Essentials of Obstetrics and Gynecology, 4th ed. 2007

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Essentials of Obstetrics and Gynecology
Neville Hacker, J. George Moore, and Joseph Gambone
ISBN-10: 0721601790
ISBN-13: 978-0721601793

This popular resource continues to offer step-by-step guidance on how to evaluate, diagnose, and manage a wide range of obstetric and gynecologic disorders. The 4th Edition of this bestseller has been completely revised and reorganized to present a more up-to-date approach to the field, with less emphasis on traditional hospital-based practice. It uses the APGO/CREOG curriculum objectives as a framework, with a special emphasis on women's health issues.



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PHIRST Published; Tadalafil Approved for PAH

The Food and Drug Administration has approved tadalafil (Adcirca, United Therapeutics) for the treatment of pulmonary arterial hypertension (PAH). The drug, a phosphodiesterase type-5 inhibitor, is the active ingredient in the FDA-approved erectile-dysfunction drug cheap cialis (Lilly) and is now available in the 40-mg dose for the purpose of increasing exercise capacity in patients with World Health Organization (WHO) class 1 PAH.

Coinciding with the approval of tadalafil, the Pulmonary Arterial Hypertension and Response to Tadalafil (PHIRST) trial is now published online May 26, 2009 in Circulation and shows that tadalafil 40 mg was well tolerated and improved exercise capacity and quality-of-life measures in patients with PAH. In addition, the drug reduced the time to clinical worsening, and side effects were reported as mild or moderate, the most common being headache.

On the basis of the favorable efficacy and safety data, lead investigator Dr Nazzareno Galiè (University of Bologna, Italy) and colleagues state that the drug "offers a clinically meaningful addition to the currently approved treatment options."

Improves Six-Minute Walk Test Distances

Currently, treatment of PAH includes the use of prostanoids, endothelin-receptor antagonists, and sildenafil, another FDA-approved phosphodiesterase type-5 inhibitor. Like sildenafil, tadalafil increases cyclic guanosine monophosphate (cGMP), which is the final mediator in the nitric-oxide pathway. Studies with sildenafil have shown that the drug, the active ingredient in erectile dysfunction drug Viagra (Pfizer), improves exercise capacity and hemodynamic parameters.

In the PHIRST study, investigators randomized 405 individuals with pulmonary arterial hypertension to treatment with tadalafil 2.5 mg, 10 mg, 20 mg, or 40 mg or to placebo for 16 weeks. Roughly half of subjects in each study arm were treated with background bosentan (Tracleer, Actelion), an endothelin-receptor antagonist.

At 16 weeks, tadalafil 10 mg, 20 mg, and 40 mg increased the distance walked in six minutes in a dose-dependent manner, although the 40-mg dose was the only dose that reached statistical significance compared with placebo. The time to clinical worsening and quality-of-life scores were all significantly improved with tadalafil 40 mg, but changes in WHO functional class were unaffected by treatment.

The placebo-adjusted change in six-minute-walk distance in the treatment-naive patients was 44 m, compared with 23 m for patients also receiving bosentan. Secondary end points also tended to be better in treatment-naive patients compared with bosentan-treated subjects.

These data, suggest investigators, "support the hypothesis that increases in exercise capacity may be blunted in patients already treated with PAH-targeted medications compared with treatment-naive subjects." The reasons for the effect are not clear but might be related to a "ceiling" reached that limits additional improvements in patients on background therapy, they write.

The most common side effects associated with use included headache, myalgia, and flushing, and most events were reported as mild or moderate. Regarding the FDA approval, tadalafil should be avoided in patients with severe renal and liver impairment and should not be used in patients taking nitrates, according to the label.

United Therapeutics will market tadalafil for PAH in the United States. The company obtained the marketing rights to sell the drug for PAH from Eli Lilly in 2008.

Galiè has served as a member of the PHIRST steering committee for Eli Lilly and has participated in advisory boards and/or served as a paid lecturer for Actelion, Pfiz


  1. Galiè N, Brundage BH, Ghofrani HA, et al. Tadalafil therapy for pulmonary arterial hypertension. Circulation 2009; DOI:10.1161/circulationaha.108.839274. Available at: Abstract
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Clinical Neurology , 7th ed. 2009

Clinical Neurology , 7th cheap cialis. 2009
(LANGE Clinical Medicine)
Roger Simon, David Greenberg, Michael Aminoff
ISBN-10: 0071546448
ISBN-13: 978-0071546447
McGraw-Hill Professional

No other book makes the link between basic neuroscience and current approaches in diagnosis and treatment easier to understand than Clinical Neurology. Distinguished by its practice-oriented approach to neurology based on the patients' presenting symptoms, this classic has been updated and revised to make it even more clinically-relevant and enjoyable to read.

  • Essential concepts are presented within the framework of problems encountered in a clinical setting for greater relevance to real-world practice
  • Chapter outlines provide a quick overview of each topic
  • Treatment protocols reflect the most recent advances in the field
  • Advances in molecular biology and genetics are incorporated throughout to enhance understanding of neurologic disease
  • A step-by-step description of the neurologic examination
  • More than 200 tables and figures


Clinical Neurology 6th cheap cialis. 2005 in PDF