Bret P. Nelson, MD

• Department of Emergency Medicine
• Mount Sinai School of Medicine
• New York, New York

By the same token effective erectile dysfunction treatment safe levitra extra dosage 100mg, when serum phosphorus is abnormally high lipitor erectile dysfunction treatment purchase levitra extra dosage 60 mg, even dangerously so erectile dysfunction in diabetes type 2 cheap levitra extra dosage 100 mg overnight delivery, phosphorus continues to be absorbed from the diet at a rate only slightly lower than normal erectile dysfunction drugs herbal order levitra extra dosage 40mg. Phosphorus absorption is reduced by aluminum-containing antacids and pharmacological doses of cal cium carbonate reflexology erectile dysfunction treatment purchase 60mg levitra extra dosage fast delivery. However erectile dysfunction frequency age buy levitra extra dosage 60 mg lowest price, when consumed at intakes in the typical adult range, calcium does not significantly interfere with phosphorus absorption. In adults, 85 percent of phosphorus is found in bone, with the remaining 15 percent distributed through the soft tissues. In healthy adults, the amount of phosphorus excreted in the urine is essentially equal to the amount absorbed through diet, less small amounts lost in the shedding of skin cells and intestinal mucosa. This is because this age range brackets a period of intense growth, with growth rate, absorption efficiency, and normal values of inorganic phosphorus in the extracellular fluid changing during this time. Dietary intake of phosphorus appears to be affected more by total food intake and less by differences in food composition. People with a high intake of dairy products will have diets with higher phosphorus density values because the phosphorus density of cow milk is higher than for most other foods. People who consume several servings per day of colas or a few other soft drinks that contain phosphoric acid also tend to have high phosphorus intake. A 12 ounce serving of such beverages contains about 50 mg, which is only 5 percent of the typical intake by an adult woman. However, when consumed in a quan tity of 5 or more servings per day, such beverages may contribute substantially to total phosphate intake. Dietary Supplements Phosphorus supplements are not widely used in the United States. Absorption of this form requires the presence of phytase, an enzyme found in some foods and in some colonic bacteria. Because yeasts can hydro lyze phytate, whole grains that are incorporated into leavened bread products have higher phosphorus bioavailability than do grains used in unleavened bread or breakfast cereals. Also, unabsorbed calcium in the digestive tract combines with phytic acid and interferes with its digestion and absorption. However, the higher amounts of phosphorus contained in cow milk and soy formulas offset this decreased bioavailability. Dietary Interactions There is evidence that phosphorus may interact with certain nutrients and di etary substances (see Table 2). This is because phosphorus is so ubiquitous in the diet that near total starvation is required to produce dietary phosphorus deficiency. However, if inadequate phosphorus intake does occur, such as in individuals recovering from alcoholic bouts, from diabetic ketoacidosis, and from refeeding with calorie-rich sources without paying at tention to phosphorus needs, it is realized as hypophosphatemia. Aluminum When taken in large doses, antacids that contain aluminum may interfere with phosphorus absorption. Treating malnutrition: the refeeding of energy-depleted individuals, either orally or parenterally, must supply adequate inorganic phosphate. Hyperphosphatemia from dietary causes becomes a problem mainly in individuals with end-stage renal disease or in such conditions as vitamin D intoxication. High intakes of polyphosphates found in additives may inter fere with the absorption of iron, copper, and zinc. Dietary phosphorus supports tissue growth and replaces phosphorus stores that are lost through excretion and the shedding of skin cells. High intakes of polyphosphates found in additives may interfere with the absorption of iron, copper, and zinc. The ratio of extracellular to intra Tcellular potassium affects nerve transmission, muscle contraction, and vascular tone. Fruits and vegetables, particularly leafy greens, vine fruit, and root veg etables, are good food sources of potassium. Although uncommon in the gen eral population, the main effect of severe potassium deficiency is hypokalemia. Hypokalemia can cause cardiac arrhythmias, muscle weakness, and glucose intolerance. Moderate potassium deficiency, which typically occurs without hypokalemia, is characterized by elevated blood pressure, increased salt sensi tivity, an increased risk of kidney stones, and increased bone turnover. An inad equate intake of potassium may also increase the risk of