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There was little competition to challenge our position as the world s most powerful nation through most of the twentieth century Europe and Japan were rebuilding; the former Soviet Union, Communist China, postcolonial Africa, and other Socialist countries in Asia and Latin America traded very little, and compared to the United States their domestic markets were tiny The United States was, indeed, number one with no close second for decades In foreign policy, we maintained supremacy from 1945 through the 1990s by offering select countries protection under our NATO/nuclear umbrellas against the purported Soviet threat We built military bases abroad and planted troops and weapons in many countries Washington maintained a simple but effective global strategy amid a simple bipolar world: Protect those who traded with us But the post-Cold War era requires a wider, more sophisticated perspective The United States is still the single most important economy today, but it competes with many more countries in many more industries than just a generation ago Global trade hundreds of times greater today than in the 1950s has become a mind-boggling human activity Millions of tons of natural resources are hyperef ciently extracted, mined, and moved in and out of dozens of countries; millions of factories worldwide manufacture billions of high- and low-tech items; dense transportation networks coordinate the global distribution of resources and goods by land, air, and sea to far- ung markets previously familiar to us only from spices and old poems And this entire system (if one could even call freewheeling, frenetic, global trade a system ) is supported by a wide range of nancial players and marketplaces connecting savers, investors, manufacturers, workers, and consumers Trillions in currencies circle the world electronically 24/7 Revved up trade has reduced poverty worldwide with hundreds of millions of people living longer and better, and with more hope than ever before If the world is going to continue to grow sustainably and pull the remaining poor out of deprivation, we must begin to recognize the complex interactions and interconnections that constitute the blurring new millennium one in which countries are clearly separate yet inexorably bound in a global system at the same time2 And with this urry of cross-border activity comes new risks and threats such as terrorism, diverging demographics, resource shortages, nancial imbalances,.

Hormones, Metabolism, Aging, and Men s Health especially the case of the big and big big PRLs that have high molecular weights [243] With immunological assays, excessive secretion of macroprolactins resembles a classical HPRL, while it has in fact generally no pathological consequence Macroprolactinemias account for 10% [244] to 22% [245] of all HPRLs and are typically observed in otherwise normal individuals, mostly women with normal reproductive function despite high PRL levels, but also some ED patients in whom they seem coincidental [246,247] Many of these cases suffered from psychogenic impotence In such cases serum T is usually normal, as are computerized tomography (CT) scans and magnetic resonance imaging (MRI) of the hypothalamic pituitary area PRL-lowering agents are ineffective in improving sexual function, although the PRL level can be normalized Such a discrepancy should lead to PRL chromatographic analysis, or precipitation of the macromolecules with polyethylene glycol, in a laboratory which specializes in endocrinology, allowing identi cation of the macroprolactin However a diagnosis of macroprolactinemia in an ED patient should preclude neither MRI testing, since some cases are associated with pituitary adenomas, nor a trial of a PRL-lowering agent, since a biologic activity of the macroprolactin has been demonstrated at least in some women, including reversal of amenorrhea and infertility on dopamine-agonist therapy [221]

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Some precautions are critical to avoid false HPRLs resulting from stress (especially from venepuncture) and meals Blood sampling must be performed fasting, following a 20-minute rest in a quiet place Any elevated PRL level must be checked again, if possible following catheter insertion 20 minutes before sampling, and after discontinuation of any drug likely to increase PRL (Table 186) In case of discrepancy between high serum PRL and a pattern of nonendocrine sexual dysfunction, the patient may be referred to an endocrinologist who will decide about the usefulness of a PRL chromatography As already discussed, the responsibility of mild HPRLs (20 35 ng/mL) in sexual dysfunction is questionable In this respect, the threshold of signi cant HPRL is probably in the region of 35 ng/mL or 550 U/mL (1 ng/mL = 21 U/mL)

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Drug-induced HPRL is the rst etiology to consider It is responsible for a signi cant proportion of HPRLs in men Many drugs may increase PRL (Table 186) The most common are antipsychotic agents Other medications include antidepressants, some antihypertensive agents, and drugs that increase bowel motility [251] HPRL may also be secondary to hypothyroidism, renal insuf ciency, cirrhosis, and chest injury (mild or moderate in all four conditions), and to any process compressing or interrupting the hypothalamic pituitary dopaminergic transmission This includes many types of hypothalamic and pituitary tumors Primary HPRL results from a primary defect of the dopaminergic inhibitory control of PRL secretion It may be idiopathic, but in many cases it is associated with PRL-secreting pituitary adenomas These, as the other types of hypothalamic or pituitary tumors, are likely to result in tumoral complications (visual disturbances or even blindness due to compression of the optic chiasma, and hypopituitarism, which may become life-threatening if decompensated) Consequently, any man with non-drug-induced HPRL, con rmed by a repeat PRL determination after blood sampling in appropriate conditions, must bene t from morphologic investigations of the

Figure 76 Neighbor location where the node estimates its location as the centroid of the locations of anchors that it hears

Honeymoon ED is a special circumstance that is common in non-western countries The pain of this condition extends far beyond the sexual arena and involves extended families and their relationship to the newly-weds [12] Most cases, particularly in sexually na ve men, may be related to poor understanding of human sexuality, inadequate sex education, and inhibition due to cultural and religious values, performance anxiety and other psychologic factors (gender identity concerns) Counseling, anxiety reduction, sexual education and PDE-5 inhibitors,

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