A. Atiq Durrani, MD

• Orthopaedic Spine Surgeon, President
• Center for Advanced Spine Technologies
• Cincinnati, Ohio

The collection of quantitative data presented several difficulties because the information on causes of death in the three communities was inconsistent; the data began in 1977 for Wemotaci erectile dysfunction due to diabetes icd 9 generic 100mg nizagara with amex, 1972 for Manawan erectile dysfunction symptoms treatment order nizagara 50 mg visa, and 1970 for Opitciwan causes of erectile dysfunction and premature ejaculation order nizagara 100mg overnight delivery. However erectile dysfunction rap lyrics buy nizagara 25 mg overnight delivery, the Mikon Project was able to gather qualitative data to analyze risk factors and identify those persons at an increased risk of committing suicide erectile dysfunction protocol formula generic 50mg nizagara visa. These types of data include: · · · · information related to the history of those persons who committed suicide; data on attempted suicides from records of workers in social what age can erectile dysfunction occur order nizagara 100 mg otc, health, and police services from each community; testimonies of individuals who attempted suicide; and location-based family genealogy where cases of suicide and attempted suicides were identified. Table 6 indicates the mortality rate for each Atikamekw community was substantially the same based on population rates. From 1970 to 1998, the total number of recorded deaths was 390 in the three communities; 169 in Opitciwan, 81 in Wemotaci, and 140 in Manawan. Wanda Gabriel and Louise Tassй Table 6) General Mortality Rate (per 1,000), 199610 Opitciwan Mortality rate Number of deaths from 1970 to 1998 Total population of the Atikamekw Nation 2. The available demographic information did not allow for a yearly comparison nor did it allow the data to be grouped by a uniform age range. Table 7) Suicide Rate by Age Group, 199611 Suicide rate (per 100,000) Total population Age 16­20 years Age 21­25 years Age 26­30 years Age 16­25 years Age 26­35 years Opitciwan 55. From 1977 to 1998, the age of suicides in Wemotaci ranged from 16 to 42 years of age; 75 per cent were male and 25 per cent female. In Manawan, the range was similar; however, a greater number of suicides were among females (33%). In Opitciwan, the age range was greater than in the other two communities (10 to 65) but similar in gender to that noted in Wemotaci (75% male; 25% female). Table 8 indicates the proportion of suicides by youth and young adults from 1977 to 1998 in the Atikamekw communities. Since the mid-1980s, the increase in number of deaths by suicide surpassed the total number of deaths due to violence such as drowning, fire, murder, accidents, freezing, and intoxication. Table 8) Proportion of Suicides by Age Groups Among the Atikamekw (1977­1998)12 Age Groups 16­25 26­35 Total Opitciwan 36. Violence and suicide represented a significant Case Study Report: Koskikiwetan portion of deaths in the Atikamekw communities: 32. Violent deaths were particularly evident among male individuals: 69 per cent in Opitciwan, 83 per cent in Wemotaci, and 64 per cent in Manawan. The age range of victims were between two months and 57 years, with 32 per cent being children (2 months to 11 years). Most cases of attempted suicide took place in the home during or after the separation of couples, and use of alcohol and drugs was noted in many of the cases. Table 9 shows recent data (1998­2002) of the three Atikamekw communities on completed suicides by age and gender. The majority of individuals who committed suicide were youth and young male adults. Between 1998 and 2002 there were 11 suicides among males between 15 and 44 years of age, and four suicides among females between 15 and 24 years. There were no suicides in 1999, and this corresponded to the start of the Miromatisiwinik/Koskikiwetan project activities. However, women were physically assaulted twice as often as men, and young adults between ages 25 and 34 endured more physical assaults. Individuals with college or university education and an annual income over $30,000 were assaulted most often. In other age groups, individuals aged between 35 and 39 endured most of the abuse in both communities. In Wemotaci, almost 25 per cent of individuals who suffered sexual abuse had an annual income of less than $12,000, and 40 per cent had greater than $30,000. Table 11 provides data on Wemotaci and Manawan on sexual abuse among respondents 15 years and older. In comparing the problem of suicide attempts and suicidal thoughts in the Atikamekw communities among the Cree, Inuit, and nonAboriginal people in Quebec, it was noted that suicides were generally twice as high for members of the Atikamekw communities and for Inuit than for Cree and non-Aboriginal people in Quebec, as indicated in Table 12. General data on suicide in the communities indicated that it was mostly youth and young adults who committed suicide. Table 12) Respondents Aged 15 Years and Over Who Have Thought of Suicide, Planned, and Attempted Suicide17 Suicidal Thoughts and Actions Suicidal ideation Planned a method of suicide Tried to commit suicide Wemotaci (1977) % 18. High stress in the home could be related to the fact that about half of these individuals want to leave their home; 57. Wanda Gabriel and Louise Tassй Table 13) Psychological Distress of Respondents Aged 15 and Over Based on Characteristics Related to the Household, 199719 Characteristics Related to the Household Unsatisfactory relations in the home Lack of intimacy in the home Tensions observed in the home Rejection by members of the household Would like to leave the household 62. Table 14 compares psychological distress with sexual and physical abuse in Wemotaci and Opitciwan, but nothing describes the normal and high comparisons. For Opitciwan, there were incomplete data on suicidal ideation and suicide attempts. Nevertheless, Wemotaci and Opitciwan showed a significant higher proportion than the norm. It should be noted that results of the Mikon Project showed Wemotaci had the highest rate of suicide in 1996. In Opitciwan, the rate of sexual assaults and physical assaults were lower than in Wemotaci. Table 14) Respondents Aged 15 Years and Over Who Thought of Suicide and Were Assaulted Sexually and/or Physically in 199720 Suicidal Thoughts/Attempts Suicidal ideation during their life Suicidal ideation during the year Suicide attempts during their life* Suicide attempts during the year Wemotaci Normal % 26. Individuals between 35 and 49 years of age were among the highest for suicide attempt (75%), followed by ages 25 to 34 (50%). Statistically speaking, only percentages related to family status (single, married) showed significant differences. Individuals living as a couple had an alarming rate of suicide attempts (75%) in a greater proportion than individuals living alone. Among female individuals, the most frequently used method was ingesting drugs or chemical substances. Solvents and gasoline were frequently used as a substitute for drugs among young people in Aboriginal communities, which can have fatal consequences on the health and lives of those who use them. Wanda Gabriel and Louise Tassй Table 16) Suicide Attempts Among Respondents Aged 15 and Over Based on Gender and Method Used22 Manawan (1996) Drugs/chemical substances Slicing wrists Hanging Asphyxiation Firearm Automobile accident Other Total # of Males 2 1 5 1 11 2 ­ 13 % 15. Table 17 indicates the rate of alcohol use in the three Atikamekw communities was relatively the same as that of Quebec. The use of cannabis was almost twice as high in Opitciwan and Wemotaci than in Manawan (43. The average rate of cannabis use in the Atikamekw communities was twice as high as compared to Quebec (29. The rate of naphtha use indicated a more alarming situation in Opitciwan and Wemotaci (55. Thus, the use of alcohol and drugs, including some of the most damaging such as naphtha, was a very serious problem for the Atikamekw communities. Manawan had the lowest rate of gasoline and cocaine use and no data was available for Quebec. Table 17) Alcohol and Drug Abuse Among Young Atikamekw (1992) and Quebec (1991) Based on Type23 Type Tobacco Alcohol Cannabis Naphtha Gasoline Cocaine Manawan % 74. Among individuals who consumed the greatest amounts of alcohol, couples were in greater number than single people, and 75 per cent had only a high school education. The situation was alarming because more than half the population consumed large quantities of alcohol. However, data were not consistent across the board and must be interpreted with prudence. Table 19) Alcohol Consumption of Respondents Based on Age, Gender, Marital Status, and Education25 Opitciwan (1997) 15­24 years of age 25­34 years of age 35­49 years of age Single Part of a couple Working Unpaid occupation Inactive Less than $12 000,00 $12,000 to $29,999 7 days/week % 18. These key informants were asked to give their opinions on physical abuse, sexual abuse, children in care, incarceration, and suicide. Figure 3 indicates the perceived magnitude of change on social indicators noted by respondents. Wanda Gabriel and Louise Tassй Figure 3) Perceived Magnitude of Change on Social Indicators 10 8 # of Respondents 6 4 2 0 Suicide Incarceration Children in care Sexual abuse Physical abuse Increased Decreased Stayed the same Not sure Sixty per cent of respondents felt there was a reduction in physical abuse, particularly among those who took part in healing activities. Some respondents stated: · · · · "In general, it is less hidden; women are more inclined to report it. Although there were no dramatic differences, most respondents felt there was an increase in the reporting of sexual abuse. While respondents disagreed about change in sexual abuse rates, they were able to state that there was an increase in awareness on the subject and that the chains of silence were finally being broken. The respondents elaborated on their opinions about sexual abuse in the following manner: · · · "The silence is shattered; people are talking about it more and more. Most respondents stated they perceived an increase in awareness of parenting roles and responsibilities. Respondents also noted a trend in the community towards responsibility for children, and there were Case Study Report: Koskikiwetan conflicting opinions on the best method of intervening. The following comment clearly explains this situation: · · "There is a commitment towards community responsibility to keeping children and placing them in the community; conversely the influence of psychologists from outside is towards placing the children taken in charge outside the families and the community. Some felt that it was too early to evaluate this problem, which explained the high percentage of individuals who were not certain. Only 20 per cent of respondents felt there was a decrease in the incarceration rate, and most of those who responded had considered the problem to be connected