst is malignant mucoepidermoid carcinoma. A complete surgical intraoral excision of a mucous retention cyst is curative with few recurrences at the site. The treat ment of a simple ranula consists of either simple excision of the cyst and possible removal of the associated gland, or marsupialization of the cyst wall. In the case of plunging ranulas, treatment requires excision either intraorally or combined with a cervical incision and extirpation of the associated gland. Oral Surg Oral Med Oral Pathol Oral •6 –8 ercent f ri arysalivarytum rs ccurin Radiol Endod. Fine-needle aspiration cytology and imaging aid comfort from dry mouth, patients with xerostomia may in the diagnosis. In addi tion, many systemic conditions can result in dry mouth: Sjögren syndrome, stress, diabetes, chronic infection, and General Considerations irradiation. Xerostomia also results as a side effect of a vari Approximately 80% of salivary gland tumors occur in ety of medications. Of these tumors, approximately 75– the treatment of xerostomia is aimed at the underlying 80% are benign. There is no consistent correlation conditions; symptomatic treatment includes an increased between the rate of tumor growth and whether a tumor intake of fluids, sialagogues, mouthwashes, and artificial is benign or malignant. In addition, there are currently medications pre parotid gland are epithelial tumors. Evaluation, differential diagnosis, and treatment of xerosto approximately 50–60% of submandibular tumors are mia. It is estimated that only dental decay prevention, salivary flow stimulation, the treatment 35% of minor salivary gland tumors are benign, with pleo of chronic oral candidiasis, and the use of salivary substitutes. It is asso Most benign parotid tumors present as slow-growing, pain ciated with a number of medical conditions, including less masses often in the tail of the parotid gland. Fine-needle aspiration of salivary tumors, although not as If medications with drying agents are not effective, sensitive or specific as in other tumors (eg, the thyroid), is surgical treatment is indicated. Recurrence can be attributed to either inadequate mar in determining if a parotid tumor is benign or malignant; gins, or in the case of Warthin tumor, to its multicentricity. Complete surgical excision with uninvolved margins is the recommended treatment of benign tumors of the salivary Differential Diagnosis glands. Usually, a superficial parotidectomy with preserva tion of the facial nerve is adequate unless there is deep lobe the differential diagnoses of benign salivary gland tumors involvement. Parapharyngeal space tumors require resec not only include each other, but must also alert a clinician tion through a form of transcervical approach. Various other benign neo alone is inadequate for tumors of the parotid gland; a com plastic entities involving the salivary glands must be consid plete submandibular excision, with preservation of the ered: papillary ductal adenomas, sebaceous adenomas, marginal mandibular, lingual, and hypoglossal nerves, is ancient schwannomas, congenital epithelial tumors, cavern the treatment of choice. Radiation is not indicated in the ous hemangiomas, and ectopic extraglandular tissues. With the complete removal of the tumor and excision of the affected gland, the prognosis is excellent. There is rare malignant transfor Pleomorphic adenomas, or benign mixed tumors, are mation of Warthin tumor, monomorphic adenomas, and the most common neoplasms of the salivary glands the benign salivary tumors to be described. They represent approximately 60–70% about the incidence of the malignant transformation of of all parotid tumors and 90% of submandibular tumors found in the submandibular gland. These neoplasms affect females more Complete excision ensures an excellent prognosis; how than males and are commonly seen in the third to sixth ever, recurrence occurs if there are positive margins.

