-HOW TO PERFORM ? A MODERN PERSPECTIVE & DEFINITION
---DR.D.R.NAKIPURIA
SEX although cannot be discussed or expressed openly in our society as it is a topic of intense personal matter and allowed to discuss by grown up or adults or matured in personal couple group or an advice by seniors to upcoming matured adults to practise it as per their experience.Beside this our society think its discussion may destroy social fabric as may stimulate youngster in early sexuality or indulgence of adults and old in abnormal sexuality beside legal partner.SEX has been broadly defined as meeting of two partners of opposite sex or meeting two external genital organs of opposite sex whether any pleasure or satisfication is achieved by this or not.As man has got Penis and it is penetrated in to vagina through introitus by man so he is called active partner and as female simply receives Penis so is called Passive partner but modern detail analysis of patients achieving full satisfication and pleasure by Sex and persons remaining unsatisfied and psychosocially disturbed after Sex has redefined this definition of SEX.
it is very important for a man being active partner realise very much,any defect in performance of Sex either of arousal or desire or LIBIDO or lack of excitement on stimulation by seeing or reading sexual activities or seeing or touching opposite sex partner or her activity or by stimulation through eyes,talk,exhibition or touch of partner or self induced involuntary erection( under influence of body hormones) i.e.,tightening,straightening,thickening and hardening of penis with slight secretion of seminal fluid over glans region with easy slipping of foreskin over it or called as ERECTION or it may be failure of pushing this erect penis in partner�s vagina through introitus or Ext.Genitilia Vulva or discharge of Seminal fluid into vagina immediately after penetration i.e.,EARLY EJACULATION resulting in loss of satisfication and pleasure as strokes gives more and more pleasure which reaches to peak slowly keeping pace with speed and force applied for stroke.by penis.The force is more applied by a thickened, tightened and straight erected penis ,that is why a good erection is mandatory for a good performance of sex.lack of such erection is called Erectile Dysfunction(ED).This enjoyment becomes more excited as partner� vagina contracts involuntary or by active contraction of Pelvic muscles by partner is increased.Therefore ,apathy of partner,less excitement or lack of attention in sex by partner or deficiency of active cooperation and actions in Sex also result in getting good satisfication and pleasure.Female although by misnomer called as inactive partner but actually her cooperation from the stage of getting desire,attention,environment of Sex to getting aroused or ORGASM either by self excitement or by stimulation by partner by look,touch or reading books or watching video etc.,or after fourplay by partner which is very important in Female as they are less easily excited or reach peak to Orgasm and without her active cooperation Sex remains less pleasant and unfulfilled in satisfication.Role of Accessory or additional Genital organs like Body contour,Pubic Hairs,Moustache,hairs over chest/limbs(in Male),Face color of Body,color of Iris of eye ,shape,size of Eyes,Placement of Eyebrows,straight beak like nose,mouth opening,lips ,fore head,style of hairs over scalp,and contour,fullness,bogginess tightening,size ,shape resistance,compressibility of breast with coloring of areola and stargtening of nipples with shape of belly being scaphoid and centrally placed elliptical umbilicus ,proturbance of buttocks,broadening of Hips with slender slim straight fingers,toes limbs, soft palm and sole with absent of hairs over any part of body except straight small shiny pubic hairs with thickened puffy Labial folds is very important as they play indirect role to either initiate Sex or Libido or later to maintain Sex or good performance or more sustainable play.Early Ejaculation leads to flaccid ,small ,shrunken Penis which freezes immediately a Male partner as female is either at peak of orgasm or getting arousal for orgasm ,such sudden discharge makes her completely dissatisfied and uncomfortable as shrunken flaccid penis cause no dilatation of strchable compressed thickened roomy vagina or touching of cervix of Uterus or deep pockets of vagina around cervix or fournix .So either expressed by modern educated Female partner voluntarily or involuntarily expressed by face or body activities immediately or on subsequent occasion of Sex initiation by male partner who realises this as his biggest failure and suffer from self realised Gilty consciousness leading to Psychosocial disbalance leading to further damage in getting arousal or erection or performance of sex and vice versa.
Therefore,we have realised that sex is no more confined to one partner ,one partner may be less active but other partner can make him co active similiarly an uninterested or freezed partner can freeze or dissatisfy another partner.Previously if one partner is not performing particularly a male doesnot get erection or arousal to perform sex we called it IMPOTENCE and similiary a female doesnot get pregnancy after intercourse we called IMPOTENCE but it should be better termed as INFERTILITY but now a days sex has been better defined as stated above in following stages.
StgageI: Self or stimulated Aroursal and arousal of partner with full Orgasm.
Stage II:Erection of penis with penetration and reception of such erected penis by an active partner.
Stage III;-Mantenance of coital activites by cooperation of both partner ( both are as active no active or passive nomenclature).
StageIV;-Discharge or Ejaculation of Seminal fluid in vagina or condom or ouside gradually allowing partner to cool gradually and slowly.
Sex in different positions or in different openings beside vagina as Anal or oral or Arm pit sex is not called perversion but resource to achieve more pleasure and satisfication in which any of these four stage is fortified depending on which separate methodology we adopt like kissing or messaging of Breast increase stage I and III ,oral ,armpit and anal sex improves stage II,III and IV.Sex with children or old people or desibilated or mentally retarded people or against will of partner forcefully or under intoxification with alcohol ,drugs or sleeping pills is a crime and this needs no discussion as it is always painful .SEX IS A RESOURCE TO BRING JOY, HAPPINESS , SATISFICATION,LIKENESS,ADHERANCHE AND MORE HUMAN BONDAGE WITH LOVE IN LIFE IF IT PAINS EITHER PARTNER DURING OR AFTER PERFORMANCE IT SHOULD NOT BE CALLED SEX.Sex ,how much discarded for discussion openly in society is need of human being to mantain its progeny in universe but Sex is the only simple natural method of producing future generation but every act of Sex is not necessarily mean production as Human has reached highest growth in Animal Kingdom,he has to restrict the number of his progeny,that is why he has learned to enjoy Sex without production by developing so many methods of contraception like Condom,spermicidal jelly tablets,foams ,vaginal condom,pessary jellies,IUCDs ,oral contraceptive pills/injections/patches for female and male,sex during safe period,external ejaculation etc.,
Lack of availability of partner in war time battalions leads to sex with same sex partner and gradually a class of people called as GAY or LESBIANS has evolved in society in good number across the globe,they are perfect Humanbeings with good mental and social judgement but they got enjoyment with same sex or HOMOSEXUAL.They are no more defined as perverted or sexually abnormal persons ,many countries provide their activity as normal as Sex among HETROSEXUAL exist.even in India,their such act is now not under any screeing of unlawful activity.gradual wecome and accept of these Homosexual have added further definition of SEX where in Stage II erection of penis or penetration of Penis may or may not present and partner may utilise aroused finger /hand /toe or any soft compressible toy/instrument after excitement for penetration or simply with external genitilia or with accessory Genital organs as mentioned above completes further stages of SEX where Ejaculation may or may not come avoiding need of any contraception to avoid pregnancy but needed to arrest spread of sexual transmitted disease like HIV,Syphlis,Gonorrhoea,Herpes,Hepatitis B & C ,etc.But in this Homosexual activity which is regarded as abnormal activity by many as it turned very purpose of SEX and human existence of Love for man and woman keeping our social fabrics intact also involves very intimate cooperation of both partners,here both partners are highly active members as lethargy or apathy of one partner cannot initiate this at all and this strong love,affection,intimacy,bondage and physical contact has lead to more increase in their numbers in society .
In modern time if SEX is not performed keeping intact all 04 stages of SEX with strong bondage affinity and adherence of both partners leads to breaking in relations or crimes where SEX is performed by male as simple formality of penetration after slight or full erection knowing nothing about arousal of opposite partner and ejaculation ,satisfication,pleasure,enjoyment is left behind or never asked or taken care of where female is always acts as passive receiver and Male as dominant partner serve as active partner without any question or liking of opposite partner or self realisation of failure covered under social dominance of male over female or a female even unsatisfied either gets satisfication by illegal means or remain unsatisfied but never asks or challenge male partner under social obligation of male dominance and even pay price of Infertility (being discarded by family or divorced ) even having her no fault.Sex can be performed in many style and ways with use of fragrance,sweet smelling scents,powders,lotions,jeelies,perfumes wearing alluring clothes or creating inductive environment like rose petal bathing,swimming or candle light meetings under flower shade ,exorbiant seducing music and video shows,dance with slight intake of stimulants and usual duration of 10-20 minutes(which may be increased in some one who practise its regularly) for stage II-IV performance is regarded as normal Sex ,regarding frequency 1-5 times a day to once a week or month is regarded as normal sex but if its frequency reached more or filthy means of using electric vibrators,binding partner with rods,chains or belts or stimulation by smoking ,alcohol or drugs or burning partners body parts or genitilia or Accessory Genitilia by cigratte butts or by pin pricks or electric or thermal currents is perversion and abnormal sex which comes as obesity hypertension,heart disease comes after over eating.Sex under intoxication of excessive cigarette,alcohol or drug is always perfomed of low category as performance is mostly un coordinated and incomplete,so it is better to avoid it.Enviornment personal privacy and isolation is important for good Sex performance as Sex is always a private personal matter in our society,no body wants its open and frank exhibition and show.and we have been matured in this way through our culture and social rules that sex has been always a private matter of a couple through which person and society both grow,sharing and swaping of partners or multiple partners or prostitutions or Jigglos cannot be termed as normal lawful practice of society and has been regarded as offence in Sex.In no way Sex promotes separations,loneliness ,breaking and divorces and it is not limited to simple enjoyment and satisfication burning and destroying our social fabrics involving two willingful compatible and legal partners .simple meeting and performance of these IV stages where social fabrics is destroyed canot be termed as normal sex.hence sex with animals like horse,dogs,cattles canot be termed as normal Sex,these should be avoided as damage to our external genitilia or body parts may occur as animals are not trained to perform sex with human beings and many sexual transmitted disease can spread through it.As in our many acivities like eating ,reading,sleeping,playing etc we do some time nothing ,some time excess and these are termed abnormal activities ,same way in Sex if we either do apathy or doesnot involve our partner or do which should not be done or praticed or do excess then it is called abnormal sex or perversion which brings many diseases as obesity after excessive eating and Anxiety nervosa after no eating.Sex with children,mentally retarded persons or under pressure against will of even a partner is termed rape and regarded as unabailable offence in our system.

