Pathophysiology Hypopituitarism may be primary due to destruction of Investigations the anterior pituitary gland or secondary to a deciency r A mass within the sella turcica (pituitary fossa) may of hypothalamic stimulation (or excess of inhibition) best kamagra 100mg impotence webmd. Microadenomas take up less Symptoms and signs are related to the deciency of hor- contrast and macroadenomas take up more contrast buy generic kamagra 50mg on line erectile dysfunction doctor dallas. General symptoms of panhy- Ifapituitarymassisidentied,hormoneassaysshould popituitarism include dry, pale skin with sparse body beundertakentoidentifyfunctioningadenomas. On examination postural hypotension and brady- ing also helps identify any associated hypopituitarism, cardia may be found with decreased muscle power and with stimulation or suppression testing where appro- delayed deep tendonreexes. Management Investigations r Forprolactinomas medical treatment with a All functions of the pituitary should be assessed using dopaminergic drug is the treatment of choice (see sec- basal levels, stimulation tests and suppression testing tion on Hyperprolactinaemia, page 424). Progestagen is used to induce bleeding and Type Causes prevent endometrial hyperplasia. In ado- Pituitary apoplexy (haemorrhagic infarction of lescent males testosterone induces epiphyseal closure, pituitary tumour) so replacement therapy should be delayed as long as Inltration Sarcoidosis, haemochromatosis, histiocytosis X possible. Treatment of associated infertility requires Injury Head trauma complex hormone replacement to stimulate ovula- Immunologic Organ-specic autoimmune disease Iatrogenic Surgery, irradiation tion/spermatogenesis. Pituitary haemorrhage causing death of the r Gonadotrophin deciency in women may be treated lactotrophs results in failure of lactation (Sheehans with cyclical oestrogen replacement to maintain syndrome). The zona deciency glomerulosa and aldosterone secretion usually remains relatively intact, so Addisonian crisis is rare. Clinical features Hyperprolactinaemia In women hyperprolactinaemia causes primary or sec- ondary amenorrhoea, oligomenorrhoea with anovula- Denition tion or infertility. Hyperprolactinaemia is a raised serum prolactin level Oestrogen deciency can cause vaginal dryness and causing galactorrhoea and gondadal dysfunction. In men galactor- Incidence rhoea occurs occasionally, but the most common early Most common endocrine abnormality of the hypothala- features are decreased libido and sexual dysfunction, micpituitary axis. Complications Acromegaly Headache, visual impairment and hypopituitarism due to local effects of the adenoma. Sex Management M = F Prolactinomasaretreatedwithdopaminergicdrugssuch as cabergoline. The minority of tumours that do not Aetiology respond to medical treatment and hyperprolactinaemia r 95% of cases result from growth-hormone-secreting due to stalk compression are treated surgically. Sleep, exercise, stress Hypoglycaemia Postprandial hyperglycaemia/ free fatty acids Clinical features Glucocorticoids (hence short The course of the disease is slowly progressive. Soft tissue stature in children on overgrowth is the characteristic early feature, causing long-term oral steroids) enlargement of hands and feet, coarse facial features. Acne, sebaceous r Accompanying hypopituitarism is treated as appro- cysts and skin tags are common. Acanthosis nigricans priate with corticosteroids, thyroxine and gonadal of the axillae and neck may occur. Acromegaly causes increased morbidity and r Organomegaly: Thyroid and salivary gland enlarge- mortality mainly due to diabetes and cardiovascular dis- ment, hepatomegaly. Thyroid axis Macroscopy/microscopy The tumour is solid and trabecular, often 1 cm in diame- terbythe time of diagnosis. Oestrogens conversely increase the sensitivity suppress growth hormone production. Large tumours re-absorption of colloid by the cells and the production may be resected by transfrontal craniotomy. The majority of T is converted from the less active 3 r Octreotide or lanreotide, a long-acting somatostatin T4 by peripheral tissues. Disorders of the thyroid axis are analogue, may be used prior to surgery, following in- shown in Table 11. Fur- Age ther classication is based on whether the patient is hy- Increases with age. Irregularmultinodularenlargementofthethyroidgland, which