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Jeffrey A Brinker, M.D.

Jeffrey A Brinker, M.D.

  • Professor of Medicine
  • Joint Appointment in Radiology and Radiological Science


A daily and weekly programme cheap 200mg pirfenex with amex, including both sufficient activity and rest order pirfenex online now, is essential buy discount pirfenex 200 mg on line. It can keep fatigue within acceptable levels, which some patients find a greater obstacle than the pain. A general rule of thumb is that a particular activity is not damaging if the pain subsides relatively quickly once the activity is stopped. However, an activity may be regarded as causing excess physical strain if the pain and fatigue generally last longer than two days. This may involve adapting the way in which an object is held, adapting the patient’s posture or carrying out the sub-tasks involved in the activity in a different order so that, for example, the patient can walk a longer total distance than before. For patients with generalised hypermobility, adaptations usually call for the use of measures that help protect the joints. These joint protective measures are described below as rules of daily living, which have been adapted from those used in the treatment of rheumatoid arthritis. It is essential that the patient has knowledge of his/her own abilities and limitations in order to apply the rules of daily living correctly, by means such as, but not limited to: a) Maintaining optimal physical condition. This includes getting a good night rest (a good mattress, pillow and an armchair for resting during the day), maintaining muscle strength and movement, maintaining a healthy diet and body weight, wearing adequate footwear and avoiding cold and damp environments. It may be advisable to plan periods of rest and to divide tasks into smaller sub-tasks. Many people with hypermobility syndromes plan extra rest periods and only light tasks or no tasks at all towards the end of the day, when they often experience an increase in symptoms. For others, it is important to begin the day slowly and not to plan many tasks straight away. Productive days can also be planned, but these should generally be alternated with less busy days. It may help to perform certain activities while sitting in order to save energy and reduce the physical stress caused by those activities, such as showering, getting dressed, making sandwiches, cooking, ironing, and enjoying hobbies. Placing appliances such as refrigerators, dishwashers or washing machines at a suitable height can avoid unnecessary bending. Furthermore, stretching can be avoided by arranging cupboards in such a manner that commonly used items are within easy reach. Long periods of standing or sitting in one position are best avoided, as are repetitive activities. Physical load should be divided over several joints where possible, for example, by using two hands rather than one to lift objects such as pans or mugs. Since some patients suffer from reduced proprioception (the sense of relative position and movement), visual control of movement can provide good support when performing certain activities. Extra long handles (to increase leverage) and the use of thick handgrips can serve to lighten some tasks. Sharp knives, lightweight pans and ready- meals can all help to make the task of cooking a lot easier. Easy-care or non-iron garments, that can be put on and taken off easily, can also help patients to save their energy. For example, someone to help with the housework, heavy work in particular, can help prevent excess physical strain. Moreover, this allows generalised hypermobility patients to save their limited energy resources for other activities. Therapy is necessary because relatively small injuries can worsen easily into large wounds, which do not heal well and can result in unsightly scarring. Some examples of skin protective measures are taking care with home furnishings by avoiding furniture with sharp points, being careful when walking on slippery floors or loose rugs, wearing protective clothing for certain activities, making sure that pressure ulcers do not develop when lying or sitting in the same position for long periods, and taking extra care when using splints or support socks/stockings as the skin can tear easily. Assistive devices, adaptive measures and services/facilities Physicians and patients are often afraid that the use of assistive devices and adaptive measures will result in physical decline, assuming that the muscle and joint conditions will deteriorate as the assistive devices take over normal tasks. This assumption, however, does not hold if the right assistive devices are used for the right applications. The aim of occupational therapy is to increase the patient’s functional potential; assistive devices and adaptive measures the role of occupational therapy in Ehlers-Danlos syndrome 343 therefore serve to make the patient more active and independent, rather than increase passivity. It is true that shower stools, special work/office chairs and wheelchairs result in patients standing and walking less. However, this does not mean that these devices actually promote physical decline, but rather that they are used in order to prevent incorrect physical load or excess physical strain. The object is indeed to find a balance between physical load and capacity and so prevent both excess, incorrect load and too little physical load. It is important to bear in mind that the use of splints does involve the risk of physical decline. Studies have shown that a large percentage of assistive devices and adaptive measures are purchased at too high a price, are not used, or are used incorrectly and thus fail to meet the patient’s needs. This can happen when people try to find hasty solutions without performing adequate problem analysis beforehand. Moreover, problems can also occur when the right type of device or facility is used, but in the wrong size or version. There is a huge number of types and brands of assistive devices on the market, and choosing the right one depends very much on the individual situation for which it is intended. Furthermore, some assistive devices are complicated to use and therefore impractical. The degree of difficulty involved in choosing the right equipment is therefore high; practical training and instruction is essential, and it can be helpful if the occupational therapist visits the patient at home. It may be useful to plan a follow-up visit after the treatment has ended, to check whether the device is being used correctly and is providing adequate support.

