Forzest

Emile R. Mohler, MD, MS

• Associate Professor of Medicine
• University of Pennsylvania
• Director of Vascular Medicine
• University of Philadelphia Health System
• Philadelphia, Pennsylvania

Occurrence in the United States the last case of smallpox in the United States occurred in the Rio Grande Valley of Texas in 1949 impotence support group cheap forzest 20 mg. Because of the relative frequency and seriousness of vaccine-related complications and the low risk of smallpox outbreak in the United States erectile dysfunction drugs patents buy cheapest forzest and forzest, routine vaccination is not recommended for the vast majority of healthcare workers or for the general U impotence grounds for annulment order cheap forzest on-line. As of July 31 impotence sentence order forzest 20 mg with amex, 2004 icd 9 code erectile dysfunction due diabetes order genuine forzest on line, 39 erectile dysfunction caused by heart medication buy generic forzest 20 mg online,608 healthcare 6 workers and first responders had been vaccinated nationally. Variola major was more common and caused more severe disease relative to variola minor. The virus typically enters the body via respiratory or oral mucosa and is carried by macrophages to regional lymph nodes from which a primary rd th asymptomatic viremia develops on the 3 or 4 day after infection. The reticuloendothelial organs th th are invaded and overwhelmed leading to a secondary viremia around the 8 to 12 day after infection. Seven to 17 days following infection, fever, malaise, and extreme exhaustion begin. A maculopapular rash first presents on the face, mouth, pharynx, and forearms and spreads to the trunks and legs. The rash progresses to a vesicular and pustular th stage (round and deeply embedded). Scars are formed 1-4, 6 from sebaceous gland destruction and granulation tissue shrinking and fibrosis. Although most data supports communicability with rash onset, some low level of communicablity is present prior to rash onset because viral shedding from oral lesions occurs during the 1 to 2 days of fever preceding rash onset. However, secondary transmission peaks 3 to 6 days after fever st th onset (1 week after rash onset), and 91. Scabs are not very infectious because the tight binding of the fibrin matrix retains the virions; however secondary cases have been documented through transmission from direct contact with contaminated clothing 1-4, 6 and bedding. Mortality is most commonly associated with toxemia of circulating immune complexes and soluble variola antigens and is seen in the second week of illness. It is characterized by a short incubation period, prostrating prodromal illness, severe systemic toxicity and high mortality (90-97%). The lesions do not progress to the pustular stage, instead remaining soft, velvety and flattened. If the patient survives, the lesions will resolve by desquamation without scabs or scarring. It is characterized by a short incubation period, prostrating prodromal illness, severe systemic toxicity, and high mortality (96%). The rash begins as a dusky erythema, followed by extensive petechiae, mucosal hemorrhage, and intense toxemia. These patients usually died during week 1 of illness, often before the development of the typical pox lesions. The pre-eruptive illness is typical in duration and severity as ordinary smallpox; however, during the eruption, fever is absent and the skin lesions are superficial, pleomorphic, fewer in number, and evolve rapidly. Variola sine eruption occurred in about 30 to 50% of vaccinated contacts of smallpox cases. It is characterized by a sudden onset of fever, headache, occasional backache which resolves within 48 hours, influenza-like symptoms and no rash. Variola Minor Variola minor, caused by different strains of variola, is a milder form of smallpox. Compared with variola major, there are milder constitutional symptoms, discrete lesions that evolve a bit more rapidly, lower rates of hemorrhagic disease, and only rare fatal outcomes (<1%). The illness may be difficult to distinguish clinically from modified smallpox and variola without eruption. In the early 1900s, variola minor became prevalent in the United States, Latin America, and Europe. In 2003, an outbreak of monkeypox, associated with prarie dog contact, took place in the midwestern United States. However, monkeypox is milder and has prominent lymphadenopathy and a shorter duration of rash. Diagnosis of smallpox will be clinical initially, but Inform your lab that smallpox is under followed by laboratory confirmation. If a patient is determined to be at high risk for smallpox, clinicians should call their local public health authorities immediately and obtain photos of the patient. Public health will provide guidance on specimen collection and packaging and will facilitate transport of specimens to the appropriate public health laboratory. Definitive laboratory identification and characterization of the variola virus requires several days. Treatment the management of confirmed or suspected cases of smallpox consists of supportive care, with careful attention to electrolyte and volume status, and ventilatory and hemodynamic support. General supportive measures include ensuring adequate fluid intake (difficult because of the enanthem), 1-4, 6 alleviation of pain and fever, and keeping skin lesions clean to prevent bacterial superinfection. Immunity from prior vaccination Protection from smallpox is estimated to last between 11. Those who were previously vaccinated may retain some protection that could decrease the severity of the disease and allow for greater mobility thereby 12 complicating public health response. Postexposure prophylaxis Postexposure prophylaxis for smallpox is the administration of vaccinia vaccine after suspected exposure to smallpox has occurred but before symptoms are present. Immunity generally develops within 8 to 11 days after vaccination with vaccinia virus. Because the incubation period for smallpox averages about 12 days, vaccination within 4 days may confer some immunity to exposed persons and reduce the likelihood of a fatal outcome. Postexposure vaccination may be particularly important for those vaccinated in the past, provided that revaccination is able to boost the anamnestic immune response. If a case or cases of smallpox occur, public health authorities will conduct surveillance and implement containment strategies. Ring vaccination will be important and includes identification of contacts of cases and provision of prophylaxis and guidance on monitoring for symptoms. Large-scale voluntary vaccination may be offered to low-risk populations to supplement and address public concerns. All lots of Dryvax vaccine expired February 20, 6, 14 2008, and were destroyed by March 31, 2008. The Dryvax vaccine should be administered by trained, vaccinated personnel using a bifurcated needle that is stroked against the skin until blood appears. Should smallpox vaccination be deemed necessary, it will be coordinated by local, state and federal health agencies. Likelihood of adverse effects is 3 to 4-fold higher in infants and in primary recipients. Vaccine Adverse Events Reporting System of recently vaccinated people, there was a rate of 26. Adverse events included the following: 33% cardiac, 25% nonspecific chest pain, 21% neurological, 14% infection, 3% malignancy, 3% pulmonary (noninfectious), and 1% 13, 15, 16 normal vaccination response. Vaccination during the pre-exposure period is contraindicated for certain persons. During a smallpox emergency, however, all