may be hyperthyroid (toxic) or is commonly eu- thyroid (nontoxic). Clinical features Patients may present for cosmetic reasons, with thyro- Incidence/prevalence toxic symptoms, or because of complications. Multin- 25% of cases of thyrotoxicosis are due to multinodular odular goitre can present with a particularly promi- goitre. Causes include the following: r Benign follicular adenoma: Single lesions with well- Macroscopy/microscopy developed brous capsules. Nodules may be cystic, haemorrhagic and - hormones, which may result in hyperthyroidism. Enlargement of the gland can cause tracheal compres- r Thyroid cyst (1525%): These may be simple cysts sion leading to shortness of breath and choking. About more common with retrosternal goitre, when the nod- 15% are necrotic papillary tumours. Toxic multinodular goitre has a particularly high incidence of cardiac arrhythmias and other cardiac complications. Clinical features Patients may present with a palpable lump or may be diagnosed on incidental imaging. Ultrasound scanning of the thyroid may be useful r History of neck irradiation exposure. Cystsand r Malignancy is more common in children and patients nodules may be aspirated by ne needle aspiration for over 60 years. Investigations Management r Thyroid function tests are used to determine thyroid Subtotal thyroidectomy may be required for cosmetic status. Isotope scans may also be used to demon- reasons or due to compression symptoms or thyrotoxi- strate either a cold nodule, a hyperactive gland (toxic cosis. Patients must be medically treated and euthyroid multinodular goitre) or a cold gland containing a before surgery. A solitary mass within the thyroid gland that may be r Fine needle aspiration for cytology is used to differen- solid or cystic. Incidence Management 5% of population have a palpable solitary thyroid nod- Benign lesions only require treatment if they cause hy- ule. Up to 50% of population have a solitary nodule at perthyroidism or for cosmetic reasons. Weight loss with increased or normal appetite Graves disease is an autoimmune thyroid disease. Proptosis (exophthalmos) with lid retraction, stare and Sex lid lag are prominent features, and in its most severe F > M form it may cause sight loss due to damage to the optic nerve. Thyroid dermopathy (also called pretibial myxoedema) r Fifteen per cent of patients have a close relative with is a thickening or orange-peel appearance of the skin, Graves, and 50% of relatives have circulating thyroid most often affecting the lower leg. Microscopy The thyroid epithelial cells are increased in number and size with large nuclei. This causes a generalised, uncontrolled stimulation lymphocyte inltration may also be seen.

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Penile venous surgery in impotence: results in Lane B Z buy 50 mg kamagra fast delivery erectile dysfunction at 25, Ausmundson S J purchase kamagra with amex erectile dysfunction blood flow, Butler R S et al. Progress in Retinal & Eye Research dose regimens of apomorphine, an open-label study. Trans Am Evaluation of transurethal alprostadil for safety and efficacy in Ophthalmol Soc 1999;97(pp 115-128):-128. Correcting impotence in the male dialysis patient: experience with testosterone replacement and vacuum Kromann-Andersen B. Physician-rated patient preference and patient- and partner-rated Labbate Lawrence A, Grimes Jamie B, Hines Alan et al. The role of androgen deprivation therapy combined Lowy M, Collins S, Bloch M et al. Urology questionnaire correlates: change in erection quality 2002;60(3:Suppl 1):Suppl-44. Non- prosthetic surgery in the treatment of erectile Lewis R L, Sadovsky R, Eardley I et al. Long-term experience of self-injection therapy with prostaglandin Li M K, Lim P H, Wong M Y et al. Scand J Urol Nephrol the treatment of erectile dysfunction: results of a multicentre 1996;30(5):395-397. East Afr Med J of sildenafil citrate (Viagra) in a multi-racial population in 2000;77(2):76-79. Nocturnal penile tumescence activity unchanged after long-term Livi U, Faggian G, Sorbara C et al. Br J Urol the treatment of sexual impotence after heart transplantation: 2001;165(3):830-832. Treatment of erectile dysfunction after kidney transplantation with Lombardo T, Giammusso B, Frontini V et al. Br J affected by erectile dysfunction treated with transurethral