Adrian Gerard Murphy, M.B. B.CH. B.A.O., M.B.B.Ch., Ph.D.
- Assistant Professor of Oncology
https://www.hopkinsmedicine.org/profiles/results/directory/profile/10003334/adrian-murphy
A number of other antimicrobial ointment neosporin purchase discount erythromycin, eponymous antibiotics for dogs dental infection buy erythromycin 500 mg online, signs of meningeal irritation have been described antibiotic resistance cattle buy erythromycin from india, of which the best known are those of Kernig and Brudzinski antibiotics in chicken discount erythromycin generic. Meningism is not synonymous with meningitis bacterial replication buy erythromycin without prescription, since it may occur in acute systemic pyrexial illnesses (pneumonia antimicrobial resistance definition purchase erythromycin 250mg with amex, bronchitis), especially in children. Moreover, meningism may be absent despite the presence of meningitis in the elderly and those receiving immunosuppression. Metamorphopsias are often transient and episodic, occurring, for exam ple, during migraine attacks, epileptic seizures, with psychotropic drug abuse, and following petechial intraparenchymal haemorrhages. Rarely, they are long lasting or permanent, for example, following brain infarction (most commonly involving the occipito-parietal or temporoparietal cortex: lesions on the right are more likely than those on the left to give metamorphopsia) or tumours. Retinal disease causing displacement of photoreceptors may produce metamorphopsia: micropsia due to receptor separation in retinal oedema, macropsia due to recep tor approximation in retinal scarring. Occasional cases of metamorphopsia have been reported with lesions of the optic chiasm, optic radiation, and retrosple nial region. Indeed, it seems that metamorphopsia may occur with pathology at any point along the visual pathway from retina to cortex. The Amsler Chart Manual (test charts to determine the quality of central vision, by Prof. Marc Amsler of Zurich) includes charts to demonstrate metamorphopsia (numbers 5 and 6). Metamorphopsia and visual hallucinations restricted to the right visual hemi eld after a left putaminal haem orrhage. There is a poor correlation between micrographia and the side, severity, or duration of classical parkinsonian features, and its response to levodopa preparations is very variable. These observations, along with reports of isolated micrographia with cortical lesions demonstrated by neuroimaging, suggest that the anatomical basis of micrographia may be at the level of the cortex (dominant parietal lobe) rather than the basal ganglia. Micrographia has also been described following large right anterior cere bral artery infarcts and lacunar infarcts involving the putamen and genu of the internal capsule. It is the most common form of metamorphopsia and is most often associated with lesions of the right tem poroparietal cortex, although macular oedema and optic chiasm lesions may also cause micropsia. Hemimicropsia, -221 M Microsomatognosia micropsia con ned to one visual hemi eld, has been recorded. The entirely subjective nature of the disorder may account for the relative rarity of reports. Seeing objects smaller than they are: micropsia following right temporo-parietal infarction. Cross References Chorea, Choreoathetosis; Impersistence; Trombone tongue Miosis Miosis is abnormal reduction in pupillary size, which may be unilateral or bilateral. If only one pupil appears small (anisocoria), it is important to distinguish miosis from contralateral mydriasis, when a different differential will apply. Cross References Agnosia; Neglect Mirror Apraxia Patients with mirror apraxia presented with an object that can be seen only in a mirror, when asked to reach for the real object will reach for the virtual object in the mirror. They are usually symmetrical and most often seen when using distal muscles of the upper limb. Mirror move ments are frequently present in young children but prevalence decreases with age. These movements are uncom mon after acquired brain lesions with no relationship to speci c anatomical areas. They are also seen in 85% of patients with X-linked Kallmann syndrome (hypogonadotrophic hypogonadism and anosmia). There is some neurophysiological evidence from patients with X-linked Kallmann syndrome for the existence of an ipsilateral corticospinal pathway, consistent with other evidence that the congenital condition is primarily a disorder of axonal guidance during development. Concurrent activity within ipsilateral and contralateral corticospinal pathways may explain mirroring of movements. Alternatively, a failure of transcallosal inhibition, acquired at the time of myelination of these pathways, may contribute to the genesis of mirror movements. A de cit of sustained attention has also been postulated as the cause of mirror movements. Failure to rec ognize oneself in a mirror may also be a dissociative symptom, a symptom of depersonalization. This may occur sponta neously, apparently more often in left-handers, or in right-handers attempting to write with the left hand following left-sided brain injury. The author Lewis Carroll occasionally wrote mirror letters but these differ from his normal script, unlike the situation with Leonardo whose two scripts are faithful mirror images. The device was also used by the author Arthur Ransome in his 1939 novel Secret Water. Jane Austen wrote one letter (1817) to a young niece in which script runs from right to left but with word order reversed within words. Various neural mechanisms are proposed to explain mirror