contraindications would be reviewed in the context of the risk of smallpox exposure, and updated recommendations would be issued by public health authorities. Cidofovir 7 and topical ophthalmic antiviral agents are also recommended by some experts. Cutaneous complications included desquamation, massive subcutaneous fluid accumulation with electrolyte abnormalities and renal failure, or, less commonly, secondary bacterial infection of smallpox lesions. Infrequently, smallpox patients experienced encephalitis, osteomyelitis, corneal ulceration, or ocular keratitis. Ordinary-type smallpox with confluent lesions, rather than discrete lesions, carried a much higher risk of massive exfoliation, tissue destruction, bacterial sepsis, and death. Those with discrete lesions, nonhemorrhagic and nonflat-type, are less likely to become critically ill or require much supportive care and can be more easily managed outside the hospital. These people should be isolated and monitored at home or in a nonhospital facility, and smallpox vaccination should be provided to caregivers and household members. Patients with evidence of severe disease or presentations that suggest progression to severe disease is likely should be considered for admission to a negative-pressure environment 2, 6 with strict maintenance of Airborne Precautions. Clinicians should notify local public health authorities, their institutions infection control professional, and their laboratory of any suspected smallpox cases. Public health authorities may conduct epidemiological investigations and will implement disease control interventions to protect the public. Infection control professionals will implement infection control precautions within the healthcare setting. Smallpox is transmissible from person to person by exposure to respiratory secretions and by direct contact with pox lesions and fomites. Airborne and Contact Precautions in addition to Standard Precautions should be implemented for patients with suspected smallpox and until all scabs have separated. Healthcare workers caring for patients with suspected smallpox should be 18, 19 vaccinated immediately. Decontamination Survival of the virus in the environment is inversely proportional to temperature and humidity. All bedding and clothing of smallpox patients should be minimally handled to prevent re-aerosolization and autoclaved or laundered in hot water with bleach. Standard disinfection and sterilization methods are deemed to be adequate for medical equipment used with smallpox patients and cleaning surfaces and rooms potentially contaminated with the virus. Hemorrhagic smallpox is rare but can be confused with invasive meningococcal disease, rickettsial infections, or gram-negative sepsis because of the patients ill appearance, petechial and purpuric lesions, and hemorrhagic manifestations. Smallpox is most often transmitted through direct contact with respiratory droplets as a result of close (within 2 meters) or face-to-face contact. Viruses can also travel over greater distances as airborne particles, particularly in cases with coughing. Transmission has occasionally been linked to fomites carried on clothing or bedding that has been contaminated by dried respiratory secretions or draining skin lesions. Since 2003, many health departments have established smallpox preparedness teams consisting of providers who have been pre-vaccinated against smallpox who can asssist with the response to a suspected case of smallpox. Orthopoxviruses: Vaccinia (Smallpox Vaccine), Variola (Smallpox), Monkeypox, and Cowpox. Smallpox: Current, comprehensive information on pathogenesis, microbiology, epidemiology, diagnosis, treatment, and prophylaxis. Infectiousness of smallpox relative to disease age: estimates based on transmission network and incubation period. Acute, Generalized Vesicular or Pustular Rash Illness Testing Protocol in the United States. Notice to Readers: Newly Licensed Smallpox Vaccine to Replace Old Smallpox Vaccine. Adverse events associated with smallpox vaccination in the United States, January-October 2003. Neurologic adverse events associated with smallpox vaccination in the United States, 2002-2004. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, 2007. Consider as a possible cause for severe joint pain and discontinue drug if appropriate. Advise patients of the characteristic symptoms of heart failure and to immediately report such symptoms. A subset of these reports involved patients with renal impairment, some of whom were prescribed inappropriate doses of sitagliptin. A return to baseline levels of renal impairment has been observed with supportive treatment and discontinuation of potentially causative agents. Five placebo-controlled add-on combination therapy studies were also conducted: one with metformin; one with pioglitazone; one with metformin and rosiglitazone; one with glimepiride (with or without metformin); and one with insulin (with or without metformin). In an additional, 24-week, placebo-controlled factorial study of initial therapy with sitagliptin in combination with metformin, the adverse reactions reported (regardless of investigator assessment of causality) in 5% of patients are shown in Table 2. In a pooled analysis of 19 double-blind clinical trials that included data from 10,246 patients randomized to receive sitagliptin 100 mg/day (N=5429) or corresponding (active or placebo) control (N=4817), the incidence of acute pancreatitis was 0. Hypoglycemia In the above studies (N=9), adverse reactions of hypoglycemia were based on all reports of symptomatic hypoglycemia. A concurrent blood glucose measurement was not required although most (74%) reports of hypoglycemia were accompanied by a blood glucose measurement 70 mg/dL. In a pooled analysis of the two monotherapy studies, the add-on to metformin study, and the add-on to pioglitazone study, the overall incidence of adverse reactions of hypoglycemia was 1. There were no severe hypoglycemia episodes reported in other studies except in the study involving coadministration with insulin. In an additional, 30-week placebo-controlled, study of patients with type 2 diabetes inadequately controlled with metformin comparing the maintenance of sitagliptin 100 mg versus withdrawal of sitagliptin when initiating basal insulin therapy, the event rate and incidence of documented symptomatic hypoglycemia (blood glucose measurement 70 mg/dL) did not differ between the sitagliptin and placebo groups. The clinical significance of this added increase in serum creatinine relative to placebo is not known. Because these reactions are 6 reported voluntarily from a population of uncertain size, it is generally not possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Hypersensitivity reactions including anaphylaxis, angioedema, rash, urticaria, cutaneous vasculitis, and exfoliative skin conditions including Stevens-Johnson syndrome; hepatic enzyme elevations; acute pancreatitis, including fatal and non-fatal hemorrhagic and necrotizing pancreatitis [see Indications and Usage (1. The estimated background risk of major birth defects is 6-10% in women with pre-gestational diabetes with a Hemoglobin A1c >7% and has been reported to be as high as 20-25% in women with a Hemoglobin A1c >10%. Data Sitagliptin is secreted in the milk of lactating rats at a milk to plasma ratio of 4:1. In both efficacy analyses, the effect of treatment with sitagliptin was not significantly different from placebo. At week 20, the change from baseline in HbA1c in patients treated with sitagliptin (N=107) was 0.