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Procedural Step: Tell the hand on your watch and begin patient what you are counting anxiety 9 to 5 cheap 40 mg geodon visa. Ideally depression definition mayo clinic cheap geodon 20 mg visa, the pulse should going to anxiety disorder symptoms buy geodon 40 mg cheap do using be counted for 1 full minute; how terms the patient can ever anxiety upon waking order geodon 80mg on-line, if the pulse is regular it is understand. Reason: this keeps the patient calm and provides the patient with necessary Reason: this will give you the beats per information to give informed consent. Procedural Step: If the rhythm is is lying down, rest the patient’s irregular, then count it for a full forearm across the chest. Reason: this position will help you Reason: It is possible to miss some heart count the patient’s respirations, when beats by not counting an irregular pulse you get to that assessment, without the for a full minute. Procedural Step: Place the pads Reason: Rhythm refers to whether the of your first two fingers directly pulse is regular (doesn’t change) or over the radial artery. A weak, thready pulse may indicate shock, while a full bounding (strong) pulse could indicate high blood pressure. Procedural Step: Wash your hands before pro viding care to another Reason: the fingertips are sensitive and patient. Procedural Step: Record Reason: An abnormality may indicate a the rate, rhythm, and health problem. Procedural Step: Put on artery on one side and then the gloves if there is any other side. The carotid pulse is blood or other body used to check for a pulse when car fluid present. Procedural Step: Use the pads of your findings on the your first two fingers, and place patient’s chart. Procedural Step: Immediately felt, then begin cardiac compres report any abnormalities to your sions. Reason: this is how the carotid pulse Reason: An abnormality may indicate a is measured. There are many other places in the human body where the pulse may be felt (see Figure 12-1). Some of the more common pulse sites are listed below: * the temporal artery: this artery is located on the face in front of the ear. Since this pulse may be difficult to locate, it is generally not used for a pulse rate. The pulse that is Carotid palpated at this location is used primarily for a blood pressure check. Apical * the femoral artery: Found in the right Brachial and left groin, this pulse is often used to check for circulation in the legs. Radial the popliteal artery: this pulse is locat Femoral * ed behind the knee and, like the femoral artery, may be used to check for circulation in the legs. Popliteal * the dorsalis pedis: this pulse is located on top of the foot and is used primarily to check for circulation in the feet. To allow air to enter and exit the body, the ribs, chest muscles, and diaphragm move spontaneously in response to messages from the brain. Respiration provides the cells of the body with the energy required to perform their specific functions. This energy is obtained when food is metabolized (chemi cally altered) at the cellular level. When more energy is required by the muscle cells, such as during exercise, the rate of res piration increases. The normal rate of breathing can also be altered by excitement, drugs, and a number of disease processes. If breathing patterns are altered and the body is deprived of oxy gen, serious damage can occur to the vital organs. Therefore, to prevent a patient from inadvertently altering the true rate, try to conceal the fact that respirations are being counted. For example, respiration can be measured without a person’s knowledge by observing and counting breaths after taking the pulse. In addition to measuring respirations, it is also important to observe the pat terns of the respirations. Respiratory patterns are defined as follows: * Abdominal: respirations using primarily the abdominal muscles while the chest is mostly still * Apnea: the cessation of breathing; may be temporary or permanent * Bradypnea: breathing that is abnormally slow * Cheyne-Stokes respiration: a grossly irregular breathing pattern composed of intermittent periods of apnea lasting from 10 to 60 seconds followed by periods of fast and slow breathing * Decreased: very little air movement in the lungs * Dyspnea: difficult or painful breathing; shortness of breath * Hyperpnea or tachypnea: breathing that is faster or deeper than that which is produced during normal activity. Also known as hyperventilation * Kussmaul’s breathing: deep, gasping respirations; air hunger * Labored breathing: difficult breathing that uses shoulder muscles, neck muscles, and abdominal muscles the volume of air that is exchanged with each respiration can be determined by placing one hand on the patient’s chest and feeling the chest rise and fall. Patients who are having difficulty breathing usually will sit up and lean for ward in an effort to breathe easier. A person who is experiencing these symptoms must be seen immediately by the physician. Procedural Step: Count the rate for ration after obtaining the patient’s 30 seconds and multiply that num pulse. This final value will be the number of breaths per minute Reason: To prevent the patient from. Procedural Step: Wash Reason: Respiration is documented as your hands if possible. Procedural Step: If in an inpatient Reason: Universal setting, identify the patient or client Precaution. Procedural