writing, includ ing bilateral cerebral representation of language, motor programmes, or visual memory traces or engrams. The mechanisms may differ between a true mir ror writer like Leonardo and someone performing the task for amusement like Carroll. The ability to read mirror reversed text as quickly as normally oriented text has been reported in some autistic individuals. Misidenti cation Syndromes these are de ned as delusional conditions in which patients incorrectly identify and reduplicate people, places, objects, or events. Psychiatric, neurological and medical aspects of misidenti cation syndromes: a review of 260 patients. It occurs with right parietal region injury (hence left-sided limbs most often involved) and may occur in conjunction with anosognosia, left hemispatial neglect, and (so called) constructional apraxia. Cross Reference Negativism Mitmachen A motor disorder in which the patient acquiesces to every passive movement of the body made by the examiner, but as soon as the examiner releases the body part, the patient returns it to the resting position. His speech was uent without paraphasia although impoverished in content, with recurrent themes repeated almost verbatim. Confronted with objects of different colours, he was unable to point to them by colour since all appeared red to him. The features seem to be distinct from erythropsia (persistent) or phantom chromatopsia (nor mal visual acuity). Monoparesis of the arm or leg of upper motor neurone type is usually cortical in origin, although may unusually arise from a cord lesion (leg more frequently than arm). In clinical usage, the meaning overlaps not only with -227 M Motor Neglect that of emotional lability but has also been used in the context of pathological laughter. Cross References Emotionalism, Emotional lability; Pathological crying, Pathological laughter; Witzelsucht Motor Neglect Motor neglect is failure to move the contralesional limbs in the neglect syndrome, a more severe impairment than directional hypokinesia. Cross References Directional hypokinesia; Eastchester clapping sign; Neglect Moving Ear A focal dyskinesia characterized by ear movement has been described. Muscle hypertrophy may be generalized or focal and occurs in response to repetitive voluntary contraction (physiological) or repetitive abnor mal electrical activity (pathological. Muscle enlargement may also result from replacement of myo brils by other tissues such as fat or amyloid, a situation better described as pseudohypertrophy. Cross References Calf hypertrophy; Masseter hypertrophy; Myotonia Mutism Mutism is absence of speech output. Mydriasis Mydriasis is an abnormal dilatation of the pupil, either unilateral or bilateral. If only one pupil appears large (anisocoria), it is important to distinguish mydriasis from contralateral miosis, when a different differential will apply. Such disorders may be further characterized according to whether the responsible lesion lies within or outside the spinal cord: intrinsic or intramedullary lesions are always intradural; extrinsic or extramedullary lesions may be intradural or extradural. It may be possible to differentiate intramedullary from extramedullary lesions on clinical grounds, although this distinction is never absolute because of clinical overlap. These features are dependent on the extent to which the cord is involved: some pathologies have a predilection for posterior columns, central cord, etc. Drugs useful in the treatment of myoclonus include clonazepam, sodium val proate, primidone, and piracetam. Cross References Asterixis; Chorea, Choreoathetosis; Dystonia; Fasciculation; Hiccups; Jactitation; Myokymia; Palatal tremor; Tic; Tremor Myoedema Myoedema, or muscle mounding, provoked by mechanical stimuli or stretching of muscle, is a feature of rippling muscle disease, in which the muscle contractions are associated with electrical silence. Myokymia Myokymia is an involuntary, spontaneous, wave-like, undulating, ickering movement within a muscle (cf. Neurophysiologically this corresponds to regular groups of motor unit discharges of peripheral nerve origin. Myokymia is thus related to neuromyoto nia and stiffness, since there may be concurrent impairment of muscle relaxation and a complaint of muscle cramps. Neurophysiological evidence of myokymia may be helpful in the assess ment of a brachial plexopathy, since this is found in radiation-induced, but not neoplastic, lesions.
The forelimbs are attached to the spine by the scapulas via the shoulder sling of muscles (trapezius infection games proven erythromycin 250 mg, rhomboideus treatment for uti gram negative bacilli erythromycin 500 mg fast delivery, serratus ventralis cranialis and caudalis antibiotic resistance threats cdc purchase generic erythromycin online, subscapularis) antimicrobial yarn suppliers buy erythromycin 500 mg with amex. The hind limbs are attached to the iliums of the hip at the coxo femoral joint infection news buy cheap erythromycin 250mg line, where the head of the femur articulate in the 278 Lines of Compensation 279 13 antibiotics for dogs urinary infection buy erythromycin now. The coxofemoral articulation shows a similarity with the shoulder articulation and the temporomandibular articulation. External lines of compensation are the lines that affect the outer aspect of the horse, both in its superficial and deep muscle layers. Diagonal lines of compensation exist between the skull and shoulders, the shoul ders and hips, and the skull and hips. Between the Skull and Shoulders the intersection point A of lines 1 and 2 on