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In M1 patients weight loss pills 892 cheap 60 mg xenical visa, administration of anti-androgens as monotherapy A should not be considered weight loss groups buy cheap xenical 120 mg line. B Castrate Patients should not be started on second-line therapy unless their testosterone A resistant status serum levels are < 50 ng/dL weight loss pills excedrin buy xenical amex. No clear-cut recommendation can be made for the most effective drug for A secondary treatment weight loss pills gallatin tn xenical 120mg without a prescription. Bone protective agents may be offered to patients with skeletal metastases A (denosumab being superior to zoledronic acid) to prevent osseous complications. Calcium and vitamin D supplementation must be systematically considered when A using either denosumab or bisphosphonates. In patients with neurological symptoms, spinal surgery or decompressive A radiotherapy might be indicated as emergency interventions. Vulnerable patients (reversible impairment) may be given standard treatment after resolution of geriatric problems; 3. Advanced disease (locally advanced / metastatic disease) Evaluation of bone mineral status and prevention of osteoporotic fracture are recommended in 2b A patients at high-risk of fractures. Despite technical improvements, there is still a significant risk of cancer recurrence after therapy. It has to be emphasised that the treatment recommendations for these patients should be given after discussion with a multidisciplinary team. However, it must be stressed that most patients within the low-risk subgroup have an excellent outcome even without any salvage treatment. Therefore, the decision to treat these patients should be made after careful consideration of the pro and cons, taking into account the life expectancy of the patient and his expectations. Patients within the high-risk subgroup need early and aggressive salvage treatment [715]. However, more sensitive methods are needed to detect metastatic patients among candidates for local salvage treatment. In contrast, 11Cor 18F-Choline and 11C-Acetate have shown promising results in the early detection of local and distant recurrences [240]. However, their accuracy remains difficult to assess because most published studies are retrospective, evaluate heterogeneous populations (often mixing recurrences after various types of primary treatments), use non-standardised definitions of biochemical failure and are limited by the lack of a reliable histological gold standard. Furthermore, results may be reported on a per-patient or a per-lesion basis and may combine the detection of local recurrences and distant metastases [240]. Recent studies report overall sensitivities and specificities of 55-96% and 57-100%, respectively [240, 722-724]. One study found a sensitivity of 64%, a specificity of 90%, a positive predictive value of 86% and a negative predictive value of 72% [728]. The main explanation for the low sensitivity was the lack of detection of micrometastases in lymph nodes. In contrast, others found poor specificity with a 30-47% false-positive rate [729-731]. However, 18F-Fluoride is limited by a relative lack of specificity and by the fact that it does not assess soft-tissue metastases [248]. Therefore, the role of these techniques in detecting occult bone or lymph node metastases in the case of biochemical failure remains to be assessed. The dose delivered to the prostatic bed also tends to be uniform as it has not been demonstrated that a focal dose escalation at the site of recurrence improves the outcome. Given the morbidity of local salvage options, it is thus necessary to obtain histological proof of the local recurrence before treating the patient [718]. However, more recent data suggest that higher total doses can achieve higher rates of biochemical control at 3-5 years [757]. However, depending on the applied techniques and accepted constraints, a satisfactory consensus has not yet been achieved. Intermittent androgen deprivation provided potential benefits with respect to physical function, fatigue, urinary problems, hot flushes, libido, and erectile function. In these patients, the median actuarial time to the development of metastasis will be 8 years and the median time from metastasis to death will be a further 5 years [363]. As a general rule, strong recommendations regarding the choice of any of these techniques cannot be made as the available evidence for these treatment options is of (very) low quality. The following is an overview of the most important findings regarding each of these techniques with a proposal for their indications. However, this must be weighed against the possible adverse events, which are increased compared to primary surgery because of the risk of fibrosis and poor wound healing due to radiation. The authors compared the oncological outcomes of the two salvage treatment options after mean follow-up periods of 7. In addition, 8-40% of patients reported persistent rectal pain, and an additional 4% of patients underwent surgical procedures for the management of treatmentassociated complications. However, the published series are relatively small, therefore this treatment should be offered in experienced centres only. The biochemical relapse-free survival after 5 years was 69% (median follow-up 36 months). Grade 2 late side effects were seen in 15% and one patient developed Grade 3 incontinence. However, the crude rate of > grade 2 toxicity was 46% and > grade 3 toxicity was 11%. These side effects were comparable with a series of 31 patients treated with salvage 125I brachytherapy in the Netherlands. Important complication rates were mentioned and are at least comparable to other salvage treatment