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A prosthetic implant comprised of a silicone shell erectile dysfunction pump surgery order levitra once a day, with saline or cohesive silicone filler causes juvenile erectile dysfunction discount levitra master card, is placed underneath the breast tissue (subglandular implant) or under the pectoralis muscle (subpectoral implant) varicocele causes erectile dysfunction cheap levitra uk. Initiation of estrogenic and antiandrogenic therapy stimulates the development of breast tissue in transgender women impotence in young males cheap levitra 20mg with amex. In the absence of solid evidence for an optimal length of time on feminizing hormone therapy prior to augmentation, some sources recommend a minimum of 6 months of hormone therapy prior to surgery, to allow hormone-related breast development to progress. The choice of implant, type, and position is governed by the woman’s preoperative body habitus and wishes, in consultation with a board-certified breast or plastic surgeon. Subglandular implant placement may be preferred when there is adequate breast and subcutaneous tissue to cover the implant, and prevent visible implant seams and rippling. Subpectoral implant placement may be preferred when saline implants are used, or in the absence ofadequate soft tissue to disguise the shape of the implant. Breast augmentation procedures are often performed as a “same-day,” ambulatory procedure under general anesthesia; operative time is approximately 2 hours. Recovery is fairly rapid over the course of several weeks, though some patients may experience prolonged soreness, swelling, and mild bruising. A small incision is made along the new inframmary crease and a space for the implant is created in the subglandular or subpectoral planes described above. The incisions are closed with several layers of sutures and the patient generally feels well enough to go home the same evening. In general, results are durable and complications are rare for feminizing augmentation mammoplasty. Surgical data on augmentation mammoplasty specific to transgender women [2,5] are limited; some data are extrapolated from data published on non-transgender women undergoing this procedure. In one study, 75% of transgender women reported satisfaction in long-term follow-up with implant-based June 17, 2016 134 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People augmentation, with the majority of dissatisfaction related to subjective aesthetic outcome (primarily inadequate breast size) rather than technical surgical complications. A plastic surgery referral is also appropriate for a patient presenting late after augmentation mammoplasty with new symptomatic or objective breast complaints related to prior breast augmentation (e. Benign and malignant breast tumors are always in the differential diagnosis and should be worked up appropriately. Women who present with subjective dissatisfaction after previous breast augmentation may require a second surgical consultation or referral to another plastic surgeon. Prior to any referral for breast surgery, patients should be medically, psychologically, and socially stable, up-to-date in regard to breast cancer screening if indicated), and have reasonable postsurgical expectations. Anesthetic complications particular to gender-affirming feminizing mammoplasty In addition to standard anesthetic complications, patients undergoing feminizing mammoplasty should be assessed for risk factors for venous thromboembolism,and appropriate mechanical and chemoprophylaxis measures applied based on individual risk factors. Management of perioperative estrogen therapy and estrogenic risks of venous thromboembolism are discussed elsewhere in this protocol. Hematoma A hematoma typically presents early (within 1-2 weeks) after augmentation mammoplasty, typically as a localized or unilateral swelling accompanied by pain and bruising at the surgical site. Specifically, the patient should be counseled to avoid strenuous activity and situations where the chest could be exposed to external trauma. Additionally, strict medical adherence (especially in regard to withholding anticoagulant, antiplatelet, and certain herbal medications and compliance with antihypertensive medications) can decrease incidence of postoperative hematoma. June 17, 2016 135 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People Hematomas are typically treated with surgical re-exploration, evacuation with identification of the bleeding source, and reclosure, with or without exchange of the prosthetic implant. An untreated large hematoma can result in secondary complications, such as infection, capsular contracture, or implant malposition. There is no evidence in the plastic surgery literature to support the routine use of drains in augmentation mammoplasty. A delayed seroma is generally abnormal, and should be evaluated by a plastic surgeon. The severity of infection can range from a mild incisional cellulitis to a purulent periprosthetic infection. The most common pathogens in periprosthetic infections are skin flora, and as a result, surgeons go to extensive