Dr Ho Siew Hong delivered a public lecture on differentiating prostate cancer from non cancer enlargement of the prostate during the Prostate Awareness Month 2008
Prof. Nicholas Harvey's presentation from Osteoporosis 2016: Calcium, with or without vitamin D supplementation, is not associated with ischaemic heart disease or cardiac death: the UK Biobank cohort.
Find out more at: https://nos.org.uk/conference
Dr Ho Siew Hong delivered a public lecture on differentiating prostate cancer from non cancer enlargement of the prostate during the Prostate Awareness Month 2008
Prof. Nicholas Harvey's presentation from Osteoporosis 2016: Calcium, with or without vitamin D supplementation, is not associated with ischaemic heart disease or cardiac death: the UK Biobank cohort.
Find out more at: https://nos.org.uk/conference
Sex after acute myocardial infarctio(Heart attack).
There are fears of having another heart attack or dying during sex. One woman even had to convince her husband that she wasn't going to die in bed. But women also expressed a motivation to return to sex as a way to get back to their normal life and not be stigmatized as a heart patient. We heard that a lot.This presentation solves so many such doubts spread in society.
Steroid Sparing Regimens in Kidney TransplantationAbdullah Ansari
Mechanisms of action of steroids
Rationale for steroids minimization
Steroid minimization strategies
Very low maintenance dosages
Complete withdrawal early after transplantation (three to six months post-surgery)
Complete withdrawal later after transplantation (six months to one year post-surgery)
Steroid free maintenance, after rapid withdrawal within a week
Complete avoidance
This powerpoint presentation deals with the chief recommendations of ISBMR osteoporosis recommendations. It also encompasses relevant articles which have been cited for formulation of the article.
An introduction to week 1 of a free online course on enhancing prostate cancer care, delivered by Sheffield Hallam University in the UK (Oct-Nov 2014). Week 1 focuses on diagnosis.
Historical background
The concept of incremental dialysis
The residual kidney function and its significance
Incremental hemodialysis
Observational studies on incremental HD
The candidates for incremental HD
The potential benefits and risks associated with incremental HD
Incremental peritoneal dialysis
The intact nephron hypothesis in reverse
Sex after acute myocardial infarctio(Heart attack).
There are fears of having another heart attack or dying during sex. One woman even had to convince her husband that she wasn't going to die in bed. But women also expressed a motivation to return to sex as a way to get back to their normal life and not be stigmatized as a heart patient. We heard that a lot.This presentation solves so many such doubts spread in society.
Steroid Sparing Regimens in Kidney TransplantationAbdullah Ansari
Mechanisms of action of steroids
Rationale for steroids minimization
Steroid minimization strategies
Very low maintenance dosages
Complete withdrawal early after transplantation (three to six months post-surgery)
Complete withdrawal later after transplantation (six months to one year post-surgery)
Steroid free maintenance, after rapid withdrawal within a week
Complete avoidance
This powerpoint presentation deals with the chief recommendations of ISBMR osteoporosis recommendations. It also encompasses relevant articles which have been cited for formulation of the article.
An introduction to week 1 of a free online course on enhancing prostate cancer care, delivered by Sheffield Hallam University in the UK (Oct-Nov 2014). Week 1 focuses on diagnosis.
Historical background
The concept of incremental dialysis
The residual kidney function and its significance
Incremental hemodialysis
Observational studies on incremental HD
The candidates for incremental HD
The potential benefits and risks associated with incremental HD
Incremental peritoneal dialysis
The intact nephron hypothesis in reverse
Das: Physical Health in the In-Patient Mental Health Settinghenkpar
Wonca Working Party on Mental Health
World mental Health Day
presentation Dr Mrigendra Das (UK)
Physical Health in the In-Patient Mental Health Setting
Hormones, Cognition, and Mood Changes in Older AdultsLouis Cady, MD
HORMONES, COGNITION AND MOOD CHANGES IN OLDER ADULTS. This is Dr. Cady's lecture from the Age Management Medical Group meeting in las Vegas, NV, PRESENTED 12 2 2012.
