26.Role of hormones during gender selection.pdfsaleeemmalik259
‘Male-typical development results from prenatal or neonatal exposure to testicular hormones,
whereas female-typical development happens in the absence of testicular hormones, according
to the classical model of hormonal influences on mammalian sexual differentiation.’
Treatment of male infertility is an important aspect of infertility treatment. Many factors can be prevented with lifestyle modifications and appropriate treatment.
Amenorrhea - Define, Cause, Sign and Symptoms, Type- Pathological and Physiol...sonal patel
Amenorrhea - Define, Cause, Sign and Symptoms, Type- Pathological and Physiological Amenorrhea and It's Treatment and management, Cushing Syndrome - Define, Causes, Sign And Symptoms in PPT made By Sonal Patel
26.Role of hormones during gender selection.pdfsaleeemmalik259
‘Male-typical development results from prenatal or neonatal exposure to testicular hormones,
whereas female-typical development happens in the absence of testicular hormones, according
to the classical model of hormonal influences on mammalian sexual differentiation.’
Treatment of male infertility is an important aspect of infertility treatment. Many factors can be prevented with lifestyle modifications and appropriate treatment.
Amenorrhea - Define, Cause, Sign and Symptoms, Type- Pathological and Physiol...sonal patel
Amenorrhea - Define, Cause, Sign and Symptoms, Type- Pathological and Physiological Amenorrhea and It's Treatment and management, Cushing Syndrome - Define, Causes, Sign And Symptoms in PPT made By Sonal Patel
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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
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.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
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
2. Male Reproductive System
Clinical Considerations (Continued)
Other Male RH
Anomalies:
• Klinefelter's Syndrome
• Intersexuality
(Hermaphroditism):
True I.; Male Pseudo-
(MP)
• Complete Androgen
Insensitivity Syndrome
(CAIS)
Other Male RH
Anomalies:
• Trans-Sexuality
• Trans-Genderism
=====================
Participatory Activity 5.9:
What clinically important
psychosocial issues cut across
these anomalies?
3. Male Reproductive System
Clinical Considerations – 58a
Other Male Anomalies of the
Reproductive System
• Intersexuality
True intersexuality
Female pseudo-intersexuality
Male RH Disorders:
1. Klinefelter’s syndrome*
2. Hermaphrodites* : True H.
Pseudo-H
3. Androgen Insensitivity
Syndrome (AIS)*
Activity 5.10
1. Concerning ‘Sexual Differentiation
Defects’, what are the common
causes of male and female inter-
sexuality, respectively?
2. Describe ‘female pseudo-
hermaphrodites’; male pseudo-
hermaphrodites’; ‘True
hermaphrodites’and other related
terms.
3. Summarize about the anomalies in
male and female Reproductive
systems (comparing various
information sources and texts)
4. Enumerate male RH disorders.
4. Male Reproductive System
Clinical Considerations – 58b
B: Other Anomalies of the Reproductive System
1. Intersexuality
• c. True intersexuality:
occurs when an individual has both ovarian and
testicular tissue (ovotestes) histologically, ambiguous
genitalia, and a 46,XX genotype.
• d. True intersexuality is a rare condition whose cause
is poorly understood.
5. Male Reproductive System
Clinical Considerations – 58c
Male RH Disorders:
1. Klinefelter’s syndrome*
2. Hermaphrodites* : True H.
Pseudo-H
3. Complete Androgen
insensitivity syndrome
(CAIS)*
Klinefelter’s syndrome.
6. Urinary System Development
Clinical Considerations – 58d
• Inter-sexuality Clinical Taster
• Read the story herein, which
depicts a typical real life
account in clinical practice*
Activity 5.11a:
• Inter-sexuality offers a real
challenge to all stake holders .
1. List the stake holders
affected.
2. As a clinician also in the
loop, how will you deal with
the situation if a case landed
in your hands one day?
3. How is inter-sexuality
actually managed
professionally in health
sector?
7. Male Reproductive System
Clinical Considerations - 64
B: Other Anomalies of the
Reproductive System
2. Female pseudo-
intersexuality (FP):
l. Treatment includes
immediate infusion of
intravenous saline and long-
term steroid hormone
replacement, both cortisol and
mineralocorticoids (9-
fludrocortisone).
m. The photograph in the figure
opposite shows a patient (XX
genotype) with female
pseudointersexuality
due to CYP21A2 deficiency.
Masculinization of female
external genitalia is apparent,
with fusion of the labia majora
and enlarged clitoris [(see
arrow to inset); He turned out
a boy, upon final evaluation]*
8. Male Reproductive System
Clinical Considerations - 65
B: Other Anomalies of the
Reproductive System
3. Male pseudo-intersexuality
(MP):
• a. MP occurs when an individual
has only testicular tissue
histologically and various stages
of stunted development of the
male external genitalia.
