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C. Fadi. Institute of Paper Science and Technology.

In other tissues buy 20mg cialis soft amex erectile dysfunction pump implant, stretching in several directions is achieved by alternating layers where fibers run in the same orientation in each layer 20mg cialis soft with amex erectile dysfunction what to do, and it is the layers themselves that are stacked at an angle. Dense irregular elastic tissues give arterial walls the strength and the ability to regain original shape after stretching (Figure 4. As you toss the ball high in the air, a burning pain shoots across your wrist and you drop the tennis racket. After examining your swollen wrist, the doctor in the emergency room announces that you have developed wrist tendinitis. She recommends icing the tender area, taking non-steroidal anti-inflammatory medication to ease the pain and to reduce swelling, and complete rest for a few weeks. She issues a stern warning about the risk of aggravating the condition and the possibility of surgery. She consoles you by mentioning that well known tennis players such as Venus and Serena Williams and Rafael Nadal have also suffered from tendinitis related injuries. Tendinitis is the inflammation of a tendon, the thick band of fibrous connective tissue that attaches a muscle to a bone. Most often, the condition results from repetitive motions over time that strain the tendons needed to perform the tasks. Persons whose jobs and hobbies involve performing the same movements over and over again are often at the greatest risk of tendinitis. While older adults are at risk for tendinitis because the elasticity of tendon tissue decreases with age, active people of all ages can develop tendinitis. Young athletes, dancers, and computer operators; anyone who performs the same movements constantly is at risk for tendinitis. Although repetitive motions are unavoidable in many activities and may lead to tendinitis, precautions can be taken that can lessen the probability of developing tendinitis. For active individuals, stretches before exercising and cross training or changing exercises are recommended. All of the preventive measures aim to increase the strength of the tendon and decrease the stress put on it. With proper rest and managed care, you will be back on the court to hit that slice-spin serve over the net. Supportive Connective Tissues Two major forms of supportive connective tissue, cartilage and bone, allow the body to maintain its posture and protect internal organs. Embedded within the cartilage matrix are chondrocytes, or cartilage cells, and the space they occupy are called lacunae (singular = lacuna). Cartilaginous tissue is avascular, thus all nutrients need to diffuse through the matrix to reach the chondrocytes. The three main types of cartilage tissue are hyaline cartilage, fibrocartilage, and elastic cartilage (Figure 4. Hyaline cartilage, the most common type of cartilage in the body, consists of short and dispersed collagen fibers and contains large amounts of proteoglycans. Both strong and flexible, it is found in the rib cage and nose and covers bones where they meet to form moveable joints. Bone’s rigid extracellular matrix contains mostly collagen fibers embedded in a mineralized ground substance containing hydroxyapatite, a form of calcium phosphate. The histology of transverse tissue from long bone shows a typical arrangement of osteocytes in concentric circles around a central canal. Cancellous bone looks like a sponge under the microscope and contains empty spaces between trabeculae, or arches of bone proper. The formed elements circulating in blood are all derived from hematopoietic stem cells located in bone marrow (Figure 4. Leukocytes, white blood cells, are responsible for defending against potentially harmful microorganisms or molecules. Some white blood cells have the ability to cross the endothelial layer that lines blood vessels and enter adjacent tissues. Lymphatic capillaries are extremely permeable, allowing larger molecules and excess fluid from interstitial spaces to enter the lymphatic vessels. Lymph drains into blood vessels, delivering molecules to the blood that could not otherwise directly enter the bloodstream. In this way, specialized lymphatic capillaries transport absorbed fats away from the intestine and deliver these molecules to the blood. When attached between two movable objects, in other words, bones, contractions of the muscles cause the bones to move. Other movements are involuntary, meaning they are not under conscious control, such as the contraction of your pupil in bright light. Muscle tissue is classified into three types according to structure and function: skeletal, cardiac, and smooth (Table 4. Comparison of Structure and Properties of Muscle Tissue Types Tissue Histology Function Location Long cylindrical fiber, Attached to bones and striated, many Voluntary movement, produces heat, protects around entrance points Skeletal peripherally located organs to body (e. Skeletal muscles generate heat as a byproduct of their contraction and thus participate in thermal homeostasis. Shivering is an involuntary contraction of skeletal muscles in response to perceived lower than