to individual awareness or to individuals dealing with their problems better. Moreover, 13 per cent felt there was an increase in the incarceration rate due to a different approach to maintaining order. Finally, only six per cent of respondents felt the number of incarcerated individuals had decreased. Forty-six per cent of respondents noted a significant increase in the number of suicides in the communities. Several pointed out that in January 2002 there were three suicides: theyoungestvictimwas11yearsold. Only 20 per cent of respondents thought there had been a decline in the number of suicides, 20 per cent believed there was no change, and a small number were not sure if any change occurred. Reporting Results this section will examine the progress and successful accomplishments that occurred over the short term to highlight the logical link between activities and results achieved by Koskikiwetan; however, it should be noted that training and therapy activities were still ongoing and this case study covered only a short period of time (two years). Intergenerational relations have been seriously weakened because of residential schools. The following discussion deals more specifically with short-term results during the two years of operation, with an emphasis on activities in the second year (2000­2001). All information sources suggest that Koskikiwetan was able to: · · · · · · · · · create awareness of the Legacy; establish a support network; improve the quality of information on residential schools; reduce denial; increase participation of community members in various project activities; integrate the Inner Child approach with traditional healing culture; reduce suffering; address intergenerational relationship problems; and through pre- and post-therapy support and counselling activities, made it possible to set milestones for healing and logistical follow-up. Results Achieved in Awareness Activities During the second year of operation, the project team modified education and awareness activities in collaboration with the regional coordinator, local committees, and workers to take place in the bush or at traditional sites. In addition, Survivor involvement during project development and coordination at both regional and local levels ensured that the team could refer to Survivor testimony. Initially, it became clear that local workers were not sufficiently informing their community. Using community radio and television as well as publishing articles in local papers corrected the situation. Now, local workers and the regional coordinator regularly make presentations on the project. The video, Miromatisiwinik (Wind from the North), and sharing circles proved to be very effective means of education and awareness because they served as triggering tools, which lead several Survivors to begin a healing process. Results Achieved in Training Activities the project team instituted a review and healing process called "therapy follow-up" (to distinguish it from post-therapy follow-up). This consisted of bringing together the therapy team, local workers, regional coordinator, and other resource persons such as Elders to continually assess training and therapy activities. This made it possible to implement any short-term changes to the program that were needed and to discuss the development of the therapeutic approach. This lead to several changes to training activities, including the development of a training package that was better adapted to Atikamekw culture and spirituality. As a result, training was undertaken using the Inner Child therapeutic approach, taken from the Intergenerational Impacts therapy and adapted traditional Atikamekw healing. Case Study Report: Koskikiwetan the team also allowed for time off during training so that trainees could work on personal issues. Once the healing began, trainees were then able to share their experiences in order to avoid reproducing the attitudes and behaviours associated with the Legacy. As a result of these changes, the project team was able to observe active participation and a greater satisfaction among numerous trainees. Thirty-two people who came from health, social service, and education sectors of the Council of the Atikamekw Nation received training on sexual and physical abuse during the first two years of the project. During the second year there were two successful training sessions on sexual abuse that were given by six workers from the three Atikamekw communities. A clinical supervisor service was available once a month to provide technical and psychological support to local workers and therapists. Support services and steps to protect personnel working on the project included consultation sessions with a clinical counsellor and telephone consultations with a trainer who provided Inner Child therapy. There were also reporting sessions for accountability purposes with local committees, exchange sessions with Elders and speakers integrated into the healing process, as well as support sessions between workers and the regional coordinator. Seven of 15 people interviewed had taken training and most considered it was relevant and satisfactory. One would have liked to have "more training on sexual abuse" and another "was very unsatisfied" with the number of training sessions. Five of seven respondents felt that the training "helps them to better manage their clients. Two workers particularly appreciated the Inner Child therapy they were offered before training had begun.

Laws erectile dysfunction herbal medications generic nizagara 50mg otc, policies and practices that cover media conduct during elections · these are generally gender neutral erectile dysfunction shakes menu cheap 50 mg nizagara otc. Gender training for the media · More resources towards capacity building for the media · Training of social media on responsible reporting erectile dysfunction oral treatment generic 50mg nizagara visa. Part of the responsibility is with the media and the other with political parties who do not send women to take part in debates unless they think that the questions that will be put concern women causes of erectile dysfunction in younger males discount 100 mg nizagara. Other recommendations · Encourage women to be involved in the media coverage/ownership of media houses erectile dysfunction pump hcpc buy generic nizagara 100mg on line. Media commentary and analysis during elections this can be enhanced through: · Sensitisation and guidelines established in terms of media analysis of gender erectile dysfunction groups in mi best 50 mg nizagara. There is a need for long term planning and resource mobilisation to ensure aspiring women politicians can be supported throughout the process. Through those channels, women and gender equality advocates successfully promote legislation and mechanisms to advance gender equality and eliminate discriminatory laws against women. They play a critical role in requiring decision makers to be accountable for upholding the human rights of women and girls. These groups also play an active role in building the capacity of prospective candidates, serve as gender, media and election watchdogs, and help to mediate conflict in some instances. It "refers to the space for collective action around shared interests, purposes and values, generally distinct from government and commercial for-profit actors. Expanding the research to civil society more broadly is important in future research. The chapter concludes with recommendations for strengthening civil society efforts. The desk top internet research found the largest number of such organisations (23) in Southern Africa; followed by East Africa (21); West Africa(14); the Horn (9) and two each in Central and North Africa. Ace Project, Civil society advocacy for gender equality in politics and inclusive participation in electoral process <aceproject. Getting the right message: Gender Links training workshop with women parliamentarians in Lesotho. The Protocol is a sub-regional instrument for promoting gender equality that brings together global and African commitments in one binding instrument. Gender Links based in Johannesburg, with offices in ten Southern African countries, provides the secretariat for the Alliance. They participate in the mobilisation of communities especially women during elections using methods such as focus groups. They advocate for legal reform and review of electoral procedures; promoting gendersensitive media coverage of the electoral process; and strengthening the gender component in election observation. In a landmark pronouncement, Mnangagwa signaled his support for a quota for women in local government following intense lobbying at the inaugural Women Councilors Indaba meeting held in Victoria Falls in December 2020. While Zimbabwe presently has a Constitutional quota for women at the national level, women in local government have repeatedly been excluded from these provisions, despite a commitment in the 2013 Constitution to gender parity in all areas of political decision-making. This figure has declined by two percentage points each election since 2013, when 11 12 13 Strategic Initiative for women in the Horn of Afriva Network < While there is a quota for women at the national level that is due to expire in 2023, this does not apply at the local level. Women councilors argued that whatever we arrangements pertain in 2023, they need to be extended to the local level. We are therefore requesting for the institution of temporary special measures to increase the proportion of women at the local level. Specifically, that women at the local level be given 30% proportional representation seats. What is important is that the issue is now squarely on the political agenda, with enough time before the 2023 elections for the necessary amendments to be made. To keep up the pressure, the President urged that the Women Councilors Indaba become an annual event. Should Zimbabwe adopt a quota for women in local government, it will join several Southern African Development Community countries that have done so. Women in Law Southern Africa - Zimbabwe has drafted a gendered model electoral framework to promote the principles of inclusiveness and gender equality as prescribed in the Constitution, and International and regional instruments that Zimbabwe has signed and ratified. The discussion paper considers an alternative gendered Model Electoral Law Framework for Zimbabwe with the intent of reinforcing an electoral system that facilitates the equal representation of women and men in line with the foundational principles, values and fundamental rights14 entrenched in the 2013 Constitution, as well as the relevant international law norms and standards relating to gender inequalities. The Declaratory Order sets out that the President of Zimbabwe violated Section 17 (1) (b) (ii), Sec 90 (1) and Sec 104 (4) of the Constitution of Zimbabwe and the Gender Commission failed in its duty to monitor issues concerning gender equality as