Before initiating ventilatory support erectile dysfunction causes symptoms and treatment buy cheap forzest 20mg on-line, clinicians must evaluate for mechanical causes of distress impotence 40 year old buy genuine forzest, including pneumothorax or airway obstruction erectile dysfunction drugs recreational use purchase genuine forzest online. Ventilatory strategy should anticipate the increased risk of pneumothorax as compliance increases and time constants lengthen erectile dysfunction caused by neuropathy discount 20mg forzest with visa, especially with the rapid improvement that can be seen after surfactant administration erectile dysfunction drugs over the counter uk buy discount forzest 20mg online. Flow rates of 7 to 12 L/minute are needed to provide a relatively square pressure waveform erectile dysfunction doctor in kolkata purchase forzest overnight delivery. Rates are generally set initially at 20 to 40 breaths/minute, and adjusted according to blood gas results. Caffeine citrate may be used to facilitate spontaneous breathing before extubation and may increase the success rate of extubation in very low birth weight infants. Initial settings are based on auscultation of good breath sounds and are increased as needed to maintain adequate minute ventilation and oxygenation. In general, pressure is weaned rst, while the rate remains high, or by 10% drops in rate alternating with pressure, as tolerated. High-frequency ventilation may be initiated if conventional ventilation fails to maintain adequate gas exchange at acceptable settings. High-frequency ventilation should be used only by clinicians familiar with its use. Peak pressures on the jet ventilator are initially set approximately 20% lower than on those being used with conventional ventilation, and adjusted to provide adequate chest vibration assessed clinically and by blood gas determinations. The frequency is usually set at 420 breaths/minute, with an inspiratory jet valve on-time of 0. Care must be exercised to avoid lung hyperination, which might adversely affect oxygen delivery by reducing cardiac output. It is set to provide adequate chest vibration, assessed clinically and by blood gas determinations. Piston amplitude is adjusted by frequent assessment of chest vibration and blood gas determinations. Frequency is usually not adjusted unless adequate oxygenation or ventilation cannot otherwise be achieved. The severity of the syndrome is related to the associated asphyxial insult and the amount of uid aspirated. The aspirated meconium causes acute airway obstruction, markedly increased airway resistance, scat-. The obstructive phase is followed by an inammatory phase 12 to 24 hours later, which results in further alveolar involvement. Aspiration of other uids (such as blood or amniotic uid) has similar but milder effects. Because of the ball-valve effects, the application of positive pressure may result in pneumothorax or other air leak, so initiating mechanical ventilation requires careful consideration of the risks and benets. If airway resistance is high and compliance is normal, a slow-rate, moderate-pressure strategy is needed. Use of patient-triggered ventilation may be helpful in some infants and avoid the need for muscle relaxation. Weaning may be rapid if the illness is primarily related to airway obstruction, or prolonged if complicated by lung injury and severe inammation. The optimal strategy is to wean infants off the ventilator as soon as possible to prevent further mechanical injury and oxygen toxicity. If this is not feasible, ventilator settings should be minimized to permit tissue repair and long-term growth. Acute decompensations can result from bronchospasm and interstitial uid accumulation. In addition, peribronchial and perivascular air may compress the airways and vascular supply, causing air block. Because the time constants for interstitial air are much longer than those for the alveoli, we sometimes use very rapid conventional rates (up to 60 breaths/minute), which may preferentially ventilate the alveoli. High-frequency ventilation is an important alternative therapy for severe air leak and, if available, may be the ventilatory treatment of choice. Occasionally, apnea is severe enough to warrant ventilator support, even in the absence of pulmonary disease. This may result from apnea of prematurity, during or following general anesthesia, or from neuromuscular paralysis. Although this problem is more common in the neonate receiving long-term ventilation, acutely ill newborns may occasionally benet from sedation. In preterm infants, nonpharmacologic methods, such as limiting environmental light and noise and providing behavioral supports may help decrease agitation and limit the need for sedative medications. Although unequivocal data are not available, gas exchange may be improved in some infants following muscle relaxation. Prolonged muscle relaxation leads to uid retention and may result in deterioration in compliance. All infants receiving mechanical ventilation require continuous monitoring of oxygen saturation and intermittent blood gas measurements. As a complex and invasive technology, mechanical ventilation can result in numerous adverse outcomes, both iatrogenic and unavoidable. Obstruction of endotracheal tubes may result in hypoxemia and respiratory acidosis. Equipment malfunction, particularly disconnection, is not uncommon and requires functioning alarm systems and vigilance. Aortic thrombosis from umbilical arterial catheters, occasionally leading to renal impairment and hypertension 3. Emboli from ushed catheters, particularly to the lower extremities, the splanchnic bed, or even the brain D. Subglottic stenosis from prolonged intubation; risk increases with multiple reintubations 2. Blood gas monitoring in neonatal critical care units allows (i) assessment of pulmonary gas exchange; (ii) determination of hemoglobin oxygen saturation and arterial oxygen content; and (iii) evaluation, although limited, of adequacy of tissue oxygen delivery. In emergency situations, sufficient oxygen to abolish cyanosis should be administered. Oxygen monitoring with pulse oximetry should be initiated as soon as possible, and the concentration of oxygen should be adjusted to maintain saturation values within a targeted range. An oxygen blender and pulse oximeter should be used whenever supplemental oxygen is administered. Monitoring of oxygen use is necessary to reduce both hypoxic injury to tissues and to minimize oxidative injury to the lungs or the immature retina of the premature infant. Arterial oxygen tension (PaO2), measured under steady state conditions from an