normal body temperature. Under the light microscope, muscle cells appear striated with many nuclei squeezed along the membranes. The striation is due to the regular alternation of the contractile proteins actin and myosin, along with the structural proteins that couple the contractile proteins to connective tissues. The cells are multinucleated as a result of the fusion of the many myoblasts that fuse to form each long muscle fiber. Unlike skeletal muscle fibers, cardiomyocytes are single cells typically with a single centrally located nucleus. A principal characteristic of cardiomyocytes is that they contract on their own intrinsic rhythms without any external stimulation. Attached cells form long, branching cardiac muscle fibers that are, essentially, a mechanical and electrochemical syncytium allowing the cells to synchronize their actions. The attachment junctions hold adjacent cells together across the dynamic pressures changes of the cardiac cycle. It forms the contractile component of the digestive, urinary, and reproductive systems as well as the airways and arteries. Neurons propagate information via electrochemical impulses, called action potentials, which are biochemically linked to the release of chemical signals. Neurons display distinctive morphology, well suited to their role as conducting cells, with three main parts. A long “tail,” the axon, extends from the neuron body and can be wrapped in an insulating layer known as myelin, which is formed by accessory cells. The synapse is the gap between nerve cells, or between a nerve cell and its target, for example, a muscle or a gland, across which the impulse is transmitted by chemical compounds known as neurotransmitters. Bipolar neurons possess a single dendrite and axon with the cell body, while unipolar neurons have only a single process extending out from the cell body, which divides into a functional dendrite and into a functional axon. When a neuron is sufficiently stimulated, it generates an action potential that propagates down the axon towards the synapse.

Cerebral or spinal arteriovenous malformations occur in some families and may cause subarachnoid hemorrhage purchase cheap cialis soft on-line can erectile dysfunction cause low sperm count, seizures discount 20 mg cialis soft overnight delivery erectile dysfunction fertility treatment, or paraplegia. Biopsy of an acute skin lesion reveals an aseptic vasculitis with fibrinoid necrosis of vessel walls and perivascular cuffing of vessels with polymorphonuclear leukocytes. Granular deposits of immunoglobulin reactive for IgA and of complement components may be seen on immunofluorescent study. Therefore, deposition of IgA-containing immune complexes with consequent activation of complement is 374 Hematology thought to represent the pathogenetic mechanism for the vasculitis. The disease begins with the sudden appearance of a purpuric skin rash that typically involves the extensor surfaces of the feet, legs, and arms and a strip across the buttocks. Most patients also have fever and polyarthralgia with associated periarticular tenderness and swelling of the ankles, knees, hips, wrists, and elbows. The disease usually remits after about 4 wk but often recurs at least once after a disease-free interval of several weeks. In most patients, the disorder subsides without serious sequelae; however, some patients develop chronic renal failure. The presence of diffuse glomerular involvement or of crescentic changes in most glomeruli predicts progressive renal failure. Vascular Purpura Caused By Dysproteinemias Hypergammaglobulinemic purpura is a syndrome that primarily affects women. It is characterized by a polyclonal increase in IgG (broad-based or diffuse hypergammaglobulinemia on serum protein electrophoresis) and recurrent crops of small, palpable purpuric lesions on the lower legs. Cryoglobulinemia is characterized by the presence of immunoglobulins that precipitate when plasma is cooled (ie, cryoglobulins) while flowing through the skin and subcutaneous tissues of the extremities. In amyloidosis, deposits of amyloid within vessels in the skin and subcutaneous tissues produce increased vascular fragility and purpura. Periorbital purpura or a purpuric rash that develops in a nonthrombocytopenic patient after gentle stroking of the skin should arouse suspicion of amyloidosis. In some patients a coagulation disorder develops, apparently the result of adsorption of factor X by amyloid. Leukocytoclastic Vasculitis A necrotizing vasculitis accompanied by extravasation and fragmentation of granulocytes. Causes include hypersensitivity to drugs, viral infections (eg, hepatitis), and collagen vascular disorders. The most common clinical manifestation is palpable purpura, often associated with systemic symptoms, such as polyarthralgia and fever. Autoerythrocyte Sensitization (Gardner-Diamond Syndrome) An uncommon disorder of women, characterized by local pain and burning preceding painful ecchymoses that occur primarily on the extremities. However, most patients also have associated severe psychoneurotic symptoms, and psychogenic factors, such as self-induced purpura, seem related to the pathogenesis of the syndrome in some patients. Platelet disorders Platelet