These individuals have a 46,XY
genotype.
• b. MP is most often observed
clinically in association with a
condition in which the fetus
produces a lack of androgens
(and MIF).
B: Other Anomalies of the
Reproductive System
3. Male pseudo-intersexuality
(MP):
• c. This is caused most commonly
by mutations in genes for
androgen steroid biosynthesis
(e.g., 5-reductase 2 deficiency or
17-hydroxysteroid
dehydrogenase).
• d. Normally, 5-reductase 2
catalyzes the conversion of
testosterone (T) S
dihydrotestosterone (DHT), and
17-hydroxysteroid dehydrogenase
3 catalyzes the conversion of
androstenedione S testosterone.
9. Male Reproductive System
Clinical Considerations - 66
B: Other Anomalies of the Reproductive System
3. Male pseudo-intersexuality (MP):
• e. An increased T:DHT ratio is diagnostic (normal 5; 5-
reductase 2 deficiency 20–60).
• f. The reduced levels of androgens lead to the
feminization of a male fetus.
• g. MP produces the following clinical findings:
underdevelopment of the penis and scrotum
(microphallus, hypospadias, and bifid scrotum) and
prostate gland.
The epididymis, ductus deferens, seminal vesicle, and
ejaculatory duct are normal.
10. Male Reproductive System
Clinical Considerations - 67
B: Other Anomalies of the Reproductive
System
3. Male pseudo-intersexuality (MP):
• h. These clinical findings have led to
inference that DHT is essential in the
development of the penis and scrotum
(external genitalia) and prostate gland in a
genotypic XY fetus.
At puberty, these individuals demonstrate a
striking virilization.
• i. The photograph in the figure opposite shows a
patient (XY genotype) with male pseudo-
intersexuality.
The stunted development of male external genitalia is
apparent.
The stunted external genitalia fooled the parents and
physician into thinking that this XY infant was a girl.
In fact, this child was raised as a girl (note pigtails). As
this child neared puberty, testosterone levels
increased, and clitoral enlargement ensued.
This alarmed the parents, and the child was brought
in for clinical evaluation.
11. Male Reproductive System
Clinical Considerations - 68
B: Other Anomalies of the
Reproductive System
4. Complete androgen insensitivity
(CAIS; or testicular feminization
syndrome):
• a. CAIS is an X-linked recessive
genetic disorder caused by a loss-of-
function mutation in the AR gene on
chromosome Xq12, which encodes
for the androgen receptor.
The androgen receptor is a member
of the steroid-thyroid-retinoid
superfamily of receptors.
• b. The lack of androgen receptor
function results in defective
virilization in 46,XY males despite the
presence of bilateral testes and
normal testosterone production.
B: Other Anomalies of the
Reproductive System
4. Complete androgen insensitivity
(CAIS; or testicular feminization
syndrome):
• c. Even though the developing male
fetus is exposed to normal levels of
androgens, the lack of androgen
receptors renders the phallus,
urogenital folds, and labioscrotal
swellings unresponsive to androgens.
• d. The testes may be found in the
abdomen, inguinal canals, or the
labia majora.
The testes are surgically removed to
circumvent malignant tumor
formation.
12. Male Reproductive System
Clinical Considerations - 69
B: Other Anomalies of the Reproductive System
4. Complete androgen insensitivity (CAIS; or
testicular feminization syndrome):
• e. CAIS individuals have the following
characteristics: the presenting cause is
primary amenorrhea; there is little of no
axillary or pubic hair; there are normal-
appearing female external genitalia; the
labia and clitoris are normal or slightly
underdeveloped; the vagina is either absent
or short and blind ending; there is absence
or near absence of Müllerian structures in
the urogenital tract (i.e., uterus, uterine
tubes, cervix, superior third of the vagina);
breast development is that of a normal
female; patients are taller and heavier than
normal females; psychosocial orientation is
female; and maternal instincts are present.
• f. The photograph in the figure opposite
shows a patient (XY genotype) with CAIS.
Complete feminization of male external
genitalia is apparent.
13. Male Reproductive System
Clinical Considerations - 70
B: Other Anomalies of the Reproductive System
5. Trans-sexualism:
• This is a condition in which a person with apparently
normal bodily sexual differentiation of one gender is
convinced that he or she is actually a member of the
opposite gender.
• Although trans-sexualism has been traditionally
considered only a psychological issue, the sexual
differentiation of the brain depends on the presence or
absence of androgens, and the bed nucleus of the stria
terminalis in the brain has been implicated in sexual
differentiation of the brain.
14. Male Reproductive System
Clinical Considerations - 71
B: Other Anomalies of the Reproductive System
6. Trans-genderism:
• This is a condition in which a person decides to
have an in-between sex status.