figure 13. The two mastoid processes of the skull receive four lines of compensation from the other point of anchor. Transversal Lines of Compensation Transversal means between the two sides of the horse. The trans verse plane runs perpendicular to the median plane that divides the body lengthwise in two equal halves. There are three main lines of compensation, those of the skull, the shoulders, and the hips. During resting periods, a horse usually stands on one hind leg while resting the other. These transversal lines become critical when the horse is recov ering from an injury because he will shift his weight to avoid pain. A long period of recovery can lead to some very serious com pensatory phenomenas in both the fascia and the muscles. A bad case of uncomfort able shoes, eventually creating the beginning of an abscess, would quickly spread muscular and fascial tension over the entire shoul der area. Consider also the crural, tarsal, metatarsal, and digital fasciae of the lower hind leg. Again, a bad case of uncomfortable shoes will eventually create the begin ning of an abscess and quickly spread muscular and fascial tension over the entire hip area. When a horse accidentally slides to the side with one leg underneath his belly, this will seriously affect his deep fascia and ligaments governing that side of the limb. Also, falls from uneven landings when jumping can cause a lot of stress in the deep fascia layers right down to the skeleton. Side Lines of Compensation Side lines are the lines of compensation on the lateral flank of the horse, parallel to the median plane. It is important to acknowledge these side lines of compensation as they play an important role in equine locomotion at all gaits, but especially during the canter and gallop. During resting peri ods, a horse usually stands on one side while resting the other. This is critical when the horse is recovering from an injury, favoring one side for a long period of time. A bad case of cervical luxation (joint displacement) at any level along the seven vertebrae that comprise the cervical section would quickly cause muscular and fascial compensatory tension on either neck side. Consider also the carpal, metacarpal, and digital fasciae of the lower foreleg, and the crural, tarsal and metatarsal, and digital fasciae of the lower hind leg. Here, too, a bad case of thoracolumbar or lumbo-sacral luxa tion (displacement) at any level along the 18 thoracic vertebrae that comprise the thoracic section or the 6 vertebrae that com prise the lumbar section, or the sacrum, getting out of alignment with the hips, would quickly cause muscular and fascial compen satory tension on either side of the body. When the horse is at rest, using his stay mechanism so he can rest, these lines of compensation prevail. Both the transversal and the side lines of compensation will help him brace himself as a reflex to better 13. Indeed, depending on the nature of the problem at hand, even the diago nal lines of compensation may be involved. As stated earlier in this chap ter, the coxo-femoral articulation of the hip, the scapulo-humeral articulation of the shoulder articulation, and the temporo mandibular articulation of the skull work in concert via all the muscular and fascial lines of compensation. He also moves his limbs forwards and backwards, adducts and abducts them, sometimes with a minimum of inver sion or eversion of the hoof depending on the demands of the rider. Please make an important note of: the location of the center of gravity sitting in front of point B, the crossing of the diagonals of compensation between the shoulders and hips the very busy crossings, points A and C in figure 13. There are an equal amount of lines of compensation on either side of the withers; how ever, the withers anchor 12 lines of compensation plus the respective transversal lines. So when there is some restriction developing in any articula tions and the associated muscles and fascia, you need to check on all the articulations. This thorough checking will allow you to bet ter determine the source of primary or secondary compensation. This process will also contribute to a much better overall massage and lasting benefits. It is well known that during locomotion the horse chases its own center of gravity. This leaves one wondering about the inter nal forces at play inside the core of the body cavities and along the spine. Unfortunately, no scientific equine research on this partic ular topic is available, but common sense prevails. Many of the equine disciplines such as dressage, jumping, polo, and reining really put a fair amount of stress over the neck structure. All of the equine dis ciplines put a fair amount of stress over the hip structure. Note how the withers and middle of the neck carry a lot of line intersections, emphasizing the stress level in these areas. A solid knowledge of the equine lines of compensation is impor tant as it helps you better understand the patterns of muscular and fascia compensation. A saddle that causes discomfort to a horse not only inhibits the movement of that horse, but also leads to the formation of compensatory tension in both the fascia and the muscular systems as a horse always strives to keep optimal performance in relation to his center of gravity. In other words, the center of gravity is that point where an object balances perfectly. The center of gravity in a horse is located at the intersection of the dotted lines as shown in figure 14. During faster paces, when the outline of the horse is lengthened, the center of bal ance moves forward. However, in