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Other Agents Bethanechol: Bethanechol impotence over the counter order super levitra with amex, a muscarinic agent that causes uncoordinated gastric contractions causes of erectile dysfunction in 20 year olds 80mg super levitra with mastercard, is of historical value, but has no current role in the management of gastroparesis. Its prokinetic effects are those of increased lower esophageal sphincter tone, and improved antral, jejunal, and colonic motility. Cisapride provides symptomatic relief for a wide spectrum of patients, and has become the treatment of choice for medium and long-term management of gastroparesis. The routine dose is 10-20mg four times daily (preferably given 30 minutes before meals and at bedtime). The major concern, however, are the more than 270 cases of serious cardiac arrhythmias that have been associated with cisapride use. Although a rare occurrence, this ventricular arrhythmia may result in hypotension, syncope, or even sudden death. As a result, cisapride has been withdrawn from the open market, and is only available on special request from the manufacturer. Domperidone: A benzimidazole derivative, Domperidone acts as a peripheral Dopaminergic (D2) receptor antagonist. Because it minimally crosses the blood-brain barrier, domperidone is devoid of metoclopramide central nervous system side effects: it very rarely causes hyperprolactinemia, gynecomastia, galactorrhea, impotence, and amenorrhea. Domperidone, however, has anti-emetic properties as a result of its action on the chemoreceptor trigger zone. Anti-Emetic Therapy Prokinetic therapy will, for the most part, offer relief from the nausea and vomiting that accompany gastroparesis-either indirectly by promoting motility, or through the anti-emetic properties of substances such as metoclopramide and domperidone. Occasionally, however, a refractory patient is encountered for whom additional therapy is required. Phenothiazine derivatives (promethazine and prochlorperazine) act by antagonizing dopamine receptors. Other anti-emetic agents include thiethylperazine and trimethobenzamide, the use of which may be limited by extrapyramidal side effects, especially if used in conjunction with metoclopramide. Ondansetron is available as a liquid and lingual dissolving tablet, of which both are well tolerated and quickly absorbed. Endoscopic Therapy Decompressive Gastrostomy: Some patients who are refractory to dietary and medical interventions may benefit from an endoscopically placed gastrostomy tube (surgical or fluoroscopic placement can be undertaken when endoscopic placement is unsuccessful or not feasible). This device helps drain the stomach, thus aiding in the avoidance of nausea and vomiting flares. In such cases, in order to avoid dehydration and malnutrition, a jejunostomy tube may be considered. Complications of percutaneously placed tubes include: 1% procedure death, 25% infectious complications, in addition to peristomal leak, perforation, fistula formation, dislodgement, or tube dysfunction from clogging. Surgical Therapy Surgical intervention has not been studied, and thus has no role in the management of gastroparesis. Novel Therapies Botulinum Toxin Studies suggest that type I diabetics suffer from poor coordination of antro-pyloro-duodenal contraction and relaxation functions. More importantly, when they do experience contractions, they suffer a failure of pyloric relaxation. Botulinum toxin, a product of the bacteria Clostridium botulinum, is a neurotoxin that prevents acetylcholine release from nerve terminals. When locally injected into striated or smooth muscle segments, it prevents muscle contraction. As a result, botulinum toxin has been reported as a therapeutic agent in several spastic muscular conditions, including achalasia, hypertensive lower esophageal sphincter, anismus, sphincter Of Oddi dysfunction (go to the Sphincter of Oddi Dysfunction section), and chronic anal fissure. Similarly, in patients with gastroparesis due to pylorospasm, there is excessive smooth muscle tone with failure to relax. Prolonged pyloric contractions may cause functional resistance to gastric outflow. To date, only a few patients have been treated with pyloric injections of botulinum toxin. Preliminary reports, however, have described good response in decreasing pyloric resistance and improving gastric emptying. Gastric Pacing There has recently been increasing interest in treating gastroparesis by gastric electric stimulation. Although early tests did not met with success, more recent studies have demonstrated some effect. The concept consists of implanting electrodes on the gastric serosa (through open or laparoscopic approach), thus providing continuous or intermittent.