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Until 2–3 months postpartum buy pirfenex 200 mg fast delivery, basal levels are approximately 40–50 ng/mL buy pirfenex 200mg on line, and there are large (about 10–20-fold) increases after suckling cheap pirfenex online master card. Throughout breastfeeding, baseline prolactin levels remain elevated, and suckling produces a two-fold increase that is essential for continuing milk 39, 40 41 production. The pattern or values of prolactin levels does not predict the postpartum duration of amenorrhea or infertility. Maintenance of milk production at high levels is dependent on the joint action of both anterior and posterior pituitary factors. Prolactin sustains the secretion of casein, fatty acids, lactose, and the volume of secretion, while oxytocin contracts myoepithelial cells and empties the alveolar lumen, thus enhancing further milk secretion and alveolar refilling. The optimal quantity and quality of milk are dependent upon the availability of thyroid, insulin and the insulin-like growth factors, cortisol, and the dietary intake of nutrients and fluids. In women who breastfeed for 6 months or more, this is 45 accompanied by significant bone loss even in the presence of a high calcium intake. However, bone density rapidly returns to baseline levels in the 6 months after 46 weaning. The bone loss is due to increased bone resorption, probably secondary to the relatively low estrogen levels associated with lactation. It is possible that recovery is impaired in women with inadequate calcium intake; total calcium intake during lactation should be at least 1500 mg per day. Nevertheless, calcium 47 supplementation has no effect on the calcium content of breast milk or on bone loss in lactating women who have normal diets. Furthermore, studies indicate that 48, 49 any loss of calcium and bone associated with lactation is rapidly restored, and, therefore, there is no impact on the risk of postmenopausal osteoporosis. Viruses are transmitted in breast milk, and although the actual risks are unknown, women infected with cytomegalovirus, hepatitis B, or human immunodeficiency virus are advised not to breastfeed. Vitamin A, vitamin B 12, and folic acid are significantly reduced in the breast milk of women with poor dietary intake. As a general rule approximately 1% of any drug ingested by the mother appears in breast milk. In a study of Pima Indians, exclusive breastfeeding for at least 2 months was associated with a lower rate of adult onset noninsulin-dependent diabetes mellitus, partly because 50 overfeeding and excess weight gain are more common with bottlefeeding. Frequent emptying of the lumen is important for maintaining an adequate level of secretion. Indeed, after the 4th postpartum month, suckling appears to be the only stimulant required; however, environmental and emotional states also are important for continued alveolar activity. Vigorous aerobic exercise does not affect the 51 volume or composition of breast milk, and therefore infant weight gain is normal. The ejection of milk from the breast does not occur as the result of a mechanically induced negative pressure produced by suckling. Tactile sensors concentrated in the areola activate, via thoracic sensory nerve roots 4, 5, and 6, an afferent sensory neural arc that stimulates the paraventricular and supraoptic nuclei of the hypothalamus to synthesize and transport oxytocin to the posterior pituitary. The efferent arc (oxytocin) is blood-borne to the breast alveolus-ductal systems to contract myoepithelial cells and empty the alveolar lumen. Milk contained in major ductal repositories is ejected from openings in the nipple. In many instances, the activation of oxytocin release leading to