indwelling catheter, is the gold standard for oxygen monitoring. Most sources consider 50 to 80 mm Hg to be an acceptable target range for newborn PaO2. Premature infants who require respiratory support may exhibit wide swings in PaO2 values. In such circumstances, a single blood gas value may not accurately reect the overall trend of oxygenation. To minimize sampling and dilutional artifacts, arterial blood gas samples should be collected in dry heparin syringes that are commercially available for this purpose. Most blood gas analyzers allow determination of blood gas values, as well as other whole blood parameters, on 0. Samples should be analyzed within 15 minutes or preserved on ice if sent to a remote laboratory site. Blood gas sampling by percutaneous puncture is utilized when the need for measurement is infrequent or an indwelling catheter is not available. However, the discomfort of the puncture may result in agitation and a fall in PaO2, such that the value obtained underestimates the true steady state value. This technique requires extensive warming of the extremity, free-owing puncture, and strictly anaerobic collection. Proper collection techniques are often difficult to guarantee in the clinical setting however, and capillary sampling should not be used for determination of PaO2. Continuous blood gas analysis via an indwelling catheter has been advocated to provide rapid, real-time data and reduce the volume of blood required for repeated blood gas measurements. However, because of technical limitations, a role for these devices in neonatal intensive care has not been established. Noninvasive oxygen monitoring provides real-time trend data that are particularly useful in babies exhibiting frequent swings in PaO2 and oxygen saturation. Noninvasive devices also may reduce the frequency of blood gas sampling in some patients. Pulse oximetry is the primary tool for noninvasive oxygen monitoring in neonates. Pulse oximeters provide continuous measurement of hemoglobin oxygen saturation (SpO2) with a high level of accuracy (3%) when compared to control values measured by co-oximetry, at least down to the range of 70%. Oximeters depend upon different absorption characteristics of oxygenated versus reduced hemoglobin for various wavelengths of light. Differences in transmission of two (usually red and near infrared) or more wavelengths through tissues with pulsatile blood ow are measured. Using the measured values, the proportion of oxygenated and reduced hemoglobin is calculated and displayed as percent saturation. Pulse oximetry does not measure the PaO2 and, thus, is insensitive in detecting hyperoxemia. Due to the shape of the oxyhemoglobin dissociation curve, if SpO2 is 95%, PaO2 is unpredictable. Patient movement and the low amplitude pulse wave of small premature infants may introduce artifacts that result in false episodes of desaturation, although software modications have reduced this problem. Other potential sources of artifact include inappropriate sensor placement, presence of high intensity light (some phototherapy devices), fetal hemoglobin values 50%, and presence of carboxyhemoglobin or methemoglobin. The optimal range of oxygen saturation, especially for preterm infants, is uncertain. Transcutaneous oxygen monitoring (PtcO2) can be useful in management of acute cardiopulmonary disease during the rst 2 weeks of life or if arterial catheterization is not possible. Low values should be avoided because of the association with lung injury due to excessive volume distension of the immature lung. Lack of a catheter, however, limits the availability of this sampling for many patients. Blood obtained by percutaneous arterial puncture is an alternative but may not reect steady state values because of artifacts introduced by pain and agitation. Venous blood from a central catheter also may be useful in certain circumstances. However, if signicant hypoventilation or circulatory dysfunction is present, this relationship is unpredictable. The extremity must be warmed and a free-owing blood sample collected under strictly anaerobic conditions without squeezing the extremity. Gas calibration of the electrode is required and a calibration factor must be built into the algorithm. The need for a high level of user attention and expertise has severely limited the use of this technique. Mechanical ventilation typically occurs at relatively rapid rates compared to adult strategies, and most ventilator circuits deliver a continuous fresh ow of gas throughout the respiratory cycle. However, the technique may be useful for trend monitoring in babies with more uniform distribution of ventilation. This monitoring is performed during intraoperative care, including that of neonates, using capnography, capnometry, or mass spectroscopy. Several devices are marketed for bedside pulmonary function testing in infants and young children. Likewise, most newer generation ventilators graphically display a variety of measured or calculated parameters. Despite the added cost and increasing availability of these modalities, evidence of benecial effect on neonatal outcomes is lacking. Tidal volume measurements may be used to assist in manual adjustment of ventilator settings. Alternatively, such measurements may form the basis for software-automated ventilator adjustments designed to maintain a dened range of delivered tidal volume (volume guarantee) or consistent tidal volume delivery employing minimal peak airway pressure (pressure-regulated volume control). Marked variations in measured tidal volume exist among devices from different manufacturers. Although newer modes of ventilation may improve consistency of delivered tidal volume, a signicant proportion of values still remain outside the target range. Reasons for these discrepancies include differences in site of measurements in ventilator systems, variations in tubing system compliance, and use of differing strategies to compensate for endotracheal tube leaks. In addition, some software algorithms average adjustments in tidal volume over several breaths. Despite these shortcomings, tidal volume measurements employing the same device consistently over time may provide clinically useful information during chronic mechanical ventilation and may be helpful with weaning following surfactant treatment where rapid changes in lung compliance and delivered tidal volume are of signicant concern (see Chap. Because of rapid breathing, onset of inspiration often occurs before end-expiratory closure of the loop is achieved. As a result, normal tracings are difcult to obtain and clinical application of this technique in small infants is limited.

