Diltiazem

By J. Rozhov. Carnegie Mellon University. 2018.

If ejaculation is not possible during penetrative sexual intercourse 60mg diltiazem free shipping, it may be induced by direct stimulation of the fraenum of the penis by masturbation or by using a vibrator cheap diltiazem 180 mg mastercard. If this is unsuccessful, rectal electroejaculation may produce what is actually an emission. In men who cannot ejaculate using the vibrator, or where electroejaculation is difficult, a hypogastric plexus stimulator can be implanted to obtain seminal emission, using a single Figure 13. Men with lesions above T6 are at courtesy of Professor SWJ Seager, Washington DC, USA. If this occurs activity should be curtailed, the man sat upright, and if necessary given sublingual nifedipine. For erection: • Oral sildenafil • Intracavernosal drugs Preparation for sexual intercourse • Vacuum erection aid and compressive retainer ring • Penile implant (small risk of infection or extrusion) Preparation for sexual intercourse includes ensuring that the • Sacral anterior root stimulator bladder is as empty as possible. A man with an indwelling For ejaculation or seminal emission: catheter should preferably remove it, but it may be strapped • Vibrator back on to the shaft of the penis. The able-bodied partner tends to be the more • Hypogastric plexus stimulator active, and this has a bearing on the positions used for To collect spermatozoa: intercourse. The quality of the (possible in men during ejaculation, and in women during labour, if seminal fluid may improve with repeated ejaculations, however, lesion above T6) and successful insemination has been reported both with the • Sublingual nifedipine or vibrator and by electroejaculation. It is essential to obtain • Glyceryl trinitrate (potentially fatal interaction with sildenafil) microbiological cultures of the seminal fluid and to eradicate 68 Later management and complications—I any infection prior to proceeding with any attempt at Box 13. The success rate has recently improved with the use of assisted conception techniques, including enhancement • If lesion complete above T10, labour may be painless, therefore of seminal fluid, intrauterine insemination, and assisted admit to hospital early, before labour commences reproductive technology, such as in vitro fertilisation (IVF) and • Increased risk of assisted delivery because of paralysis of intracytoplasmic sperm injection (ICSI). Autonomic dysreflexia during labour is a risk in patients with lesions at T6 and above, but this complication can be prevented by epidural anaesthesia. Fulfilment in relationships It should be emphasised that emotional and psychological factors are as important as physical factors in a satisfying relationship and that such a relationship is possible even after severe spinal cord injury. This needs reiterating, particularly to young men who are otherwise apt to see their altered sexual function as a profound loss. Although sensation in the sexual organs may be reduced or absent, imaginative use can be made of touching and caressing, as areas of the body above the level of the spinal cord lesion may develop heightened sensation as erogenous zones. Some couples find that the extra time and effort required for sexual expression after one of them has suffered a spinal cord injury enriches their lives and results in a more understanding and caring relationship. Transrectal electroejaculation combined with in-vitro fertilization: effective treatment of anejaculatory infertility due to spinal cord injury. Human Reproduction 1997;12:2687–92 • Cross LL, Meythaler JM, Tuel SM, Cross AL. Sexual problems associated with spinal and may develop heightened sensation cord disease. Spinal • Extra time and effort required can result in more understanding cord disease—diagnosis and management. New York: Marcel and caring relationship Dekker, 1998, chap 28 69 14 Later management and complications—II David Grundy, Anthony Tromans, John Hobby, Nigel North, Ian Swain Later respiratory management of high tetraplegia Box 14. Modern portable ventilators that use a 12-volt battery can be mounted on a wheelchair, allowing the patient a degree of freedom and independence. Speech is possible with an uncuffed tracheostomy tube around which air can escape to the larynx. In a small number of these patients the anterior horn cells of the phrenic nerve are spared and it may be possible to implant a phrenic nerve stimulator to achieve ventilation. The advantages of electrophrenic respiration are that it is more physiological than positive pressure ventilation and it gives the patient more freedom, the equipment being much lighter than a mechanical ventilator. The long-term ventilator-dependent patient needs • Mechanical “domiciliary” ventilation 24-hour care by a team of carers competent to undertake Advantages of electrophrenic respiration endotracheal suction, but not necessarily including a • More physiological than positive pressure ventilation qualified nurse. It may be further complicated by the enforced period of bed rest during which a state of sensory deprivation ensues. The frustrations associated with the physical Acute stage: limitations of such a severe injury are compounded by the fact • Initial stress reaction that most patients are young and before injury led active lives, • Sensory deprivation often expressing themselves mainly through physical activities. Later stages: The sudden inability to continue in this manner and the need • Anxiety and depression to lead a more ordered life can mean a very difficult and • Post-traumatic stress disorder prolonged period of adjustment. Failure to recognise that this • Cognitive problems process can continue for as long as two or three years may • Detecting psychological problems damage the process of rehabilitation and the patient’s ultimate • Appropriate referral • Family resettlement. The patient needs time to come to terms with his • Psychological support and therapy or her new status and to make decisions about the future without undue pressure.