options. The 5-year metastasis-free survival rate was 88% with hormone therapy versus 92% with watchful waiting (p = 0. In such patients occult micro-metastasis might exist, but are usually undetectable using conventional methods [824]. Although 33% will develop bone metastases within 2 years [825], there are no available studies suggesting a benefit for treatment. These factors may be used when deciding which patients should be evaluated for metastatic disease. However, in the absence of prospective data, the modest potential benefits of a continuing castration outweigh the minimal risk of treatment. In addition, all subsequent treatments have been studied in men with ongoing androgen suppression and therefore it should be continued indefinitely in these patients. Side effects related to mineralocorticoids and liver function were more frequent with abiraterone, but mostly grade 1/2. The predictive factors were visceral metastases, pain, anaemia (Hb < 13 g/dL), bone scan progression, and prior estramustine before docetaxel. Sipuleucel this an active cellular immunotherapy agent consisting of autologous peripheral blood mononuclear cells, activated in vitro by a recombinant fusion protein comprising prostatic acid phosphatase fused to granulocyte-macrophage colonystimulating factor, which is an immune-cell activator. The overall tolerance was acceptable, with more cytokine-related adverse events in the Sipuleucel T group, but the same grade 3-4 in both arms. As the number of effective treatments available increases and without head to head trials or data assessing the effectiveness of different sequencing options it is not clear how to choose the first “second-line” treatment. In the absence of other data, the inclusion criteria from licensing trials have been used to prioritise treatment sequencing. Eastern Cooperative Oncology group performance status was used to stratify patients. Several groups have used second-line intermittent docetaxel re-treatment in patients who had clearly responded to first-line docetaxel. Main side effects outcomes: More mineralocorticoid adverse events with abiraterone. Patients received a maximum of 10 cycles of cabazitaxel (25 mg/ m2) or mitoxantrone (12 mg/m2) plus prednisone (10 mg/day), respectively. This drug should be administered by physicians with expertise in handling neutropenia and sepsis, with granulocyte colony-stimulating factor administered prophylactically in the high-risk patient population. The benefit was observed irrespective of age, baseline pain intensity, and type of progression.
Doctors who have access to weight loss pills approved fda buy xenical with mastercard prisoners in custody have a heavy responsibility to weight loss pills ketone buy generic xenical 120 mg line ensure that they are properly treated during detention and interrogation weight loss vitamins cheap xenical line. In all cases of suspected or alleged ill-treatment of prisoners weight loss 360 quality xenical 120mg, it is essential that the doctor carry out a methodical and detailed “head-to-toe” examination. All injuries and marks must be accurately recorded and photographed, and the appropriate authorities must be informed immediately. Increasingly, forensic physicians are involved in assessments of refugees and asylum seekers to establish whether accounts of torture (both physical and psychological) are true. This role is likely to expand in the future, and the principles of independent assessment, documentation, and interpretation are, as with other 150 Payne-James et al. Introduction the term bite mark has been described as “a mark caused by the teeth alone, or teeth in combination with other mouth parts” (10). Recognition, recording, analysis, and interpretation of these injuries are the most intriguing challenges in forensic dentistry. Biting can establish that there has been contact between two people—the teeth being used for offense or defense. When individual tooth characteristics and traits are present in the dentition of the biter and are recorded in the biting injury, the forensic significance of the bite mark is greatly increased. Early involvement of the forensically trained dentist, with experience in biting injuries, is essential to ensure that all dental evidence from both the victim and any potential suspect(s) is appropriately collected, preserved, and evaluated. There may be insufficient evidence to enable comparisons to be made with the biting edges of the teeth of any particular person, but, if the injury can be identified as a human bite mark, it may still be significant to the investigation. It is important that the forensic dentist discusses with investigators the evidential value of the bite mark to enable resources to be wisely used. Clearly, conclusions and opinions expressed by the forensic dentist often lead him or her into the role of the expert witness subject to rigorous examination in court. The forensic physician will mostly be involved with biting injuries to human skin and any secondary consequences, including infection and disease transmission, but should be aware that bites in foodstuffs and other materials may be present at a crime scene and be easily overlooked. It is essential that a human bite can be distinguished from an animal bite, thus exonerating (or incriminating) the dog or cat next door. The following sections will consider issues surrounding bites to human skin caused by another human. Early recognition of a patterned injury (suspected of being caused by biting) by medical personnel, social services, and other investigating agencies is extremely important; the injury may be the only physical evidence and must not be lost. Ideally, the forensic dentist should be contacted sooner rather than later when a possible biting