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Male Circumcision Quality Assurance: A Guide to Enhancing the Safety and Quality of Services outlines the roles and responsibilities of national and district programme managers for implementing safe quality male circumcision services and provides guidance for the planning of a national quality assurance programme erectile dysfunction treatment honey cheap forzest 20mg free shipping. It defines ten quality standards against which the quality of services can be measured and used as part of a continuous process of service improvement erectile dysfunction zenerx purchase 20mg forzest fast delivery. The guide is supplemented by the Male circumcision services quality assessment toolkit which is used by facility managers and providers to assess their own performance erectile dysfunction symptoms causes buy discount forzest on line. It can be used by national and district managers to conduct external assessments of facilities stress and erectile dysfunction causes discount forzest online american express. The toolkit includes a scoring tool erectile dysfunction doctors in coimbatore buy forzest american express, into which users can enter assessment findings and monitor progress towards meeting the standards erectile dysfunction va disability compensation purchase forzest 20 mg otc. This document provides guidance to help programmes improve the efficiency of clinical and surgical activities so that they can strengthen their capacity to meet demand for male circumcision services. It addresses clinical techniques, staffing, facility space, client scheduling and flow, commodities management, cost efficiencies, and quality assurance. It also includes detailed model lists of equipment and supplies required to support a male circumcision programme. A guide to indicators for male circumcision programmes in the formal health care system lists indicators that programmes can use to monitor and evaluate progress towards their programme objectives. Adaptable to different country situations, the guide includes indicators of demand for, and supply of, male circumcision services, as well as measures to assess secondary effects of the programme, such as changes in sexual behaviours at the individual and community levels. Final technical editing and layout were undertaken by Pat Butler and, respectively. Circumcision is the surgical removal of the foreskin, the fold of skin that covers the head of the penis. It is widely practised for religious and traditional reasons, often within the first two weeks after birth, or at the beginning of adolescence as a rite of passage into adulthood. It may also be performed for medical reasons to treat problems involving the foreskin. How circumcision is performed During a circumcision, the foreskin is freed from the head of the penis (glans) and removed. When done in a newborn baby, the procedure is simpler and quicker than in adolescents and adults. In order to make an informed decision, every potential client or parent is entitled to full information about the benefits and risks of the procedure. The decision of an adult or young man to be circumcised, and the decision of a parent to have his or her son circumcised, should be based on culture, religion, personal preference, and evidence-based information provided by a health care worker. Benefits If circumcision is being done for reasons other than the treatment of a specific medical problem, the health benefits are primarily preventive, and may only be realized long after the procedure. Circumcision may reduce the risk of acquiring some infections and related complications, but does not guarantee complete protection. Some of these conditions are common, while others are less so, and the degree of risk of the individual is likely to depend on his behaviour and where he lives. Risks As for any surgical procedure, there are risks associated with circumcision. While the benefits of circumcision may be wide-ranging and long-term, any problems generally occur during or soon after the procedure. These complications are rare when circumcision is performed by well trained, adequately equipped, experienced health care personnel, and are usually easily and rapidly resolved. Data from controlled trials 4, 6 show that fewer than 1 in 50 procedures result in complications. A sub-analysis of 10 African studies, involving men considered to be at high risk of becoming infected, found a 3. However, it is important to note that, of the 191 circumcised men, 62% were Muslim. When non-Muslim men were assessed separately, the circumcised group was small and no significant protective effect was found. This illustrates the difficulty of separating the effect of male circumcision from that of other cultural factors. On the strength of these results, the Independent Data Monitoring Committee recommended that the men initially assigned to the delayed circumcision group should be offered the procedure without further delay, without waiting the full 21 months. Following release of the study results, circumcision was offered without further delay to the men in both nonintervention groups. These cells are present in high density in the epithelium of the inner foreskin, and are close to the surface because the layer of 18, 19 keratin is thin. In an in vitro study, viral uptake by cells from the mucosal surface of foreskin was 7 times more efficient than that by tissue from the female 20 cervix. The inner mucosal surface of the foreskin lacks the thick layer of keratin that covers most exposed skin. The highly vascularized foreskin mucosa, and in particular the frenulum, is prone to tearing and bleeding during intercourse. The incidence of invasive penile cancer is significantly lower in circumcised men than in uncircumcised men, though this condition is 28,10 extremely rare. Acceptability of circumcision among African men Surveys and qualitative studies among young as well as older men in six African countries have found that a considerable proportion expressed interest in circumcision, ranging from 45% in Harare, 29 Zimbabwe, to over 80% in a large survey in Botswana. These studies indicate that many men would willingly undergo circumcision if it could be performed safely and at reasonable cost. In the surveys, the men reported that their main interest in circumcision was related to hygiene, infection control and, for some, a belief that condom use is easier for men who are circumcised. Adult male circumcision: results of a standardized procedure in Kisumu District, Kenya. Male circumcision among the peoples of East Africa and the incidence of genital cancer. Role of male behavior in cervical carcinogenesis among women with one lifetime sexual partner. Susceptibility to human immunodeficiency virus-1 infection of human foreskin and cervical tissue grown in explant culture. Male circumcision, penile human papillomavirus infection, and cervical cancer [letter]. In addition, it may provide some protection against other sexually