Urol 1998;159(6):1927-1930. A goal-oriented, cost- Relationship among serum testosterone, sexual effective approach to the diagnosis and treatment of 24 male function, and response to treatment in men receiving erectile dysfunction. The impact of marital satisfaction and psychological counselling on the Mark S D, Keane T E, Vandemark R M et al. Int J Impot Res Impotence following pelvic fracture urethral injury: 1998;10(2):83-87. Vardenafil (Levitra) for erectile dysfunction: a systematic review and meta-analysis of clinical trial reports. Efficacy and safety of daily tadalafil in men with erectile dysfunction previously unresponsive Martin-Morales A, Moncada Iribarren I, Cruz Navarro N et al. Br J Sex Med 2004;1(3):292 [Efficacy and safety of two dosing regimens with Tadalafil in 300. Prognostic factors for response to sildenafil in patients with erectile dysfunction. Prospective comparative study with intracavernous sodium nitroprusside and McMahon C G. A pilot study of the role of prostaglandin E1 in patients with erectile dysfunction. Efficacy, safety and patient acceptance of sildenafil citrate as treatment McClure R D. Hypogonadal impotence intracorporeal injection nonresponse with sildenafil treated by transdermal testosterone. Vardenafil Therapy on the Clinical Progression of Benign Prostatic improved erectile function in a "real-life" broad Hyperplasia. Intracavernous injection probe of vasoactive Mittleman M A, Glasser D B, Orazem J. Clinical trials preparations in the diagnosis of erectile dysfunctions in patients of sildenafil citrate (Viagra) demonstrate no increase with diabetes mellitus. Azerbaidzhanskii Meditsinskii Zhurnal in risk of myocardial infarction and cardiovascular 2002;(pp 17-19):-19. Efficacy of sildenafil citrate at 12 hours after dosing: re-exploring Merrick G S, Butler W M, Lief J H et al. Partner responses to sildenafil citrate (Viagra) treatment of erectile dysfunction. Does Testosterone Have a Role in Erectile switching from prostaglandin E(1) intracavernosal Function?. Undetectable prostate specific antigen at 6-12 months: a new marker for early Montorsi F, Guazzoni G, Barbieri L et al. The effect success in hormonally treated patients after prostate of intracorporeal injection plus genital and audiovisual brachytherapy. An open- vasoactive pharmacotherapy: the impact of a new self-injection label, uncontrolled dose-optimization study of device. Clinical reliability of multi-drug intracavernous vasoactive Mulhall J P, Guhring P, Parker M et al. Acta Diabetol Lat the impact of sildenafil citrate on lower urinary tract 1994;31(1):1-5. Vardenafil provides reliable efficacy over time in men with erectile Mulhall J P, Jahoda A E, Ahmed A et al. Vardenafil for the treatment of erectile dysfunction: A critical review of the Mulhall J P, Jahoda A, Aviv N et al. Eur Urol sildenafil citrate on sexual satisfaction profiles in men 2005;47(5):612-621. Long-term safety and tolerability of tadalafil in the treatment of erectile Mulhall J P, Land S, Parker M et al. Br J Sex Med interventions using published randomised trials: systematic 2005;2(4):532-542. Erection hardness: a unifying factor for defining response in the Moore R A, Edwards J E, McQuay H J. Lower self-reported supplementation for hypogonadal impotence: assessment of depression in patients with erectile dysfunction after biochemical measures and therapeutic outcomes. Br J of partnership in patients with erectile dysfunction Urol 1994;152(4):1115-1118. Efficacy and safety of tadalafil across ethnic groups and various risk factors Murat Basar M, Tekdogan U Y, Yilmaz E et al. The in men with erectile dysfunction: Use of a novel noninferiority efficacy of sildenafil in different etiologies of erectile study design. Efficacy of sildenafil as prostaglandin E1 is effective in patients with erectile the first-step therapeutic tool for Japanese patients dysfunction not responding to phosphodiseterase 5 inhibitors. Role of sildenafil septicemia following intracavernous injection therapy for citrate in treatment of erectile dysfunction after radical erectile dysfunction in diabetes. Early combination therapy: intracavernosal injections and sildenafil following Ohebshalom M, Mulhall J P. Transdermal and topical radical prostatectomy increases sexual activity and the return of pharmacotherapy for male sexual dysfunction.