Hence sex requires two active willing legal partners for its true performance,if partners are either excited by oneself or by simple stimulation of each other and a private suitable place and time is selected,Sex can be performed excellently without need of any counselling, advice ,medicine or artificial allurement environmental things as mentioned above.In society so many quack doctors or self styled sex specialist doctors or therapy are advertised in print,electronic and internet media claiming better and best Sex.Nothing like this actually exist,if both partners are really happy and pleasant a good sex has been performed irrespective of its total duration and duration of any stage mentioned above or overlapping of stages,it is a continous live processnot a machnary computer which will always move through stages by giving every stage a good time ,these stages has ben enumerated to uderstnd Sex in better way .if intimacy,adherence and closeness achieved in partners with Conception(reproduction) then Sex has fulfilled its target(reproduction is not necessary as mentioned above) and there is no role of any thing ,instrument,medicine,doctor,counselling or therapy .A rumor is spread regarding penis size,so many instruments,medicines or message oil or sold to increase its size but for a better performance of sex only 2-4 inch penis is enough as only outer 2inch of vagina is sensitive to penetration so such size odf penis will give pleasure to both man and woman and till today no convincing scientific medicines has been discovered which can increase penis size,thickness or tightening.No medicine or therapy has come which increase arousal or libido in male or female (Testosterone helps only those male who have got less its amount in Blood not in normal male where if it used may cause prostatic cancer or toother virilising effect)but so amny are sold in market for increasing desireness or lure for sex .Sex is a totally personal psychological matter which can be easily controlled and maintained by psychological counselling removing childhood fear,apprehension or any doubt about Sex as sex is painful,sex is crime,sex is abnormality,sex always result in pregnancy,sex is discarded things and sex is a formality to be performed after marriage in first night only and after that on demand by husband (wife has go no right to ask sex or question sex),limited sex after child births,no sex after menopause,no sex during menstruation ,no sexual discussion among family or with children or in school ,our external genitilia are dirty parts of waste disposable only so should be never cleaned or cared for.A good development has taken place in some patients of actual Erectile Dysfunction (ED) where Sildefinal or tadalfil gives good result but it has got no effect on many patients of ED too and in normal persons it never increases size or erection of penis but sold like anything and even female takes it where it has got no role ,same way for delayed ejaculation so many medicines and creams and injections are marketed which is better controlled by psychological counselling and gradual practise and learning style of performing sex under guidance of an expert.After unprotected sex to avoid pregnancy I-pill or unwanted 72 are sold openly in market which are nothing but high doses of oestrogen and progesterone which completely disturb a woman�s menstrual cycle and in many woman as suffering from migraine,thrombosis,hypertension,jaundice etc., they are contraindicated so government should ban selling of these drugs with harmful side effects by advertising in TV and printed media as youngsters are now developing live in relations and sexual activities openly with removal of fear of getting pregnancy but risk of developing sexual transmitted diseases like HIV,Gonorrhoea,herpes ,septic abortions and infertility.
DR.D.R.NAKIPURIA

