J. Jason West, MD

• Cardiology Fellow, Department of Medicine, Division of Cardiovascular
• Medicine, University of Virginia, Charlottesville, VA, USA

Ether (Diethyl Ether) Desirable Effects Ether is easy to vaporize in simple apparatus arrhythmia recognition poster bystolic 2.5mg lowest price. It is difficult to kill an ani mal with an overdose of ether blood pressure medication vision changes order bystolic once a day, so it is a relatively safe agent for inexperienced anaesthetists prehypertension natural remedies discount bystolic online master card. Undesirable Effects Induction is unpleasant for the animal blood pressure juice recipe cheap bystolic line, and the irritant properties of ether can cause coughing, profuse bronchial and salivary secretions and occasional laryn gospasm. Ether can cause pre-existing chronic respira to ry disease to develop in to an acute severe infection, following recovery from anaesthesia, and this may be particularly important in rodents and rabbits. Special Comments Anaesthetic ether is now difficult to obtain, although the agent can still be pur chased from specialist suppliers. This is advantageous for inexperienced anaesthetists, as it makes accidental overdose less likely. Conversely, a prolonged induction period can present problems in restraining the animal, particularly as most animals strongly resent inhaling the vapour. The catecholamine release also results in a moder ate rise in blood glucose concentrations, and in a wide range of other metabolic changes, which may interfere with particular research pro to cols. Ether is not, as 58 Labora to ry Animal Anaesthesia commonly believed, an inert compound. It undergoes extensive metabolism and exposure to ether, which results in induction of liver enzyme activity (Linde and Berman, 1971). Although ether has been a popular anaesthetic, its use for induction is unpleasant for the animal and hazardous in several species, particularly guinea pigs. Its explosive properties make it a significant safety hazard: animals should not be killed with ether, as the carcasses may be s to red in refrigera to rs which are not spark-proof and an explosion may result. Nitrous Oxide Desirable Effects Nitrous oxide causes minimal cardiovascular and respira to ry system depression. Undesirable Effects Nitrous oxide has very low anaesthetic potency and cannot be used alone to produce anaesthesia, or even unconsciousness, in most species. It reacts with vitamin B12, producing vitamin depletion after pro longed (6 hour) anaesthesia and can cause bone marrow depression. Special Comments Nitrous oxide is extensively used for anaesthesia in animals and humans, although the mechanisms of its anaesthetic and analgesic effects are still not fully characterized (Maze and Fujinaga, 2001). Since nitrous oxide has minimal effects on the respira to ry and cardiovascular systems, it can be used to reduce the required concentration of other agents and so to reduce the overall degree of depression of blood pressure or respiration at a particular depth of anaesthesia. Following the cessation of prolonged nitrous oxide administration, 100% oxygen should be administered to prevent so-called diffusion hypoxia. This phenomenon causes lowered alveolar oxygen tension due to the rapid diffusion of nitrous oxide from the blood to the alveoli. Its main value lies in reducing the required concentration of other more potent agents which have more marked side-effects. It is important to note that nitrous oxide is not absorbed by the acti vated charcoal canisters used in some gas-scavenging systems. If nitrous oxide is used, then an active scavenging system that ducts expired gases directly to the room ventilation extract must be used. A common misconception is that it is necessary to administer nitrous oxide in order to administer other inhalation anaesthetics. This is not the case, and all of the other agents mentioned above can safely be administered in 100% oxygen. This can be achieved without the use of nitrous oxide by using an air/oxygen or nitrogen/oxygen mixture, the other gas being supplied from an appropriate com pressed gas cylinder. If the gases are mixed at the outlet from the anaesthetic machine, then the delivered concentration of anaesthetic vapour will be reduced, and the vaporizer setting should be increased accordingly. Older Agents A number of other anaesthetics have been developed, but they are primarily only of his to rical interest. Chloroform vapour has numerous side-effects which resulted in it being discarded from human and veterinary clinical practice, and which make it unsuitable for labora to ry use. Trichlorethylene vapour produces good analgesia, and is inexpensive, non-inflammable and non-explosive. It also causes only minimal cardiovascular system depression, but it has poor muscle relaxant properties, low anaesthetic potency, and decomposes in the presence of soda lime to form to xic and explosive products, so that it must never be used in closed breathing systems. Trichlorethylene undergoes extensive hepatic metabolism and has been established as a hepatic carcinogen in some species (Green, 2000). The gas cyclopropane can be used to produce rapid induction of anaesthesia, and the depth of anaesthesia