injury is discovered to ensure that all evidence is collected appropriately. All too often the dentist is brought in at a later date, when there has been incorrect recording of the bite mark and the injury is partly healed and distorted or fully healed and no longer visible. Reliance may then have to be placed on ultraviolet photography to demonstrate the “lost” injury (11). Injury Assessment 151 Bites can be found on the victim or the assailant (living, deceased, child, or adult). It is well known that biting is often a feature in nonaccidental injury to children (see Chapter 5). If a bite mark is found on an anatomical site that is accessible to the victim, it becomes necessary to exclude him or her from the investigation. If the answer to the first question is “don’t know,” “possibly,” or “yes,” then request the assistance of the forensic dentist. Ensure that swabs are taken from the injured site (with controls) and photographs should be taken. Make sure that you know which forensic dentists are available in your area; this will prevent delays and frustration. You will need to know whether your local forensic dentist has experience and training in bite mark-analysis or whether he or she focuses mainly on identifications. The forensic dentist will examine the suspected biting injury and consider the following: • Whether the injury is oval or round. However, note that a mark from only one arch does not mean that it is not a biting injury. Characteristics, such as tooth size, shape, displacement, rotations, wear facets, etc. Differential Diagnosis It is important to remember that other injuries can mimic bite marks. The following have all been queried as biting injuries: • Dermatological conditions. In a single bite mark, one or any combination of several or all of these components may be present, and they may be discrete or superimposed. However, the complex situation may become even more complicated when there are multiple bite marks at a single location where they may overlap as a result of the biter trying to get a better “grip;” all this leads to interpretation difficulties. In attempting to get answers to these questions, a clearer picture of the incident may develop. Anatomical Distribution of Bitten Sites It can be seen from the anatomical distribution of the bite marks studied by the author (see Fig. This graph does not distinguish between male and female, child or adult, or whether there were multiple bites to one person, but serves purely to illustrate that it is essential for medical personnel to thoroughly examine the body for biting injuries and carefully document the findings. Record the anatomical location and nature of the injury and its size, shape, and color. In many cases, there are multiple bite marks on the body, some that the victim may not be aware of or recall. Multiple bite marks on the body, produced by the same perpetrator, may vary Injury Assessment 153 153 154 Payne-James et al. In short, do not jump to the conclusion that there are multiple biters or vice-versa. Nor should it be assumed that a small biting injury has been caused by a child; it may be an incomplete adult bite. If the marks on the skin can be identified as being made by the smaller deciduous (baby) teeth, it would suggest the mark has been inflicted by a young child. Evidence Collection As soon as it has been established that the injury has been caused by biting, the injury should be photographed and swabbed for saliva. In addition, it may be necessary to take an impression of the injured site to preserve any possible indentations. Clearly, the taking of forensic samples is not always possible when the injured party needs urgent medical attention. Often, the forensic dentist is provided with photographs taken some time after the incident date and after medical intervention (see Fig. Saliva Saliva is deposited on the skin (and clothing, if present) during biting and sucking. The saliva swabs (with controls) must be clearly and correctly labeled and stored appropriately (see Chapter 3). Oral saliva samples will be needed from any potential suspect, and the victim of an assault if there is a possibility that the victim bit the assailant (or self-infliction is suspected). It is essential for correct photographic procedures to be followed to minimize distortions. Police photographers experienced in crime scene and other injury photography may still find the assistance of the forensic dentist useful, because Injury Assessment 155 Fig. Skin is not the best impression material, and various papers and reports have shown the importance of photographing the victim in the same position as when bitten in an attempt to minimize distortion (15,16). Changes in the injury with time (in both the living and the deceased) may mean that the injury pattern appears clearer after a day or two. There is no reliable way of knowing when an injury will reveal the most detail, and, therefore, repeat photography. Photograph Protocol • Anatomical location of bite mark (and identification of bitten person). Ultimately, the forensic dentist will select the best photographs and have them reproduced to life-size (1:1) for analysis and comparison work. At the time of writing, conventional film photography is still widely used, but the use of digital photography is progressing rapidly. Whatever the future brings, it is essential that standards, protocols, and appropriate training are in place. Dental Impressions Dental impressions taken from the potential biter by the dentist (or appropriately qualified person) after a thorough dental examination will be cast into hard dental models. Dental impressions taken of an individual in custody are intimate samples and require the appropriate authority and consent for your jurisdiction.