09434143550
***Author is an expert Sex and HIV practitioner

Migraine is a serious type of Headache which occurs with so much robust type of headache mostly in one half of head with throbbing or pulsating type prececded by an aura or a smell or perception of some thing going to happen,blackspots in eye field,flickering movements of eye,face and hands or sensation of tingling type or numbness in head or any part of body preceded by nausea or vomiting feeling or vomiting and patient become very sensitive to light or sound needing a dark room and a noise less enviornment for soothing .This type of Headache is believed to be caused by extreme sensitivity of Blood Vessels and nerves to many chemicals and toxins yet to be discovered or many other physical agents like bad or unpleasant smell or flashing ,extreme cold or hot or un familiar enviornment any psychological insult like fear,apprehension,tension,anger,happiness or grief leading to contraction or dilatation of these blood vessels There is no cure or medications for migraine headache but the drugs can help reduce the frequency and severity of migraines.Migraine usually affects more female than male ,usually middleaged ladies are involved and subsides in intensity after menopause but seen too commonly in male too and involves children too.Migrain attack is severe one and usually last for 12-24 hrs but may last for 2-3 days and usually remission and recurrence are common ,mostly recurs in week or monthly wise but in some days it may occur at days interval.Usually it subsides normally without leaving any spot or complication like paressis or paralysis of any part or any defects in sensory or motor nerves of Body or any epileptic or any other type of slow or rapid movements or uncontrol of bowel and bladder or any type of para or sympathetic alterations.
There are many drugs specifically designed to treat migraine which are given below,some are drugs which abort or stops attack of Migraine once it has started like NSAIDs,Triptans,Ergot derivative,butabital,barbiturates,anxiolytic and sedative with opiates ,others are used to prevent its recurrance like B-Blockers,calcium channel blocker,Angiotensin receptor blockers,major tranquilisers and antivomiting medicines,anti epleptics,anti depressants,serotonin uptake or receptor inhibitors,anti histaminic like Cyprohepatidine,Botulinum and norepinephrine receptor or uptake inhibitors but still after their use recurrence is delayed but not completely inhibited.
Aborting drugs:-------These types of drugs are taken during migraine attacks and are designed to stop symptoms that have already begun. These are taken as soon as symptoms of a migraine occur. It may help if you take rest or sleep in a dark room after taking them.
Nonsteroidal anti-inflammatory drugs (NSAIDs):? Ibuprofen,Paracetamol or Aspirin or Diclofenac sodium or Acllofenac,Rafecoxib, Etorcoxic ,Naproxen,Indomethacin etc., may help relieve mild migraines.Combination of acetaminophen, aspirin and caffeine also may ease moderate migraines .Side effects: can lead to ulcers, gastrointestinal bleeding and rebound headaches.
Triptans: Both oral and injectable preparation even nasal spray is also available,Sumatriptan has been widely used rizatripan is showing promising result.
Used for severe migraine attacks.DRUGS ARE AS FOLLOWS:-Sumatriptan, rizatriptan ,Naratriptan, zolmitriptan, Almotriptan, frovatriptan and eletriptan .Side effects: nausea, dizziness and muscle weakness.They are not used in heart attack and stroke.
ERGOT DERIVATIVES:Used for pain lasting for more than 48 hours.DRUGS ARE'--- Ergotamine,Dihydroergotamine, Antivomiting or nauseating Medications if nausea or Vomiting present : Metoclopramide,prochlorperazine.
Butalbital:It is a sedative which is used in combination with other drugs for migraine attacks. Combination of butalbital with aspirin or acetaminophen Combination with caffine and codeine but rebound headache ,withdrwal symptoms.
OPIATES: Medicines containing narcotics, particularly codeine, are sometimes used to treat migraine pain when people can't take triptans or ergot.
Side effects: Habit-forming and patients are usually addicted.
Preventive medications:
These drugs are taken daily on a regular basis, to reduce the severity or frequency of migraines. Are used when two or more debilitating attacks a month occur and if pain-relieving medications aren't helping or symptoms include a prolonged aura or numbness and weakness.
Cardiovascular drugs:
Beta blockers: Commonly used to treat high blood pressure and coronary artery disease ? can reduce the frequency and severity of migraines.
Calcium channel blockers: Verapamil also may be helpful in preventing migraines and relieving symptoms from aura.
Antihypertensive medications: Lisinopril and candesartan are useful in reducing the length and severity of migraines..Side effects: Dizziness, drowsiness or lightheadedness.
Central Nervous System drugs:
Tricyclic antidepressants: Amitriptyline, nortriptyline and protriptyline .
Selective serotonin reuptake inhibitors (SSRIs) and serotonin and nor epinephrine reuptake inhibitors (SNRIs): Venlafaxine may be helpful in preventing migraine.
Anti-seizure drugs: Divalproex and Topiramate, and Gabapentin .Side effects: Nausea and vomiting, diarrhea, cramps, hair loss, and dizziness.
Major Tranqualisers : Trifluperazine,(Sibelium,no miraine)prochlorperazine(Stemetil).
Cyproheptadine: This antihistamine specifically affects serotonin activity. Doctors sometimes give it to children as a preventive measure.
Botulinum toxin type A: Botulinum toxin type A injections in mutiple sittings over head is sometimes used for treatment of chronic migraines,but relapses are common after 6-12 months of therapy.
Dr.D.R.Nakipuria
,09434143550

