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Damasio stresses that all living organisms are born with devices designed to solve automatically buy discount viagra vigour 800 mg on line, without proper reasoning required purchase viagra vigour cheap online, the basic problems of life buy viagra vigour with amex. The simpler reactions are incorporated as components of the more elaborated and complex ones. Emotion is high in the organization, with more complexity of appraisal and response. According to Damasio, an emotion is a complex collection of chemical and neural responses forming a distinctive pattern. When the brain detects an emotionally competent stimulus, the emotional responses are produced automatically. The result of the responses is a temporary change in the state of the body, and in the brain struc- tures that map the body and support thinking. In this view, feelings are based on the feedback of the emotional bodily and brain responses to the brain; they are the end result of the whole machinery of emotion. It has been suggested that the insula is involved in the representation of peripheral autonomic and somatic arousal that provides input to conscious awareness of emotional states. It appears that the feedback of autonomic and somatic responses are inte- grated in a so-called meta-representation in the right anterior insula, and this meta-representation seems to provide the basis for the subjective image of the material self as a feeling entity, that is emotional awareness (83). In men and women alike, meanings of a sexually competent stimulus will automatically generate a genital response, granted the genital response system is intact. The difference between men and women in experienced sexual feelings have to do with the relative contribution of two sources. The rst source is the awareness of this automatic genital response (peripheral feedback), which will be a more important source for mens sexual feelings than for womens sexual feelings (87). For women, a stronger contribution to sexual feelings will come from a second source, the meanings generated by the sexual stimulus. In other words, womens sexual feelings will be determined to a greater extent by all kinds of (positive and negative) meanings of the sexual stimulus than by actual genital response. It was found that women rated more pictures as highly negatively arousing than did men. The memory task revealed that women had better memory for the most intensely negative pictures. Exposure to the emotional stimuli resulted in left amygdala activation in both sexes, the central brain structure for implicit memory (77). Explicit memory is situated in the neocortex and is mediated by the hippocampus (89). These ndings may suggest that in pro- cessing emotional stimuli, explicit memory is more readily accessible in women. If these ndings would hold for sexual stimuli, we may have a neural basis for our suggestion that sexual stimuli activate explicit memory in women, and that the different meanings sexual stimuli may have, inuence sexual feelings. Gender Differences in Sexual Feelings Our hypothesis is that in women other (stimulus or situational) information beyond stimulus explicitness determines sexual feelings, whereas for men per- ipheral feedback from genital arousal (and thus stimulus explicitness) is the most important determinant of experience of sexual arousal. This hypothesis ts well with the observed gender difference in response concordance. It coincides with Baumeisters assertion that women evidence greater erotic plas- ticity than men (90). After reviewing the available evidence on sexual behavior and attitudinal data of men and women, he concluded that womens sexual responses and sexual behaviors are shaped by cultural, social, and situational factors to a greater extent than mens. Both womens and mens sexuality are likely to be driven by an interaction of biological and sociocultural factors. Evolutionary arguments often invoke differential reproductive goals for men and women (91). Given these reproductive differences, it would have been particularly adaptive for the female, who has a substantial reproductive investment and a clearer relationship to her offspring, not only to manifest strong attachments to her infants but also to be selective in choosing mates who can provide needed resources. This selectivity mandates a complex, careful decision process that attends to subtle cues and contextual factors. Consistent with mens and womens reproductive differences, Bjorklund and Kipp proposed that cognitive inhibition mechanisms evolved from a neces- sity to control social and emotional responses (92). Women are better at delaying gratication and in regulating their emotional responses. The emotional signicance of events or situations, in addition to the evol- utionary point of view, can be put in perspective by looking at the sorts of actions that are instigated by the emotional valence of sexual events or situations. Female Sexual