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Digest of recent discussions on ISSM mail (January / February 2002)Hussein Ghanem MD
Dr. Yoshi Sato opened the discussion about the current status of intracavernous injection (ICI) therapy. Seven responses from ISSIR members confirmed that although the use of ICI has declined after the introduction of oral erectogenic agents, yet it remains as a very important and effective second-line treatment option. Dr. Amr El Meliegy initiated a discussion about the role of the primary care physician in the treatment of ED. He pointed out that psychogenic ED patients who are just given oral therapy without properly understanding the etiology of their disease will always need an aid to achieve a successful erection. Dr. Bonierbale and Dr. Moser agreed that psychogenic factors have too much slipped our minds, while Dr. Antonio Morales suggested that the regular psychological impact of ED can be managed by the physician interested in ED treatment. In an interesting discussion, Dr. Wijaya and Dr. Rodrigues Jr suggested that ISSIR need to develop guidelines for primary care physicians in order to help them make adequate referrals in ED cases. Topic 1: A new case of Nocturnal PriapismEdgardo Becher MD This is a 29 years old man with a history of more than 20 events of nocturnal priapism over the last 8 months. He needed chemical reversion in all cases after 8 to 24 hours. Besides these events, he has normal erections resulting in normal intercourse and never had a priapism after sex. He has no history of hematological disorders or substances abuse. MRI of the spine is normal. He is a heavy cyclist that used to ride 60 kilometers a day.I saw him with a 24 hours priapism and upon draining 20 ml of dark blood from the corpora, the episode subsided after 8 mg of phenylephrine. Before the reversion, Color Duplex US showed a minimal arterial signal. I asked for a selective arteriogram that was performed during a priapism event and showed some sort of a lacunar images in both sides that were embolized. Full sleep lab was normal with 3 normal erections.I will appreciate your input. Edgardo Becher Response from: Gregory A. Broderick, MD Edgardo: good case; I am interested to hear how others would manage it. Your patient now has 'stuttering priapism'. Your work-up is consistent with low flow, ischemic priapism. Hormonal suppression does work in these cases, but LHRH agonists should be last resort.Try an antiandrogen like Casodex or Flutamide. You will find literature as far back as the 1960's using estrogen (DES) to treat young men with stuttering priapism econdary to sickle cell disease.I would also teach him to self-inject with 1cc of Phenlyephrine [200 mcg/cc]. He should do this if a morning erection does not subside. Greg Response from: Sidney Glina MD There was a recent publication on the Brazilian Journal of Urology on two cases of stuttering priapism treated with Finasteride 5mg with good results. Sidney Topic 2: Viagra in Premature EjaculationFrederique HEDON MD I would like to request the comments of the ISSIR membership on a rather trivial problem encountered twice in my daily practice: A 40 years old man was referred to me for moderate erectile dysfunction: normal sexual interest, rigid morning erections, he lost his erection shortly after penetration or ejaculated immediately. Performance anxiety was very high. This problem occurred following a crisis in the couple (his wife had an extramarital affair). In addition this man had been throughout his life a premature ejaculator.
Two sessions of sexual and couple counselling failed to improve ED. I thus added Viagra 50 mg before intercourse in combination with the same counselling. Erections returned to normal. Premature ejaculation also disappeared (time to ejaculation over 15 mn). The couple relationship dramatically improved. They decided to stop Viagra. ED did not recur but premature ejaculation did, at the same level as in the past (time to ejaculation less than 2 mn following penetration). They tested again Viagra. Again the man became able to control his ejaculation latency. From this time they want to continue Viagra as treatment of premature ejaculation. This is the second case I see. Do other members of the ISSIR have similar experiences with Viagra or even Apomorphine in cases with premature ejaculation? Thanks for your input. Frederique HEDON, MD Response from: Dr. Andik Wijaya Dear Dr. HEDON, I had a few experiences similar with you. Not just using Viagra, but also with others medication such as Intra Corporal Injection. I named the kind of Premature Ejaculation in these cases as Secondary Premature Ejaculation. It means the premature ejaculation was caused by the erectile dysfunction as primary problem. Patients with this condition were afraid they might not complete sexual intercourse because of loss of erection before ejaculation happens. So in his subconscious he drives to faster to gain ejaculation. When his erection is getting well, he isn�t afraid of losing his erection during intercourse, he is then able to control his ejaculation. That's my opinion based on my experiences. Kind regards,
