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One excellent way to decrease or completely eliminate pres- sures and expectations is to become less goal-oriented by renaming such activities sexplay generic 375mg keftab free shipping. Sexual expression may be directed to parts of the body other than the genitals discount keftab 375 mg on-line, increasing cuddling, caressing, mas- sage, or other forms of touch, and it may involve experimenting with oral sex, masturbation, a vibrator, or other devices. Emotional reactions may be an issue for both the person with MS and his or her partner because anxiety, guilt, anger, depression, and denial are the natural consequences of coping with any chronic ill- ness. Couples should be sensitive to the fact that some painful feelings may not improve or disappear with communication and support. In that case, it may be helpful to seek professional help in response to depression or anxiety that will not go away. To avoid bowel, bladder, and catheter problems during inter- course, fluids should be reduced approximately two hours before sexual activity and the bladder should be emptied before lovemak- ing. Be prepared in case an accident occurs despite these precau- tions, and remember that it is not a catastrophe. If a catheter is used, it may be taped over a man’s penis or to a woman’s abdomen. A vaginal lubricant such as K-Y jelly should be used whether a woman uses a catheter or not. Spasticity or leg spasms may be minimized by timing antispas- ticity medication so that it is maximally effective during sexual 133 PART III • Your Total Health activity. Having intercourse in a side position, with the knees bent or using pillows for support, may make a difference and should be tried. A vibrator may compensate for a loss of deep pressure sense, which is reflected as impaired sensation, numbness, and tingling. A number of different types are available, including hand-held, penis- shaped, and others. A new device called "Eros" has been approved by the FDA for sexual dys- function in the female. It places gentle suction on the clittoral region while applying a gentle vibration. The judicious use of a frozen bag of peas rubbed gently in the vaginal area has been reported to increase sensation and decrease pain for some people. Lubrication difficulties in women may be managed by vaginal pack- ets of lubricants that open on impact, such as Replens or Astroglide.

Some 48 LIFE CYCLE STAGES women cannot imagine leaving their children in the care of another during these early years cheap keftab 250mg with mastercard, while others are unwilling to remain home full-time with an infant discount keftab 750 mg overnight delivery, no matter how engaging its personality. When the mother has decided to return to work after finding suitable childcare, there is still the inevitable sick child or emergency. Although spouses agree in theory that their careers are of equal importance, there in- evitably arises the question of which spouse leaves work to retrieve a sick child or who remains home when communicable childhood illnesses prevent the child from attending the childcare center. The decision is often based on which spouse’s income is higher or whose employment offers the greatest potential for growth. Employers may pay lip service to the family-friendly workplace, but are less likely to promote the employee who prioritizes family over long hours and high productivity (Bradt, 1989). Additionally, contempo- rary society does not universally esteem mothers who forgo careers in order to parent full time. By applauding the hardworking father and devaluing the stay-at-home mom, there seems little in modern America that supports cou- ples’ efforts to prioritize family life. SEX AND INTIMACY Sexual intimacy is the emotional barometer of a relationship, and most couples are eager to return to their prechildbirth sexual activity after the customary six-week postnatal visit. But sex, like most activities after the birth of a baby, usually requires some adaptation, accommodation, and patience. Although women, in theory, may be eager for the physical affection and intimacy of sex, physiological and emotional issues may interfere, at least initially. Sex may be simply physically uncomfortable for her still-healing body, especially if there has been the added complication of caesarian sur- gery. Fatigue from lack of sleep and the stress of a demanding new role may diminish sexual desire. A postnatal body that bears little resemblance to the prepregnancy one may engender negative feelings regarding self- image. Nursing mothers may experience themselves as one giant milk bot- tle, on call day and night for a demanding infant. Men, too, have to contend with the mixed emotions they experience at this time, perhaps conflicting feelings about their wife’s body being both a source of sexual pleasure and nourishment for their child.