Arousal Disorder 141 from orgasm, but may also involve intimacy or bonding. Sexual stimuli, through negative experience, may be associated with aversion and thus turn off any possi- bility for positive arousal (94). Sustained sexual arousal, which may increase in intensity, must be satisfying in itself or predict the satisfaction of other concerns. This idea also implies that, depending on the circumstances, there may be nonsexual concerns that attract attention with greater intensity, and thus detract attention from sexual stimuli. The experimental evidence and theoretical notions presented earlier strongly suggest that for women, sexual dysfunction is not about genital response. This study demonstrated that it is difcult to be sure that sexual arousal problems are not caused by a lack of adequate sexual stimulation, and that impaired genital response cannot be assessed on the basis of an anamnestic interview. In medically healthy women impaired genital responsiveness is not a valid diagnostic criterion. Bancroft, Loftus and Long subsequently investigated which sexual problems predicted sexual distress in a randomly selected sample of 815 North American heterosexual women aged 2065, who were sexually active (16). The best pre- dictors were markers of general emotional and physical well being and the emotional relationship with their partner during sexual activity. The study provided data supporting the possibility that relationship disharmony may cause impaired sexual response rather than the opposite. On the other hand, a high sexual distress score does not automatically implicate sexual dysfunction. In this chapter, we have argued that many women with a medical condition have sexual problems that may or may not be caused by the disease directly, but that the sexual problems of healthy women are better explained by lack of adequate sexual stimulation and sexual and emotional closeness to their partner. Similarly, Tiefer (96) has presented a New View of Womens Sexual Problems that strives to de-emphasize the more medicalized aspects of sexual problems that currently prevail, and that looks at problems rather than at dysfunctions [see also Refs. Bancroft (98) argues that a substantial part of the sexual problems of women are a logical, adaptive response to life circumstances, and should not be considered as a sign of a dys- functional sexual response system, which would explain why prevalence gures based on frequencies yield much higher dysfunction rates (19) than actual distress gures. The latest classication proposal also embraces the personal distress cri- terion and has reintroduced a subjective criterion, but avoids an answer to the question of when a sexual problem is a dysfunction. In this proposal the word dysfunction is used to mean simply lack of healthy/expected/normal response/interest, and is not meant to imply any pathology within the woman (15). This does again suggest, however, that we have clear criteria for healthy and normal response. The answer to the question of what is not a sexual dysfunction is more easy than generating clear cut criteria for sexual dysfunction. Female Sexual Arousal Disorder 143 cannot be understood as adaptations to life circumstances and which cause sexual distress, should be considered a dysfunction.

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This fact is evident from Bernoullis equation purchase genuine viagra vigour on line, which shows that if the height and velocity of the uid remain constant viagra vigour 800 mg low cost, there is no pressure drop along the ow path order viagra vigour with american express. The product of the pressure drop and the area of the pipe is the force required to overcome the frictional forces that tend to retard the ow in the pipe segment. Note that for a given ow rate the pressure drop required to overcome frictional losses decreases as the fourth power of the pipe radius. Thus, even though all uids are subject to friction, if the area of the ow is large, frictional losses and the accompanying pressure drop are small and can be neglected. The ow becomes turbulent with eddies and whirls disrupting the laminar ow (see Fig. In a cylindrical pipe the critical ow velocity vc above which the ow is turbulent, is given by vc (8. The symbol is the Reynolds number, which for most uids has a value between 2000 and 3000. Therefore, as the ow turns turbulent, it becomes more dicult to force a uid through a pipe. Blood is not a simple uid; it contains cells that complicate the ow, especially when the passages become narrow. Furthermore, the veins and arteries are not rigid pipes but are elastic and alter their shape in response to the forces applied by the uid. Still, it is possible to analyze the circulatory system with reasonable accuracy using the concepts developed for simple uids owing in rigid pipes. The blood in the circulatory system brings oxygen, nutrients, and various other vital substances to the cells and removes the metabolic waste products