lengths to avoid contamination. However, most authors would advocate for implant removal in cases that fail to resolve, with delayed secondary augmentation performed in 6-12 months, once the patient has time to heal and fully clear the infection. Patients should be cautioned on appropriate scar care, including sun avoidance in the early postoperative period. Patients with darker or oily skin types or a prior history of hypertrophic scar or keloid formation should also be aware of their increased risk for these complications. In general, scarring from surgical incisions can be improved by following some basic tenets of postsurgical wound care. Firstly, reduction of mechanical stress and tension across the wound by following postsurgical activity restrictions is paramount to reducing scar width. Tension across the incision can result in minute wound disruptions, causing excessive or widened scar formation. Patients should be counseled that incisions predictably look the worst in the early stage of healing, up to 10 weeks postoperatively, before they begin to remodel over the next several months to up to one year. Hyper- or Hypopigmentation can also result in a more noticeable scar during this time of remodeling. We therefore recommend sun avoidance, or strong sunblock applied over a healed incision for the first year postoperatively. This can take the form of gentle scar massage (beginning no earlier than 2 weeks postoperatively and after the wound is fully healed), taping, or silicone gels and sheets. Implants placed prior to the late 2000s contained a liquid silicone gel which was prone to leakage, both due to shell rupture and leaching. Currently available silicone breast th th implants (4 or 5 generation implants, also termed cohesive gel implants), even a break in the outer shell of the implant will not allow free silicone gel to escape the implant. Implant malposition and capsular contracture Implant malposition can occur over time as the breast adapts to breast implant placement and aging. Pathologic fibrotic capsule formation, known as capsular contracture, can cause the implant to be hard and palpable, or cause implant displacement, breast deformation, or even breast pain related to the implant. Once symptomatic or disfiguring, implant removal and surgical excision of the capsule is indicated. Capsular contracture rates in modern implants are felt to be less than 10%, although long-term followup is needed. Inadequate size and aesthetic deformities A long-term study of transgender women who underwent augmentation mammoplasty found that 16% of the patients underwent a second augmentation procedure for breasts that were too small. A number of aesthetically unappealing complications can occur and result in dissatisfaction requiring revisional surgery and secondary augmentation. These complications are generally a result of a combination of technique and patient anatomy. Some of these complications can include a visible implant and implant folding or rippling, which occurs in saline implants or when the patient has inadequate soft tissue covering the implant. Other patients can develop asymmetry related to scar formation or displacement over time by the action of the pectoralis June 17, 2016 137 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People muscle (in the case of submuscular implants). These deformities will need to be addressed with secondary revision breast augmentation procedures. Breast masses Breast cancer epidemiology and screening in transgender women is covered elsewhere in this protocol. For those transgender women requiring screening or diagnostic mammography or breast ultrasound, both are possible with breast implants. However, mammography cannot detect implant-related complications, such as ruptures. Injection of silicone and other non-medical substances by unlicensed providers is covered in detail elsewhere in this protocol. Long-term outcome of augmentation mammaplasty in male-to-female transsexuals: a questionnaire survey of 107 patients. The effect of hematoma on the thickness of pseudosheaths around silicone implants. June 17, 2016 138 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People 10. Silicone breast implants and magnetic resonance imaging screening for rupture: do U. Food and Drug Administration recommendations reflect an evidence-based practice approach to patient care? June 17, 2016 139 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People 29. In this technique, a vaginal vault is created between the rectum and the urethra, in the same location as a non-transgender female between the pelvic floor (Kegel) muscles, and the vaginal lining is created from penile skin.
Syndromes
- Nausea
- Nausea and vomiting
- Degenerative bone conditions
- Vomiting
- Difficulty breathing (in severe cases)
- Dilation and curettage (D and C)
- In some cases, surgeons can use your own pulmonary valve to replace the damaged aortic valve. The pulmonary valve is then replaced with an artificial valve (this is called the Ross Procedure). This procedure is ideal for people who do not want to take blood thinners for the rest of their life.