Andik Wijaya Couple Clinic Indonesia Response from: Dr. Juza Chen Dear Dr. Hedon, At the ESSIR meeting in Rome I have Present paper "The role of Viagra in treatment of PE" and have demonstrated that Viagra can have additive effect in treatment of patients with PE. I am glad that your observation is supporting results of our study. Juza Chen, MD Response from: Dr. Gregory A. Broderick Dr. Hedon This is a very interesting phenomenon and one that merits investigation. Although none of my Viagra patients have made the claim that premature ejaculation improved, I have used low dosage self-injection therapy in these patients for years. Viagra should reduce refractory time, was you patient able to get a second erection on the same evening with Viagra? Men with premature ejaculation generally find the second erection of the evening more durable. Gregory A. Broderick, MD Response from: Dr. Emre Akkus Some of my patients declared that not only their quality of erections but also their PE improved with Viagra. I asked them the same question that Dr. Broderick has raised (Whether it worked in their second or third erections) And it worked in their first erections and coital attempts. This of course is not the scientific way to say that Viagra works for PE. But Dr Chen 's study must be performed by others as well to clarify the issue. Emre Akkus Response from: Dr. Selim Cellek Our in vitro experiments with human corpus cavernosum showed that PDE-5 inhibitors prolong nitric oxide-dependent relaxation as well as increase the latency and decrease the magnitude + duration of noradrenergic contraction (Cellek, S. and Moncada, S. (1997) Nitrergic control of peripheral sympathetic responses in the human corpus cavernosum: a comparison with other species. Proc. Natl. Acad. Sci. U.S.A. 94, 8226-8231). This may explain the observation suggesting that patients with PE may benefit from PDE-5 inhibitors since ejaculation has been suggested to be a noradrenergic contractile process. Regards Selim CELLEK, M.D., Ph.D. Response from: Dr. Jacques Buvat Dear Dr Hedon, Thanks for reporting your interesting observation on ISSIRList. I have also seen some patients presenting both ED and premature ejaculation who claimed they were able to adequately control their ejaculation when on Sildenafil. This improvement in their PE was not due to a reduction in their refractory time, since it occurred from the first ejaculation. I have also observed this phenomenon in patients on intracavernosal injections. Most of these men were anxious persons with high performance anxiety. Most had become PE at about the same time that ED occurred, supporting the hypothesis that performance anxiety or another disturbing psychological factor resulting in an increased adrenergic tone was at the origin of both dysfunctions. However I have also seen 2 men with the same history as yours: very anxious, PE throughout their life, ED occurring later, in their forties. After some time of alprostadil auto-injections for the first one, and of Sildenafil intake for the second one, ED seemed cured since spontaneous erections had returned, making them again able to have intercourse without any pharmacological help. But PE persisted unless they used alprostadil ICI or the Sildenafil tablets before intercourse. Finally they continued their pharmacological treatment only for correcting their PE. Of course it should not be inferred from the some anecdotal observations reported on the list that Sildenafil or the injections are a first-line therapy for PE. Such an effect was not reported in the preregistration studies of Sildenafil. In addition I have seen many men who had both ED and PE and who remained PE on Sildenafil despite a good efficacy on their ED. However some recent papers support the possible interest of Sildenafil in at least some patients with PE. A study by Abdel-Hamid et al, recently published in the International Journal of Impotence Research (2001, 13: 41) compared 3 Serotonin Reuptake Inhibitors, including Paroxetine, and Sildenafil, according to a prospective randomized double blind cross-over design. Sildenafil was associated with a significantly higher intravaginal ejaculatory latency time and sexual satisfaction than all other treatments. Two open studies have also been reported during the ESSIR meeting in Rome. The first one, by Juza Chen et al, recently reminded by Dr Chen on ISSIRList, observed after Sildenafil taken on demand a (slightly) significant decrease in the average score of PE in 58 PE resistant to other treatment modalities. The second one, by Montorsi et al, obtained better results in ejaculatory latency time and intercourse satisfaction by using Paroxetine + Sildenafil than by using Paroxetine alone. Further controlled studies are thus desirable. They are certainly needed before any definite conclusion can be made. Jacques Buvat MD Topic 3: External Traction Penile DevicesDr. Calide Gomes Dear Colleagues, I am Dr. Calide Gomes, urologist from Brazil, member of Brazilian Society of Urology. I have been questioned by some of my patients about the indications, contra-indications, results and complications on the usage of an external traction penile device called J.E.S. extender, for penile lengthening purposes. I have sought medical literature about the subject but haven't found any. I am aware of ISSIR recommendations about penile enhancement surgeries but not about the use of such devices. So, I would be very grateful to hear from you on the subject. What the official position of ISSIR on that specific matter is as well as any other pertinent information. I am Looking forward to hear from you. Regards, Calide Gomes, M.D. Response from: Dr. Hussein Ghanem Dr. Calide Gomes requested information about the use of external traction penile devices. I am not aware of any research about the subject. However, in a survey on penile augmentation surgery (Issue 4 of ISSIR news bulletin), 2 articles -by Dr Austoni, Dr Giovani & Dr Colpi- mentioned the use of penile traction devices post-operatively, apparently to decrease the chances of the penis being entrapped into the scar at the site of the severed suspensory ligament. Other authors also reported the use of penile traction following suspensory ligament surgery (1,2). Apart from this occasion -postoperative use- there doesn't seem to be any scientific basis for the use of penile traction devices. 