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Some possible reasons for the uterus to erectile dysfunction pump nhs buy viagra sublingual in united states online rupture following laparoscopic myomectomy are listed in table 18 erectile dysfunction specialists buy viagra sublingual 100 mg on line. Moreover erectile dysfunction doctor in columbus ohio buy viagra sublingual with a mastercard, the uterus is an organ which undergoes remarkable structural changes (hypertrophy and hyperplasia), both during pregnancy and puerperium. Massive enlargement of the uterus during pregnancy can result in weakening of the uterine scar, increasing the risk for uterine rupture. Besides this natural disadvantage, the microsurgical procedure (laparoscopic myomectomy) is associated with less perfect reconstruction of uterine tissue in comparison to abdominal myomectomy. As a result, the risk of uterine rupture is more with laparoscopic procedure in comparison to abdominal procedure. Also, when the myomas are deeply embedded in the myometrium or are large in size or numerous, proper repair of the uterine wall may not be possible with laparoscopic procedure. Wide use of electrosurgery for obtaining hemostasis during laparoscopic surgery may be another factor involved in reducing the scar strength. Use of electrosurgery may result in poor vascularization, tissue necrosis and adverse effects on scar strength. Excessive bleeding during the surgery can result in hematoma formation, which can weaken the uterine walls by resulting in the formation of fibrous tissue. If the edges of the wound are accurately sutured, the healing of the uterine wound takes place through regeneration of myometrial muscles. On the other hand, if the edges of the wound are not approximated properly, healing occurs by secondary intention, thereby resulting in the formation of fibrous tissue, which considerably weakens the post-operative scar. Thus, in order to avoid scar rupture during pregnancy, precautions to be taken are listed in table 18. Laparoscopic myomectomy, due to limited exposure may result in less effective removal of the Menorrhagia due to Leiomyomas Table 18. Incomplete removal of myoma tissue may result in development of recurrence following laparoscopic myomectomy. Hysteroscopic myomectomy can be performed as a simple outpatient procedure where a hysteroscope is placed into the uterine cavity and the leiomyomas are resected out (figures 18. The technique of hysteroscopic resection of submucous leiomyomas was first described by Neuwirth and Amin in 1976. Since the use of hysteroscope requires instillation of fluid inside the uterine cavity, it is important to A B C Fig. The procedure is performed laparoscopically, in which either a laser or a cryo needle is passed directly into the fibroid to destroy both the fibroid tissue and the blood vessels feeding it. Presently, myoma coagulation is not recommended for women desiring future fertility because the procedure is thought to result in the formation of scar tissue, which is likely to weaken the strength of the uterine wall. Due to this, there are high chances of uterine rupture during the pregnancy in case the woman conceives following myolysis. Although some women who underwent the procedure have conceived and have been uneventfully delivered by cesarean section, the fertility and pregnancy outcomes after laparoscopic myolysis remain unknown. Presently, however the patients undergoing myolysis are advised not to attempt to conceive following the procedure. The indications for myolysis include symptomatic patient presenting with menorrhagia, pelvic pain or pressure symptoms due to fibroids pressing upon the adjacent organs; presence of four or fewer myomas with a size of less than 5 cm; or if the size of the largest subserosal myoma is less than 10 cm in diameter. Other concomitant laparoscopic pelvic surgery such as adhesiolysis, excision of endometriosis or adnexal surgery, can be carried out at the same time. Sometimes, concomitant hysteroscopic endometrial ablation is performed at the end of laparoscopic myolysis to further assist in the treatment of menorrhagia. Complications associated with myolysis include pelvic infection, bacteremia and bleeding. Thus, laparoscopic myolysis may present an alternative to myomectomy or hysterectomy for selected women with symptomatic intramural or subserous fibroids who wish to preserve their uterus, but do not desire future fertility. According to the European Society of Hysteroscopy, submucous leiomyomas have been classified into three categories depending on the degree of myometrial invasion (figure 18. Myomas belonging to the categories T-0 and T-1 should be attempted using a hysteroscope. However, hysteroscopic resection should not normally be attempted in fibromyomas belonging to T-2 category. This is so because, when submucous myomas have intramural extensions greater than 50%, hysteroscopic resection may be associated with a higher rate of complication, including increased rate of conversion to laparotomy, higher rates of intravascular extravasation of distending media, prolonged operating times and increased requirement for repeat surgery. Therefore, endoscopic removal of intramural or submucosal leiomyomas larger than 5 cm in diameter or with myometrial involvement greater than 50% should be attempted only by very experienced endoscopists. Besides uterine fibroids, the technique of embolization has been used to treat various other medical pathologies like, inoperable cancers, brain aneurysms, arteriovenous shunts in the lung, etc. Though anesthesia is usually not required, the procedure is usually performed under sedation. The interventional radiologist introduces and manipulates a catheter through the femoral artery into the internal iliac and uterine arteries (figure 18. Once the fibroids are visualized on X-ray, an Myoma Coagulation (Myolysis) 354 Myoma coagulation, also known as myolysis, is a laparoscopic procedure which helps in shrinking the fibroids Chapter 18 Menorrhagia due to Leiomyomas Fig. The dying cells of the fibroids may release toxins, which may cause irritation of the surrounding tissues, thereby causing pain and inflammation in the first few days following the procedure. Though the rate of recovery usually varies from one woman to the other, it usually takes a few months for the fibroids to fully shrink and the full effect of the procedure to be evident. Till date, this procedure has been performed in approximately 30,000 women in the United States and another 20,000 women worldwide. As a result, presently there is limited evidence regarding the safety and efficacy of the procedure. The world-wide success rate of the procedure in producing improvement of symptoms has been considered to be approximately 85%. About 90% of women who were symptomatic due to the large size of their fibroids would experience a significant improvement in their symptoms. Till date, only four fatalities have been reported among more than 30,000 procedures which have been performed worldwide. Early acute abdominal pelvic pain: Nearly all women may experience some degree of acute pain within the first few weeks, often requiring hospitalization with intensive pain management protocols and monitoring. It often responds to pain control with analgesics like opiates and non-steroidal antiinflammatory drugs. Compared to normal uterine cells, fibroid cells are much more sensitive to low oxygen saturation. Thus, due to the lack of sufficient blood supply, the fibroids become avascular and shrink, ultimately resulting in cell death, their degeneration and eventual absorption by the myometrium. The normal myometrium, on the other hand, receives new blood supply from vaginal and ovarian vasculature. However this is unlikely to cause any problem because the chances of malignancy in cases of fibroids are extremely low. Persistent or chronic pain: In 5% to 10% of women, the pain persists for more than 2 weeks. Persistent pain in the absence of infection or pain lasting longer than 2 to 3 months may require surgical intervention. Transcervical fibroid tissue passage: Overall, transcervical fibroid tissue passage may occur in approximately 2.