Step: If you measured Reason: Difficulty in breathing indi the radial pulse, keep the patient’s cates a health problem. Reason: Having the patient’s arm in this position will make it easier to detect the rise and fall of the patient’s chest. It the pressure exerted by the reflects the blood pressure when the heart contracts. The diastolic pressure reflects circulating blood against the blood pressure when the heart is at rest and is recorded as the bottom number the w alls of the arteries. For example, if a person has a systolic pressure of 120 and a diastolic pressure of 80, the blood pressure would be recorded as 120/80. The blood pressure is affected by a number of factors, such as the amount of blood and other fluids that are present in the body, the condition of the arteries, and the force of the heartbeat. Age, exercise, obesity, food, pain, stress, stimulants, steroids, and some medications can cause the blood pressure to increase; whereas weight loss, fasting, depression, and blood loss can lower the blood pressure. For example, pre menopausal women tend to have blood pressure measurements that are approxi mately 10 mm Hg lower than men. Similarly, a person’s chances of having low blood pressure or high blood pressure increase if one or both parents suffered from the condition. Although blood pressure increases during exercise, an exercise program helps to lower blood pressure overall. The heart beats (or works) as fast as it needs to in order to get blood, oxygen, and nutrients to the entire body. A strong, healthy heart that pumps efficiently allows blood to circulate throughout the body at a lower pressure than a heart that is in poor condition and has to work harder to perform the same function. This is why trained athletes tend to have lower blood pressure than average people. Physical training increases the heart’s pumping efficiency and improves the health of the peripheral vascular system. The blood pressure measurement is a source of valuable information for the health care provider. Specific abnormalities in blood pressure are indications of var ious health problems. If a positive result is obtained, meaning that the blood pres sure is either too high or too low, experienced medical assistance should be sought immediately. Low blood pressure (hypotension) may indicate shock, dehydration, or internal injury. Possible causes might be heart failure, heat exhaustion or heatstroke, diabetes, or liver disease. High blood pressure (hypertension) can be a dangerous precursor to cardiac problems and strokes. High blood pressure can exert extreme pressure on blood vessels, including the vascular regions of the brain. Possible causes might be obesity, lack of physical activity, too much salt in diet, and stress. To measure a person’s blood pressure, a sphygmomanometer (blood pressure cuff) and a stethoscope will be needed.

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Adrenal antibodies detect asymptomatic auto-immune adrenal insufficiency in young women with spontaneous premature ovarian failure anxiety 100 order geodon 40mg on line. Chen S mood disorder flashcards order geodon 20mg on line, Sawicka J mood disorder in children buy geodon canada, Betterle C anxiety 5 year old generic geodon 40 mg with visa, Powell M, Prentice L, Volpato M, Rees Smith B, Furmaniak J. Heterozygous fragile X female: historical, physical, cognitive, and cytogenetic features. Anti-Mullerian hormone follow-up in young women treated by chemotherapy for lymphoma: preliminary results. Progressive decline of residual follicle pool after clinical diagnosis of autoimmune ovarian insufficiency. Falorni A, Laureti S, Candeloro P, Perrino S, Coronella C, Bizzarro A, Bellastella A, Santeusanio F, De Bellis A. Steroid-cell autoantibodies are preferentially expressed in women with premature ovarian failure who have adrenal autoimmunity. Prevalence of thyroid autoimmunity in sporadic idiopathic hypoparathyroidism in comparison to type 1 diabetes and premature ovarian failure. Occurrence of gonadoblastoma in females with Turner syndrome and Y chromosome material: a population study. Maternal thyroid deficiency during pregnancy and subsequent neuropsychological development of the child. Fluorescence in situ hybridisation analysis and ovarian histology of women with Turner syndrome presenting with Y-chromosomal material: a correlation between oral epithelial cells, lymphocytes and ovarian tissue. Smoking, body mass index, socioeconomic status and the menopausal transition in a British national cohort. Linkage analysis in blepharophimosis-ptosis syndrome confirms localisation to 3q21-24. Kalantari H, Madani T, Zari Moradi S, Mansouri Z, Almadani N, Gourabi H, Mohseni Meybodi A. Circulating auto-antibodies against the zona pellucida and thyroid microsomal antigen in women with premature ovarian failure. Cyclophosphamide-induced ovarian failure and its therapeutic significance in patients with breast cancer. Assessment of ovarian reserve in adult childhood cancer survivors using anti-Mullerian hormone. Detection of autoantibodies directed against both the unoccupied luteinizing hormone/human chorionic gonadotropin receptor and the hormone-receptor complex of bovine corpus luteum. A 10-year follow up of reproductive function in women treated for childhood cancer. A genome-wide association study of early menopause and the combined impact of identified variants. The impact of excision