These appropriate intradermal level with the practitioner overcorproducts contain 0 weight loss virtual model generic xenical 60 mg overnight delivery. Nonetheless weight loss pills lipodrene order 60 mg xenical visa, these products are well tolerated by benefit from the thicker Zyplast product weight loss pills kardashians 60mg xenical visa. Note intradermal implantation with yellowish discoloration as the material flows into the dermis weight loss pills 30 days order xenical 120mg line. The company reports the use of a novel matrix of Hyaluronic acid fillers can be used in the treatment of acne cross-linking, which gives a longevity of up to 1 year. One caveat is that these fillers, if placed too high in the has a role in treating acne scarring, but it is a thick product. This has been particularly should be massaged when placed into the tissue and may have a noted with the Restylane family of products. They can be used in the midproduct, Evolence Breeze, has a better role for treatment of acne dermis to the subcutaneous dermis with some large particle-type scars. This product is available in Europe, but is not yet availhyaluronic acids placed deep within the tissue to revolumize the able for use in the United States. There are a variety of injectable hyaluronic acid products Hyaluronic Acids available. They can be differentiated by (a) molecular weight, Hyaluronic acids are a natural filler substance particularly (b) concentration, (c) method and degree of cross-linking, suited for treatment of aging skin. Hyaluronic acid is a major (d) particle versus monophasic technology, (5) avian versus component of the extracellular matrix, a polysaccharide with bacterial origin. However, most practitioners mix a small Sculptra has been directly shown to benefit acne scars amount of lidocaine in with the hyaluronic acids by the use of directly in a report by Beer. Hyaluronic acids are an excellent filler in that they are long Subjects also noted a gradual improvement. Sadove (17) also lasting, naturally appearing, smooth to the touch, rarely allerreported success in atrophic acne scarring using Sculptra in genic, and can be reversed with the use of hyaluronidase. Calcium hydroxyapatite However, these products must be placed in the lower portion of Calcium hydroxyapatite is a naturally occurring substance used the dermis in order to “lift” the normal-appearing dermis up to for over a decade in reconstructive surgery. The monophasic technology of the Juvederm semipermanent biodegradable soft-tissue filler composed of family of products is much preferable in that it tends to integrate calcium hydroxyapatite microspheres in a gel carrier. This prodthis product better into the dermal collagen; the particle product is useful as a deep-volume filler that also builds new colucts such as Hylaform, Captique, or Restylane and Perlane may lagen. It is helpful in acne scars by building up new subdermal tend to agglutinate within the scar (data awaiting publication). The product is Mid-face volumizing with hyaluronic acids can be helpful in placed deeply, in the immediate subcutaneous plane or deeper, a patient with acne scarring that has an accentuation due to voland the gel carrier is gradually phagocytized, leaving the calcium ume loss. The Restylane SubQ product has allows fibroblasts to attach to the scaffold and lay down a colthe same properties as Restylane products, except that the gel lageneous extracellular matrix that becomes integrated into the particle sizes are larger compared to Perlane. The microspheres are the Juvederm family of products, is a monophasic, 20-mg/ml gradually metabolized over a period of 9 to 18 months. These products are used very similarly Radiesse is a robust filler with good lift capacity. The syringe comes with Hyaluronic acids also have the advantage of being revers1. Hyaluronidase can be used to melt implanted hyaluronic retrograde injection technique should be employed into deep acid. This is commonly done if pooling, ridging, or nodules tissues or the subdermal plane. Radiesse can be a wonderful initial volumizing filler, with Poly-l-lactic acid is a biodegradable, synthetic polymer, molecucollagen or hyaluronic acids used on top of the Radiesse. When injected into the subcutaneous Fat transplantation (22, 23), or the idea of moving fat from one tissue poly-l-lactic acid causes immediate and delayed volume portion of the body to another, has a more than 100 years hisrestoration. Modern techniques of fat transplantation have roots back edema, but gradually fibroblast proliferation and neocollagenesis to 1976 when the idea of suctioning fat was developed by the is formed. Using