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Chapter 6: Genitourinary oncology 277 Microscopy Palliative radiotherapy is used for symptomatic Sheets of clear or granular cells with small or normal painful bone or skin metastases cheap sporanox 100mg line. Complications Prognosis Local spread especially into the renal vein buy generic sporanox pills, and may grow If confined to renal capsule 10-year survival is 70% order genuine sporanox line. Tumour poor if metastases present, 25% of patients present with may also spread into neighbouring tissues, such as the metastases and they have a 45% 5-year survival. Bladder cancer Definition Investigations Bladder cancer is the most common urological malig- Urinalysis shows haematuria in ∼40%. A solid tumour >3cmisdiagnostic, but sometimes a cyst is seen which needs to be differentiated Incidence/prevalence between a simple benign cyst, a complex cyst or solid Common malignancy; 1 in 5000 in United Kinddom. Management Surgical removal is the treatment of choice for those Aetiology without metastases (if there is a single metastasis this There are several risk factors for the development of can be resected along with the primary tumour). In the past, radical nephrectomy with removal of r Exposure to certain carcinogens and industries cause the kidney, perinephric fact, together with the ipsilateral as many as 20% of cases. Aromatic amines, or deriva- adrenal gland and hilar and para-aortic lymph nodes tives, which are strongly carcinogenic are commonly was routinely performed. Some now perform either total found in the printing, rubber, textile and petrochemi- nephrectomy (without removal of the adrenal or lymph cal industries. Genetic: Macroscopy r Through polymorphisms of various cytochrome P450 Low-grade tumours have a papillary structure and look enzymes, some individuals appear to oxidise ary- like seaweed. Higher grade tumours lamines more rapidly, which makes them more prone appear more solid, ulcerating lesions. T3 Deep muscle involved, through bladder wall Radiotherapy, for example for pelvic tumours, pre- (mobile mass). It is thought that in most cases, the bladder and ureters G2 Moderately well differentiated. This may ex- plain why, in many cases, there is a ‘field change’ to the Complications whole of the urothelium from renal pelvis to urethra, so Tumours of stage >T3 metastasise, but this is uncom- that multiple and recurrent tumours occur. Adenocarcinoma arises from the urachal rem- Investigations nants in the dome of the bladder. Whilst all these symptoms are most commonly be performed from the bladder upwards. Pain may be felt in the loin when there is ob- Depends on stage: struction, or suprapubically if there is invasion through i TisorTa, and T1 are initially treated by cysto- the bladder wall. Follow-up 3 months later has a 50% re- Prostate cancer currence rate and regular follow-up is needed, usu- Definition ally for 5–10 years. Age ii Localised,muscle-invasivedisease(T2,butalsohigh- >50 years (40% > 70 years, 60% > 80 years) grade T1) is optimally treated by a radical cystec- tomy – malesaretreatedbycystectomywithproximal Sex urethral and prostate removal, females require cys- Male tectomy with the whole urethra removed and an ileal conduit with urinary diversion (ureters to ileum). In Geography males it is possible to use a piece of ileum to form Varies by population (90x). Most common in Afro abladder substitute ‘substitution urethroplasty’ be- Caribbeans, common in Europe, rare in Orientals. Predisposing factors include age, ethnicity, family his- iii Locally advanced disease (T3 and T4) is life threaten- tory,genetic factors and diet, with a diet high in ani- ing and requires radical cystectomy in combination mal fat, low in vegetables showing an increased risk, but with radiotherapy or chemotherapy. Morbidity results from radiation cystitis and proctitis leading to a small Pathophysiology fibrosed rectum. In females radiation vaginitis and/or The cancer is commonly androgen-dependent, but anasensatevagina,andinmalesimpotenceoccursdue there is no evidence that its growth is driven by a to nerve damage. However, popu- r