of ovarian endometrioma on ovarian reserve: a systematic review and meta-analysis. Ovarian function after removal of an entire ovary for cryopreservation of pieces of cortex prior to gonadotoxic treatment: a follow-up study. Obstetrical and gynecological complications in fragile X carriers: a multicenter study. The effect of hysterectomy on the age at ovarian failure: identification of a subgroup of women with premature loss of ovarian function and literature review. Genetic and phenotypic heterogeneity in ovarian failure: overview of selected candidate genes. Surgical excision of endometriomas and ovarian reserve: a systematic review on serum antimullerian hormone level modifications. Association between fragile X premutation and premature ovarian failure: a case-control study and meta-analysis. Predicting age of ovarian failure after radiation to a field that includes the ovaries. Clinical evidence Family association between menopausal age of mothers and their daughters has not yet been confirmed in well designed studies. The study by Torgerson et al reports that the odds ratio of a woman having an early (<45 years) or premature (<40 years) menopause if her mother had experienced an early menopause was 6. There are numerous potential biases in such observational studies, particularly ‘recall’ bias. Recently, the study of Bentzen evaluated whether the ovarian reserve in a woman is associated with her mother’s age at menopause. The pattern of inheritance was compatible with either X-linked or autosomal dominant sex-limited, paternal and maternal, transmission. All other characteristics, such as parity, bone mineral density, and serum follicle-stimulating hormone and lipid levels were similar, as was the incidence of autoimmunity and cytogenetic abnormalities (Janse, et al. Fragile-X premutation carriers Reproductive and diagnostic options available to fragile-X premutation carriers (oocyte or sperm donation, pre implantation and prenatal diagnosis, adoption, family history of mental retardation etc. The prevalence of women who are carriers of fragile-X syndrome is estimated to be about 1 in 157 in a population without history of mental retardation, developmental abnormalities or autism and 1 in 128 when a positive history exists (Berkenstadt, et al. Markers of ovarian reserve might be useful, although the predictive value of these markers needs to be established. It may be appropriate for these women not to postpone pregnancy, although the decision to start a family is multifactorial. Oocyte freezing may be an option for fertility preservation but there are legal restrictions in some countries. Maternal menopause as a predictor of anti-Mullerian hormone level and antral follicle count in daughters during reproductive age. Preconceptional and prenatal screening for fragile X syndrome: experience with 40,000 tests. Female sex preponderance for idiopathic familial premature ovarian failure suggests an X chromosome defect: opinion. Similar phenotype characteristics comparing familial and sporadic premature ovarian failure. Genetic counseling for fragile x syndrome: updated recommendations of the national society of genetic counselors. Linkage analysis of extremely discordant and concordant sibling pairs identifies quantitative trait loci influencing variation in human menopausal age. Familial idiopathic premature ovarian failure: an overrated and underestimated genetic disease? This reported very long-term follow-up (38 years) of a cohort of women who had undergone oophorectomy (bilateral n=1097, or unilateral n=1293). Each subject was matched by age to a referent woman from the same population (n=2390). Outcomes were obtained by direct or proxy interviews, medical records in a records-linkage system, and death certificates. The main causes of premature death were cardiovascular disease, osteoporosis and fractures; this series also reported cognitive impairment, dementia, parkinsonism, reduced sexual function and psychological wellbeing (Shuster, et al. The Women’s Health Initiative observational study of 25000 women did not detect increased mortality, but had less than 8 years’ follow-up (Jacoby, et al. In a Dutch cohort of 12000 women over 17 years, life expectancy was reduced by 2 years in women who had experienced menopause before the age of 40 (Ossewaarde, et al. Jacobsen and colleagues studied a cohort of 19309 Norwegian women over 29 years of follow-up; they showed an inverse relationship between age at natural menopause and cardiovascular mortality (Jacobsen, et al. Both these analyses found that the differential risk of early menopause reduced over time, as cardiovascular risk was affected by biological ageing. The risk may be worsened by contributory factors such as obesity, and may be ameliorated by estrogen replacement therapy, but the quality of evidence is poor. A review of the literature up to 1999 showed marked differences in pregnancy rate according to the design of the study, with 4. A range of treatments including estrogens, gonadotrophins, and corticosteroids have been explored as potential treatments to increase the chance of pregnancy. Meta-analysis was not possible due to heterogeneities in design, patient selection and intervention. Follicle development to >10mm diameter was detected in most women, and overall 46% of women ovulated at least once with 2 women conceiving during the trial, but there was no apparent effect of estradiol treatment.