- Removal of the tumor (when a tumor is the cause)
Enriched grains are grain products with B Grains vitamins (thiamin erectile dysfunction best medication safe 10 mg levitra, ribo?avin impotence word meaning purchase levitra 20 mg visa, niacin bisoprolol causes erectile dysfunction levitra 10mg low price, folic acid) In the U erectile dysfunction treatment chandigarh purchase discount levitra online. Moderate evidence indicates that whole- Americans eat less than 1 ounce-equivalent of whole grain intake may reduce the risk of cardiovascular grains per day. Limited evidence also shows that consuming whole Americans should aim to replace many re?ned- grains is associated with a reduced incidence of grain foods with whole-grain foods that are in their type 2 diabetes. Consuming enough whole grains nutrient-dense forms to keep total calorie intake within helps meet nutrient needs. When re?ned grains are eaten, they should be that are higher in dietary ?ber has additional enriched. Each one-ounce slice of bread represents a 1 ounce-equivalent of of total grains with at least 3 ounces from whole grains per day. Partly whole-grain products depicted are those that contribute cup cooked rice, pasta, or cereal; 1 tortilla (6" diameter); 1 pancake (5" substantially to whole-grain intake. For example, products that contain at diameter); 1 ounce ready-to-eat cereal (about 1 cup cereal ?akes). The least 51% of total weight as whole grains or those that provide at least 8 ?gure uses an example for a person whose recommendation is 6 ounces grams of whole grains per ounce-equivalent. The whole grain should grains as whole grains should include some that have be the ?rst ingredient or the second ingredient, after been forti?ed with folic acid, such as some ready-to- water. This is particularly important ents, they should appear near the beginning of the for women who are capable of becoming pregnant. The recommendation to consume at least half of Many grain foods contain both whole grains and total grains as whole grains can be met in a number refined grains. The most direct way to meet meet the whole grain recommendation, especially the whole grain recommendation is to eat at least if a considerable proportion of the grain ingredients half of one’s grain-based is whole grains. Food Label to Track grains in the ingredients Another example is foods with at least 8 grams of Calories, Nutrients, and In- list are whole grains, the whole grains per ounce-equivalent. This information United States and explains how to use the ingredients amount of grain in the may help people identify food choices that have a list to ?nd whole grains. Moderate evidence Protein Foods shows that intake of milk and milk products is linked to Protein foods include seafood, meat, poultry, eggs, improved bone health, especially in children and ado- beans and peas, soy products, nuts, and seeds. Moderate evidence also indicates that intake addition to protein, these foods contribute B vitamins of milk and milk products is associated with a reduced (e. Intake of milk and milk products, including forti?ed The fats in meat, poultry, and eggs are considered soy beverages, is less than recommended amounts solid fats, while the fats in seafood, nuts, and seeds for most adults, children and adolescents ages 4 are considered oils. Seafood includes ?sh, such as salmon, The majority of current ?uid milk intake comes tuna, trout, and tilapia, and shell?sh, such as from reduced fat (2%) or whole (full-fat) milk, with shrimp, crab, and oysters. Almost half of the milk and milk product intake in the United States comes from Some Americans need to increase their total intake cheese, little of which is consumed in a lower- of protein foods, while others are eating more than is fat form. Americans should consume protein milk products provides the same nutrients with foods in amounts recommended for their nutri- less solid fat and thus fewer calories. It is especially important to establish the habit of drink- Consumption of a balanced variety of protein foods ing milk in young children, as those who consume milk can contribute to improved nutrient intake and at an early age are more likely to do so as adults. For example, moderate evidence individuals who are lactose-intolerant, low-lactose and indicates that eating peanuts and certain tree nuts lactose-free milk products are available. Because nuts and seeds are high in calcium, potassium, magnesium, vitamin D, and vitamin calories, they should be eaten in small portions and A. Soy beverages forti?ed with calcium and vitamins A used to replace other protein foods, like some meat and D are considered part of the milk and milk products or poultry, rather than being added to the diet. Nutrition assistance programs may have additional nutrient speci?cations for soy beverages based on Federal requirements or the nutrient needs of target populations. In addition, eating a peas, as discussed previously under Vegetables and variety of seafood, as opposed to just a few choices, Fruits, confer health bene?ts