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By: Jonathan Handy

bulletConsultant in Intensive Care Medicine,Royal Marsden Hospital,Honorary Senior Lecturer,Imperial College London

For example arrhythmia alliance trandate 100 mg line, the "who" part of the script tells us that sex should occur with someone of the other gender pulse pressure under 25 generic 100 mg trandate with amex, of approximately our own age blood pressure 4 year old child generic 100mg trandate with mastercard, of our own race heart attack jack heart attack generic 100mg trandate amex, and so on. Scripts, then, are plans that people carry around in their Why do most sexual heads for what they are interactions in our doing and what they society follow the same are going to do; they patterns? How could we find out if there are widely shared beliefs about how one should behave in a specific situation? Researchers asked male and female college students to describe a typical "hookup" (Holman & Sillars, 2012). The hypothetical script written by many participants included a basic sequence: attending a party, friends present, drinking alcohol, flirting, hanging out/talking, dancing, and a sexual encounter. Reflecting the ambiguity of a hookup, the sexual encounter might include oral, anal, or vaginal intercourse, just "fooling around" (not intercourse), or "only hugging and kissing. The widely shared nature of this script enables relative strangers to interact smoothly. One study attempted to identify the sequence of sexual behaviors that is scripted for males and females in a heterosexual relationship in our culture (Jemail & Geer, 1977). People were given 25 sentences, each describing an event in a heterosexual interaction. The standard sequence was kissing, hand stimulation of the breasts, hand stimulation of the genitals, mouth­genital stimulation, intercourse, and orgasm. Interestingly, not only is this the sequence in a sexual encounter, it is also the sequence that occurs as a couple progresses in a relationship. These results suggest that there are culturally defined sequences of behaviors that we all have learned, much as the notion of a "script" suggests. Researchers collected data from several hundred young adults in 2010 using both focus groups and questionnaires (Sakaluk et al. The participants endorsed most elements of the traditional heterosexual script identified by past research, suggesting little change. While the hookup script provides guidelines, each couple will enact that script in a unique way. What they talk about, what they eat or drink, and whether they dance will reflect the desires and expectations of each, and the course of their interaction. Scripts also tell us the meaning we should attach to a particular sexual event (Gagnon, 1990). Television programs and films frequently suggest but do not show sexual activity between people. A study of how women interpret such scenes in films found that they utilize scripts. If the film showed a couple engaging in two actions that are part of the accepted script for sexual intercourse. Coffee shops, college bars, clubs, private parties, bathhouses, bars populated by gays, lesbians, leathermen or furries, dating websites, chat rooms- all are sexual fields. People who enter a field are motivated by sexual desire, and they assess others who are present in terms of sexual desirability. Actors assess their position in the hierarchy, and their opportunities for intimacy and behavior depend on their placement in the hierarchy. In other words, fields structure the opportunities for each person to experience fulfillment of his/her sexual desire. In some sites, actors with particular attributes and desires will congregate in distinct spaces (Grazian, 2008). Groups of singles may congregate at the bar, which allows surveillance of who is coming and going and facilitates circulating around the room. The dance floor may be peopled by couples in some fields, or by singles looking to hook up in others. A buff fraternity brother may get more attention at the bar than he does at the tables. Some people can move seamlessly from field to field recognizing that their ranking changes as they cross invisible social boundaries.


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Diet arteria femoralis profunda buy trandate 100mg without prescription, smoking blood pressure zippy buy trandate 100 mg without a prescription, exercise hypertension jnc 8 summary order trandate 100mg without a prescription, attitude arrhythmia means discount trandate 100 mg visa, marital status, and socioeconomic status are all potential influences (Richard-Davis & Wellons, 2013). Controlling for a number of these variables, Caucasian women report significantly more psychosomatic symptoms (40 to 56 percent), while African American women are more likely to report vasomotor symptoms (32 to 40 percent). Japanese and Chinese women are less likely than other groups to report any symptoms. This variation is evidence against the idea that there is a universal menopausal experience. Furthermore, many women who experience symptoms such as hot flashes and night sweats report that they are not bothered by them (Avis & McKinlay, 1995; McKinlay et al. A study of midlife women assessed their daily stress levels and several potential causes (Woods et al. The experience of menopausal symptoms by itself was not associated with increases in stress. There are four approaches to the treatment/management of symptoms of menopause: hormone therapy, medications to relieve specific symptoms, complementary or alternative treatments, and seeking advice from friends and family. The current guidelines for the use of hormone therapy were drawn up jointly by 15 top medical societies in North America in 2012 (Manson, 2012); simi lar guidelines have been adopted by the British Menopause Society (Panay et al. Hormone therapy using oral estrogen is recommended to treat moderate to severe vasomotor symptoms; it is best to start it in early menopause (within 10 years of onset). If the only bothersome symptoms are genitourinary or vaginal dryness, this should be treated with vaginal estrogen or a lubricant, not a systemic medication. The use of estrogen-progesterone therapy is associated with increased risk of venous thrombosis and stroke, though the absolute risk in younger, recently menopausal women is low. A major health concern is the use of "bioidentical" compounded menopausal hormone therapy products. These products are compounds of various hormones that are described as "customized" for the patient, and prescribed by various types of physicians. These products are estimated to make up 40 percent of all menopausal hormone treatments used in the United States, and 86 percent of the women takMenopause: the cessation ing them have no idea what they of menstruation. Research indicates that use of these medications is the treatment strategy preferred by Caucasian women, and the least preferred strategy by ethnic minority women in the U. Treatments include acupuncture, herbal remedies, various spices, and other compounds. Finally, some ethnic minority women seek advice from elders and close friends as the primary means of managing menopause. The lack of estrogen causes the vagina to become less acidic, which leaves it more vulnerable to infections. Estrogen is also responsible for maintaining the mucous membranes of the vaginal walls. With a decline in estrogen, there is a decline in vaginal lubrication during arousal, and the vaginal walls become less elastic. Several remedies are available, including the use of artificial lubricants, and estrogen creams for the vagina by prescription. On the other hand, some women report that intercourse is even better after menopause, when the fear of pregnancy no longer inhibits them. There is some evidence that higher estrogen levels are associated with better sexual functioning. Physical limitations such as prior stroke and arthritis, emotional problems such as depression, and use of various medications can interfere with sexual activity. While both men and women reported these conditions, they were relatively uncommon and were not significantly related to the frequency of oral sexual activity or vaginal intercourse. The factors that were significantly related were high scores on an index of sexual desire (frequent sexual thoughts, desire), positive attitudes toward sex for oneself, and the presence of a partner with no limitations related to sexuality. Men and women who reported that their partner had limitations that interfered with sexual expression were significantly more likely to report masturbating. In fact, sex hormone production is not affected as long as the ovaries are not removed (surgical removal of the ovaries is called oophorectomy or ovariectomy). The majority of women report that a hysterectomy had no effect on their sex lives. However, approximately one-third of women who have had hysterectomies report problems with sexual response (Zussman et al.