can be altered smoothly and rapidly. Unfortunately, cyclopropane is flammable and explosive in air and oxygen, and this hazard limits the use of this anaesthetic in most labora to ries. Administration of Anaesthetics by Injection Equipment Although the equipment required for injection of anaesthetics consists basically of a syringe and a needle, some attention should be given to the range of syringe and needle sizes available and also to the use of indwelling catheters, cannulae, extension tubing and infusion devices. Syringes Plastic disposable syringes are almost universally used for delivering anaesthetics. Ensure that an appropriate-volume syringe is used so that the required dose of anaesthetic can be administered accurately. The syringes designed for insulin administration to human patients are particularly useful for administering small doses of drugs to rodents (Fig. Select a syringe design that is comfortable to hold and that enables a firm grip to be maintained even when the barrel is wet. Avoid using syringes which have been s to red for a length of time which exceeds the period recommended by the manufacturers, as the plastic may have become brittle and can fracture during use. Needles and Cannulae Disposable hypodermic needles should be used and an appropriate gauge selected for each purpose. Needles should never be resterilized, as they rapidly become blunt when used and injection with a blunt needle can cause consider able discomfort. Successful venepuncture of small vessels is particularly diffi cult to achieve if the needle has been blunted. For this reason, it is advisable to replace the needle after drawing up liquid from a rubber-capped vial. Often it is preferable to use a butterfly-type infusion set, rather than a sim ple hypodermic needle. These infusion devices provide a short length of flexible catheter between the needle and the syringe so that movements of the animal during injection are less likely to result in the needle becoming dislodged from the vein (Fig. This is particularly important when inducing anaesthesia with short-acting anaesthetic agents since the administration of an inadequate dose of drug may produce involuntary excitement. If the ensuing limb move ments result in displacement of the needle from the vein, its replacement may be virtually impossible. Even more useful for intravenous induction are indwelling catheters, since these enable successive intravenous injections of anaesthetics and other drugs to be made easily and reliably. A flexible catheter will not pierce the vessel wall should movements of the animal occur, so accidental extravascular injection will be avoided. A needle is placed in to the blood vessel, and a flexible wire passed down the needle in to the vessel. The needle is then withdrawn, and the catheter threaded along the wire and in to the vessel. In addition to the administration of anaesthetics, other drugs and intravenous fluids can be administered rapidly, even by relatively unskilled assistants. When anchoring catheters in the mar ginal ear vein in species such as the rabbit or sheep, it is helpful to cut off one wing to reduce the risk of dislodging the catheter (Fig.

Typically blood pressure levels usa bystolic 5 mg with mastercard, males are placed in to the test- reported that adrenalec to mized and ovariec to mized ing chamber for a 5-min adaptation period prior to women reported signiicantly less sexual intercourse the placement of a receptive female from prehypertension to hypertension additional evidence order 5 mg bystolic visa. The anticipa- than did women ovariec to mized only and concluded to ry behaviors develop naturally over a few trials that ovarian hormones were unimportant and that but do not develop if the chamber is baited with an adrenocortical androgens were the source of libido ovariec to mized (nonreceptive) female or another in women pulse pressure nursing discount 5 mg bystolic with visa. Dopamine recep to r antagonists decrease the women with terminal cancer blood pressure which arm buy bystolic 5mg online, who received adrenal- number of anticipa to ry level changes displayed by ec to my as a last attempt to stem hormonally sensi- male rats in bilevel chambers at doses that do not tive cancers which had been in remission and re- alter copula to ry responses once receptive females turned, this study actually provided the irst evidence are placed in to the chamber (Pfaus & Phillips, 1991). When reported changes in sexual de- a common complaint among patients taking these sire instead of sexual intercourse were compared, drugs as major tranquilizers (Crenshaw & Goldberg, they were signiicantly reduced following ovariec- 1996). Long-term use of the stimulant drug cocaine to my, whereas intercourse frequency was not. This is also reported to decrease sexual desire in men likely relects the capacity of women to engage in (MacDonald et al. We have recently found that long-term is not possible in rats and other labora to ry species. The notion that in women, this the libidinal hor- All animals will work to obtain sexual rewards, and mone has become well entrenched, leading several such behavior can be viewed as analogous to de- pharmaceutical companies to develop potential T sire. In male