A PRACTICAL APPROACH TO FIBROMYALGIA – part 1

Fibromyalgia is the name given to a collection of symptoms with no clear physiologic cause. The constellation of symptoms are clearly recognizable as a distinct pathologic entity. The diagnosis is made through clinical observations made by the examiner. Differential diagnosis must include other somatic syndromes as well as disease entities like hepatitis, hypothyroidism, diabetes mellitus, electrolyte imbalance, multiple sclerosis, and cancer. Diagnostic criteria are given as guidelines for the diagnosis, not as absolute requirements. Treatment of this condition remains individualized and relies heavily on having a therapeutic relationship with a provider. Treatment of this syndrome needs to be looked at as an ongoing process. Goal oriented treatment aimed at maintaining specific functions can be directed at helping a patient get restorative sleep, alleviating the somatic pains that ail the patient, keeping a person productive, regulating schedules or through goal oriented agreements made with the patient. Since this syndrome is chronic and may effect all areas of a persons functioning the family and social support system of the person being treated need to be evaluated. Patients often seek alternative medical treatments for this problem including diet therapy, acupuncture, and herbal therapy. Treatment must involve more than just the symptoms presented and the patient can only be treated successfully if they are willing to work at changing their own perceptions, and ways of relating to stressors in their world. Omnicef 125 5 mg/ML

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Current treatment options for ED in the cardiovascular patient

Currendy, the range of therapy for managing ED in the general population includes oral PDE-5 inhibitors such as sildenafil citrate, sublingual apomorphine, intracavernosal injection or transurethral alprostadil, vacuum constriction devices and penile implants. However, in cardiac patients on warfarin, injections and vacuum devices are not indicated because of increased risk of haematoma or bleeding

Figure 1A. Mechanism of action of sildenafil NO(S)=nitric oxide (synthase), GC=guanyl cyclase, GTP=guanosine triphosphate, cGMP=cyclic guanosine monophosphate, PDG=phophodiesterase enzymes.

Figure IB. Mechanism of action of concurrent use of sildenafil and nitrates. NO=nitric oxide, GC-guanyl cyclase, GTP=guanosine triphosphate, cGMP=cyclic guanosine monophosphate.

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Patients with cardiovascular disease and assessment for the treatment of ED

All patients with ED should undergo adequate medical assessment. It is important to establish a baseline measure of the type of activities and level of physical exertion a patient normally undertakes. The risk of a cardiac event in a patient with cardiovascular disease is higher than in a patient without cardiovascular disease; therefore, cardiovascular risk assessment should focus on the risk of further cardiovascular events at a return to sexual activity. Cardiovascular status has been split into three categories defining patients at low, intermediate or high risk. A practical framework for assessing the potential level of cardiovascular risk following a return to sexual activity is shown in table 3. Most of the patients with low or intermediate risk can be managed in primary care; otherwise exercise testing can guide management when cardiovascular risk is in doubt. If a patient can perform stage I of the Bruce protocol without significant ST-segment changes, arrhythmia or drop in systolic blood pressure, the patient is not at risk during normal sexual activity. Patients falling into the high-risk category should be evaluated and treated by their cardiologist before instituting treatment for ED. Buy Cialis Soft Tabs

Cardiovascular drug-induced ED

There are a number of drugs that are suspected of contributing to ED in cardiovascular patients. Reports have indicated an incidence range of 5 to 43% with propranolol and 4 to 32% with thiazide diuretics. There is not much evidence to confirm the effectiveness of changing drug therapy to reverse ED. However, if a relation in time exists between the start of therapy and onset of symptoms it is conceivable to stop or safely change medication and evaluate the effect on improvement of ED after two to four weeks. However, physicians should realise that the development of ED might be due to the condition being treated, rather than the drugs used.

Sexual health inventory for men

Table 2. Sexual health inventory for men.

Patient’s name:__________________________________
Date of evaluation:_______________________________
Sexual health is an important part of an individual’s overall physical and emotional well-being. Erectile dysfunction, also known as impotence, is one of the very common medical conditions affecting sexual health. Fortunately, there are many different treatment options for erectile dysfunction. This questionnaire is designed to help you and your doctor identify if you may be experiencing erectile dysfunction. If you are, you may choose to discuss treatment options with your doctor. canadian pharmacy online

Each question has several possible responses. Circle the number of the response that best describes your own situation. Please be sure that you select one and only one response for each question. cheap pharmacy

Over the past 6 months:

1. How do you rate your confidence that you could get and keep an erection?

- Very low = 1
- Low = 2
- Moderate = 3
- High = 4
- Very high = 5

2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?

