Medical Pharmacotherapy

One of the most commonly prescribed medical treatments for PD is tocopherol (vitamin E). Tocopherol serves as an antioxidant and oxygen free-radical scavenger. It is in this role that tocopherol is purported to be useful in the treatment of PD by decreasing rates of fibrosis. Although in-vitro data have shown that oxygen free radicals can produce cavernosal fibrosis, no in-vivo evidence supports this finding. In fact, studies have failed to show any significant benefit.

One randomized controlled trial in 40 patients with PD found a 35% improvement in pain with tocopherol, but there was no improvement in curvature or plaque size. Vitamin E may serve to improve the psychological impact of PD through the placebo effect. Side effects are relatively rare and mild and include nausea, vomiting, diarrhea, and blurred vision.

Para-aminobenzoate (PABA) was introduced as a medical therapy for PD after in-vitro data demonstrated a decrease in collagen production when combined with cultured fibroblasts. It is postulated that PABA works by enhancing antifibrotic properties of tissue, including decreasing tissue levels of serotonin. Again, randomized clinical data are limited.

However, one randomized placebo-controlled trial comparing PABA and placebo over 1 year demonstrated a 74% beneficial response for the treatment group compared with a 50% response in the placebo group. A beneficial response was defined as regression in plaque size and/or a reduction in penile curvature. Most of the improvement was seen in stabilization or reduction in plaque size; therefore, the authors recommended PABA as a means to limit progression of the disease. PABA is an expensive medication and is taken 4 times daily. The main side effects are gastrointestinal and include nausea, vomiting, and diarrhea.

Another agent used to treat PD is colchicine. It is thought to decrease phagocytosis of inflammatory cells, which lead to decreased collagen production and increased collagenase activity. Several studies have evaluated the efficacy of colchicine in patients with PD. One study examined 60 men presenting during the acute phase of PD.

At a mean follow-up of 11 months, the investigators noted a lessening of pain in 95% of men, with 30% of subjects reporting improvements in curvature and 22% reporting worsening of curvature. The authors proposed that patients presenting early in the disease course with less than 30° of curvature would benefit most from this agent. In another trial, 84 men with PD were randomly assigned to receive colchicine or placebo.

These patients were evaluated with penile duplex Doppler studies as well as validated questionnaires. The mean duration of symptoms was 15 months. At follow-up, there were no significant differences in pain, plaque size, or curvature between the 2 treatment groups. It is possible that colchicine may be beneficial for patients presenting only in the acute phase of the disease, as in-vitro data does show evidence of decreased collagen production if treated early in the disease process. Side effects of colchicine include nausea, vomiting, and diarrhea.

Two other oral therapies with promising in-vitro data include L-arginine and pentoxifylline. L-arginine is converted to nitric oxide by nitric oxide synthase and has been shown to reduce plaque size in a rat model. Additionally, pentoxifylline is a nonspecific scavenger of reactive oxygen species (ROS) and may also decrease plaque size. No human trials — only anecdotal reports — have been published to date using these 2 medications, but these reports do suggest a possible treatment benefit.
Intralesional Injection Therapy

Intralesional therapies, involving the injection of steroids into penile plaques, have been in use since the 1950s. The theory behind this approach was that the anti-inflammatory effects of corticosteroids would prove beneficial; results of studies have been disappointing, however. Patients treated with intralesional injections of corticosteroids have shown little benefit, especially when weighed against the side effects of tissue atrophy and immune suppression. Other intralesional therapies, however, have shown promise and may serve as a minimally invasive treatment option for patients.

Collagenases, also known as specific matrix metalloproteinases (MMPs)-1, -8, and -13, are a family of enzymes capable of degrading collagen. Gelbard and colleagues[25] were the first to study collagenases in the treatment of PD. In-vitro data showed a significant reduction in penile plaque and dispersion of collagen bundles in human tissue treated with collagenases.