dressage, during high collection where the croup is lowered, the center point shifts slightly backwards. An unbiased saddle will distribute the weight evenly over the weight-bearing surface of the saddle and onto the back without afflicting the various muscle groups and fascia of the back. The most common problem seen with a badly fitting tree is the pinching of the withers, which causes inflammation to spread directly over the trapezius, the rhomboideus, and the serratus dorsalis cranialis mus cles, as well as the thoracic, shoulder, and neck fascia layers. In some cases where the saddle ends up touching the withers, the ligamentum nuchae over the thoracic spinous processes can become inflamed. Usually this type of incident will leave the horse with white hair over the area of contact. To maintain balance they should be evenly and correctly stuffed, to compliment the build of your horse. This will result in a stable and enhanced ride, as it will promote a central seat. To properly evaluate if a saddle is well balanced, you need to look at four basic standards: Even distribution of flock throughout the panels Close fit without spinal pressure at any point Overall balance As broad a bearing surface as possible to spread weight over the back If, for any given saddle, any of these four points is not met, you can expect musculoskeletal problems to develop in your horse. A saddle that does not fit your horse properly will cause him dis comfort, leading eventually to pain. To compensate for this, the rider will sit awkwardly, resulting in poor posture with resulting back stiffness. The horse also will compensate proportionally, resulting in extra muscle and fascial tension along his entire body, directly proportional to the imbalance. Saddle Fitting 301 Any incorrect saddle will disfigure any seat or leg aids and the horse might develop a constrained stride, a refusal to canter, a resistance to jumping, an unevenness of ride, or simply a refusal to ride. This sce nario will cause the horse to compensate with his hindquarters, mostly his gluteal, hamstring, and abdominal muscles, and possibly the tensor fascia latae muscle. This compensation results in a reluc tance to work in a rounded outline or hollowness. Over a period of time, the back muscles will develop a dent where the panels touch and the thoracolumbar fascia will also become tense, caus ing some chronic rigidity over the back. The rider can easily fall behind the movement losing the ability to contain momentum and balance, especially in jumping. This scenario will cause the horse to tense up and compensate with his shoulder muscles, mostly his rhom boideus and trapezius, the triceps, possibly the serratus group, as well as the pectoral group of muscles and the foreleg muscles, resulting in a reluctance to work in an optimal forward stride. Over a period of time, the shoulder and neck fascia will also become tense, causing some rigidity over the neck action. With a saddle with too low of a pommel, the rider can easily fall out of sink with the movement rhythm, losing the ability to contain momentum and balance, especially in jumping. If there is contact between the saddle and the withers, an inflammation of the with ers might result. The horse with a cold back displays various signs and symptoms including discomfort when being saddled and/or when the rider is mounting, and during any bending exercises. The main muscles afflicted by this condition are the longissimus dorsi, the iliocostalis, the thoracolumbar fascia, the serratus dorsalis 302 Equine Massage cranialis (also known as the spinalis dorsi muscle), the serratus dor salis caudalis, and the abdominal muscles and fascia. When assessing back problems, consult a veterinarian; his expertise will determine the extent of the problem. If needed, infrared thermog raphy and X rays can help determine the nature and severity of the problem. With this feedback, the veterinarian can deliver a precise diagnosis and decide on the best course of treatment. Keep in mind that a horse with a sore back as a result of wear ing a wrong saddle might prefer working on the rein, causing more muscular compensatory tension to develop in the neck muscles such as the deep splenius, the trapezius, and the rectus capitalis, as well as in the entire neck fascia. Regardless of the type of ill-fitted saddle you may face, they all will give rise to stiffness and pressure injuries on the horse. To assist such a horse, massage and hydrotherapy are of great help as they loosen the muscles and increase blood circulation, which in turn provide better oxygenation and nutrition of the tis sues. This results in an overall increase of the healing for the sore muscles directly affected by the ill-fitting saddle. You can start helping your horse by applying some cold hydrotherapy over the back muscles (see chapter 4). Use cold sponging, ice packs, or the ice cup massage technique for about 10 minutes.