disorders may cause defective formation of hemostatic plugs and bleeding because of decreased platelet numbers (thrombocytopenia) or because of decreased function despite adequate platelet numbers (platelet dysfunction). Thrombocytopenia Thrombocytopenia is quantity of platelets below the normal range of 140,000 to 440,000/µL. Thrombocytopenia may stem from failed platelet production, splenic sequestration of platelets, increased platelet destruction or use, or dilution of platelets. However, thrombocytopenia does not cause massive bleeding into tissues (eg, deep visceral hematomas or hemarthroses), which is characteristic of bleeding secondary to coagulation disorders. Idiopathic (immunologic) thrombocytopenic purpura A hemorrhagic disorder not associated with a systemic disease, which is typically chronic in adults but is usually acute and self-limited in children. These patients may respond to glucocorticoids, which are often not given unless the platelet count falls below 30,000/µL because these drugs may further depress immune function. However, gold- induced thrombocytopenia is an exception because injected gold salts may persist in the body for many weeks. Heparin-Induced Thrombocytopenia Heparin-induced thrombocytopenia, the most important thrombocytopenia resulting from drug-related antibodies, occurs in up to 5% of patients receiving bovine heparin and in 1% of those receiving porcine heparin. The thrombocytopenia results from the binding of heparin-antibody complexes to Fc receptors on the platelet surface membrane. Platelet factor 4, a cationic and strongly heparin-binding protein secreted from 381 Hematology platelet alpha granules, may localize heparin on platelet and endothelial cell surfaces. Because clinical trials have demonstrated that 5 days of heparin therapy are sufficient to treat venous thrombosis and because most patients begin oral anticoagulants simultaneously with heparin, heparin can usually be stopped safely. Nonimmunologic thrombocytopenia Thrombocytopenia secondary to platelet sequestration can occur in various disorders that produce splenomegaly. In contrast to immunologic thrombocytopenias, the platelet count usually does not fall below about 30,000/ µL unless the disorder producing the splenomegaly also impairs the marrow production of platelets (eg, in myelofibrosis with myeloid metaplasia). In addition, functional platelets are released from the spleen by an epinephrine 382 Hematology infusion and therefore may be available at a time of stress. Splenectomy will correct the thrombocytopenia, but it is not indicated unless repeated platelet transfusions are required. The thrombocytopenia has multiple causes: disseminated intravascular coagulation, formation of immune complexes that can associate with platelets, activation of complement, and deposition of platelets on damaged endothelial surfaces. Patients with adult respiratory distress syndrome also may become thrombocytopenic, possibly secondary to deposition of platelets in the pulmonary capillary bed. Platelet consumption within multiple small thrombi also 383 Hematology contributes to the thrombocytopenia. Platelet Dysfunction In some disorders, the platelets may be normal in number, yet hemostatic plugs do not form normally and the bleeding time will be long. Platelet dysfunction may stem from an intrinsic platelet defect or from an extrinsic factor that alters the function of otherwise normal platelets. Hereditary disorders of platelet function The most common hereditary intrinsic platelet disorders are a group of mild bleeding disorders that may be considered disorders of amplification of platelet activation. Thrombasthenia is a rare hereditary platelet defect that affects platelet surface membrane glycoproteins. Thrombasthenia patients may have severe mucosal bleeding (eg, nosebleeds that stop only after nasal packing and transfusions of platelet concentrates). Bernard-Soulier syndrome is another rare autosomal recessive disorder that affects surface membrane glycoproteins. Acquired platelet dysfunction Acquired abnormalities of platelet function are very common because use of aspirin, which predictably affects platelet function, is ubiquitous. Aspirin, which modestly prolongs the bleeding time in many healthy persons, may markedly increase the bleeding time in patients with an underlying platelet dysfunction or who have a severe coagulation disturbance (eg, patients who have been given therapeutic heparin or those with severe hemophilia). Platelets may become dysfunctional, prolonging the bleeding time, as blood circulates through a pump oxygenator during cardiopulmonary bypass surgery. Thus, regardless of platelet numbers, patients who bleed excessively after cardiac surgery and who have a long bleeding time should be given platelet concentrates. During bypass surgery, giving aprotinin (a protease inhibitor that neutralizes plasmin activity) reportedly prevents prolongation of the bleeding time and reduces the need for blood replacement. The bleeding time may shorten transiently after vigorous dialysis, administration of cryoprecipitate, or desmopressin infusion. Coagulation disorders Decreased or defective synthesis of one or more of the coagulation factors can cause bleeding.