On the basis of these in-vitro data, a study was undertaken in which 31 men with PD were injected with purified clostridial collagenase. An objective improvement was noted in 65% of patients. Subsequently, a randomized placebo-controlled trial was instituted involving 49 men who were stratified into 1 of 3 groups: curvature < 30° or plaque size < 2 cm; curvature 30°-60° or plaque size 2-4 cm; or curvature > 60° or plaque size > 4 cm.

After 3 months of treatment, improvement was found in all patients in group 1, 36% of patients in group 2, and 13% of patients in group 3. A more recent prospective nonrandomized study evaluated 25 men with PD treated with intralesional therapy with purified clostridial collagenase. Significant improvements in curvature and plaque size were found at 3 and 6 months. A double-blinded, randomized study using this agent is currently under way.

Verapamil is a calcium channel antagonist that has been used for intralesional as well as transdermal treatment of PD. The rationale for its use is based on in-vitro data demonstrating that the transport of various extracellular matrix molecules (including collagen and fibronectin) is a calcium-dependent process. In addition, verapamil has also been shown to increase collagenase activity, affect cytokine expression, and decrease fibroblast proliferation in PD plaques.

The use of intralesional verapamil was popularized by Levine and coworkers, whose nonrandomized study of men with PD demonstrated improvement in penile narrowing, curvature, and plaque volume. The same investigators also followed 156 men with PD in a nonrandomized study for a mean of 30 months and found significant improvements in pain and curvature in the majority of men and only 8% of men reported worsening of their curvature.

The only randomized placebo-controlled study examining verapamil involved 14 men with PD. Results showed significant improvements in plaque volume, penile narrowing, pain, and erectile function, but overall penile curvature was not statistically different from placebo. Verapamil is generally administered in 10-mg doses every 2 weeks for a total of 12 treatment sessions. If no improvement is seen after 6 treatments, the dose may be increased to 20 mg or alternate therapies may be initiated. Additional randomized studies are needed to fully elucidate the effect of intralesional verapamil, but the initial prospective results show promise.

Interferons have been used for the treatment of PD since these molecules were found to inhibit fibroblast activity and collagen production in cultured fibroblasts from PD plaques. Several prospective studies and anecdotal reports demonstrated improvements in curvature and pain with interferon treatment (most commonly, IFN-alfa 2b). A crossover study was performed in which 7 of 21 men underwent injection with placebo for 6 weeks followed by a 1-month washout period and then a treatment course of IFN-alfa 2b.

The remaining men underwent injection with interferon only. Results were evaluated using the penile duplex Doppler ultrasound and the IIEF questionnaire. Two thirds of men in this study exhibited objective improvement in curvature. Improvements in plaque size and erectile function were seen in 71% of men. Statistically significant improvements were observed in penile pain and curvature. A follow-up study also revealed significant improvements in penile hemodynamics. R

Recently, a multicenter randomized placebo-controlled trial was conducted to compare the efficacy of intralesional IFN-alfa 2b vs saline placebo injections.[36] Fifty-five of the 117 men in this trial were randomized to receive 5 x 106 units IFN-alfa 2b every 2 weeks for 6 weeks. These men were then evaluated by penile duplex Doppler ultrasound and IIEF questionnaire. Patients who received active treatment experienced significant reductions in penile curvature (decrease of 13.5° for IFN vs 4.5° for placebo), plaque size, and pain, as well as improvements in penile blood flow.

There were no significant differences between the 2 groups in IIEF scores. Treatment with interferon is associated with myalgias, arthralgias, fever, and flu-like symptoms. These symptoms may last for 24 hours. Pretreatment with nonsteroidal anti-inflammatory drugs prior to injection usually alleviates these symptoms. Future studies regarding the use of interferon will hopefully elucidate the proper dosing regimen as well as length of treatment for optimal results.

Other Nonsurgical Management Options

There are other nonsurgical therapies for PD besides medical therapy and intralesional injections. One potential treatment option that has been studied is penile shockwave therapy. The theory behind the treatment is that initiating an inflammatory reaction through direct damage to the plaque will result in plaque resorption. However, multiple randomized studies designed to evaluate the efficacy of shockwave therapy have failed to show any improvements in curvature or plaque size.