transmitted infections, such as syphilis and herpes, but offers little or no protection against gonorrhoea and chlamydia. This contact offers an opportunity to address other aspects of mens sexual and reproductive health. These strategies include delaying the onset of sexual activity, reducing the number of sexual partners, and using condoms correctly and consistently every time they have sex. In many societies where male circumcision is performed at the beginning of adolescence, as a rite of passage to adulthood, the circumcision festival period is used also to educate young men about various health and social issues. These cultural traditions can be harmonized with modern clinical practice, to ensure the safety of circumcision, and to use the opportunity to educate the young men about a number of sexual and reproductive health issues. Male circumcision should therefore be regarded as an entry point for sexual, reproductive and other health services for men. These barriers must be addressed if men are to become more involved in sexual and reproductive health matters. The lack of services to address the sexual and reproductive health needs of men contributes 2 to stress and anxiety among them. Because gender inequality has a strong influence on womens sexual and reproductive health, programme managers need to consider the needs and perspectives of men, women and young people. It is also important to use gender-related and gender-disaggregated indicators when evaluating programmes. Who should provide sexual and reproductive health services and information to boys and men A wide range of people and organizations can provide sexual and reproductive health services and information to boys and men. Ideally, boys and young men should receive information and basic education on sexual and reproductive health from their parents. Many adolescent boys now receive some education on health, family life and sexuality in school. However, for some, the instruction comes after they have begun having sexual intercourse. Boys and men of all ages often get information on sexual and reproductive issues from their peers. One approach is to educate key youth leaders, who can then pass on accurate information to their peers. This has to be an ongoing process, to reach each new generation or group of young men. Places of worship and youth groups are important sources of information, and also provide an opportunity for counselling and skill-building in relation to sexuality, relationships, marriage and parenting. As a result, they may not know how to 5, 6 protect themselves from risk when they become sexually active. Some family planning clinics reach out to men, particularly to the partners of their female clients. The availability of male health care providers and separate consultation sessions for men may encourage men to use these services. Although family planning clinics have a long history of providing both medical and counselling services, many men see them as being only for women; equally, some providers may be uncomfortable serving men. These facilities have a long experience addressing sexual health matters, and many men are comfortable seeking services in such settings. If such centres are integrated within primary health care services, they can also provide some sexual and reproductive health services. Health care professionals play a critical role, not just as health care providers, but also as educators and counsellors. Urologists and other specialists commonly deal with certain aspects of male sexual and reproductive health, such as diagnosing and treating prostate cancer and performing circumcision or vasectomy. Primary care physicians treat large numbers of men for their general health needs, but may not have the necessary training to provide comprehensive sexual and reproductive health education and services, or be comfortable doing so. Staff providing male circumcision services should be trained to educate and counsel men about their sexual and reproductive health, and should take the time to do this. Male circumcision services provide a unique opportunity to reach men with education and counselling about sexual and reproductive health. Sexually transmitted infections More than twenty species of microorganisms are known to be transmissible through sexual intercourse. Male patients who complain of urethral discharge or pain when passing urine should be examined for evidence of a discharge. If none is seen, the urethra should be gently massaged from the ventral part of the penis towards the meatus. Examination of a urethral smear under a microscope may show an increased number of polymorphonuclear leukocytes. In men, a finding of more than 5 polymorphonuclear leukocytes per highpower field (1000) is indicative of urethritis. If a urethral discharge or genital ulcer is confirmed, the patient should be managed according to local treatment guidelines and procedures (syndromic approach). For both conditions, non-medically indicated male circumcision should be delayed until the condition has been satisfactorily resolved. Balanitis Balanitis is an inflammation of the foreskin and the glans of the penis. The condition occurs most often in men and boys who have not been circumcised and who have poor personal hygiene. The inflammation can occur if the sensitive inside surface of the foreskin is not washed regularly. Symptoms of balanitis include redness or swelling, itching, rash, pain, and foul-smelling discharge. Dead skin cells, smegma (a white substance excreted by small glands around the corona of the glans penis) and bacteria accumulate under the foreskin. This is an inflammation of the skin, with irritation, itching and rash, often caused by an irritating substance or an allergic reaction to chemicals in certain products, such as soaps, detergents, perfumes and spermicides. Glucose (sugar) in the urine that is trapped under the foreskin serves as a breeding ground for bacteria. If there is an infection, treatment should include an appropriate antibiotic or antifungal medication, according to national guidelines. In cases of severe or persistent inflammation, or if there is difficulty in retracting the foreskin, circumcision is usually recommended. If the diagnosis or treatment of balanitis is uncertain, the patient should be referred to a higher level of care. In addition, the patient should be advised to avoid strong soaps or chemicals, especially those known to cause a skin reaction. Phimosis Phimosis is a condition in which the foreskin of the penis is so tight that it cannot be pulled back (retracted) from the head of the penis. It may be caused by an infection (balanitis) or by scar tissue formed as a result of injury or chronic inflammation. A tight phimosis can interfere with urination, resulting in a thin urinary stream. In extreme cases, urine may collect between the foreskin and the glans, causing ballooning of the foreskin. In this situation an urgent circumcision is necessary, usually using the dorsal slit method.