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The abortion method used virus hitting kids cheap erythromycin 500 mg line, the length of the pregnancy antibiotic vitamins buy erythromycin 500mg free shipping, and the age of the woman afect this risk virus 792012 buy erythromycin online now. The risk of death from childbirth is 14 times greater than the risk of death from legal abortion antibiotics for urinary retention discount 500mg erythromycin visa. The annual number of deaths related to legal induced abortion has fuctuated from year to year over the past 40 years antibiotic resistance and factory farming cheap erythromycin 500 mg otc. For example antibiotic resistance conjugation buy 500 mg erythromycin amex, nine legal induced abortion-related deaths occurred in 1998, four in 1999, and 11 in 2000. Some women may experience temporary feelings of sadness or stress when making the decision to terminate a pregnancy. However, women who have chosen to have an abortion experience about the same mental and emotional health as women who have not had an abortion and women who carry an unplanned pregnancy to delivery. Pre-existing mental health and life circumstances are more infuential on mental health after abortion than the abortion itself. When Performed During the First Three Months Abortions performed during the frst three months of pregnancy are safer and easier than those performed after the frst three months. There may be some minor discomfort, either during a surgical abortion or medication abortion, much like menstrual cramps. When Performed During the Second Three Months Abortions performed during the second three months of pregnancy are more complicated than those during the frst trimester. While they are still safe, there is a greater chance of problems following a second trimester abortion than there is with a frst trimester abortion. Most women experience some discomfort during the procedure and have some cramping afterwards. Third Trimester (Late) Abortions In the last three months of pregnancy, an abortion is done only to save the life or health of the woman. Psychological responses following medical abortion (using mife-pristone and gemeprost) and surgical vacuum aspiration: A patient-centered, partially randomized prospective study. QuickStats: Pregnancy, birth, abortion, and fetal loss rates per 1,000 women aged 15-19 Years, by race and hispanic ethnicity United States, 2005. Abortion and long-term mental health outcomes: A systematic review of the evidence. The comparative safety of legal induced abortion and childbirth in the United States. Psychiatric morbdidity and acceptability following medical and surgical methods of abortion. Read all of this leaflet carefully before you start using this medicine because it contains important information for you. Your doctor will discuss with you what other form of birth control would be more appropriate. If you are not sure, talk to your doctor, pharmacist or nurse before using this medicine. Warnings and precautions Before using this medicine, you will need to see your doctor for a medical check-up. If you are unsure, talk to a doctor as some of these symptoms such as coughing or being short of breath may be mistaken for a milder condition such as a respiratory tract infection. Sometimes the symptoms of stroke can be brief with an almost immediate and full recovery, but you should still seek urgent medical attention as you may be at risk of another stroke. Most frequently, they occur in the first year of use of a combined hormonal contraceptive. The risk of developing a blood clot in a vein is highest during the first year of taking a combined hormonal contraceptive for the first time. The risk may also be higher if you restart taking a combined hormonal contraceptive (the same product or a different product) after a break of 4 weeks or more. After the first year, the risk gets smaller but is always slightly higher than if you were not using a combined hormonal contraceptive. Air travel (> 4 hours) may temporarily increase your risk of a blood clot, particularly if you have some of the other factors listed. It is important to tell your doctor if any of these conditions apply to you, even if you are unsure. If you have more than one of these conditions or if any of them are particularly severe the risk of developing a blood clot may be increased even more. If you experience mood changes and depressive symptoms contact your doctor for further medical advice as soon as possible. This may help prevent you from getting these spots or help prevent them from getting worse. These include chlamydia, genital herpes, genital warts, gonorrhoea, hepatitis B, syphilis. Your doctor will prescribe another type of contraceptive prior to start of the treatment with these medicinal products. The interfering effect of some of these medicines can last for up to 28 days after you have stopped taking them. If you think you may be pregnant or are planning to have a baby, ask your doctor or pharmacist for advice before taking this medicine. Driving and using machines You can drive or use machines while using this medicine. Risks of using combined hormonal contraceptives the following information is based on information about combined birth control pills. All combined birth control pills have risks, which may lead to disability or death. Combined hormonal contraceptives and cancer Cervical cancer Cervical cancer has been found more often in women taking combined hormonal contraceptives. However, it is possible that the combined hormonal contraceptive is not the cause of more women having breast cancer. It may be that women taking the combined hormonal contraceptive are examined more often. The increased risk gradually goes down after stopping the combined hormonal contraceptive. After 10 years, the risk is the same as for people who have never used the combined hormonal contraceptive. Liver cancer In rare cases, liver tumours which are not cancer have been found in women taking combined hormonal contraceptives. If you do not get your period within 5 days of taking the last contraceptive pill, check with your doctor before starting this medicine. You may start this medicine on Day 21 following the abortion