cardiovascular disease, particularly stroke. There is no evidence that a high intake of potassium from foods has ad verse effects in healthy people. Although the mineral is found in both the intracellular and the extracellular fluids, it is more concen trated in the intracellular fluid (about 145 mmol/L). This, in turn, affects neural transmis sion, muscle contraction, and vascular tone. Absorption, Metabolism, Storage, and Excretion In unprocessed foods, potassium occurs mainly in association with bicarbonate generating precursors like citrate and, to a lesser extent, phosphate. When po tassium is added to foods during processing or to supplements, it is in the form of potassium chloride. Healthy people absorb about 85 percent of the dietary potassium that they consume. Because insulin stimulates this pump, changes in the plasma insulin concentration can affect extracellular potassium concentration and thus plasma concentration of potassium. This is because, in a steady state, the correlation between dietary potassium intake and urinary potassium content is high. The rest is excreted mainly in the feces, and much smaller amounts are lost through sweat. Bicarbonate acts as a buffer, neutralizing diet-derived acids such as sulfuric acid generated from sulfur-containing amino acids found in meats and other high-protein foods. When the intake of bicarbonate precursors is inadequate, buffers in the bone matrix neutralize excess diet-derived acids. The resulting adverse consequences are increased bone turnover and calcium-containing kidney stones. In processed foods to which potassium has been added, and in supplements, the conjugate anion is typically chloride, which does not act as a buffer. Because the demonstrated effects of potassium often depend on the ac companying anion and because it is difficult to separate the effects of potassium from the effects of its accompanying anion, this publication focuses on nonchloride forms of potassium naturally found in fruits, vegetables, and other potassium-rich foods. Special Considerations African Americans: Because African Americans have lower intakes of potas sium and a higher prevalence of elevated blood pressure and salt sensitivity, this population subgroup would especially benefit from an increased intake of po tassium. Medical conditions associated with impaired urinary potassium excretion in clude diabetes, chronic renal insufficiency, end-stage renal disease, severe heart failure, and adrenal insufficiency. Elderly individuals are at an increased risk of hyperkalemia because they often have one or more of these conditions or are treated with one of these medications. In addition, salt substitutes containing potassium chloride should be cautiously used by these individuals, for whom medical supervision is also advised. However, supplemental potas sium can lead to acute toxicity, as well as adverse effects due to chronic con sumption (see Excess Intake). Although meat, milk, and cereal products contain potassium, they do not contain enough bicarbonate precursors to adequately balance their acid-forming precursors, such as sulfur containing amino acids. Nutrient tables of the citrate and bicarbonate content of foods are lacking, making it difficult to estimate the amount consumed of these other food components. Dietary Supplements the maximum amount of potassium found in over-the-counter, multivitamin mineral supplements is generally less than 100 mg. Dietary be more prominent in African Americans, who have a potassium increases the higher prevalence of hypertension and of salt urinary excretion of sodium sensitivity and a lower intake of potassium than non chloride. Sodium: the sodium:potassium ratio Although blood pressure is inversely associated with potassium is typically more closely potassium intake and directly associated with sodium ratio associated with blood intake and the sodium:potassium ratio, the ratio pressure than with the intake typically is more influential. The incidence of kidney However, currently there are not enough data on stones has been shown to which to make recommendations. Dietary Interactions There is evidence that potassium may interact with certain other nutrients and dietary substances (see Table 2). Severe potassium deficiency is characterized by hypokalemia, a condi tion marked by a serum potassium concentration of less than 3. The adverse consequences of hypokalemia include cardiac arrhythmias, muscle weakness, and glucose intolerance. Moderate potassium deficiency, which typi cally occurs without hypokalemia, is characterized by increased blood pres sure, increased salt sensitivity, an increased risk of kidney stones, increased bone turnover, and a possible increased risk of cardiovascular disease, particu larly stroke. In unprocessed foods, the conjugate anions of potassium are mainly organic anions, such as citrate, which are converted in the