provided in the Constitution. The application challenges the Zimbabwe Cabinet appointment to be unconstitutional because it does not meet the gender parity requirement. The President of Zimbabwe appointed five women Ministers and 18 men in his Cabinet and five Deputy Ministers women and 13 men. The Government has since filed its Opposing Affidavit, and the matter is still pending before the Court. The key statutes discussed were Section 17, 56, 80 and Section 155 of Constitution, the Constitutional Amendment number 2 and the Electoral Act. In Madagascar, the National Council of Women conducted an advocacy campaign ahead of the 2013 electoral process, reaching out to political party leaders. Zambia now has a female vice president, and most of the political parties have appointed women to key leadership positions. Women in Law Southern Africa (Zambia) and Gender Links Zambia, working closely with the Zambia Law Reform Commission, have started a campaign for a quota to be included in the Constitution, presently under review. Gender Links Zimbabwe worked with the Women in Local Government Forum to present their case to the President. Photo: Tapiwa Zvaraya Civil society advocacy efforts in Mali resulted in a gender quota bill being passed in 2015, requiring at least 30 per cent of elected or appointed officials to be women. In this advocacy work, civil society organisations joined forces with women legislators of the Network of Parliamentarian Women and the Ministry on the Promotion of Women, Children and the Family. Male allies, especially parliamentarians, also played a key role in the adoption of the law16. The Nation Media Group hosted the televised National Leadership Forum - Gender Agenda. This followed advice from the Judiciary to the President to dissolve parliament for its failure to implement the two-thirds gender representation principle. It has played a critical role in informing and mobilising African women to participate and influence policies and processes that affect their lives. Parity Now is a parallel community initiative sent to the House of Representatives citing Article 15 of the Constitution. This says that men and women citizens have the right to send their petitions to public authorities. In November 2020, Parity Now made a further effort to get a framework law establishing parity between men and women in line with Article 19 of the Constitution. The objective of this law is to go from provisions for positive discrimination to substantive equality. A White Paper aims to introduce amendments to make equality and parity between men and women a reality. A second White Paper will cover economic, social, environmental and cultural sectors. While awaiting to reach the critical mass of 30% of women, we are forced to accept the mechanism of positive discrimination", notes Ouafa Hajji. She adds that "we must encourage political parties to put more women as candidates, namely during local elections and to empower women. Women and men in this field come from different walks of life, with different educational backgrounds, experience and skills. In developing country contexts, they do not have researchers or support staff to help them prepare speeches and interventions. This opens the possibility of a symbiotic relationship between politicians and activists. They produce tools that enable candidates (local level and national) to learn about their constituencies and what is expected of them on a specific seat. The gender laboratory creates an environment for female politicians to learn from research collected on how they can do more for women in their communities and countries and aspire to be leaders and not just subordinates/supporters of political leaders who are usually men. Participants discussed methodologies for collecting gender-disaggregated data and information gathering and analysis from a gender perspective during election observation. The experiences of female in Nigerian politics was often left untold, this spurred the need to create a safe place where women aspiring to run for office could easy share their experiences led to the launch of the DecideToRun Community which can proudly boast of over 100 members. In only one year of existence, the organisation has played a pivotal role in changing the narrative and setting the context for increased female participation in Nigerian politics. The female leadership deficit in Africa remains a collative problem which largely hampers our development as a continent. The Academy will deliver on our mandate to develop a multidimensional empowerment model of capacity building that will equip women with the requisite skills and knowledge to run for elective office competitively. Agender 35 to launched in the first quarter of 2021 aims to directly support 35 women candidates by 2023 through a $10 million fund. The women were trained on leadership skills, effective communication skills, confidence and assertiveness skills, and mentorship. The training focused on Transformative Feminist Leadership, including a wide range of topics: Political career development; Building and managing a campaign; Introduction to Public Service and Volunteerism; Negotiation and consensus-building skills; Non- violent campaign strategies; Constituency outreach and voter mobilisation strategies; Resilience building and social accountability; Public speaking and mastering the art of convincing audiences; Introduction to Feminism; Etiquette and Confidence building. Women who are already active leaders received refresher training in leadership development and mentoring. These were intergenerational meetings that provided a platform for younger women to be connected with a mentor for continued mentoring and support. A total of 140 women candidates participated in these workshops, which covered gender and elections, electoral legal framework, communication, and media20. The grantees were trained on voter education methodology for the registration process, including outreach to women21. These sessions cover how to organise an electoral campaign, how to speak in public, plan an electoral campaign and budget. The Constitution and the Electoral Code of Benin are favorable to gender equality. According to the president of the 23 Ace Project, Male allies and social norm change in politics and elections: building transformative masculinities < aceproject. The final aim is to ensure the judicious presence of women in all decision-making positions and to build the capacity of the networks and associations within the platform". In this respect, capacity building sessions, advocacy and information meetings are organized to encourage political parties to open up to women in Bйnin". This platform is committed to assist "from beginning to end", the effective participation of women in the electoral processes. She adds that media play regularly organise roundtables where gender is the main subject of the debate. Bйnin needs a law on quota or on outright Case study by Isabelle Otchoumarй parity". Gender and election monitoring Election observation can contribute to democratic development by collecting information on the electoral process, assessing its quality, considering the domestic legal framework and international standards, and constructive recommendations to improve future elections. In Southern Africa, Gender Links has conducted gender audits, including media monitoring of several Southern African in the Democratic Republic of Congo, Botswana, Madagascar, Malawi, Mauritius, Mozambique, Namibia and Tanzania. Gender and media monitoring aims at bridging the gaps between women politicians and the media, "bringing them together to deliberate on the gendered nature of elections coverage. Photo: Graca Ricardo Over the last decades, election observation has evolved to integrate a long-term perspective instead of focusing exclusively on Election Day operations and procedures. There is increasing consensus that election observation should consider the Election Day and other key stages of the electoral process, such as the legal framework, voter registration, the verification of results or election complaints, among others. The Commonwealth Observer Group recommended that the new parliament should negotiate the quotas prescribed for women under Section 124 of the 2013 Constitution before its expiration in 2023. This brought together representatives of the Chapter 12 institutions, civil society, political party representatives and other key gender and elections stakeholders. This debate examined several electoral systems and quotas scenarios to ensure that Zimbabwe rises above minimum standards in 2023. Three workshops were held across the country, in Antsirabe, Mahajanga and Fianarantsoa. The training sessions covered the topics of media ethics, the role of media in the electoral process, conflict prevention and gender, media and elections. It provides that: "Every person has the right to freedom of association for any cause or purpose. Organisations formed, in violation of appropriate laws, or illegally subvert the constitutional order, or which promote such activities is prohibited. This focused on voter education, media coverage, election day procedures, training and support for elected women. The mission deployed ten international election observers and 100 domestic observers in polling centres across the country, especially in rural areas. The recommendations contained in its final report include strengthening registration campaigns for women voters, particularly in rural areas, publishing sex-disaggregated data and statistics, establishing effective procedures to ensure equity in media coverage for all candidates, as well as developing voter education and information programs specifically targeting young, illiterate or rural women. The monitoring found that women candidates only received 7% coverage in print media, 8% in radio and 11% in television32. This composition was important in that it managed to cut across all perceived barriers in the different age groups, different educational backgrounds and different social circumstances. International Gender Champions is "a leadership network that brings together female and male decisionmakers determined to break down gender barriers and make gender equality a working reality in their spheres of influence. All Gender Champions sign a pledge to no longer sit in single-sex panels and commit to treat every person with respect and fairness, value diversity, create and maintain safe workplaces and work together with other Champions in a spirit of openness, honesty and transparency37. Founded in 1995 as a platform to identify, capacitate and support men and boys who believe in gender equality and to mobilize and influence other men. It seeks to create safe spaces for men and boys to redefine masculinities through a selfintrospection processes in a safe space where they are not judged. This platform brings together men with same beliefs and willingness to change and embrace transformative masculinities.