If a patient is at high risk for syphilis and there is a signifcant risk of loss to follow-up erectile dysfunction see urologist effective 20mg forzest, presumptive treatment could also be considered broccoli causes erectile dysfunction purchase 20mg forzest with visa. Use of Treponemal Immunoassays for Screening and Diagnosis of Syphilis Guidance for Medical Providers and Laboratories in California weight lifting causes erectile dysfunction discount forzest line, February 2016 zocor impotence cheap forzest 20mg without prescription. Even in the case of a patient presumptively treated for incubating (due to known exposure) or primary infection whose initial syphilis serology is negative disease that causes erectile dysfunction purchase forzest 20 mg, repeat serologic testing should be performed 2-4 weeks following the initial nonreactive result do herbal erectile dysfunction pills work forzest 20mg on-line. Therefore, patients at signifcant repeat testing in 2 to 4 weeks would be consistent with risk for incubating syphilis, such as those reporting an delayed seroconversion associated with the treated infecexposure to a known syphilis case within the preceding tion. If the patients serum contains nontreponemal antibody, it will couple Treponemal Testing with the test antigen to form lattice-like cells with charFalse-positive treponemal test results occur in fewer than coal particles trapped inside. Figure 9 provides a decision tree that outlines public health surveillance systems) a general approach to syphilis staging. This information may be available through the local health department as part of case reporting and follow-up activities. Latent Syphilis of Unknown Duration: ing, and recommended evaluation and management, see Patients for whom there is insuffcient information Appendix B. Clinical Staging of Adult and Adolescent Patients With Serologic Evidence of Syphilis Infection/Reinfection March 2019 35 Step 5: Provide Stage-appropriate Pharmacotherapy Management of untreated syphilis in adults and adolescents must be based on the clinical stage of infection at the time of treatment. Women receiving treatment for syphilis at any time during pregnancy should be informed about the possibility of the reaction is thought to result from the release of endotoxa Jarisch-Herxheimer reaction and be advised to seek ins, lipoproteins, and cytokines from killed spirochetes and obstetric attention after treatment if they notice any fever, is seen most commonly among patients treated with benzacontractions or decreased fetal movements. Table 14 outsion, thus preventing additional cases of infection in the lines the period of infectiousness of the case-patient and community. If there is insuffcient information to determine the duration of Evaluation and presumptive treatLatent latent infection, the case-patient may have been infectious over ment of contacts exposed within Syphilis of the past year. If the case-patient also meets the diOcular, Otic, agnostic criteria for primary, secondCentral nervous system, ocular and otic infection are not or Neuroary, early latent, or latent of unknown sexually transmissible. Many patients fnd with previous posttreatment titers in order to assess it diffcult to discuss their syphilis diagnosis with ongoing or for reinfection. Therefore, prompt reporting of cases can contribute signifcantly to disease prevention. It should be noted that surveillance case defnitions, which are used for case reporting, differ to some extent from the clinical diagnostic criteria used for the purposes of treatment and patient management. March 2019 49 Step 9: Monitor Treated Patients Clinically and Serologically to Ensure Adequate Response to Therapy and Detect Reinfection Currently, there is no readily available test-of-cure for or early latent syphilis whose titers may be actively rising. In patients with serofast can take to address the possibility of treatment failure serologies, the posttreatment serologic plateau will serve among patients with recurrent signs/symptoms or those as the baseline against which future screening results are with nontreponemal titers which are rising or remain uncompared. Provide Retreatment If there is no evidence of syphilis reinfection or neurosyphilis, the patient should be retreated with benzathine penicillin G 2. Ocular slit lamp ophthalmologic examination or evaluation by an and otologic involvement can occur during any stage of otolaryngologist/audiologist. Of note, the duration of therapy for neurosyphto provide a total duration of therapy comparable to that ilis is shorter than the course needed for adequate treatused for late latent syphilis. Infordocumentation of stage-appropriate treatment in the past, mation regarding past treatment and previous serologic or lack an appropriate serologic response to therapy (see results can also be requested from the local or state Step 9). In most laboratories, the second treponemal test is performed as part of refex testing. If the second treponemal test is positive, current or past syphilis infection can be confrmed. A signifcant proportion of congenital syphilis cases are associated with a new maternal infection acquired during Risk of Jarisch-Herxheimer Reaction pregnancy (following negative serologic screening at Patients treated for syphilis during the second half of the frst prenatal visit or reinfection among women who pregnancy are at risk for premature labor and/or fetal received treatment early in the pregnancy). However, since any delay in materof syphilis, negative serologic results cannot reliably rule nal treatment can result in increased risk of fetal harm or out incubating infection. New York City Department of Health and Mental Medical Assistance for Needy Persons. Chancroid: clinical manifestations, publications/documents/id suggested syphilis diagnosis, and management. Report of seven cases and review of the Syphilis in the modern era: an update for physicians. Article 11: Interrelationships between human immunodefciency Reportable Diseases and Conditions. Title 10,Part 2: disease incidence and risk factors in human Communicable Diseases. Clinical immunodefciency virus infection in patients attending infectious diseases. Congenital syphilis: A cerebrospinal fuid treponemal-specifc antibody guide to diagnosis and management. Pathogenesis of maternalLaboratory Network laboratory guidelines for the fetal syphilis revisited. March 2019 89 Notes 90 the Diagnosis, Management and Prevention of Syphilis: An Update and Review Notes March 2019 91 Multiple coalescing dusky erythematous macules Multiple deeply erythematous macules, some of Multiple subtle mildly erythematous shiny macules with mild skin thickening in a case of secondary which have an annular appearance, on the glans seen on the scrotum of a patient with secondary syphilis; note the two healing primary ulcerations and distal shaft of the penis in a patient with syphilis. Source: New York City Department of Health Source: New York City Department of Health Source: New York City Department of Health and Mental Hygiene, Sexual Health Clinic and Mental Hygiene, Sexual Health Clinic and Mental Hygiene, Sexual Health Clinic Multiple coalescing slightly erythematous macules/ Multiple large circular patches, some of which Multiple erythematous macules and papules on patches and diffuse dermatitis causing mildly have an annular appearance, on the scrotum of a the labia, vulva, inner thighs, and perianal area in a thickened, shiny skin surface in a patient with patient diagnosed with secondary syphilis. No part of this book may be used or reproduced in any manner whatsoever without written permission except in the case of brief quotations embodied in critical articles and reviews. We are committed to assisting urban youth to become healthy and productive adults. Together with community partners, the Center conducts research to identify the needs and strengths of young people, and evaluates and assists programs to promote the health and wellbeing of young people. We would also like to thank the Charles Crane Family Foundation and the