letdown does not require initiation by tactile stimuli. These messages are the result of many stimulating and inhibiting neurotransmitters. Suckling, therefore, acts to refill the breast by activating both portions of the pituitary (anterior and posterior) causing the breast to produce new milk and to eject milk. The release of oxytocin is also important for uterine contractions that contribute to involution of the uterus. Prolactin must be available in sufficient quantities for continued secretory replacement of ejected milk. Breastfeeding by Adopting Mothers 53 Adopting mothers occasionally request assistance in initiating lactation. Successful breastfeeding can be achieved by approximately half of the women by ingestion of 25 mg chlorpromazine tid together with vigorous nipple stimulation every 1–3 hours. The primary effect of this cessation is loss of milk letdown via the neural evocation of oxytocin. With passage of a few days, the swollen alveoli depress milk formation probably via a local pressure effect (although milk itself may contain inhibitory factors). With resorption of fluid and solute, the swollen engorged breast diminishes in size in a few days. Routine use of a dopamine agonist for suppression of lactation is not recommended because of reports of hypertension, seizure, myocardial infarctions, and strokes associated with its postpartum use. Contraceptive Effect of Lactation A moderate contraceptive effect accompanies lactation and produces child-spacing, which is very important in the developing world as a means of limiting family size. If suckling intensity and/or frequency is diminished, contraceptive effect is reduced. Only amenorrheic women who exclusively breastfeed (full breastfeeding) at regular intervals, including nighttime, during the first 6 months have the contraceptive protection equivalent to that provided by oral contraception (98% efficacy); with menstruation or after 6 months, the chance 54, 55 of ovulation increases. With full or nearly full breastfeeding, approximately 70% of women remain amenorrheic through 6 months and only 37% through one year; 55 nevertheless with exclusive breastfeeding, the contraceptive efficacy at one year is high, at 92%. Fully breastfeeding women commonly have some vaginal bleeding 56 or spotting in the first 8 postpartum weeks, but this bleeding is not due to ovulation.

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Use of an aromatase inhibitor for induction of ovulation in patients with an inadequate response to clomiphene citrate buy pirfenex 200 mg with mastercard. Comparison of efficacy of aromatase inhibitor and clomiphene citrate in induction of ovulation in polycystic ovarian syndrome generic pirfenex 200mg on-line. Letrozole or clomiphene citrate as first line for anovulatory infertility: a debate buy pirfenex overnight delivery. The use of high dose letrozole in ovulation induction and controlled ovarian hyperstimulation. Comparison of letrozole and clomiphene citrate in women with polycystic ovaries undergoing ovarian stimulation. Clomiphene citrate or letrozole for ovulation induction in women with polycystic ovarian syndrome: a prospective randomized trial. Pregnancy outcome after the use of an aro- matase inhibitor for ovarian stimulation. Congenital malformations among 911 newborns conceived after infertility treatment with letrozole or clomiphene citrate. Assessing the risk of multiple gestation in gonadotropin intra- uterine insemination cycles. Risk factors for high-order multiple pregnancy and multiple birth after controlled ovarian hyperstimulation: results of 4,062 intrauterine insemina- tion cycles. A randomized study of dexamethasone in ovulation induction with clomiphene citrate. Clomiphene citrate and