The symptoms always include a sensory deficit affecting light touch impotent rage definition buy discount nizagara 100 mg line, pain xarelto erectile dysfunction nizagara 25 mg amex, and temperature perception erectile dysfunction 35 years old cheap 25 mg nizagara mastercard. Hemorrhagic vesicles reflect a serious injury to the microvasculature and indicate third-degree frostbite erectile dysfunction caused by vasectomy purchase 100 mg nizagara with visa. Differential diagnosis of frostbite includes frostnip (superficial freezing of skin without tissue destruction) as well as chilblain (pernio) and immersion (trench) foot erectile dysfunction in diabetes medscape discount 25 mg nizagara with mastercard, both of which occur at temperatures above freezing erectile dysfunction doctor patient uk generic nizagara 100mg with visa. If cyanosis persists after rewarming, the tissue compartment pressures should be monitored carefully. For prevention (as opposed to treatment), acetazolamide (125­250 mg q12h) or-when acetazolamide is contraindicated, as in sulfa allergy-dexamethasone (4 mg q12h) may be used. Hypoxia-induced impairment of nitric oxide release may play a role in vasoconstriction. The architecture of the lung is well preserved, with rapid reversibility of abnormalities. Other High-Altitude Problems · Sleep impairment ­ Increased periodic breathing and changes in sleep architecture. Diarrhea is not associated with high altitude but may indicate bacterial or parasitic infection, which is common in many high-altitude locations in the developing world. Pts taking insulin may require lower doses on trekking/climbing days than on rest days. Bubbles also appear in the venous circulation where they can incite inflammatory and coagulation cascades, damage endothelium, activate formed elements of blood such as platelets, and cause symptomatic vascular obstruction (also in arterial beds when a patent foramen ovale is present). Pulmonary and cardiovascular manifestations can be life-threatening including dyspnea, chest pain, arrhythmia, coagulopathy, and hypotension. Definitive treatment with hyperbaric oxygen administered in a compression chamber with stepwise decompression over variable periods adjusted to treatment response. If recovery is complete, diving can be resumed after a period of at least 1 month; if residual symptoms exist, diving is discouraged. Overdosage is exposure to excessive amounts of a substance normally intended for consumption (a pharmaceutical) or an illicit drug. Chemical exposures result in an estimated 5 million requests in the United States for medical advice or treatment each year, and about 5% of victims require hospitalization. Overall mortality is low (<1% of exposures); suicide attempts account for most serious or fatal poisonings (1­2% mortality). Nonpharmaceutical agents implicated in fatal poisoning include alcohols and glycols, gases and fumes, cleaning substances, pesticides, and automotive products. All available sources should be used to determine the exact nature of the ingestion or exposure. The Physicians Desk Reference, regional poison control centers, and local/hospital pharmacies may be useful for identification of ingredients and potential effects of toxins. The first step is a physical exam with initial focus on the pulse, blood pressure, respiratory rate, temperature, and neurologic status and then characterization of the overall physiologic state as stimulated, depressed, discordant, or normal (Table 32-1). Examination of the eyes (for nystagmus, pupil size, and reactivity), neuromuscular status (for tremors, dyskinesia, rigidity, dystonia), abdomen (for bowel activity and bladder size), and skin (for burns, bullae, color, warmth, moisture, pressure sores, and puncture marks) may narrow the diagnosis to a particular disorder. An increased aniongap metabolic acidosis is characteristic of advanced methanol, ethylene glycol, and salicylate intoxication, but can occur with other agents and in any poisoning that results in hepatic, renal, or respiratory failure; seizures; or shock. Hypoglycemia may be due to poisoning with -adrenergic blockers, ethanol, insulin, oral hypoglycemic agents, quinine, and salicylates, whereas hyperglycemia can occur in poisoning with acetone, -adrenergic agonists, calcium channel blockers, iron, theophylline, or the rodenticide Vacor. Ventricular tachyarrhythmias may be observed with exposure to cardiac glycosides, fluoride, methylxanthines, sympathomimetics, antidepressants, and agents that cause hyperkalemia or potentiate the effects of endogenous catecholamines. Toxicologic analysis of urine and blood (and occasionally of gastric contents and chemical samples) may be useful to confirm or rule out suspected poisoning. Quantitative analysis is useful for poisoning with acetaminophen, acetone, alcohols (including ethylene glycol), antiarrhythmics, anticonvulsants, barbiturates, digoxin, heavy metals, lithium, salicylate, and theophylline, as well as for carboxyhemoglobin and methemoglobin. When the type of poison is unknown or uncertain, blood and urine specimens for toxicologic studies should be obtained if possible before treatment is started. Adequate cardiovascular function and organ perfusion is necessary for elimination of toxin and pt recovery. If hypotension is unresponsive to volume expansion, pressors such as norepinephrine, epinephrine or dopamine may be required. Treatment with combined and blockers or combinations of blocker and vasodilator is indicated in severe sympathetic hyperactivity. Magnesium sulfate and overdrive pacing (by isoproterenol or a pacemaker) may be useful for torsades de pointes. It is acceptable to observe hemodynamically stable pts without pharmacologic intervention. It is given orally via a nippled bottle (for infants), or via a cup, straw, or small-bore nasogastric tube. The recommended dose is 1 g/kg body weight, using 8 mL of diluent per gram of charcoal if a premixed formulation is not available. When indicated, gastric lavage is performed using a 28F orogastric tube in children and a 40F orogastric tube in adults. Repeated administration of fluid (5 mL/kg) followed by aspiration results in progressive removal of gastric content. Lavage is contraindicated in pts resisting the procedure, and with ingested corrosives and petroleum distillate hydrocarbons because of risk of aspiration-induced pneumonia and gastroesophageal perforation. Syrup of ipecac, once the most commonly used decontamination procedure, has no role in the hospital setting and is no longer recommended for the management of poisoning. Propranolol, a nonselective blocker, for tachycardia with hypotension; any blocker for supraventricular or ventricular tachycardia without hypotension; elimination enhanced by multipledose charcoal, hemoperfusion, and hemodialysis; indications for hemoperfusion or hemodialysis include unstable vital signs, seizures, and a theophylline level of 80­100 g/mL after acute overdose and 40­60 g/mL with chronic exposure. At high doses, amantadine, diphenhydramine, orphenadrine, phenothiazines, and tricyclic antidepressants have additional nonanticholinergic activity (see below). Physostigmine, an acetylcholinesterase inhibitor (see below) for delirium, hallucinations, and neuromuscular hyperactivity. Specific Treatments Glucagon and calcium for hypotension and symptomatic bradycardia. Amrinone, high-dose insulin (with glucose and Cardiac glycosides Digoxin, endogenous cardioactive steroids, foxglove and other plants, toad skin secretions (Bufonidae sp. Toxicity occurs at lower drug levels in chronic poisoning than in acute poisoning. Temporizing measures include atropine, dopamine, epinephrine, phenytoin, and