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A systematic review of modify treatment with or without prior approval from the primary pharmacist-led disease management found resource use was gen- care physician had the greatest impact on A1C lowering order 60 ml rogaine 5 mastercard prostate specific antigen levels. Flexibility in the opera- experience generic 60 ml rogaine 5 with amex man health kick, the better the outcomes compared to primary care tion of the team is important rogaine 5 60 ml on line mens health your body is your barbell. Furthermore generic rogaine 5 60 ml otc prostate cancer 6 on gleason scale, the outcomes when team member, active participation of professionals from more these nurse case managers were used was equivalent or better than than 1 discipline and role expansion, have been associated with primary care providers (40). The greatest body of evi- gies that have been associated with positive outcomes are the del- dence for improved clinical outcomes in diabetes is with promo- egation of prescribing authority and the monitoring of complications tion of self-management, team changes and case management using decision support tools (33,34,38). They are often the principal medical contact for the as process outcomes, medication use and screening for complica- person with diabetes and have a comprehensive overview of all tions: promotion of self-management, team changes, case man- health issues and social supports (51). Another laborative, shared care is the ideal approach to organizing care for recent systematic review showed that education of the person with individuals with diabetes. Generally, sonalized goal setting (17,48) (see Self-Management Education and it is the person with diabetes who is facilitating the relay. Community partner- ventions, particularly those that used interactive computer tech- ships should be considered as a means of obtaining better care for nology to provide recommendations and immediate feedback of people with diabetes. For example, in addition to the diabetes health- personally tailored information, were shown to be the most effec- care team, peer- or lay leader-led self-management groups have been tive in improving outcomes of people with diabetes (67). Incorporation of evidence-based treatment algo- health regions also have developed diabetes strategies, diabetes rithms has been shown in several studies to be an integral part of service frameworks and support diabetes collaboratives. Audits and nancially compensated for the use of evidence-based ow sheets feedback lead to improvements in professional practice (72). This as well as time spent collaborating with the person with diabetes is particularly effective when combined with benchmarking (73). Pay-for-performance programs, which encourage the achievement of goals through reimbursement, are Clinical information systems more commonly used outside of Canada. Incentives to physicians to enroll people with dia- tries give an overview of an entire practice, which may assist in the betes and provide care within a nationwide disease management delivery and monitoring of patient care. Two other systematic reviews and meta- this increased to 80% with 2 strategies and to 100% of those includ- analysis of randomized controlled trials involving both type 1 and ing 3 strategies or more (p<0. In general, clinical outcomes with 10% effective if 1 strategy, 20% if 2 and 50% A1C improvement is most likely to occur when telehealth systems if 3 or more. The Diabetes Shared Care Program was a ret- control when using telehealth was better when the starting A1C rospective cohort study of 120,000 people with diabetes ran- was higher (>8. A mixed sys- telehealth technologies may be used for conferencing or educa- tematic review that looked at quantitative as well as qualitative tion of team members and teleconsultation with specialists. Ben- studies in telehealth showed that telehealth technologies in ets are noted regardless of whether the teleconsultation is type 2 diabetes produce a variety of outcomes, including improved asynchronous or synchronous (106,107). This review dened the mul- tiple telehealth technologies from simple interventions (e. No single tech- nology appears to be superior, but