Commercial products and compounded options for the treatment of erectile dysfunction. Brief overview regarding the pathophysiology, medical, and physical causes behind these disorders as well as epidemiology and prevalence of the disease.
1. A Case report of Heart Failure
2. Discussion on Heart Failure
3. Role of Peptides in Heart Failure
4. Importance of 30 days in heart failure
5. Role of ENTRESTO in Stable Heart Failure patient (PARADIGM-HF study)(HFrEF)
6. Biomarkers in Heart Failure
7. Role of ARNI in Hospitalized Heart Failure patient (PIONEER-HF study)
8. Role of ARNI in HFpEF (PARAMOUNT Trial)
9. Safety and usefulness of ACEI/ARB/ARNI
10. Role of SGPL2 inhibitors in HF with/without DM
SANDRI G. La Nutrizione Clinica al S.Eugenio. ASMaD 2017Gianfranco Tammaro
DOTT. GIANCARLO SANDRI - Convegno "Il Presente ed il Futuro della Nutrizione Clinica" - 24/03/2017 - Sala Rita Levi Montalcini - Ospedale S.Eugenio - ROMA
Sito ASMaD: http://www.asmad.net
Canale Youtube: https://youtu.be/O7NcSQjnRR4
GASBARRINI A. Nutrizione Clinica e Gastroenterologia. ASMaD 2017Gianfranco Tammaro
PROF. ANTONIO GASBARRINI - Convegno "Il Presente ed il Futuro della Nutrizione Clinica" - 24/03/2017 - Sala Rita Levi Montalcini - Ospedale S.Eugenio - ROMA
Sito ASMaD: http://www.asmad.net
Canale Youtube: https://youtu.be/FYlsQzE8xfk
PALLAGROSI R. Gli Alimenti a fini medici speciali: nuova definizione e normat...Gianfranco Tammaro
DOTT.SSA ROBERTA PALLAGROSI - Convegno "Il Presente ed il Futuro della Nutrizione Clinica" - 24/03/2017 - Sala Rita Levi Montalcini - Ospedale S.Eugenio - ROMA
Sito ASMaD: http://www.asmad.net
Canale Youtube: https://youtu.be/86dXMRSe6hQ
DE SANTIS D. Il Supporto Nutrizionale in Ospedale: ieri, oggi, domani. ASMaD ...Gianfranco Tammaro
CPSI DANIELA DE SANTIS - Convegno "Il Presente ed il Futuro della Nutrizione Clinica" - 24/03/2017 - Sala Rita Levi Montalcini - Ospedale S.Eugenio - ROMA
Sito ASMaD: http://www.asmad.net
Canale Youtube: https://youtu.be/VhUPt78wU4Y
Giorgetti G.M. Il Supporto Nutrizionale in Ospedale: ieri, oggi, domani. ASMa...Gianfranco Tammaro
DOTT. GIAN MARCO GIORGETTI - Convegno "Il Presente ed il Futuro della Nutrizione Clinica" - 24/03/2017 - Sala Rita Levi Montalcini - Ospedale S.Eugenio - ROMA
Sito ASMaD: http://www.asmad.net
Canale Youtube: https://youtu.be/hDOnIcyTagc
Franceschi F. Il Ruolo del Gastroenterologo nel DEA. ASMaD 2016Gianfranco Tammaro
PROF. FRANCESCO FRANCESCHI - 3° Giornata Master ECM in Gastroenterologia 2016 (25/11/2016) - Fondazione Santa Lucia - Sala Congressi - Roma
Sito: www.asmad.net
Canale Youtube: https://youtu.be/NZzctPkJiGI
Gasbarrini A. Microbiota, Antibiotici e Probiotici in Gastroenterologia. ASMa...Gianfranco Tammaro
PROF. ANTONIO GASBARRINI - 3° Giornata Master ECM in Gastroenterologia 2016 (25/11/2016) - Fondazione Santa Lucia - Sala Congressi - Roma
Sito: www.asmad.net
Canale Youtube: https://youtu.be/ouYcXg_ZtJM
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Best Ayurvedic medicine for Gas and IndigestionSwastikAyurveda
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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1. TERAPIA DELLA DISFUNZIONE ERETTILE : UP-TO-DATE Slide Modified: MRW 6/04 Review: Reviewer Memo: Source: Memo: Antonio Aversa MD, PhD Dipartimento di Fisiopatologia Medica “ Sapienza” Università di Roma S APIENZA U NIVERSITA’ DI R OMA
2.