or miscarriage, or on the first day of your next period, whichever comes first. To help stop irritation, do not put the new patch on exactly the same area of your skin as your last patch. You will need to complete the current cycle and remove the third patch on the correct day. During Week 4, you may pick a new Change Day and apply the first patch on that day. If you want to delay your period, apply a patch at the beginning of Week 4 (Day 22) instead of not wearing a patch on Week 4. When you have worn 6 patches in a row (so for 6 consecutive weeks), do not put on a patch in week 7. After 7 days of not wearing a patch, apply a new patch and restart the cycle using this as Day 1. He/she may also talk about whether you need to use another method of contraception. If you forget to change your patch At the start of any patch cycle (Week 1 (Day 1)): If you forget to put on your patch, you may be at particularly high risk of becoming pregnant. This usually happens in the first 3 months and especially if your periods were not regular before you started using this medicine. The chance of having a blood clot may be higher if you have any other conditions that increase this risk (See section 2 for more information on the conditions that increase risk for blood clots and the symptoms of a blood clot). You may have spotting or light bleeding or breast tenderness or may feel sick during the first 3 cycles.
Clinical evidence Complementary and alternative medicine is increasingly being used in pursuit of health and well being (Harris and Rees fever after antibiotics for sinus infection purchase erythromycin from india, 2000) vantin antibiotic for sinus infection discount 500mg erythromycin free shipping. Examples of complementary and alternative medicine are acupuncture antibiotic 3 pack order erythromycin mastercard, meditation antibiotic 2274 purchase generic erythromycin on line, massage and herbal medicines antibiotics for sinus infection and alcohol purchase erythromycin discount. Most studies on the efficacy of complementary and alternative medicine are of poor quality infection epsom salt order 500 mg erythromycin mastercard, as well being within the field of endometriosis (Chan, 2008). Furthermore, reports on a possible role for recreational drugs, physical exercise, behavioural and psychological treatment as management strategies for endometriosis associated infertility are also lacking. Therefore, randomized controlled trials of good quality are needed to investigate a possible role for complementary and alternative medicine in the treatment of endometriosis-related infertility. Based on a literature search, the following interventions can be considered for future study: antioxidant therapy (Agarwal, et al. Conclusion and considerations An extensive literature search was conducted on alternative and complementary therapies as treatment for endometriosis-associated infertility. The search terms included: nerve blocks, neuromodulators, transcutaneous electrical nerve stimulation, acupuncture, behavioural therapy, nutritional supplements (including dietary supplements, vitamins, minerals. We found no evidence of a beneficial effect of different types of nutritional supplements, complementary and alternative treatments for improving infertility in women with endometriosis. However, women with endometriosis often use these therapies in addition to traditional medical and/or surgical treatment, in an attempt to improve quality of life and to cope with the disease and the traditional treatments. The prevalence of complementary and alternative medicine use among the general population: a systematic review of the literature. This includes, but is not limited to , in vitro fertilization and embryo transfer, gamete intrafallopian transfer, zygote intrafallopian transfer, tubal embryo transfer, gamete and embryo cryopreservation, oocyte and embryo donation, and gestational surrogacy. Its efficacy and the comparative results in unexplained infertility couples are debated. The influence, if any, of the disease on the final outcome and the implications on the details of the treatment are important topics. Do infertile couples with minimal or mild endometriosis behave as couples with unexplained infertility The significance of minimal endometriosis in the results of artificial insemination with donor sperm is unclear. Classical papers suggest a negative influence, but in a double-blinded cohort study (24 women with minimal endometriosis, 51 without endometriosis) the pregnancy rates were, respectively, 8. However, the number of included patients was lower than the calculated sample size (Matorras, et al. Simplified ultralong protocol of gonadotrophin-releasing hormone agonist for ovulation induction with intrauterine insemination in patients with endometriosis. Fertility in women with minimal endometriosis compared with normal women was assessed by means of a donor insemination program in unstimulated cycles. A randomized and longitudinal study of human menopausal gonadotropin with intrauterine insemination in the treatment of infertility. Artificial insemination by husband in unexplained infertility compared with infertility associated with peritoneal endometriosis. Randomized controlled trial of superovulation and insemination for infertility associated with minimal or mild endometriosis. No difference in cycle pregnancy rate and in cumulative live-birth rate between women with surgically treated minimal to mild endometriosis and women with unexplained infertility after controlled ovarian hyperstimulation and intrauterine