from the cells. The blood is pumped through the circulatory system by the heart, and it leaves the heart through vessels called arteries and returns to it through veins. The mammalian heart consists of two independent pumps, each made of two chambers called the atrium and the ventricle. The entrances to and exits from these chambers are controlled by valves that are arranged to maintain the ow of blood in the proper direction. Blood from all parts of the body except the lungs enters the right atrium, which contracts and forces the blood into the right ventricle. The ventricle then contracts and drives the blood through the pulmonary artery into the lungs. In its passage through the lungs, the blood releases carbon dioxide and absorbs oxygen. The contraction of the left atrium forces the blood into the left ventricle, which on contraction drives the oxygen-rich blood through the aorta into the arteries that lead to all parts of the body except the lungs. Thus, the right side of the heart pumps the blood through the lungs, and the left side pumps it through the rest of the body. These in turn branch into still smaller arteries, the smallest of which are called arterioles. As we will explain later, the arte- rioles play an important role in regulating the blood ow to specic regions in Section 8. The arterioles branch further into narrow capillaries that are often barely wide enough to allow the passage of single blood cells. The capillaries are so profusely spread through the tissue that nearly all the cells in the body are close to a capillary. The capillaries join into tiny veins called venules, which in turn merge into larger and larger veins that lead the oxygen-depleted blood back to the right atrium of the heart. First the atria contract, forcing the blood into the ventricles; then the ventricles contract, forcing the blood out of the heart. Because of the pumping action of the heart, blood enters the arteries in spurts or pulses. The maximum pressure driving the blood at the peak of the pulse is called the systolic pressure. Ina young healthy individual the systolic pressure is about 120 torr (mm Hg) and the diastolic pressure is about 80 torr. As the blood ows through the circulatory system, its initial energy, pro- vided by the pumping action of the heart, is dissipated by two loss mecha- nisms: losses associated with the expansion and contraction of the arterial walls and viscous friction associated with the blood ow. Due to these energy losses, the initial pressure uctuations are smoothed out as the blood ows away from the heart, and the average pressure drops. By the time the blood reaches the capillaries, the ow is smooth and the blood pressure is only about 30 torr. The pressure drops still lower in the veins and is close to zero just before returning to the heart. In this nal stage of the ow, the movement of blood through the veins is aided by the contraction of muscles that squeeze the blood toward the heart. The rate of blood ow Q through the body depends on the level of physical activity. Of course, as the aorta branches, the size of the arteries decreases, result- ing in an increased resistance to ow. Although the blood ow in the nar- rower arteries is also reduced, the pressure drop is no longer negligible (see Exercise 8-2). The ow through the arterioles is accompanied by a much larger pressure drop, about 60 torr. Since the pressure drop in the main arteries is small, when the body is horizontal, the average arterial pressure is approximately constant throughout the body. The arterial blood pressure, which is on the average 100 torr, can support a column of blood 129 cm high (see Eq. This means that if a small tube were introduced into the artery, the blood in it would rise to a height of 129 cm (see Fig. If a person is standing erect, the blood pressure in the arteries is not uni- form in the various parts of the body. The weight of the blood must be taken into account in calculating the pressure at various locations. For example, the average pressure in the artery located in the head, 50 cm above the heart (see Exercise 8-4a) is Phead Pheart gh 61 torr. In the feet, 130 cm below the heart, the arterial pressure is 200 torr (see Exercise 8-4b). Thus, a person may feel momentarily dizzy as he/she jumps up from a prone position. This is due to the sudden decrease in the blood pressure of the brain arteries, which results in a temporary decrease of blood ow to the brain. The same hydrostatic factors operate also in the veins, and here their eect may be more severe than in the arteries. When a person stands motionless, the blood pressure is barely adequate to force the blood from the feet back to the heart. Thus when a person sits or stands without muscular movement, blood gathers in the veins of the legs. This increases the pressure in the capillaries and may cause temporary swelling of the legs. Hormones are molecules, often proteins, that are produced by organs and tissues in dierent parts of the body.