as sources of important is likely to reduce the amount of methyl mercury nutrients such as dietary ?ber. An intake of 8 or more ounces per and lower in mercury include salmon, anchovies, week (less for young children), about 20% of total herring, sardines, Paci?c oysters, trout, and Atlantic recommended intake of protein foods of a variety of and Paci?c mackerel (not king mackerel, which is seafood is recommended. In addition to the health bene?ts for the gen- Seafood eral public, the nutritional value of seafood is of Mean intake of seafood in the United States is particular importance during fetal growth and approximately 31/2 ounces per week, and increased development, as well as in early infancy and child- intake is recommended. Moderate evidence shows that con- are pregnant or breastfeeding is associated with sumption of about 8 ounces68 per week of a variety improved infant health outcomes, such as visual of seafood, which provide an average consumption and cognitive development. Women who are amounts of seafood are recommended for chil- pregnant or breastfeeding can eat all types of tuna, dren. Moderate, consistent evidence shows that the health bene?ts from consuming a variety of seafood Oils in the amounts recommended outweigh the health Fats with a high percentage of monounsaturated and risks associated with methyl mercury, a heavy polyunsaturated fatty acids are usually liquid at room metal found in seafood in varying levels. Protein foods recommendations for people who consume a vegetarian diet are described in Chapter 5. State and local advisories provide information to guide consumers who eat ?sh caught from local waters. Dietary potassium can lower blood because they contribute essential fatty acids and pressure by blunting the adverse effects of sodium vitamin E to the diet. Available evidence suggests that African Americans and individuals Oils are naturally present in foods such as olives, with hypertension especially bene?t from increasing nuts, avocados, and seafood. Americans should select a variety of food viduals can use soft margarine instead of stick marga- sources of potassium to meet recommended intake rine, replace some meats and poultry with seafood or rather than relying on supplements. Dietary ?ber Dietary ?ber is the non-digestible form of carbo- Nutrients of Concern hydrates and lignin. Dietary ?ber naturally occurs Because consumption of vegetables, fruits, whole in plants, helps provide a feeling of fullness, and is grains, milk and milk products, and seafood is lower important in promoting healthy laxation. Some of than recommended, intake by Americans of some the best sources of dietary ?ber are beans and peas, nutrients is low enough to be of public health con- such as navy beans, split peas, lentils, pin to beans, cern. In addition, as include other vegetables, fruits, whole grains, and discussed below, intake nuts. Bran, See Chapter 5 for a discus- sion of the role of supple- vitamin B12 is of concern although not a whole grain, is an excellent source ments and forti?ed foods. Potassium Dietary ?ber that occurs naturally in foods may help As described in Chapter 3: Foods and Food Compo- reduce the risk of cardiovascular disease, obesity, nents to Reduce, high intake of sodium is related to and type 2 diabetes. Adequate vitamin pro?les and glucose tolerance, and ensure normal D also can help reduce the risk of bone fractures. Fiber is sometimes added Although dietary intakes of vitamin D are below to foods and it is unclear if added ?ber provides the recommendations, recent data from the National same health bene?ts as naturally occurring sources. Most unique in that sunlight on the skin enables the body Americans greatly underconsume dietary ?ber, and to make vitamin D. Breads, rolls, buns, and pizza crust made with re?ned ?our are not In the United States, most dietary vitamin D is among the best sources of dietary ?ber, but currently obtained from forti?ed foods, especially ?uid milk contribute substantially to dietary ?ber consumption and some yogurts (Appendix 15). Natural sources of other vegetables, fruits, whole grains, and other foods vitamin D include some kinds of ?sh (e. Whole grains vary in herring, mackerel, and tuna) and egg yolks, which ?ber content. It also is available in the form compare whole-grain products and ?nd choices that of dietary supplements. Age groups of particular concern due Iron: Substantial numbers of women who are to low calcium intake from food include children ages capable of becoming pregnant, including adolescent 9 years and older, adolescent girls, adult women, as girls, are de?cient in iron. Milk and milk products contribute substantially to Sources of heme iron include lean meat and poultry calcium intake by Americans. Additional iron sources are non-heme tions may be achieved by consuming recommended iron in plant foods, such as white beans, lentils, and levels of fat-free or low-fat milk and milk products spinach, as well as foods enriched with iron, such as and/or consuming alternative calcium sources