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In contrast buy 20mg cialis soft overnight delivery erectile dysfunction internal pump, specialists is essential to help educate and train providers with a strong 12-step orientation to other physicians generic 20mg cialis soft with amex erectile dysfunction vyvanse, serve as equal partners in treatment tend to perceive evidence-based regular medical practice and provide specialty 175 183 practices as less acceptable. For many recovering paraprofessional Efforts also must be made to translate physician counselors, their counseling “trump card” is training into practice. A lack of time and that their personal experience is exemplary of resources make it difficult for physicians to 177 how recovery works. Poor training in the care of patients fourth-year medical students in New York City with addiction relates to low confidence among found that the majority (85 percent) did not physicians in their ability or competence to treat know of local smoking cessation programs to 193 such patients, negative attitudes toward patients which to refer patients. Curriculum time and the number of faculty with Only a small proportion of primary care expertise in addiction education pale in physicians feel “very prepared” to detect comparison to curriculum time and the number particular types of risky use (alcohol--19. A students and I feel that too many of our attending state-based 2006 survey of primary care physicians have not demonstrated to us that they physicians found that the vast majority (88 believe that addiction can and should be percent) screen for diabetes in adults with risk addressed and that attitude affects patient care factors such as obesity, hypertension and a 198 189 for the worse. Another national study found that 199 established, yet there often are more addiction only half of psychiatry residency programs offer -217- 205 psychiatry residency positions available than ability to provide psychosocial therapies. For example, overwhelming evidence has percent); and “smoking patients are not proven that smoking cessation interventions are interested in smoking cessation counseling” 206 clinically effective and cost effective and that a (19. Yet many medical schools do not training in caring for patients with risky 202 207 require clinical training in smoking cessation. Only about half of dental * schools and dental hygienist programs have My relapse was in part due to ignorance in the tobacco cessation clinical activities integrated in medical profession and lack of medical 210 their student clinics. Yet, nurses are not clinical psychologists are highly trained in adequately prepared to perform these services, psychosocial therapies, many of which can be particularly tobacco cessation for which applied effectively to addressing addiction in the research indicates they can be particularly 215 significant proportion of their patient population effective. Barriers to the implementation of that has co-occurring addiction and mental smoking interventions include a reported lack of 204 motivation, self- efficacy, institutional support, health disorders. Nursing school curricula screening and intervention for risky substance have little tobacco control content; there is a users and in diagnosing, treating or referring lack of tested curricula, nurse educators are not patients with addiction, some fail to identify * risky use or addiction or lack confidence in their Forty-seven percent of dental schools and 55 percent of dental hygienist programs. Specifically, cessation interventions are effective in providing although it is well understood that dosages 218 those services, and despite the important role between 60-100 mg per day promote retention in 225 pharmacists can play in preventing the misuse of treatment and reduction of opioid use, 34 219 controlled prescription drugs, most are not percent of patients are given doses of less than well trained to perform these functions, have 60 mg per day and 17 percent are given doses of * 226 little confidence to do so and believe that most less than 40 mg per day. Treatment patients are not interested in having them programs more likely to give suboptimal doses 220 intervene. The underutilization of pharmaceutical therapies in addiction treatment is another example of the Furthermore, despite the potentially vast market disconnect between addiction treatment services for pharmaceutical treatments for addiction, the and medical care. Many addiction treatment pharmaceutical industry has not made providers are unable to prescribe pharmaceutical substantial investments in the development of therapies and medical professionals who could new and effective addiction treatment 231 prescribe such therapies fail to address medications. A related problem is that some contributing factors to the increased medical medical professionals appear to have a treatment of mental health disorders, such as disproportionate concern about the safety risks depression and anxiety, in the past two decades of addiction medications relative to medications has been the development and marketing of aimed at treating other medical conditions. However in recent years, the addiction medications have been noted and pharmaceutical industry has cut back safety concerns raised--particularly with regard