NUTRITIONAL NEEDS OF CHILDREN

There are two fundamentally different kinds of food needs- energy requirements & structural requirements. The body requires energy for many activities such as beating of the heart, breathing, digestion of the food & voluntary muscular activity. Energy is also needed for growth. This energy requirement expressed in calories is obtained chiefly from carbohydrates & fats.

1. Energy Requirements: The amount of energy needed in terms of calories varies from individual to individual & is dependant upon a number of variables, none of which can be considered independently but rather are part of a constellation. It differs with size. A large child requires more energy producing foods than a small child. It differs with the rate of activity of the body processes while at rest, i.e. with a basal metabolic rate. The faster the rate of basal metabolism, meaning the faster the heart beat, respiration etc. The greater the number of calories used in a given time & conversely, the lower the rate, the lower the number of calories needed.
The energy requirement differs too with the amount of voluntary activity. A very active child requires more calories per day than a quiet one. The same child will need more calories during a day of vigorous activities than during one of quiet activities.
Energy requirements differ also in accordance with the efficiency of the body in using foods. Some bodies are more economical in the use of foods than others. In some cases food is more easily digested & absorbed than in others. In all individuals some food value is lost in bowel elimination, but the amount varies considerably from child to child. Finally, the need for calories depends on the rate of growth. The fast growing child will need more calories than the slow growing child. During the periods of his life when the impetus to grow is more intense, infancy & early adolescence, the amount of energy required for growth will be greatest.
In proportion to their weight, children�s food needs are greater than those of adults because of children�s relatively greater basal metabolism, their tremendous activity & their growth. Boys generally catch up with their fathers in need for calories at 13 years & exceed them by 16 percent at 18. By 10 years of age girls already exceed their mothers by 11 % & at 13 by 16 % in their energy needs.

2. Structural Requirements: the structural requirement covers the need for materials which go to make up tissues & to regulate the functions of those tissues. The necessary food elements or nutrients are 40 in number. They include amino acids from proteins, at least one digestive product of carbohydrates (glucose), some unsaturated fatty acids or acids (derived from the digestion of fats), minerals & vitamins. The body needs all these in adequate amounts for the building & repair of its tissues & for these tissue�s daily activities. Since all foods do not contain all of these nutrients, a balanced diet of �protective� foods, i.e. foods rich in the essential nutrients, is necessary.

3. Importance of Minerals: Minerals serve as constituents of tissues. Calcium & Phosphorus are responsible for the rigidity of the bones & teeth. The softer bones of children contain less minerals than the firmer bones of adults. The process of hardening called ossification demands Calcium & Phosphorus in generous quantities. An inadequate amount of these minerals may result in poor teeth & poorly formed bones. Poor teeth are a barrier to good health & attractiveness. Poorly formed bones detract from the attractiveness of an individual & limit his physical efficiency.
Minerals serve as regulators of body process. The part played by minerals in the beating of the heart & in the activity of the nerves has been mentioned. For coagulation of the blood the body needs calcium in the blood. Phosphorus takes part in the chain of events in muscle activity & in the transfer of energy. The digestive juices such as salivary, gastric & intestinal juices, depend upon minerals for their acidity or alkalinity. Minerals regulate the flow of liquids by means of which substances are absorbed, passed to and from body cells & excreted through kidneys or intestines.