Other therapies include iontophoresis, which involves the use of electric currents to improve transdermal drug penetration. Typically this treatment is used in conjunction with topical verapamil.[38] Small nonrandomized studies have shown some improvement. However, the results are still inferior to those of intralesional injection therapy. Further studies are currently under way. An intriguing treatment option that has been studied in recent trials is the use of penile traction devices. These extenders are typically used in conjunction with intralesional therapy.

A small pilot study (N = 10) conducted by Levine and colleagues evaluated the use of a penile traction device and found a 33% reduction in curvature and increases in penile length between 0.5 and 2 cm. These devices, which are typically worn for a total of 4-8 hours per day, are cumbersome for some patients, but initial data appear encouraging. Further studies are certainly needed to evaluate this treatment option.

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Employment for medical assistants is projected to grow much faster than average, ranking medical assistants jobs among the fastest growing occupations over the 2006-16 decade. Job opportunities should be excellent, particularly for those with formal training. Medical assisting programs are offered in vocational or technical medical assistant school, junior colleges and online distance education programs. As we know, www.medassistant.org provides a good model of a online program for medical assistants.

Anyway, the sheer number of distance learning and online degrees available is enormous and is growing daily. Similarly the number of schools and institutions that offer online is also expanding rapidly. An online programs are often very flexible and allow students to study online at their own pace and convenience, this makes becoming a well trained medical assistant easier now then ever.

Anxiety goes right along with fear. Many men suffer from distress due to sexual insecurity and the fear of doing it wrongly. The fear increases the excitement, and forces the ejaculation to occur faster than wished for. This typically results in more anxiety and horror and multiplies the likelihood that it may take place again.

Another reason for premature ejaculation is anger and tension in the relationship. Therapists have established men who possess underlying anger towards there partner to have explosive emotional reactions when aggravated by even the slightest thing. This is truthful for sex as much as it is road rage. Any sentiment whether bad or good is amplified. The man might even decide to ejaculate early on purpose as an act of selfishness and carelessness towards his mate.

Whatever the cause might be. It is vital that you determine which you feel is accountable for your own premature ejaculation. Then you can begin to search for an effective method to stop premature ejaculation.

Chocolate makes your bones more dense, it prevents heart disease, its thought to attract abundance, and its full of mood-boosting and intelligence-boosting neurotransmitter precursors. Healthy, wealthy, wise and happy. So it is as easy and eating all the Hershey’s bars you can get a hold of? Well, not quite…

Like so many things in our modern world, its the processing of chocolate that makes all the difference. This isn’t just the New Age Hippy types saying this either (as one, the author feels comfortable making this statement). Food chemists and researchers who analyze the molecular makeup of our diets are of the same opinion. It’s RAW, minimally-processed chocolate that’s the miracle food. Un-roasted, un-cooked plain old powdered chocolate, better known as ‘Cacao’, is far superior in every way for your health. Cacao is one of the few foods on the planet now being called a ’super’-food, as it’s nutrient density is so high and its health benefits are so great. Note that ‘organic’ does not mean ‘raw’. Even the premium organic hot-chocolate powders found in the high-end health food stores is still roasted and usually processed with alkali (called ‘Dutch Processing’, making it easier to dissolve in water, and destroying most of the antioxidants at the same time). This means that 99% of the chocolate products on the shelves are NOT the superfood you wished they were, but it also points the direction to how to include chocolate in your life on an exceptionally health daily basis. We’ll get to some recipes in a moment, but first a few points to help you remember why raw chocolate is where it’s at.