external cardiac pacing for bradydysrhythmias and magnesium, lidocaine, or phenytoin for ventricular tachydysrhythmias. Internal cardiac pacing and cardioversion can increase ventricular irritability and should be reserved for refractory cases. Nicotinic signs and symptoms: hypertension, tachycardia, muscle cramps, fasciculations, weakness, and paralysis. Myoclonus, seizures, hypertension, and tachyarrhythmias can occur with baclofen, carbamazepine, and orphenadrine. Elimination of phenobarbital and possibly other long-acting agents enhanced by multiple-dose charcoal. Pharmacologically related agents: zaleplon, zolpidem rate of recovery of inactivated sodium channels. Some agents also have 2 agonist, anticholinergic, and sodium channel-blocking activity (see above and below). Some agents can cause anticholinergic and sodium channel (membrane) blocking effects (see above and below). Baclofen, carisoprodol, cyclobenzaprine, etomidate, metaxalone, methocarbamol, orphenadrine, propofol, tizanidine and other imidazoline muscle relaxants. Chloral hydrate, ethchlorvynol, glutethimide, meprobamate, methaqualone, methyprylon. Amyl and sodium nitrite (without thiosulfate) for similar toxicity in hydrogen sulfide poisoning. Hyperbaric oxygen for moderate to severe carbon monoxide poisoning and for cyanide or hydrogen sulfide poisoning unresponsive to other measures. Methemoglobin inducers Aniline derivatives, dapsone, local anesthetics, nitrates, nitrites, nitrogen oxides, nitro- and nitroso hydrocarbons, phenazopyridine, primaquine-type antimalarials, sulfonamides. Oxidation of hemoglobin iron from ferrous (Fe2+) to ferric (Fe3+) state prevents oxygen binding, transport, and tissue uptake (methemoglobinemia shifts oxygen dissociation curve to the left). Nontransferrin-bound iron catalyzes formation of free radicals that cause mitochondrial injury, lipid peroxidation, increased capillary permeability, vasodilation, and organ toxicity. Clinical Features Initial ethanol-like intoxication, nausea, vomiting, increased osmolar gap, calcium oxalate crystalluria. Hemodialysis also useful for enhancing ethylene glycol elimination and shortening duration of treatment when ethylene glycol level >8 mmol/L (>50 mg/dL). Initial nausea, vomiting, Endoscopy and gastrostomy if clinical toxicity abdominal pain, diarrhea. Hemodialysis also useful for enhancing methanol elimination and shortening duration of treatment when methanol level >15 mmol/L (>50 mg/dL). Hemodialysis for coma, cerebral edema, seizures, pulmonary edema, renal failure, progressive acid-base disturbances or clinical toxicity, salicylate level >7 mmol/L (>100 mg/dL) following acute overdose. Nausea, vomiting, diarrhea, ataxia, choreoathetosis, encephalopathy, hyperreflexia, myoclonus, nystagmus, nephrogenic diabetes insipidus, falsely elevated serum chloride with low anion gap, tachycardia. Coma, seizures, arrhythmias, hyperthermia, and prolonged or permanent encephalopathy and movement disorders in severe cases. Hemodialysis for coma, seizures, severe, progressive, or persistent encephalopathy or neuromuscular dysfunction, peak lithium level >8 meq/L following acute overdose. Clinical Features Specific Treatments Serotonin receptor antagonists such as cyproheptadine, discontinue offending agent(s). Membrane-active agents Altered mental status (agitation, confusion, mutism, coma, seizures), neuromuscular hyperactivity (hyperreflexia, myoclonus, rigidity, tremors), and autonomic dysfunction (abdominal pain, diarrhea, diaphoresis, fever, flushing, labile hypertension, mydriasis, tearing, salivation, tachycardia). Lidocaine for monomorphic ventricular tachycardia (except when due to class Ib antiarrhythmics). Magnesium, isoproterenol, and overdrive pacing diphenhydramine), carbamazepine, local anesthetics (including cocaine), opioids (meperidine, propoxyphene), orphenadrine, quinoline antimalarials (chloroquine, hydroxychloroquine, quinine), cyclic antidepressants (see above). Toxicity Acute arsenic poisoning results in necrosis of intestinal mucosa with hemorrhagic gastroenteritis, fluid loss, hypotension, delayed cardiomyopathy, acute tubular necrosis, and hemolysis. Chronic arsenic exposure causes diabetes, vasospasm, peripheral vascular insufficiency and gangrene, peripheral neuropathy, and cancer of skin, lung, liver (angiosarcoma), bladder, and kidney. Treatment If acute ingestion, gastric lavage, activated charcoal with a cathartic. Absorbed through ingestion or inhalation; bound by metallothionein, filtered at the glomerulus, but reabsorbed by proximal tubules (thus, poorly excreted). Acute cadmium inhalation causes pneumonitis after 4­24 h; acute ingestion causes gastroenteritis. With inhalation: pleuritic chest pain, dyspnea, cyanosis, fever, tachycardia, nausea, noncardiogenic pulmonary edema. Lead Manufacturing of auto batteries, lead crystal, ceramics, fishing weights, etc. Distributed widely in soft tissue, with half-life Identification and correction of exposure sources is critical. In adults, acute exposure causes similar symptoms as in children as well as headaches, arthralgias, myalgias, depression, impaired short-term memory, loss of libido. Physical exam may reveal a "lead line" at the gingiva-tooth border, pallor, wrist drop, and cognitive dysfunction. Correction of dietary deficiencies in iron, calcium, magnesium, and zinc will lower lead absorption and may also improve toxicity. New guidelines have been proposed recommending monitoring of cumulative exposure parameters (Kosnett, 2007). Chronic exposure to metallic mercury vapor produces a characteristic intention tremor and mercurial erethism: excitability, memory loss, insomnia, timidity, and delirium ("mad as a hatter" -hat makers used mercury in the manufacturing process). On neurobehavioral tests: decreased motor speed, visual (1200 mg at bedtime) have been shown to lower blood lead levels in pregnant women. Mercury Metallic, mercurous, and mercuric mercury (Hg, Hg+, Hg2+) exposures occur in some chemical, metal-processing, electrical-equipment, automotive industries; they are also in thermometers, dental amalgams, batteries. Elemental mercury (Hg) is not well absorbed; however, it will volatilize into highly absorbable vapor. Mercury is excreted in urine and feces and has a half-life in blood of ~60 days; however, deposits will remain in the kidney and brain for years. Mercury binds sulfhydryl groups and interferes with a wide variety of critical enzymatic processes. Toxicity lower exposures impair renal function, motor speed, memory, coordination. Acute ingestion of inorganic mercury causes gastroenteritis, the nephritic syndrome, or acute renal failure, hypertension, tachycardia, and cardiovascular collapse, with death at a dose of 10­42 mg/kg. Ingestion of organic mercury causes gastroenteritis, arrhythmias, and lesions in the basal ganglia, gray matter, and cerebellum at doses >1. Children exposed to mercury in any form may develop acro dynia ("pink disease"): flushing, itching, swelling, tachycardia, hypertension, excessive salivation or perspiration, irritability, weakness, morbilliform rashes, desquamation of palms and soles. Toxicity from elemental or inorganic mercury exposure begins when blood levels are >180 nmol/L (3. If renal failure occurs, treat with peritoneal dialysis, hemodialysis, or extra-corporeal regional complexing hemodialysis and succimer. High exposure during pregnancy causes derangement of fetal neuronal migration resulting in severe mental retardation. Dimethylmercury, a compound only found in research labs, is "supertoxic"-a few drops of exposure via skin absorption or inhaled vapor can cause severe cerebellar degeneration and death.