HOW TO CONDUCT FOCUS GROUPS/ 79 TABLE 8: STRATEGIES FOR DEALING WITH AWKWARD SITUATIONS SITUATION STRATEGY Break-away Say: ‘I’m sorry 60mg diltiazem for sale, would you mind rejoining the group as this conversations is really interesting? Dominance First of all stop making eye-contact and look at other people expectantly 60mg diltiazem otc. If, however, leadership tendencies aren’t immediately obvious, but manifest themselves during the discussion, try to deal with them as with ‘dominance’, above. If this still fails, as a last resort you might have to be blunt: ‘Can you let others express their opinions as I need to get as wide a variety as possible? The other members were happy to do this as they were free to express themselves and their opinions were quite different from those of their self-appointed ‘leader’. Disruption by On rare occasions I have come across individuals whowant participants to disrupt the discussion as much as possible. They will do this in a number of ways, from laughing to getting up and walking around. I try to overcome these from the start by discussing and reaching an agreement on how participants should behave. Usually I will find that if someone does become disruptive, I can ask them to adhere to what we all agreed at the beginning. Sometimes, the other participants will ask them to behave which often has a greater influence. Defensiveness Make sure that nobody has been forced to attend and that they have all come by their own free will. Be empathetic – understand what questions or topics could upset people and make them defensive. Try to avoid these if possible, or leave them until the end of the discussion when people are more relaxed. These facilities can be hired at a price which, unfortunately, tends to be beyond the budgets of most stu- dents and community groups. Your local college or university might have a room which can be set up with video recording equipment and the in- stitution may provide an experienced person to operate the machinery. If your institution doesn’t provide this fa- cility, think about whether you actually need to video your focus group as the more equipment you use, the more po- tential there is for things to go wrong. Most social re- searchers find that a tape recording of the discussion supplemented by a few handwritten notes is adequate (see Chapter 7 for further discussion on different methods of recording). Ideally, it needs to be small and unobtru- sive with an inbuilt microphone and a battery indicator light so that you can check it is still working throughout the discussion, without drawing attention to the machine. A self-turning facility is useful as you get twice as much recording without having to turn over the tape. The recorder should be placed on a non-vibratory surface at equal distance from each participant so that every voice can be heard. Before the participants arrive, place it in the HOW TO CONDUCT FOCUS GROUPS/ 81 centre of the room and test your voice from each seat, varying your pitch and tone. Participants in focus groups tend to speak quietly at the beginning, but once they be- gin to relax, they tend to raise their voices. Be aware of any noise which could disrupt the recorder, such as tick- ing clocks or traffic outside. CHOOSING A VENUE It is extremely important to make sure you choose the right venue for your focus group as this will affect parti- cipation levels, the level of discussion and the standard of recording. You should ask yourself the following ques- tions when considering a venue: X Is the venue accessible in terms of physical access for those with mobility difficulties? X Is it accessible in terms of ‘mental’ access, that is, would the type of people you intend to recruit feel comfortable entering that building? X Is the room big enough to accommodate the number of people you intend to recruit? X Is there anything which could distract the participants (loud noises, telephones, doorbells, people entering the room, people walking past windows, etc)? Once you have chosen your venue, you need to arrive early to make sure that the seating is arranged in an appropri- ate manner. There is no set rule for this – think about your participants and arrange it accordingly. For exam- ple, business people might prefer a boardroom style seat- ing arrangement, whereas adult learners may prefer an informal seminar style arrangement. RECRUITING YOUR PARTICIPANTS Without participants you have no focus group.

