Liza Isabel Genao Gonzalez, MD
 https://medicine.duke.edu/faculty/liza-isabel-genao-gonzalez-md Adoption and foster care as alternatives to process primarily muscle relaxant at walgreens order mestinon online pills, although not exclusively spasms urethra order cheap mestinon, deals family-building through fertility treatment with risks to the patient muscle relaxant flexeril 10 mg cheap 60 mg mestinon overnight delivery. Living without children [24] risks pertain to the primary patient muscle relaxant in spanish order mestinon with amex, to the potenthe medical aspects of each particular fertility tial offspring and to the donor patient, whose treatment are complex and involve steps that are behavior is outside the control of the primary extraordinary in most realms of patient care. However, certain core elements are essential to any informed consent process, including It is reasonably anticipated that eggs banked for for the egg donation patient: donation might not actually be provided to the 1. The physician, not a physician-designee, coneventual recipients/intended parents until, ducts the informed consent discussion. The consent should occur after a review of the giving rise to a host of practical and liability conessential elements, including: cerns. Center for Disease Control [Internet], cited October ment should be based on her time, inconvenience, 27, 2012. The New York State Task Force on Life and the Law those eggs should not be based on number of eggs Assisted reproductive technologies: analysis and recthat they will receive. The baby business: elite eggs, designer genes, refiect clinic expenses, such as storage, laboratory and the thriving commerce of conception. Boston: fees, and the payment to the donor (apportioned Harvard Business School Press; 2006. Repetitive oocyte donation, donors continues to grow, as does the technology: Fertil Steril [Internet]. However, developing treatpdf, and Practice Committee of the American Society ments are burdened with the responsibility of for Reproductive Medicine and the Practice Committee of the Society for Assisted Reproductive extra diligence, measured application, and careTechnology. Recommendations for gamete and ful disclosures to patients about their risks and embryo donation, Fertil Steril [Internet]. Offices for Human Reproduction, 760 edge, and attitudes about the use of their oocytes and N. Baltimore: ete and embryo donation: a committee opinion, Fertil the Johns Hopkins University Press; 2010. Applegarth removal of ovaries, poor egg or embryo quality, Introduction recurrent miscarriage often stemming from chromosomal deficiencies, and advanced In the past 30 years, advances in reproductive maternal age. In the midthe focus of this chapter is to provide a 1980s, these advances subsequently led to the review of historical and current literature use of donated oocytes, enabling many infertile pertaining to psychosocial aspects of oocyte women and their partners, as well as single donation and to describe the psychological and males and homosexual male couples, to counseling issues that may arise for both become parents. Oocyte donation has no identifying information and with whom addresses a number of female medical condithe family will have no contact before, during, tions, including primary ovarian insufficiency or following the donation process. Applegarth others, is stressed, with the goal of benefiting all both medically and psychologically. The Review of Literature authors found significant differences on test scores between donors who completed donation Formal studies that address various psychologicycles and those who were excluded for psychocal aspects of egg donation are plentiful. They stressed the importance of address not only the psychosocial factors inhernot only the use of psychological testing in donor ent in providing or receiving oocytes but also candidate screening but also a careful review of often consider levels of satisfaction experienced the L (Lie) scale when considering donor selecby both as a result of this family-building tion. They again stressed the importance of careful psychological evaluaAn early study [1] on the psychological status of tion, given the tendency of potential donors to oocyte donors (N=26) indicated that donor canminimize psychiatric symptoms. They found that self-reported psyleast one significant family event such as death of chological symptoms and self-esteem were a parent, parental divorce, chemical dependency within the normal range, and 82 % of donors or psychiatric disorder in a relative, or sexual were moderately to very satisfied with the donaabuse. The researchers noted that donors (N=23) were moderately to extremely satisfied who were willing to donate again were signifiwith the donation experience [2 ]. Of note, ticipate and their compliance, they were not Purewal and van den Akker [7] reviewed 64 studpredictive of donor satisfaction at follow-up. They found distinct differences nificant family events are predictive of the between known, compensated, volunteer, and decision to become an oocyte donor. Differences potential donors on demographic characteristics, in