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By A. Tragak. Antioch University Los Angeles. 2018.

Quite a number of women think they are not attractive to their partner and that he will be able to ejaculate when making love with another woman generic tramadol 50mg mastercard. Some of these men may struggle to ejaculate with such des- peration that they may physically exhaust themselves order 100mg tramadol, and sometimes even their partner tramadol 100 mg discount, in the attempt buy 50mg tramadol amex. Delayed ejaculation may occur in coitus, masturbation (either by the patient or by the partner), as well as during anal or oral intercourse. Throughout the years, a variety of terms have been used to refer to this eja- culatory disorder. In the acquired form, the disorder appears somewhere in life after previous normal ejaculatory functioning. Symptoms If ejaculation is delayed in all situations, in all sexual activities and with all partners, the disorder is generalized. Prevalence In contrast with premature ejaculation, lifelong delayed ejaculation is a relatively uncommon condition in clinical practice. Acquired delayed ejaculation has little higher preva- lence of 34% in men below the age of 65. The psychological ideas and explanations may have face validity in some individual cases, but there are no well-controlled studies that support a general- ization of any of the various psychological hypotheses. The psychological, cultural, and religious factors that may lead to lifelong delayed ejaculation clearly requires further investigations. According to this view, there is a variability in the extent of delayed ejaculation, from mildly delayed to severely delayed and lastly a failure of ejaculation. In case this is true, it means that men may be born with a bio- logical vulnerability to develop delayed ejaculation. Whether environmental factors affect the neurobiological vulnerability remains to be understood. From animal and human studies, it is known that in particular it is the ser- otonergic system which is involved in ejaculation. Whether dopa- mine and oxytocine play a role in lifelong delayed ejaculation remains to be elucidated. Unfortunately there is no drug treatment available for delayed ejaculation in men. Various treatments have been used to treat men with delayed ejaculation: Vibratory and electrical stimulation, a variety of sexual exercises, and a range of psychotherapeutic techniques (8891). These treatments have been used sep- arately or in combination with one or more others. Research on the effectiveness of these treatments is limited to uncontrolled studies on individual patients or short series of patients (92). The percentage of success to cure lifelong delayed ejaculation, however, is unknown. Electrical stimulation (94) of the internal ejaculatory organs by a transrectal electrical probe (electro-ejaculation) is mainly used to obtain semen in paraplegic men. This intervention is extremely painful in men with normal sensation and is not an option to treat lifelong delayed ejaculation. Masturbation exercises have been extensively used in the treatment of delayed ejaculation. Kaplan (85) describes a method in which a period of undemanding sensate focus exercises is followed by a period in which a man masturbates, initially alone and subsequently in circumstances in which he becomes gradually closer to his female partner. Once the patient has had an orgasm in the presence of his partner, he masturbates in a number of steps in which the penis is closer to the vagina during masturbation. Finally, he enters the vagina and combined coital and manual stimulation is then used to induce ejaculation. Because controlled studies are not available, it is very dif- cult to evaluate the results. The overall impression of these different approaches is that some patients are actually cured after treatment although most patients are only somewhat improved or unchanged. In the absence of comparative studies, it is not possible to compare the effectiveness of different treatments. Because of these methodological deciencies, no rm conclusion or recommendation on the optimal treatment approach can be given (92). At present, a combination of masturbation exercises and general therapeutic interventions may have a chance for success. In spite of the above-mentioned treatment options, it is generally believed that lifelong retarded ejaculation is difcult to treat. In my opinion, continuous psychological, cultural of religious factors prohibiting sexual feelings may perhaps lead to a release of stress hormones that might disturb the full develop- ment of or even damage cerebral areas and neuronal pathways that are important for the ejaculation process. This might be one of the reasons that although psychological factors may heavily contribute to retarded ejaculation, psychother- apy alone is often hardly effective. Further research of lifelong retarded ejacula- tion is of utmost importance to unravel the neurobiology and interaction with psychological factors of this distressing ejaculatory disorder. Acquired Delayed Ejaculation Psychological Factors The only way to determine the cause(s) of delayed ejaculation is the clinical inter- view. There are no specic characteristics of psychologically induced acquired delayed ejaculation. In addition, the onset may be sudden, the delay may be situational and also intermittent. Some factors may be related to the development of acquired delayed ejaculation, such as a psychological trauma (for example, the discovery of the partners indelity), or lack of sexual and psychological stimulation (inadequate technique or lack of attention on sexual cues). Organic Factors The onset of ejaculation delay may be sudden or gradual and deteriorates pro- gressively to global unremitting ejaculatory inhibition. Androgen deciency or hypogonadism may be accompanied by loss of sexual desire and delay of ejaculation. Alcohol can delay or abolish ejaculation by a direct effect after acute abuse and indirectly by neurological or hormonal disturb- ances during chronic abuse. Treatment of Acquired Delayed Ejaculation In order to exclude pharmacological causes of delayed ejaculation, one has to carefully review the patients concomitant drugs that are likely to inhibit ejacula- tion. In those cases, an alternative drug should be tried, or in case of antidepres- sants, reduction of dose or antidote may be required (95). Most patients require general advice on reducing precipitating factors, reduction in alcohol use, nding more time for sexual activity when not fatigued. Most of the literature consists of hypotheses that have not been investigated according to methodological well- designed studies. Both in the general population and in the clinical practice, the prevalence of delayed ejaculation is rather low (84). Furthermore, delayed ejaculation is known as a disorder that is relatively difcult to treat (92). Although controlled studies do not exist, clinical experience suggests that the outcome is rather poor (92).

