Learn about Erectile Dysfunction and Sildenafil Citrate Online

Have you ever wondered how sildenafil acts within your body to help you solve your problems with erectile dysfunction?  Thanks to the instant availability of the Internet and computer devices, you will now be able to learn about ED and sildenafil citrate online right at your fingertips.

If you are curious as to how PDE5 inhibitors such as sildenafil work inside your body, then you can browse on search engines by simply typing in the search box the words sildenafil citrate online.  When you read about the mechanics of the action of sildenafil citrate online, you will learn that it helps protect the enzyme cGMP (short for cyclic guanosine monophosphate) from being degraded by the cGMP-specific PDE5 (short for phosphodiesterase type 5 enzyme) which are evidently located in the penile corpus cavernosum of men.  The free radical NO (short for nitric oxide) found in the penile corpus cavernosum adheres itself to what are called the guanylate cyclase receptors, which then results to the occurrence of elevated amounts of cGMP, thereby leading to the vasodilation or relaxation of the smooth muscles of the inner lining cushions of the helicine arteries (tendril-like arteries of the penis importantly involved in the process of its erection).  Once the smooth muscles relax, it will result to vasodilation and therefore there will be an increased supply of blood flowing into the penile spongy tissue, and the end result would be a successful penile erection.

Additionally, what you would also learn about sildenafil citrate online is that its special molecular makeup is somewhat similar to cGMP (located in the penile corpus cavernosum as well) and functions as an aggressive binding element of PDE5 in the penile corpus cavernosum, which results to more concentrations of cGMP and even better occurrences of erections. Avery important information that men will learn through reading about sildenafil citrate online is that sildenafil will be rendered useless without the introduction of one or more sexual stimuli, since only a sexual stimulus will be the only factor that can initiate the activation of the nitric oxide and cGMP inside a man’s body. Read more…

CMA's resolution-mad meeting: the digested read

The CMA's had a busy week, at its .

How busy? Well, they passed 108 resolutions in just three days.

To save you the trouble of having to read through all three days'-worth (see , , , if you really want to), we here at NRM did the hard work and whittled them down to a nice concise Top 15.

A quick glance at some of these issues can give you a good idea of what are likely to be some of the newsworthy issues in Canadian health politics over the next year (aside, of course, from the widely reported and continuing debate over privatization). We've also provided some suggestions for further reading, in italics.

Top 15 CMA resolutions of 2007:

  • Home ops The Canadian Medical Association will develop a policy framework and design principles for access to publicly funded medically necessary services in the home and community setting that can become the basis for urging governments to develop a Canada Extended Health Services Act.
  • Pharmacare The Canadian Medical Association urges governments, in consultation with the Canadian Life and Health Insurance Association and the public, to establish a Catastrophic Prescription Drug Program to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies. [PEI's Dr Scott Cameron pushed this issue ahead, and .]
  • Rare diseases The Canadian Medical Association urges the federal government to establish a program for access to expensive drugs for rare diseases that are either part of the Special Access Program or have been approved by Health Canada.
  • Home care The Canadian Medical Association and its provincial/territorial medical associations and affiliates recommend that governments undertake pilot studies to support informal caregivers and long-term care patients, including those that:
    A) explore tax credits and/or direct compensation to compensate informal caregivers for their work;
    B) expand relief programs for informal caregivers that provide guaranteed access to respite services in emergency situations;
    C) expand income and asset testing for residents requiring assisted living and long-term care; and
    D) promote information on advanced directives and representation agreements for patients. [Crowded hospitals mean patients get tossed out earlier than they used to be, so home care is becoming .]
  • Pharmacist prescribing The Canadian Medical Association recommends that pharmacists not be given independent prescribing authority. [Pharmacists were .]
  • Chronic illness The Canadian Medical Association calls on governments to implement organizational and financial incentives for better management of patients with chronic diseases.
  • Pay for performance The Canadian Medical Association will prepare for presentation to General Council in 2008 a research paper that compares health outcomes in physician payment models in the delivery of primary and specialty care. [P4P, ()?]
  • Hospital funding The Canadian Medical Association will work with the federal government to commission a strategic peer-reviewed research competition to assess the international experience with service-based funding for hospital services through the use of case-mix groups or diagnosis-related groups. [For more on this, check out NRM's reporting on and BC's recent announcement of a pilot project.]
  • Going green The Canadian Medical Association calls on the federal government to provide funding and/or tax incentives to assist the health care sector and health care professionals to adopt more environmentally sensitive practices. [Conservative cuts to enviro-friendly programs last year.]
  • Support for GPs The Canadian Medical Association will study the "gap in generalism" and collaborate with other stakeholders to identify proactive measures that will help to fill the gap and enable generalists to thrive in our health care system. [The FP shortage was one of the reasons .]
  • Drug ads The Canadian Medical Association urges the federal government to strengthen laws that ban direct-to-consumer advertising of prescription drugs to prohibit the "disguised" advertisements that promote drugs without naming them. [This item, underreported in the press lately, may be coming to a head soon. CanWest is suing the government to overturn the current drug-ad laws, according to the Globe and Mail.]
  • IMGs The Canadian Medical Association supports a national standardized assessment protocol to evaluate international medical graduates. [Remember from earlier in 2007? It's not going away anytime soon.]
  • Smoke tax for health The Canadian Medical Association and its provincial/territorial medical associations urge governments to allocate all taxes collected from tobacco products toward health care for Canadians.
  • Butt out in cars The Canadian Medical Association urges all levels of government to implement a Canada-wide ban on smoking in vehicles carrying children. [George Smitherman who smoke with kids in the car.]
  • Whistleblower protection The Canadian Medical Association will develop and advocate strongly for the implementation of policy to safeguard physicians from fear of reprisal and retaliation when speaking out as advocates for their patients and communities. [A pressing matter, considering one Alberta doctor who was this past year for speaking out about cancers caused by oilsands development.]

Photo:
Check out our website:

Not in our name: pro-Medicare docs blast CMA

president Dr Danielle Martin (right) and resident-board member Dr Simon Turcotte, blasted the Canadian Medical Association over its declaration of support for private healthcare at its controversy-laden annual meeting in Vancouver this week.

In their op/ed to Montreal daily Le Devoir earlier this week, Drs Martin and Turcotte :

En tant que médecins et membres de l'AMC, nous devons demander à notre association pourquoi elle ne fait pas la promotion de solutions qui accroîtraient l'accès aux soins en fonction des besoins, dans le cadre du régime public, où les ressources médicales sont souvent sous-utilisées? Pourquoi l'AMC maintient-elle sa proposition de pratique mixte et d'assurance-maladie privée, qui auront pour conséquence de drainer hors du système public le personnel infirmier, les techniciens et autres dont il a besoin? Pourquoi l'AMC ferme-t-elle les yeux sur les données probantes, sur les risques que poserait le développement d'un nouveau marché des soins de santé?

Au cours de son assemblée, l'AMC aura l'occasion de faire preuve d'une approche plus constructive lors des discussions portant sur les soins à domicile, l'assurance-médicaments et la santé environnementale, de manière à améliorer et à moderniser le système de santé financé publiquement, pour le rendre apte à répondre aux besoins de tous, non seulement des mieux nantis.

Les récentes sympathies de l'AMC pour l'assurance privée et la pratique mixte ne figurent pas à l'ordre du jour des débats en assemblée; leur sort devrait s'apparenter à celui des mauvais remèdes, rapidement rejetés.
Translation, in short: For the public good, doctors must oppose the CMA's recent policy-efforts, which would benefit the well-off and do not address the well-being of the population at large. Policies that threaten to weaken the public system should be rejected.

Check out our website:

Drug diaries: I'll show you mine if you show me yours

Writing on his healthcare implementation and compliance blog , Alignmed, psychiatrist Dr Allan Showalter offered to NRM for our recent article about drug diaries (“,” Vol 4, No 13, July 30, 2007).

Dr Showalter liked our version of the diary (click for a printable PDF copy), and shared his own version (above) on his site.

Check out our website:

How to beat RateMDs, Round 2

This flashy little animated ad*, left, has recently begun popping up on leading medical blog , tempting physicians with the promise of a way to fight back against the much-maligned ratings site RateMDs.com.