tailoring of the technology for 1. Be organized around the person living with diabetes (and their sup- the patient and implementation, as well as user interface, appears ports). The person living with diabetes should be an active partici- to improve adoption and outcomes (96,97). Another systematic pant in their own care and shared-care decision making; and self- review of information technology found that telehealth in both manage to their full abilities; and type 1 and type 2 diabetes populations is a more effective M. Be facilitated by a proactive, interprofessional team with specic training in diabetes. The team should be able to provide ongoing self- Self-Management Education and Support, p. S130 type 2 diabetes; Grade C, Level 3 (27) for type 1 diabetes for both Type 1 Diabetes in Children and Adolescents, p. The following quality-improvement strategies should be used alone Type 2 Diabetes and Indigenous Peoples, p. Ascensia Diabetes Care, Astra, Lilly; and other support from Novo Nordisk Canada Inc. An interprofessional team with specic training in diabetes and sup- received investigator-initiated funding from AstraZeneca. No other ported by specialist input should be integrated within diabetes care deliv- ery models in the primary care [Grade A, Level 1A (17,25)] and specialist author has anything to disclose. Glycemic control and morbidity in the [Grade B, Level 2 (45,47)] or registered dietitian [Grade B, Level 2 (42)] Canadian primary care setting (results of the diabetes in Canada evaluation to improve coordination of care and facilitate timely changes to diabetes study). Treatment gaps in the management of cardiovascular risk factors in patients with type 2 diabetes in Canada. The following individuals should work with an interprofessional team with Cardiol 2010;26:297302. Home telemonitoring of patients with diabetes: A system- (108)] atic assessment of observed effects. Women with pre-existing diabetes who require preconception coun- care teams operating on the interface between primary and specialty care are associated with improved outcomes of care: Findings from the Leuven Dia- selling and prenatal counselling [Grade C, Level 3 (5557,59,60) and betes Project. Referral to an interprofessional team with specialized training may be con- 2013;10:E26. Individuals with type 2 diabetes who are consistently not meeting the new millennium. Adults with depression and diabetes for collaborative care and, in public health preparedness. Interventions to improve the manage- ment of diabetes mellitus in primary care, outpatient and community Level 2 (98)] settings. The chronic care model for type 2 dia- care model [Grade A, Level 1A (106)] betes: A systematic review. Intervention types and outcomes of inte- decrease in A1C, an increase in quality of care (i. J Eval Clin Pract adherence), a decrease in health service use and cost, and an 2016;22:299310. Effects of quality improvement strat- (97,103,105)] egies for type 2 diabetes on glycemic control: A meta-regression analysis. Performance improvement based on inte- grated quality management models: What evidence do we have? Pharmacist-led chronic disease manage- ment strategies on the management of diabetes: A systematic review and meta- ment: A systematic review of effectiveness and harms compared with usual analysis. Systematic review and meta-analysis of targeting primary care or community based professionals on cardio-metabolic randomised controlled trials of psychological interventions to improve glycaemic risk factor control in people with diabetes. The relationship between orga- type 2 diabetic patients: A cluster randomized trial in primary care. Can a chronic care model collabora- anomalies in the offspring of women with diabetes mellitus: A meta-analysis. Meta-analysis of the effective- tality and malformation rates to general population levels. J Matern Fetal Med ness of chronic care management for diabetes: Investigating heterogeneity in 2000;9:1420. Collaborative care for comorbid depression and patients by primary care physicians, advanced practice nurses and clinical phar- diabetes: A systematic review and meta-analysis. Diabetes Res Clin Pract control of high blood pressure in people with diabetes: A systematic review 2009;85:11931.