Chemotherapy is increasingly used with surgery, or lation studies have shown that men with higher testos- may be used alone as a palliative measure. Neoad- terone levels appear to be at greater risk of prostate juvant chemotherapy (i. Depends on stage and grade at presentation and the age r In most cases it is diagnosed either on rectal exam- of the patient. Recurrence is common and may be of ination as the finding of an asymmetric prostate, a a higher grade (25%). Some patients appear to have a nodule or a hard, irregular craggy mass, often alter- few,minorrecurrences,whereasothershavewidespread, ing the median groove. T1 has an 80% 5-year survival and diagnosed because of the finding of a raised prostate T4 has 10% 5-year survival (but very age dependent). Macroscopy Management The tumours usually are in the peripheral zone of the This depends on the tumour staging, grade and also on prostate and appear as hard yellow-white gritty tissue the patient’s age and co-morbidity, as many of the treat- (see Table 6. Organ-confined, low-grade disease: r These tumours tend to grow slowly, in older patients Microscopy (>70 years) and those likely to die of co-morbidity be- Most are well differentiated and consist of small acini fore the cancer causes significant symptoms or metas- in a glandular pattern. However, rad- Gleason score: The biopsy material is examined under ical surgery is a major operation, with a 60% incidence a microscope and a Gleason grade 1–5 (grade 1 being of impotence (compared to 16% preoperatively) and most differentiated, grade 5 the least) is assigned to the anincreaseinurinaryincontinence. These also cause complications such as acute and chronic ra- two grades are then added together to give the Gleason diation proctitis (diarrhoea, urgency, bleeding), and score (2–10). Complications Metastatic or high grade local disease: Urinary tract infection and renal tract obstruction may r Treatment is for symptoms only (palliative). Chapter 6: Genitourinary oncology 281 iv Chemotherapy is not as effective and is used mainly Aetiology for non-responsive disease. Ten per r Throughout treatment a multidisciplinary approach cent of all testicular tumours develop in testes which is needed with regard to palliation of symptoms. A family phosphonates are used for bone pain and to prevent history is also a known risk factor as is infertility. Localised radiation is used for bone pain and recently bone-targeting radioisotopes have been Pathophysiology developed for those with multiple metastases. If confined to It appears that these atypical cells are formed early prostate: 80% have 5-year survival and 60% have 10- in gestation and may be influenced by events in utero. If metastases are present: 20% have 5-year They then lie dormant, until puberty, when they spread survival and 10% have 10-year survival. In some individuals, they become ma- lignant and either develop along the seminomatous or teratomatous line. Introduction to testicular tumours Definition Classification Tumours of the testis may be classified broadly into those The main components of the testis are the germ cells arising from the germ-cell line and those arising from (spermatogonia), the sex cords or seminiferous tubules non-germ cells. Leydig cells normally pro- ducetestosterone,soLeydigcelltumourshavethepoten- Sex tial to produce steroid hormones at levels high enough Males to have systemic effects. Both Leydig cell and Sertoli cell Germ Cell Tumours Seminoma (40%) Teratoma (32%) Mixed (14%) Arise from germ cells in the Embryonic Extraembryonic seminiferous tubules Tissue Tissue Figure 6. Other tumour types include nous spread leads to metastases most commonly in the lymphoma and metastases. A dull ache Scrotal biopsy should be avoided, as this increases the or dragging sensation in the lower abdomen or per- risk of local spread and recurrence. Associated gy- Management naecomastia or lymphadenopathy should be looked Testicular cancer is now one of the most curable solid for, as well as any evidence of metastases, e. A testicular prosthesis may iliac and para-aortic lymph nodes via the spermatic be placed at the time of surgery.

