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• Professor of Medicine
• Member in the Duke Clinical Research Institute

https://medicine.duke.edu/faculty/karen-patton-alexander-md

Luteal phase: this phase is from ovulation until the first day of the menstrual cycle generic questran 4 gm on-line. Premenstrual Dysphoric Disorder: A recurring cyclic cluster of predominately behavioral symptoms developing 7-14 days prior to buy cheap questran 4 gm line menstruation (during the luteal phase) and dissipating when menstruation or the follicular phase begins order questran 4 gm amex. Premenstrual Syndrome: A Recurring cyclic cluster of physical and behavioral symptoms developing 7-14 days prior to menstruation (during the luteal phase) and dissipating when menstruation or the follicular phase begins. Qi: Is the life force that flows throughout the organ systems of the body, and is a fundamental substance that helps maintain activities in the body. It�s the foundation for the zang-fu (organs) and meridians (acupuncture points are located on these) (Cheng & Deng, 1999). The search was expanded to include symptoms of both disorders as search words to gather more data. This researcher therefore expanded the search to include associated symptoms of both syndromes. Menstrual cycle synopsis: A menstrual cycle�s length can vary between 21 and 35 days with an average cycle length of 28 days. Day one of the menstrual cycle begins on the first day of menstrual bleeding, which typically lasts for three to five days. There are four phases of the menstrual cycle: follicular, ovulatory, secretory, and luteal. When one of the follicles is �mature� it bursts open and typically one egg is released from the ovary, and travels into the fallopian tube to await fertilization. The ovaries, an endocrine gland, secrete estrogen and progesterone to help thicken and maintain the thickness of the uterine lining. The leftover remains of the burst follicle then become the corpus luteum, which secretes its� own progesterone as well to prepare for possible fertilization. If fertilization occurs the corpus luteum has a life span of about ten weeks after ovulation, then the placenta takes over progesterone production. If no fertilization occurs, the corpus luteum decays after twelve to fourteen days. Progesterone levels drop signaling menstruation to occur, the shedding of the uterine lining (Flaws, 2005). The World Health Organization (2015) notes that reproductive aged females are from 15-49 years of age. It is important to rule out any other medical disorder, disease, or differential diagnoses that are continuously present and not only in the luteal phase. Keep a symptom journal or calendar for one to three months to be sure the symptoms are cyclic (coinciding with multiple menstrual cycles), and/or cause impairment or interfere in the life of the patient (Dickerson et al. One affective and one somatic symptom must be experienced five days prior to menses and be present in three consecutive menstrual cycles. The symptoms must abate within four days of menstruation and not reoccur until day 13 or later of the cycle. These symptoms are existent in the privation of alcohol, drugs, hormones and pharmaceutical treatments. The patient must also experience a disruption in their daily life (social, relationships, work, etc). According to the current version of the Diagnostic and Statistical Manual of Mental Disorders (5th ed. In most menstrual cycles during the past year, five (or more) of the following symptoms were present for most of the time during the last week of the luteal phase, began to remit within a few days after the onset of the follicular phase, and were absent in the week after menses, with at least one of the symptoms being 1, 2, 3, or 4: 1. Markedly depressed mood, feelings of hopelessness, or self depreciating thoughts 2. Persistent and marked anger or irritability, or increased interpersonal conflicts 5. The disturbance markedly interferes with work or school, or with social activities and relationships with others. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, dysthymic disorder or a personality disorder (although it may be superimposed on any of these disorders). Criteria A, B, and C must be confirmed by prospective daily ratings during at least two consecutive symptomatic cycles. Dysmenorrhea refers to lower abdominal pain or other discomforts before, during or after menstruation, � Zhou & Qu (2009).