The upper border is in the fourth to fth intercostal Palpate for lymphadenopathy space on percussion purchase rogaine 5 60 ml with mastercard prostate oncology on canvas. The liver may be of normal size but low because of hyperinated lungs in chronic obstructive airway Abnormal masses disease buy cheap rogaine 5 60 ml on line prostate cancer 2b lobes. Palpate for abnormal masses particularly in the epigastrium (gastric carcinoma) and suprapubic Spleen region (bladder distension cheap rogaine 5 60 ml visa prostate volume formula, ovarian and uterine buy 60 ml rogaine 5 free shipping man health malaysia. The spleen enlarges diagonally downward and monly palpable in the left iliac fossa. Check for ascites: examine for shifting dullness by patient lying on the right side with the left leg exed noting a change in percussion note with the patient and abducted. Consider Paracentesis may occasionally be required for the reliefofseveresymptoms;repeatedparacentesisleads. Smooth narrowing, usually at lower end of Non-infectious diarrhoea oesophagus in association with reux or hiatus hernia. Salmonella typhimurium uncommon in Western diagnostic countries Chronic diarrhoea. Yellow colouration of the skin and sclerae is usually A normal reticulocyte count virtually excludes hae- only apparent when the serum bilirubin is over molytic jaundice. Hepatic jaundice causes deep yellow jaundice pro- infectious mononucleosis or viral hepatitis. Measure the ability of the liver to perform normal skin caused by hypercarotinaemia. Liver enzymes (alkaline phosphatase, transamin- or surgery for intra-abdominal carcinoma ases) are indicators of ductal or liver cell damage. In obstructive jaundice the alkaline phosphatase is cinoma or in earlycirrhosis,tender ininfectious and greatly elevated compared with transaminases; in acute alcoholic hepatitis and occasionally in hepatocellular disease transaminases are predomin- congestive heart failure antly raised. Conjugated bilirubin is secreted in the Causes bile and degraded in the gut by bacteria to form Common urobilinogen. Haemolyticjaundiceisacholuric(nobilirubininthe urine) but the urine contains excess urobilinogen. Obstructive jaundice produces dark brown urine disease or abnormal liver function tests suggests the with excess bilirubin but a reduction of urinary presence of malignant secondary deposits in the bone urobilinogen (little or no bilirubin reaches the gut or Pagets disease. Consider measuring isoenzymes if because of the obstruction and therefore cannot be there is doubt. Causes of increased hepatic alkaline phosphatase In the early stages of acute viral hepatitis, excess urobilinogen may sometimes be present before clin-. With increasing severity, bil- angitis, primary biliary cirrhosis) iary obstruction develops and as conjugated bilirubin. The recipro- Causes of increased bone alkaline phosphatase (osteo- cal effect also occurs during recovery. Slight Abdominal radiology in jaundice elevation is consistent with obstructive jaundice. Isotope liver scans may demonstrate secondary reects the amount of muscle damage deposits. Fresh frozen plasma will quickly re- and chronic hepatitis, cirrhosis and following drugs versetheprothrombintimeforthedurationofthe that induce microsomal enzymes procedure. Nausea Vomiting Fatigue Itching Congenital non-haemolytic Urinary tract Dysuria infection Frequency hyperbilirubinaemias Nocturia These may explain persistent jaundice in the young Haematuria after viral hepatitis or slight jaundice in the healthy. About 40% Polycystic kidneys of cases have a reduced red cell survival with a Familial nephritis consequent increase in bilirubin production. Diagnosisisbyexclusion:thereisnohaemolysisand the other liver function tests are normal. Key features in the history of a patient with renal Basic investigations disease are shown in Table 5. For the non-specialist stu- dent, trainee or physician, it is important to develop a logical and systematic approach to the clinical history Cognitive function and examination based on knowledge of the under- Lossofmemoryforrecenteventsmorethanfordistant lying anatomy and physiology. Neurological diagno- events is a feature of organic cerebral disease and an sis has been transformed by advances in radiology early feature of dementia. A score of less than 24 indicates cognitive impairment: 2125 suggests de- mentia (likelihood ratio5), and 20 or less is highly suggestive of cognitive impairment (likelihood History ratio8). Key features of the history in a patient with neuro- logical disease are shown in Table 6. Other tests of cognitive function Concentration: serial sevens Examination of the nervous Ask the patient: system. Examination of the nervous nation requires to be rich and famous is a large, system also requires clear communication with the secure supply of wood. Neurological system 41 Receptive (sensory) dysphasia Eyes Observe: Observe and examine:. The following para- examine for a central scotoma graphs outline a system for examination of the