G/A An adrenal carcinoma is generally large erectile dysfunction drugs egypt cheap nizagara 100 mg overnight delivery, spherical and well-demarcated tumour crestor causes erectile dysfunction order nizagara 50mg amex. On cut section impotence after prostatectomy purchase 100mg nizagara otc, it is predominantly yellow with intermixed areas of haemorrhages erectile dysfunction drugs best discount 50mg nizagara fast delivery, necrosis and calcification erectile dysfunction due to diabetic neuropathy buy discount nizagara 100mg on-line. M/E the cortical carcinoma may vary from well-differentiated to anaplastic growth male impotence 30s generic 100 mg nizagara visa. Benign tumours: these are less common and include pheochromocytoma and myelolipoma. Tumours arising from embryonic nerve cells: these are more common and include neuroblastoma and ganglioneuroma. Its name is derived from its characteristic dark brown black appearance of this tumour caused by chromaffin oxidation of catecholamines. The extra-adrenal pheochromocytomas arising from other paraganglia are preferably called paragangliomas, named along with the anatomic site of origin. Most pheochromocytomas are slow-growing and benign but about 10% of the tumours are malignant, invasive and metastasising. Thus, the traditional "10% rule" for pheochromocytoma is 10% familial, 10% malignant, 10% extra-adrenal. The clinical features of pheochromocytoma are predominantly due to secretion of catecholamines, both epinephrine and norepinephrine. G/A the tumour is soft, spherical, may be quite variable in size and weight, and well-demarcated from the adjacent adrenal gland. On cut section, the tumour is grey to dusky brown with areas of haemorrhages, necrosis, calcification and cystic change. On immersing the tumour in dichromate fixative, it turns brown-black due to oxidation of catecholamines in the tumour and hence the name chromaffin tumour. The tumour cells are arranged characteristically as well-defined nests (also termed as zellballen pattern) separated by abundant fibrovascular stroma. The tumour cells are large, polyhedral and pleomorphic with abundant granular amphophilic or basophilic cytoplasm and vesicular nuclei. M/E It consists of well-differentiated adipose tissue in which is scattered clumps of haematopoietic cells are seen. Vast majority of cases occur within the abdomen (in the adrenal medulla and paravertebral autonomic ganglia) and rarely in the cerebral hemisphere. The clinical manifestations of neuroblastoma are related to its rapid local growth, metastatic spread or development of hormonal syndrome. Metastatic spread occurs early and widely through haematogenous as well as lymphatic routes and involves bones (especially skull), liver, lungs and regional lymph nodes. G/A the tumour is generally large, soft and lobulated mass with extensive areas of necrosis and haemorrhages. Cut surface of the tumour is grey white and may reveal minute foci of calcification. The tumour cells are small, round and oval, slightly larger than lymphocytes, and have scanty and poorly-defined cytoplasm and hyperchromatic nuclei. They are generally arranged in irregular sheets separated by fibrovascular stroma. The central fibrillar material stains positively by silver impregnation methods indicating their nature as young nerve fibrils. Prognosis of neuroblastoma depends upon a few variables; favourable prognostic features are as under: i) Age of child below 2 years. It is derived from ganglion cells, most often in the posterior mediastinum, and uncommonly in other peripheral ganglia and brain. M/E It contains large number of well-formed ganglionic nerve cells scattered in fibrillar stroma and myelinated and non-myelinated nerve fibres. These tumours are also called chemodectomas because of their responsiveness to chemoreceptors. M/E the thyroid is composed of lobules of colloid-filled spherical follicles or acini. They are lined by cuboidal epithelium with numerous fine microvilli extending into the follicular colloid that contains the glycoprotein, thyroglobulin. Calcitonin-secreting C-cells or parafollicular cells are dispersed within the follicles. Iodine trapping by thyroidal cells involves absorbing of iodine from the blood and concentrating it more than twenty-fold. The condition is more frequent in females and is associated with rise in both T3 and T4 levels in blood, though the increase in T3 is generally greater than that of T4. The usual symptoms are emotional instability, nervousness, palpitation, fatigue, weight loss in spite of good appetite, heat intolerance, perspiration, menstrual disturbances and fine tremors of the outstretched hands. Cardiac manifestations in the form of tachycardia, palpitations and cardiomegaly are invariably present in hyperthyroidism. The clinical manifestations of hypothyroidism, depending upon the age at onset of disorder, are divided into 2 forms: 1. Cretinism or congenital hypothyroidism is the development of severe hypothyroidism during infancy and childhood. This is the period when brain development is taking place; in the absence of treatment the child is both physically and mentally retarded. The presenting features of a cretin are: slow to thrive, poor feeding, constipation, dry scaly skin, hoarse cry and bradycardia. As the child ages, clinical picture of fully-developed cretinism emerges characterised by impaired skeletal growth and consequent dwarfism. The term myxoedema connotes non-pitting oedema due to accumulation of hydrophilic mucopolysaccharides in the ground substance of dermis and other tissues. The striking features are cold intolerance, mental and physical lethargy, constipation, slowing of speech and intellectual function, puffiness of face, loss of hair and altered texture of the skin. Detection of autoantibodies the following autoantibodies against different thyroid cell antigens are detected: i) Thyroid microsomal autoantibodies (against the microsomes of the follicular cells). Genetic basis the disease has higher incidence in first-degree relatives of affected patients. G/A the classic form is characterised by diffuse, symmetric, firm and rubbery enlargement of the thyroid which may weigh 100-300 gm. Sectioned surface of the thyroid is fleshly with accentuation of normal lobulations but with retained normal shape of the gland. The fibrosing variant has a firm, enlarged thyroid with compression of the surrounding tissues. There is extensive infiltration of the gland by lymphocytes, plasma cells, immunoblasts and macrophages, with formation of lymphoid follicles having germinal centres. There is decreased number of thyroid follicles which are generally atrophic and are often devoid of colloid. The follicular epithelial cells are transformed into their degenerated state termed Hurthle cells (also called Askanazy cells, or oxyphil cells, or oncocytes). Etiology of the condition is not known but clinical features of a prodromal phase and preceding respiratory infection suggest a possible viral etiology. The disease is more common in young and middle-aged women and may present clinically with painful moderate thyroid enlargement with fever, features of hyperthyroidism in the early phase of the disease, and hypothyroidism if the damage to the thyroid gland is extensive. G/A There is moderate enlargement of the gland which is often asymmetric or focal. M/E the features vary according to the stage: Initially, there is acute inflammatory destruction of the thyroid parenchyma and formation of microabscesses. These granulomas consist of central colloid material surrounded by histiocytes and scattered multinucleate giant cells. G/A the thyroid gland is usually contracted, stony-hard, asymmetric and firmly adherent to the adjacent structures. M/E There is extensive fibrocollagenous replacement, marked atrophy of the thyroid parenchyma, focally scattered lymphocytic infiltration and invasion of the adjacent muscle tissue by the process. The disease is more frequent between the age of 30 and 40 years and has five-fold increased prevalence among females. G/A the thyroid is moderately, diffusely and symmetrically enlarged and may weigh up to 70-90 gm. On cut section, the thyroid parenchyma is typically homogeneous, red-brown and meaty and lacks the normal translucency. There is considerable epithelial hyperplasia and hypertrophy as seen by increased height of the follicular lining cells and formation of papillary infoldings of piled up epithelium into the lumina of follicles which are small. The colloid is markedly diminished and is lightly staining, watery and finely vacuolated. Patients are usually young women who present with symmetric, moderate enlargement of the thyroid gland with features of thyrotoxicosis, ophthalmopathy and dermatopathy. Ocular abnormalities are lid lag, upper lid retraction, stare, weakness of eye muscles and proptosis. In extreme cases, the lids can no longer close and may produce corneal injuries and ulcerations. The fundamental defect is deficient production of thyroid hormones due to various etiologic factors, but most common is dietary lack of iodine. Cyclical hyperplastic stage followed by involution stage completes the picture of simple goitre. Such endemic areas are several high mountainous regions far from the sea where iodine content of drinking water and food is low such as in the regions of the Himalayas, the Alps and the Ande. These substances are drugs used in the treatment of hyperthyroidism and certain items of food such as cabbage, cauliflower, turnips and cassava roots. Sporadic (non-endemic) goitre Non-endemic or sporadic simple goitre is