most breads and cereals. Women who are from the diet requires careful replacement with other pregnant are advised to take an iron supplement as food sources of calcium, including forti?ed foods. Folate: Folic acid fortification in the United States has been successful in reducing the incidence Vitamin D of neural tube defects. Many Americans do not eat the variety and Women who are pregnant are advised to consume amounts of foods that will provide needed nutri- 600 mcg of dietary folate equivalents70 daily ents while avoiding excess calorie intake. Sources of food folate include should increase their intake of vegetables, fruits, beans and peas, oranges and orange juice, and whole grains, fat-free or low-fat milk and milk dark-green leafy vegetables such as spinach and products, seafood, and oils. Folic acid is the form added to can help promote nutrient adequacy, keep calories foods such as fortified grain products. Consuming these foods is associated with a health Vitamin B12: On average, Americans ages 50 bene?t and/or with meeting nutrient needs. They provide an array of nutrients, includ- to absorb naturally occurring vitamin B12. However, ing those of public health concern: potassium, the crystalline form of the vitamin is well absorbed. It is important Therefore, individuals ages 50 years and older are that while increasing intake of these foods, Ameri- encouraged to include foods forti?ed with vitamin B12, cans make choices that minimize intake of calories such as forti?ed cereals, or take dietary supplements.
High-quality management of diabetes cannot occur in isolation from other co- existing physical or mental health disorders erectile dysfunction book buy levitra 10mg fast delivery, nor can management ignore age and socioeconomic issues erectile dysfunction herbal remedies buy generic levitra online. These comorbidities may or may not be diabetes related and awareness and treatment of comorbidities is related to erectile dysfunction doterra purchase discount levitra on-line better glycaemic control erectile dysfunction 16 buy levitra cheap online. Studies of symptomatic burden have found that adults with type 2 diabetes aged ?60 years report more physical symptoms such as acute pain and dyspnoea, and are more likely to have 80 General practice management of type 2 diabetes cognitive impairment and physical disability than those without diabetes. People <60 years report more psychosocial symptoms, such as depressed mood and insomnia. Within low socioeconomic groups, fnancial stressors may also play a role in treatment choices. Hence the management of diabetes should always be considered as part of a comprehensive management plan, which addresses whole-patient priorities. General practice management of type 2 diabetes 81 Approach to multimorbidity A number of comorbidities are commonly associated with diabetes (see Table 12. The best approach for a patient with multimorbidity is the subject of international debate. Unfortunately multimorbidity increases clinical complexity, which is unlikely to be effectively addressed by more sophisticated guidelines114,119–121 or the chronic care model. Recognise clinical context and prognosis Consider clinical management decisions within the context of risks, burdens, benefts, and prognosis of a patient’s life (e. Set treatment priorities with the patient Focus on outcomes that matter most to the individual. Shared decision making with patients is vital to ensure care is aligned with their values and preferences. Recognise the limitations of the evidence base Many of the patterns of multiple morbidity are concordant, having similar pathogenesis and therapeutic management strategies (e. Clinical guidance regarding discordant conditions such as steroid dependent conditions (which potentiate poor glycaemic control), mental health conditions, chronic pain, cancer or conditions that alter medication pharmacokinetics (e. The absolute harms and benefts of diabetic medications and burdens are not readily known in these populations. Other unknowns are the realistic estimate of beneft to the patient and the treatment horizon (i. General practice management of type 2 diabetes 83 Optimise therapies Polypharmacy (taking >5 medications) is one consequence of following single disease guidelines in people with multimorbidity. It is also associated with higher rates of adverse drug events and hospitalisation, and is often particularly problematic in people who are physically frail121 or have cognitive impairment. Adherence to therapy can be much more diffcult for patients taking numerous medications for multiple conditions. Painful conditions (both acute and chronic) are common in patients with type 2 diabetes. Arthritis is particularly problematic as it can reduce self-management capability (e. Arthritis (and any other cause of pain) can also affect the patient’s ability to engage in physical activity. Fractures – research has shown that overall fracture risks are signifcantly higher for both men and women with type 2 diabetes. The increased risk of hip