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These observations may be the source of considerable puzzlement even in the well-functioning couple medicine naproxen 500mg cheap coversyl 4 mg mastercard, but may have even greater impact on the couple struggling to deal with problems involving painful intercourse medicine grace potter lyrics cheap 8mg coversyl fast delivery. Anxiety has been shown to be an independent predictor of the pain of dyspareunia symptoms 89 nissan pickup pcv valve bad purchase coversyl 4mg fast delivery, aside from structural factors treatment zinc overdose cheap coversyl 8mg with visa. Together with the vaginal lengthening described, this may serve to move sensitive areas (eg, the posterior cul-de-sac with endometriosis) farther away from contact with the penis. When the uterus is retroverted, vaginal expansion and lengthening seem to occur more anteriorly, in the area between the bladder and the uterus. A more anteriorly directed angle of penile entry is likely to be more comfortable in this circumstance. This understanding of sexual physiology is the basis for some of the counseling suggestions described below. Reviewing the evolution of the pain over time (months, years) will often help clarify clinical symptoms. For example, dyspareunia may start with posterior cul-de-sac endometriosis, and over time, other areas such as pelvic floor and hip muscles may start to contribute pain signals. When the pain has become this complex, aggressive treatment of the only known "disease" (endometriosis) will often fail if the other components are not addressed. Along with this history, one gathers a more complete picture of the resources the couple has brought to bear on the problem by asking about their interpretations regarding the cause of the pain, their attempts at solution, the nature of the conversation between them about the problem, and finally their expectations of the degree of effect of the problem on their relationship. If this problem is not solved, what do they think would happen with the relationship Physical Examination Techniques There may be only one physical element in simpler cases, but more often there is a list of factors, including abdominal, pelvic floor, or hip muscle dysfunction or pain, visceral functional disorders, and some inflammatory and/or structural causes. At times, intrinsic sensitivity of the abdominal wall can be a problem, especially when couples use the male superior position for intercourse. Areas of point tenderness should be examined with and without the patient elevating her head off the table, which provokes contraction of the rectus muscles. If the discomfort is the same or increased with abdominal wall flexion, then the myofascial structures of the abdominal wall may be involved in pain generation. In addition to customary visual inspection and palpation, if indicated by history, sensory mapping of the vulva and vaginal vestibule should be done with a cotton-tipped applicator. Careful retraction of the labia majora and minora is needed to adequately visualize the posterior vestibule. Erythema and excessive sensitivity of the vestibule tissue to the cotton tip applicator is present in vulvar vulvar vestibular syndrome, discussed below. Inserting one index finger into the vagina just past the introitus, while asking for contraction and relaxation, allows assessment of her control of the bulbocavernosus muscles. Including a question or two about sexual comfort as a routine part of every gynecologic visit legitimizes the subject and makes it easier for the patient to voice concern when there is a problem. The history begins with a review of the precise location of the pain during intercourse. The differential diagnosis of pain at the vaginal introitus and vulva is, of course, entirely different from that for deep dyspareunia. Uncontrolled levator contraction is often accompanied by pain, and may contribute to dyspareunia. Palpating the urethra and base of the bladder produces some bladder pressure and urinary urgency, whereas in women troubled with painful bladder syndrome, the pain of the chief complaint will often be elicited by this maneuver. A normal-appearing cervix may be sensitive if it has been involved in previous bouts of cervicitis, obstetric trauma, or conization or loop electrosurgical excision procedure. Gentle pressure with a cottontipped applicator will elicit abnormal sensitivity (allodynia) of the cervix. Single digit transvaginal palpation of the adnexal areas on each side will reliably detect tenderness when any substantial adnexal pathology is present. Adding the abdominal hand too soon in this process will confuse the clinician by mixing together nociceptive signals from the myofascial structures of the abdominal wall with whatever signals might be coming from the uterus, adnexa, or other visceral structures. Having completed the single digit vaginal examination, the abdominal hand may be added to further evaluate the size, shape and mobility of the pelvic viscera. Rectovaginal examination is a standard part of the pelvic examination and merits particular attention when deep dyspareunia is reported, because this will often detect posterior cul-de-sac endometriosis.