Dietary fat and breast cancer in the National Health and Nutrition Examination Survey buy sporanox 100 mg with mastercard. Dietary and anthropometric determinants of plasma lipo- proteins during a long-term low-fat diet in healthy women order generic sporanox canada. Effects of dietary fat restriction on particle size of plasma lipoproteins in postmenopausal women cheap 100 mg sporanox. Changes in plasma lipoproteins during low-fat, high-carbohydrate diets: Effects of energy intake. Prospective study of diet and female colorectal cancer: The New York Univer- sity Women’s Health Study. Weight loss on a low-fat diet: Consequence of the imprecision of the control of food intake in humans. Changes in bone turnover in young women consuming different levels of dietary protein. Impairment of hemolytic complement activation by both classical and alternative pathways in serum from patients with kwashiorkor. A longitudinal analysis of the impact of dietary intake and physical activity on weight change in adults. Long-term cholesterol-lowering effects of 4 fat-restricted diets in hypercholesterolemic and combined hyperlipidemic men. Determinants of total and high density lipoprotein cholesterol in boys from Finland, the Netherlands, Italy, the Philippines and Ghana with special refer- ence to diet. Total cholesterol and high density lipoprotein cholesterol levels in populations differing in fat and carbo- hydrate intake. The role of fatty acid saturation on plasma lipids, lipoproteins, and apolipoproteins: I. Effects of whole food diets high in cocoa butter, olive oil, soybean oil, dairy butter, and milk chocolate on the plasma lipids of young men. High-monounsaturated fatty acid diets lower both plasma choles- terol and triacylglycerol concentrations. Beneficial effects of a diet high in monounsaturated fatty acids on risk factors for cardio- vascular disease. Diet, prevalence and 10-year mortality from coronary heart disease in 871 middle-aged men. The inverse relation between fish consumption and 20-year mortality from coronary heart disease. The protective effect of a small amount of fish on coronary heart disease mortality in an elderly population. Alcohol, fish, fibre and antioxidant vitamins intake do not explain population differences in coronary heart disease mortality. Effects of diet and sexual maturation on low-density lipoprotein cholesterol during puberty. Lagström H, Jokinen E, Seppänen R, Rönnemaa T, Viikari J, Välimäki I, Venetoklis J, Myyrinmaa A, Niinikoski H, Lapinleimu H, Simell O. Nutrient intakes by young children in a prospective randomized trial of a low-saturated fat, low- cholesterol diet. Influence of dietary fat on the nutrient intake and growth of children from 1 to 5 y of age: The Special Turku Coronary Risk Factor Intervention Project. Cell cycle arrest and induction of apoptosis in pancreatic cancer cells exposed to eicosapentaenoic acid in vitro. Lapinleimu H, Viikari J, Jokinen E, Salo P, Routi T, Leino A, Rönnemaa R, Seppänen R, Välimäki I, Simell O. Prospective randomised trial in 1062 infants of diet low in saturated fat and cholesterol. Dietary fat in relation to body fat and intraabdominal adipose tissue: A cross- sectional analysis. Habitual dietary intake versus glucose tolerance, insulin sensitivity and insulin secretion in postmenopausal women. Dietary fat and appetite control in obese subjects: Weak effects on satiation and satiety. No change in glucose tolerance and substrate oxidation after a high-carbohydrate, low-fat diet. Compliance in a randomized clinical trial of dietary fat reduction in patients with breast dysplasia. Some lifestyle factors in human lung cancer: A case control study of 792 lung cancer cases. Energy intake required to main- tain body weight is not affected by wide variation in diet composition. Relationship between urinary calcium and net acid excretion as determined by dietary protein and potassium: A review. Effects of soybean fiber on cecal digestion in rats previously adapted to a fiber-free diet. High propionic acid fermentations and mineral accumulation in the cecum of rats adapted to different levels of inulin. Nutrient intakes and body weights of persons consuming high and moderate levels of added sugars. Protection of conju- gated linoleic acids against 2-amino-3-methylimidazo[4,5-f]quinoline-induced colon carcinogenesis in the F344 rat: A study of inhibitory mechanisms. Effect of high-carbohydrate-low-fat diets on plasma glucose, insulin and lipid responses in hypertriglyceridemic humans. Modified lipoproteins, cytokines and macrovascular disease in non-insulin-dependent diabetes mellitus. Monounsaturated fatty acid-enriched diet decreases plasma plasminogen acti- vator inhibitor type 1. Linoleic acid intake and susceptibility of very-low-density and low density lipoproteins to oxidation in men. Role of fat, animal protein, and dietary fiber in breast cancer etiology: A case-control study. Dietary fiber, weight gain, and cardiovascular disease risk factors in young adults. Dietary habits and incidence of noninsulin-dependent diabetes mellitus in a population study of women in Gothenburg, Sweden. Reduction of blood pressure and plasma triglycerides by omega-3 fatty acids in treated hypertensives. Dietary (n-3) polyunsaturated fatty acids improve adipocyte insulin action and glucose metabolism in insulin-resistant rats: Relation to membrane fatty acids.