tumescent anesthesia, fat can be readily harvested injection technique in order to increase volume of the deep tisand transferred to a syringe for reimplantation. It is important to note that there have been several reports be helpful in acne scarring by restoring the loss of subcutaneous of papule and nodule development, and these have been related fat and replacing volume, which stretches the overlying skin and to either intradermal injection or placement under thin skin, distends the acne scars. Depending on the degree of revolumization, anywhere benefit from a pan-facial lipoaugmentation concurrent with the from 2 to 6 vials of Sculptra may be needed. Calcium hydroxyapatite was used deeply, and, after 6 weeks, was superficially overlaid with Cosmoderm injectable collagen. Donor fat is extracted from a donor site with common areas Silikon-1000 is commonly used legally off-label for this purbeing the thigh, buttocks, or inner knee. It became more widely used in the 1970s and 1980s, tial to not disrupt the adipocytes. In local anesthesia, a No-Kor needle, and a blunt-tipped 18-gauge the 1980s, mounting cases of adverse events led health authorifat infiltrator. The goal is to place multiple tiny deposits of harties to investigate the cosmetic safety of this product. Opponents advocate that in the number at the end of the brand name, is expressed in cendespite use of proper technique and products, serious adverse tistokes (cS) units, with 100 cS being the viscosity of water and events are common and unpredictable. However, for the unique and disfiguring defects and up to 2 ccs for larger areas of atrophy) at each sesdefects associated with serious acne scarring, patients and physion with multiple sessions staged at monthly intervals or longer. Acne scarring: a review of current treatment and permanence in improving and/or correcting these types of modalities. Skin conditions and related need a history of acne scarring who showed improvements from for medical care among persons 1–74 Years, United States, injections of liquid silicone at the initial treatment session and 1971–1974. Acne scarring: a classificadescribe the safety, effectiveness, and precision of silicone in tion system and review of treatment options. J Am Acad addition to highlighting the fact that its permanence is what Dermatol 2004; 22: 434–8. In vivo stimulation of that liquid injectable silicone is a precise and permanent filling De Novo collagen production caused by cross-linked substance used for soft-tissue augmentation and can improve hyaluronic acid dermal filler injection in photodamaged and/or eliminate depressed, broad-based acne scars with the human skin. Skin filling: collagen and other injectables of the Furthermore, in a recent testimony, 35 skin biopsies obtained skin. Injectable collagen for correction of depressed facial scars were examined by light soft tissue augmentation. Facial Plast Surg 2004; bilateral, prospective comparison of calcium hydroxy20: 125–8. Volumizing effect of a new hyaluronic acid for soft tissue augmentation of nasolabial folds and sub-dermal filler: a retrospective analysis based on 102 other areasw of the face. Facial Plast Surg for harvesting, preparation, application and perception of 2009; 25: 95–9. A single-center, open-label study on the use of polyfied 1000-cSt silicone oil for treatment of human immuL-lactic acid for the treatment of moderate to severe scarring nodeficiency, virus-associated facial lipoatrophy: an open from acne on varicella. Treatment of acne scars with liqfor the treatment of dermal fat atrophy after severe acne. DerRadiographic and computed tomographic studies of calcium matol Surg 2007; 33(Supp 2): 5186–92. The ment as an alternative to laser, chemical peelings, and results of repetitive sessions on scars were reported by Camirand dermabrasion. The epidermis and particularly and the holes in the epidermis were too close and too shallow. All these techniques worked because the needles break old col• There are no risks of hyperpigmentation. Performed under local anaesthetic with sedation, the getting the information out to the medical community. This promotes the normal wound healing that his results in Baran’s Cosmetic Dermatology in 1994, but his develops in three phases (Figure 9. In 1995 Orentreich and Orentreich (1) described other platelets, leucocytes, and fibroblasts. After the platelets have ‘‘subcision’’ as a way of building up connective tissue beneath been activated by exposure to thrombin and collagen, they release retracted scars and wrinkles. This process involves a complex concatenaneously and independently, used a similar technique to treat the tion of numerous factors that are important in upper lip by inserting a 15-gauge needle into the skin and then tunneling under the wrinkles in various directions, parallel to 1. After neutrophils to pass through the vessel walls and enter the 1 to 2 years, they noticed that even though the pigment was long damaged area; gone, it was replaced by actual melanin, while the scars were 3.