Retinopathy and plications Trial/Epidemiology of Diabetes Interven- (54 mg/dL) should be reported in clinical trials: nephropathy in patientswithtype 1 diabetesfour tions and Complications and Pittsburgh Epidemiology a joint position statement of the American Diabe- years after a trial of intensive therapy cheap 800 mg viagra vigour. Hypo- diabetic microvascular complications in Japanese Association between 7 years of intensive treat- glycemia anddiabetes:a report of aworkgroupof patients with non-insulin-dependent diabetes ment of type 1 diabetes and long-term mortality 800 mg viagra vigour with amex. Effect of intensive blood-glucose control of Cardiology Foundation purchase viagra vigour with paypal; American Heart Asso- dementia in older patients with type 2 diabetes with metformin on complications in overweight ciation. Dia- tional treatment and risk of complications in the American Heart Association. Severe hypoglycemia and cular and microvascular complications of type 2 Engl J Med 2015;372:21972206 risks of vascular events and death. Glucose control and vascular correction appears in Diabetologia 2009;52: talityofpatientswithdiabetesreportingsevere complications in veterans with type 2 diabetes. Potential overtreatment of diabe- of transplantation of human islets in type 1 dia- of hyperglycaemia on microvascular outcomes in tes mellitus in older adults with tight glycemic betes complicated by severe hypoglycemia. Diverse causes of hypoglycemia- EpidemiologyofDiabetesInterventionsandCom- position statement of the American Diabetes Asso- associated autonomic failure in diabetes. In- ciation and the European Association for the Study J Med 2004;350:22722279 tensive diabetes treatment and cardiovascular of Diabetes. Diabetes Care 2009;32:13351343 Diabetes Care Volume 41, Supplement 1, January 2018 S65 American Diabetes Association 7. There is strong and consistent evidence that obesity management can delay the progression from prediabetes to type 2 diabetes (1,2) and may be benecialin the treatment oftype2 diabetes (38). In overweight and obese patients with type 2 diabetes, modest and sustained weight loss has been shown to improve glycemic control and to reduce the need for glucose-lowering medications (35). Small studies have demonstrated that in obese patients with type 2 diabetes more extreme dietary energy restriction with very- low-calorie diets can reduce A1C to,6. Weight lossinduced improvements in glycemia are most likely to occur early in the natural history of type 2 diabetes when obesity-associated insulin resistance has caused reversible b-cell dysfunction but insulin secretory capacity re- mains relatively preserved (5,8,10,11). The goal of this section is to provide evidence- based recommendations for dietary, pharmacologic, and surgical interventions for obesity management as treatments for hyperglycemia in type 2 diabetes. S66 Obesity Management for the Treatment of Type 2 Diabetes Diabetes Care Volume 41, Supplement 1, January 2018 Table 7. The latter two well-controlled diabetes (A1C less than strategies may be prescribed for carefully 6. Greater c Diet,physical activity, and behavior- energy decit or provide approximately weight loss produces even greater bene- altherapydesigned toachieve. A maintaining long-term weight loss in pa- lifestyle intervention group of the Look c For patients who achieve short- tients with type 2 diabetes. Such programs should sive lifestyle intervention participants patients health status and preferences. In- ticipation in high levels of physical blood pressure, and lipid-lowering med- terventionsshould beprovided bytrained activity (200300 min/week). A ications than those randomly assigned to interventionists in either individual or c To achieve weight loss of. Agents associated with weight loss force lifestyle changes including physical trained interventionist and focus on on- include metformin, a-glucosidase inhibi- activity. Dipeptidyl peptidase ful weight loss against the potential risks ipationinhighlevelsofphysicalactivity 4 inhibitors appear to be weight neutral. Some com- Unlike these agents, insulin secretagogues, medications are contraindicated in women mercial and proprietary weight loss pro- thiazolidinediones, and insulin have often who are or may become pregnant. Women grams have shown promising weight loss been associated with weight gain (see in their reproductive years must be cautioned results (25). Assessing Efcacy and