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The hours spent on campus in lectures discount sporanox uk, tutorials purchase 100mg sporanox amex, practicals or in the feld—known as ‘contact hours’—depend on the program students enrol in buy generic sporanox 100mg, study mode selected (internal, external, online or fexible learning) and course choices. This diary snapshot is only one example of how a student may choose to schedule their university study and life. Life experience through Global Learning All students will have the opportunity to study overseas through a range of programs, including student exchange, study tours and summer and winter schools. Wirltu Yarlu provide a The new facility will foster the transformation of health range of services, schemes and preparation programs that education, research and patient care through high-quality are designed to support your desire to gain educational clinical training spaces. Wirltu Yarlu is a place where students can soar on inter-professional learning and use of simulation in to new heights. Small group discovery Rural placements There is a commitment to give all students the opportunity Enrolment in the Bachelor of Medicine and Bachelor to learn in small groups, peer-to-peer and under the of Surgery requires students to undertake rural clinical guidance of leading academics and researchers. Commonwealth supported students (in both experience will enhance students initiative and creativity bonded and unbonded places) need to complete four weeks maximising studying in a research intensive university. For of rural placements before graduation, with 25% of students information visit: required to complete one year of clinical training in a rural site. The test is held in July with results released in academics of international distinction. The Clinical Skills each week of clinical skills study in a Mathematical Studies, or equivalent and Medical Professional and Personal hospital setting. In year 3, clinical skills communication, leadership - all essential training is conducted primarily in the public to quality medical practice. These placements will be held the clinical cases that are core to years 1–3 degree at the University of Adelaide, in a wide range of organisations, including of the degree. Some students will be usually required due to the competiveness Years 4–6 able to undertake year 5 in a rural setting. Year 6 is focused on what students need to placements in teaching hospitals and know for their internship. Clinical practice Students will have access to state-of-the-art of an overseas or interstate attachment. Medical professional and anatomy, health simulation and clinical skills laboratories. While there are lectures, much Year 6 focuses on preparing students personal development learning will occur in small group tutorials. A major emphasis is placed on professionalism, The following three streams form the The timetable in years 4–6 may look communication, clinical reasoning, and grounding of the frst three years. Learning is to advance and fully participate in the structured around clinical cases of the most clinical attachments offered in years 4–6. For Rural background information including the registration closing All applicants are advised to read the 2016 entry pathway date and test, visit: www. The guide details information to apply under the rural background entry will be based on a combination of for domestic, international and onshore pathway. To fnd out more, visit ensure they understand the requirements of There are two distinct parts to the www. For There are two types of Commonwealth Information on our website provides advice 2015 dates, visit: www. University of Adelaide and who do not projects involving children or people who have any other tertiary record (students are 3. International international applicants must be able to students or domestic students practising For more details, visit: demonstrate English language skills at medicine outside of Australia will need to www. International applicants please note that of applicants admitted to the University successful completion of this degree may of Adelaide degree. All applicants are Clinical placements require signifcant time not qualify them to practice/register in their encouraged to consider alternative programs commitments of students, which may home country. They will have to contact the when applying for medicine, such as the include time periods normally regarded as relevant health registration bodies of their Bachelor of Health Sciences or the Bachelor after hours. This includes (but is not limited to) textbooks, equipment, medical testing, frst aid certifcates and student amenities fees. Students will undertake an advanced research project in nutrition, reproductive health or epidemiology, areas in which the University has an international research reputation. Students taking the Advanced degree will have early opportunities to be involved in the research activities and culture that are hallmarks of a research university. They will gain in-depth understanding of research across the spectrum of knowledge creation, application and translation. Throughout their degree, they will have access to tailored mentoring and career development planning. Students who have not yet completed their Year 12 studies, or a Credit average for tertiary studies. A Aboriginal Education, or studying in the supports the Aboriginal and Torres dedicated study space is provided as a safe Faculty of Health Sciences: Strait Islander students within the and quiet home base for our Aboriginal and Web: www. The Faculty also provides a Telephone: 08 8313 6275 Yaitya Purruna assists Aboriginal and Torres dedicated Student Services Support Offcer Strait Islander students studying nursing, who is co-located in this area to provide medicine, dentistry, oral health, psychology or students with ongoing support. Sitting within the School of Population Health in the Faculty of Health Sciences, the Yaitya Purruna Indigenous health unit is part of the overall Aboriginal and Torres Strait Islander Education Strategy at the University of Adelaide. The unit focuses on the following: > Advocating and providing support for all Aboriginal and Torres Strait Islander students studying in the Faculty of Health Sciences. Group of Eight universities provide opportunities for all students to Open Day offers important information Sunday 00 August 2015 beneft from a world-class education, for future students and parents, as well while enhancing Australia’s wellbeing www. Everyone is invited global challenges, and contributing to to discuss study and career options the global knowledge economy through with the University’s friendly staff and their teaching and research activities. Students with strong interests in more than one area of study may wish to consider a double or combined degree. The application closing date for 2016 entry and how to apply, can be obtained by is 30 September 2015. Bachelor of Medicine contacting us (refer below for details) or and Bachelor of Surgery, and Bachelor of English language visiting the scholarships website: Dental Surgery applicants should refer to www. Students may be required to pay for specialist completion of the International Baccalaureate equipment, reading materials, etc. For more information on Permanent residency Commonwealth supported students studying an other program-related fees and charges, visit equivalent full-time study load were as follows. Program intake For accommodation options and costs please These annual fees are indicative only as actual visit: www. Updated information can be found Please refer to individual programs on Degree on the University website: www. Further information is available at: Adelaide (refer below for details) to check information provided by third parties. If they do not have the answer @uniofadelaide enquirers will be referred to faculty/school/ discipline staff for expert advice. With a growing range of entry pathways, scholarships and support for students, our aim is to ensure the leaders of tomorrow have the opportunity to excel.

