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Peeling is the application of chemical agent to bring about exfoliation of the epidermis with remodeling of the collagen and elastic fibers in the dermis .A peel removes several layers of sun damaged skin cells, leaving fresh skin, which has a more even surface and colour.It may stimulate new collagen to be formed improving texture.The result of the first peel may be disappointing, but after repeated peels, significant improvements is usually evident.Principles of chemical peels⦁ Exfoliation of superficial dead layer of skin (Stratum Corneum)⦁ Promotes collagen production⦁ Stimulates new cell growth ⦁ Cleansing of clogged pores⦁ Reduces production of the sebum by the oil glands⦁ Regulation of moisture levelChemical Agents used for peeling⦁ AHA----Alpha Hydroxy Acids- i.e Glycolic Acid , Lactic Acid, Mandelic acid⦁ BHA----Beta Hydroxy Acids- i.e Salicylic Acid⦁ PHA----poly Hydroxy Acids – combination peel⦁ TCA----Trichloroacetic Acid⦁ Phenols----Carbolic AcidTypes of peels⦁ Very Superficial ----Glycolic acid⦁ Superficial ----Lactic acid⦁ Medium ----PHA, Salicylic acid, TCA⦁ Deep ----PhenolsOf these peels the Alpha Hydroxy Acids are the most commonly used.Introduction –Benefits of AHA’s were first discovered by Dr. Eugene van scott in 1970.AHA- Alpha hydroxyl acids----They are also called as fruit acids as they occur naturally in certain fruits. Different AHA’s with their sources-----⦁ Glycolic Acid – Sugarcane⦁ Lactic acid – Fermented milk⦁ Mandelic Acid –Bitter Almonds⦁ Malic acid – Apples⦁ Tartaric acid- GrapesOf these the Glycolic acid & Lactic acids are used generously.Glycolic acid has the smallest molecular weight and is easily able to penetrate the skin. It is a weak acid. It has a keratolytic action .with higher pH it acts as a moisturizer . since it is a weak acid it does not a self neutralizing action by coagulation of proteins hence it has neutralized with water or weak buffer.Glycolic acid result in superficial skin injury and are well tolerated-the ‘lunchtime’ peel. They remove thin lesion on the skin surface, reducing pigment and surface dryness.There are newer glycolic peels which are most potent and still do not irritate. These peels contain Strontium Nitrate. One such brand widely used is Refinity(70% glycolic acid+strontium nitrate) and Cosmoderm(50%glycolic acid+strontium nitrate)INDICATION OF GLYCOLIC ACID1) Acne2) Hyperpigmentation3) Freckles4) Fine lines and wrinkles5) Sun spot6)Open pores7) Clogged pores8) Under eye dark circlesCONTRAINDICATIONS:1)Active infection2) Open cuts3) Photosensitivity4) Past reaction to peel5) Facial surgery in three monthsQUALITIES OF GLYCLIC ACID:Full face or spotsVery superficialExpensiveLong lifeAvailable as liquidDifficult to preparePRMING:Preparing the skin before the peelPriming is done for period of 10 days daily with a lower concentration of glycolic acid (6%) applied only at night. Stop application on day 11, 12, 13th and the pel is done on the 14th day.BENEFITS OF PRIMING :1) More uniform penetration of the peel2) Reduces the risk of hyper pigmentation3) Reduces wound healing timePEEL SENSITIVITY TEST:It is done on the side of the neck to detect sensitivity to the peeling agent .During this first apply 20% GA and watch for 3 mins. Patient will feel slight burning or itching sensation. If this sensation is mild with no redness on the area for 3 mins that means the patient can tolerate the peel on face. So wash the peel with cold water and proceed for the face.On the hand if after application you notice redness with 1-2 mins then immediately neutralize the part . Dilute the peel with 2 drops of rose water , repeat the test patch on other side of neck. If patients tolerates this then do the diluted peel on the face.On the day of peel:Materials Required for peel----⦁ Required peel⦁ Neutraliser⦁ Measuring cups x2⦁ Brush x 2⦁ Cleanser⦁ Vaseline⦁ Ear bud⦁ Head band⦁ Cotton⦁ Rose water⦁ Eye pads⦁ Mask⦁ Sun screenPROCEDURE:1)Elevate the client's head by 45 degrees.2) Tie Head band3) Cleanse of the face with pre- peel cleanser ( to be used according to the skin texture , I. e. oily, normal , dry etc)4)Apply Vaseline to sensitive areas like outer and inner canthi of eyes , angle of month and nose with ear bud.5) If client is about to undergo peeling for the first time, then a Peel Sensitivity Test should be performed.6) Apply 1 ml 20 % Glycolic acid in stroke with peel brush . As you touch the peel brush on face start the timer. Strokes should be outward to inward , single stroke application approximately time of application should be 45 secs, and peel to be kept for 3 mins only. This 3 mins includes your time of application also.7) Mild itching and burning sensation is experienced, which is normal.8) After 3 mins, dab the under eye and upper eye with cold water 1st then neutralize the rest of the face with 2ml of neutralizer.9) Neutralization of peel can be done 2-3 times in same manner During neutralization patient feels warm sensation. This is due to acid base reaction.10) Then clean the face with cold water and give cold compress the face