less common than the endemic variety. G/A the enlargement of the thyroid gland in simple goitre is moderate (weighing up to 100-150 gm), symmetric and diffuse. Hyperplastic stage is the early stage and is characterised by tall columnar follicular epithelium showing papillary infoldings and formation of small new follicles. Involution stage generally follows hyperplastic stage after variable period of time. This stage is characterised by large follicles distended by colloid and lined by flattened follicular epithelium. It is characterised by most extreme degree of tumour-like enlargement of the thyroid gland and characteristic nodularity. The enlargement of the gland may be sufficient to not only cause cosmetic disfigurement, but in many cases may cause dsyphagia and choking due to compression of oesophagus and trachea. Possibly, epithelial hyperplasia, generation of new follicles, and irregular accumulation of colloid in the follicles-all contribute to produce increased tension and stress in the thyroid gland causing rupture of follicles and vessels. This is followed by haemorrhages, cystic change, scarring and sometimes calcification, resulting in development of nodular pattern. G/A the thyroid in nodular goitre shows asymmetric and extreme enlargement, weighing 100-500 gm or even more. Cut surface generally shows multinodularity but occasionally there may be only one or two nodules which are poorly-circumscribed. Clinically, it appears as a solitary nodule which can be found in approximately 1% of the population. Besides the follicular adenoma, other conditions which may produce clinically apparent solitary nodule in the thyroid are a dominant nodule of nodular goitre and thyroid carcinoma. G/A the follicular adenoma is characterised by four features so as to distinguish it from a nodule of nodular goitre: 1. On cut section, the adenoma is grey-white to red-brown, less colloidal than the surrounding thyroid parenchyma. The tumour cells are benign follicular epithelial cells lining follicles of various sizes. These cells may also form trabecular, solid and cord patterns with little follicle formation. Microfollicular (foetal) adenoma consists of small follicles containing little or no colloid and separated by abundant loose stroma. Normofollicular (simple) adenoma has closely packed follicles like that of normal thyroid gland. Macrofollicular (colloid) adenoma contains large follicles of varying size and distended with colloid. Trabecular (embryonal) adenoma resembles embryonal thyroid and consists of closely packed solid or trabecular pattern of epithelial cells. Hurthle cell (oxyphilic) adenoma is an uncommon variant composed of solid trabeculae of large cells having abundant granular oxyphilic cytoplasm and vesicular nuclei. Atypical adenoma is the term used for a follicular adenoma which has more pronounced cellular proliferation so that features may be considered indicative of malignancy such as pleomorphism, increased mitoses and nuclear atypia. Primary lymphomas of the thyroid comprise less than 5% of thyroid cancers and majority of them possibly evolve from autoimmune (lymphocytic) thyroiditis. In line with most other thyroid lesions, most carcinomas of the thyroid too have female preponderance and are twice more common in women. Carcinoma of the thyroid gland has 4 major morphologic types with distinctly different clinical behaviour and variable prevalence. External radiation the single most important environmental factor associated with increased risk of developing thyroid carcinoma after many years of exposure to external radiation of high dose. Genetic basis Familial clustering of thyroid cancer has been observed, especially in medullary carcinoma. It can occur at all ages including children and young adults but the incidence is higher with advancing age. Involvement of the regional lymph nodes is common but distant metastases to organs are rare.

Clearly this depends on the epidemic but is an important consideration in all investigations erectile dysfunction psychological treatment techniques buy 100 mg nizagara. For example erectile dysfunction and high blood pressure generic nizagara 25mg otc, an epidemic of hepatitis A in Pascagoula top 10 causes erectile dysfunction buy nizagara 25 mg otc, Mississippi erectile dysfunction jacksonville florida generic 25 mg nizagara with mastercard, in 1961 erectile dysfunction pills supplements buy nizagara 50mg low cost, might have disrupted production by a local company of atomic submarines for the U erectile dysfunction pump 25 mg nizagara with amex. Upon arrival in Pascagoula, by using a local directory, the investigating epidemiologist contacted patients by telephone. After completing interviews with selected patients, the epidemiologist contacted an equal number of controls. An analysis of these data at the end of the first day of the investigation strongly indicated that ingestion of raw shellfish was the risk factor involved. The epidemiologist was able to come to this conclusion before interviewing all of the patients. On the basis of these early findings, a decision was made to publicize the problem and to recommend that raw shellfish no longer be eaten. This action terminated the occurrence of new exposures; after completing interviews with all patients, the initial preliminary conclusion was confirmed. Early in an investigation, categorizing cases as possible, probable, or confirmed on the basis of available data and knowledge is often necessary. An example of the importance of categorization occurred during the investigation of Legionnaires disease in Pennsylvania in 1976. The initial case definition required that patients had been in the main conference hotel. Illnesses of certain other patients met the clinical case definition except that they had not been in the hotel; thus their illnesses were put in a separate category called "Broad Street pneumonia. The Board Street pneumonia cases were included in the final tabulation for the outbreak. Four more updates followed, with the last reporting identification of the bacterium that caused the disease (14) 11 months before publication in a peer-reviewed journal (15). After all the patients have been interviewed during an investigation, the data should be oriented by time, place, and person. Then a hypothesis should be developed on the basis of the data that have been collected. After a hypothesis has been identified that fits the facts, corresponding control and prevention measures should be determined and implemented. Surveillance must be maintained to evaluate whether the hypothesis was correct and the control strategy is working. However, if cases continue to occur, the investigation has to be continued and different hypotheses tested. Preliminary evidence implicated tomatoes as the transmission vehicle, but further epidemiologic and microbiologic investigations identified jalapeno and serrano peppers as the primary vehicles. Recently epidemiologists have used the Internet as a tool for data collection, although the validity of that use remains under scrutiny. The fact that the weekly edition can, in fact, be published electronically at any time, day or night, can facilitate case ascertainment in an ongoing investigation. Meanwhile, the WorldWide Web has opened channels of communication that are more timely and far reaching than could have been imagined in 1961. Well-crafted, timely, and accurate updates of an investigation help the medical and public health communities, as well as the public, stay abreast of ongoing investigations, and they assist in implementing timely interventions to protect the public. A secondary benefit of a report is its value as a useful training document for current staff and incoming epidemiologists. The report should identify the risk factors that resulted in the epidemic, and the report should be disseminated to the population involved in the epidemic to educate the public about control and prevention measures. Also, the report can be distributed to other public health professionals to help prevent a future similar problem. The results of an investigation often indicate the need for other studies related to the disease or injury. For example, investigation of epidemics of Ebola virus hemorrhagic fever identified control measures. What remains unknown and continues to be investigated is the reservoir for Ebola virus, which might be another mammal. Rapid technology development in the laboratory has improved diagnostic precision and reduced the time necessary to make a diagnosis. These improvements should continue, for example, to identify pathogens in imported foods at the place of importation and among persons who now travel more extensively and more rapidly around the globe. Similarly, increased use of electronic health records will facilitate more timely and accurate data collection as well as real-time dissemination of recommended control measures to clinicians and health-care facilities. Statisticians continue to develop new statistical methods that will provide insights through refined data analysis. For example, mathematical modeling, especially in complex and time-consuming investigations. Improved techniques for training also need to be developed so that the technology of epidemic investigations can be used effectively by public health personnel both in the United States and internationally. It still often publishes the first scientific report of an unfolding epidemic investigation, and the reports continue through the different stages of the outbreak or incident. Epidemic assistance by the Centers for Disease Control and