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Instruments used for quantitative radiation measurements must be calibrated for the radiation measured purchase kamagra 50 mg with amex causes of erectile dysfunction in 30s. The instruments should be available for use at all times when radioactive material is in use discount kamagra 50mg on line erectile dysfunction 60784. The licensee should possess survey instruments sufficiently sensitive to measure the type and energy of radiation used, including survey instruments used to locate low energy or low activity seeds (e. Usually, it is not necessary for a licensee to possess a survey meter solely for use during sealed source diagnostic procedures, since it is not expected that a survey be conducted each time such a procedure is performed. In these cases, it is acceptable for the meter to be available on short notice in the event of an accident or malfunction that could reduce the shielding of the sealed source(s). Surveys may be required to verify source integrity of the diagnostic sealed source and to ensure that dose rates in unrestricted areas and public and occupational doses are within regulatory limits. Provide one or both of the following: A statement that: "Radiation monitoring instruments will be calibrated by a person qualified to perform survey meter calibrations. Furthermore, licensees may rely on the providers dose label for the measurement of the dosage and decay-correct the dosage to the time of administration. Equipment used to measure dosages must be calibrated in accordance with nationally recognized standards (e. The measurement equipment may be a well ion chamber, a liquid scintillation counter, etc. For other than unit dosages, the activity must be determined by direct measurement, by a combination of radioactivity measurement and mathematical calculation, or by a combination of volumetric measurement and mathematical calculation. Licensees must assay patient dosages in the same type of vial and geometry as used to determine the correct dose calibrator settings. Using different vials or syringes may result in measurement errors due, for example, to the variation of Bremsstrahlung created by interaction between beta particles and the differing dosage containers. Licensees are reminded that beta emitters should be shielded using a low atomic-numbered material to minimize the production of Bremsstrahlung. When a high activity source is involved, consideration should be given to adding an outer shield made from material with a high atomic number to attenuate Bremsstrahlung. To perform these measurements, the applicant must possess appropriately calibrated dosimetry equipment. Except for manual brachytherapy sources and low dose-rate remote afterloader sources where the source output or activity is determined by the manufacturer, the applicant must possess a calibrated dosimetry system (e. The licensee must maintain records of calibrations of dosimetry equipment for the duration of the license. The calibration procedures should address, in part, the method used to determine the exposure rate (or activity) under specific criteria (i. For sealed sources used in therapy, and in particular, for new types of use, licensees should select dosimetry equipment that will accurately measure the output or the activity of the source. Other Equipment and Facilities The applicant must describe additional facilities and equipment for the radiopharmaceutical therapy program to safely receive, use, store, and dispose of radioactive material. The applicant should focus on facilities to be used for radioactive drug therapy administration and patient accommodations (i. I-131 sodium iodide is the most widely used source of radiopharmaceutical therapy. If the radionuclide is administered in volatile liquid form, it is important to place the patient dosage in a closed environment (i. Also note there are hazards associated with volatile iodine in pill form; applicants should consider this in establishing their radiological controls. If a shielded viewing window will be used, the thickness, density, and type of material used should 30 be specified. If a closed-circuit television system (or some other electronic system) will be used to view the patient, the backup system or procedure to be used in case the electronic system malfunctions should be specified, or the applicant must commit to suspending all treatments until the electronic system is repaired and functioning again. The communication system should allow the patient to communicate with the unit operator in the event of medical difficulties. An open microphone system can be used to allow communication without requiring a patient to move to activate controls. The interlock system must cause the source(s) to be shielded if the door to the treatment room is opened when the source is exposed. The interlock system must also prevent the operator from initiating a treatment cycle unless the treatment room entrance door is closed. Further, the interlock must be wired so that the source(s) cannot be exposed after interlock interruption until the treatment room door is closed and the source(s) on-off control is reset at the