3.
4. The Prevalence of Comorbid Conditions Increases With ED Severity Shabsigh R et al. J Urol. 2005;174:662-667. Comorbidity ED Severity None Mild Mild to Moderate Moderate Severe High Blood Pressure 24% 25% 32% 42% 39% High Cholesterol 20% 25% 27% 35% 38% Enlarged Prostate 10% 16% 16% 23% 26% Heart Trouble 3% 7% 10% 16% 34% Anxiety 13% 15% 18% 19% 18% Diabetes 11% 8% 11% 16% 24% Depression 8% 8% 12% 12% 12% Heart Attack/Surgery 4% 7% 8% 13% 29% Hardening of Arteries 3% 6% 7% 10% 13% Spinal Cord Injury 3% 5% 5% 3% 5% Prostate Cancer 0 1% 1% 1% 0
5.
6.
7. Major Risk Factors for ED: Chronic Diseases 1. Martin-Morales A et al. J Urol . 2001;166:569-575. 2. Braun M et al. Int J Impot Res . 2000;12:305-311. 3. Goldstein I. Am J Cardiol . 2000;86(suppl):41F-45F. 4. Feldman HA et al. J Urol . 1994;151:54-61. Chronic Disease Increased ED Risks* Diabetes 1,2 4.1 Prostate disease 1 2.9 Peripheral vascular disease 1 2.6 Cardiac problems 1 1.8 Hyperlipidemia 1 1.6 Hypertension 1,2 1.6 Depression 3,4 1.8 * Age-adjusted odds ratio. Prostatic symptoms on the International Prostate Symptom Score (IPSS) questionnaire.
8.
9. The Aging male ‘Pyramid’ Slide Modified: MRW 6/04 Review: Reviewer Memo: Source: Memo: Aversa A et al, IJU, in press
35. Potenziale di impiego degli inibitori della PDE5 nell’EP IA Abdel-Amid, Drugs 2004;64(1):13-26 Modulazione della risposta contrattile di dotti deferenti, vescicole seminali, prostata e uretra Tramite le vie NO/cGMP e cAMP Tramite inibizione della neurotrasmissione adrenergica Tramite azione diretta Induzione di uno stato di analgesia periferica Probabilmente tramite la via NO/cGMP Riduzione delle risposta simpatica centrale Tramite la via NO/cGMP e azione su MPOA Interazione con i classici neurotrasmettitori Prolungamento della durata dell’erezione Accumulo di cGMP nelle cellule cavernose Miglioramento dell’ossigenazione del tessuto penieno INIBITORI DELLE PDE5 MIGLIORAMENTO DELLA EP
36.
Editor's Notes
Key point: This section discusses the practical management of ED in patients.
Key point: Not only are couples who are experiencing ED frequently burdened with significant psychological conditions, ED may also signal the presence of a more serious underlying disease. Specific points: It is medically important to diagnose and treat ED. ED is often associated with comorbid conditions that may not have been detected previously, such as cardiovascular disease, diabetes, and depression. ED-associated distress can have a serious negative impact on the patients’ overall quality of life as well as on interpersonal relationships. The evaluation of ED should include a determination of potential underlying causes and the identification of appropriate treatment following a complete medical assessment. Retention of potency is a strong motivator for men. Physicians can use this motivation to drive better medication compliance and better adherence to advice on lifestyle modification. Thus, it is important to query patients regarding sexual function. Goldstein I. Int J Impot Res . 2000;12(suppl 4):S147-S151. Goldstein I. Am J Cardiol . 2000;86(suppl):41F-45F.