insemination. The review included 22 studies, consisting of 2,377 cycles in women with endometriosis and 4,383 in women without the disease. The use of antibiotic prophylaxis at the time of oocyte retrieval in women with endometriomas seems reasonable. In women with endometrioma, clinicians may use antibiotic prophylaxis at the time of oocyte retrieval, although the risk of ovarian D abscess following follicle aspiration is low (Benaglia, et al. Endometrioma and oocyte retrieval induced pelvic abscess: a clinical concern or an exceptional complication Benaglia L, Somigliana E, Vercellini P, Benedetti F, Iemmello R, Vighi V, Santi G and Ragni G. Does controlled ovarian hyperstimulation in women with a history of endometriosis influence recurrence rate In this review, three individual studies comprising of a total of 228 patients were considered. The authors note that the quality of the studies was poor and thus are potentially at risk of methodological bias. Consequently, they state in their conclusions that there remains a need for high quality randomized studies using up-to-date assisted conception techniques. The odds of live birth are also improved, but the magnitude of this is unreliable due to the poor quality of the single study that included this as an outcome. This review and its included studies fail to address the potential adverse effects of the intervention and specifically do not consider miscarriage rates, multiple pregnancy rates or ectopic pregnancy rates. Regarding the quality of the included evidence, it should be noted that the number of studies, the number of included patients and the quality of the included studies were low. A systematic review confirms these results, but states that excision is more favourable than drainage with regard to recurrence of the endometrioma and of pain, and with regard to spontaneous pregnancy (Hart, et al. This conclusion is drawn from several studies but is weak because of limited consistency in the interpretation of the results. Based on no difference in pregnancy rate, some authors advise cystectomy, whereas others advise caution with surgery because of the possible harmful effect on ovarian reserve. Clinical evidence and recommendations on surgery for pain in women with ovarian endometrioma are discussed in section 2. Recommendations In infertile women with endometrioma larger than 3 cm there is no evidence that cystectomy prior to treatment with assisted reproductive A technologies improves pregnancy rates. Interventions for women with endometrioma prior to assisted reproductive technology. Does ovarian surgery for endometriomas impair the ovarian response to gonadotropin More information on surgery for pain in women with deep endometriosis, including the complication rates, is discussed in section 2. Recommendation the effectiveness of surgical excision of deep nodular lesions before treatment with assisted reproductive technologies in women with C endometriosis-associated infertility is not well established with regard to reproductive outcome (Bianchi, et al. Extensive excision of deep infiltrative endometriosis before in vitro fertilization significantly improves pregnancy rates. Papaleo E, Ottolina J, Vigano P, Brigante C, Marsiglio E, De Michele F and Candiani M. Deep pelvic endometriosis negatively affects ovarian reserve and the number of oocytes retrieved for in vitro fertilization. As endometriosis is an estrogen-depending condition, the use of hormonal therapy in women with menopausal symptoms and a history of endometriosis may reactivate residual disease or produce new lesions. The potential of malignant transformation of endometriosis and the regimen of hormonal therapy to be applied to women with a history of endometriosis experiencing menopausal symptoms are other relevant issues are discussed. Clinical evidence the literature search revealed a systematic review that included two randomized controlled trials regarding recurrence of pain and endometriosis lesions in patients submitted to bilateral oophorectomy (Al Kadri, et al. In the first, 10 patients received continuous transdermal estrogen plus cyclical oral progestagen, and 11 received tibolone. After 12 months, 4 patients in the first group and 1 in the second experienced moderate pelvic pain. In the second study, 115 patients received continuous transdermal estrogen plus cyclical oral progesterone, and 57 received no hormonal treatment. After 45 months, 4 of the patients in the treated arm and none in the non treated arm reported recurrence of pain. The authors found recurrence of the endometriosis in 2/115 treated patients and none in the control group. Neither of the included studies reported on malignant transformations or mortality. Considering basic knowledge about eutopic and ectopic endometrial tissue, it seems advisable to use continuous combined estrogen-progestagen regimes in those patients requiring estrogen-containing treatment. Data suggesting that unopposed estrogens might be a risk factor for ovarian malignancy in endometriosis patients with high body mass index are also very limited. The ideal interval to start hormonal therapy after surgical menopause is also not known, and decisions in this cannot be made on the basis of available evidence. No information exists on possible consequences of the use of non-hormonal pharmacological treatments in this context. We found no high-quality evidence on the recurrence of disease in menopausal endometriosis patients treated with hormone replacement therapy. Although the literature search included women with endometriosis after both