dramatically on investments in the development 223 of new pharmaceutical therapies for these and to smoking cessation treatments, side effects 233 exist for many medications aimed at treating other mental health conditions. The large other health conditions and typically are profits that pharmaceutical companies were able acknowledged as an acceptable risk of treatment. Addiction treatment providers do not speak with Coupled with the rising cost of research and clarity or consistency about what the goals of development, the fact that pharmaceutical treatment are, what counts as quality treatment, companies face dramatic losses once the patents how performance and outcomes should be on many of their largest money-making drugs measured and what practices should be expire makes the current climate for the implemented to improve treatment and achieve development of new innovative medications * 239 measurable outcomes. For example, transporters that underlie addiction and that are organizations like the Council on Graduate promising targets for the development of Medical Education and the National Advisory 235 medications to prevent and treat addiction. Council on Nurse Education and Practice are public-private partnerships with Congressional Aside from economic concerns, other factors mandates to provide sustained assessment of the inhibiting investments in new pharmaceutical 241 needs of the medical and nursing fields. Even for which states that every physician must assume smoking cessation, which offers a huge clinical responsibility for the diagnosis and potential market, investments are negligible referral of patients with addiction and explicates compared with the costs associated with the particular competencies needed to fulfill that developing medications to treat the responsibility. Despite these and other efforts by government and professional Translating the rapidly-evolving science of organizations to put forth guidelines and addiction into science-based treatments will principles aimed at ensuring proper training in require dramatic changes in incentives for the risky substance use and addiction, physicians pharmaceutical industry to invest in innovative continue to be insufficiently equipped to address medications, increased public understanding that 242 the needs of their substance-involved patients. Such inconsistency in goals makes and outcome measurement, including limited measuring and assessing the effectiveness of consensus regarding core quality standards and treatment very difficult. The primary goals of medical care are the prevention, diagnosis and treatment of illness, injury and disease, and the consequent 246 relief of pain and suffering. The picture is not as clear in addiction treatment: there is little agreement among addiction treatment providers about what the goals of treatment are or should be and whether successful treatment is defined by abstinence, a reduction in clinical symptoms or a reduction in negative health and social 247 * consequences. Program Staff Further complicating the measurement of Directors Providers outcomes is the failure to understand that Tobacco addiction in many cases is a chronic disease that Complete abstinence 49. Government and private funders Inadequate Insurance Coverage and insurance companies increasingly are pressing addiction treatment programs to In spite of recent expansions in coverage for demonstrate the effectiveness of their programs intervention and addiction treatment through 250 health care parity laws and the Affordable Care and services. However, most programs do not measure performance or treatment outcomes or Act, insurance coverage for addiction and have reliable evaluation data to demonstrate the related services remains severely limited 251 compared with coverage for other health efficacy of their services. This lack of insurance coverage 252 for effective--and cost-effective--intervention addiction treatment. The asked about the three main ways that their end result is that millions of Americans are program evaluates how well it is doing, the most denied treatment, health care costs continue to common response offered was “program rise as do social consequences and costs, and 257 completion rates” (68. Its strength is a clear and long- to conduct and support “research, training, overdue recognition of the nature of the disease health information dissemination and other of addiction and the importance of addressing it programs with respect to the cause, diagnosis, in a unified way. The result is a disjointed array of programs and  Shifting evaluation efforts from a focus on efforts that often have quite different performance-based measures that document perspectives and approaches to addressing the the process of service delivery to a focus on issues surrounding substance use and addiction, patient outcomes, and rewarding those which further contributes to the segmented view programs that demonstrate positive patient 265 of addiction as multiple substance- and outcomes; and behavior-specific problems, rather than a single disease with different manifestations. Although these supporting research and prevention are steps in the right direction, the research efforts; advocating for state and federal documented in this report demonstrates clearly policies that would expand access to that