when patient complaining of any of any burning .11) Apply face mask for 20 mins.12) Remove the mask and apply sunscreen according to the skin type .Precautions: While doing peel if there is unbearable burning , stinging , frosting immediately neutralize the peel with cold compress.POST PEELING CARE –1) Can wash with plain water after 2 hours. Soap can be applied after 12 hours.2) There will be mild redness for 1-2 hours.3) Avoid direct sunlight . Apply sunscreen 20 min before sun exposure.4) Avoid swimming and sweating for 2-3 days.5) No facial bleach , treading , waxing , plucking for 7 day before and after peel.6) Avoid make up for 12 hours.7) Do not use medicated cream 2days before and after peel.8) Do not pick, Picking delays healing causes scarring.9) Moisturize- use moisturizers after peel.OTHER PEELS-1 ) BETA HYROXY ACID – SALICYLIC ACID –Salicylic acid is derived from sweet birch , willow bark and wintergreen leaves. It is lipophilic and act as a kerotolytic agent by dissolving the intercellular lipids, surrounding the keratinized epithelial cells. Due to its lipophilic nature it acts on the sebaceous follicle, has excellent comedolytic activity and hence is very useful for acne. It has anti inflammatory and antimicrobial properties. INDICATIONS:# Active pustular acne# Open poresPROCEDURE—Salicylic acid is used only as spot peel.DO NOT USE ON FULL FACE.Used inA combination with glycolic peel.2) POLY-HYDROXY ACID PEEL-Also called as body peel .To be used only on body.INDICATION:Fine lines and wrinklesRehydration of skinDark back , elbow , forearmsPigmented feet , handsPROCEDURE-Same as glycolic acid. Only in this case test patch not required as we are doing on body. Cleaning, application, timer , neutralization remains the same. Post Peel Instructions remains same for all peel procedures.SKIN WHITENING PEEL—(PEEL BOOSTER)---INDICATIONS*Tanned skin*Pigmented skin*Melasma*Dark underarms , hands, feet…PROCEDURE: *Elevate the clients head by 45 degrees*Tie hand –band*Cleanse of the face with pre-peel cleanser( to be used according to the skin texture .i.e.oily , normal dry etc.)* Apply Vaseline to sensitive areas like outer and inner canthi of eyes, angle of mouth and nose with ear bud.*Take 1 ml of peel booster in a measuring cup and with the brush apply it in same direction on the entire face. NO TIMER is required .After application let it dry completely.* After drying now over the booster apply 1ml of glycolic acid 20% ( here timer is necessary)* Time for 3 mins if patient is comfortable then neutralize after 3 min.2)LACTIC ACID PEEL:-INDICATIONS:-Sensitive skin-Dehydrated dull skin-Under eye dark circles4) DARK CIRCLE PEEL:-INDICATIONS:--⦁ Under eye dark circles.⦁ Periorbital melanosis⦁ Fine lines, wrinkles⦁ Open pores.5)ANTIACNE PEEL:-INDICATIONS:-*Acne*Boils , Pustules.*FolliculitisDIFFERENCE BETWEEN AHA and BHA AHA BHA1) They are water soluble 1)They are lipid soluble2) Has keratolytic action. 2) Anti-inflammatory, anti-microbial, comedolytic3) Requires neutralization 3) No neutralizer required4) No frosting occurs 4) Pseudofrost occurs5) Glycolic 5)Salicylic6)For pigmentation 6) For acne7) Prepared from sugarcane 7) Prepared from Sweet birch, willow bark, Wintergreen leaves.Combination Peels – Multiple peeling agents in combinations are used to compliment their synergistic activity and inhance their efficacy and depth.E.g. Salicylic acid with a Mandelic acid targets the Seborrhea, residual acne, post acne pigmented early grade 1 scars as well as textural improvement. Mandelic acid has antibacterial properties and is safer for dark skin types.Sequential Peels – One peel is printed and terminated and followed sequentially by another peel in the same sitting which can be termined or left on slow release peel.E.g. Salicylic acid followed by Mandelic acid, Glycolic acid or Retinol peel. Salicylic acid peel followed by a TCA obtains moderate depth effects.Switch Peels – Includes usage of different peeling agents in rotation in subsequent sittings. E.g. Salicylic acid or a Retinol peel in comedogenic or Inflammatory acne switched over after clearance to Glycolic , Mandelic or phytic in subsequent sessions to improve scars and texture.Slow Release Peels – Some peels works on controlled (gradual)release of the product progressively and ensures complete penetration and full action of all components in the solution. Easy phytic peel composed of three hydroxyl acids with phytic acid, 3 AHA are glycolic acid, lactic acid and mandelic acid.