console. This would constitute a circuit that generates the audible alarm when either the source retracted and radiation present or appropriate internal error condition(s) exist; o The source safe and radiation present signal should also be self-testing. If a source not safe input is received without a corresponding radiation present signal, the circuit should generate an interlock/warning circuit failure signal that will cause the source to retract. This circuit must be manually reset to continue treatment; o The audible alarm should be sufficiently loud to be clearly heard by the facilitys responsible device/patient monitoring staff at all times; and o No provisions for bypassing this alarm circuit or for permanently silencing the alarm should be made to the circuit as long as the room radiation monitor is indicating the presence of radiation. If any circuitry is provided to mute the audible alarm, such circuitry should not mute the alarm for a period of more than 1 minute. Controls that disable this alarm circuit or provide for silencing the alarm for periods in excess of one minute should be prohibited. If the alarm circuit is inoperative for any reason, licensees should prohibit further treatment of patients with the device until the circuit has been repaired and tested. If the alarm circuit fails during the course of a patient treatment, the treatment in progress may continue as long as continuous surveillance of the device is provided during each treatment cycle or fraction. Applicants may submit information on alternatives to fixed shielding as part of their facility description. This information must demonstrate that the shielding will remain in place during the course of patient treatment. Item 10: Radiation Protection Program Each licensee must develop, document, and implement a radiation protection program commensurate with the scope of the licensed activity. The licensee is also responsible for the conduct of all individuals handling licensed material. Annual Audit of the Radiation Safety Program All licensees must annually review the content and implementation of the radiation protection program. The applicant should develop and implement procedures for the required review or audit of the radiation protection programs content and implementation. Reviews or audits of the content and implementation of the radiation protection program must be conducted at least annually. As part of their review programs, licensees should consider performing unannounced audits of authorized and supervised users to determine if, for example, Operating and Emergency Procedures are available and are being followed. It is essential that once identified, violations and radiation safety concerns are corrected comprehensively and in a timely manner. The following three-step corrective action process has proven effective: Conduct a complete and thorough review of the circumstances that led to the violation.

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Homozygous combined generic kamagra 50 mg with visa erectile dysfunction doctors in texas, and are in- r Thalassaemia major and symptomatic thalassaemia compatible with life purchase kamagra 100mg mastercard erectile dysfunction injection medication. This Clinical features aims to suppress ineffective erythropoesis and pre- r Thalassaemia minor/trait is asymptomatic with a vent bony deformity, while allowing normal growth mild hypochromic microcytic anaemia. Iron overload is prevented by the r Thalassaemia intermedia causes symptomatic mod- use of the chelating agent desferrioxamine, which is erate anaemia with splenomegaly. Splenectomy should be considered in patients ure to thrive and recurrent infections. Bone the production of fetal haemoglobin ceases and the marrow transplantation has been used successfully patient becomes symptomatic with a severe anae- in young patients with severe -thalassaemia major. Extramedullary haemopoesis causes hepato- Other treatments under investigation include gene splenomegaly, maxillary overgrowth and trabecula- therapy and drugs to maintain the production of fetal tion on bone X-rays. Random X inacti- vation (Lyonisation) means that some heterozygous fe- Glucose-6-phosphate dehydrogenase males may also have symptoms. Clinical features With such a wide variety of genes and enzymatic activity, Aetiology aspectrum of clinical conditions occur. Investigations Pathophysiology During an attack the blood lm may show irregularly IgMorIgG antibodies are produced, which bind to red contracted cells, bite cells (indented membrane), blister cells. Autoimmune haemolytic anaemia Denition Clinical features Acquired disorders resulting in haemolysis due to red The clinical features, specic investigations and manage- cell autoantibodies. Splenectomy may be indicated if lymphatic leukaemia, haemolysis is severe and carcinoma and drugs such refractory. Cold haemagglutinin May be primary or secondary IgM antibodies agglutinate best Treat any underlying cause and disease to Mycoplasma at 4C, often against minor avoid extremes of temperature. Denition A pancytopenia due to a loss of haematopoetic precur- Investigations sors from the bone marrow. Full blood