4. Importance of Vitamins: The vitamins, as regulators of body processes, have a vital role to play in keeping children well & furthering their development. The vitamins now recognized as contributing to the health & growth of children are Vitamin A, D ,C, K, Thiamine, Riboflavin, Niacin, B-6, Folic acid & B-12. Vitamin K aids in the formation of prothrombin, which is associated with the mechanism of blood clotting.

VITAMIN �A : is a necessary part of the visual process & thus is associated with the ability to see in dim light. Vit-A is also necessary for maintaining the health of epithelial tissue, namely, the tissue of skin, covering of the eye, the lining of respiratory, alimentary & genitourinary tracts. Deficiency of Vit �A structurally impairs �the body�s first line of defense�. In addition it is necessary for the orderly development of bones & teeth. It is also essential for the formation of enamel of teeth.
Source of Vitamin A - Milk, Butter, Liver, Fish Liver Oils and Egg Yolk.

VITAMIN �D : IS essential for the normal growth & mineralization of the bones & the teeth. The body cannot make proper use of the Calcium & Phosphorus supplied by food unless Vit- D is present.
Source of Vitamin D - Fish Liver Oil, Milk, Butter, and Yeast.

Thiamine (Vit- B 1) : Is one of the vitamins in the B-Complex. Thiamine is essential for the maintenance & normal function of the nervous system. It has been found that Thiamine is necessary to carry carbohydrate metabolism through an essential step.
Source - Cereals, Grains, Beans, Nuts, Pork and Duck.

RIBOFLAVIN (Vit-B 2) : Plays an important role in the internal environments in which the body cells live, where it is involved in the life processes of active cells. Riboflavin is essential to growth & to normal nutrition at all ages. A deficiency produces characteristic changes in the lips, tongue & skin.
Source - Dairy products, offal and leafy vegetable.

NIACIN: Is involved in the life processes of the cells. It prevents Pellagra, with its characteristic skin lesions, digestive & nervous disturbances, provided all other essentials are included in the diet.
Source - Found in many food stuff including plant, meat, (particularly Offal).

VITAMIN �B 6 : Is a member of the enzyme system in certain metabolic processes, including those of neural tissue. Arrested growth & disturbances in functioning of the nervous system have been noted to follow deprivation of B 6 in infancy. Also alteration in tryptophan metabolism in pregnancy has been relieved by administration of B 6 .
Sources - Widely found in animal and plant food stuff.

FOLIC ACID : Has been found to play an important part in the body�s blood forming activities. It is effective in the treatment of certain types of anaemia.
Sources - Found in green vegetables, spinach and Broccoli.

VITAMIN �B 12 (Cyanocobalmine ) : Plays an essential metabolic role & is essential for the prevention or treatment of pernicious anaemia, a disturbance of red blood cell formation.
Sources - It is found in Meat, Fish, eggs and milk but not in plant. It's also found in papayas, cantaloupes, strawberries, broccoli, Brussels sprouts, tomatoes, asparagus and parsley.

VITAMIN C : Is essential to the health of intercellular material which acts as cementing substance in holding the cells of a tissue in their precise positions.
Sources � Lemon, orange, amla, potatoes.

5. Functions of Proteins : Proteins make up a part of all body cells & participate in nearly all life processes; therefore, they are necessary for growth. Through digestion they are broken down into amino acids which are used by the body in building its tissues; bones, muscle, nerves, skin, blood etc. Eight of these amino acids cannot be manufactured in the body & so must be supplied in the diet. Deficiencies in particular amino acid may lead to specific types of injury e.g. when Argimine is deficient there is a decrease in the number of sperms & their motility.
Proteins are necessary for the manufacture of enzymes used in the hormones of the endocrine glands, such as thyroxin of the thyroid gland, epinephrine of the adrenals & insulin of the pancreas. They function in regulating the flow of fluid in & out of cells.

6. Functions of carbohydrates & fats : carbohydrates & fats as the chief sources of energy, are necessary for growth, & they furnish energy for the growth process. Carbohydrates & fats also furnish the body with adipose tissue, which serves as a protection against the loss of heat, act as a cushion to the abdominal organs & is a potential source of body energy. Certain fats perform another important function i.e. they are carriers of vitamin A & D. Glucose, a digestive product of carbohydrates is a constant constituent of the blood.

7. Role of Water: The human being lives in water, even though it is not an aquatic species. Water is a part of every tissue in the body, even of the proverbially dry bone. In children the percentage of water in tissues is higher than in adulthood. Matured bone contains nearly half its weight in water. About 75% of muscle & 80% of the grey matter of the brain are water. No cell can carry on its activities when it is absolutely dry & most cells must be constantly bathed with fluid in order to do their work. These cells have their food brought to them & their waste products removed by the water route, the blood. Many of these waste products are eliminated through the urine. Water serves as a regulator of body temperature. Evaporation from the skin, perspiration, provides one of the most important methods of removing surplus heat from the body. Water protects internal organs. The central nervous system is bathed by the cerebrospinal fluid. Fluid also lubricates joints, thereby making movements at joints easy. Water is therefore tremendously important in life. Rubner estimated that a man could lose most of his stores of glycogen & of fat & even half of his protein without serious danger to life, but a loss of 10% of body water is serious & a loss of 20% is scarcely to be endured.