These include: y Insomnia y Agitation order genuine sporanox on line, anxiety and panic attacks y Hallucinations y Blood vessel constriction Excessive doses can cause death through heart failure or lung damage generic sporanox 100mg with amex. After discontinuing regular use of any form of cocaine discount sporanox 100 mg fast delivery, the user will experience a ‘crash’ – severe depression and tiredness, along with excessive eating and sleeping. The experience of the ‘crash’ brings about its own risks with some cocaine users becoming so depressed that they may attempt suicide. Some will attempt to counteract the ‘crash’ through a self-medication approach using tranquillisers, alcohol, or injecting heroin and cocaine “speedballs”. However, it is difficult to predict who will m aintain control of their cocaine use and who will becom e chronic dependent users. Whilst it can be prescribed and dispensed, it is illegal to produce, possess or supply (except on prescription). It is also illegal to allow one’s premises to be used for producing or supplying cocaine. Administration Amphetamine can be taken: y By mouth y By sniffing/snorting y By smoking y By dissolving in water and injecting 57 Drug Facts Desired Effects The intensity of effects depend on the mode of administration. A small dose of around 30mgs taken orally will have a similar effect to the natural release of adrenaline, preparing the body for ‘fight or flight’ in response to stress or an emergency. Higher doses see: y Users become overactive, boastful and they may indulge in repetitive behaviour. Duration of Effects The duration of effects will depend on the purity of the drug, the mode of administration and the tolerance of the user. Signs and Symptoms of Use Signs and symptoms are similar to cocaine as both drugs are stimulants, including: y Unusual confidence y Hyperactivity and insomnia y Being very talkative y Nose irritation – it may be runny or itchy due to “snorting”. Short Term Risks Repeated use of small doses may see some users experience: 58 Drug Facts y Irritability y Confusion y Dizziness121 Given the way that am phetam ines stim ulate the body in a sim ilar fashion to adrenaline, its use, particularly when bingeing or after m ore sustained use, m ay contribute to feelings of deep depression, exhaustion, sleepiness and extrem e hunger as the body addresses postponed fatigue and the depletion of energy. Those who use high doses of am phetam ines on a regular basis are likely to develop ‘am phetam ine psychosis’. This drug-induced condition is sim ilar to schizophrenia and includes: y Thought disorders y Hallucinations y Feelings of being persecuted, which in turn may lead to hostility, aggression and violence towards others, as the user defends themselves against their imagined persecutors. This condition will usually disappear when drug use ceases but for some people will persist for a considerable period of time. Given the intensity of the mood-altering effects experienced, particularly in relation to the rush associated with higher doses and more efficient administration, “… severe psychological dependence can develop …”. Various amphetamines are also controlled by the 1970 Medical Preparations (Control of Amphetamines) Regulations which equally prohibits their manufacture, preparation, importation, sale and distribution. Where amphetamines are needed for treatment of a patient, the Minister of Health & Children can grant a licence to allow their supply; however, they are not available for normal prescription by doctors or pharmacies. However, the use of naturally occurring hallucinogenics such as mescaline found in the Peyote cactus and psilocybin found in magic mushrooms (referred to as teonanacatl ‘flesh of the gods’ by the Aztecs124) have a considerable history. In a wide range of cultural and geographic settings, there is evidence of hallucinogenics being utilised as an aspect of religious ritual to prom ote detachm ent from reality and to induce ‘m ystical’ visions; this particular deploym ent of psychoactive substances was renewed in the late 1950s and throughout the 1960s whereby users sought to expand their m inds and raise their consciousness through the use of hallucinogenics as part of hippie counter-culture. A tiny am ount (30 m icrogram s) is needed to produce hallucinations which m ay last for up to 12 hours. It peaks 2 to 3 hours later and the effects usually wear off after 12 to 15 hours. An increase in pulse, blood pressure and temperature, in addition to widening of the pupils can be experienced by the user. However, effects are difficult to predict as they depend upon the experience and expectations of the individual, the potency of the tab ingested