- No sexual activity = 0
- Almost never or never = 1
- A few times (much less than half the time) = 2
- Sometimes (about half the time) = 3
- Most times (much more than half the time) = 4
- Almost always or always = 5

3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?

- Did not attempt intercourse = 0
- Almost never or never = 1
- A few times (much less than half the time) = 2
- Sometimes (about half the time) = 3
- Most times (much more than half the time) = 4
- Almost always of always = 5

4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?

- Did not attempt intercourse = 0
- Extremely difficult = 1
- Very difficult = 2
- Difficult = 3
- Slightly difficult = 4
- Not difficult = 5

5. When you attempted sexual intercourse, how often was it satisfactory for you?

- Did not attempt intercourse = 0
- Almost never of never = 1
- A few times (much less than half the time) = 2
- Sometimes (about half the time) = 3
- Most times (much more than half the time) = 4
- Almost always of always = 5

Add the numbers corresponding to questions 1-5. If your score is 21 or less, you may be showing signs of erectile dysfunction and may want to speak with your doctor. Visit canadian online pharmacy

Score:_________________

Recognition of ED by the cardiologist

Sexual function is widely considered to be of importance in quality of life. This function is frequently altered in patients with coronary artery disease. As mentioned earlier, ED may be among the first manifestations of disease because the erectile function heavily depends on both the arterial system perfusing the penis as well as on the delicate endothelial system within the smooth musculature of the cavernous bodies. Because the arterial system must enlarge considerably in diameter to enable penile tumescence, these vessels may be more sensitive to atherosclerotic occlusion than the coronary circulation or other vasculature. The assessment of erectile status may indeed give clues to clinically silent yet progressive coronary, peripheral or cerebrovascular disease as well as to underdiagnosed hypertension, diabetes, or other endocrine disorders. Patients with multivessel coronary disease may have greater difficulty achieving an erection than those with single-vessel disease. On top of the intrinsic effects of cardiovascular disease, drugs used to treat heart disease such as p-blocking agents and thiazide diuretics have been associated with the development of ED. Omnicef antibiotics

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Erectile dysfunction equivalent to endothelial dysfunction?

The discovery of nitric oxide with its regulating properties of vascular tone played a pivotal role in the understanding of vascular physiology and opened unprecedented avenues for research in the development of many cardiovascular drugs. Nitric oxide released by vascular endothelial cells induces smooth muscle cell relaxation and inhibits vascular smooth muscle proliferation. Nitric oxide exerts many of its effects by activation of soluble guanyl cyclase, resulting in increased production of cyclic guanosine monophosphate (cGMP), which results in lower intracellular calcium levels and therefore, vasodilatation. Nitric oxide is widely recognised as the most important factor involved in corpus cavernosal smooth muscle relaxation, and hence in erection. A correlation between erectile dysfunction and endothelial dysfunction in type II diabetic men is established, involving a defective nitric oxide activity, linked to reduced nitric oxide availability. canadian online pharmacy

The concentration of intracellular cGMP is regulated by the rates of production and elimination of cGMP. The rate of production is controlled through the nitric oxide-guanyl cyclase activity. The rate of elimination depends on the activity of phophodiesterase enzymes (PDE) responsible for the breakdown of cyclic nucleotides cAMP and cGMP. Four phosphodiesterase isoforms have been identified in human penile tissue (types 2, 3, 4, and 5); PDE-5 is the most important form of PDE in cavernosal smooth muscle. Inhibition of this enzyme by a PDE-5 inhibitor such as sildenafil (Viagra) enhances nitric oxide-induced vasorelaxation by increasing vascular smooth muscle cGMP concentration. Generic Sildenafil has been shown to be an effective oral treatment for erectile dysfunction in men, including men with diabetes. In a brachial artery flow-mediated dilatation study (FMD, a marker of endothelial function), the favourable short- and long-term effect of sildenafil on FMD was recendy demonstrated. The beneficial effect of prolonged cheap sildenafil therapy may have implications for management of erectile dysfunction as well as cardiovascular disease, especially in patients with diabetes. Just recently Halcox et al. studied the effects of the phophodiesterase inhibitor sildenafil on coronary and peripheral vascular function, platelet activation, and myocardial ischaemia. The authors concluded that sildenafil dilates epicardial coronary arteries, improves endothelial dysfunction and inhibits platelet activation in patients with coronary artery disease.  Read the rest of this entry »