Dr. Nahida M.Mulla.M.D.
Vice Principal,
Professor of Repertory & PG Guide,
HOD Repertory.
HOD Paediatric OPD,
A M.Shaikh Homoeopathic Medical College, Hospital & PG Research Centre, Nehru Nagar, BELGAUM (Karnataka)

Mobile : 09448814660

Build self confidence & self-esteem in your children:
Simple ways to build your child�s self confidence and esteem for a happier child and better parent/child relationships.
All Parents want their children to be confident. Reassurance is something we are all aware of as a parental tool to build confidence, but there are other techniques you can utilize to help build your children�s confidence level. There are three simple, yet very important things to remember:
# 1. Praise.
Praise your children daily on a job well done, or a situation you observe them handling appropriately. Let them know that you approve, and why. When your youngest child colors a nice picture and is eager to show it to you, be sure to praise them. But, also be sure to pick out a singular aspect of the picture to comment on. This tells even the youngest of children that you are interested in what they have accomplished. Praise should go beyond your acknowledgement of the piece of art; it should say to the child that you have paid attention to the details in the picture as well. With this method of praising, and singling out particular reasons a child�s confidence can soar.
# 2. Reliability and Consistency.
Children of all ages not only want to know, but need to know that they can depend on their parents or guardians to be consistent. If you have set rules for a specific dinnertime, be consistent. Do not let the teenager (or any member) of your household upset a family routine or set rule due to a preference, such as eating at friend�s house at the last minute, or being late for dinner due to a game. While there will always be exceptions to this practice, if you are consistent in any given family situation or rule your children will know they can rely on you. Although this strategy might not be popular in your home at first, your family will eventually accept and expect certain rules. They will learn to respect your decisions through your dependability as well. Through the child�s confidence in you his own confidence grows.
# 3. Trust
Trust, as we all know is �earned�. You can and should start building trust between you and your children as early as toddler hood. Nothing builds confidence in humans like trust. Be sure to remain consistent (as mentioned above) when you allow your children to venture forth in new areas. It is not always easy for a parent to feel sure of their children�s abilities, albeit a new bike, or riding that bike to the neighborhood store. Start with small and realistic steps that are agreed upon and carried out. Each success is the essential ingredient to building trust between child and parent.
Building self esteem in kids:
A child�s self esteem is one of the single most important things you can help your child to develop. A good self esteem helps a child to be confident, try new things, get along well with other children, do well in school and countless other things. The way a child feels about himself affects nearly every aspect of his life and children look to adults to learn about who they are. If a child is ignored, for example, he will feel unimportant and will act out in either two ways, he will behave badly to attract attention to himself or he will fade into the woodwork, believing that he is not important enough for anyone to take notice of him. Both examples show evidence of low self esteem.
If you want to build good self esteem in your child, you need to start when they are babies. Children begin to learn about themselves from the very beginning and if you start out right, the rest will be easy. Talk to your baby and praise her often, even for tiny victories like learning to drink from a cup, give your baby applause and let her know she is spectacular. When children see that they can accomplish things it boosts their esteem, especially if it is noticed and praised by adults.
Ask your child for his opinion on things: �What do you think of that movie we just saw?� �What restaurant do you like best?� If you ask for their opinion, they will feel important and valuable. Include your child on family decisions and always consider his input. Don�t ever ridicule your child or tell him that his idea is silly, instead, even if the idea is a little silly, you could say, �That�s a different way of looking at it!� or �How creative!�
Basically, you should treat your child with the respect that you would give to any other person and give plenty of praise and acknowledgement of his status as an important part of the family. Your child will gain friends more easily when he feels comfortable with himself and you will have the peace of mind of knowing he feels good about himself.
Oh, how delicate the thing called self esteem can be! As adults, most of us have noticed that if we are told something often enough, we might end up believing it. If those things happen to be negative, it can be so destructive!
It is very damaging for a child to hear negative things about him or herself. Unfortunately, these things often come from avenues other than their peers or the school bully. Haven�t we overheard parents saying things like �take that outfit off, you look awful!� Or saying within hearing range of a child �Johnny will never make anything of himself. He won�t even sit down to do his homework.�
Too many people simply don�t stop to think of the impact their words might have on an impressionable child. If a young teen experiments with makeup, as an example, words to the effect of �wipe it off, you look like a tramp!� will damage for a very long time while saying �I think a lighter shade of that color would look even prettier� builds self esteem because their efforts have been noticed.
It is hard to determine at exactly what age a child starts �taking it all in� and building what is to be their own self image in their mind. Certainly by the time they�re old enough to understand what �if you keep being too lazy to understand that math work, you�ll never make anything of yourself in life� means. If they start believing that life will be a waste, it will be an uphill battle to build self esteem and the desire to succeed in life. It could make much difference to hear instead �I know you�re having trouble with that math work, Billy. Why don�t we sit down together and figure it out? You�re very smart and I know that between us, we can conquer it.�
How a child views himself relies greatly on those he trusts. The parents. There will be enough peer pressure and bullies over the years; and what the child hears from a parent needs to counteract negative things others will say. It only takes a few short breaths to say �I�m so proud of you!� or �You look great today!�
I recently had an interview with a delightful girl of 15. She had been having some problems in many areas of life. She finally mentioned that she was dating and had been for a while. I took the plunge and asked what led to that decision. She thought for a moment and answered, �Oh, that�s easy. My mother told me that no boy would ever want to go out with me.�
Make your children feel good about themselves. It takes little effort to voice the things you admire about a child. Something like �that shirt really brings out the color of your eyes beautifully� just might make the difference between a terrific day or lousy day for them. If there is a decision they can help with, it�s a perfect opportunity to voice something you admire. �Will you help me choose curtains for your room? You have great taste in things like that.�
Remember, a confident child is assured in love and patience. A confident child is a happy child.
Dr. Nahida M.Mulla.M.D.
Vice Principal,
Professor of Repertory & PG Guide.
HOD of Paediatric OPD.
A.M.Shaikh Homoeopathic Medical College, Hospital & PG Research centre, Nehru Nagar, Belgaum � 590010 (Karnataka)

Mobile: 09448814660.