non-anonymous versus anonymous donors as motives for donation, and issues relating to well as issues regarding compensation versus disclosure and attitudes towards the resultant non-compensation of donors may also be imporoffspring. The researchers also found that a tant factors not only in the psychological status of significant proportion of oocyte donors and donors but also in the decision and motivation to women from the general population were premove forward with donation. Klock and between donor groups highlight a need for Covington [4] have stressed the importance of the specific types of psychosocial evaluation and thorough screening of potential donor candidates, counseling because it is not useful to generalize 3 Oocyte Donation: Psychological Aspects 43 across donor groups [7]. Notably, however, the and colleagues [12] reported on 144 couples who amount of financial compensation received by were counseled by a psychologist regarding the donors did not correlate with the importance that kind of donation to be used. About 69 % of recipithey attributed to the financial payment they ent couples preferred known donation. They Approximately one-third of recipient couples stress that education and counseling of oocyte preferred an anonymous donor so as to create donor candidates can be improved so as to ensure explicit boundaries around the families involved that they better understand potential side effects [12]. The and colleagues directly suggest that their findings research was categorized into six focused areas: have important implications for pretreatment motivation; desired donor characteristics; the counseling [13 ]. Despite this extensive non-anonymous, or anonymous) are also very information, the author concluded that there was complex and include a number of future implicastill much to be learned about the psychosocial tions that impact the family, the couple, the 44 L. She emphasizes that although eggs Screening, and Evaluation and sperm are similar types of cells, there appear in Oocyte Donation to be different understandings of the practice of donation on the parts of sperm banks, donor egg the psychosocial constructs that underlie the agencies, clinics, and perhaps society in general. Similarly, the use of standardized psychoPsychological Screening, Evaluation, logical testing varies among evaluating cliniand Education of Oocyte Donors cians, including the screening tools themselves. Unfortunately, however, and interpretation can be outsourced to a qualithe greater focus of most fertility clinics that perfied professional. Other important aspects of the informed about the medical procedures involved clinical interview are to assess the presence of and to provide informed consent. However, the screening is the intent to protect all parties involved use of well-validated, objective measures of psyas completely as possible and to decrease the poschopathology and psychological adjustment is sibility of later regret or strained relationships. This the case of known donation, siblings or cousins form of evaluation can help identify unseen psy(intrafamilial donation) are most often the donor chopathology, validate the findings of the clinical candidates, and careful evaluation is critical. Applegarth have to assist the potential donor in concluding for the experience of pregnancy and childbirth. It that the donation is not advisable as well as help may also provide a genetic link to the male partto provide a rationale for ending the process. Yet, for many, despite an expanding during the pre-donation evaluation of known or comfort level with oocyte donation, fears and non-anonymous should include [15 ]: fantasies may also linger.
I am positioned as separate from the clinical staff and spasms hindi meaning purchase cheap mestinon online, both figuratively and physically muscle relaxant 4211 v purchase discount mestinon online, on the side of the young women spasms just below sternum buy mestinon 60 mg fast delivery. She also states during a small group discussion that she likes the face stickers and is using these to represent the feelings or position of the people involved spasms vs spasticity discount mestinon 60 mg with visa. In various tasks in her diary Ainsley reflected on how she felt on the three injection days. Ainsley states not having had an injection before but I believe that she has had her childhood vaccinations but could not remember those. Ainsley reflected positively about the vaccine, particularly after the first and second injections as she then knew what to expect and had time to see that nothing negative or adverse had happened to her thus previous fears had been allayed. Despite this, the images she drew throughout the diary would focus on the needle and blood. Ainsley has used feathers decoratively in Figure 27 but it is unclear why Ainsley has used the feathers here. In the front cover of her diary Emily has stuck a black and white photograph of herself from 2007 and has apologised, in writing next to it, for not having a more recent photo. At the end of the text in which she describes her horse, Emily signs the page with her name and a