Prevention: role of the Epidemic Intelligence Service. A multistate outbreak of Escherichia coli O157:H7­associated bloody diarrhea and hemolytic uremic syndrome from hanburgers: the Washington experience. Multistate outbreak of Salmonella serotype Tennessee infections associated with peanut butter-United States, 2006­2007. Multiple-serotype Salmonella gastroenteritis outbreak after a reception-Connecticut, 2009. Infectious hepatitis traced to the consumption of raw oysters: an epidemiologic study. Outbreak of Salmonella serotype Saintpaul infections associated with multiple raw produce items-United States, 2008. Since 1961, advances in molecular sciences, analytical chemistry, and technology have revolutionized the public health laboratory investigative capacity, capability, and specificity and have emphasized the importance of more independent laboratory research. The term "molecular epidemiology" is widely applied, and the number of diseases for which laboratory diagnoses are available today is substantially larger. This article describes the principles and practices of the state-of-the-art public health laboratory in 1961 and provides examples of scientific, technologic, and strategic advances since that time that characterize the still evolving public health laboratory of the 21st century. Subsequently, progress and contributions made by the public health laboratories are provided in a more detailed account by using several illnesses and conditions of public health importance as examples. The basic procedures for isolation and identification of polioviruses in cell cultures were slow but well developed, benefitting from 30 years of concentrated laboratory research to understand the disease and develop a vaccine. Although a remarkable humanitarian achievement, the introduction of live vaccine into the environment and the clinical and epidemiologic need to differentiate vaccine strains from wild strains proved a major challenge to the laboratory. Outbreaks were differentiated into infectious or serum hepatitis on the basis of clinical and epidemiologic grounds, and the totals (72,651 cases in 1961) were combined. Because development of an influenza virus vaccine had been a high priority of the U. Classification according to H (hemagglutinin) and N (neuraminidase) antigens was yet to come. Rabies was a notifiable disease in humans and animals, with three and 3,599 cases reported, respectively, in 1961 (2). Diagnostic procedures were evolving from the traditional histologic staining for Negri bodies to specific fluorescent antibody staining, greatly increasing confidence in laboratory diagnosis. Human vaccines for anthrax had already been developed in the United Kingdom and the United States. Outbreaks of salmonellosis, shigellosis, staphylococcal food poisoning, pathogenic Escherichia coli, typhoid fever, and botulism were commonly reported in volume 10, week 1. Mingled among these reports were 25 apparent foodborne disease outbreaks of unknown etiology by mid-year. The need for discovery of new and more precise characterization of already recognized etiologic agents of diarrhea was evident. Listed clinical conditions of unproven etiology included rubella, erythema infectiosum, and cat-scratch fever. Roseola infantum, now known to be caused by one of eight human herpesviruses (type 6), exemplifies the progress made during the past 50 years. The following sections review these and other diseases and provide some insight into the scientific and technical advances that have revolutionized the public health laboratory capabilities during the past 50 years. The growing capabilities of the poliovirus laboratory coincided with the launch of the global polio eradication initiative in 1988. Continuously evolving molecular techniques and novel technologies eventually made possible the sequencing and comparing of poliovirus genomes in real time. Linking these advances to the newly established poliovirus evolutionary rate provided previously unimagined detailed information about individual poliovirus isolates. The Islamabad, Pakistan, polio laboratory, one of 147 laboratories in the polio network, processed >15,000 fecal and sewage samples and isolated 137 polioviruses in 2009. Genomic sequencing of these 137 isolates from Afghanistan and Pakistan provided data that identified virus origins, transmission zones of circulating wild viruses, and viruses that were not closely related. Information about virus origin and transmission inform the program of inadequately immunized populations. Distantly related viruses provide evidence of evolutionary gaps and inform the program of surveillance weaknesses that must be improved. Molecular epidemiology plays a key role in all aspects of the poliovirus eradication initiative. Hepatitis In 1961, a report of an outbreak of infectious hepatitis A among chimpanzee handlers (7) generated considerable interest, suggesting nonhuman primates might be possible models for human hepatitis. However, 18 years would pass before the virus would be propagated in cell culture, which would make laboratory diagnosis and a vaccine possible (8). In 1963, the serendipitous discovery of an antigen in human blood (9) led to the eventual association of this protein with serum hepatitis B and development of a highly effective vaccine in the early 1980s. The development of diagnostic tests for hepatitis A and B viruses led to recognition of three other etiologic agents (types C, D, and E). In few other infectious diseases has progress been as rapid and effects on disease reduction as dramatic. The biology-based laboratory test then in use also figured prominently in the 1974 landmark legal ruling (Reyes vs. By 1984, the laborious but definitive newly developed oligonucleotide fingerprinting technique confirmed the Reyes poliovirus isolate as wild (4). Influenza In 1961, lessons learned from the overwhelming laboratory workload during the A2 pandemic of 1957­58 were still being implemented. The test was performed over a 3-day period in a large room with two big tables specially designed for the purpose in the new (1960) virology laboratory building. The average run of paired serum samples from 50 patients used approximately 4,000 test tubes (all to be washed and reused), 60 wire test tube racks, and nearly 100 pipettes. On day 1, six antigens were prepared, test tubes marked, and serum sequentially diluted (by mouth pipette). On the morning of day 2, the four essential test reagents were prepared and standardized. In the afternoon, 8­10 laboratory personnel were rounded up; given instructions and pipettes; and marched around the table adding one ingredient in precise sequence. On the morning of day 3, the final indicator reagent was added and the results read, tube by tube, against the ceiling lights, trusting no one had added materials to the wrong test tubes or in the wrong sequence. The greatest advances in understanding the influenza virus closely parallel the phenomenal advances in molecular technology. The pandemic influenza A (H1N1) 2009 virus was demonstrated to be a triple genetic reassortant with an antigenic structure similar to those of the influenza viruses circulating early in the 20th century (11). Yet to benefit from these major breakthroughs in science is the killed influenza vaccine, which has seen only incremental improvements since 1961. Development of new diagnostic and molecular subtyping tools with emphasis on standardization and quality control led the path for establishing the Laboratory Response Network that was instrumental in analyzing approximately 200,000 environmental and clinical specimens during the 2001 anthrax attacks (13). Although the first report of naturally occurring anthrax toxin genes in a species (B. Rapid detection in clinical specimens and molecular subtyping of biothreat agents, which were demonstrated to be of critical importance for public health response in 2001, are now the standard in approximately 150 Laboratory Response Network laboratories in the United States and worldwide. Foodborne Diseases (PulseNet) Methods for characterizing etiologic agents of diarrhea, such as multilocus enzyme electrophoresis and ribotyping, first became available and used during the 1980s. However, no method was broadly accepted and standardized for use on different organisms until after the E. From November 1992 through February 1993, approximately 700 laboratory-confirmed infections with E. Distinct clinical presentation associated with this pathogen was first described in 1983 and subsequently recognized as an important cause of bloody diarrhea and the most common cause of renal failure in children (hemolytic uremic syndrome) (16). This national molecular subtyping network for foodborne disease surveillance later became known as PulseNet (18) and was officially launched in 1998 by the White House. One such PulseNet-detected outbreak in Colorado in 1997 resulted in the largest meat recall thus far (19). PulseNet quickly expanded to include other etiologic agents of foodborne diseases: Salmonella and Shigella spp, Listeria monocytogenes, Campylobacter jejuni, Vibrio cholerae, and Yersinia pestis ( PulseNet has been instrumental in improving foodborne disease surveillance and outbreak investigations, especially outbreaks in which the cause might be the same but affected persons are geographically far apart. Critically important is the PulseNet approach to building public health infrastructure in state and local health departments with methods, equipment, and training that can be used broadly.

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