Biologic Mesh
From SAGES Surgical Wiki
1 Introduction
2 Basic science of biologic meshes
3 Indications for use
3.1 Non contaminated setting
3.2 Bridging the gap
3.3 Reinforcement of the repair
3.4 Contaminated Setting
3.5 Prophylaxis during stoma creation
3.6 Hiatal Hernias
4 Conclusion
5 References


Introduction
Biologic mesh development resulted from a search for a biomaterial that could address the problems associated with permanent synthetic mesh, including chronic inflammation and foreign body reaction, stiffness and fibrosis, and mesh infection. Since the introduction of biologic mesh, the market has been rife with new biologic materials attached to largely unsupported claims of superiority and safety. With data comprised mainly from animal studies and Level III evidence, there has been little science regarding these materials, yet surgeons have been using these materials with increasing frequency driving a multi-million dollar market.

Basic science of biologic meshes
Most often derived from human or porcine dermis, these materials have been processed to acellular, porous extracellular matrix scaffolds of collagen and elastin. Some source growth factors remain and attract endothelial cells and subsequent fibroblasts into the mesh. These host cells release additional chemoattractants that signal the migration of other structural cells. The three-dimensional nature of the mesh and porosity allow cells to enter the mesh and adhere. What happens from there is a cycle of remodeling consisting of degradation of the biologic mesh and regeneration of the collagen scaffold with host tissue. The balance of this degradation and rebuilding process, and the speed with which it occurs, influences the ultimate strength and structure of the biologic mesh hernia repair.
The processing of the biologic mesh for production is by and large a proprietary procedure, making it difficult for surgeons to access information and answer several questions about the final products. These uncertain areas include decellularization, the sterilization process, the source of human dermis in terms of donor age and body part, and the crosslinking process. The cells are removed from the grafts in different ways: physical means such as dessication, chemical processes, or enzymatic reactions. Some of the products are terminally sterilized while others are not, resulting in variations in storage and pre-use hydration requirements. Sterilization options include gamma radiation, ethylene oxide, or hydrogen peroxide. Some companies instill chemicals, such as gluteraldehyde, into the biologic graft to induce additional crosslinking bonds in the graft to slow down the degradation process in the hope of leading to a stronger host collagen framework. However, this is a not a natural feature of the donor tissue and there is concern about the lack of remodeling in too heavily crosslinked grafts. This unintended feature could result in a poorly integrated graft and foreign body reaction, similar to some permanent synthetic meshes.
The advantage of crosslinked mesh versus non-crosslinked mesh remains a controversial area. Early investigation at Washington University presented at the 2009World Hernia Congress and the 2010 American Hernia Society Meeting showed increased stiffness for two crosslinked biologic mesh products (porcine dermis and bovine pericardium) compared to the non-crosslinked bovine pericardium mesh. 1-2 Greater cell infiltration was seen in the non-crosslinked mesh. Future investigation is warranted as to whether these characteristics are clinically important or if the crosslinked mesh poses an increased risk for infection by preventing collagen breakdown and macrophage migration.

Indications for use
The theoretical advantage of biologic mesh over synthetic mesh has appealed to surgeons, mostly in the United States. These meshes are not widely favored nor used in Europe and elsewhere due to the high cost of the biologic mesh over its cheaper and more widely applicable synthetic mesh counterpart. Over the last decade, surgeons have utilized biologic mesh in a variety of cases ranging from primary ventral and inguinal hernia repair in non-infected fields, recurrent hernias, reinforced hernia repair, hernia prophylaxis, and the most widely used application, hernia repair in the contaminated or potentially contaminated field.

Non contaminated setting
The use of biologic mesh in primary or recurrent ventral or inguinal herniorrhaphy in the noncontaminated and previously uninfected field is difficult to justify due to the high material cost without added benefit. There is very little data regarding the performance of biologic mesh in these settings.

Bridging the gap
The poor performance of the mesh in terms of laxity in a bridging repair makes this an unacceptable repair in the noncontaminated setting. Blatnik et al documented a recurrence rate of 80% for bridging repair with acellular dermal matrix at an average cost of $5,100 per patient, comparing the repair to an �expensive hernia sac.�3 The laxity associated with biologic mesh has been documented in other series.4

Reinforcement of the repair
The use of allograft or xenograft as reinforcement of a primary ventral hernia repair is felt to be a more sound approach. This fits with what we know of the science of biologic meshes in that placement in well-vascularized tissue is favorable for the ingrowth and remodeling process. Rosen�s group at Case Western investigated this and found a reduction in ventral hernia recurrence rate with a components separation midline repair reinforced with acellular dermal matrix (20%) compared to the 80% recurrence after bridging allograft repair.5

Contaminated Setting
The presence of contamination may limit the applicability of permanent synthetic mesh in some hernia repairs. Biologic mesh may be acceptable for this purpose or for placement in open wounds as a staged closure in complex abdominal wall reconstruction. There is limited data in both of these areas, with some noting a high risk of hernia recurrence and associated infection. The data is mostly limited to animal models and case series. 6,7 However, the lack of suitable alternatives has made biologic mesh attractive for contaminated field hernia repair.

Prophylaxis during stoma creation
The role of biologic mesh has been explored in prevention of parastomal hernias. An ongoing study of human dermis allograft placed at the time of construction of ileal conduits after cystectomy shows promising results with a decreased risk of hernia occurrence (30.4% v. 6.3%).8 Biologic mesh has also been used in the treatment of parastomal hernias where infection is a concern.9 With increasing reports of prophylactic synthetic mesh placement at the time of ostomy construction, the use of biologic mesh in this preventative setting may decline.