Earlier surgical intervention may provoke further new bone formation 60 mg diltiazem mastercard, thus compounding the original condition diltiazem 180mg on-line. Treatment with disodium etidronate suppresses the mineralisation of osteoid tissue and may reverse up to half of early lesions when used for 3–6 months, and non-steroidal anti-inflammatory drugs are also used to prevent the progression of this complication. Postoperative radiotherapy may halt the recurrence of the problem if early surgical Box 6. It usually increases in severity during the first few weeks after injury, after the period of spinal shock. In incomplete lesions it is often more pronounced and can be severe enough to prevent patients with good power in the legs from walking. Patients with severe spasticity and imbalance of opposing muscle groups have a tendency to develop contractures. It is important to realise that once a contracture occurs spasticity is increased and a vicious circle is established with further deformity resulting. It maintains muscle • Improve comfort/posture bulk and possibly bone density, and improves venous return. An irritative lesion in —tizanidine the paralysed part, such as a pressure sore, urinary tract —dantrolene infection or calculus, anal fissure, infected ingrowing toenail, or —diazepam fracture, tends to increase spasticity. With these drugs, • intrathecal block (rarely used)—6% aqueous phenol the liver function tests need to be closely monitored. For example, in patients with severe hip adductor spasticity obturator neurectomy is effective. Alternatively, motor point injections, initially with bupivacaine, followed by either 6% aqueous phenol or 45% ethyl alcohol for 30 Medical management in the spinal injuries unit a more lasting effect, are useful in selected patients. Botulinum toxin also has a limited use in patients with localised spasticity. If oral agents are failing to control generalised spasticity intrathecal baclofen will often provide relief. If a small test dose of 50micrograms baclofen given by lumbar puncture relieves the spasticity, a reservoir and pump can be implanted to provide regular and long-term delivery of the drug. It is now rare to have to resort to destructive procedures involving surgical or chemical neurectomy, or intrathecal blocks with 6% aqueous phenol or absolute alcohol. The effect of phenol usually lasts a few months, that of alcohol is permanent. The main disadvantage in the use of either is that they convert an upper motor neurone to a lower motor neurone lesion and thus affect bladder, bowel, and sexual function. The central fill port is used for the administration of intrathecal baclofen, and the side catheter access A contracture may be a result of immobilisation, spasticity, or port is used for direct intrathecal access of other drugs or contrast, muscle imbalance between opposing muscle groups. If these measures fail to correct the deformity or are inappropriate, then surgical correction by tenotomy, tendon lengthening, or muscle division may be required. For example, a flexion contracture of the hip responds to an iliopsoas myotomy with division of the anterior capsule and soft tissues over the front of the joint. They • Muscle and soft tissue division may affect not only the skin but also subcutaneous fat, muscle, and deeper structures. The commonest sites are over the ischial tuberosity, greater trochanter, and sacrum. Pressure sores are a major cause of readmission to hospital, yet they are generally preventable by vigilance and recognition of simple principles. The cushion should be selected for the individual • Suitable cushion and mattress, checked regularly patient after measuring the interface pressures between the • Avoid tight clothes and hard seams ischial tuberosities and the cushion. Shearing forces to the skin from underlying structures are avoided by correct lifting; the skin should never be dragged along supporting surfaces. Patients must not lie for long periods with the skin unprotected on x ray diagnostic units or on operating tables (in this situation Roho mattress sections placed under the patient are of benefit). A pressure clinic is extremely useful in checking the sitting posture, assessing the wheelchair and cushion, and generally instilling pressure consciousness into patients.