cranial. Sense of smell Ask the patient: Ptosis Has there been any recent change in your sense of. Diplopia is maximal when looking in the direction of action of the paralysed muscle. Ask the patient to: If the patient has noticed diplopia: Clench your teeth (masseters, 5th nerve, motor). Face Neck (11th nerve) Facial expression (7th nerve, motor) Observe: Ask the patient to:. Explain what you are reexes doing to the patient: I am going to test the strength of some of your muscles Asimpleaide-memoireforreexesandcontrolling Shoulder (C5): muscle groups is 12345678 Hold both arms out in front of you and close your eyes Ankle jerk S1, 2 Observe drifting of one arm indicating: Knee jerk L3, 4 Biceps jerk C5, 6. Lift the thumb disease vertically and dont let me push it down Muscular weakness alone may make the patient un- steady in all these tests, and this may resemble an Opposition of thumb: median nerve: intention tremor. In all modalities use a single touch; moving a stimu- Vibration sensation: lus induces two-point discrimination. Establish the normal response by placing the tuning Joint position sense (proprioception), vibration sense fork onto the sternum and checking the patients and accurate sensation (pin-prick, two-point discrim- recognitionofthevibrationsensation. Establish the normal response by touching cotton prominences in the ngers, wrists and elbows. Establish the normal response: with the patient Close your eyes and say Now every time you feel the looking, hold a nger by its sides (holding the top touch and bottom introduces diffuse touch sensations). Examine the arms systematically along the distri- Move the nger up and down, explaining what you bution of the dermatomes. Instruct the patient, demonstrating what you mean: Knee extension (L3, L4): Put your heel on your knee and slide it down your Now straighten your leg shin. Establish the normal response by touching closeandbepreparedtosupportthemifyoususpecta cotton wool or neurotips pin onto the sternum sensory abnormality. Examine the legs systematically along the distribu- position sense (posterior column lesion) tion of the dermatomes. Ensure during testing that the tuning fork is vibrat- Ask the patient to stand with feet together: ing but not making a loud noise. Establish the normal response by placing the tuning fork onto the sternum and checking the patients recognition of the vibration sensation. Visual eld defects With your eyes closed say Yes if you can feel the Field defects (Fig. Work distally to proximally, checking over bony indicates loss of the temporal eld of vision and prominences in the toes, ankles and knees.

However buy 60 ml rogaine 5 with mastercard prostate massage therapy, it is equally important to not collude with the patients unrealistic expectations of either his or her own idealized capacities discount rogaine 5 60 ml prostate oncology group, or an idealization of the treating clinicians abilities cheap 60 ml rogaine 5 with amex mens health big book of exercises pdf. These fantasies are based on ignorance and may reect unresolved psychological concerns purchase 60 ml rogaine 5 free shipping androgen hormone secreted by. There are situ- ations when it is appropriate to either make a referral within a team approach or to decline to treat a patient. Signicant, process based, developmental predisposing factors, usually speak to the need for resolution of psychic wounds prior to the introduction of the sexual pharmaceutical. Sexuality is a complex interaction of biology, culture, developmental, and current intra and interpersonal psychology. Restoration of lasting and satisfying sexual function requires a multidimensional understanding of all of the forces that created the problem, whether a solo physician or multidisciplinary team approach is used. Psychotherapy: Special Issue: Empirically Supported Therapy Relationships: Summary Report of the Division 29 Task Force. Vardenal: a new approach to the treatment of erectile dysfunction, Curr Urol Rep, Curr Sci Inc 2003; 4:479487 14. Efcacy and safety of tadalal for the treatment of erectile dysfunction: results of integrated analyses. Drivers and barriers to seeking treatment for erectile dysfunction: a comparison of six countries. A comparison of nefazodone, the cognitive-behavioral analysis system of psychotherapy, and their combination for the treatment of chronic depression. The Management of Benign Prostatic Hyperplasia, Amer- ican Urological Association Education and Research, Inc. Self-injection of papaverine and phentolamine in the treatment of psychogenic impotence. The combined use of sex therapy and intra-penile injections in the treatment of impotence. Combination of psychosexual therapy and intra-penile injections in the treatment of erectile dysfunctions: rationale and predictors of outcome. Intracavernous injections and overall treatment of erectile disorders: a retrospective study. Evaluation and treatment of ejaculatory disorders, in atlas of male sexual dysfunction [Ed: Lue, T. Treatment of erectile