body to bicarbonate. Consequently, an inad equate intake of potassium is also associated with a reduced intake of bicarbon ate precursors. Bicarbonate acts as a buffer, neutralizing diet-derived noncarbonic acids such as sulfuric acid generated from sulfur-containing amino acids found in meats and other high-protein foods. If the intake of bicarbonate precursors is inadequate, buffers in the bone matrix neutralize the excess diet-derived acids. In processed foods to which po tassium has been added, and in supplements, the conjugate anion is typically chloride, which does not act as a buffer. Excess diet-derived acid titrates bone, leading to increased urinary calcium and reduced urinary citrate excretion. The possible adverse consequences are increased bone demineralization and an increased risk of calcium-containing kidney stones. Special Considerations Climate and physical activity: Heat exposure and exercise can increase potas sium loss, primarily through sweat, thereby increasing potassium requirements. Diuretics: Often used to treat hypertension and congestive heart failure, thiazide-type diuretics increase urinary potassium excretion and can lead to hypokalemia. Potassium-sparing diuretics prevent diuretic-induced potassium loss and are often concurrently used with thiazide-type diuretics. Individuals who take di uretics should have their serum potassium levels regularly checked by their health care providers. Very low-carbohydrate, high-protein diets: Low-grade metabolic acidosis oc curs with the consumption of very low-carbohydrate, high-protein diets to pro mote and maintain weight loss. These diets, which may be adequate in potas sium due to their high protein content, are inadequate as a source of alkali because fruits are often excluded from them. Gastrointestinal discomfort has been reported with some forms of potas sium supplements. The specific product or vehicle in which the potassium supplement is provided is the critical determinant of the risk of gastrointestinal side effects. Special Considerations Problem pregnancy: High levels of potassium should be consumed with care by pregnant women with preeclampsia. The hormone progesterone, which is elevated during pregnancy, may make women with undetected kidney prob lems or decreased glomerular filtration rate (a side effect of preeclampsia) more likely to develop hyperkalemia when potassium intake is high. The ratio of extracellular to intracellular potassium levels affects neural transmission, muscle contraction, and vascular tone. Selenoproteins regulate thyroid hormone actions and the re S dox status of vitamin C and other molecules. Most selenium found in animal tissue is in the form of selenomethionine (the major dietary form of selenium) or selenocysteine, both of which are well absorbed. The method used to estimate the requirements for selenium relates to the intake needed to maximize the activity of the plasma selenoprotein glutathione peroxidase, an oxidant defense enzyme. Although some studies indicate a potential anticancer effect of selenium, the data were inadequate to set dietary selenium requirements based on this potential effect. Food sources of selenium include meat, seafood, grains, dairy products, fruits, and vegetables, and the major dietary forms of selenium appear to be highly bioavailable. However, the selenium content of foods greatly varies de pending on the selenium content of the soil where the animal was raised or where the plant was grown. Although the function of all selenoproteins has not yet been characterized, selenium has been found to regulate both thyroid hormone actions and the redox status of vitamin C and other molecules. Absorption, Metabolism, Storage, and Excretion Most dietary selenium is in the form of selenomethionine (the major dietary form of selenium) or selenocysteine, both of which are well absorbed. Other forms of selenium include selenate and selenite, which are not major dietary constituents, but are commonly used in fortified foods and dietary supplements. Ingested selenite, selenate, and selenocysteine are all metabolized directly to selenide, the reduced form of selenium. Selenide can be metabolized to a precursor of other reac tions or be converted into an excretory metabolite. The breath may also contain volatile metabolites when large amounts of selenium are being excreted. Although some studies indicate a potential anticancer effect of selenium, the data were inadequate to set dietary selenium require ments based on this potential effect. Food animals in the United States and Canada usually have controlled diets to which selenium is added, and thus, the amounts found in muscle meats, milk, and eggs are more consistent than for plant-based foods. Dietary intake of selenium in the United States and Canada varies by geo graphical origin, based on the selenium content of the soil and meat content of the diet.