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It produces a potent neurotoxin impotence icd 9 code order viagra sublingual 100 mg amex, tetanospasmin impotence related to diabetes cheap viagra sublingual 100mg fast delivery, which causes tetanus impotence treatments order viagra sublingual us, an acute neurologic condition characterized by painful muscular contractions. Tetanospasmin is an exceedingly potent, high molecular weight protein toxin, consisting of a heavy chain (100kD) subunit that binds the toxin to receptors on neuronal cells and a light chain (50kD) subunit that blocks the release of inhibitory neural transmitter molecules within the central nervous system. Elevated incidence rates also were observed for persons aged over 60 years, diabetics, and intravenous drug users. Accidental parenteral inoculation of the toxin is the primary hazard to laboratory personnel. Because it is uncertain if tetanus toxin can be absorbed through mucous membranes, the hazards associated with aerosols and droplets remain unclear. Special Issues Vaccines the vaccination status of workers should be considered in a risk assessment for workers with this organism and/or toxin. While the risk of laboratory-associated tetanus is low, the administration of an adult diphtheriatetanus toxoid at 10-year intervals further reduces the risk to laboratory and animal care personnel of toxin exposures and wound contamination, and is therefore highly recommended. Corynebacterium diphtheriae Corynebacterium diphtheriae is a pleomorphic gram-positive rod that is isolated from the nasopharynx and skin of humans. The organism is easily grown in the laboratory on media containing 5% sheep blood. Natural Modes of Infection the agent may be present in exudates or secretions of the nose, throat (tonsil), pharynx, larynx, wounds, in blood, and on the skin. Travel to endemic areas or close contact with persons who have returned recently from such areas, increases risk. Naturally occurring diphtheria is characterized by the development of grayishwhite membranous lesions involving the tonsils, pharynx, larynx, or nasal mucosa. An effective vaccine has been developed for diphtheria and this disease has become a rarity in countries with vaccination programs. Francisella tularensis Francisella tularensis is a small gram-negative coccobacillus that is carried in numerous animal species, especially rabbits, and is the causal agent of tularemia (Rabbit fever, Deer fly fever, Ohara disease, or Francis disease) in humans. Type A and Type B strains are highly infectious, requiring only 10-50 organisms to cause disease. The incubation period varies with the virulence of the strain, dose and route of introduction but ranges from 1-4 days with most cases exhibiting symptoms in 3-5 days. Occasional cases were linked to work with naturally or experimentally infected animals or their ectoparasites. Natural Modes of Infection Tick bites, handling or ingesting infectious animal tissues or fluids, ingestion of contaminated water or food and inhalation of infective aerosols are the primary transmission modes in nature. Occasionally, infections have occurred from bites or scratches by carnivores with contaminated mouthparts or claws. Direct contact of skin or mucous membranes with infectious materials, accidental parenteral inoculation, ingestion, and exposure to aerosols and infectious droplets has resulted in infection. Infection has been more commonly associated with cultures than with clinical materials and infected animals. Laboratory personnel should be informed of the possibility of tularemia as a differential diagnosis when samples are submitted for diagnostic tests. Helicobacter species Helicobacters are spiral or curved gram-negative rods isolated from gastrointestinal and hepatobiliary tracts of mammals and birds. There are currently 20 recognized species, including at least nine isolated from humans. Since its discovery in 1982, Helicobacter pylori has received increasing attention as an agent of gastritis. Natural Modes of Infection Chronic gastritis and duodenal ulcers are associated with H. Transmission, while incompletely understood, is thought to be by the fecal-oral or oral-oral route. Legionella pneumophila and other Legionella-like Agents Legionella are small, faintly staining gram-negative bacteria. They are obligately aerobic, slow-growing, nonfermentative organisms that have a unique requirement for L-cysteine and iron salts for in vitro growth. There are currently 48 known Legionella species, 20 of which have been associated with human disease. Natural Modes of Infection Legionella is commonly found in environmental sources, typically in man-made warm water systems. The mode of transmission from these reservoirs is aerosolization, aspiration or direct inoculation into the airway. The spectrum of illness caused by Legionella species ranges from a mild, self-limited flu-like illness (Pontiac fever) to a disseminated and often fatal disease characterized by pneumonia and respiratory failure (Legionnaires disease). Although rare, Legionella has been implicated in cases of sinusitis, cellulitis, pericarditis, and endocarditis. Surgery, especially involving transplantation, has been implicated as a risk factor for nosocomial transmission. Laboratory Safety and Containment Recommendations the agent may be present in respiratory tract specimens (sputum, pleural fluid, bronchoscopy specimens, lung tissue), and in extrapulmonary sites. A potential hazard may exist for generation of aerosols containing high concentrations of the agent. Leptospira the genus Leptospira is composed of spiral-shaped bacteria with hooked ends. Leptospires are ubiquitous in nature, either free-living in fresh water or associated with renal infection in animals. These organisms also have been characterized serologically, with more than 200 pathogenic and 60 saprophytic serovars identified as of 2003. Growth of leptospires in the laboratory requires specialized media and culture techniques, and cases of leptospirosis are usually diagnosed by serology. Animals with chronic renal infection shed large numbers of leptospires in the urine continuously or intermittently, for long periods of time. Common routes of infection include abrasions, cuts in the skin or via the conjunctiva. Higher rates of infection observed in agricultural workers and other occupations associated with animal contact. Laboratory Safety and Containment Recommendations the organism may be present in urine, blood, and tissues of infected animals and humans. Ingestion, accidental parenteral inoculation, and direct and indirect contact of skin or mucous membranes, particularly the conjunctiva, with cultures or infected tissues or body fluids are the primary laboratory hazards. Gloves should be worn to handle and necropsy infected animals and to handle infectious materials and cultures in the laboratory. Listeria monocytogenes Listeria monocytogenes is a gram-positive, non-spore-forming, aerobic bacillus; that is weakly beta-hemolytic on sheep blood agar and catalase-positive. It may also be isolated from symptomatic/asymptomatic animals (particularly ruminants) and humans.