Safety in medical care settings withclose medical A recent meta-analysis of 227 random- Efcacyandsafetyshouldbeassessedatleast monitoring, short-term (3-month) inter- ized controlled trials of antihyperglycemic monthly for the rst 3 months of treatment. Whenever possi- The rationale for weight loss medications tine monitoring of micronutrient ble, medications should be chosen to is to help patients to more consistently S68 Obesity Management for the Treatment of Type 2 Diabetes Diabetes Care Volume 41, Supplement 1, January 2018 care. C postoperative follow up ranging from bolic surgery in such patients will require c People presenting for metabolic 1 to 5 years have documented sustained larger and longer studies (72). However, the me- tions about the long-term effectiveness health conditions until these condi- dian disease-free period among such in- and safety of the procedures (73,74). With gery should be evaluated to assess Adverse Effects or without diabetes relapse, the majority Metabolic surgery is costly and has associ- the need for ongoing mental health of patients who undergo surgery main- ated risks. Candidates for metabolic obese patients with type 2 diabetes com- The safety of metabolic surgery has im- surgery with histories of alcohol or sub- pared with various lifestyle/medical inter- proved signicantly over the past two de- stance abuse, signicant depression, sui- ventions (35). Individu- studies attempting to match surgical metabolic operations are typically 0. Major complications rates chiatric symptoms do not interfere with several organizations and government are 26%, with minor complications in weight loss and lifestyle changes. Targetingweightlossinterventions 2015;373:1122 Reduction in the incidence of type 2 diabetes to reduce cardiovascular complications of type 2 33. N Engl J diabetes: a machine learning-based post-hoc ciation of pharmacological treatments for obesity Med 2002;346:393403 analysis of heterogeneous treatment effects in with weight lossand adverse events: a systematic 3. Lifestyle weight-loss intervention domized placebo-controlled clinical trial of lorca- 1990;39:905912 outcomes in overweight and obese adults with serin for weight loss in type 2 diabetes mellitus: 4. The evidence for the effectiveness of son of weight-loss diets with different composi- abolic surgery in the treatment algorithm for medical nutrition therapy in diabetes manage- tions of fat, protein, and carbohydrates. Effect of duodenal- abetes: normalisation of beta cell function in as- carbohydrate on fat mass, lean mass, visceral ad- jejunal exclusion in a non-obese animal model sociation with decreased pancreas and liver ipose tissue, and hepatic fat: results from the of type 2 diabetes: a new perspective for an old triacylglycerol. Partial meal re- Associationof bariatric surgery withlong-termre- diabetes: an underutilized therapy? Clinicaloutcomesofmetabolicsurgery:efcacy cacy of commercial weight-loss programs: an up- et al. Effects of of glycemic control, weight loss, and remission of dated systematic review. The evolution of very- tients in Sweden (Swedish Obese Subjects Study): American College of Cardiology/American Heart low-calorie diets: an update and meta-analysis. Lancet Association Task Force on Practice Guidelines; Obesity (Silver Spring) 2006;14:12831293 Oncol 2009;10:653662 Obesity Society. Appropriate body-mass index for Asian Baseline body mass index and the efcacy of hy- sociation between bariatric surgery and long- populations and its implications for policy and in- poglycemic treatment in type 2 diabetes: a meta- term survival. The Di- Spring) 2014;22:513 2010;376:595605 abetes Surgery Summit consensus conference: 17. Ann Surg 2010;251:399405 S72 Obesity Management for the Treatment of Type 2 Diabetes Diabetes Care Volume 41, Supplement 1, January 2018 48. Care 2016;39:941948 Lancet 2011;378:108110 Roux-en-Y gastric bypass surgery or lifestyle with 73. Obes Surg 2012;22: type 2 diabetes: feasibility and 1-year results rierstoappropriateuseofmetabolic/bariatricsur- 677684 of a randomized clinical trial. Diabetes Care 2016;39:954963 bility of addition of Roux-en-Y gastric bypass to 62. Surg Clin North Am trolled type 2 diabetes in mild to moderate obe- assessment of bariatric surgery. Bariatric sur- ogists; Obesity Society;AmericanSociety for Met- multisite study of long-term remission and re- gery for obesity and metabolic conditions in abolic & Bariatric Surgery.

