Italian pharmacy online: cialis senza ricetta medica in farmacia.
metabolic and sexual/reproductive adverse events asso-
Comments: The finding of an isolated hymenal in-
ciated with antimanic agents and co-prescribed psycho-
jury without bruising or injury to the external genita-
tropic medications. Carbamazepine, and co-prescribed
lia is diagnostic of a penetrating injury, and raises
selective serotonin reuptake inhibitors and antipsy-
suspicions of sexual abuse. Although straddle injuries
chotics impart the highest risk of developing metabolic
usually cause signs of trauma to the external genitalia,
and sexual/reproductive adverse events and require vigi-
very rarely isolated penetrative hymenal injuries have
lant monitoring in preadolescent and adolescent patients.
been reportedwith accidental injury. This may occurin the context of falling onto a projecting object. A
careful social history should always be elucidated torule out sexual abuse, and child abuse physiciansshould be consulted.
Labial Bruising Due toa Straddle Injury: A Case
Severely Obese AdolescentFemales Seeking Bariatric
Joe¨lle Dennie, MSc, MD, FRCSC,Anne Smith, MBBS, FRACP, and
Yasmin Jayasinghe, MBBS, FRANZCOGRoyal Children’s Hospital, Parkville, Victoria, Australia
Jennifer B. Hillman, MD, MS, RachelJ. Miller, MD, and Thomas Inge, MD, PhD
Background: Straddle injuries are known for caus-
Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
ing lacerations, ecchymoses and abrasions to the ex-ternal genitalia, including the mons, clitoris and
Background: Obesity affects nearly every organ
labia. Impalement injuries can also cause trauma to
system in the body, including the reproductive organs.
the vagina, anus, rectum and peritoneal cavity as well
For example, polycystic ovary syndrome (PCOS) is
as the external genitalia. Injuries to the hymen often
more common among obese than non-obese females.
raise the suspicion of sexual abuse. We present a case
Additionally, contraceptive options are often limited
of an alleged straddle injury resulting in an isolated
by obesity-related comorbidities that are contraindica-
tions to estrogen-containing contraceptives. Some
Case: A 7 year old girl presented to the Emergency
contraceptives result in weight gain, and others have
Department with vaginal bleeding soon after falling
decreased efficacy with severe obesity. As bariatric
onto a bed rail. The fall was reported to have been wit-
surgery has recently become a treatment option for se-
nessed by her female cousin, and family members in the
verely obese adolescents, gynecologic consultation
house at the time became aware of events immediately.
among this group has become even more essential.
She was otherwise healthy. An examination in the ED
The American College of Obstetricians and Gyneco-
revealed no laceration or bruising visible on the labia
logists recommends postponing pregnancy 12-18
majora or minora. There was a small purple bruise on
months after bariatric surgery due to the surgically
the inner right thigh. Clot and fresh blood was seen
induced catabolic state and nutritional concerns.
coming from the introitus, but the exact site of injury
Intrauterine contraception is a viable contraceptive
was hard to visualize. She denied any abdominal pain
alternative and provides non-contraceptive benefits.
and was able to pass urine. Behavioural assessment
Little is known about reproductive issues and accept-
was consistent with her history. When she was exam-
ability of the levonorgestrel releasing intrauterine sys-
ined under general anesthesia, a small 3mm laceration
tem (IUS) among severely obese adolescents seeking
was observed at the base of the hymen at the 7 o’clock
position. It did not extend to the edge of the hymen
Methods: This is a retrospective chart review of fe-
which did not appear to be injured. There was minimal
males who underwent bariatric surgery at an aca-
bruising to the fossa navicularis. The bleeding ceased
demic children’s hospital in the Midwestern United
States from September 2006 through mid-November
After discussion with the child forensics service
2008. We included girls age 13 and older who were
a further careful social history was taken following
seen preoperatively for gynecologic consultation
the examination under anesthesia. No concerns regard-
(n528) and excluded girls with hypothalamic amen-
ing sexual abuse were raised by the parents or child.
orrhea or other conditions associated with primary
Identify Potential Subjects History of type 2 diabetes mellitus on stable doses of either monotherapy or dual combination therapy with metformin, pioglitazone, or a sulfonylurea OR a stable dose of insulin (±20%) alone or with metforminHbA1c 6.5% (48 mmol/mol) to 8.0% (64 mmol/mol) within prior 3 monthsEnsure subject meets all inclusion/exclusion criteriaObtain serum HbA1c ≥ 6.5% (48 m
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