heart sticker. This is suggestive of her completing the diary at my request; she is purposely signing off as you would a letter or note to a known recipient. Emily often spoke of her poor attendance record at school and she seemed to lack any great investment in academic achievements or additional school activities. She also repeated some of the tasks, particularly on the day when we met for her to return her completed diary to me. Some of this confusion over which tasks she had completed could be down to her having moved house during the period of the diary work. In keeping with her scattered style of entries there are two written entries about the hall. Twelve pages on from the first description (Figure 29) is a drawing of the hall and over the page is the scribbled out hall description. There are pink dashes to the right of the black line (representing the blue screen) at the top of the hall and in the first four rows of chairs. At the end of the written description for this task Emily has again signified that she is writing the diary for me. I read this as a concern that Emily wanted to perform well for me and my research project. She has drawn round the star in various colours to outline it and on the rest of the page she has drawn pink and purple hearts. Emily has simply used red pen and pencil to create this diary entry which may be indicative of the straightforward way in which she views the needle; something that has to be done and which does not have any additional niceties related to it through the use of colours, stickers, ribbons etc. At the bottom of the page is a smiley face she has drawn with a wide mouth possibly representing shock or being scared. In this task Emily does not relate the answer or the situation to me as her audience. Emily directly references me or uses my name five times in her diary and she also stuck in two of the notes I have sent her in the post; the first is a checklist of tasks which she asked me to send her and the second is a note I sent when I was sending her a folder, that the young women had requested, to keep all their materials in. But this is maybe not so easily the case when I consider this alongside the level of self-investment and direction Emily has displayed in order to add to her diary. I find the juxtaposition of these both intriguing and indicative of the world outside of the vaccine diaries. I prompted the young women twice to decorate the diary and make it about themselves; once at the start of the project and once during the half term. Practicing their versions of young woman in response to the vaccine follows from the assertions above regarding the parameters within which they are able to form their identity. Often when differences are experienced in relation to a medical intervention, these are put down to the individual rather than the intervention 136 affecting people differently.
Following are several hypothetical scenarios to help you the determine cost of maintaining a certain size mouse colony for a known amount of time spasms from dehydration buy generic mestinon on-line. The example on the following page incorporates these considerations into a straightforward step-by step algorithm muscle relaxant allergy purchase mestinon 60mg without a prescription. In some situations spasms vs spasticity buy mestinon 60mg without a prescription, such as when maintaining colonies with sublethal genes or genes with variable penetrance muscle relaxant gas generic mestinon 60 mg with visa, the algorithm may need to be modifed. Mouse sperm the Jackson Laboratory 13 Sizing Mouse Colonies Example: Strain characteristics How many breeding females are needed to Breeding scheme Homozygotes x homozygote produce 10 female & 10 male homozygotes per Breeding lifespan 32 weeks week using a homozygous female x homozygous Number of Litters Produced 4 litters male breeding schemefi Litter frequency 1 litter/8 weeks (4 litters/32 weeks) Litter size 6 pups (3 females, 3 males) Ofspring Genotypes Homozygotes only Percent Useful Ofspring 100% Number of experimental mice needed 1. Number of mice to be produced weekly Multiply Lines 1 x 4 x 5 x 6 x 7 (round to nearest whole number) 22 Colony productivity 9. Calculate number of breeding females needed Divide Line 8 by Line 12 (round to nearest whole number) 30 Number of breeding females needed to keep colony productive 14. Calculate number of replacement breeders needed per week Divide Line 13 by Line 11 (round up to nearest whole number) 1 15. Calculate the number of additional breeders needed to provide replacement breeders Divide Line 14 by Line 12 (round up to nearest whole number) 2 Total number of breeders needed 16. Our colony management services are offered both in Bar Harbor, Maine, and Sacramento, California. Through the optimized use of mouse and box space, we can deliver cost-effective and dependable breeding projects scaled to meet your needs. Costs depend on factors such as strain background, fertility, and the number of mice provided to us. Previous sperm cryopreservation methods for these mice resulted in poor fertilization and uneconomical recovery. A minimum of 16 straws of sperm