Energy and stimulation is at the heart of the chocolate experience, but many people are sensitive to chocolate’s effects. There are however, significant differences in the alkaloid structures of raw and roasted chocolate. Raw chocolate’s stimulation comes primarily from theobromine, which has little anxiety producing effects. Studies by natural wellness professionals and user reports both note that while commercially prepared dark chocolate has a very stimulating action that caffeine sensitive individuals may find too strong, an equivalent amount of raw cacao does not. The stimulating effects are reported mild, gentle, and without a ‘crash’ that is often associated with caffeine. A reason for mothers to think about creating their own raw chocolate treats for their children, too. The jury is still out on the actual amount if caffeine in raw chocolate; some investigators have found none, some have found small amounts in the ’skin’ of the cacao beans, and others of found only small amounts in beans that have fermented somewhat (an indication of a lower-quality cacao). Either way, if you’ve refrained from chocolate because of it’s caffeine content, raw cacao may just be your answer to enjoying this treat again.

The really big news about chocolate has been it’s antioxidant profile. Chocolate contains significant amounts of polyphenols — the same important antioxidants found in green tea, red wine and green apples — but in greater amounts. Dark chocolate contains an impressive 5% of these compounds, yet raw chocolate is made up of an incredible 10% concentration of these possibly life-extending molecules. Both roasting and processing with alkali (to make Dutch cocoa) reduce antioxidant concentration. Further, the increased absorbability of powdered raw cacao (perhaps the most versatile form of raw chocolate) over cacao nibs give them an edge in ORAC value, a measure of Oxidative Radical Absorbance Capacity.

Maybe the most intriguing constituents of chocolate are it’s mood-altering chemicals besides its stimulation. Many users of raw chocolate find and even greater boost than from commercial chocolates. Like caffeine, some of the molecules attributed to mood-enhancement are also heat sensitive. Tryptophan, a precursor to serotonin, is present in significant amounts and is known to be broken down by heat (and apparently it’s not the Tryptophan in the turkey dinners that makes one tired, it’s the three servings followed by pie and ice cream!). Other natural constituents are dopamine and precursors to dopamine, one molecule called the ‘love chemical’ and another called the ‘bliss chemical’. Add to these monoamine oxidase inhibitors which actually enhance the activity of all of the above mood brighteners. Finally, there’s lots of easily absorbed magnesium in raw chocolate, a mineral associated with serotonin production (many pharmaceutical antidepressants increase serotonin activity), and the ability to relax. The easiest way to add this broad spectrum of bliss-inducing nutrients to your health program is simple: a daily dose of raw chocolate.

Need more be said? Ready for some recipes? The simplest means of eating raw chocolate is snacking on cacao nibs. These are small pieces of cacao beans that mix well with natural granolas or dried fruit. For the absolute most profound positive effects on your health, AND the most versatile form of raw chocolate for your recipes, pre-powdered raw chocolate is the best choice. The powder can be added to any drink, or easily made into bars, drops or other shaped candies. By far the most often enjoyed recipe for raw chocolate powder is the simple chocolate drink: Put one heaping tablespoon raw cacao powder, one teaspoon raw agave nectar, and one teaspoon high quality coconut oil in a blender (note that coconut oil quality varies greatly - a good coconut oil should taste pleasant by itself and have no chemical or rancid flavor which would otherwise be noticed in your chocolate drink). Add eight to twelve ounces of hot (but not boiling water) and blend at low speed for about ten seconds. That’s it; Chocolate magic that’s easily adjusted to your tastes — experimenting in whatever way comes to mind is highly encouraged.

There are lots and lots of recipes out there, and great reading on raw chocolate’s health benefits and preparation. You’ll cacao powder often combined with other super nutritious foods in smoothies and good-for-you deserts. Natural organic candies start with the same ingredients as the drinks, but without the liquid. Just make a paste, adding pecans, coconut shavings or whatever you like, and chill to harden. As you’re not baking anything, there’s little to go awry, and really, so many possibilities. By using raw chocolate, you’ll open up a whole new world of cooking for yourself and your family — and if you hadn’t before, you might just find yourself really motivated to treat yourself to natural health and wellness.

If you are not planning on ever having kids in the future the most effective methods of contraception would be vasectomy and female sterilization.