Key point: ED is frequently associated with other serious, treatable disorders. Specific points: The strong association of ED with other conditions should prompt further diagnoses, for example: The most common condition associated with ED is hypertension. According to Burchardt et al., 68% of men with hypertension have ED. 1 A publication by Levine and Kloner in the American Journal of Cardiology in 2001 brings together the published work of Pritzker and Billups, showing that performing a lipid screen in a group of men with ED indicates that dyslipidemia is strongly associated with ED. 2 Bearing this association in mind, it is not surprising that Pritzker reports in his findings that in a group of 50 men presenting with ED, 28 (56%) had a positive stress test, and 20 of these had significant underlying coronary occlusions on angiography. The strength of this association in patients presenting to urologists remains to be confirmed. 3 The prevalence of diabetes in men with ED is about 20%; the exact number varies by study. 4 The prevalence of depression in men with ED is about 11%; the exact number varies by study. 5 1. Burchardt M et al. J Urol . 2000;164:1188-1191. 2. Levine L and Kloner R. Am J Hypertens . 2001;14:1210-1213. 3. Pritzker MR. Circulation . 1999;100(suppl 1):I-711. Abstract 3751. 4. Braun M et al. Int J Impot Res . 2000;12:305-311. 5. Seftel A. J Urol . 2004;171:2341-5
Main Point: The incidence of comorbidities increases as the severity of ED worsens. Results from the Cross-National Survey on Men’s Health Issues, which was a population-based, international survey of men using the health care systems of participating countries: US, Germany, UK, France, Italy and Spain. Men were 20-75 years old. A total of 28,691 men completed the screening questionnaire and provided their age. Shabsigh R, et al. J Urol 2005;174:662-667.
Key point: ED may be the first sign of underlying heart disease and thus may be an early warning signal for physicians. Specific points: In a study by Kaiser et al., 30 men with ED (non-neurogenic in etiology) who had no other identified medical problems and 27 age-matched normal men were recruited. Men were excluded if they had a history of recent smoking, hypertension, hyperlipidemia, or serious chronic diseases (e.g., diabetes mellitus). The men were then evaluated for systemic vascular integrity and function abnormalities, including measurements for coronary calcification, aortic pulse wave velocity, brachial and carotid artery diameters, intima-media thickness, compliance and distensibility, and brachial artery endothelium-dependent and independent response. Tests also included a blood chemistry profile and an ED questionnaire. In spite of the lack of clinical cardiovascular symptoms (other than ED) or other cardiac risk factors, there were clear indications that men with ED had a peripheral vascular abnormality in the NO-GMP pathway, as measured by brachial artery flow-mediated vasodilation (FMD) and vasodilation following sublingual nitroglycerine. This abnormality was present despite a normal CAD risk score, normal systemic vascular stiffness measures and vascular structure. This NO-GMP abnormality may be the cause of ED and be the first manifestation of CV disease. IIEF is the International Index of Erectile Function Questionnaire. The IIEF Erectile Function (EF) Domain score has a range of 1-30. Kaiser DR et al. JACC. 2004;43:179-84.
Key point: Men with any of these major risk factors should routinely be asked about ED. Specific points: A wide variety of situations/conditions represent major risk factors for ED: Advancing age Chronic conditions (e.g., hypertension, diabetes, depression, cardiovascular disease) Medications (e.g., thiazide diuretics, beta-blockers, serotonin reuptake inhibitors (selective or not, including fluoxetine, etc.) Unhealthy behaviors (e.g., alcohol abuse, cigarette smoking) Feldman HA et al. J Urol. 1994;151:54-61.
Key point: When ED is suspected, the physician should evaluate the patient’s condition comprehensively in order to characterize the ED and to identify other underlying conditions that the presence of ED may signal. Specific points: It is important to identify the underlying cause of ED in a patient. 1 Underlying causes may be due to: The presence of a chronic disease that had been undiagnosed, such as diabetes, prostate diseases, vascular disease or hypogonadism. 1 Depression 2 Extrinsic factors such as a concomitant medication or life style issues. 1 If warranted, the physician may elect to perform more specialized tests, for example if there is evidence of significant endocrine, psychogenic, or vascular disease. 1. Recommendations of the 1st International Consultation on Erectile Dysfunction. In: Jardin A et al, eds. Erectile Dysfunction . Plymouth, UK: Health Publication, Ltd; 2000:711-726. 2. Goldstein I. Am J Cardiol . 2000;86(suppl):41F-45F.