rats, those behaviors have included was successful in reinstating sexual desire in wom- performance in obstruction boxes (Jenkins, 1928; en, but that E alone was effective in two of the three Moss, 1924; S to ne, Barker & Tomlin, 1935; War- studies in which women were not hypoestrogenic ner 1927), straight-alley running (Beach & Jordan, (Alexander at al. Because of concerns about 1956a; Shefield, Wulff, & Backer, 1951; Ware, 1968), the long term consequences of estrogen therapy, few maze learning (Drewett, 1973; Eliasson & Meyer- human studies use estradiol levels that would not be son, 1975; Hetta & Meyerson, 1978; Kagan, 1955; considered hypoestrogenic. In a potential sex partner behind a wire-mesh screen female rats, tes to sterone is capable of synergizing (Damsma et al. Indeed, to gain access to receptive females (Becker, Rudick, & Jenkins, 2001; Jenkins & Becker, male guinea pigs will lean to run an alley (Seward & 2003; Mermelstein & Becker, 1995) found increased Seward, 1940), male pigeons will learn to peck keys dopamine release in the striatum and nucleus ac- (Gilbertson, 1975), and male stickleback ish will cumbens of females that had to press a lever to gain learn to swim through rings (Sevenster, 1973). Some appetitive instrumental sexual responses are Indeed, lesions of the striatum reduced the eficien- expressed easily, without much prior experience cy of females to pace the copula to ry interactions. Those behaviors can be reduced follow- ing castration, indicating that gonadal steroid actions 1. They person or conspeciic, or to ward a place in which can also be reduced after a devaluation of the re- potential sex partners have been found in the past. Res to ra- preferences exist for gender, and within gender for tion of bar pressing in male rats with lesions of the certain individually-deined physical features that basolateral amygdala can be made following infu- people ind attractive (shape of face, smile, eye or sions of amphetamine to the nucleus accumbens, hair color, body type, etc). Preferences also exist indicating that mesolimbic dopamine release is criti- for scents, for certain types of clothing, even for fe- cal for the expression of that behavior, and suggest- tish objects. There are likely as many combinations ing that the extensive glutamate projections from of these as there are people, and the role of such basolateral amygdala to the nucleus accumbens preferences is to focus the attention of individuals modulate dopamine release (Everitt, 1990). Dopa- on other individuals so that sexual interactions can mine antagonists administered systemically to male occur. Some preferences are determined by par- rats reduce running speed in a runway that leads to ticular cultures or epochs within a culture, whereas a goal box containing a sexually receptive female others are learned during a critical period of sexual (Lopez & Ettenberg, 2001). It is likely that different dopa- particular features with sexual gratiication entices mine terminal regions play a role in different types people to seek out those features in future sexual of unconditioned and conditioned sexual activity. We would the literature for over 50 years, they have not been never deny that preferences exist in humans that are mined extensively by sex researchers to study the conditioned by experience; yet arguments continue effects of drugs that activate or inhibit other neu- to be made that the sexual preferences of animals rotransmitter systems. Likewise, they have been ap- (and even humans) are hard-wired for ultimate re- plied sparingly to females. Bermant (1961) and Ber- productive success and itness, rather than more mant and Westbrook, (1966) reported that female proximate rewards, such as sexual pleasure. This latter dimension with a dopamine agonist or antagonist (amphet- represents an exciting new foray in to a level of ani- amine, cis-lupenthixol)or opioid agonist or antago- mal behavior that approximates our own. For example, an open ield, except at higher doses that induced numerous studies have shown that male rats spend mo to r deicits (Agmo, 2003a). Likewise, sexually centive cues, infusions of the dopamine antagonist receptive females spend more time near gonadally cis-lupenthixol to the ventral tegmental area of male intact, sexually active males versus castrated, sexu- rats decreases the percentage of time spent near a ally inactive males (Gilman & Westbrook, 1978). It is also ies have been conducted in Y-mazes, T-mazes, known that sexually experienced males are relative radial-arm mazes, or open ields, that contain goal resistant to many treatments that disrupt sexual be- boxes baited with teathered receptive versus non- havior in inexperienced males, including castration, receptive conspeciics. However, that receptive females versus nonreceptive females and fact leads to the question of what is actually being for sexually receptive females versus males, but not studied. Meisel and Sachs (1994) note that, in the for sexually nonreceptive females versus males. Indeed, Agmo reported that the inten- could also be measuring social afiliation, opportu- sity of preference for a live receptive female could nity to engage in aggression, curiosity, or a reaction be generated by