dexamethasone in treatment of clomi- phene citrate-resistant polycystic ovary syndrome: a prospective placebo- controlled study. A randomized clinical trial of treatment of clomiphene citrate-resistant anovulation with the use of oral contraceptive pill suppression and repeat clomiphene citrate treatment. Effect of ejaculatory abstinence period on the pregnancy rate after intrauterine insemination. Effect of the total motile sperm count on the efficacy and cost-effectiveness of intrauterine insemination and in vitro fertilization. Efficacy of superovulation and intrauterine insemination in the treatment of infertility. Laparoscopic drilling by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome. Advanced age, obesity, and drugs, have a negative effect Experimental Research on Vascular on fertility. Different hypothalamic, pituitary, thyroid, adrenal, and ovarian disorders may affect fertil- Biology (BioVasc), Biomedical ity as well. We here provide information Center, Universidade do Estado about how to identify endocrine patients with ovulatory dysfunction. Foi feita uma revisão das causas, manejo e tratamento das causas endócrinas rcvweiss@gmail. Os dados epidemiológicos sugerem que cerca de 10% a 15% Received on Sept/30/2013 dos casais são inférteis. Os problemas de anovulação são responsáveis por 25% a 50% das causas Accepted on Nov/25/2013 de infertilidade feminina. A idade avançada, a obesidade e as drogas têm um efeito negativo na ferti- lidade. Diferentes transtornos hipotalâmicos, pituitários, tireoideanos, adrenais e ovarianos também podem afetar a fertilidade. Fornecemos aqui informações sobre como identifcar pacientes endocrinológicos com disfunções ovulatórias. As mulheres devem ser aconselhadas a evitar fatores limitadores de forma a proteger sua fertilidade. Other reports de- not using contraception and after six months in women scribe ovulatory disorders as responsible for more than > 35 years (1). Epidemiological data suggest that about half of the causes of female infertility (2). Five percent of couples of hysterossalpingography) and endometrial cavity sta- have unexplained infertility and 15% became pregnant tus (by transvaginal ultrassound ou hysteroscopy), as during the study. The most common identifable fac- these two are common causes of female infertility. The main factors to be addressed in sure normal sexual development, and may provide an the infertile couple are presented in fgure 1. In this situation, secretory changes oc- cosity increases and mucus becomes sticky, grainy, and cur in the mucus, and vaginal cytology; and proges- tacky (gestagenic mucus). Effectively, is possible to collect a sample of the mucus and let it however, no oocyte is released to the tubes. All these dry on a slide to be examined in a microscope at low three modalities will be here referred to as ovulatory magnifcation: a typical pattern, resembling fern leaves dysfunctions. Hypoestrogenic women show little or no mucus Evaluation of the infertile woman during the genital exam, together with a pale mucosa. Nowadays, personal devices, which are in fact mini microscopes, using saliva instead of cervical mucus, may act like monitors of the ovulation period. Samples dry and are magnifed by the lens, showing the same ferning pattern present in cervical mucus when estrogen levels are high, allowing women to detect their possible period of ovulation. Female causes: (A) Ovarian Hormonal cytology fator; (B) Tubo-peritoneal fator; (C) Uterine fator; (D) Cervical fator. When ovulation occurs, cells become closer to each History and physical exam other and basophilic. Regular cycles, low abdominal pain in the middle of the cycle for a few hours and abundant mucus, all sug- Basal body temperature gest ovulation.

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However buy pirfenex 200mg without a prescription, developments over the past two decades indicate that the complex sequence of events known as the menstrual cycle is controlled by the sex steroids and peptides produced within the very follicle destined to ovulate discount pirfenex 200 mg fast delivery. The hypothalamus and its direction generic 200 mg pirfenex visa, and the pituitary, are essential for the operation of the entire mechanism, but the endocrine function that leads to ovulation is brought about by endocrine feedback on the anterior pituitary. A full understanding of this feature of reproductive biology will benefit the clinician who faces problems in gynecologic endocrinology. With this understanding, the clinician can comprehend the hitherto mysterious, but significant, effects of stress, diet, exercise, and other diverse influences on the pituitary-gonadal axis. Furthermore, we will be prepared to make advantageous use of the numerous neuropharmacologic agents that are the dividends of neuroendocrine research. To these ends, this chapter offers a clinically oriented review of the current status of reproductive neuroendocrinology. Hypothalamic-Hypophyseal Portal Circulation the hypothalamus is at the base of the brain just above the junction of the optic nerves. In order to influence the anterior pituitary gland, the brain requires a means of transmission or connection. The blood supply of the anterior pituitary, however, originates in the capillaries that richly lace the median eminence area of the hypothalamus. The superior hypophyseal arteries form a dense network of capillaries within the median eminence, which then drain into the portal vessels that descend along the pituitary stalk to the anterior pituitary. The direction of the blood flow in this hypophyseal portal circulation is from the brain to the pituitary. Section of the neural stalk which interrupts this portal circulation leads to inactivity and atrophy of the gonads, along with a decrease in adrenal and thyroid activity to basal levels. Thus, the anterior pituitary gland is under the influence of the hypothalamus by means of neurohormones released into this portal circulation. There also exists retrograde flow so that pituitary hormones can be delivered directly to the hypothalamus, creating the opportunity for pituitary feedback on the hypothalamus. An additional blood supply is provided by short vessels which originate in the posterior pituitary that in turn receives its arterial supply from the inferior hypophyseal arteries. The Neurohormone Concept A considerable body of evidence indicates that influence of the pituitary by the hypothalamus is achieved by materials secreted in the cells of the hypothalamus and transported to the pituitary by the portal vessel system. Indeed, pituitary cell proliferation and gene expression are controlled by hypothalamic peptides and their receptors. In addition to the stalk section experiments cited above, transplantation of the pituitary to ectopic sites . With retransplantation to an anatomic site under the median eminence, followed by regeneration of the portal system, normal pituitary function is regained. This retrieval of gonadotropic function is not accomplished if the pituitary is transplanted to other sites in the brain. Hence, there is something very special about the blood draining the basal hypothalamus. An exception to this overall pattern of positive influence is the control of prolactin secretion. Stalk secretion and transplantation cause release of prolactin from the anterior pituitary, implying a negative hypothalamic control. Furthermore, cultures of anterior pituitary tissue release prolactin in the absence of hypothalamic tissue or extracts. The neurohormone that controls prolactin is called prolactin-inhibiting hormone and is dopamine. In addition to their effects on the pituitary, behavioral effects within the brain have been demonstrated for several of the releasing hormones. Brain peptides require gene transcription, translation, and posttranslational processing, all within the neuronal cell body, the final product being transported down the axon to the terminal for secretion. Small neuroendocrine peptides share common large precursor polypeptides, called polyproteins or polyfunctional peptides. These proteins can serve as precursors for more than one biologically active peptide. It is present in both neural and nonneural tissues, and receptors are present in many extrapituitary tissues (such as the ovarian follicle and the placenta). Prompted by its existence in other species, a search for its presence in humans was ultimately successful. Although it is highly regulated by input from other sites, its function is essential for sustaining life. Pituitary development and activity are under the control of the hypothalamus (with input from other central nervous sytem sites), and pituitary response is finely tuned by hormonal messages from tissues that are the targets of the pituitary trophic hormones. In addition, the pituitary has its own autocrine/paracrine system for enhancement and suppression of growth and function. But the pituitary gland is the focus for all of this activity, and this central, coordinating role is critical for normal life. Prolactin Secretion Prolactin gene expression occurs in the lactotrophs of the anterior pituitary gland, in decidualized endometrium, and the myometrium. In addition, prolactin gene transcription is regulated by the interaction of estrogen and glucocorticoid receptors with 5¢ flanking sequences. Mutations in the sequences of these flanking regions or in the gene for the Pit-1 protein can result in the failure to secrete prolactin. Molecular studies indicate that Pit-1 participates in mediating both stimulatory and inhibitory hormone signals for prolactin gene transcription. However, alterations in Pit-1 gene expression are not involved in pituitary 9 tumor formation.

