By Y. Tjalf. Philander Smith College. 2018.

Three etiologies account for over 90% of the cases: trichomonas (25%) kamagra 100 mg with amex erectile dysfunction ring, Candida (Candida albicans cheap 50mg kamagra erectile dysfunction treatment vitamins, yeast) (25%), and bacterial vaginosis (40%). Metronidazole and other 5-nitroimidazoles (tinidazole, ornidazole) are used in the treatment of trichomonas. Vaginal yeast infections (candida) are treated primarily with antifungal imidazole drugs (clotrimazole, econazole, isoconazole and miconazole). The preparations, which are available over the counter, generally comprise pessaries or creams inserted high into the vagina. Oral or intravaginal metronidazole is effective in the treatment of bacterial vaginosis. Intravaginal administration of metronidazole results in much lower systemic levels than oral administration, thus side-effects such as nausea, alcohol intolerance and peripheral neuropathy, as well as the risk of possible teratogenic effects, are reduced with vaginal treatment. Estrogens At the onset of menopause, at approximately 50 years of age, there is a decline in circulating estrogen, which worsens over the next 7–8 years. A related physiological event associated with a decline in estrogen levels is a substantial reduction in vaginal blood flow, with concomitant drying of vaginal tissue. Symptoms of dry vagina include discomfort with tight fitting clothing, burning sensation, purulent discharge, postcoital bleeding, lack of lubrication with sexual arousal, and dyspareunia. There is also a substantial rise in vaginal pH to as high as 7, which increases the incidence of vaginal infections. Vaginal estrogen creams are highly effective in the treatment of atrophic vaginitis. A very low dose is recommended in order to minimize absorption of the estrogen and therefore combat endometrial stimulation. Modified vaginal release estrogen tablets and an estrogen impregnated vaginal ring are also available to treat vaginal dryness. Spermicidal agents 275 These include nonoxynol-9, octoxinol and p-di-isobutylphenoxypoly(ethoxyethanol). Spermicidal contraceptives are useful additional safeguards but do not give adequate contraceptive protection if used alone; they are suitable for use with barrier methods. They have two components: a spermicide and a vehicle which itself may have some inhibiting effects on sperm activity. The systemic absorption of these drugs had previously been considered only from the standpoint of toxicity. However, in addition to local delivery, there has recently been considerable interest in the possibility of vaginal delivery for the systemic delivery of drugs, via the mucous membranes of the vagina. Current technologies in vaginal drug delivery are concerned with the systemic delivery of drugs such as estrogens, progesterones and prostaglandins. New technologies are exploring the systemic delivery of, for example, therapeutic peptides and proteins, via the vaginal route. This chapter reviews the structure and physiology of the vagina and the present and future utilization of the vagina for drug delivery. It is normally collapsed on itself and can hold between 2–3 g of fluid or gel without leakage to the outside. Microscopically, the vaginal wall consists of: • the epithelial layer, with underlying basement membrane; • the lamina propria (connective tissue); • the muscular layer; • the tunica adventitia (the vaginal fascia, which consists of loose connective tissue).

However order 100 mg kamagra visa impotence means, on peripheral smear examination purchase 50mg kamagra free shipping erectile dysfunction age at onset, 60 atypical lymphocytes and only 6 monocytes were noted. Atypical lymphocytes are often misclassified by automated cell counters as monocytes. Therefore, the automated analyzer differential must not be released and the manual differential count must be relied upon for diagnostic interpretation. Review the following scatterplot, histograms, and Answers to Questions 8–9 automated values on a 61-year-old woman. D All of the automated results have R or review flags indicated; none can be released without verification procedures. Review the automated results from the previous Additionally, the platelet count must be verified by question. None of the automated counts can be released without follow-up verification Hematology/Apply knowledge to identify sources of error/Instrumentation/3 1. Refer to the following scatterplot, histograms, and Answer to Question 10 automated values on a 45-year-old man. A The platelet clumping phenomenon is often induced before releasing these results? Redrawing a sample from the patient using a sodium citrate tube usually corrects this phenomenon and allows accurate platelet enumeration. Platelet clumps cause a spurious decrease in the platelet count by automated methods. Warm specimen at 37°C for 15 minutes; rerun specimen Hematology/Apply knowledge to identify sources of error/Instrumentation/3 36 Chapter 1 | Hematology 11. Refer to the following scatterplot, histograms, and Answer to Question 11 automated values on a 52-year-old woman. D The presence of a high titer cold agglutinin in a before releasing these results? The patient’s red blood cells will quickly agglutinate in vitro when exposed to ambient temperatures below body temperature. Warm the specimen at 37°C for 15 minutes; rerun the specimen Hematology/Apply knowledge to identify sources of error/Instrumentation/3 1. Refer to the following scatterplot, histograms, and Answer to Question 12 automated values on a 33-year-old woman. C The rule of thumb regarding the Hgb/Hct correlation before releasing these results? This rule is violated in this patient; therefore, a follow-up verification procedure is indicated. To correct for the presence of lipemia, a plasma Hgb value (baseline Hgb) should be ascertained using the patient’s plasma and subsequently subtracted from the original falsely elevated Hgb value. Warm the specimen at 37°C for 15 minutes; rerun the specimen Hematology/Apply knowledge to identify sources of error/Instrumentation/3 38 Chapter 1 | Hematology 13. Refer to the following scatterplot, histograms, and Answers to Questions 13–14 automated values on a 48-year-old man. To increase the yield and thereby facilitate counting, differential smears should be prepared using the buffy coat technique. Similarly, the patient’s age and the lack of atypical lymphocytes make infectious mononucleosis unlikely. Myelodysplastic syndromes may involve the erythroid, granulocytic, or megakaryocytic cell lines but not the lymphoid cells. Warm specimen at 37°C for 15 minutes; rerun specimen Hematology/Select course of action/Instrumentation/3 14.