Syndromes
- Common peroneal nerve dysfunction
- Loud breathing
- Sodium blood test
- Diarrhea
- Addison disease
- Spread of the tumor into surrounding areas
- Iron overload (hemochromatosis)
As he finds that his ejaculation is controllable weight loss smoothie recipes cheap xenical 60 mg without a prescription, he no longer becomes anxious about his performance weight loss 1 week cheap 120mg xenical free shipping. Third weight loss workout plan order xenical 60mg mastercard, he learns to 7 weight loss pills 60 mg xenical otc prolong the pleasure of arousal for longer periods of time, which gives his wife more opportunity for enjoyment as well. What about the man suffering from premature ejaculation who blames his wife for not being sexy enough to reach orgasm in the brief time of their intercoursefi A man with this attitude needs more than mechanical training, such as the squeeze-technique exercises. He needs to develop a whole new view of the lovemaking process, which will change his entire approach. The greatest problem stems from the man’s belief that once he has ejaculated, the sex act is over. As he becomes aware of his wife’s needs for love and tenderness and a good physical climax, and as he learns to meet those needs, the cycle of failure and anxiety and resentment and frustration will be broken—even before ejaculatory control is attained. This is medically described as the inability to ejaculate during intercourse at least one-quarter of the time. Erectile dysfunction is the inability to gain an erection when you want it at least half of the time. It can be a psychological factor that inhibits the ejaculatory response just as though the patient anticipated punishment by an electric shock each time he ejaculated or even had an impulse to ejaculate. In some cases there simply is not enough physical stimulation at the glans of the penis in intercourse. Well-lubricated manual stimulation of the glans of the penis by the wife may be necessary. Note that in chapter 13 we said that elderly men do not always need to ejaculate and should not force it. This is different from the inhibited ejaculation suffered by some younger men, who may suffer pain if ejaculation is inhibited. What can be done about the problem of urine continuing to drain from the penis after a man has finished urinatingfi The narrowest part of the man’s urethra, the tube from the bladder to the outside, is just below the prostate gland and is called the membranous urethra. Just below this part is the section called the bulb of the urethra, which is of larger diameter. The urine remaining in this part of the urethra can be easily forced out by placing the fingers behind and above the scrotum and in front of the anus and then pressing upward and forward very firmly. The man with this problem will need to practice this and experiment to find the exact spot to push to help himself. Many people seem to think that elderly folk who are still interested in sex are abnormal. People should get rid of their myths about the elderly and let the elderly be themselves—ordinary people with sometimes an extra need for love and affection. The young will eventually learn that they have no exclusive rights to love and marriage. Researchers have shown that normal interest in and capacity for sex continue into the eighties. It’s much harder to explain sex organs to little girls than to little boys, who can see their penis. The right words should be used without any note of reserve or defensiveness: vagina, uterus, and so forth. It should be explained that her organs are tucked away inside her, that this is God’s special plan to provide a very important place where a baby can start growing from a seed. If she questions differences between herself and a brother, explain that a little boy cannot have a baby, but that a little girl can someday have a baby and nurse it. All answers to children’s questions should be straightforwardly given, communicating that we are God’s creation and He has a perfect plan for men and women as the background of all information on sex. Children get much of their knowledge about sex from other children in the form of “dirty words. Even though there is no actual entrance of the penis into the vagina, or even contact with the vagina, it