• This type of person wants (1) to rid himself or
herself of their natal sex without seeking
reassignment to the opposite sex or (2) wants
only partial adaptation to the opposite sex.
• There may be a part-time social transition to the
opposite sex.
15. Male Reproductive System
Clinical Considerations [Summary]- 72
Summary Table of Female and Male Reproductive System Development
Adult Female Indifferent Embryo Adult Male
Ovary, ovarian follicles, rete
ovarii
Gonads Testes, seminiferous tubules,
tubuli recti, rete
testes, Leydig cells, Sertoli
cells
Uterine tubes, uterus, cervix
superior one third of vagina
Hydatid of Morgagni
Paramesonephric
duct
—
superior one third of vagina
Hydatid of Morgagni Appendix
testes
----
Appendix vesiculosa,
Gartner’s duct
Mesonephric duct Epididymis, ductus deferens,
seminal vesicle,
ejaculatory duct
Appendix vesiculosa, Gartner’s
duct Appendix epididymis
16. Male Reproductive System
Clinical Considerations [Summary]- 73
Summary Table of Female and Male Reproductive System Development
Adult Female Indifferent Embryo Adult Male
Glans clitoris, corpora
cavernosa clitoris
Phallus Glans penis, corpora cavernosa
penis, corpus
vestibular bulbs
Labia minora Urogenital folds Ventral aspect of penis
Labia majora, mons pubis Labioscrotal
swellings
Scrotum
Ovarian ligament, round
ligament of uterus
Gubernaculum Gubernaculum testes
— Processus vaginalis Tunica vaginalis
N.B: Italics indicate a vestigial structure
17. Summary
True Intersexuality:
(True Hermaphrodite)
Possession of both ovarian
and testicular tissue
(ovotestes; histologically
evident)
Ambiguous genitalia
Having 46, XX genotype
Female Pseudo-Intersexuality (FP)
[Pseudo-hermaphrodite)
An individual with only
ovarian tissue
(histologically evident)
Masculinization of female
external genitalia
Having 46, XX genotype
Associated with CAH
18. Male Reproductive System
Clinical Considerations - 59
Activity 5.13:
1. Write short notes about:
‘Persistent Müllerian Duct
Syndrome’ (see it’s picture
opposite).
Hypospadias (types)
1. How do they present
clinically?
2. How are they managed
and what challenges are
anticipated during its
management?*
Persistent Müllerian Duct Syndrome
• Müllerian ducts fail to regress
• Possess both male and female sex organs
19. How to break Bad News
• Examples of 'Bad
News'
• How to break bad
news to patients*
• How to handle
reactions to the
bad news *
Activity 5.12b:
1. Give examples of areas
which consist of ‘bad
news’ to patients/clients. *
2. Outline suggested steps on
how a clinician should
handle such a situation. *
20. SUMMARY
RH Anomalies in Males & Females
Participatory Activity 5.12a:
1. Who are the Stake Holders involved?
2. What are the challenges faced by the stake
holders?
3. How are the challenges managed?
4. Counselling approaches? (Dealing with 'Bad
News')
21. How to break Bad News
Getting started:
Plan the discussion and unless really
unavoidable, don’t delegate this task;
Confirm medical facts of underlying
problem (e.g. cancer, cerebral palsy and side
effects of depo provera); Intersexuality
Create conducive environment for effective
communication;
• Ensure privacy and adequate sitting
arrangement;
• Ensure the affected person(s)/immediate
people of interest (e.g. both husband and
wife) are present for the discussion;
• Prevent interruptions during discussion
(allocate adequate and appropriate time);
Establish starting point
rapport: what the affected
person(s) (e.g. a couple)
know(s) about the underlying
problem, in order to establish
the starting point of the
discussion (e.g. intersexuality,
etc)
Establish how much the
affected person(s) wants to
know about the problem
22. How to break Bad News
Share the information in a
sensitive but straightforward
manner;
Do so in bits and not in a single
monologue talk, giving room for
questions and requests for
clarification from the affected
person(s) (e.g. a couple).
Allow time for response to
feelings from the affected
person(s)
Allow for expression of emotions (crying, anger,
sadness, love, anxiety, guilt, e.t.c);
Plan for way forward:
E.g:
•Inter-sexuality: Visit specialist for scheduling
surgical operations; appropriate medications
•Cerebral palsy will require occupational therapy,
frequent treatment of recurrent infections, special
schools attention, acceptance of reality by whole
family and friends;
•Secondary Infertility: will require further tests to
confirm irreversibility of fertility or specialized
treatment of the same; Child adoption may be
discussed as an option for the couple if they so wish.
•Cancer diagnosis: Radiotherapy; Chemotherapy;
Combined Chemotherapy and Radiotherapy; Hospice
personnel and counselors involvement in the
management of the patient and the affected family.