are cryopreserved for each strain and stored in liquid nitrogen at two sites for three years. Optional recovery of live born mice (for verification of recoverability) is strongly recommended. End user support is provided through our moderated listserv discussion group, which you can join when downloading the sofware. Course: Colony Management, Principles and Practices this newly-expanded four-day workshop was designed and is taught by The Jackson Laboratory staf. It provides invaluable training for students, scientists, animal care technicians and other personnel who manage research and production mouse colonies. It is a platform for data analysis and in silico hypothesis testing, and enables investigators to choose optimal strains for their research, including physiological studies, drug and toxicology testing, and modeling disease processes. Backcross: A cross between a strain that is heterozygous for the alleles from two parental strains and one of those parental strains. Coisogenic strain: A strain that difers from an established inbred strain by a mutation at only one locus. Congenic strain: A strain formed by backcrossing to an inbred parental strain for 10 or more generations while maintaining heterozygosity at a selected locus. Consomic (chromosome substitution strain): A strain in which one chromosome has been replaced with the homologous chromosome from another strain. When F1 siblings are crossed to each other, their ofspring are considered to be members of the second flial generation or F2. Genetic drif:The constant tendency of genes to evolve, even in the absence of selective forces. A genotype may be either homozygous (with two identical alleles), heterozygous (with two diferent alleles), or hemizygous (with only one allele). Inbred strain: A strain that has been maintained by sibling (sister x brother) matings for 20 or more consecutive generations. Intercross: A cross between two organisms that have the same heterozygous genotype at all loci. Recombinant inbred strain: A special type of inbred strain formed from an initial outcross between two well-characterized inbred strains followed by at least twenty generations of inbreeding. Rotation length: Length of time before breeders are replaced (considered the optimum reproductive life span). Segregating inbred strain: Segregating inbred strains are inbred stains in which a particular allele or mutation is maintained in the heterozygous state. They are maintained by inbreeding (usually brother x sister mating) with forced heterozygosity (selection for heterozygotes) at each generation for the locus of interest. Substrain: A substrain has known or probable genetic diferences from the parental inbred strain. Litter frequency 1 litter/8 weeks (4 litters/32 weeks) Litter size 6 pups (3 females, 3 males) Ofspring Genotypes 25% Homozygotes, 50% Heterozygotes, 25% Wild-type Percent Useful Ofspring 25% Homozygotes Number of experimental mice needed 1. Number of mice to be produced weekly Multiply Lines 1 x 4 x 5 x 6 x 7 (round to nearest whole number) 88 Colony productivity 9. Calculate number of breeding females needed Divide Line 8 by Line 12 (round to nearest whole number) 118 Number of breeding females needed to keep colony productive 14. Add Line 13 and Line 15 Note: Approximately 44 heterozygous females and males per week not needed for experiments but useful for breeding will be produced. Terefore, breeding colony size need not be adjusted/increased to produce replacement breeders. Weaning cages ~11 females & ~11 males weaned per week will require ~ 6 cages (5 animals per cage separated by sex) the Jackson Laboratory 19 Example A2: Strain characteristics How Many Breeding Females are Needed to Breeding scheme Heterozygotes x heterozygote Produce 20 Male Homozygotes per Week UsingAppendix Breeding lifespan 32 weeks a Heterozygous Female x Heterozygous Male Number of Litters Produced 4 litters Breeding Schemefi Litter frequency 1 litter/8 weeks (4 litters/32 weeks) Litter size 6 pups (3 females, 3 males) Ofspring Genotypes 25% Homozygotes, 50% Heterozygotes, 25% Wild-type Percent Useful Ofspring 12. Frequency with which mice are needed If weekly, enter 1 If every other week, enter 2 If once a month, enter 4 1 4. Number of mice to be produced weekly Multiply Lines 1 x 4 x 5 x 6 x 7 (round to nearest whole number) 176 Colony productivity 9. Calculate number of breeding females needed Divide Line 8 by Line 12 (round to nearest whole number) 235 Number of breeding females needed to keep colony productive 14. Calculate number of replacement breeders needed per week Divide Line 13 by Line 11 (round up to nearest whole number) 4 15. Calculate the number of additional breeders needed to provide replacement breeders Divide Line 14 by Line 12 (round up to nearest whole number) 6 Total number of breeders needed 16. Add Line 13 and Line 15 Note: Approximately 88 heterozygous females and males per week not used for experiments but useful for breeding will be produced. Weaning cages ~11 females & ~11 males weaned per week will require ~ 6 cages (5 animals per cage separated by sex) 20 the Jackson Laboratory Example A3: Strain