Shapiro Family Foundation for their support for the Guide. Members of the scientifc Advisory Board The Scientifc Advisory Board provided insight and information in their professional review of the chapters. Russell, PhD eral Pediatrics & Adolescent MediProfessor & Director, Frances Mccine, Department of Pediatrics & Clelland Institute for Children, Department of Population, Family & Youth & Families, Norton School Reproductive Health, Johns Hopkins of Family & Consumer Sciences, School of Medicine & Bloomberg University of Arizona School of Public Health acknowledgmenTs vii Members of the Adolescent Colloquium The Adolescent Colloquium was formed as a partnership with the Center for Adolescent Health in 2005 to provide important contributions to the shaping of this project. Special thanks to Layne Humphrey and Christine Verdun Schoennberger for their dedication and hard work on the early version of the Guide. Disclaimer: While many people have provided guidance in the development of this book, The Teen Years Explained: A Guide to Healthy Adolescent Development represents the thoughts of its authors, who are responsible for its content. It does not refect the views of the Adolescent Colloquium, the Scientifc Advisory Board, the State of Maryland government agencies, Johns Hopkins University, nor any of its funders. But make room on the bookshelf, because the time has come with the release of The Teen Years Explained: A Guide to Healthy Adolescent Development. By compiling in plain English the science behind adolescence, the authors have produced a comprehensive yet accessible resource that 1) explains, without oversimplifying, the complex processes of development; 2) challenges and empowers adults to invest more attention, more time, and more resources in adolescents as they transition to adulthood; and 3) gives youthdevelopment professionals the knowledge they need to ensure that healthy adolescent development is an explicit goal of their work. Everything from basic social development theory to cutting-edge neuroscience is packed into this guide, making it a useful reminder of some key principles underlying the youth development movement and a resource for adults who fnd themselves helping teens navigate a world that likely feels diferent from the one they grew up in. At the Forum for Youth Investment, we are committed to supporting leaders who are working on youth issues. One thing we try to do is meet people where they are, but quickly help them see a bolder path. Simple catchphrases often help us do that, and three in particular are reinforced by this guide. Problem-free isnt fully prepared Core supports & opportunities In the 1990s, this phrase helped capture both the need for, and of youth problem prevention approaches to , risk reduction. Ensuring teenagers enter adulthood addiction-free, without dropping out of school, and with no arrest record is a short-sighted goal that refects low expectations. Embracing adolescence as a time of opportunity is difcult, Sexual activity Dropouts & given the real risks associated with & substance illiteracy this period and the unacceptable abuse numbers of young people who are, in fact, dangerously disconnected. Yet Core supports reframing development as a positive, normative process is critical if parents, & opportunities Isolation, Delinquency professionals, and institutions are to depression & violence support, socialize, challenge, & suicide and instruct. The scientifc evidence now frmly supports the notion that, while development unfolds across diferent domains, developmental processes are inextricably intertwined. Behavioral health afects learning; cognitive development afects behavioral health; civic engagement infuences identity development. Young people dont grow up in programs, they grow up in communities Gracefully avoiding a scientifc debate about the role of nature vs. The range of environments they encounter grows with the increasing autonomy of adolescence. Cognitive development doesnt stop when the school bell rings, and social development doesnt kick in upon arrival at the teen center. The Guide challenges us to remember that while we will not and should not always have control over adolescents, we can, in fact, shape many of the settings where they spend time. Creating contexts that nurture growth and minimize risk requires the kind of working knowledge of adolescent development that this guide ofers. We need youth-centered, not system-centered, approaches The vast majority of policy and practice conversations about youth well-being taking place across the country focuses on systems. Increasingly, conversations are taking place across multiple systems: How can juvenile justice and child welfare work together better to support transitioning youth How can schools and community-based organizations work together to reduce the dropout rate While these attempts to work across systems are promising, most are still system-centered conversations. As a result, they are organized around and constrained by expertise and assumptions about systems, as opposed to expertise and assumptions about young people and their developmental needs. Over the years, the Forum for Youth Investment has moved away from leading with terms like adolescent development and youth development. Stating that we wanted to help leaders leverage the considerable fnancial and human resources spent addressing specifc problems. This guide is a welcome and essential tool for every adult who has contact with young people. Preventing Problems, Promoting Development, Encouraging Engagement: Competing Priorities or Inseparable Goals Knowledge of adolescent developDuring adolescence, children gain 50 ment empowers people who work with percent of their adult body weight, beyoung people to advance teens develcome capable of reproducing, and exopment. And it allows us all to sustain perience an astounding transformation appreciation and compassion for the in their brains. Missing transforming the relatively inefcient multiple strategies for supporting from the plethora of resources brain of the child into a leaner, more young peoples development. Young people develop positive the vast majority of young people: Adding even more complexity, this attributes through learning and normal, healthy development. This out-of-sync pattern of development experience guide is an attempt to fll that void. Troughout this guide, the term It describes the changes that happen In early adolescence a young person positive youth development is used. Tat pattern can reverse understanding, based on research, this guide is based on several key later on as growth spurts occur in difthat healthy development is best ideas, all of which are supported by ferent areas of development. Most adolescents succeed in school, are attached to their families and their communities, and emerge from their teen years without experiencing serious problems such as substance abuse or involvement with violence. Rather, they are a time of concentrated social, emotional, and cognitive development. Normal, healthy development is uneven Adolescence includes periods of rapid physical growth and the emergence of secondary sexual characteristics We use the term adolescent throughout The Teen Years Explained: A. It includes young people of all cultures and ethnicities, abilities and physiologic, cognitive, and emotional disabilities, as well as gays, lesbians, transgender and bisexual youth. Adolescents develop these healthy development are provided same time, adolescents are not simply core assets when they experience throughout this guide. A young responding to developmental inputs person learns that he or she is good at Community has a role: in the same way. They interpret and resomething (competence) when given putting adolescence in context spond to each new experience through the opportunity to try and practice Before the mid-1980s, adolescent the lenses of their innate personalities new things. Little attention was paid to essential to understand the strengths The positive youth development the settings in which children live.