From her extensive experience in programs addressing diabetes and depression and related areas of health promotion buy tramadol 200 mg otc, Dr cheap 100mg tramadol fast delivery. Ludman provided the Diabetes Initiative valuable expert consultation in developing activities related to healthy coping and provided helpful comments on drafts of this Guide order tramadol 50mg with visa. Throughout the Guide buy tramadol 50 mg without a prescription, program managers is intended to refer to those responsible for guiding program development and implementation. For program managers, the goal of the Guide is to introduce the range of approaches that addresses negative emotions and may enhance healthy coping in adults with diabetes. The objective is to help program managers increase their knowledge of healthy coping approaches in order to expand existing services or develop new programs for dealing with negative emotions. For practitioners implementing self-management programs, the goal of the Guide is to provide an introduction and overview of diverse approaches with enough detail to help practitioners determine which may be especially suitable for incorporation into their own work. In no way does the Guide provide sufficient detail to enable one to become competent in delivering any particular healthy coping strategy. Rather, it aims to acquaint the professional with a sense of how intervention approaches may be used and key features in their application, along with identification of sources of further information. In the pages that follow, we describe a variety of approaches to address negative emotions and promote healthy coping in individuals with diabetes. In addition to providing broad descriptions of each approach, we comment briefly on the nature and strength of the evidence base supporting the effectiveness of the approach by citing research conducted with individuals who have diabetes and other chronic illnesses. We also provide program examples from the Diabetes Initiative of the Robert Wood Johnson Foundation to illustrate how some of these approaches have been integrated into real- world settings. Implementation considerations are included to guide program managers, educators, and counselors as to whether a particular intervention approach may be useful in their setting and with their population. Additional resources such as web links are also provided for those interested in more detailed information about particular approaches. This Guide was developed by the National Program Office of the Diabetes Initiative. It is informed by the research and patient education literature as well as the experiences of the fourteen grantees of the Initiative and their varied and innovative approaches to enhancing services for healthy coping. Healthy coping applies to all aspects of diabetes, thus making it important to integrate interventions that address negative emotions and healthy coping into diabetes self management programs. It has become clear that doing so is quite feasible and ultimately beneficial to program recipients, while providing professional satisfaction for those expanding their programs in these directions. Thus, many readers of this Guide are already familiar with approaches to self management that are also helpful in dealing with the range of negative emotions experienced by those with diabetes. Tips for Practice At a number of points in the Guide, Tips for Practice provide detailed suggestions for key implementation steps. Many of these include suggestions for how to present ideas for healthy coping in a way that helps individuals accept the new ideas rather than causing them to become defensive or resistant. These tips alert readers to important features of interventions they may be considering. At the same time, these tips also provide information that may be of use to managers. A common challenge in any area of organizational or program management is knowing when to drill down and explore the details of an operation to assure its success. Managers of diabetes care programs will not routinely immerse themselves in the details of interventions for negative emotions. However, their ability to drill down effectively when necessary requires some feel for nuances of programs that may be critical to their success. Thus, the Tips for Practice may assist program managers in making more informed decisions about recruiting appropriately trained individuals, understanding problems that may emerge, and knowing how best to monitor