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Online PG Diploma Certificate Course in Asthma Medicine.Asthma Rehabilatation Autonomous Institute Course.Course InformationDelivered over one year, the online part time distance learning Postgraduate Diploma in Asthma Relief and Rehabilatation course is specially developed for busy health professionals. Course of 6 weeks duration; the course is designed to be practical and clinically focused.Our course is the only online Postgraduate Diploma in Asthma Medicine .On completion of this course graduates Doctor will be able to demonstrate:A critical awareness of current issues affecting the care of patients undertaking Asthma treatments.An advanced knowledge of Asthma Medicine and other associated conditions that will facilitate decision-making in unpredictable and/or complex situations.An ability to use knowledge to adapt professional practice to meet the changing demands of health care systems.An in-depth understanding of the scope and delivery of Asthma treatments including horizon scanning of potential new treatments for the wider population.Course StructureThe online course and is a part-time distance learning course. It consists of 6 weeks duration.Module 1 - Asthma – Symptoms, Signs and InvestigationsModule 2 - Asthma and AllergyModule 3 - Chronic Obstructive Pulmonary DiseaseModule 4 - Thoracic oncology and pleural diseaseModule 5 - Respiratory infections; diagnoses and managementModule 6 - Wider Respiratory HorizonAssessmentThe course puts assessment at the heart of learning by using clinical scenarios to facilitate problem-solving, critical analysis and evidence-based care. The scenarios act as both the focus for learning and assessment thus embedding assessment within the learning process.Monitors, assesses and marks each student throughout the module.Students use the skills gained during the lectures to engage with the different activities (see below).Clinical case scenarios with case based discussion - 40%Individual learning portfolio - 10%Individual activity - 20%Case based examination - 30%Teaching MethodsEach module has the same format. Using an online platform The lecture series are delivered by the faculty and tutors, they are a pre-course organiser, giving students the tools required to undertake the online course such as:Scientific writingLevels of evidenceHarvard referencingReflective writingThe lectures series give an opportunity to meet face to face with tutors/other students prior to the online course. Students who are not able to attend, should request a skype/telephone call to orientate them onto the course and are advised to review the lecture slides.Health professionals working within a clinical setting, both UK and overseas, with a related Healthcare Science degree (including international qualifications) are eligible to apply for the PG Diploma in Asthma Rehabilitataion Course Medicine course.Applicants should submit copies of the following with their application:Qualification certificatesOne written referenceCourses for General PractitionersCourses for DoctorsACADEMY OF ASTMA AND ALLERGYWNHO CLINIC TILAK ROAD , SADASHIV PETH PUNE DHANWANTARI APPARTMENT OFFICE-3 Opposite ICICI Bank PUNE-411030FEES-15, 000/- FOR INDIAN STUDENT AND 500$ FOR INTERNATIONAL STUDENT.NOTE-FEE PAYABLE TO WNHO HEALTH CARE PVT.LTD BY DEMAND DRAFT AND CONTACT FOR ONLINE TRANSACTION -020-24463540, MOBILE- 09822006427. EMAIL- wnhohealthacarepvt.ltd@gmail.comwebsite- www.wnhohealthcare.com / www.wnhocare.co.in
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PSYCHO-SEXUAL COUNSELLING COURSE BY INDIAN SOCIETY OF SEX MEDICINE The term psychosexual therapist is interchangeable with sex counsellor A psychosexual therapist is a specialist with an undergraduate degree in health or allied health, such as medicine, nursing, psychology, social work, counselling, physiotherapy or occupational therapy, and has further training and education in psychosexual therapy/sexual health/sexology.Psychosexual therapy focuses on the experiences an individual and his or her partner(s) has with sexual function/dysfunction, commonly referred to as sexual difficulties. Some of the common sexual difficulties include: loss of libido or desire for sex, lack of sexual enjoyment, pain experienced during sexual behavior such as vaginismus, vulvodynia, difficulty experiencing orgasm, fear of sex, body image issues related to sexual intimacy, erectile difficulties, such as rapid or delayed ejaculation, compulsive sexual behaviors, sex and porn addictions, performance anxiety, mismatched sex drives in a relationship, and/or differences in sexual preferences.A psychosexual therapist will assist the individual and his or her partner to resolve the sexual difficulty by focusing on the behavioral aspect of their function/dysfunction, combined with counselling and/or psychotherapy to address any underlying issues that contribute to the person’s and/or couple’s experiences. The psychosexual therapist is sex positive, non-judgmental and is comfortable in discussing a wide range of sexual health and relationship issues.