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Wendel Naumann Cervical cancer is the fourth most common malignancy and the fourth leading cause of cancer-related death in women erectile dysfunction treatment bayer purchase 100mg viagra sublingual amex, with an estimated 5 erectile dysfunction kidney generic 100 mg viagra sublingual visa, new cases and 311 erectile dysfunction medication causes 100mg viagra sublingual otc, deaths anticipated worldwide in 2 1. Surgery is the most important treatment modality impacting survival in early-stage disease. Technique videos that are applicable to both laparoscopic or open radical hysterectomy will be emphasi ed. Naumann romising xperimental Techniques That May Decrease ocal ailure ate After adical ysterectomy M. Lam ostoperative Short-Term utcomes of obotic Sacrocolpoperineopexy ersus obotic Sacrocolpopexy M. Eddib atient xperience With nhanced ecovery and arly Discharge for Minimally nvasive Sacrocolpopexy: A ualitative Study L. Matthews ational Analysis of erioperative Morbidity of aginal ersus aparoscopic ysterectomy at the Time of terosacral igament Suspension G. Gebhart Surgical epair of esicovaginal istula: A ariation of the lap-Splitting Technique R. Ecker aparoscopic Catheter mplantation for Targeted Therapy Delivery in the Treatment of udendal euralgia and ther ntrapelvic Causes of europathic ain N. Einarsson Surgical elvic euroanatomy: An verview of Commonly ncountered erves in enign Gynecologic Surgeries and Safe Dissection Techniques C. Sun reterolysis, asolysis and eurolysis: the Trifecta in Deep nfiltrating ndometriosis A. Lee Gastrointestinal Symptoms as a redictor of Deep nfiltrating ndometriosis of the osterior Compartment of the elvis on M maging P. Burnett uestions Answers, Distillation Moderators: Christopher Eswar, Ping Liu this session presents several high-quality surgical videos as well as investigative analyses on a variety of topics concerning reproductive issues encountered in daily practice. Learning Objectives: At the conclusion of this activity, the participant will be able to: 1) Discuss different types of surgical techniques for reproductive issues. Raymond yaluronic Acid Gel educes the ate of ntrauterine Adhesions After Dilatation and Curettage in Women With Miscarriage: Multicentric rospective andomi ed Controlled Trial ( yfaco Study) J. Goldman artial Cystectomy for Deeply nfiltrating ndometriosis f the ladder With Cystotomy Repair C. Butler cient Myometrial Defect Closure in a ayer by ayer ashion After obot-Assisted aparoscopic Adenomyomectomy: A ovel Technique A. Kim An Analysis of the ood And Drug Administration Maude Database for Approved Devices in bstetrics and Gynecology S. Maurice Acceptability of a obotic ysterectomy Simulation System Who s the Target Audience A. Thakar etroperitoneal Anatomy: A Guide to aparoscopic elvic Sidewall Dissection D. Lager aparoscopic Management of xogenic Cesarean Section regnancy With Transient terine Artery Clipping F. Patzkowsky Trends and is actors for aginal Cuff Dehiscence After aparoscopic ysterectomy D. Thiel 3:12 3:12 3:1 3:1 3:2 3:2 3:33 3:33 this advanced surgical tutorial will cover state of the art o ce, diagnostic and operative hysteroscopy. Hysteroscopic surgery is the least invasive approach for the management of a myriad of intra-uterine structural abnormalities. This session will share tips and tric s from the Masters, to safely and e ciently perform many of these procedures in the o ce setting. The epidemic of C-sections has led to new entities such as sthmocele, or cesarean scar defect, which requires highly speciali ed hysteroscopic s ills to perform sthmoplasty. The faculty will also navigate the diagnosis and management of ntra-uterine adhesions or Ashermans syndrome. Learning Objectives: At the conclusion of this activity, the participant will be able to: 1) erform o ce hysteroscopy, diagnose and treat sthmocele, ntrauterine adhesions, and retained products of conception. Whiteford Assessing ain and Sleep atterns in ndometriosis: A ilot Study sing assive adio Sensors M. Katabi atient utcomes ollowing nitiation of Medical Cannabis in Women With Chronic elvic ain T. Thiel eep Your andmar s Close, and the ypogastric erve Closer: An Approach to erve-Sparing ndometriosis Surgery A. Lemos ong Term utcomes of ost- perative ormonal Suppression in atients With ndometriosis: A Systematic eview and Meta-Analysis A. Carey ndosearch: the nternational Clinical Trial to Test a Cluster of iomar ers to Diagnose ndometriosis A. Jansen ncidence and redictors of ersistent elvic ain ollowing ysterectomy in Women With Chronic elvic ain S. Brummett uestions Answers, Distillation 4:1 evator Avulsion: A eview of Surgical Anatomy and epair Technique for rimary osterior erineal ernias M. Shapiro easibility of utpatient Combined aparoscopic Apical And aginal rolapse Repair M. Einarsson aparoscopic Sacrocolpopexy With aginal rosthetic Adhesive: Multicenter rospective Study of 45 atients J. Estrade Comparison of 3 -Day Complication ate etween Minimally nvasive ysterectomy With and Without Concomitant rogynecologic rocedure L. Thompson Superficial ndometriosis Can e Seen on ltrasound: A ilot Application of SalineInfusion Sonopodography M. Condous the ole f Shaving Technique n the Treatment f ecto- aginal ndometriosis D. Diagnostic Wor out, aparoscopic Treatment and utcomes: the xperience of a Single Third evel eferral Center on 2 atients D. Ceccaroni Diaphragmatic ndometriosis: Classification of esions in a etrospective Series of 15 atients Treated by Minimally- nvasive Surgery in a Single Third- evel eferral Center G. Kim, Khara Simpson this session provides a loo into trends and best practice in robot-assisted gynecologic surgery. Learning Objectives: At the conclusion of this activity, the participant will be able to: 1) dentify trends in the use of robotic surgery in comparison to alternative approaches 2) identify best practices for safety in robotic surgery and 3) review robotic approaches to other benign gynecologic conditions including fibroids, other benign pelvic masses, and endometriosis. Kaur cacy of the loc in the Transverse Abdominal lane n aparoscopic And obotAssisted ysterectomy. Vargas ffect of Age and rior Gynecologic Surgery on athologic Diagnosis in atients ndergoing enign ysterectomy A. Foley A esident Guide to aparoscopic Myomectomy With ndometrial Cavity reservation M. Movilla ntra- perative actors dentified During aparoscopy ysterectomy Are Correlated With ncreased ost- perative ain and pioid se V. Chohan Transversus Abdominis lane (Tap) loc With iposomal upivacaine for aparoscopic ysterectomy With mbilical Contained Tissue xtraction: A etrospective Study L.