Key point: A number of prescription medications have been linked to ED. If a patient receiving treatment with any of these medications complains of ED, adjusting the dose of medication or switching to another therapeutic agent may be considered. Specific points: Antihypertensive agents, mainly thiazides and thiazide-like diuretics, 1 and, to a lesser extent, beta-blockers, 2 have been reported to adversely affect sexual function. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers are less likely to affect sexual function. 2 Sexual dysfunction occurs commonly in patients taking antidepressants. 3 Hormonal chemotherapeutics, particularly the antiandrogens, including 5-alpha reductase inhibitors, also increase the risk of ED. 4 Grimm RH Jr et al. Hypertension . 1997;29:8-14. Suzuki H et al. J Hypertens . 1988;6(suppl):S649-S651. Clayton AH et al. J Clin Psych. 2002;63:357-366. Higano CS. Urology . 2003;61(suppl 1):32-38.
Key point: The sexual history is important to determine the extent and duration of the erectile dysfunction. The medical history can help to identify the causality and facilitate determining existing comorbidities and ruling out associated co-morbidities, as appropriate. 1,2 Specific points: It is necessary to establish the partner’s awareness of the ED and gauge their interest in resolution of the condition. The most successful treatment is usually associated with the female partner’s wish to restore sexual intimacy to the relationship. Recommendations of the 1st International Consultation on Erectile Dysfunction. In: Jardin A et al, eds. Erectile Dysfunction . Plymouth, UK: Health Publication, Ltd; 2000:711-726. The Process of Care Consensus Panel. Int J Impot Res . 1999;11:59-70.
Key point: Screening for ED is a relatively easy way to have a major impact on patients’ lives. Specific points: Sexual dysfunction can have a large impact on a patient’s overall physical and emotional well-being. 1 ED may be a marker of a previously unrecognized condition such as hypertension, heart disease, depression, or diabetes. 1,2 Men with ED have a lower quality of life than those without sexual dysfunction. 3 Improved patient satisfaction and patient-clinician relationships are the result of open dialog on sexual dysfunction. 1 In men who have ED and clinical depression, symptoms may improve as they respond to ED treatment. 3 Eid JF, Sadovsky R. Cliniguide ® to Erectile Dysfunction . New York, NY: Lawrence DellaCorte Publications, Inc; 2001. Shabsigh R et al. Urology . 1998; 52:848-852. Seidman SN et al. Am J Psych . 2001;158:1623-1630.
Key point: This section discusses the practical management of ED in patients.
Key point: As with the management of most diseases, treatment begins with changes in patient habits, lifestyles, and other modifiable risk factors and progresses to more invasive treatments as needed. Recommendations of the 1st International Consultation on Erectile Dysfunction. In: Jardin A et al., eds. Erectile Dysfunction . Plymouth, UK: Health Publication, Ltd; 2000:711-726.
Key point: Unhealthy lifestyle may contribute to development of ED. Therefore, clinicians should recommend behavior modification to their patients 1-3 Specific points: The following lifestyle modifications should be encouraged: smoking cessation, 1,2 avoidance or limitation of alcohol, 1 eating a healthy diet, 2 and proper exercise 3 Recommendations of the 1st International Consultation on Erectile Dysfunction. In: Jardin A et al, eds. Erectile Dysfunction. Plymouth, UK: Health Publication, Ltd; 2000:711-726. Feldman HA et al. Prev Med. 2000;30:328-338. Derby CA et al. Urology. 2000;56:302-306.
Key point: A number of prescription medications have been linked to ED. If a patient receiving treatment with any of these medications complains of ED, adjusting the dose of medication or switching to another therapeutic agent may be considered. Specific points: Antihypertensive agents, mainly thiazides and thiazide-like diuretics, 1 and, to a lesser extent, beta-blockers, 2 have been reported to adversely affect sexual function. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers are less likely to affect sexual function. 2 Sexual dysfunction occurs commonly in patients taking antidepressants. 3 Hormonal chemotherapeutics, particularly the antiandrogens, including 5-alpha reductase inhibitors, also increase the risk of ED. 4 Grimm RH Jr et al. Hypertension . 1997;29:8-14. Suzuki H et al. J Hypertens . 1988;6(suppl):S649-S651. Clayton AH et al. J Clin Psych. 2002;63:357-366. Higano CS. Urology . 2003;61(suppl 1):32-38.