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These new improvements lead to a decrease in the early mortality from 50 % in the 8 rst patients buy 200mg pirfenex visa, to 20 % in the last 10 patients purchase 200mg pirfenex visa. In the literature pirfenex 200mg with mastercard, reported studies reveal substantial variation in the anatomical inclusion and exclusion criteria employed, with anatomical suitability rates ranging from 34% to100% (25, 26, 27, 28). Accumulating published data suggests that endovascular treatment of emergent aortic lesions is feasible in selected patients in institutions with experience with endovascular techniques. This is the reason why advanced research is necessary to develop new devices specially adapted to emergent aortic implantations 259 A B. In conclusion, this article, constructed with 6 different chapters, provides a current overview of different aspects of aortic surgery in France. Beside the six large centres that were asked to present a speci c area of their activity here, numerous other French and foreign vascular surgery departments will present a large selection of communications about the modern treatment of aortic disease, during our next meeting (21-24 June, 2013). Roberto Chiesa (Milan) and all the Administration Council of the French Society of Vascular Surgery will be honoured to welcome you, during this scienti c and friendly event in Nice, the most Italian French city... Endovascular treatment of infrarenal abdominal aneurysms by the Stentor system: preliminary results of 79 cases. Mid-term results of a second generation bifurcated endovascular graft for abdominal aortic aneurysm repair: the French Vanguard trial. Becquemin J, Bourriez A, D’Audiffret A, Zubilewicz T, Kobeiter H, Allaire E et al. Mid-term results of endovascular versus open repair for abdominal aortic aneurysm in patients anatomically suitable for endovascular repair. Midterm survival after endovascular versus open repair of infrarenal aortic aneurysms. J Endovasc Ther 2002 Mar -Apr;9 (2):203 -7 2002 Mar ;9 ():203 -207 2002 April 1;9:203-7. Peroperative factors in uencing the outcome of elective abdominal aorta aneurysm repair. Eur J Vasc Endovasc Surg 2000 Jul ;20 (1):84 -9 2000 Jul ;20 ():84 -89 2000 July 7;20:84-9. Abdominal aortic aneurysm sac behavior following Cook Zenith graft implantation: a ve-year follow-up assessment of 212 cases. Colon ischemia following abdominal aortic aneurysm repair in the era of endovascular abdominal aortic repair. A randomized controlled trial of endovascular aneurysm repair versus open surgery for abdominal aortic aneurysms in low- to moderate-risk patients. Outcomes of secondary interventions after abdominal aortic aneurysm endovascular repair. Collected world and single center experience with endovascular treatment of ruptured abdominal aortic aneurysms. An analysis of the French multicentre experience of fenestrated aortic endografts: medium-term outcomes. Technical aspects, current indications, and results of chimney grafts for juxtarenal aortic aneurysms. Endovascular repair of ruptured abdominal aortic aneurys: logistic and short-term results. Impact of endovascular repair on early outcomes of ruptured abdominal aortic aneurysms. In uence of endograft oversizing on device migration, endoleak, aneurysm shrinkage, and aortic neck dilation: results from the Zenith Multicenter Trial. Research Unit (e-Services for Life and Health) Scienti c Institute San Raffaele 2012 has been a great year for the bicycle in Italy: it has been con rmed as the new means of transportation for urban mobility and leisure. Bicycle’s great potential makes it an ideal instrument for the development of a healthy, ecological and sustainable lifestyle where physical activity and mobility can become essential triggers both for individuals’ and society’s greater care and attention towards health and the environment. It’s main objective is to promote the correct and safe use of this revolutionary (as well as entertaining) means of transport and to promote users’ knowledge and awareness of every aspect of the bicycle’s ecosystem, through an interdisciplinary and hands-on approach. The Bicycle University strives to address the world of the bicycle in a multilayered manner so as to involve the individual in a process of growth - be he/she a cyclist (either beginner or expert, commuter or tourist), the owner of a business (from the bicycle store owner, to the manager of a B&B specialized in housing cyclists), or a public administrator. The aim of the Bicycle University’s hands-on approach is to provide all the tools necessary to widen and deepen cyclists’ personal motivation, and general knowledge on bicycles and their conscientious use. At the same time, the Bicycle University also strives to provide professionals with useful suggestions 264 regarding urban planning, the integration and the supply of technological services, the development of an educational and