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Once the basic situation was in hand and the new regime consolidated its power erectile dysfunction medicines order line super levitra, the use of state torture began in a systematic and regular way erectile dysfunction foods buy super levitra online now. A number of state organisations, both civilian police and military forces, practised torture. This article appeared in the Guardian, and was based on conversations with people accused of supporting the resistance organisation called the Patriotic Front by such acts as publishing leaflets and hiding Mikis Theodorakis. Many of these defendants had been tortured but none dared declare it openly in the courtroom. The article did not mention any names and took particular care that no one could be identified, for the risk of being tortured again was a very real one. The large number of political prisoners and reports about ill-treatment prompted Amnesty International to send two lawyers to Greece at the end of December 1967. Despite the extreme difficulties in making contact with arty victims, they managed to interview sixteen persons who claimed they had been tortured, and they gathered the namcs of thirty-two others who were still in prison, but who, according to second-hand evidence, appeared to have been the victims of torture. When they left Greece at the end of January they published a report on their findings which listed the methods of torture, the places of torture, and certain torturers, but it mentioned no victims by name as they feared reprisals and would not permit the use of their names. This report received considerable attention in the press, and the issue was seriously posed though the government of Greece did not yet react, and the report suffered from the fact that it gave no names. One of the lawyers then returned to Greece two months later where he was allowed to visit certain 88 Amnesty International report on torture Legal remedies 89 prisoners in prison. Nine of the I 2 prisoners he saw said they had been tortured by falanga or electric shock. International newspapers like the Times of London, Le Monde, and the New York Times had carried stories on thc subject. The Greek regime, following the second Amnesty Report, took the offensive on this issue. Inside the country they tightened up security and intimidated victims in order to prevent reports of torture from getting out. The Report of the Red Cross was treated by the Greek government as its strongest argument even though the Report gave the position of the victims, who stated thcy had been tortured, and thc position of the police, who claimed there was no torture. Despite the fact that out of 131 prisoners, 46 complained of torture or ill-treatment, the Greek government used selected excerpts from the confidential Red Cross report to announce publicly that the Red Cross had found no evidence of torture. The Red Cross complained about publishing it in this way and the whole report was released. The official texts included here are excerpts of letters from the State Department to members of the Congress who made inquiries at the request of their constituents. The answers of the Greek Government to charges of torture were exceedingly crudely phrased and created an unfavourable impression on public opinion abroad. Thc State Department answcrs are drafted for a more sophisticated audience and the language of the letters is the guarded language of the lawyer seeking to protect his client. The first inquiries produccd what was to be the basic position taken by the State Department from April 1967 to July 1968: Our tentative conclusion is that there have unfortunately been instances of mistreatment of prisoners in individual cases. Our impression is that these instances occurred particularly with the rounding up, the detention and trial of members of the Patriotic Front, which is regarded by Greek officials and public opinion generally as a Cornmunist-dominated group. During that period, which had its highpoint in the summer and fall of 1967, a series of home-made bombs were exploded in public places in Athens resulting in the death of an innocent bystander, and the police seem to have resorted in a number of cases to excessive means in order to uncover the responsible persons. Since the dispersal of the Patriotic Front, reports of mistreatment of prisoners have declined. Members of the Patriotic Front, a left wing organisation including persons from varying political persuasions, had been arrested and rounded up during August, September and October. On 30 November 1967 a bomb exploded on the roof of the Ministry of Justice and a passer-by, Katerina Milona, was killed by a section of falling pipe. This was the only fatal bombing incident in 1967 and 1968 and it occurred after the Patriotic Front had been arrested, tortured, tried and imprisoned. In the middle of February some prisoners were taken from jail and brought to the laid-up warship Elli at the Scaramang Naval Base for interrogation. The government alleged a plot against the navy by 115 intellectuals and navy enlisted men. Those in Athcns who worried about these matters knew of what was going on and tried to alert public opinion abroad. It was known soon after that one prisoner, Naval Petty Officer Constantinos Paleologos, had died undcr torture, and the details regarding the others became known when some of the victims were returned to prison at the beginning of March. One of these victims, Gerassimos Notaras, described his tortures to the Amnesty delegate and confirmed the reports that the Elli had been used for torture.
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