count and blood lm will demonstrate a pan- cytopenia with absence of reticulocytes. A bone marrow Aetiology/pathophysiology aspirate and trephine shows a hypocellular marrow with Aplastic anaemia can be either congenital or much more no increased reticulin (brosis). This agents, supportive care (blood and platelet transfusions) is an autosomal recessive aplastic anaemia with limb and some form of denitive therapy. Otherdrugsmaycauseaplasticanaemia Immunosuppressive therapy is used as rst line treat- through dose dependent (e. Prognosis Clinical features The course is dependent on the severity of the dis- Patients present with the features of pancytopenia: ease and the age of the patient. In the United Kingdom, travellers to these ar- 3year survival but there is a signicant risk of developing eas who do not take adequate precautions are at greatest paroxysmal nocturnal haemoglobinuria, myelodysplas- risk. Transmission occurs predominantly by the bite of the female Anophe- Denition les mosquito although transmission may occur by blood Malaria is an infection caused by one of the four species transfusion or transplacentally. Incidence Worldwide there are 300500 million cases of malaria Pathophysiology peryear with a mortality rate of up to 1%. In the United Parasites consume red cell proteins, glucose and Kingdom there are 15002000 cases per year, most of haemoglobin. They affect the red cell membrane making which are caused by Plasmodium falciparum. The inci- the cell less deformable and ultimately causing cell ly- dence in the United Kingdom is rising. Falciparum induces cell surface adhesion molecules on red cells causing adhesion to small vessels and un- Geography infected red cells. This leads to occlusion within the Endemic malaria is found in parts of Asia, Africa, Cen- microcirculation and organ dysfunction. Resistance to tral and South America, Oceania and certain Caribbean malaria is conferred by genetic variation: 1. Fertilisation occurs forming sporozites Sporozoites which migrate to the salivary glands. Sporozoites develop within hepatocytes over weeks before being released as merozoites. In vivax and ovale some remain in liver as a latent infection Release as merozoites Erythrocytic phase 3. Merozoites enter red blood cells, and pass through several stages of development finally resulting in multiple 4. The red blood cells rupture phase a few merozoites releasing merozoites into the circulation. In the able to swallow, is vomiting or has impaired con- gametocyte stage there is genetic recombination causing sciousness intravenous quinine is used. Treatment should be considered in patients with Clinical features features of severe malaria even if the initial blood Most patients have a history of recent travel to an en- tests are negative. The classical description of paroxysmal chills vere cases intensive care may be required. Examination may reveal tachycardia, pyrexia, subsequent treatment with primaquine to eradicate hypotension, pallor and in chronic cases splenomegaly. In general where there is no chloroquine resistance Complications weeklychloroquineisused. It may also lead to severe intravascular haemol- endemic area (in order to detect establish tolerance) ysis causing dark brown/black urine (blackwater fever) and should continue for 4 weeks after leaving the en- particularly after treatment with quinine. Investigations Diagnosis is by identication of parasites on thick and thin blood lms. Although the rst specimen is positive in 95% of cases at least three negative samples are re- Myelodysplastic and quired to exclude the diagnosis. The thick lm is more myeloproliferative disorders sensitive for diagnosis and the thin lm is used to dif- ferentiate the parasites and quantify the percentage of Myelodysplastic syndromes parasite infected cells. Supportive therapy includes red blood cell and platelet transfusions and the use of antibiotics for infections. Al- Incidence logeneic stem cell transplantation is potentially curative 20 per 100,000 per year over the age of 70 years. These conditions have some common features: r Refractory cytopenia with multilineage dysplasia and r Extramedullary haemopoesis in the spleen and liver. Pathophysiology There may be transformation from one condition to an- The disorder arises from a single abnormal stem cell. Clinical features Patients with myelodysplastic syndrome typically present with symptoms of anaemia, thrombocytopenia Incidence (spontaneous bruising and petechiae or mucosal bleed- 1per 100,000 per year. Investigations Bone marrow aspirate examination shows normal or in- creased cellularity with megaloblastic cells and some- Sex times ring sideroblasts and abnormal myeloblasts. Almost all patients have the Philadelphia chromosome, a Cytogenetic remission is achieved in 70% of patients. Initiallythereisachronicindolentphase lasting35years,followedbyanacceleratedphaselasting Polycythaemia vera 6 to 18 months. Myeloid precursors and megakaryocytes may is often found from an incidental full blood count. Investigations Age r Full blood count and blood lm reveal a high neu- Most commonly presents over the age of 50 years.

V. Muntasir. Sierra Nevada College. 2019.