fracture has been observed despite patients having higher bone mineral density. Obstructive sleep apnoea or sleep deprivation from any cause can aggravate insulin resistance, hypertension and hyperglycaemia. The usual approach to obstructive sleep apnoea is diagnosis via a sleep study and management with individualised interventions including continuous positive airway pressure. Driving licence requirements, particularly in commercial drivers, are particularly relevant. A growing body of evidence suggests that diabetes and some anti-diabetic treatments may increase cancer risk. Patients with diabetes should undergo appropriate cancer screening 84 General practice management of type 2 diabetes as recommended for all people in their age and sex. Patients should also try to reduce modifable cancer risk factors, including quitting smoking, losing weight and increasing physical activity levels. The presence of kidney disease worsens cardiovascular risk and limits the number of hypoglycaemic medication options available. Mental health issues such as diabetes-related distress, depression and anxiety are common. Rates of depression are increased by 15% in people with diabetes compared with people without diabetes. Olanzapine and clozapine are associated with higher rates of diabetes compared with other antipsychotic agents. Periodontitis can result in tooth loss and other dental complications that can interfere with the diet. Additionally there is a two-way relationship between diabetes and periodontitis – the management of periodontitis may lead to a modest reduction in HbA1c of approximately 0. Oral and periodontal health reviews should be incorporated in to the systematic individualised care of patients with diabetes. Early prevention and intervention may prevent permanent dental loss and help aid in glycaemic control. There will always be a tension between multiple drug therapy to approach recommended goals and health issues from polypharmacy, drug interactions and confusion (especially in the elderly). In 2007–08, 63% of people with diabetes reported using medications to help manage their condition; 13% of people with type 2 diabetes reported using insulin; and approximately 6% of people with diabetes reported using vitamin or mineral supplements or herbal remedies, although this is likely to be underestimated. It is important to understand the overall medication burden as it can lead to many issues including non-adherence, increased risk of falls and hypoglycaemia. Contributing factors to non-adherence may include cost, complex treatment schedules and side effects. Patients on prescribed monotherapy may be using complementary therapy or misusing their prescribed medication. Medication use, both conventional and complementary, should be reviewed at least once per year as part of the annual cycle of care. Pharmacists can be an invaluable resource as they have access to extensive medications databases, can detect potential drug interactions and provide useful advice to both the health professional and person with diabetes. Some drug interactions are dangerous and special care is required in older patients and patients with comorbidities such as renal impairment and autonomic neuropathy. A full list of potential drug interactions is beyond the scope of these guidelines. However, a summary of medications that can cause adverse events such as hyperglycaemia and those that can affect blood glucose levels are listed in Appendix K. Reporting of adverse events Many medications are becoming available for the management of diabetes for which long-term safety data is not yet available. Primary healthcare professionals have an important role to play in identifying and reporting adverse events and possible drug interactions. Home medicines review Multiple systematic reviews have concluded that there is a lack of evidence for improved health outcomes for medication reviews. Beneft has been proposed where pharmacists work in close liaison with primary care doctors. A survey of pharmacy customers found that 72% of respondents had used complementary medicines within the previous 12 months; 61% used prescription medicines daily and 43% had used these concurrently. Multivitamins, fsh oils, vitamin C, glucosamine and probiotics were the fve most popular complementary medicines. Of the medications used, approximately 42% potentially necessitated additional patient monitoring or could be considered inappropriate for patients with diabetes. Clinical manifestations include menstrual dysfunction, infertility, hirsutism, acne, obesity and glucose intolerance. Women with this disorder have an established increased risk of developing type 2 diabetes and a 2. Polycystic ovaries and exclusion of other aetiologies such as hyperthyroidism, hyperprolactinaemia, congenital adrenal hyperplasia, androgen-secreting tumours and Cushing’s syndrome. Clinical and/or biochemical signs of hyperandrogenism and exclusion of other aetiologies such as congenital adrenal hyperplasia, androgen-secreting tumours and Cushing’s syndrome.