bedding that contained estrous to other incentive aspects of the stimulus animal that odors, suggesting that olfac to ry cues are important have nothing to do with sexual behavior. Indeed, although these kind of several key brain regions known from lesion studies preferences are displayed by sexually naive males, to be critical for male sexual behavior, including the they are not as strong as those displayed by sexually medial preoptic area, bed nucleus of the stria ter- experienced males (Carr, Loeb & Wylie, 1969), indi- minalis, medial amygdala, nucleus accumbens, and cating that sexual experience increases the incen- ventral tegmental area (Bialy & Kaczmarek, 1996; tive value of sex-related odors in the rat. Repeated Bressler & Baum, 1996; Kippin, Cain & Pfaus, 2003; exposure to estrous odors are known to sensitize Newman et al. Pavlovian conditioning in which neutral stimuli asso- We have developed a model to examine the role of ciated with sexual reward become conditioned sex- associative learning on sexual partner preferences ual incentives. Such conditioned preferences can in male and female rats during sexual interaction. Males in several control ulate with females of two strains of quail that have groups were either not exposed to the odor or had different plumage color (brown versus blond). Sub- the odor randomly paired with sexually receptive and sequently, males chose to spend more time in the nonreceptive females. On a inal test, each male was proximity of females whose color was the same as presented with two receptive females in a large open that of females with whom they had copulated previ- ield (Figure 5, to p). Similarly, males allowed to copulate with fe- males that were adorned with bright orange feathers subsequently spent more time near, and engaged in more sexual activity with, females similarly adorned compared to unadorned females. Domjan and Hall (1986) also demonstrated that males would stay in the vicinity of a window in their home cage through which they could see a sexually receptive female during a precopula to ry period. However, this behav- ior developed only if the males had the opportunity to copulate with the female after the precopula to ry pe- riod. A variant of this procedure, similar to that used to study anticipa to ry mo to r responding in rats, was Figure 5: Open ield partner preference paradigm. Male quail were after which two receptive females, one bearing a placed in to a chamber that contained a window and conditioned cue. After a 10-min pe- Latency and frequency measures for mounts, intrott riod, the sliding door opened, and the animals could missions, and ejaculations are then calculated for interact freely (Balthazart et al. Choice of female for irst mount, intromission, or ejaculation, and the and Hall (1986) and Mendelson and Pfaus (1989), distribution of these measures across the test, are only males that copulated with the females during this then determined for each male. Castrated males did males are placed in to the open ield that already not develop this conditioned proximity behavior, nor contains two sexually vigorous males, one bearing did males that did not copulate. Bett duced the time spent near the window males trained cause males tested in pairs with a single female will prior to castration, and subsequent replacement crawl over one another, they must wear rodent jacktt ets that are tethered to opposite corners of the open with tes to sterone or estradiol res to red the behavior. Latency and frequency meatt inhibi to r, decreased the appetitive social proximity sures for mounts, intromissions, and ejaculations response, but increased the frequency of mount at- are calculated for each male, along with proceptt tempts. In contrast, amfonelic acid, a compound that tive measures of solicitation and hops and darts, enhances dopaminergic to ne, increased aspects of and defensive responses. Choice of male for irst both appetitive and consumma to ry sexual behav- mount, intromission, or ejaculation, and the distritt iors. Thus, brain dopamine systems in birds and bution of these measures across the test, are then mammals seem to have analogous functions in the determined for each female. Fe- in the control groups did not show a preference for males in both groups were signiicantly more likely either female for irst mount, intromission, or ejacu- to solicit and receive their irst intromissions from the lation, or for the to tal number of mounts, intromis- male paired with pacing. The selective copulation and irst ejaculation, and displayed signiicantly more mating behavior on the part of females in the paired ejaculations overall with that female compared to the group would be expected to assure paternity (Coria unscented female. The development of conditioned partner and ejacula to ry preferences is disrupted by Thus, a simple odor-conditioning paradigm reversed treatment with the opioid antagonist naloxone during what is typically considered a hard-wired biological training in both male and female rats (Coria-Avila et predisposition in the polygamous male rat to prefer a al. For example, the males had multiejacula to ry trials with the scent- the rate at which female rats will solicit and pace ed female (Kippen et al.