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Using the pour plate technique new erectile dysfunction drugs 2013 100mg viagra sublingual free shipping, inoculate and incubate for 40-48 hours at 35 ± 2°C for bacteria and at 30 ± 2°C for yeasts erectile dysfunction klonopin 100 mg viagra sublingual otc. Expected results Cultures should be read within 5-7 days after incubation and once a week thereafter for up to impotence definition inability order 100 mg viagra sublingual with amex 8 weeks. Number of colonies (bottles): No colonies = Negative Less than 50 colonies = Actual Count 50 to 100 colonies = 1+ 100 to 200 colonies = 2+ Almost confluent (200 to 500) = 3+ 3. Bottles may be examined by inverting the bottles on the stage of a dissecting microscope. Summary and Explanation Wallenstein Medium is a glycerolated egg yolk medium containing malachite green. Slanted and bottled media should be incubated in a horizontal plane until the inoculum is absorbed. Tubes and bottles should have screw caps loose for the first 3 weeks to permit circulation of carbon dioxide for the initiation of growth. Principles of the Procedure the water in these tubes is purified (deionized) water that is ready and convenient for use as a diluent or suspending medium. The preferred medium for agar dilution tests with anaerobes is Wilkins-Chalgren Agar or Brucella Agar. Dextrose is the carbon source, and sodium chloride maintains the osmotic balance of the media. L-arginine and sodium pyruvate are added to provide the proper environment for anaerobic growth. This medium can be rendered moderately selective for enteric pathogens, particularly Shigella, by the addition of sodium desoxycholate (2. Its use is recommended for Salmonella isolation after selenite or tetrathionate enrichment in food analysis; both coliforms and Shigella are inhibited. Additionally, the medium was formulated to increase the frequency of growth of the more fastidious pathogens,4 which in other formulations have often failed to grow due to the inclusion of excessively toxic inhibitors. The results obtained in a number of Summary and Explanation A wide variety of media have been developed to aid in the selective isolation and differentiation of enteric pathogens. Due to the large numbers of different microbial species and strains with varying nutritional requirements and chemical resistance patterns, investigators have developed various formulae to meet general as well as specific needs relative to isolation and identification of the microorganisms. Incubate (*) cultures at 30-35°C for 18-48 hours and (**) culture at 35-37°C for 18-72 hours. Incubate (*) cultures at 30-35°C for 18-48 hours and (**) culture at 35-37°C for 18-48 hours. Lysine is included to enable the Salmonella group to be differentiated from the nonpathogens. The nonpathogenic H2S producers do not decarboxylate lysine; therefore, the acid reaction produced by them prevents the blackening of the colonies. It utilizes sodium desoxycholate as the selective agent and, therefore, it is inhibitory to gram-positive microorganisms. After the salmonellae exhaust the supply of xylose, the lysine is attacked via the enzyme lysine decarboxylase, with reversion to an alkaline pH, which mimics the Shigella reaction. To prevent similar reversion by lysine-positive coliforms, lactose and sucrose (saccharose) are added to produce acid in excess. Add 20 mL of an aqueous solution containing 34% sodium thiosulfate and 4% ferric ammonium citrate. Hydrogen sulfide production under alkaline conditions causes colonies to develop black centers. This reaction is inhibited by the acid conditions that accompany carbohydrate fermentation. Lysine decarboxylation in the absence of lactose and sucrose fermentation causes reversion to an alkaline condition and the color of the medium changes back to red. Differentiation of Salmonella from other organisms that also grow on this medium is based on fermentation of xylose, lactose and sucrose, decarboxylation of lysine and the production of hydrogen sulfide. Phenol red is added as an indicator of pH changes resulting from fermentation and decarboxylation reactions. Summary and Explanation Numerous media have been developed for isolating and differentiating enteric pathogens. This is particularly true for Salmonella isolation media where overgrowth of Proteus, Providencia and Pseudomonas can dramatically interfere with the detection and isolation of Salmonella. They also evaluated its sensitivity in detecting and isolating Salmonella using fecal-contaminated farm samples containing high numbers of competing bacteria. Presumed Salmonella colonies must be confirmed by biochemical and/or immunological methods. Non-Salmonella strains that are not completely inhibited on this medium may be encountered and must be differentiated from Salmonella. Freshly inoculated plates and plates held over several days may develop multicolored, metallic looking crystals/flecks on the surface. Inoculate a suitable Salmonella enrichment broth (such as Tetrithionate Broth) and incubate at 35°C for 18-24 hours. Expected results Typical Salmonella colonies (H2S-positive) appear black or black-centered with a yellow periphery after 18-24 hours of incubation. Upon continued incubation, the colonies become entirely black or pink to red with black centers. Most Citrobacter colonies that grow on this medium are yellow without evidence of blackening. Growth of Enterobacter aerogenes and Escherichia coli is markedly inhibited; colonies that do grow appear yellow without evidence of blackening. The autolysis is carefully controlled to preserve the naturally occurring B-complex vitamins. Yeast extract is considered a non-animal product and is used extensively for many non-animal formulations for bacterial, fungal, mammalian and insect cell culture. B factor, a growth substance necessary for the production of rifampin in a Nocardia sp. With its low endotoxin level and high content of naturally occurring B vitamins, it is an ideal substitute for fetal bovine serum. Bacto Yeast Extract, Technical and Yeast Extract were developed to provide products priced for the biotechnology/pharmaceutical market with acceptable clarity and growth promoting characteristics. Media formulations containing yeast extract are specified in standard methods for various applications. The yeast is harvested, washed and resuspended 622 Yeast Extract glucose in water, where it undergoes autolysis, or self-digestion. The resulting yeast extract is then filtered to produce a clear product and subsequently made into a powder by a spray-drying process. Typical analysis Refer to Product Tables in the Reference Guide section of this manual.