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MALE ERECTILE DISORDER (IMPOTENCE)DefinitionPersistent or recurrent inability to attain, or to maintain until completion of sexual activity, an adequate erection.This is also known as ‘Erectile Dysfunction’. The disorder may cause marked distress or interpersonal difficulty. There are different patterns. Some individuals report inability to obtain erection from the beginning of sexual experience, while others reports being able to experience erection only during masturbation or on awakening, but not during the coitus. Some experience adequate erection, but lose it when attempting penetration. Still others report that they have an erection that is sufficiently firm for penetration, but they lose erection before or during thrusting.Male Erectile disorder is frequently associated with anxiety, fear of failure, pressure of sexual performance, and decreased sexual excitement and pleasure. This can disrupt marital relationship and may be the cause of unconsummated marriage and infertility.EtiologyAging: With advancing age, The orgasm is less intensive, The ejaculate is reducedThe interval between the two-successive act is increased.Psychological factors:FatigueDepression, Stress, Mental disorders, Guilt, Fear of failure, Low self esteemReligious restrictionsHomosexualityLong/ serious illnessTraumatic initial experienceNegative feeling towards the partnerResentment Hostility Lack of interestVascular causes:Use of tobacco/alcoholAtherosclerosisPeyronie’s diseaseDiabetesHypertensionVenous leak or occlusionTraumaSurgeryRadiationHormonal causes:HypogonadismHyperprolactinemia DiabetesThyroid diseaseAndrogen deficiencyEstrogen excessAdrenal, pituitary or hypothalamic diseaseNeurogenic causes:Peripheral neuritisAutomatic neuropathy (in diabetes)Multiple sclerosisSpinal cord diseaseDrug related causes:Antiandrogens (cyproterone acetate, flutamide, estrogen)H2 receptor antagonists (cimetidince, famotidine)Diuretics (spironolactone, thiazides)Antihypertensive (beta blockers, ace inhibitors, ganglion blockers)Anticholinergics (atropine, probanthine, dicyclomine)Antidepressants (M. A. O., Tricyclic)Antipsychotics (tranquilizers)CNS Depressants(barbiturates)Substance abuse (heroin, marijuana, alcohol, tobacco)MiscellaneousRenal failureProstatectomyPitfallsA detailed history is essential before arriving at the diagnosis of impotence. Many times, sexual stimulation is not adequate in duration and intensity. Morning erection while awakening is suggestive of psychological origin of impotence. Psychological aspects of erectile problem should always be evaluated in all the cases of erectile difficulty even when the cause is organic. Performance anxiety, fear of failure, over concern with pleasing the partner, ignorance about sexual anatomy and physiology are major causes of erectile problem. The degree of penile erection required for successful vaginal penetration should be enquired. There are individuals who feel that they need a steel hard erection for penetration. This is not necessary. Nature has designed vagina in such a way that the male gets maximum erection followed by ejaculation in the vagina. The male needs to be convinced that if the alignment of vagina and penis is perfect, and the women is stimulated enough, the male will be successful in penetration even if he gets partial erection. Fur there he gets the rigidity during penile thrusting.Sometimes premature ejaculation is associated with impotence. At times, anejaculation is misinterpreted as impotence. Many times, vaginismus in female is the root cause of impotence in the male. He tries at the right site and in the right direction, but since the vaginal opening does not relax, the penis gets tried and he loses the erection. In unconsummated marriage, he may try at a wrong site and lose the erection. Some individuals try penetration at the right site and in the right direction, but since the vaginal opening does not relax, the penis gets tried and he loses the erection.In unconsummated marriage, he may try at a wrong site and lose the erection. Some individuals try penetration at the right site but in a wrong direction, and so they may lose the erection. Some are not aware that they have to make to-and-fro pelvic movements. Such individuals remain quiet after penetration, and ultimately lose the erection. Man is the only animal doing coitus in a face to face position. Coitus is the only act that is performed in the dark and the individual has no opportunity to learn from others. InvestigationsBlood Sugar estimation: Fasting and P.P.Lipid ProfileF.S.H., L.H., Prolactin & TestosteroneT3, T4, T.S.H.Diagnostic testsStamp Test: A long strip of postal stamps is wound around the base of the penis at night before going to bed. Next morning if the perforations of the strip are found to be torn off, impotence is supposed to be of psychological in origin.Peno- brachial index: The ratio of penile systolic blood pressure to that of brachial systolic blood pressure is normally 0.6. If found to be low impotence is vascular in origin.Papaverine Injection Test: Papaverine is a vasoactive drug. Using a 26 gauge needle, 30 mg Papaverine is injected at the mid-shaft of Corpus cavernosum of penis. He is isolated, asked to stoke the penis and exposed to erotic literature (or erotic fantasy). Erection will occur in 10 to 15 minutes. If the erection is short-lived or partial, then impotence is considered as vasculogenic. If the erection is full, then impotence is considered to be neurogenic or psychogenic in origin. Caution: This test should be performed in a hospital setting or where the facilities for detumescence are available. The patient should be observed for next few hours till the erection