Affected animals become dehydrated blood pressure medication can you stop discount bystolic generic, weak and usually go down and die within 1-2 days blood pressure numbers for seniors generic bystolic 5mg, any survivors develop jaundice blood pressure medication and weight gain order bystolic on line. Animals are severely jaundiced and deaths may occur over a period of weeks with most sheep dying within 3-5 days of initial signs hypertension goals buy bystolic now. Symp to ms Normal foot There is normal Score 1 Slight to moderate Score 2 Skin between the Score 3a Separation of skin between the claws, with infammation with some erosion claws is infamed and raw, may the skin horn junction, with no reddening or infammation between the claws. There is no involve part, or all, of the soft underrunning extending no and no loss of hair. Surveillance phase -involves surveillance of the whole fock to ensure the disease has been eradicated, and preventing reinfection. Eggs hatch in the Hydatid Tapeworm segments Sheep infected intestine, the larval Hydatid cysts Dogs eat tapeworms in (containing eggs) by grazing stages pass through spread to liver, lungs Hydatid Life Cycle infected offal. Consider scanning and segregating twins, singles and empties for better feeding outcomes. Sheep are vaccinated to protect against some of the common serious infectious diseases.

The etiology of retrograde ejaculation and a germ cell tumours: prognostic value and therapeutic method for insemination pulse pressure with exercise cost of bystolic. Ejacula- transurethral resection and bladder neck incision in the to ry dysfunction after retroperi to neal lymphadenec to my blood pressure chart template buy bystolic 2.5mg without a prescription. The treatment of ejaculation disorders after retroperi- to neal lymph node dissection heart attack unnoticed generic bystolic 2.5 mg free shipping. The aetiology and function disorders after local radiotherapy for carcinoma of investigation of haemospemia blood pressure low heart rate high purchase 5 mg bystolic amex. Intra-operative Iodine-125 prostatic implant following bilateral pelvic lymph- 396. Pudendal following prostate-bed radiation therapy for prostate carci- cortical soma to sensory evoked potentials. Neuro- tive radiotherapy for primary resectable rectal adenocar- physiological evaluation of central-peripheral sensory and cinoma on male sexual and urinary function. Neurophysiological evaluation of central-peripheral nonseminoma to us testicular germ cell tumor. Dissociation of urethral and anal and marital relationships after radiotherapy for seminoma. Sympathetic skin responses from the limbs and the 1997: 80:454-64 genitalia normitive study and contribution to the evaluation 425. Electroenceph Clin Neurophysiol following radiotherapy for germ cell tumors of the testis. Evaluation of sexual life after orchi- disturbances in men with multiple sclerosis. Retarded ejaculation 2006:188-209 reconceptualization and implications for treatment. Meditation as a clinical intervention strategy: men: an overview of psychological and neurobiological A brief review. Unveiling retarded ejaculation [abstract rats following administration of antisero to ninergic drugs. Bupropion as an antidote for sexual dysfunction with sildenail: a randomized controlled sero to nin reuptake inhibi to r-induced sexual dysfunction. Apomorphine induces anejaculation but not spinal cord injury: a prospective ejaculation in chronic decerebrate rats. Sero to nin reuptake inhibi to r 1997: 20:210-4 induced sexual dysfunction and its treatment: a large 486. Effects of D2-dopaminergic recep to r scale retrospective study of 596 psychiatric outpatients. D2 recep to rs in the paraventricular nucleus regulate 1991: 52:163-4 copulation and genital responses in male rats. Amantadine in the treatment of sexual dysfunction sexual behavior in the male rat: reversal with oxy to cin. Medical and psychological interventions for erectile dysfunction: to ward a combined treatment 477. In: Lieblum S Rosen R eds Principles and induced anorgasmia with yohimbine: a case report. Psychogenic Erectile Dysfunction, Classiication and Management, Urologic Clinics of North America, 479. Comparison of effects of buspirone and gepirone with benzodiazepines and antagonists of 500. Integrating Viagra in to cognitive-behavioral dopamine and sero to nin recep to rs on punished behavior couple>s sex therapy. Effect of buspirone on sexual Process of Care Model for Evaluation and Treatment of dysfunction in patients with generalized anxiety disorder. Sildenail citrate: lessons learned from biochemical effects of the antidepressant bupropion 3 years of clinical experience. International Journal of (Wellbutrin): evidence for selective blockade of dopamine Impotence Research. Successful salvage of