A moisture uptake rate of about 1% per kiln to equalize the lumber until the moisture is inside these month can then be sustained throughout a humid season impotence aids order generic levitra extra dosage on-line. Kiln-dried softwood dimension lumber generally Comparable initial and sustaining moisture uptake rates are has an average moisture content of 19% or less; the average about 1% per month in open (roofed) sheds and 0 hot rod erectile dysfunction pills 100 mg levitra extra dosage. Dry lumber piled solid in the open for relatively short periods with a minimum pile cover of waterproofed paper whenever possible erectile dysfunction treatment with injection generic levitra extra dosage 60 mg amex. Because keeping rain out completely is diffcult impotence yoga discount 100mg levitra extra dosage with visa, storing solid-piled lumber in the open for long periods is not recommended erectile dysfunction causes drugs order levitra extra dosage now. If framing lumber must be stored in the open for a long time erectile dysfunction shake recipe buy levitra extra dosage with american express, pile on stickers with good base support and cover the piles. Re-pile using stickers for solid-piled material that has be come wet again is good practice. Finish and Factory Lumber Keep kiln-dried items such as exterior fnish, siding, and ex terior millwork in a closed unheated shed. Interior trim, fooring, cabinet work, and lumber for processing into furniture should be stored in a room or closed shed where relative humidity is controlled. In addition, store kiln-dried and machined hardwood dimension or softwood cut stock under controlled humidity conditions. Dried and machined hardwood dimension or softwood lum ber intended for remanufacture should also be stored under controlled humidity conditions. Under uncontrolled condi tions, the ends of such stock may attain a higher moisture content than the rest of the stock. Color rang quent shrinkage will cause splitting or open glue joints at es from bluish gray to black. The simplest way to reduce relative hu midity in storage areas of all sizes is to heat the closed space shed in a western location increased 2. Protect all manufactured stock from precipitation and spray, because If the heating method is used, and there is no source of liquid water on a solid pile tends to be absorbed by the moisture except that contained in the air, the equilibrium wood instead of evaporating. It is important to determine the dehumidifer is used, monitor or control if needed the aver moisture content of all stock when received. Under such circumstances, exposed ends and Plywood and Structural Items surfaces of boards or cut pieces will tend to dry to the low It is good practice to open-pile green or partially dried lum equilibrium moisture content condition, causing shrinkage ber and timbers using stickers and protect from sunshine and and warp. Framing lumber and plywood 4% or more below the moisture content of the core of fresh with 20% or less moisture content can be solid-piled (no ly crosscut boards can cause end checking. Simple remedies stickers) in a shed that has good protection against sunshine are to cover piles of partially manufactured items with plas and direct or wind-driven precipitation. However, a better tic flm and lower the shop temperature during non-work practice for stock with greater than 12% moisture content is hours. Dry wood undergoes small changes in dimension with nor As an example, assuming the width of a fat-grained white mal changes in relative humidity. This ideal condition is diff or quartersawn, this procedure will probably overestimate cult to achieve, but some drying and shrinkage of the frame width shrinkage and underestimate thickness shrinkage. Construction Thoroughly consider the type of framing best suited to the Lumber and Trusses whole building structure. Methods should be chosen that will minimize or balance the use of wood across the grain Although it is good housekeeping practice, lumber is often in vertical supports. These involve variations in foor, wall, not protected from the weather at construction sites. The factors involved and details of is commonly placed on the ground in open areas near the construction are covered extensively in Wood-Frame House building site as bulked and strapped packages. In addition, cover the packages with plas In heavy timber construction, a certain amount of shrinkage tic tarpaulins for protection from rain. A column that bears directly on a wood Pile lumber that is green or nearly green on stickers under a girder can result in a structure settling as a result of the per roof for additional drying before building into the structure. If not provided the same procedure is required for lumber treated with a for in the design, shrinkage may cause weakening of the waterborne preservative but not fully re-dried. One means of eliminating building parts, such as roof trusses, sometimes lie unprotect part of the shrinkage in mill buildings and similar structures ed on the ground at the building site. In warm, rainy weath is to use metal post caps; the metal in the post cap separates er, moisture regain can result in fungal staining. The same thing is the lumber also results in swelling, and subsequent shrink accomplished by bolting wood corbels (tassels or braggers) age of the framing may contribute to structural distortions. Extended storage of lumber at moisture contents greater When joist hangers are installed, the top of the joist should than 20% without drying can allow decay to develop. Framing lumber, even thoroughly air-dried fooring should be near 12% moisture content to mini stock, will generally have a moisture content greater than mize openings between boards as they approach moisture that recommended when it is delivered to the building site. When standard 38 or 64-mm (nominal 2 or If carelessly handled in storage at the site, the lumber can 3-in. Builders can schedule their work of greater depth for heavy design loads, the joist material so an appreciable amount of drying can take place during should be somewhat less than 12% moisture content if the the early stages of construction. When Interior Finish the house has been framed, sheathed, and roofed, the fram ing is so exposed that in time it can dry to a lower moisture Normal seasonal changes in the moisture content of interior content than could be found in yard-dried lumber. The fnish are not enough to cause serious dimensional