and there environment within which the drug is taken. A bad trip may include: y Frightening mood changes and severe terrifying thoughts y Anxiety and feelings of loss control y Depersonalisation (a feeling of floating outside one’s own body) y Disorientation and panic y Fear of going mad or dying 61 Drug Facts For the distressed user, reassurance plays a significant role in addressing serious panic, anxiety or even psychotic reactions. Unpleasant reactions are likely if the user is mentally unstable, anxious or depressed. Users are at risk of being injured due to delusions, particularly in relation to the perceived ability to fly or walk on water. There are no exact figures for fatalities arising from accidents or suicide in relation to acid but death due to over-doses is non-existent. Flashbacks can be particularly dangerous if experienced when one is driving, working at heights or operating m achinery. Tolerance will develop with m ore sustained use which m ay, in som e instances, act to reduce habitual use. In an Irish context, it is thought that the Liberty Cap mushroom (Psilocybe semilanceata) which grows wild, is the one most commonly used. This mushroom is small, with a thin stem and a head which is said to resemble head gear worn during the French Revolution, hence its name. This “… is a com plicated task, requiring reference to relevant botanical texts and som e expertise in the classification of m ushroom s and is not a task to be perform ed while hallucinating. The number of mushrooms taken in any one episode of use will vary depending on the experience and expectations of the user; with anything from 8 to 300 mushrooms being reported. There are reports of users having the heightened awareness of sound and colour and the sensation of objects changing shape. Users have reported: y Nausea, vomiting and abdominal pain This may occur because of ingesting poisonous mushrooms. Users have also referred to the experience of bad trips which may include: y Feelings of depersonalisation y Panic and anxiety y Psychotic reactions y Aggression and hyperactivity y Tingling limbs and flushing The duration of a bad trip is normally around 12 hours, with no long-term effects and the negative experiences listed above can be dealt with through friendly reassurance. There are also reports of users engaging in rash behaviour such as running in and out of traffic or along railway lines, which obviously increases the likelihood of fatal or non-fatal accidents. Recurrence of panic/anxiety attacks often triggered by alcohol use are experienced by some users. Long Terms Risks There is little evidence as to the long-term effects of frequent use of magic mushrooms, however, tolerance develops rapidly. There are no major withdrawal symptoms when use ceases and whilst a user may develop a psychological dependence, physical dependence is not a feature. Opiates are strong, sleep inducing painkillers and are found in over the counter painkillers containing codeine, cough m edicines, anti-diarrhoea preparations, dihydrococaine and buprenorphine (used to treat m oderate to severe pain), and m ethadone (prescribed as a substitute for dependent heroin users in either m aintenance or detoxification program m es). It has been recognised as one of the country’s m ost pressing drug problem s, given the im pact not just on the individual user but also on their fam ily and com m unity (and typically Dublin com m unities “… characterised by poverty and generalised deprivation … ”140). Physical Description Heroin, at the time of production, is a white, odourless powder which over time darkens to varying shades of brown and develops a vinegar like smell. As with other substances, injecting into a vein maximises the effects of the drug. Corrigan states “there are no serious diseases attributable to chronic narcotic use that would parallel the dam age to the liver and lungs caused by alcohol and tobacco”. This lasts less than a minute and includes a: y Warm flushing of the skin y Sexual excitement, followed by:  A dream-like state of peacefulness and contentment  Reduced feelings of pain  Reduced aggressive tendencies and sexual drive143 However, the sought after euphoric effects of heroin are m ost closely associated with the early stages of use. For those whose use becom es progressively m ore frequent and habitual, little euphoria is experienced. Equally, m any first tim e users of heroin experience feelings of nausea and vom iting. In theory, the duration of the effects of heroin is between six to eight hours, however, given the level of impurities in heroin the reality is that the effects last for a considerably shorter time.

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