Vasectomy is a surgical procedure which prevents the sperm from being released and mixed up with semen when a man ejaculates. During vasectomy the vas deferens is sealed on each of the testicles, which is the narrow tube that connects the testicles to the urethra through which the sperm flows out during the ejaculation. By doing so the sperm does not mix with the semen but instead is broken down and reabsorbed by the body and hence the female egg can not be fertilized. This procedure does not notably affect the volume, appearance, smell or any other characteristics of the ejaculation. Most men feel a little sore afterwards. In some rare cases there can be bleeding, pain and high temperature. If you notice these symptoms, contact your doctor immediately. You can have sex when you feel like it, which could be as soon as just several hours after the operation, but you should still be using other means of contraception for a while since there could be some left-over sperm in the tubes leading to the penis. You should keep in mind that once you have a vasectomy you are most likely never going to have kids again. There is a procedure that can be done to reverse vasectomy, but its success rate is very low.

Female sterilization is a surgical procedure which involves sealing or cutting the fallopian tubes, connecting ovaries and uterus, hence making it very hard for the eggs to reach the sperm and become fertilized. Although it is extremely hard for the eggs to pass through, it is not completely impossible. The success rate of sterilization is about 99%, so there is still a 1 in 200 chance of getting pregnant. If you do get pregnant the chance of it being an ectopic pregnancy, where the egg is implanted outside the womb, is very high, so it is important to see your doctor right away due to the high risk of such pregnancies being fatal. Sterilization doesn’t have any long-term health side effects, it does not affect your sex drive or interfere with your hormone levels and periods. You may experience some slight bleeding and pain right after the sterilization is performed, but unless it gets worse there is nothing to be concerned about. You can have sex as soon as it feels comfortable, but you should use other means of contraception until you get your first period to avoid getting pregnant.

The next way of contraception is a birth control pill. It is an oral tablet that contains the synthetic version of two hormones ��” progesterone and estrogen. At the beginning of a menstrual cycle the levels of estrogen rise, and the uterus starts to get ready for a fertilized egg by thickening its lining called endometrium. About 14 days into the menstrual cycle the estrogen level peaks and the ovulation occurs, which is the release of an egg by one of the ovaries. After ovulation takes place, progesterone level begins to rise, which continues to prepare the uterus for a fertilized egg for about 7 more days. If the fertilized egg attaches to the endometrium the conception occurs. If it doesn’t occur, the level of both hormones drops, signaling to the thickened endometrium that it can shed and this is how the menstruation begins. The principle on which all birth control pills work is keeping a constant level of estrogen and progesterone in the body. Without the rise of these hormones the ovary does not get signaled to release an egg and hence there is no possibility of getting pregnant.

There are two types of birth control pills based on what hormones they contain and in what amount: progestin-only pills and combination pills.

Progestin-only pills contain no estrogen. This type of pill does three things. First of all, it makes the body think that you are pregnant thus preventing the ovulation. Secondly, it changes your uterus in such a way that if an egg is still released the pregnancy is much less likely to happen. And finally, it thickens the mucus between the uterus and vagina making it hard for the sperm to pass through and reach an egg. Due to the lack of estrogen, progestin-only pills are perfect for breastfeeding mothers, since estrogen can worsen the quantity and quality of milk, it is also not associated with risks of heart disease or blood clots, therefore this type of pills is usually recommended for women over 35, women who smoke, overweight or have history of high blood pressure. You may have irregular bleeding patterns once you start taking the progestin-only pill. You may also find yourself feeling hungry more often, which goes away once you are off the pill. This type of pill works most efficient if taken at the same time every day, otherwise if you take it later than 3 hours from your usual time an additional contraceptive should be used for the following 48 hours.