characteristics How Many Breeding Females are Needed to Breeding scheme Homozygotes x homozygote Produce 40 Female Homozygotes Every Two Breeding lifespan 32 weeks Weeks Using a Homozygous Female Number of Litters Produced 4 litters x Homozygous Male Breeding Schemefi Litter frequency 1 litter/8 weeks (4 litters/32 weeks) Litter size 6 pups (3 females, 3 males) Ofspring Genotypes All homozygotes Percent Useful Ofspring 50% female homozygotes Number of experimental mice needed 1. Frequency with which mice are needed If weekly, enter 1 If every other week, enter 2 If once a month, enter 4 2 4. Weaning cages ~11 females & ~11 males weaned per week will require ~ 6 cages (5 animals per cage separated by sex) the Jackson Laboratory 21 Example A4: Strain characteristics How Many Breeding B6. Ofspring Genotypes 50% Heterozygotes; 50% Mutant homozygotes Percent Useful Ofspring 50% Mutant homozygotes Number of experimental mice needed 1.
The 2009 Endocrine Society Guidelines recommend monitoring serum estradiol and maintaining levels at the June 17 muscle relaxant drugs flexeril order discount mestinon on line, 2016 32 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People mid-cycle range for non-transgender women back spasms 38 weeks pregnant buy mestinon with mastercard. There is no evidence that higher estradiol levels in patients with adequate androgen suppression results in additional feminization or breast development muscle relaxant 500 mg buy mestinon 60mg with amex. Maintaining estrogen levels in the physiologic range for menstruating non-transgender women minimizes risks and side effects spasms heart buy discount mestinon 60 mg online, and makes sense clinically. In patients who have been using self-administered conjugated estrogens, or ethinyl estradiol, it is reasonable to check a total estrogens level, which may provide a more accurate estimate in these cases. Monitoring hormone levels in patients using injected estrogen Pharmacokinetic studies of injected estrogen have been limited. A single study suggests similar pharmacokinetics when estradiol is injected subcutaneously, rather than intramuscular. While transgender women do not menstruate, those with female-range hormone levels will lack the erythropoetic effects of male-range testosterone, and it may be reasonable to use the female-range lower limit of normal when interpreting H&H. Conversely, the lack of menstruation, and potential for pulsatile undetected androgen activity in those with retained gonads make it reasonable to use the male-range upper limit of normal for H&H. Using the male-range upper limit of normal for alkaline phosphatase and creatinine may also be appropriate for transgender women due to retained bone and muscle mass or myocyte counts, respectively. This is of particular importance in transgender women using spironolactone who are registered as female, and may have a lab result flag showing an abnormal elevated creatinine. Lower and upper limits of normal to use when interpreting selected lab tests in transgender women using feminizing hormone therapy Lab measure Lower Limit of normal Upper Limit of normal Creatinine Not defined Male value Hemoglobin/Hematocrit Female value Male value Alkaline Phosphatase Not defined Male value Individualized dosing based on patient centered goals Some patients may desire limited hormone effects or a mix of masculine and feminine sex characteristics. Examples include retention of erectile function with otherwise maximum feminization, or minimal feminizing effects with the exception of body or facial hair elimination or breast growth. While manipulation of dosing regimens and choice of medication can allow patients June 17, 2016 34 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People to achieve this goal, it is important to have a clear discussion with patients regarding expectations and unknowns. Specifically, it is not possible to select in advance an exact hormone regimen that will predictably allow patients to arrive at a specified configuration of sex characteristics. The best approach in these cases is to start with low doses and advance slowly, titrating to effect. At the same time, response to hormone therapy is also individualized and measures such as breast growth are variable in both degree and time course. Likely predictive factors of speed and degree of feminization include genetics, age at initiation of therapy, and body habitus. All transgender women who smoke should be counselled on tobacco risks and cessation options at every visit. Many transgender women may be unable or unwilling to quit smoking; this should not represent an absolute contraindication to estrogen therapy. After an in depth and careful informed consent discussion, it is reasonable to prescribe estrogen using a harm reduction approach, with a preferred route of transdermal estrogen. It is reasonable check both total and bioavailable testosterone levels, and consider reduction of androgen blockade to allow an increase in testosterone, depending on patient goals. This study found no correlation between sexual desire and testosterone levels in the transgender women, though a significant