program approaches for effectiveness. For some time, this has been apparent to clinicians and patient educatorsas well as those with diabetes and their familiesand is widely reported in 1 research literature. Not only can poor metabolic control and the complications that come with it induce an array of negative emotions, but negative emotions can in turn hinder a persons ability to manage diabetes and maintain metabolic control. The types of negative emotions and problems with coping that occur in diabetes cover a wide spectrum. Not only are people with diabetes more likely than the general population to experience clinical depression, but depression is also likely to interfere with diabetes management and affect processes related to metabolic control. Anxiety, frustration, stress, concerns about diabetes and its complications and anger are some of the many other negative emotions that make living with diabetes more difficult. Manifestations may range from anxiety over day-to-day events Diagnosable to mild transient distress related to being Daily Problem, e. These manifestations may wax and wane over the course of the many years that people live with diabetes. Successful coping with negative emotions, however, will almost always enhance diabetes management and quality of life. Intervention Approaches for approaches can be adapted for use Addressing Negative Emotions across the range of types and Daily Diagnosable Problem, severity of disorders. Enhanced attention to coping with negative emotions within traditional self-management programs (e. Although all of these approaches are often referred to as stress management interventions, they actually are a diverse array of approaches that parallel the diversity of the type and severity of negative emotions seen in individuals with diabetes. For those, it may be beneficial to make psychological or other counseling services available within a care setting or to enhance referral resources for specialty care (psychological, social work, and/or psychiatric services). As will become clear through the pages of this Guide, healthy coping may be promoted across the entire range of self management programs. At the same time, it includes very specific interventions such as Cognitive Behavioral Therapy or meditation. Adding complexity, some approaches to healthy coping have both broad and specific applications. For example, problem solving is an approach found in almost every self-management intervention. At the same time, it is also a distinctive type of psychotherapy for emotional problems. The same kind of breadth applies to stress management and cognitive behavioral approaches. Although this breadth and confusion of boundaries may make the field seem somewhat chaotic, it is an important feature of healthy coping interventions. Healthy coping, negative emotions, and diabetes management: a systematic review and appraisal. Initial screening is frequently which involves taking a full personal and followed by further assessment to document social history with specific questions the extent and severity of problems that are determined as the interview progresses. Alternately, the assessment format may be Screening generally involves evaluating highly structured with the administration of individuals to determine the likelihood that one or more standardized questionnaires. Its primary purpose is to detect interview by a trained professional or through and identify conditions for which early a self-administered questionnaire given to the treatment will result in better outcomes and patient. Additionally, screening threshold score above which individuals are may aid program managers in determining the likely, with some known level of certainty, to prevalence and severity of a condition in their have the emotional health problem to a degree client population so that needed services can that impacts functioning and quality of life. Regardless of the format or degree of Screening for emotional health problems structure, the clinicians assessment skills and typically involves assessing whether judgment play an important role in arriving at individuals experience various negative a full understanding of the problem. Screening helps identify those with screening and assessment program into place increased levels of distress who would benefit is that services are available to clients who are from more in-depth evaluation of the issue and identified as having emotional health contributing circumstances, e.