The company advertised, , is an American medical malpractice insurance firm that specializes in fighting back against threatened lawsuits by threatening patients with counter-suits. (We wrote about Medical Justice on this blog last month here.)

:

In Florida, physicians are sued at a rate of 15% per year. (FPIC 2004 Q1 statistics, Crittenden)

Matched by specialty, the overall suit rate for Medical Justice Plan Members practicing in Florida is less than 2%.
The company, founded by Dr Jeffrey Segal (right) recommends a against would-be malpractice litigants: One, deter frivolous lawsuits. Two, warn perpetrators with a strategic Early Intervention Program. Three, prosecute counterclaims when necessary.

Is this merely deterrence or is it intimidation? Depends on your perspective. Patient advocate/website designer John Swapceinski (left), of RateMDs fame, is furious about the company's idea of having doctors ask patients to sign nondisclosure agreements before agreeing to treat them. The idea is that if a doctor proved that all his or her patients had signed such agreements then even an anonymous posting on RateMDs.com would have to be a breach of contract, thus giving physicians ammunition in the fight to remove negative ratings from the website. “I would have a real problem with that and I would try to put up a fight to prevent that from happening,” .

After that interview, Mr Swapceinski initiated , titled "Medical Injustice." Here are some of his cohorts' responses:
"I would personally not be likely to even want to be treated by a physician that was so paranoid about what might be said about them by a patient so as to request that such a document be signed by them. For me, that would be a signal to get the hell out of their office asap and never go back." - JaneQPatient

"Provided it was allowed to be implemented (don't know the legalities of it), I can tell you it would work after the first few patients got caught. From experience, its not hard to recognize your patients on the internet. People tend to write the way they talk, and most patients (well, people in general) can't help but divulge personal information about themselves when they write. It would not be difficult to identify a patient that way in many cases." - CanDoc

"So does that mean all doctors will have that?? I don't think my doc even uses a computer!! I know he doesn't have any in his office." - Ms77Doodlebug

You can read the Medical Justice


*NB: Canadian Medicine/NRM does not endorse the service advertised. Image republished only to illustrate the news story.

Check out our website:

NB doc on trial for arson and drug trafficking, lawyer quits

The lawyer representing Dr Corinna Golding (right), a Rothesay, NB, family physician on trial for arson, uttering threats and narcotics trafficking, has , reports the New Brunswick Telegraph-Journal today.

Her lawyer, Gary Miller, stated in an affidavit to the court that his relationship with Dr Golding has "irreconcilably broken down [because she has] not fulfilled her retainer obligations in that she has failed to follow our instructions in violation of an express condition of our retainer agreement, which goes to the core of the conduct of her defence."

The Telegraph-Journal reports that no details on that claim are available, but logic dictates that the "violation of an express condition" may refer to recent charges brought against Dr Golding for having contact with a witness in her case -- presumably the young man, Nelson Getson, who was sentenced to six months in prison for the burning of Dr Golding's van. Her arson charge stems from that incident; she is alleged to have paid Mr Getson, the 19-year-old who claims he was her lover, with Percocet pills in exhange for burning the van. (Dr Golding, 41, maintains that he was nothing more than a patient of hers.)

Mr Getson was sentenced to an extra two months imprisonment for having contact with Dr Golding in September 2006 and for having assaulted her the previous month.

Dr Golding's licence to practise was suspended by the NB College of Physicians and Surgeons last September.

Her trial begins on Monday, August 27. She decided to have the case heard by just the judge, without a jury.

Check out our website:

Public health boss blasts Maclean's for HPV 'guinea pig' hysteria

"Our girls are not guinea pigs" declares, citing safety concerns about Gardasil, the human papillomavirus (HPV) vaccine.

The morning after Emily Cunningham got a shot of Gardasil, the new vaccine that protects against four strains of the human papilloma virus (HPV) that can cause cervical cancer and genital warts, she woke up with a headache, and neck and back pain. By 9 p.m. that evening in April, she had a fever so high "you could feel the heat rising from her a foot away," according to her mother, Laurie. She was delirious during the night, and the following day couldn't walk without assistance. Bedridden for nearly a week, the 18-year-old from Wyoming missed school, and took Tylenol every four hours. "If Emily had been the only one to get sick we would have said she must have had something else [like the flu]," explained Laurie, "but we know of three other students to have reactions, that is why we are concerned."