correlation was found between hormones and desire in non-transgender women. Due to higher levels of co-occurring conditions in older individuals, there may also be higher risk of adverse effects. Expected effects of this may be similar to non-transgender women experiencing menopause. Transgender women who retain their gonads but withdraw hormone therapy may experience return of virilization. A discussion of the pros and cons of this approach, with individualized and shared decision making is recommended. Pituitary adenoma (prolactinoma) and galactorrhea: Prolactin elevations and growth of pituitary prolactinomas are theoretical risks associated with estrogen therapy; several cases have been reported. It is noted that some transgender women experience a minimal amount of galactorrhea early in their hormone therapy course. Venous thromboembolism: Data from studies of menopausal women suggest no increased risk of venous thromboembolism with the use of transdermal estradiol. Routine screening for prothrombotic mutations is not recommended in the absence of risk factors. Migraine: Migraines have a clear hormonal component and may be exacerbated by estrogen therapy. Patients with a history of migraines should consider starting with a low dose and titrating upward as tolerated. Oral or transdermal estrogen may be preferred to the potentially cyclic levels associated with injected estrogen. In fact one study found that transgender women experience improvements in social functioning and reduced anxiety and depression once estrogen therapy is begun. For patients with a prior history of estrogen sensitive cancer (breast, pituitary), consultation with an oncologist is recommended. June 17, 2016 43 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People heparin or compression devices). There is no evidence to suggest that transgender women who lack specific risk factors (smoking, personal or family history, excessive doses or use of synthetic estrogens) must cease estrogen therapy before and after surgical procedures, in particular with appropriate use of prophylaxis and an informed consent discussion of the pros and cons of discontinuing hormone therapy during this time. A comparison of the shortterm effects of oral conjugated equine estrogens versus transdermal estradiol on C-reactive protein, other serum markers of inflammation, and other hepatic proteins in naturally menopausal women. Mechanisms in endocrinology: epidemiology of hormonal contraceptives-related venous thromboembolism. Spironolactone with physiological female steroids for presurgical therapy of male-to-female transsexualism. Androgen-deprivation therapy and bone loss in prostate cancer patients: a clinical review. Evolution of gonadal axis after sex reassignment surgery in transsexual patients in the Spanish public health system. Cyproterone acetate induces a wide spectrum of acute liver damage including corticosteroid-responsive hepatitis: report of 22 cases. Testosterone replacement in older hypogonadal men: a 12-month randomized controlled trial. Comparative pharmacokinetics and pharmacodynamics after subcutaneous and intramuscular administration of medroxyprogesterone acetate (25 mg) and estradiol cypionate (5 mg). Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. June 17, 2016 46 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People 37. Effects of cross-gender steroid hormone treatment on prolactin concentrations in humans. Single-dose pharmacokinetics of sublingual versus oral administration of micronized 17 beta-estradiol. Estrogen deficiency in severe postpartum depression: successful treatment with sublingual physiologic 17beta-estradiol: a preliminary study. Hormonal contraception in women with migraine: is progestogen-only contraception a better choicefi Do cosmetic surgeons consider estrogencontaining drugs to be of significant risk in the development of thromboembolismfi June 17, 2016 48 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People 8. Sexual and gonadal effects include an increase in libido, clitoral growth, vaginal dryness, and cessation of menses. Prior use of oral methyltestosterone and other synthetics commonly encountered in bodybuilding communities has resulted in unsubstantiated concerns about negative hepatic effects of testosterone use in transgender men. Testosterone is available in a number of injected and topical preparations, which have been designed for use in non-transgender men with low androgen levels (see table). Since the label dosing (not included in table) for these medications are based on the treatment of men with low, but not no, testosterone, higher dosing may be needed in transgender men (see table) than are commonly used in non-transgender men. Dose increases should be based on patient response and/or monitored hormone levels. Testosterone undecanoate has been used extensively for transgender care outside of the U. Benefits of subcutaneous administration include a smaller and less painful needle, and may avoid scarring or fibrosis from long term (possibly > 50 years) intramuscular therapy (Grading: T O M). Mestinon 60mg for sale. Myoclonic jerking. |