dysfunction in men with depressive symptoms: results of a placebo-controlled trial with sildenal citrate. Presented at 6th Congress of the European Society for Sexual Medicine, Istanbul, Turkey, 2003. Cognitive and social science aspects of sexual dysfunction: sexual scripts in therapy. Successful Salvage of Sildenal (Sildenal) Failures: Benets of Patient Education and Re-Challenge with Sildenal. Presented at the 4th Congress of the European Society for Sexual and Impotence Research, Sept. Sildenal failures may be due to inadequate instructions and follow-up: a study of 100 non-responders. It encourages the belief that sexually healthy women agree to sex or initiate it mostly because they are aware of sexual desirebefore any sexual stimulation begins. Indeed, this is in accordance with the traditional model of human sexual responding of Masters, Johnson, and Kaplan. As we will see, this conceptualization contradicts both clinical and empirical evidencewomen in established relationships infrequently engage in sex for reasons of sexual desire (16). That sense of desire, or need, or hunger is nevertheless felt once subjectively aroused/excited. When that arousal is insuf- cient or not enjoyed, motivation to be sexual typically fades. In other words, although not usually the prime reason for engaging in sex, enjoyable subjective arousal is necessary to maintain the original motivation. So, lack of subjective arousal is key to womens complaints of disinterest in sex. This imprecision presents a major dilemma to both clin- icians and the women requesting their help. Any formulation of a hypoactive sexual desire/interest disorder must take into account the normative range of womens sexual desire across cultures (7), age, and life cycle stage (8). Desire for sex typically lessens with relationship duration and increases with a new partner (6). Womens sexual enjoyment and desire for further sexual experiences were acknowledged early last century. Before that time, there had been variable denial or intolerance and endeavors to curb womens sexuality. Unfortunately, sub- sequent to that acknowledgement, came the assumption that womens sexual function mirrors mens experiences. Female Hypoactive Sexual Desire Disorder 45 arousal is not simply a matter of genital vasocongestion. The only published randomized controlled trial using physiological (or at least close to physiological) testosterone supplementation did not result in any increased desire as in having sexual thoughts, over and beyond placebo, but did show increased pleasure and orgasm intensity and frequency. Subjective arousal was not reported, but, given the improvement in pleasure and orgasmic experiences, its improvement is implied (25). To identify reasons women willingly initiate/agree to sexwith a view to understanding why some do not. To review a model of sexual response that permits motivations (reasons/incentives), for being sexual, over and beyond sexual desire. To clarify that it is the womans arousability (along with the usefulness of sexual stimuli and context) that determines whether she will access sexual desire. In other words, for women, the concept of responsive desire or desire accessed during the sexual experience may be as or more important than initial desire as measured by sexual thoughts and sexual fantasies. To critique the traditional markers of sexual desire as they apply to womenand the questionable relevance of their lack. To outline the assessment of low desire and the associated low arousa- bility, thereby identifying therapeutic options. To review what is known of the biological basis of womens sexual desire and arousability, including the role of androgens. To review psychotherapy, pharmacotherapy, and the biopsychosexual approach to the management of womens lack of sexual interest/desire. Further reasons include increasing the womans sense of well being, of attractiveness, womanlinesseven to feel more normal (26). Simply wanting to share something of herself that is very precious, to sense her partner as sexually attractive (be it his/her strength and power, or ability to be tender/considerateor both), are further reasons. Incen- tives that might supercially appear unhealthy are also common, for example, to placate a needy (and increasingly irritable) partner (26), or do ones duty. The concept of rewards or spin offs from being sexual is currently being empirically researched. The degree of emotional intimacy with her partner that may have even been the major motivating force, is also a very important inuence on her arousability to the sexual stimuli. Various other psychological and biological factors will inuence this arousability such that the processing of the sexual information in her mind may or may not lead to subjective arousal (2731). This accessed or triggered sexual desire and the subjective arousal continue together, each reinforcing the other (32,33). A positive outcome, emotionally and physically, increases the womans motivation to be sexual again in the future (32).