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The stimulation of the central nervous system by marrubium also stimulates the stomach to depression symptoms veterans buy cheapest geodon secrete digestive juices depression symptoms thoughts of death best order geodon, helping the stomach to depression after test e buy geodon uk digest food depression quest endings order geodon without a prescription. The reaction also stimulates the flow of bile from the gall bladder, which eases flatulence by changing the chemical composition of the contents of the large intestine. The herb will also help rid the body of excess water weight and the feeling of bloating. Some studies claim that Horehound helps to stop the high and low blood-sugar reactions after eating high-carbohydrate meals and snacks. Horehound is said to have a relaxing effect on heart tissue and is used by some herbalists as a circulatory tonic to help lower blood pressure. The marrubium may steady the heartbeat in low doses, but a physician must be consulted before using it in this situation, and larger doses may cause abnormal heartbeat. Dosages: Take two (2) capsules, one (1) to two (2) times each day with water at mealtimes. Precautions: Horehound is not advisable for pregnant or nursing women, younger children or adults over sixty-five years of age. Those with heart problems or stomach ulcers should not use Horehound without consulting with a physician. Women with menstrual problems should avoid Horehound, as it may increase menstrual flow. Juniper Berry promotes urine flow and helps to clear the kidneys, bladder and prostate of toxic wastes, while at the same time helping to combat urinary infections in both men and women. Plant Description: the common Juniper is a bitter, aromatic, prickly bush or tree that thrives in most soils, tolerating both acid and alkaline soils and dry and wet conditions, in sun or partial shade and often in exposed positions. Juniper encompasses many species and is usually a low-growing, ornamental shrub that rises to a height of six or eight feet, but it may also grow as a tree to a height of thirty feet. It is a slow-growing, coniferous evergreen with silvery green, spiny needles, flowers and berries, which take up to three years to ripen. Both male and female plants are necessary for berry production, and Juniper is cultivated for the slightly resinous, sweet-flavored berries that are borne only on the female bush. Junipers are widely distributed throughout the Northern Hemisphere, and the berries are used for medicinal and commercial purposes. It is said that the flavor of the berries is stronger the farther south the plant is grown, and Juniper is a rare and endangered species in some states of the United States. In the middle ages, the scent of Juniper was believed to ward off plague, contagious diseases and leprosy. For hundreds of years, Juniper Berry has been (and still is) an herbal remedy for urinary tract problems, including urine retention and gallstones and is an old folk remedy for gout. In the 1500s, a Dutch pharmacist used Juniper Berries to create a new, inexpensive diuretic drink that he called gin, which was not only used for medicinal purposes, but its delightful juniper-flavor (and other obvious enjoyments) became a very popular beverage. In North America, the Native Americans believed that Juniper would cleanse and heal the body and keep away infection, and different tribes used it to treat a wide range of illnesses from kidney complaints to stomachaches, colds and syphilis. The Navajos used it for flu, and because it was an excellent survival food, many of the tribes used it to fight off starvation by drying and grinding the berries into cakes. Roasted Juniper Berries have been ground and used as a substitute for coffee, and the berries are frequently used as a spice for pickles, sauerkraut, game, pork and in patés. The word gin is a shortened form of the Dutch, genever, which was originally derived from the Latin, juniperus. Some of the constituents in Juniper include the volatile oils, camphene, cineole, myrcene, alpha and beta-pinene and terpinene (the active ingredients), as well as resin, sugar, gum, lignin, wax, salines, beta-carotene, betulin, borneol, catechin, glycolic acid, limonene, linalool, menthol, rutin, tannins, calcium, chromium, iron (and many other valuable minerals), B-vitamins and vitamin C. Medical Uses: Juniper Berry is an effective diuretic and antiseptic that not only promotes the flow of urine, but also treats infection of the urinary tract at the same time. As a diuretic, the herb stimulates the kidneys and bladder to get rid of retained and excess water (possibly also helping to treat obesity). Juniper increases the filtering of waste products by the kidneys and helps to expel prostate sediment and gallstones. The herb helps to prevent the crystallization of uric acid in the kidneys, retaining it in a solution and passing it in the urine; this is of great benefit to those suffering from gout (a condition marked by painful inflammation of the joints caused by deposits of uric acid). As an antiseptic and further aiding urinary and prostate health, Juniper Berry is helpful in combating bacteria, including bladder and urinary infections, such as cystitis, urethritis, prostatitis, vaginitis and inflamed kidneys, etc. The active volatile oil content helps to eliminate gas and expel intestinal flatulence and assists in the digestion of gassy foods like cabbage, etc. The herb has been used to ease stomach cramps, colic and indigestion; and in small doses, it stimulates the appetite. The anti-inflammatory properties of Juniper Berry are thought to ease the pain of rheumatism, arthritis, sore muscles and gout. Juniper Berry has traditionally shown excellent results in the treatment for lung disorders as an effective expectorant and decongestant. It is highly recommended in catarrhal conditions and has helped to ease breathing and treat bronchial asthma, emphysema, sinusitis, head colds, flu and general congestion. Juniper Berry is considered a purifier of the blood and overall system cleanser, and by removing acid and toxic wastes from the body, the herb helps to reduce overall susceptibility to disease. Discontinue use for at least two (2) weeks before beginning another four (4) week regimen. Precautions: Pregnant women should not use Juniper Berry, because it stimulates the uterus and may cause abortion. If kidney disease is suspected, Juniper berries may over-stimulate the kidneys and adrenals and should be avoided. Juniper should not be used in cases of heavy menstrual flow, and the herb may interfere with the absorption of iron and other minerals. Plant Description: Goldenseal is a hardy, herbaceous, North American woodland perennial that grows under two feet in height with a thick, yellow root and a single, erect stem producing leaves and a flower. From the flower, a single, red, inedible fruit emerges, but it is the roots, dug from three-year-old plants, that are used in herbal medicine. Few wildflowers were as important to the American Indians as the versatile Goldenseal. The roots supplied the Cherokee and Iroquois with a brilliant yellow dye for their weapons and clothing, a paint for their faces and medicinal remedies for indigestion, inflamed eyes, mouth ulcers, cancer, tuberculosis and edema. It may not have been effective for all those ailments, but its efficacy as an antiseptic and in stopping bleeding was well noted. Pioneers quickly adopted Goldenseal, and it became a mainstay of American folk medicine, frequently sold as an ingredient in patent medicines in traveling medicine shows. The root is an ingredient in many herbal remedies, as it not only possesses medicinal virtues of its own, but it also appears to enhance the potency of other herbs. Goldenseal has also found its way into modern medicine as a treatment for inflamed eyes, and some drug manufacturers include an alkaloid extracted from the root in their eye drops. Used at the first sign of a cold, flu or sore throat, it may stop further symptoms from developing. The berberine content in Goldenseal possesses strong antibiotic and antiseptic activity against a wide variety of bacteria and fungi, combating vaginal inflammations, sore throat, and bladder and intestinal infections. As an antibacterial, Goldenseal is thought to further fight skin infections and skin ulcers (when used topically and internally) and is an antiseptic mouthwash (fighting sore throat). In treating periodontal disease, Goldenseal destroys the bacteria that cause the disease and relieves inflamed gums. Goldenseal is an immensely popular herb that has long been used as an immune enhancer and a body cleanser that promotes healthy glandular functions. In laboratory studies, the berberine in Goldenseal was thought to increase blood flow to the spleen and stimulate the activity of macrophages, blood cells that are an important part of the immune system. In regulating healthy glands, the herb is said to be of overall benefit to the liver, pancreas, spleen, thyroid and lymphatic system. Because Goldenseal is thought to increase the flow of digestive enzymes and is considered an effective herb for improving overall digestion and easing disorders of the digestive tract, including heartburn (particularly when it is associated with emotional tension), inflamed peptic ulcers, constipation and indigestion. Several early Native American tribes also used Goldenseal extensively for treating digestive problems. Goldenseal, sometimes called "King of the Mucous Membranes" is thought to have a soothing effect on inflamed mucous membranes and, as such, has been thought to help the respiratory system (by easing congestion), chronic inflammation of the colon, rectum and hemorrhoids.

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