is possible for enough semen discharged around the outside of the vagina to get inside and produce a pregnancy. I have been responsible for the obstetrical care of three virgins who became pregnant this way, even though two of them did not know what intercourse was. She was playing with a friend and did not realize she was pregnant until in her sixth month. Gabriel Nahas, author of the book Keep Off the Grass, reports that the chemicals in marijuana can cross the placenta and reach the unborn child. Laboratory tests with four different kinds of animals show that there is a higher incidence of abortion and other abnormalities when the animals are given a dose of marijuana equivalent to one joint a day. The effects of all 421 have not been determined, and there are additional ingredients to be isolated. Why is the herpes virus infection so dangerous when the mother is infected at the time of her baby’s birthfi One-half of all newborns who are infected during passage through the vagina die shortly thereafter. Do you have any suggestions for the pastor who wishes to give helpful instruction to couples who come to him for premarital counselingfi The need is great for more Christian premarriage counseling, which presents both the necessary physical information and the biblical principles of marriage. Several courses online from Baptist Bible College on solving marriage problems, sexual dysfunctions, and premarriage counseling taught by Dr. But the secular world has become preoccupied with physical technique; much of the Christian world is debating the implications of the biblical order of relationships in Ephesians 5; and seldom does anyone venture into the area between, where the dynamics of the sexual union in marriage are considered—not physical techniques, not the deep underlying principles, but how two people committed in marriage actually interact in love to approach the “one flesh” experience. After the Bible has dealt with the basic order of husband and wife (sacrificial love and submission), it leaves much to our own understanding concerning these dynamics of the sexual relationship. The Bible’s silence does not imply that the last word has already been said, but rather that God in His vast good sense allows each of His creatures to explore the unlimited possibilities inherent in the relationship He Himself thought up. These unlimited possibilities somehow converge into an offering that two people make of themselves to each other, an offering that reflects all that they are separately and all that they will become together. Without trying to pin down the specifics, which will be as different in every marriage as the individuals involved, we can make these observations about the dynamics of the sexual relationship between man and wife. First, the sexual relationship is meant to be full of life, rich in emotion, and ever changing within the security of the marriage commitment. When lovemaking takes on a tiresome sameness of routine, both partners may feel a vague sense of dissatisfaction with unnamed longings, even though they do not realize that something precious is missing. That missing something, of course, is the free and active expression of a living love! Sometimes a dull routine develops because either husband or wife fears change and tries to keep the act of love static as a security measure. The choice becomes another form of burying one’s goods in the ground, because one is “afraid. What keeps the relationship vital and moving is a joyous pattern of mutual response, the kind we see pictured in the ever-changing relationship of Solomon and his bride in Song of Solomon. The two lovers had periods of almost indescribable pleasure interspersed with changes of fortune and diversities of feeling. Then after he had turned away, her heart was moved for him, and she sought him until they were reunited. Their reunion became a glorious blending of mutual pleasure, as he poured forth words of intense appreciation: “How fair and how pleasant art thou, O love, for delights! Those almost perfect moments that sometimes happen between lovers tempt us to become collectors, trying to capture and repeat our favorite experiences. They are pleasant to remember, but a clinging to the past often causes us to miss out on the new delights that are still ahead. The time when our love relationship is admittedly less than perfect will always leave room for movement toward each other. As long as we are committed to each other, we need not fear the constant change within marriage, the ebb and flow of the relationship of two lovers, for it is a sign of life.
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