surgical menopause and natural menopause, no evidence could be retrieved on the latter. The recommendations on surgical menopause could be extrapolated to women with endometriosis and natural menopause, bearing in mind the differences between both patient groups. Recommendations In women with surgically induced menopause because of endometriosis, estrogen/progestagen therapy or tibolone can be B effective for the treatment of menopausal symptoms (Al Kadri, et al. The true prevalence of asymptomatic peritoneal endometriosis is not known, but between 3 and 45% of women undergoing laparoscopic sterilisation have been observed to have the disease (Gylfason, et al. Clinical evidence Surgical excision or ablation (and its inherent risks of damage to the bowel, bladder, ureter and blood vessels) for an incidental finding of asymptomatic endometriosis cannot be endorsed, because no clinical trials have been performed to date to assess whether surgery is beneficial, Furthermore, the risk that asymptomatic minimal disease will become symptomatic is low (Moen and Stokstad, 2002). Conclusion and considerations Based on the lack of evidence, the guideline development group reached the following good practice point for an incidental finding of asymptomatic endometriosis at time of surgery. As the natural course of the disease is unknown and despite the small risk that asymptomatic minimal disease will become symptomatic, the general consensus from the guideline group is that clinicians have a duty of care to inform patients about an incidental finding of endometriosis. A long-term follow-up study of women with asymptomatic endometriosis diagnosed incidentally at sterilization. Association between endometriosis and risk of histological subtypes of ovarian cancer: a pooled analysis of case-control studies. Since the cause of endometriosis is unknown, the potential of primary prevention is limited. One of the risk factors for endometriosis seems to be having a first-degree family member with the disease, although the specific genetic origin of this association is still unknown. The increased disease prevalence which has been found in first-degree relatives of women with endometriosis results in questions from patients and family members on how they can prevent the development of endometriosis. Therefore, we performed a literature search for interventions that could influence the development of endometriosis, although not specifically for women with increased risk for endometriosis. However, interventions for prevention of disease development could be beneficial for these women as well. Clinical evidence When comparing women with surgically diagnosed endometriosis to women without a diagnosis of endometriosis, there is evidence that current use of oral contraceptives has a protective effect against the development of endometriosis, but this effect is not observed in past or ever contraceptive users (Vercellini, et al. However, the protective effect observed in current users can be related to the postponement of surgical evaluation due to temporary suppression of pain (Vercellini, et al. The association was limited to participants with no past or current infertility (p=0. Conclusion and considerations We performed a broad literature search on endometriosis and primary prevention, and also searched for factors associated with the occurrence, prevalence and development of endometriosis. We only found evidence on oral contraceptives and physical exercise: Recommendations the usefulness of oral contraceptives for the primary prevention of C endometriosis is uncertain (Vercellini, et al. References Vercellini P, Eskenazi B, Consonni D, Somigliana E, Parazzini F, Abbiati A and Fedele L. Oral contraceptives and risk of endometriosis: a systematic review and meta-analysis. There is controversy concerning the relationship between different forms of cancer, and the nature of the association. No consensus exists concerning means to affect the risk of cancer in women with endometriosis. Clinical evidence Endometriosis is not associated with an overall increased risk of cancer (Somigliana, et al. The diagnosis of endometriosis is associated with an increased risk of ovarian cancer. The risk for breast cancer was found to be increased in women with endometriosis in 3 out of 8 cohort studies (not increased in 5) and in 4 out of 5 case control studies (decreased in 1) (Munksgaard and Blaakaer, 2011). Endometriosis is not associated with an altered risk of uterine cancer (Munksgaard and Blaakaer, 2011) Endometriosis is associated with a lower risk of cervical cancer in most (2/3) cohort studies and one case control study (Munksgaard and Blaakaer, 2011). Conclusion and considerations A causative relationship between endometriosis and ovarian cancer has not been demonstrated. The lower risk of cervical cancer has been attributed to 80 increased referral and cervical surveillance among women with endometriosis. More evidence is needed before suggesting a change in the current overall management of endometriosis. The association between endometriosis and gynecological cancers and breast cancer: a review of epidemiological data. Somigliana E, Vigano P, Parazzini F, Stoppelli S, Giambattista E and Vercellini P. Association between endometriosis and cancer: a comprehensive review and a critical analysis of clinical and epidemiological evidence. Heavy menstrual bleeding: Abnormally heavy and prolonged menstruation at regular intervals. Infertility (clinical definition): A disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse (Zegers-Hochschild, et al.