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Mechanism of action Dapsone is a competitive inhibitor of dihydropteroate (folate) synthase stroke treatment 60 minutes discount coversyl 4 mg visa, thereby impairing production of dihydrofolic acid symptoms crohns disease order cheap coversyl line. Control and prevention of tuberculosis in the United Kingdom: code of practice 2000 medicine identification generic coversyl 4 mg on line. Management of opportunist mycobacterial infections: Subcommittee of the Joint Tuberculosis Committee of the British Thoracic Society medicine 2015 lyrics 8mg coversyl otc. Chemotherapy and management of tuberculosis in the United Kingdom: recommendations 1998. Pharmacokinetics Dapsone is well absorbed (90%) from the gastro-intestinal tract. Drug interactions the metabolism of dapsone is increased by hepatic enzyme inducers. The very success of antibacterial therapy has created ecological situations in which opportunistic fungal infections can flourish. In addition, potent immunosuppressive and cytotoxic therapies produce patients with seriously impaired immune defences, in whom fungi that are nonpathogenic to healthy individuals become pathogenic and cause disease. Itraconazole or voriconazole oral Caspofungin if failing azole therapy Aspergillus Amphotericin B i. Its spectrum is broad and includes Aspergillus and Candida species, Blastomyces dermatitidis (which causes North American blastomycosis), Histoplasma capsulatum (which causes histoplasmosis), Cryptococcus neoformans (which causes cryptococcosis), Coccidioides immitis (which causes coccidioidomycosis) and Sporotrichum schenckii (which causes sporotrichosis). Amphotericin is insoluble in water, but can be complexed to bile salts to give an unstable colloid which can be administered intravenously. Amphotericin B is normally given as an intravenous infusion given over four to six hours. Several liposomal or lipid/colloidal complex amphotericin preparations have now been formulated, and are less toxic (particularly less nephrotoxic), but more expensive than the standard formulation. Liposomal amphotericin is reserved for patients who experience unacceptable adverse effects from regular amphotericin or in whom nephrotoxicity needs to be minimized. Topical amphotericin lozenges or suspension are used for oral or pharyngeal candidiasis. Nystatin works in the same way as amphotericin B, but its greater toxicity precludes systemic use. Its indications are limited to cutaneous/mucocutaneous and intestinal infections, especially those caused by Candida species. Little or no nystatin is absorbed systemically from the oropharynx or gastrointestinal tract, and resistance does not develop during therapy. Cutaneous infections are treated with ointment and vaginitis is treated by suppositories. Adverse effects Nystatin can cause nausea and diarrhoea when large doses are administered orally. Available for topical (nystatin and amphotericin) treatment of common mucocutaneous fungal infections. Amphotericin is used intravenously for deep-seated and severe fungal infections. Intravenous amphotericin is toxic, causing fever, chills, hypotension during infusion, nephrotoxicity, electrolyte abnormalities and transient bone marrow suppression. Systemic toxicity (especially nephrotoxicity) of amphotericin is reduced by using the liposomal/ lipid/micellar formulations. Amphotericin combined with 5-flucytosine may be used in severe infections and immunosuppressed patients. Mechanism of action Amphotericin is a polyene macrolide with a hydroxylated hydrophilic surface on one side of the molecule and an unsaturated conjugated lipophilic surface on the other. Some imidazoles are also used systemically, although they have limited efficacy and significant toxicity. It results from vasoconstriction and tubular damage leading to acute renal impairment and sometimes renal tubular acidosis. Mechanism of action of azoles (imidazoles and triazoles) Imidazoles competitively inhibit lanosterol 14-demethylase (a fungal cytochrome-haem P450 enzyme), which is a major enzyme in the pathway that synthesizes ergosterol from squalene. This disrupts the acyl chains of fungal membrane phospholipids, increasing membrane fluidity and causing membrane leakage and dysfunction of membrane-bound enzymes.