1) Alter GJ. Penile enlargement surgery. Tech Urol 1998 Jun;4(2):70-6 Hussein Ghanem MD Topic 4: Status of Intracavernous Injection (ICI) TherapyDr. Yoshi Sato Dear members: I would like ask you about intracavernous injection (ICI) therapy. Unfortunately, ICI therapy is not approved in Japan! So, our Japanese society of impotence research is trying to make available this useful therapy. So, my questions are following: 1) How many percentage of ED patients are using the ICI therapy in your clinic? sincerely Yoshi Sato Response from: Dr. Sidney Glina After the launch of sildenafil the number of patients using ICI decreased significantly in my practice. Around 10% of the patients are using it; mainly the patients who already had been using before sildenafil. Sidney Glina Response from: Dr. Edgardo Becher Regarding Dr. Sato's inquiry in ICI. I would agree with Dr. Glina that most of the users are either those who were using it before sildenafil or those non-responders unwilling to receive an implant. At our clinic it is a bout 15%. In Argentina compound pharmacies are common and trimix is widely available and very inexpensive (around US$ 25 per 4.25 ml vial of Bennet's formula) Edgardo Becher Response from: Dr. Bernard Fallon It's about $100 in our area and not so easily available. Our University Hospital pharmacy makes it. Not too many patients now, since Viagra. About 40 new patients per year, and about half of those stay on it. longer than 6 months. Bernard Fallon Response from: Dr. Milton Maxwell Lakin At our institution Cleveland clinic a large number of patients use injection. Currently i would say 20 to 30 % of patients are viagra failures.mant are post surgical from prostate or bladder cancer and many are diabetic. I don't know the number worldwide but it is probably considerable the expense of the med will be dependent on how much phentolamine is needed it can be expensive. sincerely dr lakin Milton Maxwell Lakin, M.D. Response from: Dr. Juhana Piha Since 1994 I have had about 10 000 patients suffering ED. Before Viagra, most of my patients used alprostadil (dose 10-30 mikrogr), and men with severe dysfunction used alprostadil combined with phentolamine. After Viagra most of the patients changed to the peroral (sildenafil) therapy. However,15-20 % of my patients are still using or preferring ICI therapy. There are two reasons: 1. Oral therapy is insufficient and 2. ICI therapy is more reliable compared with po. therapy. As you know, the effect of po. therapy is dependent on the situation eg. on the amount of sexual desire. I think that ICI therapy is still the most effective treatment of ED in severe cases. I am waiting with great interest the reports of the combined therapies (sildenafil+ICI, sildenafil+apomorphine, ICI+apomorphine etc.) Juhana Piha Response from: Dr. Jacques Buvat Dear Dr Sato, It is really a pity that ICI therapy is not approved in Japan, though the first paper on the use of Alprostadil for ICI therapy came from your country, in 1996. In addition it has been proved that Alprostadil ICIs were effective in a large part of the patients resistant to Sildenafil (in up to 88% according to Shabsigh et al, Urology, 2000, 55 : 477). About 10% of the ED patients treated in my clinic are on ICI therapy. Some of them were already treated with this therapy before the launch of Sildenafil and proved to be resistant to this oral drug, or did not wish to change for it because they were afraid of the possible risks of this drug, or because they were fully satisfied with the injections. But most of them are "new" patients in whom there was either a contra-indication to Sildenafil (as nitrates or NO donors) or failure of this drug. In addition, some patients with neurological ED do prefer the injections to Sildenafil, because in France the Alprostadil ICI are reimbursed by the National Health Insurance Company in this specific indication, whereas Sildenafil is not. In France the drug the most used for ICI is Alprostadil. Moxisylyte is still used in some very sensitive cases, at risk of priapism as some neurological or psychological patients. The mixtures are a little used, because they are not approved. Personally I am using them in case of failure of the dose of 20 mcg as of Alprostadil. Some reliable patients are on papaverine because they cannot afford the other, more expensive, drugs. You could probably easily obtain the world sales' figures of the different drugs presently used by contacting Pharmacia-Upjohn and Schwarz Pharma in order to support your request to the Japanese Health Authority. There is no doubt that ICI remains a very