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Since some patients with an acute abdomen require resuscitation and early surgical treatment order viagra vigour no prescription, it is important to assess the patient and establish a plan of management as soon as possible buy 800mg viagra vigour otc. The initial goal if the patient has an acute abdomen is not necessarily to make a definitive diagnosis buy 800 mg viagra vigour otc, but rather to identify if the patient requires prompt surgical intervention. Mechanism Acute abdominal pain may be referred to the abdominal wall from intraabdominal organs (visceral pain) or may involve direct stimulation of the somatic nerves in the abdominal wall (somatic pain). Foregut pain is typically epigastric in location, midgut pain is central, and hindgut pain is felt in the lower abdomen. Organs that are bilateral give rise to visceral pain that is predominantly felt on one or the other side of the body. Somatic pain corresponds more directly to the anatomic site of the underlying pathology. Somatic pain occurs with stimulation of pain receptors in the peritoneum and abdominal wall. History The history should focus on the chronology, location, intensity and character of the pain. One example is the intermittent, mid-abdominal pain of uncomplicated small bowel obstruction. Another is the intermittent flank pain radiating anteriorly to the groin that accompanying ureteric obstruction from a renal stone. Irritation of the diaphragm, from peritonitis, for example, may cause shoulder tip pain. The character and subsequent evolution of acute abdominal pain may give a clue as to the site and nature of the underlying pathology. Associated Symptoms Anorexia, nausea and vomiting are more common in diseases of the gastrointestinal tract but are not specific to a particular disorder. This generally applies to a subset of such patients presenting for evaluation in the emergency department. Analgesia may impair the sensitivity of physical examination when signs are subtle. The physical exam begins with an evaluation of blood pressure, pulse and respiratory rate. Abdominal pathology may lead to systemic effects such as hypotension, tachycardia, or tachypnea. A careful physical examination will also identify pertinent extra-abdominal findings such as jaundice or lymphadenopathy. Unlike examination of other systems, auscultation is often performed before palpation. Palpation can stimulate intestinal peristalsis and alter the result of auscultation. Causes of ileus include the postoperative state, medications such as narcotics, or peritonitis. Palpation should begin in an area away from where pain is experienced, progressing to the area of pain last. Guarding refers to contraction of abdominal wall muscles when the First Principles of Gastroenterology and Hepatology A. Involuntary guarding occurs as a protective mechanism when peritoneal inflammation (peritonitis) is present. Voluntary guarding occurs when a patient tenses abdominal wall muscles in response to that abdominal wall pressure. In some instances of peritonitis, the muscles are in a state of continuous contraction. In subtle situations, peritonitis is suggested by the triggering of pain in the area of suspected pathology (e. Gentle percussion is also a very useful way to assess peritoneal irritation, as well as to assess the nature of abdominal distention. Rebound tenderness, another sign of peritonitis, is elicited by deeply palpating the area of concern and then suddenly releasing the abdominal wall. This manoeuvre can be very distressing to the patient with peritonitis, so it is often not done. Rectal and pelvic examinations should be carried out and recorded by at least one examiner. Intra-abdominal conditions requiring surgery (open or laparoscopic) are the most common causes of an acute abdomen. They must always be included in the differential diagnosis, therefore, and confirmed or excluded promptly. In other instances, the specific diagnosis and the need for surgery may take some time to establish. The likelihood of specific diagnoses varies to an extent with the age of the patient. Clinical presentations are more likely to be atypical in the elderly and in patients with coexisting conditions (such as diabetes or stroke). Particular care must be taken to not overlook an important intra-abdominal process in such patients. One must always consider in the differential diagnosis: (1) intra-abdominal conditions for which surgery is not indicated (e. Differential Diagnosis of Acute Abdominal Pain o Peptic Ulcer Disease o Bowel obstruction o Mesenteric ischemia/infarction o Diverticulitis o Gastroenteritis o Ruptured Abdominal Aortic Aneurysm o Cholecystitis o Incarcerated hernia o Pancreatitis o Hepatitis o Appendicitis o Pyelonephritis / Cystitis o Functional Conditions ( eg. Investigations In many instances, a careful history and physical examination provide the clinical diagnosis. Chest and plain abdominal x-rays are obtained routinely unless the diagnosis is clear (e. Ultrasound is very useful in the diagnosis of biliary tract disease (gallstones), abdominal aortic aneurysm, gynecologic disease and is often used in suspected appendicitis. Other imaging modalities that may be ordered depending on the case include intravenous pyelography to assess the genitourinary tract or mesenteric angiography. Laparoscopy has an important diagnostic role, as well as allowing definitive surgical therapy (e. Approach to Management A reasonably specific diagnosis or focused differential can usually be established early on. In some individuals, acute abdominal pain of mild to moderate severity resolves without a confirmed diagnosis. In patients with more serious conditions, intravenous fluid administration, other supportive measures and monitoring must be instituted following rapid initial assessment, even before a specific diagnosis can be made. In such individuals, diagnostic and therapeutic manoeuvres must proceed in a coordinated and efficient manner.