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Results Before the results can be calculated for each clinical specimen latest erectile dysfunction drugs order viagra sublingual us, the test must be determined to best erectile dysfunction pills review order cheapest viagra sublingual and viagra sublingual be valid erectile dysfunction 19 purchase viagra sublingual 100mg free shipping. If the test still fails after a repeat, then one or more of the reagent or test parameters was likely in error, and troubleshooting should be performed. Ifthisrequirementisnotmet,non-specificbackgroundisbeing generated, and the result must be reported as uninterpretable. Without testing of a convalescentspecimen,anegativeresultmayreflecttestingofanacute-phasespecimenobtainedbefore 90 antibodyhasrisentodetectablelevels. Interpretation Itisfurtherrecommendedthatforsera,allpositiveresultsshouldbeconfirmedbytitrationusing6,2-fold dilutions of the serum specimens compared to a similar titration of the negative control serum. Safety the procedure should be performed under laboratory safety conditions that take into consideration the potential infectiousnatureoftheserumspecimensinvolved. Reagents Microplate washer Microplate reader Incubator Singleandmulti-channelpipettors Reagent reservoirs 94 Ziploc bags, paper towels Clinical Acute and convalescent human serum specimens Note:Storealldiagnosticspecimensat4°Cpriortotesting,andat-20°Cafterallanticipatedtestinghasbeen completed. Coattheinner60wellsof96wellplateswith75µl/welloftheappropriategroup-reactivemonoclonal antibody diluted in coating buffer according to prior titration. Totherightthreewellsofeachblock,add50µlperwellofnormalantigendilutedinwashbufferto the same concentration as the viral antigen. Addpositive control human serum (Ref) diluted in wash buffer according to a previous titration, and a negative human serumcontrol(N)diluted1:400inwashbuffertoablockof6wellseach. Add35µlperwellofstopsolutiontoallwells,includingtheouterrowsofwellsontheplate(theplatereader itself should be set to zero on some of these wells). Thisshouldoccurwhennewlotnumbersofreagentsare introduced, and at the very least, once a year. It is recommended that the mean optical density of the positive controlserumreactedontheviralantigenbesettoapproximately. Thestandardizationofreagentsisnormallyachievedviatitration, always comparing the optical densities of the reagents when reacted on viral and normal antigen. These results on a more 100 acute sample cannot rule out the infection as the antibody response may not have had time to form. Once investigated, it is sent back the fullformattoregionalWorldHealthOrganizationoffice. In an epidemic response, space sprays should be carried out with handheld sprayers whenever possible, or with truck-mounted sprayers to increase speed of coverage, every two to three days. Examples of insecticides for cold aerosol or thermal fog application against mosquitoes. R e s i s t a n c e The s t i n g Frequent application of the same insecticide or class of insecticide may select for individual mosquitoes that are able to survive pesticide applications. The insecticides available for use as adulticides are limited, and fall into three chemical classes: organophosphates, carbamates, and pyrethroids. Some products for larviciding have different modes of actions, such as insect growth regulators and microbials tools. Control programs must include a resistance monitoring program81-83 (additionalreferencesareavailableat. A quality assurance program should monitor applicator performance and control outcomes. Control failures may be due to misapplication, incomplete coverage, or insecticide resistance, and must be corrected immediately. The entire emergency containment operation needs to be conducted rapidly, so human and other resources devoted to this effort should be matched to the size of the containment area. Malaria control personnel and others with suitable training may be utilized to accomplish goals of the containment effort. In addition to participating in a national communication effort, immediately inform the community (residents, schools, churches, businesses, etc. Topics should include mode of spread, symptoms, advice to consult a physician if symptoms appear, and community involvement to eliminate standing water from containers and to allow health inspectorsintohomesforapplicationofanti-mosquitomeasures. Conduct indoor and outdoor insecticide applications to eliminate adult mosquitoes. Simultaneously conduct container elimination/protection and larviciding to eliminate the production of new mosquitoes. Special attention should be given to cryptic or subterranean bodies of water that can produce Aedes mosquitoes, such as roof gutters, drains, wells, elevated water tanks, water meters, and even septic tanks. Some containers, such as useful implements (paint trays, buckets) and bottles should be stored in a way to prevent themfromcollectingwater. Containers that cannot be prevented from holding water for any reason should be treated with a larvicide. For example, containers holding water for animal or human consumption require the application of larvicides that have been licensed in the country for that particular purpose. For other larvicides that can be applied to containers holding non-potable water, see Table F2. Alternatively, or concurrently with source reduction, residual insecticides can be applied to containers holding non-potable water (to inner/outer walls) to kill the larvae and pupae and to nearby outdoor surfaces to kill landing or resting adult mosquitoes. This type of insecticide application is donewithhand-heldcompressionsprayersandmuchcarehastobetaken toavoidsprayingnearunprotectedwater-storagecontainersorpets. Monitorhousesandbuildingsintheneighborhoodsthatarebeingtreated and implement special control rounds after working hours, weekends, and holidaystoassurethatnearly100%ofhomesandbusinessesaretreated. Activating a command center (Emergency Operations Center), either physical or virtual, where epidemiologists, entomologists and vector control specialists, educators, media communicators, etc. Epidemiological services need to be organized so that daily, detailed reports are sent to all authorized personnel in the affected areas (states, municipalities). To be successful, it will be necessary to establish an efficient system of communications, allowing for feed-back reports and the receipt of acknowledgements (by e-mail,fax,telephone,etc. Dissemination of this information needs to be done in a way that no personal information oridentifiersarereleasedtothepublicatanytime. Ensuring that infected and febrile persons are protected from mosquito bites by using bednets at home and in hospitals. Inareaswheredengueisendemic, 114 knowledge from a retrospective analysis of dengue virus transmission or previous experience with dengue viruses should be used to guide vector control operations. An epidemic is generally a series of smaller outbreaks occurring simultaneously in several different places within a country (neighborhoods, cities, municipalities, states), where the number of disease cases is unusually large. This means that epidemic control measures may need to be applied concurrently in several locations. Large-areacontrolofmosquitopopulationsovershortperiodsbyspraying insecticides from truck- or aircraft-mounted equipment has not proven effectiveinreducingdenguetransmission. Large-scaleoutdoorapplication ofpesticidesmaybebeneficialwhenusedinconjunctionwithothercontrol measures as part of an integrated mosquito control program. In the case of endemic areas, conduct the retrospective epidemiological study at this level, so that stratification serves operational purposes. All premises, businesses and other areas (parks, cemeteries, abandoned lots, areas along creeks, illegal dumps, etc. Area-wide vector control measures imply having sufficiently trained personnel, equipment, and supplies to treat the environment where Aedes mosquitoes are being produced. For this reason, vector controlmeasuresneedtoachieveaveryhighefficiency,asmeasuredby the elimination of an extremely large proportion of vector mosquitoes.