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Clevidipine is formulated in a lipid emulsion and is contraindicated in patients with an allergy to blood pressure 200120 discount trandate 100 mg on-line soybeans hypertension exercise trandate 100 mg low cost, soy products pulse pressure pediatrics generic 100mg trandate with mastercard, eggs 2013 generic trandate 100 mg otc, egg products, or those with defective lipid metabolism. Because of the lipid load associated with infusion, it is recommended to give less than 1000 mL of clevidipine per 24-hour period (average of 21 mg/hour) with consideration of triglyceride monitoring and coadministration of other lipid emulsions. Because lipid emulsions can serve as a growth medium for bacteria, clevidipine vials should be discarded after 12 hours of being punctured. Similar to nicardipine, clevidipine is well tolerated with minimal adverse effects. These adverse effects, again, include those largely related to vasodilation: headache, nausea, vomiting, and tachyarrhythmias as well as fever. Finally, nicardipine is about one-third the cost of clevidipine, which is about one-fourth the cost of sodium nitroprusside per vial. Although clinical considerations often supersede cost considerations, in the era of cost containment and reimbursement uncertainty, drug costs are very important considerations. Because of the rapid venous vasodilation with nitroglycerin, it can reduce relative venous return and subsequently myocardial preload (Ignarro 2002). In addition to the peripheral effects of nitroglycerin, coronary artery vasodilatory effects occur without the complication of coronary steal (Adebayo 2015; Mann 1978). One key consideration with the clinical use of nitroglycerin is the tachyphylaxis that occurs, possibly because of sulfhydryl depletion (because of the lack of a nitrate-free interval), requiring frequent escalations in dosing to maintain hemodynamic effects (Hirai 2003; Larsen 1997; Needleman 1975). This tachyphylaxis usually occurs over the first 24­48 hours, and if intravenous blood pressure control is still required at those time intervals, additional or alternative agents may be warranted. In addition, by rapid escalations in dosing, patients become more at risk of the potential adverse effects of nitroglycerin, including flushing, headache, erythema, nausea, and vomiting. The intravenous formulations that are available and used for this indication include the -selective antagonists esmolol and metoprolol and the combination 1- and -antagonist labetalol (Rhoney 2009). Metoprolol has -selectivity similar to esmolol, but given its slower onset, intravenous push administration, and longer duration of activity, metoprolol has less titratability and can lead to extended, overaggressive, unintentional correction, placing patients at risk of induced ischemic complications (Bertel 1987; Reed 1986; Strandgaard 1984; Bannan 1980). Because of their -selectivity, neither of these agents has direct vasodilatory effects, and blood pressure control is solely through the negative inotropic and chronotropic effects (Melandri 1987; Bourdillon 1979). Labetalol is a combination 1- and -antagonist, which, according to the prescribed labeling, in intravenous formulation, primarily exerts its hemodynamic effects through the -antagonist properties, given that the ratio of 1 to is about 1:7 compared with 1:3 in the oral formulation. Early studies of high-dose (1 mg/ kg, or 50 mg) intravenous bolus dosing compared with continuous intravenous infusions showed a better safety profile with continuous infusions, leading to the conclusion that labetalol should be given as a continuous infusion (Cumming 1979a; Cumming 1979b). This data should be cautiously interpreted as the intravenous bolus dosing at the time was much larger than dosing that is now considered standard and safe. Although continuous infusion labetalol is considered safe, overaggressive, unintentional correction has been reported when labetalol is used in this manner (Malesker 2012; Fahed 2008; Jivraj 2006). Because of the extended duration of action (see Table 1-5), each dose should be titrated cautiously. Of note, labetalol is one of the medications of choice for pregnancy-related hypertensive crisis. All -antagonists must be avoided in patients with acute presentations of systolic heart failure for whom the negative inotropic effects could be harmful. Hydralazine can be delivered either by intravenous or intramuscular injection at similar doses (Rhoney 2009). He presents with a stabbing sensation in his middle back and additional pain in his chest. His vital signs include blood pressure 210/122 mm Hg and heart rate 130 beats/minute. If further reduction in blood pressure is needed after achieving heart rate control, any arterial vasodilator can be used, including nicardipine, clevidipine, or sodium nitroprusside, with preference given to agents that are readily titratable if signs/symptoms of overaggressive, unintentional correction occur. Beyond having a relatively slow onset, there can be delays in peak effects of up to 4 hours after administration (Rhoney 2009). A bolus dose may last 12­24 hours, making dose adjustment difficult and raising significant safety concerns.

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