awareness support system, and technology innovation by providing a meeting-place for end-users and business actors. The main sections that compose the experimental program of the Bicycle University are as follows: History of the bicycle this section will analyze the bicycle’s evolution over history, focusing speci cally on its role and its use over time. Some of the topics that will be covered include: • Leonardo Da Vinci and the bicycle. Man this section will address the bicycle as instrument for man’s wellbeing, from a physical, emotional and social point of view. Some items of this unit will include: • the bicycle: an instrument for health promotion, recreation and sports, discovery and knowledge. The medium this unit will focus more in depth on the physical and mechanical aspects of the bicycle, as well as the technological evolutions that have changed the medium as well as the accessories. This part of the course will also tackle topics such as public administration’s planning activities, services (commercial and non) that can be offered to cyclists, especially technological infrastructures and integrated ones. The educational program offered by the Bicycle University is extremely wide but can be directed in such a way so that it can be replicated over time and scaled according to the resources available and the target audience. The rst Bicycle University will be launched during the 5th “Aortic Surgery and Anesthesia - How to do it” International Congress. Such an event was chosen in order to highlight the importance of adopting a more healthy lifestyle through correct physical activity. Since this rst edition of the University will address only a few of the themes previously mentioned, and will focus on forming the cyclist. The topics will be presented through a series of seminars and will focus on the road code, the standards for safety and quality in cycling activity, the potentials of new technologies, the biomechanics of both man and the bicycle, the relationship between the cyclists and the urban environment, cyclist safety and comfort and the use of the bicycle as instrument for man’s wellbeing, from a physical, emotional and social point of view.

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The researchers estimated “that only 14% of women in 396 a general population know when they ovulate 200 mg pirfenex mastercard. Interviews of Latina and black women in the United States using fertility awareness methods found that most women abstained from sexual intercourse when they perceived they were 398 fertile buy generic pirfenex 200 mg line, but that only half accurately perceived when they were fertile buy pirfenex with a mastercard. Many had not received 399 accurate information from health care providers or family members. Even women who are actively trying to become pregnant do not know when they ovulate. In a 1997 study in Auckland, New Zealand, only 26 percent of the 80 women struggling with infertility in the study had adequate fertility awareness, and 46 percent did not understand the symptoms of fertility or their meaning, despite the fact that all had been trying 401 to conceive for at least two years. However, 80 percent of women who had received natural 402 family planning instruction previously had adequate fertility awareness knowledge. Likewise, a 2012 study of 204 women who visited fertility clinics in Melbourne, Australia, over 83 percent of whom had attempted to get pregnant for at least one year, found that only 12. Dubois, Validating Signals of Ovulation: Do Women Who Think They Know, Really Know? Health and fertility literacy Fertility literacy “is important for Many lifestyle factors affect fertility, improving reproductive health, including cigarette smoking, caffeine pregnancy outcomes, and chronic consumption, exercise, body mass index 406 disease prevention. A number of significant impact on fertility and risk of modifiable factors have a significant pregnancy and delivery complications for negative impact on fertility, and thus it both mother and baby. Many lifestyle factors affect fertility, including cigarette smoking, caffeine 409 410 411 412 consumption, exercise, body mass index (being underweight or overweight), stress, 413 and rotating shift work. Age also has a significant impact on fertility and risk of pregnancy 414 and delivery complications for both mother and baby. Women, university-educated people, and people from very high Human Development Index countries fared better, and results suggest that education plays a greater role in fertility knowledge than 416 fertility and parenting experiences. The Australian study on women and men of reproductive age found that more than 40 percent did not know the fertility risks associated with smoking 417 and obesity in women. Age-related misconceptions about fertility are very common, even among highly educated individuals, and are becoming more prominent as postponing childbearing grows, especially in