Emily's story is only one of 1,637 complaints involving Gardasil, filed as of May to the Vaccine Adverse Event Reporting System (VAERS), a national surveillance database sponsored by the Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC) in the United States.
The magazine's accusations outraged Dr David Butler-Jones, the Chief Public Health Officer of Canada and head of the Public Health Agency of Canada. He wrote to the magazine's editors last Friday to express his concerns:
Having a healthy debate is essential; however, Dr. Butler-Jones believes that the way Maclean's has approached the issue of the HPV vaccine is inappropriate and one-sided. The suggestion that as public health officials we would support a vaccine that would put the health, or worse, the lives, of girls and women at risk, is irresponsible. The health and safety of Canadians is of paramount importance to me and to public health officials across the country.

The Council of Chief Medical Officers of Health concurred with Dr Butler-Jones. Dr Perry Kendall, chief medical officer of BC (where the vaccine ) told the Canadian Press that the article was "alarmist."

In the current issue of NRM, Owen Dyer questions . (HPV vaccine programs have already been put in place in Newfoundland and Labrador, PEI, Nova Scotia and Ontario.) In addition to speaking to epidemiologist Dr Abby Lippman about the safety and efficacy questions raised by her recent CMAJ commentary (PDF), Mr Dyer raises questions about potential conflicts of interest in Merck dealings with staffers in the offices of Prime Minister Stephen Harper and Ontario health minister George Smitherman. Also, it turns out the SOGC's research that supports the vaccination programs was funded by Merck -- to the tune of $1.5 million.

Photo:
Check out our website:

US Health honcho launches blog - where's Tony?

US Health & Human Services secretary Mike Leavitt (left) has .

Our own federal health minister, Tony Clement (right), appears to be behind the times on this one. Will we see a Clementblog any time soon? Only time will tell, though the current government's history of opacity would suggest not.

On the other hand, Minister Clement already has a personal video message available on the Health Canada website in which he strolls through a gym. A sample sentence or two: "Hi! I'm Tony Clement, Canada's Minister of Health, and today I'd like to share with you some 'Food for Thought,' information available to everyone on Health Canada's web site."

He signs off: "I'm Tony Clement. You, stay healthy."


Photo:

Check out our website:

Following up on the 2005 Toronto death of a newborn from opiate toxicity, to limit prescriptions of codeine-containing products to the bare minimum.

The danger is that some women have a genetic mutation that makes them "ultra-rapid metabolizers" of codeine, which becomes morphine and can be passed through breast milk to infants. The case report about the Toronto newborn was (subscription required).

NRM in our June 15 issue, explaining the science behind the genetic mutation and ultra-rapid metabolizing. We reported on Toronto's Motherisk program's five options for physicians to reduce the threat of injury from codeine in breastfeeding:

  • Avoid using codeine in breastfeeding mothers. But this may leave the mother with uncontrolled pain.
  • Give the codeine but avoid breastfeeding. No neonatologist, however, is going to recommend stopping breastfeeding at this crucial early stage if it can possibly be avoided.
  • Give codeine, but limit concentrations by not giving a high dosage (240 mg/day codeine) for more than a few days. But the Motherisk team worries that this may not control pain adequately, and could still lead to toxic levels of morphine in the milk of ultrarapid metabolizers.
  • Genotype all mothers, then limit codeine only in the cases of fast metabolizers — those with two or three 2D6 genes. This is the ideal solution, but unfortunately would be very expensive, and few centres currently have the facilities to do it.
  • Use old-fashioned clinical judgement. The mother should be informed of the potential for opioid toxicity, then she and the infant should be monitored closely for danger signs. If symptoms appear, administering naxolone, morphine's antidote, will generally solve the problem and, in doing so, confirm it.
Also, read the , which outlines similar strategies and concludes that limiting codeine use in breastfeeding women is advisable, and the on the subject for more.

Check out our website: