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Although these drugs have been found to enhance erectile function in those with such problems buy avapro 150 mg on line diabetic pie recipes, men who are taking medications such as organic nitrates cheap 300 mg avapro free shipping diabetes type 2 memory loss, which reduce blood pressure, e. In addition, and a rather obvious point, sexual activity, and particularly sexual intercourse, involves vigorous exercise, and men who have undertaken almost no exercise for several years, perhaps with an underlying undiagnosed cardiac problem, may find themselves in difficulty – as in undertaking any vigorous activity without prior preparation. However, because many men with MS are in younger age groups than those in which major problems have occurred, it is likely that the difficulties will be found to be fewer amongst most men with MS. Other help available Even if the nerve pathways from the brain to the penis are damaged in the middle or upper parts of the spinal cord, the pathways in the lower part of the spinal cord may still be intact. If this is the case, stimulating your penis directly, most helpfully with a vibrator, could result in an erection. You could also induce an erection by placing the (non-erect) penis in your partner’s well-lubricated vagina – with your partner sitting astride you. However, it is important that this is undertaken carefully, for if sensation levels are low, your penis might be damaged by being folded over, without this problem or any subsequent injury, being realized at the time. There are a range of devices used in treating men’s erectile problems, although many of them are now being replaced with Viagra or other related drugs, because they are less intrusive and more effective. Vacuum pumps The least intrusive of these options is the vacuum pump, which should be available to you on prescription. A tube is placed over the flaccid 64 MANAGING YOUR MULTIPLE SCLEROSIS penis, sealed at the bottom round the base of the penis, and air is pumped out either manually or by a battery-operated pump. A band is then slipped from the bottom of the pump around the bottom of the penis, the pump removed and the penis then stays erect with the blood trapped inside. It is important not to keep the band round the base of the penis for longer than 30 minutes, and the placing of the band round the bottom of the penis may require some dexterity. Injections,prostheses and aids Other more intrusive forms of erectile assistance include penile injections that relax the smooth muscle normally inhibiting blood flow into the penis, thus allowing an erection; or penile prostheses that can be inserted surgically that allow an erection to take place with various forms of mechanical assistance. There are a wide range of issues and concerns relating to the use of penile injections and prostheses, and both require an exceedingly well- organized and planned approach to sexual activity, and intercourse in particular, which some have found difficult to reconcile with anticipated emotions and feelings. If Viagra, Cialis or Levitra are not available, then you should seek a referral from your GP or neurologist to a physician specializing in these other techniques. There are also a number of artificial aids that do not require medical consultation or prescription, and these may include latex or similar penises, some of which are hollow and can incorporate a flaccid penis. Vibrators and other aids in the form of a penis are also available in sex shops or by mail order. Psychological problems and ‘libido’ Depression or fatigue, which are indirect (or secondary) symptoms of MS, may play as large a part in the way that you feel sexually as does primary neurological damage. If such symptoms are treated successfully, then your sexual drive (often called your libido) may increase. If the primary cause of your decreasing sexual drive lies in primary neurological damage, then this is harder to deal with directly. You and your partner could consider first sensual activity experiences, without you feeling the immediate pressure for sexual intercourse. Ensure that you make time to enjoy the experiences with each other without feeling hurried or under pressure. As in other relationships where circumstances SEXUAL RELATIONSHIPS 65 change, new, and possibly exciting and stimulating, patterns of mutual exploration may need to be learnt or re-learnt. Problems during intercourse Incontinence If you haven’t had one already, visit your doctor for an assessment of the problems you have with incontinence. Try and ensure that you have no urinary infections, which can make your bladder problems worse if left untreated. The following advice can help reduce the risk of ‘accidents’ during intercourse: • Reduce your intake of fluids for an hour or two beforehand. If the woman has problems with spasticity in her legs, then such a position is likely to reduce the possibility of annoying cramps and rigidity. Sometimes lubrication can be helped by direct stimulation of the genital area; or try to set up an environment which is relaxing and conducive to sexual thoughts and experiences. As far as additional lubrication is concerned, K-Y Jelly or a similar water-soluble substance can be very helpful. Substances like Vaseline are not recommended because they do not dissolve in water, and they are likely to leave residues which could give rise to infections.

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Patients with severe clinical symptoms may not have substantial mucosal thickening on CT buy 150 mg avapro overnight delivery metabolic disease awareness week 2013. Arango and Kountakis (47) reported cheap 300mg avapro with amex diabetes diet vitamins, on the other hand, that higher clinical symptom scores were seen in patients with severe abnormality on CT, compared with patients with normal or minimum findings on CT, and that the differences between these two groups were statistically significant. The fact that patient symptom scores did not correlate with the extent of the disease on CT may not necessarily indicate poor accuracy of sinus CT. When sinus CT is normal for a patient with a clinical diagnosis of chronic sinusitis, it is uncertain whether sinus CT underestimates disease or the patient warrants other diagnoses. Imaging Findings of Chronic Sinusitis Sinus CT may show mucosal thickening in various degrees, from minimal mucosal thickening to severe opacification of the paranasal sinuses. Fre- quently, for various reasons, sinus CT shows no or only minimal mucosal abnormality. Those patients with persistent chronic sinusitis symptoms have taken antiinflammatory medication as well as nasal spray; thus the degree of mucosal inflammation is usually subtle. Some ear, nose, and throat (ENT) surgeons schedule CT scan 4 to 6 weeks after antibiotic treat- ment, in order to see fine bone detail, which is often obscured by mucosal disease. Alternatively, those patients may have some other disease mimic- king chronic sinusitis. At the other extreme, sinus CT may show severe opacification of all paranasal sinuses. Occasionally, bone thickening or scle- rosis of the affected sinus is seen, suggestive of chronic periosteal inflam- mation. Polypoid soft tissue masses seen within the nasal cavity along with complete sinus opacification is suggestive of sinonasal polyposis (Fig. Chronic sinusitis is occasionally caused by fungi, such as aspergillosis or mucormycosis. There are three distinct categories of sinus fungal infec- tion, allergic fungal sinusitis, invasive fungal sinusitis, and fungal ball (also called sinus mycetoma). Chronic inspissated secretion may appear in a high attenuation central region separated from the sinus wall on noncontrast CT (Fig. Acute inva- sive fungal sinusitis presents with a rapid clinical deterioration and has very poor prognosis. Imaging studies often show infiltrative soft tissue abnormalities with gross bone destruction. Fungal ball is a chronic fungal infec- tion within the sinus, resulting in a well-defined expansile soft tissue mass with mottled foci of calcification. Chapter 12 Imaging Evaluation of Sinusitis: Impact on Health Outcome 225 Figure 12. A coronal CT image shows severe opacification of all paranasal sinuses with soft tissue fullness within the nasal cavity, suspicious for sinonasal polyposis. Sclerotic changes are also seen in the ethmoid septi, suggestive of chronic inflammation. A noncontrast axial CT image shows high attenuation soft tissue fullness within the ethmoid and sphenoid sinuses bilaterally with expansile bone erosion along the left laminae papyracea. Although MRI is not a primary imaging study for the evaluation of sinusitis, signal characteristics of sinus secretions were evaluated in chronic sinusitis patients. Normal sinus secre- tions consist predominantly of water; thus it appears as low T1 and high T2 signal intensities. As the sinus secretions become more viscous, the T1 signal intensity increases and the T2 signal intensity slowly decreases. Fur- thermore, as sinus secretions become more desiccated and sludge-like, they appear as low intensity in both T1 and T2 signals (50), and may become signal void. Fungal sinusitis is also associated with signal void on MRI as paramagnetic substance deposition such as manganese is fairly commonly seen with fungal infection. Summary of Evidence: The roles of sinus CT for chronic sinusitis patients are to support clinical diagnosis, to evaluate the extent of disease, and to provide detailed anatomy to assist treatment planning. The literature sug- gests that sinus CT findings do not always correlate with patients’ clinical symptoms. Whether patients with a normal CT but with persistent clinical symptoms should undergo surgery remains controversial.

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The way forward purchase 150 mg avapro amex diabetes symptoms gain weight, pending more formal assessments of CAM therapies avapro 300mg cheap diabete games, is to provide as accurate and unbiased information as possible for those who are considering their use. There are certain key questions that you should ask yourself in relation to any CAM therapy, particularly a new one about which substantial claims are being made: • What detailed evidence is there that the CAM therapy might help my MS? Have leading MS Research Centres or the MS Society supported the use of the therapy? One of the difficulties for people with MS in relation to many CAM therapies is that, for the most part, they are focused on treating ‘the whole person’ and on general health, rather than specifically focused on the MS. However, as a broad principle, even if the course of your MS is not changed but your general health is improved, this can be helpful in managing your life with MS. Of course there are many stories about individual cases where a CAM therapy is argued to have dramatically changed the course of MS. Although such stories are very attractive and enticing to people with a condition such as MS, you would be right to be sceptical yourself about whether the CAM therapy itself had caused this change, and even more so about the general effects of such a therapy on all people with MS. You should be very wary about claims of ‘miraculous’ or ‘amazing’ results from a CAM therapy. Also be concerned about the main evidence for a CAM being given in the form of individual testimonials, rather than through more COMPLEMENTARY THERAPIES AND MS 33 systematic research. MS is notoriously unpredictable and thus it requires a very careful and controlled study to eliminate any other reasons for a change in the MS. As a broad guide, the issue for people with MS considering using a CAM therapy is balancing what you consider to be the personal benefits against any side effects and the costs incurred. Realistically it is unlikely that a cure will be found for MS from amongst CAM therapies. However, by feeling better through using them, you may consider that your symptoms have been eased and you feel a lot better about day-to-day living – not least because, unlike many professional staff in the hard- pressed NHS, many complementary therapists have the time to discuss your concerns at length. A book called Therapeutic Claims in Multiple Sclerosis (see Appendix 2) evaluates many therapies proposed for MS. It has to be said that the evaluation is from a very robust scientific point of view, the evaluations are decisive and usually dismissive on the grounds of lack of scientific evidence for effectiveness. Nevertheless, descriptions of the main aspects of the therapy are helpfully given. A book more sympathetic to the possibilities of CAM therapies in MS, but which is still based on rigorous evaluations, has been written by A. Bowling (Alternative Medicine and Multiple Sclerosis), and there is an associated website that may be helpful to people with MS (see Appendix 2). For another sympathetic view of the possible benefits of complementary medicine, you might try the Institute of Complementary Medicine (see Appendix 1), which adopts a very rigorous approach to the evaluation of such therapies, or the individual professional associations of the therapy concerned. This would also enable you to check the qualifications, experience and regulation of their members. Safety of complementary therapies Few complementary therapies have been fully scientifically evaluated, especially in relation to MS. Almost any therapy, scientifically evaluated or not, that has the power to produce very good and positive results, has the potential to do harm. Although complementary therapies are considered as ‘natural’ and, almost by association, to be intrinsically safe, this is not always the case. For example, some herbal medicines have to be very carefully targeted to symptoms and very sensitively administered, otherwise they may be harmful. Note that practitioners may expect initial ‘reactions’ or ‘aggravations’ or symptoms as part of the effective working of the therapy. A competent therapist should both warn you about these and what to do, if and when they occur. Finding a practitioner Finding a competent practitioner for a complementary therapy is not always easy. There is little statutory regulation for qualifications or practice for most of the therapies and therapists. However, the best ways of finding a practitioner are through: • an MS resource or therapy centre, where often other people with MS and staff in the centre will have experience of particular therapists; • a recommendation or referral from a neurologist, GP or other healthcare professional; • registers set up by the professional bodies of whichever therapy you are interested in; • referral for homeopathy to one of the NHS hospitals providing this service; • contacting the British Complementary Medicine Association, or the Institute of Complementary Medicine (see Appendix 1). Ask whether practitioners are trained and licensed; whether they are insured for malpractice, negligence or accident; and how complaints are handled. One of the key things is to try and ensure that whichever therapist you go to has a good understanding of MS.

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