The second type of birth control pills, combination pills, are the most commonly used ones, and as their title suggests contain both estrogen and progestin hormones. Combination pills can be monophasic or multiphasic based on whether the level of hormones stays the same or changes during the first 3 weeks of a menstrual cycle. Monophasic pills contain the same amount of progesterone and estrogen in the first 21 pills with either 7 more placebo pills containing no hormones at all to keep the woman in the habit of taking pills every day, or they can come in a 21-day pack without any pills for the remaining 7 days. During these last 7 days the menstruation takes place. The newest generation of combination pills Yaz 28 and Loestrin 24 Fe come in 24-day packs, which means that there are 24 active pills and the menstruation only lasts 4 days. Also there are pills like Seasonale that contain 84 active pills followed by 1 week of placebo pills, which means that you will get you period every 3 months. Multiphasic pills contain a different amount of progesterone and estrogen in each pill and have to be taken at specific times. These pills were designed to reduce the side effects of monophasic pills and usually tend to have a lower dosage of hormones per each pill pack following a female body’s cycle more accurately.

There are also continuous use pills which come in packs of 28 pills and have to be taken continuously without any breaks, which means that you will not get a regular period, although you still might get some occasional spotting. Among the advantages of combination pills are decreased menstrual blood loss, less severe premenstrual symptoms, more regular menstrual cycles, and reduced risks of ovarian or endometrial cancers. The possible side effects could include nausea, vomiting, headaches, and spotting. In some very rare cases combination pills might lead to hypertension or blood clots.

Generic Drug Equivalents are a boon in disguise, both for the consumer and the producer. And if generic drugs are bioequivalent to braded drugs and are surely much cheaper than their braded counterparts then it is very much logically understandable why they are so popular.

For the consumer, generic drugs are a boon. Economically weaker section of society that also includes a large percentage of older population is hugely benefited by the generic drugs. These generic drugs have the same composition yet are much cheaper than the original drugs. Being affordably priced these generic drugs can be easily purchased by the economically weaker section of society who would have otherwise ailed through the illness due to costly drugs.

These generic drugs are supposedly the exact same chemical compound although a few variations are allowed so long as the counterpart generic can match the same bioequivalent effects of the original compound. Once these copycat drugs come on the market, the competition between them and the original product generally creates a price drop that can save the consumer and insurance companies a great deal of money while providing the same beneficial medicine.

However, there are dozens of other dementias including, to name just a few: Multi-Infarct Dementia, Frontotemporal Dementia (FTD), Pick’s Disease, Progressive Aphasia, Corticobasal Degeneration, Lewy Body Dementia, Senile Dementia, Binswanger’s Disease, Vascular Dementia, Parkinsonian, etc.

From a care giver’s point of view, it almost doesn’t matter which dementia is at hand. The perpetual grief and mourning felt by the care givers will be the same regardless of the specific process affecting his or her loved one.

My special interest is in Multi-Infarct Dementia because that is the one affecting my mother and the one I write about in my book: DEMENTIA DIARY: A Care Giver’s Journal.

Here is the way one physician described Multi-Infarct Dementia to me. It is caused by multiple strokes, some call them mini-strokes. The victim of this condition may not be, indeed usually is not, aware that anything out of the ordinary has occurred. Neither are his or her significant others.

Perhaps there is momentary weakness, headache, or dizziness, but nothing major. Over time, however, enough damage is done to the brain that symptoms begin to appear such as: confusion, impaired judgment, aphasia, irritability, depression, mood swings, inertia, significant memory loss, and a host of possible others. Not all symptoms are experienced by every sufferer, but sooner or later most of them may appear.

The symptoms of Multi-Infarct Dementia are not really all that different from Alzheimer’s or other dementias. I’ve been given to understand that these differences are subtle, hard to tell apart for a layman.

Health care professionals have explained that if one were to line up sufferers of each of the various dementias next to one another you could probably differentiate them–but that’s what it would take.

I should say that I am not a physician or a professional expert in these diseases. I am, by profession, a hospital administrator, so I am trained to understand the language of the clinicians. What I know comes from 15 years of watching my mother sink into her opaque world, plus 15 years of discussions with physicians providing her medical care.

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