During the last century proven rogaine 5 60 ml prostrate knotweed, prema- ture ejaculation has been considered from both a medical and a psychological view discount 60 ml rogaine 5 visa mens health ebook the six-pack secret, often resulting in contrasting psychotherapeutic and drug treatment approaches cheap rogaine 5 60 ml mastercard prostate cancer 85 year old man. For a better understanding of the current debate regarding its etiol- ogy and treatment quality rogaine 5 60 ml prostate vs breast cancer, it is important to consider the history of how clinicians thought about and treated premature ejaculation. History Waldinger (5,15) distinguishes four periods in the approach to and treatment of premature ejaculation. The First Period (18871917): Early Ejaculation In 1887, Gross (16) described the rst case of early ejaculation in medical litera- ture. Although publications were rare, it is worth noting that during the rst 30 years of its existence in the medical literature, early ejaculation was viewed as an abnormal phenomenon but not signicantly as a psychological disturbance. The Second Period (19171950): Neurosis and Psychosomatic Disorder In 1917, Abraham (18) described early ejaculation as ejaculatio praecox and stated that it was a symptom of a neurosis caused by unconscious conicts. On the other hand, some phys- icians stated that premature ejaculation was due to anatomical urological abnormalities, such as a too short foreskin frenulum or changes in the posterior urethra, which had to be treated with incision of the foreskin or electrocautery of the verumontanum. Schapiro described two types of premature ejaculation, type B in which early ejaculation existed from the rst intercourses and type A, which led to erectile dysfunction. Many years later, both types became distinguished as the primary (lifelong) and secondary (acquired) forms of premature ejaculation (20). The Third Period (19501990): Learned Behavior The biological component of premature ejaculation and therefore also drug treat- ment, advocated by Schapiro, was ignored by the majority of sexologists who advocated psychoanalytic treatment. This neglect became even more pronounced after Masters and Johnson (21) claimed the high success rates of behavioral therapy in the form of the squeeze technique, an adaptation of the stopstart tech- nique published by Semans (22) in 1956. Masters and Johnson stated that men with premature ejaculation had learned this rapidity behavior as a result of their rushed initial experiences of sexual intercourse. Prevalence Premature ejaculation is often cited as being the most common male sexual dys- function. Although it has been estimated that as many as 36% of all men in the general population experience premature ejaculation (24), other estimates have been lower. For example, Gebhard and Johnson (25), from a reanalysis of the Kinsey data, determined that 4% of the men interviewed reported ejaculating within 1 min of intromission. The large differences in prevalence numbers are mainly due to the use of various and often totally different denitions of prema- ture ejaculation that have been used. Only by the general use of an empirically dened denition and identical tools to measure the ejaculation time, methodo- logically correct epidemiological studies can provide reliable prevalence data. Evidence-Based Medicine Evidence-based medicine means that the formulation of a seemingly attractive hypothesis of the cause of a disease is not enough for scientic acceptance. There needs to be empirical evidence, preferably replicated in various controlled studies. Male Ejaculation and Orgasmic Disorders 225 For many decades, premature ejaculation was considered to be a psycho- logical disorder that had to be treated with psychotherapy. However, psychologi- cal treatments and underlying theories mostly relied on case reports, series of case report studies, and opinions of some leading psychotherapists and sexo- logists. I believe this to be a typical example of authority- or opinion-based medicine (15). In contrast to authority-based medicine, evidence-based medicine (26) has been accepted today as the hallmark for clinical research and medical practice. In spite of these studies, the belief persists among those involved in sexology that premature ejaculation is a psychological disorder. In order to unravel this dichotomy, it is important to apply principles of evidence-based medicine to both the psychological and neurobiological approaches to premature ejaculation and its treatments. Evidence-Based Research: Psychotherapy The psychoanalytic idea of unconscious conicts being the cause of premature ejaculation has never been investigated in a manner that allowed generalization, as only case reports on psychoanalytic therapy have been