Its origin is from the tendinous arch extending from the body of the pubis to purchase discount questran line the ischial spine buy 4 gm questran with visa. This tendineus arch best 4gm questran, called the arcus tendineus levator ani, is formed by a thickening of the obturator fascia and serves as a lateral landmark and point of attachment for some vaginal suspension procedures. The levator ani is inserted into the central tendon of the perineum, the wall of the anal canal, the anococcygeal ligament, the coccyx, and the vaginal wall. The levator ani assists the anterior abdominal wall muscles in containing the abdominal and pelvic contents. It supports the vagina, facilitates defecation, and aids in maintaining fecal continence. During parturition, the levator ani supports the fetal head while the cervix dilates. The anterior portion of the levator ani complex serves to close the urogenital hiatus and pull the urethra, vagina, perineum, and anorectum toward the pubic bone, whereas the horizontally oriented posterior portion (levator plate) serves as a supportive diaphragm or �backstop� behind the pelvic viscera. Loss of normal levator ani tone, through denervation or direct muscle trauma, results in laxity of the urogenital hiatus, loss of the horizontal orientation of the levator plate, and a more bowl-like configuration. Such configurations are seen more often in women with pelvic organ prolapse than in those with normal pelvic organ support (9). Traditional teaching is that the levator ani muscles are innervated by the pudendal nerve on the perineal surface and direct branches of the sacral nerves on the pelvic surface. Evidence indicates that the levator ani muscles are innervated solely by a nerve traveling on the superior (intrapelvic) surface of the muscles without the contribution of the pudendal nerve (10�15). This nerve, referred to as the levator ani nerve, originates from S3, S4, and/or S5 and innervates both the coccygeus and the levator ani muscle complex (10). After exiting the sacral foramina, it travels 2 to 3 cm medial to the ischial spine and arcus tendineus levator ani across the coccygeus, iliococcygeus, pubococcygeus, and puborectalis. Occasionally, a separate nerve comes directly from S5 to innervate the puborectalis muscle independently. Given its location, the levator ani nerve is susceptible to injury through parturition and pelvic surgery, such as during sacrospinous or iliococcygeus vaginal vault suspensions. Urogenital Diaphragm the muscles of the urogenital diaphragm anteriorly reinforce the pelvic diaphragm and are intimately related to the vagina and the urethra. They are enclosed between the inferior and superior fascia of the urogenital diaphragm. Blood Vessels the pelvic blood vessels supply genital structures as well as the following: � Urinary and gastrointestinal tracts � Muscles of the abdominal wall, pelvic floor and perineum, buttocks, and upper thighs � Fasciae, other connective tissue, and bones � Skin and other superficial structures Classically, vessels supplying organs are known as visceral vessels and those supplying supporting structures are called parietal vessels. Major Blood Vessels the course of the major vessels supplying the pelvis is illustrated in Figure 5. In general, the venous system draining the pelvis closely follows the arterial supply and is named accordingly. Not infrequently, a vein draining a particular area may form a plexus with multiple channels. Venous systems, which are paired, mirror each other in their drainage patterns, with the notable exception of the ovarian veins. General Principles �Control blood supply� and �maintain meticulous hemostasis� are two of the most common exhortations to young surgeons. In developing familiarity with the pattern of blood flow in the pelvis, several unique characteristics of this vasculature should be understood because of their potential implications to surgical practice: the pelvic vessels play an important role in pelvic support. They provide condensations of endopelvic fascia that act to reinforce the normal position of pelvic organs (16). There is significant anatomic variation between individuals in the branching pattern of the internal iliac vessels. There is no constant order in which branches divide from the parent vessel; some branches may arise as common trunks or may spring from other branches rather than from the internal iliac. This variation may be found in the branches of other major vessels; the ovarian arteries are reported to arise from the renal arteries or as a common trunk from the front of the aorta on occasion. The inferior gluteal artery may originate from the posterior or the anterior branch of the internal iliac (hypogastric) artery. Patterns of blood flow may be asymmetric from side to side, and structures supplied by anastomoses of different vessels may show variation from person to person in the proportion of vascular support provided by the vessels involved (16). The pelvic surgeon must be prepared for deviations from �textbook� vascular patterns. The pelvic vasculature is a high-volume, high-flow system with enormous expansive capabilities throughout reproductive life.