This term represents a broad spectrum of men from those who identify as homosexual or gay erectile dysfunction my age is 24 levitra 20mg low price, to erectile dysfunction doctors in maine generic levitra 20mg with amex men who identify as bisexual erectile dysfunction 40 order cheap levitra line, to erectile dysfunction code red 7 buy levitra 10mg free shipping men who engage in sexual activity with other men but who identify themselves as heterosexual rather than homosexual or bisexual. Therefore, the health challenges vary considerably due to the risky nature of some sexual encounters. Transgendered men often face particular issues in relation to physical and psychological well-being (Lombardi, 2001). Obvious challenges arise for both men and women who find themselves trapped in a physical body that does not represent who they feel themselves to be. Recognition of the physical and emotional health challenges faced by individuals as they come to terms with their dissociation and as they go through possible therapy options by both practitioners and policy makers is important, not least as this is a significant equalities issue. London, Institute of Alcohol Studies Bajos N, Guillaume A, Kontula O (2003) Reproductive health behaviour of young Europeans. Volume 1 Strasbourg, Council of Europe Publishing Bauer R, Steiner M (2009) Injuries in the European Union: Statistics Summary 2005-2007. N Engl J Med 348:1625–38 Canadian Fitness and Lifestyle Research Institute (1996) The Economics of Participation in Prevention Bulletin No 10 Cavill N, Kahlmeier S, Racioppi F (2006). Journal of Physical Activity and Health 6:805-817 Department of Health and Children (2005) Obesity: The Policy Challenges. Hawkins House, Dublin Department of Health and Children (2008) National Men’s Health Policy: Working with men in Ireland to achieve optimum health and wellbeing. International Journal of Behavioral Medicine 13:153–162 Directorate General for Health & Consumers (2007) Attitudes Towards Alcohol. Journal of Studies on Alcohol 66:111-120 Edwards S, Launder C (2000) Investigating muscularity concerns in male body image: development of the Swansea Muscularity Attitudes Questionnaire. European Commission Eurobarometer (2006) health and Food Special Eurobarometer 246/ Wave 64. Brussels, European Commission European Commission (2009) Survey on Tobacco: Analytical Report. Journal of Social and Clinical Psychology 21:566-579 General Secretariat, Council of the European Union (2004) European Drugs Strategy (2005-2012). American College of Sports Medicine and the American Heart Association 116(S9):1081-1093 Haslam D, James W (2005). The Lancet 366:1197-1209 Helmchen L (2001) Can structural change explain the rise in obesity? Gender differences in relationships among perceived attractiveness, life satisfaction, and health in adults as a function of Body Mass Index and perceived weight. Psychol Men Masculinity 2:108-116 Medibank (2008) The cost of physical inactivity. American Journal of Public Health 94:96–102 Mladovsky P, Allin S, Masseria C et al. Psychology of Men and Masculinity 4(2):111-120 Mulhall J, King R, Glina S (2008) Importance of satisfaction with sex among men and women worldwide: Results of the Global Better Sex Survey. Journal of Sexual Medicine 5(4):788–795 146 Naska A, Fouskakis D, Oikonomou E et al. European Journal of Clinical Nutrition 60: 181-190 Nikula M, Koponen P, Haavio-Mannila E, et al. Journal of Epidemiology and Community Health 62(9):823-828 Parmenter K, Waller J, Wardle K (2000) Demographic variations in nutrition knowledge in England. Health Education Research 15(2):173-184 Pomerleau J, Lock K, McKee M (2006) The burden of cardiovascular disease and cancer attributable to low fruit and vegetable intake in the European Union: differences between old and new Member States. Public Health Nutrition 9(5):584-595 Shephard R (1996) Worksite fitness and exercise programs: a review of methodology and health impact. American Journal of Health Promotion 10(6):436-451 Signorelli C, Pasquarella C, Limina R et al. Toward public health nutrition strategies in the European Union to implement food based dietary guidelines and to enhance healthier lifestyles. The costs of illness attributable to physical inactivity in Australia: A preliminary study. Gottingen: Hogrefe Wellings K, Collumbien M, Slaymaker E (2006) Sexual behaviour in context: A global perspective. New York, Cambridge University Press Zuckerman M (1983) Sensation seeking and sports. There is evidence that some men use primary health services less frequently and are more likely to need hospitalisation for the principal causes of disease. There is also evidence that men do not use preventative services at the same level as women, which may be due to