the current treatment infrastructure is treatment; and working to establish riddled with barriers to closing the vast gap addiction medicine as a recognized 267 271 between research evidence and practice. Such brief trainings use, including tobacco, alcohol and have proven effective in improving health other drugs. Recent research within the alcohol and other drugs, and to promote Medicaid and Veterans Health more broadly the adoption of these Administration systems demonstrates the 277 286 practices in the medical field. For example, in 2012, the Joint Commission announced new, * voluntary measures for hospitals that choose Screening, Brief Intervention, Referral and to provide screening, brief intervention and Treatment. The performance Our perspective is that, although tactically measurement sets related to alcohol and impressive, the [Joint Commission’s] other drugs include screening, brief measure set [regarding tobacco screening and interventions, treatment, discharge planning cessation services] is strategically flawed 287 291 and follow up. Hospitals are with risky substance use than all the urging required to choose four out of 14 possible and pleading we’ve undertaken for the past core performance measurement sets, with no 292 25 to 30 years. However, other sets of measures that hospitals may choose to be held accountable for include those that they already perform routinely, limiting the reach of this promising development which would require more effort and resources than most other 290 measurement sets. Effective, evidence-based interventions and treatment options exist that can and should be delivered through the health care system. A substantial body of research demonstrates that providing effective prevention, intervention, treatment and disease management services yields improvements in health and considerable reductions in costs to government and taxpayers; research also suggests that providing these services does not result in significant increases in insurance costs. In the face of these facts, it is unethical, inhumane and cost prohibitive to continue to deny effective care and treatment for the 40. No one group or sector alone can realize the changes required in health care practice, government regulation and spending, insurance coverage, and public understanding to bring addiction prevention and treatment and reductions in risky substance use in line with the standard of care for other public health and medical conditions. Concerted action is required on the part of physicians and other medical and health professionals, policy makers, insurers and the general public. Likewise, addiction has been seen for too long -227- as a character flaw and a moral failing rather  Connection to support and auxiliary than a preventable and treatable disease. Efforts already underway to counseling, and mutual support close this gap must be expanded and accelerated.

When stimulated by suckling order genuine cialis soft on line impotence use it or lose it, muscles in the nipple contract to harden and enlarge it so that the baby can grip and suck on it purchase cialis soft 20mg line erectile dysfunction pump ratings. The usual cause is untreated mastitis during breastfeeding, when a milk duct becomes blocked and the trapped milk and surrounding tissue becomes infected and breaks down to form pus. The admonition “breast is best” features prominently on cans of infant formula and on advertising for breast milk substitutes in many third- world countries, and there is little doubt that it is true. Because of poverty, poor hygiene and poorly prepared formula, bottle-feeding should be actively discouraged in disadvantaged areas. Breastfeeding protects the baby from some childhood infections and the stimulation it also helps the mother by stimulating the uterus to contract to its pre-pregnant size more rapidly. For the first few days the breasts produce colostrum, a very watery, sweet milk, which is specifically designed to nourish the newborn. All babies are born with a sucking reflex, and will turn towards the side on which their cheek is stroked. In the next few days, relatively frequent feeds should be the rule to give stimulation to the breast and build up the milk supply. Each will work out what is best for them, with the number of feeds varying between five and ten a day. Like other beings, babies feed better if they are in a relaxed comfortable environment, with a relaxed comfortable mother. A baby who is upset will not be able to concentrate on feeding, and if the mother is tense and anxious, the baby will sense this and react, and she will not be able to produce the “let-down reflex” which allows the milk to flow. If the baby drinks a lot, the breasts will manufacture more milk in response to the vigorous stimulation. This varies greatly from woman to woman, and some have regular periods while feeding, some have irregular bleeds, and most have none. The mini contraceptive pill, condoms, and the intrauterine device can all be used during breastfeeding to prevent pregnancy. They are normally delivered by a caesarean section, but may be delivered normally with the assistance of forceps to protect the head. Even so, the vast majority of breech births result in no long-term complications to the mother or child. In fact it is unlikely this scenario occurred, but