Key point: Psychosocial counseling may be used alone to manage ED or may be used as an adjunct to other treatment options. Specific points: Psychosocial therapy addresses 4 main areas: anxiety reduction and desensitization, cognitive-behavioral interventions, sexual stimulation techniques, and interpersonal assertiveness with couples’ communication training. Rosen RC. Urol Clin North Am . 2001;28:269-278.
Key point: Phosphodiesterase type 5 inhibitors are the most frequently used type of ED treatment. Specific points: There are 3 (PDE5) inhibitors indicated for the treatment of ED: tadalafil, 1 vardenafil HCl, 2 and sildenafil citrate 3 Apomorphine 4 is also used in some patients but is not approved for use in ED in many countries Cialis ® (tadalafil) prescribing information. Lilly ICOS LLC: Indianapolis, IN, and Bothell, WA; 2003. Levitra ® (vardenafil HCl) prescribing information. Bayer Pharmaceuticals Corp: West Haven, CT; 2003. Viagra ® (sildenafil citrate) prescribing information. Pfizer Inc: New York, NY; 2002. Uprima ® (apomorphine HCl) prescribing information. Abbott Laboratories, Abbott Park, Il, 2001.
Key point: PDE5 inhibitors block the breakdown of cyclic guanosine monophosphate (cGMP), a secondary messenger that induces vasodilation within the smooth muscle cells in the penis, amplifying the natural signaling process during an erection. There are 3 phosphodiesterase type 5 inhibitors available that are indicated for the treatment of ED: tadalafil, vardenafil, and sildenafil. 1-3 Specific points: Penile erection during sexual stimulation is caused by increased penile blood flow resulting from the relaxation of penile arteries and corpus cavernosal smooth muscle. This response is mediated by the release of nitric oxide from nerve terminals and endothelial cells, which stimulates the synthesis of cGMP in smooth muscle cells. Increased intracellular cyclic GMP results in smooth muscle relaxation and increased blood flow into the corpus cavernosum. Phosphodiesterases are enzymes that hydrolyze cyclic nucleotides such as cGMP and cAMP. The inhibition of phosphodiesterase type 5 by PDE5 inhibitors enhances erectile function by increasing the local intracellular concentration of cGMP. Because sexual stimulation is required to initiate the local release of nitric oxide, PDE5 inhibition has no effect in the absence of sexual stimulation. Each drug is taken orally and sexual stimulation is required to obtain an erection. Cialis ® (tadalafil) prescribing information. Lilly ICOS LLC: Indianapolis, IN, and Bothell, WA; 2006. Levitra ® (vardenafil) prescribing information. Bayer Pharmaceuticals Corp: West Haven, CT; 2005. Viagra ® (sildenafil) prescribing information. Pfizer Inc: New York, NY; 2006.