subsides.Rigiscan Test:This is a gold standard for evaluation of Nocturnal Penile Tumescence and rigidity(NPTR). This test is based on the physiological principle that a male gets erections 3 to 5 times during REM sleep. At night before going to sleep one ring of Rigiscan is slid over the base of the penis and the other over the tip. Next morning, the tracing obtained are studied. This test can quantify erectile tumescence and rigidity. Rigiscan tracing indicates whether the impotence is organic or psychological in origin.Arterial insufficiency and venous leaks can also be suspected on the basis of Rigiscan graphs. Patients with purely artery disease have low levels of rigidity but of adequate duration (20 minutes or more). Patients with venous leak will have varying rigidity levels with shortened duration.Penile Ultrasound: This test is for evaluation of the functioning of the penile arteries. A simple acoustic Doppler emits auditory signals or a color Doppler can help visualization of arteries. Cavernosometry & Canvernosography: This hemodynamic test is useful for diagnosing Veno-occlusive Dysfunction of the corpora. Biothesiometry, electromyography (EMG), nerve conduction studies: these tests are for evaluation of impotence. TreatmentCounselingSexual dysfunction is a marital unit problem and therefore both, husband and wife, should attend. Counseling is towards strengthening marital relationship. Wife is requested to co-operate. Client is requested to quit smoking and alcohol. He is advised relaxation exercises, yoga. The couple is educated about anatomy, physiology of sexual organs and about sexual response. Their myths and misconceptions about sexuality are countered. They are also explained that he does not have to do anything to have an erection. Erection is a physiological response to effective stimuli.Sex therapyNo sexual activity is permitted till specific instruction are given. To remove his performance fears he must stop mentally watching himself during the sexual activity. The couple is advised sensate focus exercise (mutual pleasuring) without any goal. Basic to the sensate focus is the recognition that touch is a vital part human communication that gives meaning to sexual responsiveness for both men and women. They are advised to touch each other in a communicative way. Tenderness, affection, solace, understanding desire, warmth, comfort- almost any feeling can be conveyed to the partner by touching. Though the problem is of one partner, both are involved. There is nothing like uninvolved partner. One partner is advised to trace, massage or fondle the other, using the information from verbal and nonverbal directions from the other getting partners about preferences for locations and intensity of touching. Partners are forbidden to touch breasts, genital organs or to have intercourse.After three or four days the partners are asked again to pleasure each other, but this time, caressing other part of the body, they are specifically instructed to touch the genitals and breasts but not to have intercourse. If erection occurs, as it does during the pleasuring sessions, the couple is not permitted to rush to complete the performance. They are encouraged to develop the ability to communicate with each other during the pleasuring sessions until erection regularly, but not proceeding to intercourse. After next three to four days the wife is instructed to tease the man’s genitals. When the erection is firm she stops teasing and they lie in each other’s arms until the erection goes away. She then repeats the process several times during the next half an hour. By use of teasing technique for the next three to four days, the man gradually overcomes the fear of losing his erection and getting it back.During the next step, after the preliminary sex play, the wife is instructed to straddle her husband and sit on his thighs. She Is asked to stimulate his penis to full erection and to insert it in her vagina. The therapist asks the wife to insert the penis because she knows exactly where the entrance is.After the entry has been accomplished, the wife moves forward and backward slowly on the penis (female superior coital position). If the erection is lost, the wife needs to withdraw and manipulate the penis to erection again. The couple has been told not to move demandingly. There is no pressure to perform. The therapist never instructs the couple to proceed to climax.If orgasm does occur, it should not be by plan, but allowed to be a natural involuntary happening.Once this is accomplished, the couple is instructed to resume intercourse in the man superior coital positionPharmacotherapyPharmacotherapy alone may not be effective unless it is associated with education, counselling, reassurance, countering myths & misconceptions, behavior modification, relaxation and supportive psychotherapy. 