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But they will be useful only insofar as the anatomical measures are matched with comprehensive and reliable cognitive testing 4 gm questran, in order to cheap 4gm questran free shipping test precisely the postulated structure-function correspondences within each individual generic questran 4gm on-line. Sex-ratio It is commonly accepted that males are more affected by dyslexia than females. Within the magnocellular theory, the finding that thalamic disruption was mediated by fetal testosterone in the mouse model has been interpreted as a possible explanation for the uneven sex ratio in dyslexia. In the present model, the cause of reading impairment has been shifted away from the thalamus to the cortical anomalies. In this view, the sex-ratio of dyslexia has little to do with fetal hormones, but is tightly related to possible sex differences in cortical anomalies. It turns out that the female dyslexic brains that were dissected showed fewer ectopias than male ones, and were characterized instead by a large number of small myelinated glial scars (Humphreys, Kaufmann, and Galaburda 1990). This may imply that females are less likely to have a phonological deficit, and that the deficit will be less severe on average in females, or alternatively that females require more severe neuropathology in order to exhibit behavioral problems, thereby explaining the uneven sex-ratio. But the exact functional significance of these differences in cortical anomalies is unknown, so it is at present impossible to predict the theoretical sex ratio of the phonological deficit. However, because of the hormonal mediation leading to the thalamic disruption, the model does predict an increased prevalence of the sensorimotor syndrome in males. More precisely, irrespective of the actual male/female ratio in dyslexia, it predicts that this ratio will be increased in the subpopulation with a sensorimotor syndrome, as compared to the subpopulation without it. And it predicts just the same for the sensorimotor syndrome in other developmental disorders. Such predictions could be easily tested by carrying out post-hoc analyses on already existing data sets including reliable individual data on sensory and/or motor measures. Unfortunately, only major longitudinal studies including all the relevant measures will be able to test this prediction. In the meantime, one may want to look for markers of foetal hormonal conditions that would still be measurable in the child or even in the adult. One such marker has been proposed: the ratio between the length of the second digit and that of the fourth digit (2D:4D ratio) would be inversely correlated to foetal testosterone levels (Manning et al. Furthermore, a recent study replicated this result and found that within a group of autistic-spectrum disorder children, the 2D:4D ratio was correlated with their performance in coherent motion detection and in manual dexterity (Milne et al. Obviously, such results are to be taken with caution considering the very indirect relationship between the two measures. Their interpretation may be further complicated by the fact that, as was evoked earlier, the determining hormonal conditions might not be simply a matter of testosterone concentration. This is indeed confirmed by studies of autoimmune mice that spontaneously develop ectopias (Sherman et al. Furthermore, unless total cross-heritability across different disorders is shown, the model also predicts that the precise location of cortical anomalies is under genetic control. This is consistent with the fact that different strains of mutant mice have ectopias in different locations (Denenberg et al. On the other hand, f tal hormonal conditions may be partly genetically determined, but are also more likely to be influenced by external factors. The model therefore predicts a lower heritability of the sensorimotor syndrome than of specific cognitive deficits. The possibility that some cases of sensorimotor dysfunction are due to genetically-determined cortical anomalies in visual, auditory or motor cortex, or in the cerebellum, may attenuate this prediction. It is also notable that all the specific cognitive disorders under consideration here have a complex genetic etiology involving several regions on different chromosomes. In the light of the present model, one way to understand the relationship between complex genetic etiology and specific cognitive deficit is to speculate that in dyslexia and other specific disorders, certain genes are general risk factors for the occurrence of focal anomalies like ectopias, while other genes influence the precise location of such anomalies, for instance by generating molecular gradients interacting with ectopia risk factors. Yet other genes might be risk factors for the hormonal conditions leading to the sensorimotor syndrome. These hypotheses broadly predict that the genes implicated in all these specific cognitive disorders will be partly shared (those acting as general risk factors for cortical anomalies), and partly specific to each disorder (those influencing brain localization).