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Especially the B cells contain keftab 375 mg mastercard, besides glutamate order keftab 125mg free shipping, various neuropeptides: sub- stance P (SP), calcitonin gene-related peptide (CGRP), galanin, neuropeptide Y (NPY), neurokinin A (NKA), somatostatin, cholecystokinin (CCK), bombesin, va- soactive intestinal polypeptide (VIP), dynorphin, enkephalin, etc. The proportions of peptider- gic SG cells that contain a particular peptide may differ depending on the type of peripheral nerve. CGRP is found in 50% of skin afferents, in 70% of muscle afferents, and in practically all visceral afferents. SP is found in 25% of skin af- ferents, in 50% of muscle afferents, and in more than 80% of visceral afferents. However,somatostatinislackinginvisceralafferentsbutispresentinasmallnum- ber of somatic afferents (Willis and Westlund 2004). In the SG, the quantity of SP-containing neurons (10%–29% of the cutaneous afferent population) is considerably higher (O’Brien et al. Most cells containing SP seem to be nociceptive neurons with high thresholds (Lawson et al. In guinea pigs, the CGRP expression is detected in under half the nociceptive neurons, and is not limited to nociceptive neurons (Lawson et al. It seems likely that the peptides are neuromodulators that act in concert with the fast-acting neurotrans- mitter glutamate, either enhancing or diminishing its action (Levine et al. The brain-derived neurotrophic factor (BDNF) meets many of the criteria to establish it as a neurotransmitter/neuromodulator in small diameter nociceptive 4 Functional Neuroanatomy of the Pain System PA neurons, localized in dense core synaptic vesicles (McMahon and Bennett 1999; Mannion et al. The gaseous transmitter nitric oxide (NO) is synthesized by the enzyme nitric oxide synthase (NOS) in some PA cells of the SG, and in the sensory ganglia of the cranial nerves (Morris et al. The peripheral processes of the nociceptive PA cells terminate generally as thin fibers of two types: Aδ (Group III), and C (Group IV) (Perl 1996; Bevan 1999; Basbaum and Jessel 2000; Lewin and Moshourab 2004; Willis and Westlund 2004). The Aδ-fibers are thinly myelinated, with a diameter of 1–3 µm and a conduction velocity of 5–30 m/s. More rapidly conducting nociceptive A-fibers (up to 51 m/s) have been described (Treede et al. The C-fibers are unmyelinated, with a diameter of approximately 1 µm and with a conduction velocity of 0. Goldschneider (1881) was the first to propose the existence of two pains, later universally recognized (Hassler 1960; Bowsher 1978; Craig 2003a, d). It is slowly conducted and poorly localized (Basbaum and Jessel 2000; Julius and Basbaum 2001).

On the basis of our results and the assessment of our failures order keftab 125mg visa, we recommend careful selection of patients quality 500 mg keftab. Accurate diagnosis of the lesion and the spinal level to be treated, along with accurate technical execution under CT, are key factors in ensuring the successful outcome of percutaneous treatment for this common condition. CT-guided 358 Chapter 19 Intradiscal Oxygen–Ozone in the Treatment of Herniated Lumbar Disc interventional procedures for pain management in the lumbosacral spine. Incidence of intravascular pen- etration in transforaminal lumbosacral epidural steroid injection. CT-guided epidural/peri- neural injection in painful disorders of the lumbar spine: short and ex- tended term results. Evalua- tion of the efficacy of foraminal infusions of corticosteroids guided by com- puted tomography in the treatment of radicular pain by foraminal injec- tion. Percutaneous treatment of herniated lumbar disc by in- tradiscal oxygen–ozone injection. Interven- tional spinal treatment with chemiodiscolysis with nucleoptesis with O3 and perigangliar infiltration in 150 cases. Percutaneous treatment of lumbar herniated disk with intradiscal injection of ozone mixture. Chemiodiscolysis and periradicular and peri- ganglionic infiltration with oxygen–ozone in disk herniation. Mechanism of spinal pain: the dorsal root ganglion and its value as a mediator of low back pain. Hang JD, Georgescu HI, et al: Herniated lumbar intervertebral disc spon- taneously produces matrix metalloproteinases, nitric oxide, interleukin 6 and prostaglandin E2. The inflammatory properties of con- tained and noncontained lumbar disc herniation. A dorsal-longitudinal lumbar spine, 22 Algorithm for pain arteries, 16 sacral spine, 22 management, 39 lumbosacral, 17 upper thoracic spine, 22 Allergic reaction to nonionic macrocirculation, 15–20, Angioma, cavernous, 304 contrasts, 34 16–17, 18t, 19 Anhedonia, with depression, P-aminobenzoic acid, allergic microcirculation, 20–22, 21 anxiety, 47 potential, 31 pretransverse arteries, 16 Annuloplasty, electrothermal, Amitriptyline, for depression, radicular arteries, 18 intradiscal, 121–136 34 radiculomedullary arteries, anatomy, 121–123, 122 Analgesic ladder, World 18–19 development of, 123 Health Organization, 39, radiculopial arteries, 18 history of, 123–133, 124 279 somatic arterial supply, 22 indications for, 124–133, Analgesics, 32–34. See also spinal arteries, diameter, 126–132 under drug name 18 intervertebral discs, spinal Anatomy of spine, 1–26 thoracic, 17 pain and, 123 physical components of, 1–15 ventrolateral arteries, 16 postoperative care, 133–134 anatomical space, 14–15 venous anatomy, 22–26, technique, 124–133, 126–132 bones, 1–11, 2–7, 3t 23–25, 25t Anterolateral biopsy approach discs, intervertebral, 8–11, cervical veins, 26 bone, 75 9–11 lumbar veins, 26 disc, 75 joints, intervertebral, 8–11, number of spinal veins, 25 soft tissues, 75 9–11 sacral veins, 26 Antibiotics, 32. See also under nerves, 11–14, 13 thoracic veins, 26 drug name vertebral volume, from Anesthetic agents, 31–32, Anticholinergic effects of cervical to lumbar 48–49, 49t. See also under tricyclic antidepressants, regions, 3 drug name 48 somatic arterial supply Aneurysmal bone cysts, Antidepressants, 38 cervical, 22 310–311 anticholinergic effects of, 48 lower thoracic, 22 therapy, 311 for postherpetic neuralgia, lumbar, 22 Angiography phantom limb pain, 34.