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The result is a circumferential sloughing with subsequent discontinuity of the urethra and bladder; the intervening tissue is merely the epithelium that has grown over high cholesterol causes erectile dysfunction buy discount viagra sublingual 100mg online, and become adherent to erectile dysfunction icd 9 code wiki buy viagra sublingual with amex erectile dysfunction cholesterol lowering drugs buy generic viagra sublingual 100 mg line, the periosteum of the back of the pubic bone. И Fistulas involving this level of destruction are daunting, and are rarely seen in developed countries. According to Moir, the three great problems involved in dealing with this type of fistula are: 1. The basic principles of technique needed to deal with this type of injury are complete mobilization of the bladder so that it can be drawn down low enough to create a tension-free anastomosis with the urethral remnant. Freeing the urethral remnants from their adherence to the pubic bone may require a suprapubic incision with dissection from above in order to accomplish this. In such cases Moir took care to reinforce the bladder neck with buttressing sutures, and generally brought in a MartiusХ graft for better support and a renewed blood supply. If only the posterior portion of the urethra had been sloughed and the anterior portion of the urethra was intact, Moir (1964) advocated a different technique for urethral reconstruction. In this technique, a thin catheter was stitched into position to serve as a splint for the new urethra. The margins of the urethral bed were freed from the vagina and were mobilized to allow them to be pulled together over the underlying catheter without tension. The stay sutures holding the vaginal flaps are released and the vaginal defect is closed as an Тinverted TУ using absorbable sutures. И the repair was usually buttressed with a Martius bulbocavernosus fat graft, after which the vagina was closed over the repair with vertical mattress sutures to achieve a Зbroad appositionИ of the vaginal wall. The bladder was then drained for 10 days and the vaginal sutures were removed after 21 days. Although he reported good success with this technique, with 23 of 34 women (67%) having Зperfect or near perfect controlИ six months after surgery, 8 of 34 (24%) had persistent stress incontinence, and 9% had no improvement, reconfirming the view that persistent stress incontinence remains a significant problem for many women after successful fistula closure. Similar techniques with similar results have been reported by other authors (Noble 1901; Symmonds 1969; Symmonds and Hills 1978) Various authors have described neourethral reconstruction using bladder flaps (Barnes and Wilson 1949; Flocks and Culp 1953; Su 1969; Quartey 1972; Tanagho and Smith 1972). All of these operations are based upon transabdominal techniques; however, a transvaginal approach to neourethral reconstruction using an anterior bladder flap technique was described by Elkins, Ghosh and co-workers (1992). In this technique, a neo-urethra is created by mobilizing a flap from the anterior bladder, which is then rolled into a tube. In this technique, the anterior and lateral edges of the fistula are freed up and the space of Retzius is entered transvaginally beneath the pubic bone. A 3 cm incision is made into the bladder and the anterior bladder wall is then rolled around a 16 Fr. After this is tacked down, a similar incision is made on the other side to complete mobilization of the tube. The anterior surface of the neourethra is then sutured in two layers and the posterior edge of the fistula is closed transversely, also in two layers. The neourethra is reattached to the posterior edge of the pubic symphysis, and a Martius graft is placed, before reapproximating the vaginal epithelium. This technique resulted in successful closure of the fistula in 18 of 20 cases, 4 of whom had severe stress incontinence post-operatively. Based on their extensive experience with fistulas in Addis Ababa, Ethiopia, in 1969 Hamlin and Nicholson introduced the concept of the Зdifficult urinary fistulaИ to describe the complicated aspects of the problem touched on by Moir. According to them, the Зdifficult fistulaИ ЗЙis a complex of several grave injuries occurring togetherС-namely, a) total destruction of the urethra (all walls), the remaining tissue being merely fibrous connective tissue and squamous epithelium which has grown over and become adherent to the periosteum on the back of the pubic bones; b) an extensive sloughing of the bladder neck and trigone sometimes so large as to cause one or both ureteric orifices to open directly into the vagina; and c) fibrosis to an incredible degree which 1) narrows the vagina to the diameter of one fingerbreadth, and 2) binds the remains of the bladder high up to the descending pubic rami and to the pubic symphysis. In a word, no part of the patientХs lower urinary tract has escaped some degree of damage. This is the fistula which daunts the hearts of most observers who see it for the first time. Й the gynaecologist bold enough to attempt the classical flap-splitting operation for a case like this soon discovers that he is operating in an area as confined and almost as inaccessible as the inside of the toe of a leather shoe. He will find himself freeing the bladder of scar and the lateral fixation of its torn edges by touch only. Й Within the vagina nothing exists Й except, almost quite literally, skin and bone. И In such cases, Hamlin and Nicholson recommended constructing a new urethra by creating a new ЗinnerИ urethra using the skin and fibrous connective tissue covering the pubic bones and the inferior border of the pubic symphysis. In this technique, two lateral vertical incisions about 2 cm part are made in the skin, and left and right skin flaps were then created and reflected medially until their edges could be joined together without tension in the midline underneath the urinary catheter that had been placed in the bladder. As the authors noted, ЗSuch a fragile neourethra, standing unsupported, would almost certainly necrose, and even if it survived would not restore any worthwhile degree of function. И the neourethra was then reinforced using a gracilis muscle flap taken from the thigh, preserving its neurovascular pedicle. The gracilis tendon is pulled through a tunnel in the thigh that crosses the ischiopubic ramus at the level of the urethra and is guided into the vagina, under the pubic symphysis, and is sutured to the anterior lip of the cervix, the lateral vaginal fascia, and the fibrous connective tissue covering the periosteum of the ischiopubic rami and the pubic symphysis. Once this has been accomplished, additional grafting is necessary using a Martius flap which is then covered with skin flaps. Using this technique, the authors reported no deaths and only one Зcomplete failureИ in 50 operations, this case being due to failure of the blood supply to the gracilis muscle flap. In some cases small urethro-vaginal fistulas remained, which were repaired at a subsequent operation. Surprisingly, only 8 women (16%) developed ЗsevereИ stress incontinence after this reconstruction, four of whom regained ЗsatisfactoryИ continence over time, and four of whom required an operation for stress incontinence. In the latter four patients, only two 925 of these operations were completely successful. Six patients (12%) developed a urethral stricture, three of which were successfully treated by passage of a sound and three of which required surgical correction. The remaining 35 patients (70%) were discharged home within six weeks of surgery clinically cured or with mild residual stress incontinence which did not appear to be clinically bothersome for them. Complete urethral loss from obstructed labor remains a daunting surgical challenge, to which an ideal solution has yet to be found. Similarly, there are no accepted criteria in failed cases to dictate when further attempts at closure should be abandoned and the patient should be offered some form of urinary diversion as a treatment. This reluctance is compounded by the concern of performing such a major procedure in often basic conditions. И Because urinary diversion tends to be a Зhigh technologyИ approach to fistula management, its use in countries that do not have a well-developed nursing infrastructure to support the ongoing care of such patients suggests that this technique should be used with extreme caution. For example, transplantation of the ureters into an ileal conduit requires the use of an external collecting device. The use of such appliances may well be unacceptable in the local culture and patients are likely to experience significant difficulty in obtaining suitable external appliances and may have trouble performing good stoma care. The result of such a policy could well be simply to transpose the fistula from the vagina to the abdomen! Likewise, if continent urinary diversions are performed with the creation of a catheterizable stoma, the problem of clean intermittent self-catheterization remains. This can be compounded by loss of the cathe- ter or the development of stomal stenosis, with urinary retention, reservoir breakdown, sepsis, and death. Hodges (1999) has reported a series of seven patients with intractable fistulas who were treated in Uganda by continent urinary diversion using a Mitrofanoff procedure in which the appendix is mobilized as the catheterizable stoma. There was one death 6 days after surgery, apparently from coincidental complications rather than as a direct result of the operative technique.