1. PDE5 inhibitors are found to be most effective for impotence of no known cause. These drugs maintain the erection and do not initiate the erection or increase the libido. Therefore, sexual stimulation is must. The side effects are headache, facial flushing, nasal congestion, visual disturbance and dyspepsia. Visual disturbances can occur with Sildenafil.Backache or muscle pain has been reported with Tadalafil. Special precaution is to be taken in persons having cardiovascular disease or renal impairment. PDE5 inhibitor must never be given to patients taking nitrates(e.g. Sorbitrate, Angised). Erythromycin, Cimetidine, ketaconizole, grapefruit juice or alcohol should not be taken concurrently. Generally priapism is not observed. PDE5 inhibitors should be prescribed along with alpha blockers (e.g.Prazopress), since this may cause hypotension.Sildenafil (Viagra, Caverta): Dose 25 mg to 100 mg given ½ hour after food and 1 hour before the sexual activity. Not more than once a day. Duration of action is 12 hours.Tadalafil ( Forzest, Zydalis) : Dose 10mg to 20mg. No relation to food. Given ½ hour before sexual activity. Duration of action is 12 hours.Vardenafil (Levitra) : Dose 5 mg to 20 mg. given ½ hour after food and 1 hour before sexual activity. Only once a day. Duration of action is 12 hours.The action of these drugs is dose related. To start with, minimum dose is prescribed.
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Evaluation of Male Erectile Dysfunction INTRODUCTION In recent years, the importance of physical factors in the enteropathogenesis of male erectile dysfunction has become incontrovertibly established. It is now know that erectile dysfunction can occur as a result of psychological factors, physical factors or both. HISTORY- TAKING Too often, history taking is performed very cursorily; this can lead to great blunders. Because of the intimate admixture of psychological and physical issues in erectile function, a detailed psychosexual, marital and social history is mandatory. Such a history not only improves the diagnostic yield but also goes a long way in planning proper treatment. Importantly, it can help avert many a post- operative disaster should the candidate require surgery. A detailed sexual history is invaluable. Direct questions should be asked about the rigidity and duration of erection during sleep, masturbation and sexual intercourse. History- Taking should also include a systematic check list for contributory organic factors (Table 1) often; a good history alone can lead the clinician to a working diagnosis of the relative preponderance of psychological or physical factors in any given patient. PHYSICAL EXAMINATION Although physical examination often contributes very little to the eventual diagnosis and treatment plan, the importance of its thoroughness cannot be over- emphasized. A thorough general and local examination must be performed. A complete neurogenic impotence is still made mainly by elimination of other causes coupled with a high index of clinical suspicion. INVESTIGATIONSa) General Systemic investigations contribute little to the diagnosis and management of impotence per se. However, these must be performed in the interest of the general health of the patient and to identify contributory underlying causes. Monitoring of diabetes, for example, does little to alter the continuing impact of the diabetic process on the erectile apparatus. The same is perhaps true for other systemic diseases associated with erectile dysfunction. It must be noted that even endocrine disorders usually affect the libido rather than the erection itself. Hormonal measurements, therefore, do not obviate the need for more specific tests. b) Specific The armamentarium of diagnostic gizmos and devices flooding the impotence market is quite confusing to the newcomer dabbling in impotence. While some of these are indubitably useful, many are mere research tools that contribute little to an objective diagnosis. Besides, the international literature on the subject is very contradictory and clear standards have not been enunciated for many of these tests.It is still possible, however, with the modalities available today to make a fairly accurate diagnosis of the predominant causal factor/s in any patient. It is not necessary to perform all tests on all patients. The work-up should be tailored according to the individual needs of the patient. Apart from the patient’s economic capacities, time is an important consideration especially in case of the patients coming from faraway places. The psychological make-up and the attitude of the patient are also important. An invasive test should be eschewed in favor of non-invasive ones in especially anxious. The ultimate goal of the investigative work-up is to determine whether the cause of the impotence is psychological, arterial, venous, neurological or endocrinological. It is important to remember that often many factors may co-exist in the same patient. 