Although it is difficult to compare different studies conducted at different times; IIEF EF domain scores at endpoint in this study appear somewhat smaller than those observed for tadalafil 5 mg in a previous study of once a day dosing 1 but appear somewhat larger than those reported for tadalafil 2.5 mg and tadalafil 5 mg in a pooled analysis of 5 studies of tadalafil dosed as needed. 2 This increase is not unexpected since the steady state plasma concentration for tadalafil is approximately 1.6 times the plasma concentration following a single dose. 3 1 Porst H et al. Eur Urol. 2006;50:351-359. 2 Brock GB et al. J Urol . 2002;168:1332-1336. 3 Forgue et al. Br J Clin Pharmacol. 2005;61:280-288. J. Rajfer, PJ Aliotta, CP Steidle, WP Fitch III, Y Zhao, A Yu Tadalafil Dosed once a day in men with erectile dysfunction: a randomized, double-blind, placebo-controlled study in the US Int J Imp Res (2006), in press, on line ahead of print
Key point: In addition to the PDE5 inhibitors, there are various other options available for the treatment of ED. Choice of treatment should be individualized depending on the etiology of ED and success/failure of previous treatments. Specific points: The most effective forms of testosterone replacement therapy for men with a documented hormone deficiency (e.g., androgen deficiency, hypogonadism), hormone replacement therapy 1 are intramuscular and transdermal 2 Testosterone patches and 1% gel: Testosterone levels with use of the gel are dose-dependent and stable between applications. 1 Long-acting testosterone pellets for subcutaneous implantation are available. 3 Transurethral administration or intracavernosal injection of alprostadil are localized therapies for treatment of ED. These therapies are now recommended as “second-line” therapy when oral therapy is contraindicated, intolerable, or for those who fail to respond to oral therapy. 2,4-6 Vacuum constriction devices (VCDs) are an option for men who are not interested in drug therapy or those who have specific contraindications to the available pharmacologic options. By applying negative pressure to the penis, the VCD draws blood into the cavernosal spaces. The blood is then retained by application of an elastic band to the base of the penis. A penile prosthesis may be a surgical option for patients who are intolerant to or who fail to respond to other ED treatments. This treatment option is particularly helpful for patients with specific concomitant medical conditions such as vascular or neurologic disease, or genital trauma (e.g., Peyronie’s disease) 5 For men with congenital or traumatic ED, vascular surgery may be indicated and can be curative. 2 AACE Male Sexual Dysfunction Task Force. Endocr Pract . 2003;9:77-95. Lue TF. N Engl J Med . 2000;342:1802-1813. Testopel™ pellets (testosterone) prescribing information. Physicians’ Desk Reference . 56th ed. Montvale, NJ: Medical Economics Company; 2002:3610-3611. Shabsigh R et al. Urology . 2000;55:109-113. 000;16 Recommendations of the 1st International Consultation on Erectile Dysfunction. In: Jardin A et al., eds. Erectile Dysfunction . Plymouth, UK: Health Publication, Ltd; 2000:711-726. MUSE® (alprostadil) prescribing information. Physicians’ Desk Reference. 56th ed. Montvale, NJ: Medical Economics Company; 2002:3335-3338.
Key point: In the management of ED, lifestyle modification, psychosocial counseling, and use of oral PDE5 inhibitors are first-line treatment options. Other therapies, such as intracavernosal injection or penile prostheses may be appropriate for patients with treatment failures, contraindications to oral or topical medications, and/or preferences for alternative approaches
cAMP = adenosin monofosfato ciclico; cGMP = guanosin monofosfato; MPOA = area preottica mediale dell’ipotalamo; NO = monossido di azoto E’ stato ipotizzato che il monossido di azoto agisca a livello dell’area preottica mediale dell’ipotalamo con un tono inibitorio sull’eiaculazione grazie alla riduzione del tono simpatico e d’altro canto è nota l’azione del monossido di azoto nel ridurre l’output centrale del sistema simpatico verso la periferia in molte specie animali incluso l’uomo. Questa azione può essere indotta grazie a un meccanismo dipendente dal cGMP o mediante interazione con i neurotramettitori classici; è altresì noto che la somministrazione intratecale di inibitori della PDE5 nel ratto aumenta i livelli di cGMP e di NO nell’area preottica mediale dell’ipotalamo e che i pazienti che assumono inibitori della PDE5 evidenziano anche un miglioramento della salute mentale e del benessere emotivo e vi sono evidenze che queste molecole si dimostrino poter ridurre l’ansia, rispetto al basale, nei pazienti con eiaculazione precoce con una azione sul sistema nervoso centrale simile a quella osservata sul sistema nervoso periferico.
![Why Diagnosing ED Is Important ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Slide Modified: Review: Reviewer Memo: Source: Memo: Goldstein I. Am J Cardiol . 2000;86(suppl):41F-45F. Goldstein I. Int J Impot Res . 2000;12(suppl 4):S147-S151. Francis ME., et al. J Urol. 2007;178:591-596. Selvin E., et al. Am J Med. 2007;120:151-157. Jackson G., et al. J Sex Med. 2006;3:28-36.](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)