With only the anterior portion of the muscle con tracted order generic questran on line, it rotates the unsupporting leg medially; with only the posterior portion contracted purchase questran 4gm free shipping, it rotates the unsupporting leg laterally and extends it slightly purchase discount questran on-line. Con traction on the side of the supporting leg causes stabilization of the pelvis. Trigger Points of the Gluteus Minimus Muscle Preliminary Remarks these trigger points develop quite frequently in combination with those of the gluteus medius. Examination of Trigger Points the gluteus minimus muscle can only be palpated when the gluteus medius muscle is relaxed; the origin of the glu teus medius is further proximal and su perficial. With the patient in the lateral position, palpation is performed with the hip joint flexed by 90� and abducted. Therapy of Trigger Points Aswiththegluteusmediusmuscle, direct methods such as intramuscular stimula tion by dry-needling are very effective, when followed by passive stretching with the hip joint flexed and abducted by 90�. It leads to radiation of pain into the posterior gluteal region or along the iliotibial tract across the knee down to the lateral ankle. Gluteus Minimus Muscle, Trigger Point 2 this trigger point lies in the medial or posterior portion of the muscle. It leads to radiation of pain into the posterior gluteal region and posterolateral thigh down to the posterolateral calf, approxi mately at the level of the lateral head of the gastrocnemius muscle. Miscellaneous: In case of early division of the sciatic nerve, the common fibular nerve passes across the piriformis muscle and can be constricted here (piriformis syndrome). Trigger Points of the Piriformis Muscle Preliminary Remarks the two trigger points of the piriformis muscle are often associated with chronic pain in the region of the loin, pelvis, and hip. They are activated by chronic dis orders of the lumbosacral transition but only rarely as a reaction to acute strain. In cases where the muscle is shortened, en Examination of Trigger Points trapment of the sciatic nerve (especially of the peroneal portion) takes place in ap Activation of trigger points is achieved by proximately 10% of cases due to the aber adducting the hip joint when flexed at rant course of the muscle; this should be 90� and simultaneously counter-rotating considered in the differential diagnosis. Active associated trigger points of the in With the patient lying on his/her ferior and superior gemellus muscles and stomach, the piriformis muscle can be of the obturator internus muscle appear grasped by careful deep palpation be regularly, as do those of the gluteus me tween dorsal trochanter and sacrum. Therapy of Trigger Points Inactivation is possible by conventional acupuncture and dry-needling, and also by therapeutic local anesthesia. Passive stretching supported by postisometric re laxation decisively contributes to the success of treatment. By con trast, trigger point 2 lies close to the origin and has its projection area at the 11 caudal pole of the sacroiliac joint. Both 2 22 points share a common area of radiation over and beyond the buttocks into the dorsal thigh. Structure of the female reproductive system: � the vagina: It is the canal between the uterus and the external reproductive organs. Through them, the eggs travel from the ovaries to the uterus, and inside them, the egg meets the sperm (fertilization). Then, the fertilized egg travels through the tubes to the uterus where it can stick to the uterine wall and form an embryo. Menstrual cycle: � A menstrual cycle consists of natural changes that occur in a woman�s body every month in preparation for pregnancy. The first day of a cycle is the first day of a menstrual period and the last day is that of the following period. First menstrual period: the menstrual cycle often begins at puberty between the ages of 8 and 15 (average age of 12). Phases of the menstrual cycle: There are four phases: menstruation, the follicular phase, ovulation and the luteal phase. It usually lasts three to seven days but this could change to more or less days from month to month and depending on each woman. During this phase the pituitary gland (situated at the base of the brain) releases a follicle (cyst) stimulating hormone. This hormone produces 10 to 20 follicles in the ovary and each follicle houses an immature egg. These follicles produce the hormone estrogen, which in turn thickens the lining of the endometrium in preparation to receive a fertilized egg.

References:

• https://www.gao.gov/assets/680/675544.pdf
• https://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/Practice%20and%20Parameters/Anaphylaxis-Practice-Parameter-2014.pdf
• http://samples.jbpub.com/9781284038798/9781449691301_CH01.pdf