the West. A survey of American women aged 25–35 years who had not yet had children revealed that most thought they would have a relatively easy time conceiving, and most overestimated the likelihood of getting pregnant over a month of unprotected intercourse and 420 underestimated how long it takes to get pregnant. Most of the women visited an Ob/Gyn regularly and preferred the Ob/Gyn as a source of information about fertility, but 52 percent had never discussed pregnancy plans with their Ob/Gyns and 78 percent had never discussed 421 age as an infertility risk factor; most discussed contraception during their visits. A study of 422 Canadian women found similar results about incorrect fertility knowledge. In a survey of American undergraduates, 32 percent of women and 36 percent of men overestimated the age 415 See Laura Bunting et al. A Finnish study of university students likewise found that more than half of the men and one-third of the women thought that a woman’s fertility declines markedly after the age of 45, and more than half of men and 43 percent of women 424 overestimated a woman’s chance of becoming pregnant between the ages of 34 and 40. Even female health care professionals believe they 429 can safely postpone childbearing due to overestimation of fertility at advanced ages. Knowledge of and feelings toward menstruation A woman’s awareness about her cycle should not just be limited to ovulation. Menstruation is 430 another important event that indicates the healthy functioning of the body. However, for many girls and women around the world, knowledge about menstruation is low and stigma 431 surrounds it, even though it is universal to all women. Mothers are generally the most important source of information about menstruation for girls, 423 See Brennan D. Another important source of information is formal educational materials, but these often focus on 433 hygiene—including trying to hide menstruation—and not on physiology and puberty. Adolescent girls largely do not understand what happens when menstruation occurs and 434 cannot identify reproductive anatomy. Young girls who are not able to explain what occurs during menstruation nonetheless have internalized negative beliefs about changes 436 related to menstruation. People rate a woman’s competence lower and like her less if they 437 are aware that she is menstruating, and menstruation affects a woman’s self-presentation if 438 she knows that others are aware she is menstruating. Further exacerbation is provided by menstrual product advertising, which does not provide girls and women with much information 439 about the actual menstrual cycle and its functioning. Instead, advertising communicates that periods are burdensome, with themes of silence and shame, embarrassment, avoidance of “getting caught” being on one’s period, and dirtiness, all of which result in heightening girls’ 440 and women’s insecurities surrounding menstruation. For example, a girl receives the message that she should be embarrassed if someone finds out she is currently on her period, 441 and to avoid this she must find ways to conceal menstruation with various products. She cannot objectively evaluate the products she will use to affect her cycle if her experience is one 442 of shame. The idea that menstruation is bad has led to the promotion of birth control methods that allow 432 Carol C. So long as this view perpetuates, cycle-shortening 444 and cycle-stopping methods will continue to be popular. Women who experience menstruation normatively and routinely may begin to have body shame leading to poor sexual decision-making as a result of the increasing the idea that menstruation is bad has emphasis on the desirability of menstrual led to the promotion of birth control suppression through hormonal methods that allow for short or no 445 contraception. So long as information about menstruation and are this view perpetuates, cycle-shortening influenced to view menstruation as a and cycle-stopping methods will negative experience, the choice to use such continue to be popular. First, familiarity with her cycle allows a woman to identify when a possible underlying health problem exists, which can allow her to get necessary treatment in a timely manner; unfamiliarity with her cycle means health problems can go unrecognized and worsen over time. Second, knowledge about fertility can help reduce unintended pregnancies, especially among young adults, because it empowers women and men to understand when not to have sex in 446 order to avoid pregnancy.


  • http://library.uniteddiversity.coop/Water_and_Sanitation/Encyclopedia_of_Water.pdf
  • https://www.govinfo.gov/content/pkg/CHRG-115hhrg34638/pdf/CHRG-115hhrg34638.pdf
  • http://paralife.narod.ru/en/essentials-of-spinal-cord-injury.pdf
  • http://crowston.syr.edu/papers/DDGDD01.pdf?page=2
  • http://wayneandwax.com/academic/marshall-rap-reggae-dissertation.pdf

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