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The aims of conservative surgery are: removal of both typical and atypical endometriotic implants; complete removal of endometriotic cysts (endometrioma) complete adhesiolysis medicine 7 years nigeria generic coversyl 4mg without prescription, with restoration of normal tuboovarian relationship to enhance fertility potential; relief of pain; minimize the risk of disease recurrence medicine 257 order 8mg coversyl. The hydrodissection technique permits treatment of endometriotic implants on the ureter or major vessels without causing any damage to these structures harrison internal medicine purchase generic coversyl online. Initially treatment quadricep strain cheap coversyl 4 mg online, a small port is made into the retroperitoneum using either the laser or scissors. Ringer`s lactate or saline solution is injected next to the lesion to create a protective cushion of fluid between the lesion to be excised and the underlying ureter, bladder or blood vessels. Excision of large endometriotic implants is superior to coagulation or vaporization because the technique is not associated with problems related to contamination by smoke and combustion residues. An additional advantage is, that it allows for the collection of specimen for histological diagnosis. Ovarian Endometriosis Ovarian implants of endometriosis or small endometrioma of less than 2 cm in diameter may be cauterized, resected by laser application or excised using scissors, biopsy forceps or electrodes. For endometrioma larger than 2 cm in diameter, the first step of the procedure involves adhesiolysis of the ovary on the posterior leaf of the broad ligament. In most cases, the cyst is ruptured during this step, which requires that the liquid be aspirated immediately to prevent pelvic contamination. Drainage of the cyst must be followed by removal of the capsule to prevent recurrences. The capsule of the cyst must be separated from the surrounding ovarian stroma and removed by grasping its base with forceps and pulling it away from and out of the ovarian capsule. Exposure of the right plane will permit blunt dissection by applying contralateral traction with two 5 mm-forceps. If stripping of the capsule is incomplete or difficult to accomplish, the residual part must be eradicated by laser application or electrocoagulation. Adnexectomy Adnexectomy could be necessary even in fertile patients when endometriosis has infiltrated most of the parenchyma. After coagulation with a bipolar forceps, the proximal portion of the tube and of the uteroovarian ligament must be dissected with scissors. In addition, the infundibulo-pelvic ligament is coagulated and dissected applying traction to the ovary with grasping forceps. Therefore, the mesosalpinx should be completely dissected, after coagulation, to liberate the adnexa and to extract it by use of a disposable bag. Before cutting the tissue it is important to mobilize and identify the relevant anatomical structures. Mechanical dissection with forceps or hydrodissection is not associated with any thermal effect, therefore this technique should be preferred. It suggests rectovaginal involvement, with deep endometriosis and dense adhesions, and significant distortion of the regional anatomy involving bowel, vaginal apex, posterior cervix, ureter, and major blood vessels. To facilitate localization of anatomic landmarks and identification of tissue planes, we usually place a loaded sponge forceps in the posterior fornix, and, if necessary, insert a rectal probe. To date, all medical treatment options directed toward suppression of the disease and the pain associated with endometriosis have had similar effects in terms of symptom alleviation. However, evidence-based data suggest that complete laparoscopic excision of the endometriosis offers good long-term results with regard to the degree of regression, especially in those patients with severe and debilitating symptoms. Although it is difficult to know the real incidence of deeply infiltrating endometriosis, in a study on 132 patients, covering the predefined depth of endometriotic infiltration, we found deeply infiltrating lesions in 33%. This means that to ensure complete removal of the disease and thus improve the outcome in terms of quality of life, surgery on the bowel with or without bowel resection can be necessary. Our pre-operative assessment comprises a questionnaire, physical work-up, instrumentaided investigations and serum markers.