Hiatal Hernias
Biologic mesh has been utilized in the reinforcement of paraesophageal hernia repair. The randomized controlled trial of mesh repair for paraesophageal hernia lead by Oelschlager is the only Level I human study of biologic mesh.10 This study showed a decreased risk of hernia recurrence with mesh repair, from 24% to 9%. The recommendation for mesh reinforced hiatal repair is made with some caution; significant mesh complications, ranging from mesh erosion to esophageal stenosis and fibrosis, were documented in a follow-up study.11

Conclusion
In summary, biologic grafts represent a major advancement in complex hernia repair. Further investigation regarding the appropriate indications, performance of the grafts based on individual properties such as crosslinking, and potential complications is needed. Given the high cost of most of these materials and the limited available data, biologic mesh should be used judiciously and only when permanent synthetic mesh is inappropriate, such as in the contaminated field. The FDA reported complications of these materials warrant caution and sound surgical judgment.12,13




Biologic/bioresorbable graft comparison




Brand Name
Company
Type


AdditionallyCrosslinked?
Sterilized?

Alloderm�
LifeCell
Dermis
Human
No
No

Allomax�
CR Bard
Dermis
Human
No
Yes

Collamend�
CR Bard
Dermis
Porcine
Yes
Yes

FlexHD�
MTF
Dermis
Human
No
No

Periguard�
Synovis
Pericardium
Bovine
Yes
Yes

Permacol�
Covidien
Dermis
Porcine
Yes
Yes

Strattice�
LifeCell
Dermis
Porcine
No
Yes

Surgimend�
TEI
Dermis
Bovine fetal
No
Yes

Surgisis�
Cook
Intestinal submucosa
Porcine
No
Yes

Tutopatch�
Tutogen

Pericardium
Bovine
No
Yes

Veritas�
Synovis
Pericardium
Bovine
No
Yes

XenMatrix TM
CR Bard
Dermis
Porcine
No
Yes

BioA�
WL Gore
Synthetic bioabsorbable

N/A
Yes

TIGR�
Novus Scientific
Synthetic bioabsorbable


N/A
Yes





References
1. Melman L et al. Proceedings of World Hernia Congress. Berlin, Germany. 2009
2. Melman L et al. Histologic Evaluation of Crosslinked and Non-crosslinked Biologic Mesh Materials in a Porcine Model of Mature Ventral Incisional Hernia Repair. Proceedings of American Hernia Society: Hernia Repair 2010. Orlando, FL. 2010
3. Blatnik J, Jin J, Rosen M. Abdominal hernia repair with bridging acellular dermal matrix--an expensive hernia sac. Am J Surg. 2008 Jul;196(1):47-5
4. Bluebond-Langner R, Keifa ES, Mithani S, Bochicchio GV, Scalea T, Rodriguez ED. Recurrent abdominal laxity following interpositional human acellular dermal matrix. Ann Plast Surg. 2008 Jan;60(1):76-80.
5. Jin J, Rosen MJ, Blatnik J, McGee MF, Williams CP, Marks J, Ponsky J. Use of acellular dermal matrix for complicated ventral hernia repair: does technique affect outcomes? J Am Coll Surg. 2007 Nov;205(5):654-60.
6. Saettele TM, Bachman SL, Costello CR, Grant SA, Cleveland DS, Loy TS, Kolder DG, Ramshaw BJ. Use of porcine dermal collagen as a prosthetic mesh in a contaminated field for ventral hernia repair: a case report. Hernia. 2007 Jun;11(3):279-85.
7. Candage R, Jones K, Luchette FA, Sinacore JM, Vandevender D, Reed RL 2nd. Use of human acellular dermal matrix for hernia repair: friend or foe? Surgery. 2008 Oct;144(4):703-9.
8. Harold KL, et al. Early Results of a Prospective Randomized Study Using Acellular Human Dermal Matrix (Alloderm) to Prevent Parastomal Herniation. Proceedings of American Hernia Society: Hernia Repair 2010. Orlando, FL. 2010
9. Lo Menzo E, Martinez JM, Spector SA, Iglesias A, Degennaro V, Cappellani A. Use of biologic mesh for a complicated paracolostomy hernia. Am J Surg. 2008 Nov;196(5):715-9.
10. Oelschlager BK, Pellegrini CA, Hunter J, Soper N, Brunt M, Sheppard B, Jobe B, Polissar N, Mitsumori L, Nelson J, Swanstrom L. Biologic prosthesis reduces recurrence after laparoscopic
paraesophageal hernia repair: a multicenter, prospective, randomized trial. Ann Surg. 2006 Oct;244(4):481-90.
11. Stadlhuber RJ, Sherif AE, Mittal SK, Fitzgibbons RJ Jr, Michael Brunt L, Hunter JG, Demeester TR, Swanstrom LL, Daniel Smith C, Filipi CJ. Mesh complications after prosthetic reinforcement of hiatal closure: a 28-case series. Surg Endosc. 2009 Jun;23(6):1219-26.
12. Rosen MJ. Biologic mesh for abdominal wall reconstruction: a critical appraisal. Am Surg. 2010 Jan;76(1):1-6.
13. Harth KC, Rosen MJ. Major complications associated with xenograft biologic mesh implantation in abdominal wall reconstruction. Surg Innov. 2009 Dec;16(4):324-9.
14. Gina Adrales, M.D. Biological Meshes � Indications and Shortcomings. Challenging Hernias Post-Graduate Course. 12thWorld Congress of Endoscopic Surgery. April 15, 2010