published. Masters and Johnson (21) deliberately refuted a denition of premature ejaculation in terms of a mans eja- culation time duration. Instead, they insisted on dening premature ejaculation in terms of the female partner response, for example, as a males inability to inhibit ejaculation long enough for the partner to reach orgasm in 50% of intercourses. It is obvious that their denition is inadequate because it implies that any male partner of females who have difculty in reaching orgasm on 50% of intercourses suffers from premature ejaculation. Masters and Johnson argued that premature ejaculation was conditioned by experiencing rst sexual contacts in a rapid way (e. However, Masters and Johnson, and sexologists who followed their ideas, have never provided any evidence-based data for this assumption. Regarding their proposed behavioral squeeze technique treat- ment, Masters and Johnson claimed a 97% success for delaying ejaculation. However, this very high percentage of success has never been replicated by others. However, critical comments were not appreciated in the traditional sexological thinking of the late 20th century. This nonscientically supported and uncritical belief in behavioral treat- ment still exists today, in spite of clear evidence-based medical research in favor of the neurobiological view. Further, the diagnosis of premature eja- culation was not quantied and therefore inaccurate, particularly since Masters and Johnson used an obscure denition of premature ejaculation. Baseline data were not reported, and inclusion and exclusion criteria were lacking. The assess- ment of success was subjectively reported without quantication or scoring scales. In addition, Masters and Johnson did not provide any information on their data processing. In spite of all these methodological aws, their behavioral technique has received worldwide uncritical acceptance and been promoted as the best method of treatment. Even the very poor results of two studies (34,35) on behavioral therapy (also poorly designed) could not prevent sexologists from continuing to claim the squeeze technique as the best method of treatment. Also the efcacy of these psychotherapies has only been suggested in case reports and were never investigated in well-designed controlled studies. In my opinion, the uncritical acceptance of the squeeze technique as rst choice treatment is a clear example of the inuence of opinion- or authority- based medicine, as in those years Masters and Johnson were famous for their new approaches in the treatment of sexual disorders (15). It did not seem to be an issue then that Masters and Johnsonthese so highly esteemed sexolo- gistsdid not produce any evidence-based data for their claimed discovery. Evidence-Based Research: Drug Treatment In contrast with the easily accepted behavioral treatment by sexologists, drug treatment had to prove itself far more explicitly to avoid rejection by pro- fessionals in the eld. Only a few physicians have tried to develop drug strategies to treat premature ejaculation. Currently, in spite of some residual ambiguous attitudes of many sexologists, drug treatment with serotonergic antidepressants are accepted as effective therapy. Despite of all circumstantial evidence, it should be emphasized that a scientic approach to investigating empirical evi- dence remains obligatory (40). To investigate how far differences in method- ology may be of inuence on clinical outcome of drug treatment studies, Waldinger and co-workers conducted an systematic review and meta-analysis of all drug treatment studies that were published between 1943 and 2003 (41). In this study, several methodological evidence-based criteria were com- pared such as study design (single-blind and open-design vs. Male Ejaculation and Orgasmic Disorders 227 from 79 publications on drug treatment, 35 studies involved serotonergic antidepressants. It was clearly demonstrated that both single-blind and open- design studies as well as studies using a questionnaire or subjective report on the ejaculation time led to a higher variability, that means exaggerated responses, in ejaculatory delay. Operational Denition of Premature Ejaculation For evidence-based research, it is of utmost importance to have a denition of premature ejaculation. However, because of conicting ideas about the essence of premature ejaculation, sexologists have never reached an agreement on a denition. In order to get an empirically operationalized denition, Waldinger and co-workers investigated 110 consecutively enrolled men with lifelong prema- ture ejaculation (48). In this study, men and their female partners were instructed to use a stopwatch at home during each coitus for a period of 4 weeks (Fig.

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