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Using a sterile inoculating loop or needle erectile dysfunction lubricant buy discount viagra sublingual 100mg on line, pick several isolated colonies from the primary isolation plate and streak the surface of a slant of Heart Infusion Agar what do erectile dysfunction pills look like purchase cheap viagra sublingual. Huntoon1 using fresh beef heart and Bacto Peptone what std causes erectile dysfunction best order for viagra sublingual, prepared a "hormone" broth to retain growth promoting substances. Heart infusion media are specified for the isolation of Vibrio cholerae and Vibrio species. Principles of the Procedure Infusion from beef heart and tryptose supply the nutritional requirements for growth of microorganisms in heart infusion media. These various formulations have differed in their degree of selectivity for the pathogenic species. Some were designed to isolate and differentiate Shigella species whereas others were formulated for the selective isolation of the salmonellae. Media that isolated a broader spectrum of enteric pathogens were less inhibitory to members of the nonpathogenic intestinal flora. Hektoen Enteric Agar was developed in 1967 by King and Metzger of the Hektoen Institute in order to increase the frequencies of isolation of Shigella and Salmonella organisms when compared with their recovery on other media frequently utilized in clinical laboratories at that time. The present formulation differs from that of the original in that sodium desoxycholate has been eliminated and the concentration of bile salts is reduced. Additionally, the peptone concentrations have been increased in order to offset the inhibitory effects of the bile salts. These substances inhibit gram-positive organisms but also can be toxic for some gram-negative strains. This medium contains three carbohydrates, lactose, sucrose (saccharose) and salicin, for optimal differentiation of enteric pathogens by the color of the colonies and of the medium adjacent to the colonies. The lactose concentration is higher than in many other media used for enterics in order to aid in the visualization of enteric pathogens and minimize the problem of delayed lactose fermentation. Ferric ammonium citrate and sodium thiosulfate in the medium enable the detection of hydrogen sulfide production, thereby aiding in the differentiation process due to the production of blackcentered colonies. The indicator system, consisting of acid fuchsin and bromthymol blue, has a lower toxicity than that of many other enteric media, resulting in improved recovery of enteric pathogens. Limitation of the Procedure Proteus species may resemble salmonellae or shigellae. Further testing should be conducted to confirm the presumptive identification of organisms isolated on this medium. Expected Results After incubation most plates will show an area of confluent growth. Because the streaking procedure is, in effect, a "dilution" technique, diminishing numbers of microorganisms are deposited on the streaked areas. Consequently, one or more of these areas should exhibit isolated colonies of the organisms contained in the specimen. Choose one or two well-isolated colonies that resemble Haemophilus species and perform a Gram stain to confirm that the isolate is a gramnegative rod or coccobacillus. Inoculate each quadrant with one loopful of diluted specimen and streak to obtain isolated colonies. To prevent carry-over of growth factors, sterilize the loop between inoculations of each quadrant. Inoculate each quadrant of the plate with one loopful of the diluted specimen and streak to obtain isolated colonies, sterilizing the loop between inoculation of each quadrant. Expected Results After 24 hours of incubation, the plates should show growth or no growth, depending on X and V factor requirements. The following table shows the expected growth results for various Haemophilus spp. Gram staining, biochemical tests and/or additional identification procedures should be performed to confirm findings. Tighten caps when medium surface is dry (1-2 weeks) and place in an upright position in the incubator. Read and evaluate tubes for growth and contamination every week for up to 16 weeks. Summary and Explanation Expected Results Colonies appearing should be evaluated for typical acidfastness and morphological appearance of M. Acid-fast cultures that grow only in the presence of Mycobactin J are identified as M. Principles of the Procedure Enzymatic digest of casein provides amino acids and other nitrogenous substances. Beef extract provides additional nitrogenous nutrients, vitamins and minerals required for microbial growth. Egg yolk and glycerol provide fatty acids and other nutrients required for the metabolism of mycobacteria. Nalidixic acid (N) inhibits contaminating gram-negative organisms and vancomycin (V) inhibits contaminating gram-positive organisms. Malachite green is included to help control contaminants and enhance the visibility of colonies. Procedure For details on the use of these media for characterization of Streptomyces species, consult the reference. Summary and Explanation Indole Nitrite Medium was developed to serve the dual role of detecting indole production and nitrate reduction of a wide range of microorganisms. Due to its nutritive content, the medium will support the growth of aerobes, microaerophiles and facultative and obligate anaerobes. Indole Nitrite Medium can be used for nitrite tests with members of the Enterobacteriaceae but is not recommended Principles of the Procedure the casein peptone contains tryptophan, which is attacked by certain microorganisms, resulting in the production of indole, detectable by the addition of chemical reagents to 18to 48-hour cultures. Potassium nitrate serves as the substrate for determining the ability of microorganisms to reduce nitrates to nitrites. If the medium is more than 2 days old at the time of use, boil and cool prior to use. Inoculate with fresh broth cultures diluted 1:10 and incubate at 35 ± 2°C for 2 days under appropriate atmospheric conditions. Replicate tubes should be inoculated if it is desired to test for the presence of indole or nitrites after incubation 270 Inhibitory Mold Agar for various lengths of time. The caps of tubes inoculated with obligate anaerobes should be tightened during incubation. Indole Test the test for indole may be performed as soon as heavy growth has taken place, usually after 18 to 48 hours of incubation. Nitrite Test the test for nitrites may be performed at several intervals during the incubation process if replicate tubes were inoculated. If prior tests are negative, a final test should be conducted at 48 hours of incubation. The tubed medium should be boiled for 2 minutes and cooled, without agitation, before use.
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Furthermore erectile dysfunction diabetes viagra purchase viagra sublingual cheap online, if pregnancy does not occur impotence lotion order genuine viagra sublingual line, there is no way to impotence postage stamp test purchase 100 mg viagra sublingual with visa determine whether the cause of failure was lack of fertilization or lack of implantation. Indications Indications for intracytoplasmic sperm injection are as follows: · Severe deficits in semen quality. Men who are undergoing karyotype testing should be offered genetic counseling regarding the genetic abnormalities that may be detected. Couples should be informed that intracytoplasmic sperm injection improves fertilization rates compared to in vitro fertilization alone, but once fertilization is achieved, the pregnancy rate is no better than with in vitro fertilization. This thickened zona may represent an obstacle for the normal embryo hatching, thereby interfering with the implantation. In order to facilitate the hatching of normal embryos, the procedure of assisted hatching is sometimes used for the embryos which show a thick zona pellucida. Both the procedures create a weak spot within the zona, facilitating the break of the zona and the hatching of the embryo. However, the pre-embryo is transferred into the fallopian tube via laparoscopy at the 2-pronuclei stage or 24 hours after oocyte retrieval. Before starting treatment by donor insemination, it is important to confirm that the woman is ovulating. Women with a history that is suggestive of tubal damage should be offered tubal assessment before treatment. Thus in order to qualify for this procedure, the patient must have at least one normal532 appearing and patent fallopian tube. Chapter 26 preference to intracervical insemination because it improves pregnancy rates. Women who are ovulating regularly should be offered a minimum of six cycles of donor insemination without ovarian stimulation to reduce the risk of multiple pregnancy and its consequences. Infertility Oocyte Donation Indications for oocyte donation the use of donor oocytes is considered effective in managing fertility problems associated with the following conditions: · Premature ovarian failure. All people considering participation in an egg-sharing scheme should be counseled about its particular implications. She was also referred to the nutrition specialist to help her devise a proper dietary plan in order to bring her weight under control. Since the ultrasound examination revealed findings Important Questions and Answers Q. Since the causes of infertility can be multifactorial, a suggestive of polycystic ovarian disease, she was started on clomiphene citrate in the dosage of 50 mg per day for first five days of the menstrual cycle. Ultrasound examination for follicular monitoring in this case revealed evidence of ovulation. Fertility is defined as the capacity to reproduce or the systematic approach typically is used and involves testing for male factor, ovulatory factor, uterotubal factor and peritoneal factor. Since the evaluation for male factor infertility has already been done in form of semen analysis, the next step should be towards evaluation of ovulatory factors. These must include tests such as serum progesterone level, serum basal follicle-stimulating hormone level, and clomiphene citrate challenge test. Couples concerned about their fertility should be informed that about 84% of couples in the general population will conceive within 1 year if they do not use contraception and have regular sexual intercourse. Of those who do not conceive in the first year, about half will do so in the second year (cumulative pregnancy rate of 92%). Regular sexual intercourse after every 2 to 3 days is likely to maximize the overall chances of natural conception, as spermatozoa survive in the female reproductive tract for up to 7 days after insemination. In this case, the sexual history revealed that the couple had reasonable knowledge regarding the female reproductive cycle and had been having regular unprotected sexual intercourse. Fecundability is the probability of achieving a pregnancy each month, which is approximately 20% to 25%. Taking an average fecundability of 20% per cycle, the cumulative pregnancy rate over 3 months of exposure is 57%, over 6 months is 72%, over 1 year is 85% and over 2 years is 93%. On the other hand, fecundity can be defined as the ability to achieve a live birth within 1 menstrual cycle. With regular unprotected sexual intercourse, 94% of fertile women aged 35 years or younger are likely to conceive after 3 years of trying. Obesity can lead to the aromatization of testosterone in 26 fatty tissue to estradiol, leaving less testosterone available for maintenance and virilization functions in males. This may result in a reduction in sperm production in males because the testes are not able to receive an adequate hormonal signal to produce sperms. Treatment of female infertility due to tubal obstruction by operative laparoscopy. Effects of metformin on spontaneous and clomiphene-induced ovulation in the polycystic ovary syndrome. Pregnancies after intracytoplasmic injection of single spermatozoon into an oocyte. The association between smoking and female infertility as influenced by cause of the infertility. Endometriosis and infertility: a laparoscopic study of endometriosis among fertile and infertile women. The cryopreservation of embryos is usually done prior to commencing chemotherapy or radiotherapy, both of which are likely to affect the fertility of an individual. Treatment of uterine fibroids: current findings with gonadotropin-releasing hormone agonists. Controlled ovarian hyperstimulation and intrauterine insemination for treatment of infertility. The menstrual cycles had never begun, even though she had experienced normal breast and secondary sexual development at the age of about 13 years. Primary amenorrhea is absence of menstrual cycles in a woman who had never experienced menstrual cycles before. Secondary amenorrhea on the other hand is defined as the cessation of menstruation in a woman who had been previously experiencing menstrual bleeding. This cessation must last for at least 6 months or for at least 3 of the previous 3-cycle intervals. Primary amenorrhea can be defined as follows: · Absence of menses by age of 14 years with the absence of growth or development of secondary sexual characteristics. Pathophysiology of Menstrual Bleeding As previously described in chapter 16, circulating estradiol levels in the body stimulates the growth of uterine endometrium. If pregnancy does not occur, this secretory endometrium breaks down and sheds in the form of menstrual bleeding. A complex interaction between the hypothalamic-pituitary-ovarian axis and the outflow tract (uterus, cervix and vagina) is required for the normal menstrual bleeding to take place.