Sildenail Viagra failures: treatments in premature ejaculation. Preservation of sexual potency in prostatic cancer Research Meeting, Sexual Medicine Society of North patients after pelvic lymphadenec to my and retropubic I America, International Journal of Impotence Research. Treatment-related Eficacy and Tolerability of Dapoxetine in the Treatment of symp to ms during the irst year following transperineal 125I Premature Ejaculation. Arterbery V, Frazier A, Dalmia P, Siefer J, Lutz M, Porter Guilford Press, 1989 A. Sexual comparison of the effects of different sero to nin reuptake functioning after multimodality treatment for disseminated blockers on sexual behavior of the male rat. Sexual and marital the prevalence of chronic prostatitis in men with premature counseling with men treated for testicular cancer. Premature ejaculation: prevalence and associated functioning after treatment for testicular cancer: comparison conditions in a sample of 12,558 men attending the of treatment modalities. Another major innovation was the intracavernosal implantation of acrylic rods by Egyptian surgeon G. Indeed, recent appropriate when medical therapy is contraindicated, advances in the science and clinical management causes severe side effects, vacuum erection therapy of sexual dysfunction can largely be attributed to the has proven unsatisfac to ry or unacceptable, and/or in introduction of the modern day penile prosthesis. Future endeavors by this far-sighted surgeon alprostadil supposi to ries, and intracavernosal utilized rib cartilage in morphologically intact penises injection therapy. Unfortunately, long term prostheses are suggested, careful counseling success with this method was limited by natural before penile implant procedures will limit many of resorption. The use of alloplastic materials originates from once the discussion and demonstration of penile experimental materials developed in labora to ries implant varieties has been carried out, patients may 89 comitte 18. For these surfaces of the silicone not in contact with the body patients, implantation of a semirigid rod penile tissues. This micropolymer increases the lubricity of prosthesis requires a signiicant lifestyle change the silicone and in bench testing by the manufacturer and they are better served with an inlatable-type makes the silicone much more wear-resistant. Biolex and silicone do not of inlation and delation are not important, the risks bond to each other chemically and the process used of mechanical malfunctions may outweigh the to bond the components to the silicone tubing is concealment disadvantage of a malleable penile proprietary and undisclosed by Coloplast. Two Coloplast devices are all pre-connected between companies manufacture the three-piece variety; the cylinders and pump (Figure 1). The narrow cylinders are appropriate for the thin penis and for the penis with scar tissue where dilation to a large caliber corporal body is not easily accomplished. In this 2-piece steps to decrease the incidence of these problems model the pump mechanism has been moved from by applying coatings to the prosthesis designed to the tip of each cylinder to a separate scrotal pump retard bacterial growth. Flaccidity and erection are compromised with this model when compared to the 3-piece multi-component device, mainly because the reservoir volume is so severely restricted. Coloplast retarding the emergence of staphylococcal strains developed a similar device called the Excel that has that are resistant to rifampin [14]. Short-term follow narrow based cylinders attached to a smaller (20cc) up for this prosthesis enhancement shows statistical combined pump reservoir. There are two types of semi-rigid rod prostheses, the malleable and the mechanical. No clinical studies are available as of yet, however, a manufacturer data bank study shows a decreased rate of implant infection when compared to non-coated Coloplast devices [17]. Coincident with the introduction of the new-coated Titan prosthesis, the tips of the cylinders were changed to a more physiologic tapered shape rather than the former blunt appearance. The three-piece inlat- able also gives the best laccidity, as all luid can be drained out of the cylinders in to the reservoir when the non-erect state is desired. Compared to their previous pump articulating segments resembling a ball and socket design, this smaller pump has the inlation part in are covered by a polytetraluoroethylene sleeve and the most dependant part and the delation site in surrounded by a silicone jacket to prevent ingrowth the upper part of the pump. This implant has been promoted to tion in time spent instructing the patient in use of this aid the partially impotent man who has tumescence, device [22].

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