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E332 potassium dihydrogen orthophosphate noun a chemical treatment used for potassium dihydrogen orthophosphate making water safe for human consumption potassium ferrocyanide potassium ferrocyanide noun a yellow crystalline compound used in medicines and explosives potassium gluconate potassium gluconate noun E577 potassium hydrogen carbonate noun a white powder or granular compound used potassium hydrogen carbonate in baking powder and as an antacid potassium hydrogen tartrate potassium hydrogen tartrate noun cream of tartare potassium hydroxide noun a caustic and poisonous white solid, used in making soap, potassium hydroxide detergents, liquid shampoos and matches potassium lactate potassium lactate noun E326 potassium malate noun E351 potassium metabisulphite noun E224 potassium nitrite noun E249 potassium polyphosphate noun E452 potassium proprionate noun E283 potassium salt noun a crystalline compound formed from the neutralisation of an acid potassium malate potassium metabisulphite potassium nitrite potassium polyphosphate potassium proprionate potassium salt solution containing potassium potassium sodium tartrate potassium sodium tartrate 188 potassium sodium tartrate noun a colourless crystalline salt used as a mild laxative and food preservative potassium sorbate potassium sorbate noun E202 potassium sulphate noun E515 potassium tartrate noun cream of tartar potato noun a vegetable that grows from the roots of a plant, has a brown skin and white potassium sulphate potassium tartrate potato flesh, and can be eaten boiled, roasted, fried or baked potato croquette potato croquette noun a deep-fried cylinder of mashed potato with butter, milk, seasoning and possibly eggs potato masher noun an implement for mashing boiled or steamed potatoes, consisting of a flat perforated metal or plastic disc with an upright handle, pressed onto the potatoes with an up and down movement potato ricer potato masher potato ricer noun an implement, rather like a large garlic press, for mashing potatoes potato starch noun powdered starch used as a stabilising agent poteen noun in Ireland, a spirit that has been distilled illegally, especially from potatoes potency noun the strength of something such as a drug, medicine or alcoholic drink potentially hazardous food noun food that needs to be carefully stored to keep it safe potato starch poteen potency potentially hazardous food for human consumption. Modern techniques include the use of modified atmosphere packaging and irradiation. Also called proteolytic enzyme protease inhibitor noun a compound that breaks down protease, inhibiting the replicaprotease protease inhibitor tion of viruses and development of some cancers protein protein noun a compound that is an essential part of living cells and is one of the elements in food that is necessary to keep the human body working properly proteinase proteinase noun an enzyme that splits the peptide bonds of proteins protein bodies plural noun roughly spherical structures consisting of protein encapsuprotein bodies lated in a membrane, present in all seeds, including cereals. Full form polytetrafluoroethylene ptomaine ptomaine noun a nitrogenous compound produced when protein is broken down by bacteria ptomaine poisoning ptomaine poisoning noun food poisoning caused by bacteria, but formerly believed to be caused by ptomaines ptyalin ptyalin noun an enzyme in saliva that cleanses the mouth and converts starch into sugar ptyalism noun the excessive production of saliva ptyalolithiasis noun same as sialolithiasis puberty noun the physical and psychological changes that take place when childhood ends ptyalism ptyalolithiasis puberty and adolescence and sexual maturity begin and the sex glands become active public health public health noun the study of illness, health and disease in the community. Also called ready-cooked meal ready-to-eat ready-to-eat adjective used for describing any convenience food that does not require reheating. Compare flatworm roux roundworm roux noun a mixture of fat and flour cooked to make a base for a sauce royal jelly royal jelly 206 royal jelly noun a protein-rich substance that worker bees secrete and feed to larvae in the early stages of their development and to the larvae of queen bees in all stages of their development. Compare unsaturated fat, polyunsaturated fat saturated solution saturated solution noun a solution containing the maximum amount of solid that can be dissolved in a liquid solvent and still remain in solution at a particular temperature sauce sauce noun liquid with a particular taste poured over food to give it an extra flavour sauce boat noun an oval shallow wide-mouthed jug on an oval plate, used for serving sauce boat sauces sauce chef sauce chef noun the chef in charge of preparing sauces. Compare best-before date, use-by date seltzer seltzer noun water that has been carbonated by adding sodium bicarbonate semi-hard adjective used for describing cheese that has a consistency firm enough to slice semi-hard but that is moist and pliable semi-skimmed semi-skimmed adjective used for describing milk from which some of the fat has been removed semi-soft semi-soft adjective used for describing a food