the availability of services only being available during the working day so inaccessible to many men. Men have higher levels of usage of the internet for health advice and are more likely to buy drugs through this route (and therefore more vulnerable through missed diagnosis and the rise of counterfeit drugs). Conversely men tend to show no difference to women with regard to presenting with symptoms of illness. Where services have been set up in ways that make access easier then men have used them and many have been shown to have high levels of hidden problems, both physical and emotional. Against a background of higher premature death rates among men for nearly the whole range of non-gender specific disease and illness, there is an urgent need for more targeted measures that enable boys and men to recognise their health risks and to take increased responsibility for managing their own health. There also needs to be an increased focus on how health services can be configured to be more successful at targeting men. That men’s lower contact rates with primary care services are offset by higher hospitalisation rates (Juel & Christensen, 2007) and when men do avail of primary care services, consultation times tend to be shorter than for women, and men tend to ask fewer questions (Courtenay, 2000). Men who are unemployed or in manual work tend to attend a doctor more often than those engaged in managerial or professional occupations (Office for National Statistics, 2004). Infrequent use of and late presentation to health services have been associated with men experiencing higher levels of potentially preventable health problems and having reduced treatment options (Banks, 2001; Fletcher at al. This is of particular concern in the context of men’s higher risk of developing and prematurely dying from a range of health conditions (White & Holmes, 2006). Increasing men’s use of primary care services is particularly important, since primary care is usually the gateway to accessing other healthcare services, and is a crucial link in the continuum of effective health service utilisation. In order to promote increased and more prompt usage of health services by men, it is important to identify potential limitations within existing services in not meeting men’s needs, and possible barriers within men themselves that may lead to a delay in seeking help. It is also important to identify where such barriers exist for men, in terms of the chain of events leading from perception of need through to attendance at primary care (Adamson at al. Consideration should also be given to the variability within and between men and in different help-seeking situations (Addis & Mahalik, 2003). The main differences in the provision of primary care between countries in Europe concern the presence or absence of registration with a general practitioner and the gate-keeper role of primary care (Thomas, 2005). When both of these features are present, health outcomes, in terms of morbidity and mortality tend to better (ibid). This accessibility gap between the highest and the lowest income quartiles is particularly pronounced in the new Member States (Alber & Kohler, 2004). There is also an accessibility gap between unemployed and retired people compared to those who are employed, with such disparities also being considerably higher in new Member States (ibid). There has been an increased focus on the issue of informal payments with regard to equity of access to health services. Despite universal coverage of the population by public health insurance, the authors report that informal payments are common and are a major source of inequity and inefficiency in the Greek health care system. Unofficial payments are particularly prevalent in the transition countries of Central and Eastern Europe (Gaal & McKee, 2005; Ensor, 2004). In Bulgaria, Balabanova and McKee (2002) demonstrate that the longstanding principle of comprehensive free coverage has been significantly eroded by ‘informal payments’, especially in the form of gifts. Such payments have stemmed from the low income of staff, patients seeking better treatment and acute funding shortages within the healthcare system. Men are less likely than women to report a long-standing illness or health problem (26% v 31%) or to be undergoing a medical long-term treatment (22% v 28%) (Eurobarometer, 2007 – Fig. Hypertension (35% for men, 152 37% for women) and muscle, bone and joint problems (17% for men, 28% for women) are cited as the most common reasons for medical long-term treatment. Hypertension is more of a problem in East-Central Europe and the Mediterranean, whilst muscle, bone and joint problems are more prevalent in East-Central Europe.
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