1) The Injection TestIf performed correctly, this test alone can enable a working diagnosis within one day. Drug used are prostaglandin or papaverine hydrochloride. Prostaglandin is preferable when the patient has to travel within a few hours because of the much lesser risk of priapism. Many other vaso-active substances and their combinations (most notably papaverine – phentolamine have been described. However, these are not indispensable and their non –availability should not be a deterrent to an accurate diagnosis. Papaverine hydrochloride alone is adequate for most purposes. It is cheap and freely available throughout India. Prolonged erections and priapism, should they occur, are very easy to treat. The biggest enemy of papaverine is the anxious patient. For these reasons, it is very important that the patient’s anxiety should be allayed. If necessary, the test should be repeated on more than on occasion. If there is no suspicion of neurological disease, it is safe to start with a dose of 45-60mg. A 26-30 gauge needle is used to inject the drug directly into the corpora cavernosa at the mid-shaft level. The patient should always be given the privacy of a quiet, relaxed room. This test should never be performed in a busy out- patient setting with people walking in and out. This is certain to affect the outcome of the test. The patient should be seated upright during the injection. Pressure on the puncture site should be very gentle or it can have a retrograde milking effect on the penis. This can lead to false-negative results even after appropriate dosage and can cause drug-related systemic side effects as well. After injection, the penis should be gently stroked in order to distribute the drug and facilitate the lubricating jelly help. Visual Sexual Stimulation (VSS) using erotic literature, computer software or video films may be used but doesn’t always help. Unlike in the west, erotica does not have the same effect on the Indian male. This is probably because of socio-cultural and attitudinal differences. Lastly, it must be remembered that erotic literature and films are prohibited by law in India. For these reasons, VSS can be safely omitted without notable compromise in diagnostic yield.Likewise, it may or may not be very helpful to keep the patient in his sexual partner’s company during the conduct of this test. Many men are embarrassed in their partner’s presence and this might affect the outcome of the test. The patient remains seated throughout the test, it is best to seat the patient on a large bed with his back propped against a back- rest or a wall. The legs should be stretched out on the bed. These simple precautions will prevent accidental injuries which could arise from the systemic effects of papaverine hydrochloride. If the patient is relaxed and a suitable does has been injected, a good erection will occur within 10 minutes. Erectile dysfunction secondary to arterial disease may take several minutes longer to produce an erection. Patients with neurogenic importance may develop priapism with very low doses of papaverine but this should not be a deterrent to using adequate dosages. If the erection is unequivocally rigid and the penis cannot be buckled, vasculo genic importance can be virtually eliminated and no further investigations are necessary. If the erection is not rigid enough, a second does may be employed at the same setting. This is quite safe and systemic side effects are uncommon. However, it must be emphasized that this should be performed in a hospital setting with full infrastructural back-up rather than in an office environment. Any curvature of the penis can be studied at the same time. If the erection is still not rigid enough, vascular disease must be eliminated using more sophisticated tests. A Doppler study can be easily combined with the injection test. If an objective measurement of the erection is desired either for academic, medico-legal or psychotherapeutic purpose, a real- time Rigiscan monitoring may be performed at the same session. 2) The Rigiscan Test The Rigiscan is the gold standard for NPTR (Nocturnal Penile Tumescence and Rigidity) measurement. It is the test of choice for non-invasive diagnosis.It is especially suitable for anxious patients since it can be performed in the privacy of their own bedrooms. Its ability to objectively quantify erectile rigidity and establish physical normalcy makes it an important, reassurance providing device to the patient with purely functional problems. It is also useful in medico-legal cases. Time and cost are two relative deterrents.A Rigiscan tracing showing a good number of erectile episodes with rigidity levels of 80% or more and a duration of 20 minutes or more in a single episode almost effectively rules out serious vascular disease. Arterial insufficiency and venous leaks can also be suspected on the basis of the Rigiscan graphs. Patients with purely arterial disease generally have low levels of maximum rigidity but of adequate duration. Patients with predominant venous leakage will have varying rigidity levels depending on the severity of the leakage but the duration is almost always shortened. These patients must be evaluated using other means. The erectile response to vaso-active injection can be objectively studied by the concomitant application of the Rigiscan monitor. This is called a Real time study.1 Abnormal NPTRShowing few ill sustained episodes with inadequate rigidity. All in all, the Rigiscan is an extremely useful device. In an era where many doctors as well as patients continue to believe that most impotence is predominantly due to psychological factors, it is important to eliminate psychological causes first even though such a policy grossly violates conventional medical teaching according to which organic disease must always be eliminated first. 