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Therefore purchase tramadol 200mg with visa, instructions must be clearly communicated to the professional team members with constant attention devoted to detail during the treatment process purchase tramadol 50mg with visa. Complicated processes of this nature require good planning and clear generic 50 mg tramadol free shipping, understandable procedures discount 50 mg tramadol fast delivery. To help ensure that all personnel involved in the treatment fully understand instructions in the written directive or treatment plan, the licensee should instruct all workers to seek guidance if they do not understand how to carry out the written directive. Specifically, workers should ask if they have any questions about what to do or how it should be done before administration, rather than continuing a procedure when there is any doubt. Licensees should also consider verification of written directives or treatment plans by at least one qualified person (e. The administration of radioactive materials can involve a number of treatment modalities, e. Procedures for Any Therapeutic Dose or Dosage of a Radionuclide or Any Dosage of Quantities Greater Than 30 Microcuries (1. The following is a model procedure: An Authorized User must date and sign a written directive prior to the administration of any dose or dosage. Asking or calling the patients name does not constitute positive patient identity verification. Appropriate verification methods include: measuring the activity in the dose calibrator, checking the serial number of the sealed sources behind an appropriate shield, using color-coded sealed sources, or using clearly marked storage locations. Additional Procedures for Sealed Therapeutic Sources and Devices Containing Sealed Therapeutic Sources Licensees are required to have written directives for certain administrations of doses and to have procedures for administrations for which a written directive is required. However, for some brachytherapy procedures, the use of various fixed geometry applicators (e. An Authorized User or a qualified person under the supervision of an Authorized User (e. Methods for checking the calculations include the following: o For computer-generated dose calculations, examining the computer printout to verify that correct input data for the patient was used in the calculations (e. The therapy dose will be manually calculated to a single key point and the results compared to the computer-generated dose calculations. If the manual dose calculations are performed using computer-generated outputs (or vice versa), verify the correct output from one type of calculation (e. Parameters such as the transmission factors for wedges and applicators and the source strength of the sealed source used in the dose calculations will be checked. Acceptance testing will be performed before the first use of a treatment planning or dose calculating computer program for therapy dose calculations. Each treatment planning or dose calculating computer program will be assessed based on specific needs and applications. A check of the acceptance testing will also be performed after each source replacement or when spot check measurements indicate that the source output differs by more than 5% from the output obtained at the last full calibration corrected mathematically for radioactive decay. The independent check will include an output measurement for a single specified set of exposure conditions and will be performed within 30 days following the full calibration measurements. The independent check will be performed by either: o An individual who did not perform the full calibration using a dosimetry system other than the one that was used during the full calibration (the dosimetry system will meet the requirements specified in 4731. Such media may be reused (and must be relabeled) in accordance with the manufacturers instructions. Review of Administrations Requiring a Written Directive Conduct periodic reviews of each applicable program area, e. The number of patient cases to be sampled should be based on the principles of statistical acceptance sampling and be representative of each treatment modality performed in the institution, e. If this is not possible, two people should work together as a team to conduct the review of that work. Regularly review the findings of the periodic reviews to ensure that the procedures for administrations requiring a written directive are effective. When deviations from the written directive are found, the cause of each deviation and the action required to prevent recurrence should be identified. Several such changes were to the allowable activity limits for the packages used to transport materials being returned to nuclear pharmacies. If you will be returning your radioactive waste to a nuclear pharmacy, your facility will become a shipper of a radioactive material. Limited Quantity Shipments Return shipments should be shipped as Limited Quantity Shipments. To meet the above requirements, licensees must ensure that the waste being returned does not exceed the specified limits for Limited Quantity Shipments. The total quantity of activity being returned cannot exceed the specified Limited Quantity Shipment activity whether returning used dose material or unused doses. If an unused syringe of a 25 mCi dose is held for 24 hours (4 half lives), the remaining activity is: (25 mCi) x (0. If the syringe is held for 24 hours (4 half lives), the remaining activity from a 25 mCi dose is: (25 mCi) x (0. If this limit is exceeded, please call the nuclear pharmacy for further instructions. Packages that have not been prepared for shipment back to the nuclear pharmacy in the manner described above should not be accepted for transport. As such, training is considered an essential element in reducing hazardous material incidents. Relevant training received from a previous employer or source may be used to satisfy the requirements provided a current record of training is obtained from the previous employer or other sources. If you do so, you should consider for inclusion all the features in the general guidance. State on your application, "We have developed a procedure for waste disposal for your review that is appended as Appendix P," and attach your procedure. General Guidance All radioactivity labels must be defaced or removed from containers and packages before disposal. If waste is compacted, all labels that are visible in the compacted mass must be defaced or removed. Review all new procedures to ensure that waste is handled in a manner consistent with established procedures. Consider occupational and public exposure to radiation, other hazards associated with the material and routes of disposal (e. Model Procedure for Disposal of Liquids and Gases Release to the sanitary sewer or evaporative release to the atmosphere may be used to dispose of liquids. This does not relieve licensees from complying with other regulations regarding toxic or hazardous properties of these materials. There are specific limits based on the total sanitary sewerage release of your facility. Make a record of 103 the date, radionuclide, estimated activity and concentration that was released (in millicuries or microcuries), and the vent site at which the material was released. Because the waste will be surveyed with all shielding removed, the containers in which waste will be disposed of must not provide any radiation shielding for material.

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