that holds its shape but is easily cut with a knife semi-sweet semi-sweet adjective lightly sweetened semi-vegetarian noun a person who does not eat all meats, but will eat particular types, semi-vegetarian typically fish or poultry semolina semolina noun hard grains of wheat left when flour is sifted, used in puddings, and stews senescence noun the ageing process. Compare double-acting baking powder single-blind testing single-blind testing noun a form of blind testing in which the researchers are aware from the beginning which subjects are receiving the supplement and which are receiving a placebo. Compare double-blind testing 217 single cream single-crust sliced meat single cream noun liquid cream with a relatively low fat content single-crust adjective used for describing a pie or food dish with a single layer of pastry below the filling, and none above single-malt single-malt noun a whisky that is the product of a single distillery single-serve adjective packaged in small amounts intended for one person sirloin noun the best cut of beef from the back of the animal sitiomania noun a craving for particular types of food sitiophobia noun hatred of food and eating sitology noun the scientific study of food, diet and nutrition as they relate to health sitomania noun a desire to eat particular types and quantities of foods sitotherapy noun the use of food as a therapeutic treatment sitotoxin noun any toxin developed in food by mould or bacteria. Also called food slicer slim slim verb to try to become thinner or try to lose weight slimline adjective designed to help with a weight-reducing diet slimming noun the use of a special diet or special food that is low in calories and is slimline slimming supposed to help a person lose weight slimming pill slimming pill noun a pill that supposedly helps to reduce weight, whether by increasing the metabolism, suppressing hunger or blocking the absorption of fats slimming product slimming product noun a food product that is low-calorie and designed especially for people on a weight-reducing diet slippery elm slippery elm noun 1. Camembert or Brie soft drink noun a drink that is not alcoholic, sold either ready prepared in a bottle or can soft drink or in concentrated form to be mixed with water soften soften verb 1. Also called chef potager soup spoon noun a flattish spoon used for eating soup sour adjective 1. Also called chef de rang stay-on tab stay-on tab noun a type of ring-pull that does not separate from the can when pulled steak noun 1. Also called bouillon cube stockpot stockpot noun a large pot for cooking soups and stock stock syrup noun a basic sugar solution with many uses stodgy adjective used for describing food which is heavy and filling to eat and usually stock syrup stodgy fairly tasteless stoma stoma noun an opening created surgically, especially in the abdomen to allow a feeding tube to be inserted stomach stomach noun 1. Compare diastolic blood pressure T tabbouleh noun a Middle Eastern dish consisting of bulgur wheat, mint, tomato, spring onions and other herbs, with lemon juice and various seasonings table knife tabbouleh table knife noun a knife used at table with a fork for cutting food, especially the food of a main course table salt table salt noun fine salt suitable for use on food that has been served out tablespoon noun a large spoon for serving food at table tablespoonful noun the amount contained in a tablespoon table sugar noun sugar suitable for use at table tachycardia noun a rapid heartbeat, sometimes linked to anaemia and vitamin B1 defitablespoon tablespoonful table sugar tachycardia ciency tachyphagy tachyphagy noun extremely fast eating taco noun in Mexican cooking, a dish consisting of a maize tortilla with a filling tactile adjective relating to the sense of touch tagine noun 1. Also called sauce tartare tartaric acid noun a white crystalline organic acid found in fruit, used as baking powder and in photographic processes and tanning leather tarte tatin noun an apple tart, cooked upside down, made of sliced apples cooked in butter with the pastry on top, then reversed in the serving dish tartrate tarte tatin tartaric acid tartare sauce tartrate noun any of various salts of tartaric acid used as stabilisers, the principal ones being sodium, potassium and the potassium sodium mixed salt E337 tartrazine tartrazine noun a yellow substance added to food to give it an attractive colour taste noun 1. Also called aneurin, thiamin vitamin B2 noun a water-soluble vitamin that is essential for metabolic processes and for cell maintenance and repair, present in all leafy vegetables, in eggs, milk and the flesh of warm blooded animals. Also called riboflavin vitamin B3 noun a water-soluble vitamin that occurs in the form of niacin, nicotinic acid and nicotinamide and is widely distributed in foodstuffs, with meat, fish, wholemeal flour and peanuts being major sources vitamin B5 vitamin B3 vitamin B2 vitamin B5 noun a water-soluble vitamin that is destroyed by boiling, found in all animal and plant tissues, especially poultry, liver, fish, eggs, potatoes and whole grains. Vitamin D helps in the formation of bones, and lack of it causes rickets in children.

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