caedere means “to cut” in Latin, and those delivered immediately after the death of a mother in childbirth by being cut from the mother’s womb were called caesones. It is far more likely that Julius Caesar was a descendent from such a caesones and his family adopted that title as their surname. In the last 2000 years the operation has been considerably refined to the point where about a quarter of all babies are now delivered in this manner. These include a baby that is presenting side on instead of head-first, a placenta (afterbirth) that is over the birth canal, a severely ill mother, a distressed infant that may not survive the rigours of the passage through the birth canal, and the woman who has been labouring for many hours with no success. Caesarean sections may also be performed if the mother has had a previous operative birth, if she is very small, if previous children have had birth injuries or required forceps delivery, for a baby presenting bottom first, if the baby is very premature or delicate, in multiple pregnancies where the two or more babies may become entangled, and in a host of other combinations and permutations of circumstances that cannot be imagined in advance. The decision to undertake the operation is often difficult, but it will always have to be up to the judgement and clinical acumen of the obstetrician, in consultation with the mother if possible, to make the final decision. The reasons for this include the convenience of the mother, the convenience of the doctor, the legal risks associated with natural labour and the medical risks. The rate now exceeds a quarter of all deliveries in many areas, and up to 28% in some countries, an increase from less than 20% ten years ago. A spinal or epidural anaesthetic is given to the mother, and the baby is usually delivered within five minutes. After delivery the longer and more complex task of repairing the womb and abdominal muscles is undertaken. In most cases, the scar of a caesarean is low and horizontal, below the bikini line, to avoid any disfigurement. The woman feels nothing below the waist, and although sedated is quite awake and able to participate in the birth of her baby, seeing it only seconds after it is delivered by the surgeon. Recovery from a caesarean is slower than for normal childbirth, but most women leave hospital within seven days. It does not affect breastfeeding or the chances of future pregnancies, and does not increase the risk of miscarriage. It has no medical meaning and can be easily peeled from the baby’s head, but superstitious people believe that a baby born with a caul will never die by drowning. It allows blood to flow out of the uterus during the menstrual period, and sperm to enter after intercourse for possible fertilisation of an egg. The cervix is normally filled with mucus, the composition of which changes at different stages of the menstrual cycle. It is usually thick to stop bacteria and other infections from entering the uterus, but when an egg is released (ovulation) it becomes thinner so as to make it easier for sperm to enter and fertilise the egg. Some forms of birth control are based on a woman analysing the consistency of the cervical mucus she produces, since it is an obvious indicator of when an egg is about to be released. When a baby is due to be born and the mother goes into labour, the canal through the centre of the cervix expands in a few hours to many times its normal diameter of about 3 millimetres up to about 10 centimetres to allow the baby out. The first stage of labour is when the muscles of the wall of the uterus start contracting while at the same time the muscle fibres of the cervix relax to allow expansion. If the cervix opens abnormally during pregnancy, the foetus may escape and the woman will have a miscarriage. Some women have a cervix that is prone to weakness (an incompetent cervix), and if detected early enough, the cervix can be held closed by stitches, a procedure generally carried out under general anaesthetic. Sometimes the delicate cells forming the inner lining of the cervix spread to cover the tip and replace the stronger tissue normally occurring there. Generally the treatment for cervical erosion is to destroy the unwanted cells by heat (cauterisation) or laser. Deaths from cervical cancer are second only to deaths from breast cancer, but the death rate could be dramatically reduced if all women had regular Pap smears. The deposits of pigment on the forehead, cheeks, upper lip, nose and nipples are often triggered by pregnancy or starting the oral contraceptive pill. Numerous blanching agents have been tried with minimal success, but the pigmentation usually fades slowly over several years. Its presence can be used as a diagnostic test for pregnancy, but can only be detected at least ten days after conception. False positive results can occur with cancers of ovary or testes (seminomas, choriocarcinoma) or placental tumour (hydatidiform mole). Chorionic gonadotrophin can also be injected as a medication in the treatment of infertility in women, delayed puberty in girls, failure of testicular development and failure of sperm production. Although chorionic gonadotropin has been prescribed to help some patients lose weight, it should never be used this way.

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