2) Penile UltrasoundA Doppler evaluation of the penile arteries is indicated if the erectile response to the injection test is inadequate or if the patient’s Rigiscan study is suggestive of arterial insufficiency. Pure arterial disease or trauma.Ultrasonograpic evaluation of the cavernosal arteries can be performed with varying degrees of sophistication once cavernosal smooth muscle has been effectively relaxed by vaso-active injection. A simple acoustic Doppler probe, which is inexpensive and portable, emits auditory signals which can effectively eliminate gross cavernosal arterial disease. Duplex Doppler and Colour Doppler studies can help visualization of the cavernosal arteries and measurement of flow.They can also hint at the presence of venous disease. But while these are useful for quantifying penile arterial flow and help diagnose abnormalities in the main cavernosal arteries, they cannot altogether eliminate arterial insufficiency because of their inability to image the microvasculature. Thus, a normal arterial study does not eliminate arterial disease. This is important to bear in mind. 3) DICC (Dynamic Infusion Cavernosometry & Canvernosography) The DICC is an useful hemodynamic test for the diagnosis of CVOD (Corporal Veno-Occlusive Dysfunction). In its simplest form, two cannula are inserted into the corpora cavernosa after smooth muscle relaxation has been achieved with a vaso-active injection. One cannula is connected to a pressure transducer; the other conducts saline or radio-opaque contrast solution at controlled flow rates through an adjustable flow pump. Pressures are measured after injection and 30 seconds after a pressure of 150 mm Hg has been induced. Flow rates are measured in order to induce erection and attain 150 mm Hg, to maintain erection at150 mm Hg; the study is then repeated at a pressure setting of 90 mm Hg. The Convernosal Artery Systolic Occlusion Pressure (CASOP) is also measured at the same time using a Doppler device. These are also the only universally accepted standards for DICC evaluation. There are some centers that perform an 8 or 9 track multi- phasic DICC. Radiologic visualization of leaking penile veins (cavernosography) is performed at the same sitting in many centres. Such radiologic studies are useful only if site-specific, selective ligation is planned as a surgical option. 4) Neurologic Evaluation Many tests have been used for the evacuation of neurogenic impotence. These include nerve conduction studies, biothesiometry and corpus cavernous electromyography (CCEMG), among others. None of these is 100% reliable. The diagnosis of neurogenic impotence continues to be based on elimination of vasculogenic causes, a high index of clinical suspicion and a thorough neurological examination. In any case, tests for neurogenic impotence, whatever their results, will not alter treatment options.
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WNHO’S Franchisees Eligibility Application Form.INTERNATIONAL CONFIDENCE.This application Form is for completion by applicants for WNHO Clinic {R} Fit For Life Franchisees. The information submitted on this form will be treated by WNHO as strictly private & confidential.Please help us by completing all sections carefully and thoroughly and use additional pages/appendices as necessary. This form will present information that is essential for our consideration in granting and finding eligibility.This completion of this application form places no continuing obligation on either WNHO or You. But of course we hope it will have a happy outcome for all!.Applicant’s Name & passport Size Photo.Applicant’s Firm & Date of Start Business……Telephone.. Mobile (Best Time to call)…………………Email/Website.. Nationality/Date of Birth & Marital status/City & Town.Business ExperienceHave you had any previous experience in any business ? If yes – please describe…..Will this Franchise be owned and had Assistance Qualified Doctor his degree & registration certificate and consent letter for work at your center.Business Organization.A. Will you use our WNHO Fit For Life Logo or your own Firm. Details.General InformationHow much capital do you have available to invest in a Various WNHO Preventive Health Programmed as per Wnho leaflet.Agreement.I hereby declare that to the best of my knowledge and belief, the above statement and particulars are true and complete. I also authorize you to make any enquiries you consider necessary in connection with this application. I am aware that should this application be refused, no reason need be given.I understand that any misrepresentation of factual information requested on this application form may be a cause for removal from the WNHOApplicant’s Signature Co-Applicant Signature.
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