change if application of the wall and ceiling fnish is delayed while the woodwork was properly installed. If this delay is about as ornamental beams, cornices, newel posts, stair stringers, 30 days in warm, dry weather, the framing lumber should and handrails, should be built up from comparatively small lose enough moisture so that any additional drying in place pieces. Backband trim, if mitered at the corners, should used, the period of exposure should be extended. Checking be glued and splined before erection; otherwise butt joints moisture content of door and window headers and foor and should be used for the wide faces. Design and install large, ceiling joists at this time with an electric moisture meter is solid pieces, such as wood paneling, so that the panels are good practice. Closing the house and using the heating system Flooring is usually dried to the moisture content expected will hasten the rate of drying. For amined and defects that may have developed during drying, basement, large hall, or gymnasium foors, however, leave such as warped or distorted studs, shrinkage of lintels (head enough space around the edges to allow for some expansion. Such protection may be suffcient during dry Exterior trim, such as cornice and rake mouldings, fascia warm weather, but during damp or cool weather, it is highly boards, and sofft material, is typically installed before the desirable to heat the house, particularly at night. Protect trim, siding, and window and door possible, the heating plant should be placed in the house frames on the site by storing in the house or garage until before the interior trim is installed, to be available for sup time of installation. After buildings have thoroughly dried, less heat is needed, Finished Flooring but unoccupied houses, new or old, should have some heat Cracks develop in fooring if the material takes up moisture during the winter. Such cracks can be greatly reduced by all times will keep the woodwork, fnish, and other parts of observing the following practices: the house from being affected by dampness or frost. In houses plastered in cold weather, the excess are completed and fully dry, unless a dry storage space moisture can also cause paint to blister on exterior fnish and is available. The average Department of Agriculture, Forest Service, Forest Products temperature will be lower because workers prefer a lower Laboratory. Drying hard ture content during construction than it will have during wood lumber. Before the interior trim is delivered, the outside doors and windows should be kept closed at night. Equilibrium moisture content of wood in outdoor locations in the United States and worldwide. Clausen, Supervisory Research Microbiologist Under proper conditions, wood will give centuries of ser vice. However, under conditions that permit the develop ment of wood-degrading organisms, protection must be Contents provided during processing, merchandising, and use. Wood degradation by organisms has been studied exten sively, and many preventive measures are well known and widely practiced. By taking ordinary precautions with the fnished product, the user can contribute substantially to en suring a long service life. Fungus Damage and Control Fungus damage to wood may be traced to three general causes: (a) lack of suitable protective measures when storing logs or bolts; (b) improper seasoning, storing, or handling of the raw material produced from the log; and (c) failure to take ordinary simple precautions in using the fnal product. The incidence and development of molds, decay, and stains caused by fungi depend heavily on temperature and mois ture conditions. Molds and Fungal Stains Molds and fungal stains are confned to a great extent to sapwood and are of various colors. The staining tends to occur in spots of various concentration and size, depending on the kind and pattern of the superfcial growth. Under favorable moisture and temperature conditions, stain ing and molding fungi may become established and develop rapidly in the sapwood of logs shortly after they are cut. In addition, lumber and such products as veneer, furniture stock, and millwork may become infected at any stage of manufacture or use if they become suffciently moist. Recommended moisture control measures are given bers indicate greater decay hazard. The pattern is a result of more and this can cause over-absorption of glue, paint, or wood rapid penetration preservative during subsequent processing. Increased poros by the fungus ity also makes wood more wettable, which can lead to sub radially (through sequent colonization by typical wood-decay fungi. Stain and mold-infected stock is practically unimpaired for many uses in which appearance is not a limiting factor, and a small amount of stain may be permitted by standard grading rules. Stock with stain and mold may not be entirely satisfactory for siding, trim, and other exterior millwork be cause of its greater water absorbency. The may be present, though inconspicuous, in the discolored distinction between molding and staining is made primarily areas. Both of these factors increase the possibility of decay on the basis of the depth of discoloration. With some molds in wood that is rain-wetted unless the wood has been treated and the lesser fungal stains, there is no clear-cut differentia with a suitable preservative. Typical sap stain or blue stain penetrates into the sap wood and cannot be removed by surfacing. Also, the discol Chemical Stains oration as seen on a cross section of the wood often appears Nonmicrobial or chemical stains are diffcult to control and as pie-shaped wedges oriented radially, corresponding to the represent substantial loss in wood quality. The discoloration which should not be confused with fungal brown stain, may completely cover the sapwood or may occur as specks, include a variety of discolorations in wood that are of spots, streaks, or patches of various intensities of color. The ten promoted by slow drying of lumber and warm to hot so-called blue stains, which vary from bluish to bluish black temperatures.

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Syndromes

• Blood pressure
• Chancroid (a small bump in the genitals, which becomes an ulcer within a day of its appearance)
• Skin
• The doctor makes a small cut (incision) on your back. A needle is passed through the skin into your kidney.
• Wear or bring loose clothing that buttons or zips in front.
• Hyoscine (scopolamine)