useful therapy, even if it is no more the first choice therapy. Best regards, Jacques Buvat Response from: Dr. Paulo Brito Cunha Dear Dr Sato I make use of Chlorpromazine. I do not use Phentolamine ; It is more expensive. Oral therapy is the first choice. But I think it is not the best. BRITO CUNHA , P.R. ; ANDROCL�NICA ; RIO DE JANEIRO ; BRAZIL . Vasoactive drugs . Intracavernosal(ic) and oral(or) administration in the male erectile dysfunction (med) Int J Impot Res 2001 , 13 ;(SUPP 2 ) : S-18 Paulo Brito Cunha Topic 5: The Role Primary Care Physicians In The Management Of EDDr. Amr El -Meliegy Dear colleagues, Aren�t we going too far in encouraging primary care physicians to treat ED patients? I agree that oral therapy is a safe and effective form for ED treatment. I think that we can be undertreating our patients if only poor responders to oral therapy are referred. Don't you agree that psychogenic patients who will mostly respond to oral therapy need first to know that their is primarily psychogenic whether through history or investigations as well. Knowing that is an important part of a comprehensive treatment. Psychogenic ED patients who are just given oral therapy without properly understanding the etiology of their disease will suffer the feeling that they will always need an aid to achieve a successful erection. I think that only proven organic ED patients with good response to oral therapy can be effectively treated and followed up by primary care physicians. Amr EL-Meliegy Response from: Dr. Mireille Bonierbale I am all right with you and I think that the psychogenic patients are too much slipped our minds. Mireille Bonierbale (psychiatrist sexologist) Response from: Dr. Antonio Martin Morales I don't agree. I think that not only primary care physicians but all of us involved in the management of ED patients should be aware of basic signs that allow us to identify purely "psychogenic" patients thus providing him with a proper refer to a psycho-sexologist. The "regular" psychological impact of ED can be managed by the physician interested in ED treatment. Antonio Martin Morales, MD Response from: Dr. Mireille Bonierbale I Think that the ED and the psychology of the patient are interdependent and say "pure psychogenic" is very difficult. According to the personality and the moment of the ED occur , the ED is often a language to be translate and the treatment without enough language (time also) can occur the capacity of the patient to his cure. And we must meditate if we have some patients "addict" to ICI or pill.. Excuse my bad English M Bonierbale Response from: Dr. Andik Wijaya I have experience treating around 2000 patients suffer from ED. Yet, I never identify purely psychogenic patient. Approximately 10 % of them have psychological problems as primary problem ( eg. marital problems ) When I meet 'type a' patients I always referred to psychologist or psychiatrist or marital consultant. Type b patients, usually free from their depression when Their erection getting well, or using some kind of anti depression. So primary care physicians should know when the patients should be referred to any kind of specialist. ( In my opinion ISSIR need to develop a guide line to help primary care physicians to make a good decision, when and to what kind of specialist the patients should be referred). kind regards, Andik Wijaya, M.D Response from Dr. Psic. Oswaldo M. Rodrigues Jr I do agree with Dr. Wijaya in the point that ISSIR could be the entity that present some guidelines to primary care physicians in order to help them to make adequate referrals in ED cases. May be the 2nd International Consultation on Erectile Dysfunction, in 2003 could also take care of this issue. Also the regional associations related to ISSIR should be asked to hold similar consultations before the International one happens. In my own clinic I rarely see nowadays patients complaining of ED with major organic problems. Many are referred by urologists, but also many never made to a physician before... Any one may say "of course a psychologist is not the one to be consulted for organic causes of ED". Most patients complaining of ED consults with urologists and not with psychotherapists in any way. I do see many patients to whom sildenafil doesn't work, and haven't seem any patient whom there would be any cognitive mechanism that could be modified (meaning psychologically, or psychotherapeutically modified) referring the control of PE during use o sildenafil. The one I see uses cognitive processes alike mystical processes, he believes he won't have problems, and so begins to happen. And I want to repair a conceptual usual mistake: marital problems are, indeed, psychological problems. Also, agreeing that there might be organic depression, most depressed patients I see in our clinic in Sao Paulo (Instituto Paulista de Sexualidade) are not psychiatric depressions and very related to the causes of the ED, meaning, more psychological causes to ED. Also we may recall that several antidepressants may help erection as a secondary gain of the drug, and it doesn�t mean that the mechanisms that caused ED are changed, and if the psychological mechanisms are not changed the ED will come back again in certain psychological environment. Psic. Oswaldo M. Rodrigues Jr. Response from Dr: Antonio Martin-Morales Yes, Dr. Wijaya you are right. I meant "predominantly" psychogenic, when I said "purely". It's clear for me too, that psychogenicity is an "organic" problem taken place within the CNS. I also do agree with you on the need of that guides not only for primary care physicians but for all the specialist involved in treating ED patients. I can say that in a very near future, February 19 th, we'll present to the Spanish Health Authorities a Consensus Document elaborated by 12 Scientific Associations (Andrology, Urology, Cardiology, Hypertension, Endocrinology, Psychology, Sexology, Paraplegia, etc...., till 12 societies) comprehending the basic knowledge for every physician taking care of ED, guidelines for referral, how, when and to whom, and specifics topics on each specialty to have in mind when treating men with ED and heart conditions, Endocrinologic diseases, spinal cord injury, etc, etc Antonio Martin-Morales, MD Response from: Dr. Charles Moser Dear folks, As a sexologist and primary care physician, I have a few comments about this thread. Trying to establish whether the ED has a physiological or psychological basis seems futile. First, there are no long term studies that show that sex therapy works. So it is not clear that treating a "purely" psychogenic problem with sex therapy is effective. Second, there are no studies that show that even when a physiological problem is found, treatment of that problem has any effect on the erectile dysfunction. To be clear, I am talking about long term data, there is a significant placebo effect in the short term treatment of erectile dysfunction. I do not believe that one can have psychogenic ED and that not effect physiological parameters, or that phsyiogenic ED does not effect psychological concerns. ED is a mixed disorder and should be treated as such. All ED patients that present to a sex therapist should have a medical workup and all ED patients that present to a non-psychiatrist physician should be referred to a sex therapist. The medical evaluation of patients with ED is to find co-morbid conditions. Finding and treating, hypertension, diabetes mellitus, hemochromatosis, etc. can save someone's life, but does little to reverse the ED. It is important to realize that the "causes" of ED that we discuss are really correlations. We have no mechanism to prove causation. There are studies to show that in the short term, both sex therapy and pharmacotherapy are effective for both presumed physiogenic and psychogenic ED.
Take care, Charles Moser, Ph.D., M.D. Topic 6: Primary Absolute Anorgasmia with DepressionHussein Ghanem MD Dear colleagues, I have received this message from an intelligent but quite depressed young man. I felt an urgency because of the patient's suicidal thoughts. I checked the ISSIR membership directory but couldn't find members in Belgrade to refer the patient to. I am pasting the patient's e-mail -detailing his case- and my reply below. Any suggestions regarding advising or referring this patient would be appreciated. Hussein Ghanem MD Patient's Letter: Dear Doctor In 1995, When I was 13 I had my first great erection. I felt something like pain. I never have orgasm. And after that, erections are going to be more and more rare, even than, in a primary school, last grade, I felt impotence when I was in the contact with the girl. I don�t know how the time passed and we didn�t speak about that and now I feel terribly bad because I said to some friends in the primary school that I have sperm (I was well informed about it from the medical books (my mother is a cardiologist). At the year 2000, I felt a pain in the left testicle, and went to urologist
and she said: After that, I said it to my mother and brother, and father and some
examinations were done.
Hormones: LH: 5.97U/L , FSH: 2.51 U/L, Prolactin 149mU/l, Thestosteron
3.63nmol/l, but it�s ok because I have beard and I look normal , etc
Ultrasound examination: everything is anatomically normal and exists,
seminal vesicles are tender (small), rectal probe: everything is ok.
Uretro-cysto-skopia: ejeculatory ducti are present, on the Progesteron
injection I had erection for 3 hours. I was prescribed Syntocinon injections last year, but there was no effect, and I am drinking now Tofranil 50mg. My opinion was that problem appeared from x-rays when I was 13. I had no mumps, never took drugs, etc. I was the best pupil in primary school, and a member of Mensa in secondary, and won prizes in the international competitions in mathematics. But it�s not me: I would give everything for only one ejaculation. I am so desperate that I will commit suicide Because I have been the only person to deal with my problem for 5 years, and I was so stupid to hide it, and now no one urologist knows what is the problem. Thank you for any advice. Reply: Dear You are very depressed & it sounds like an emergency. Please talk to your parents and see a psychiatrist right away. They also need to read your message. You need expert psychiatric help. Your depression and your focus on ejaculation are probably inhibiting you from reaching full sexual excitement and orgasm. After managing your acute psychological distress you can move to the evaluation of the anorgasmia with a sex therapist. To assess anorgasmia one must understand the 5 phases of the sexual response cycle. These phases are:
1) Desire Phase: As mentioned in our sexual health page, without the desire to be sexually active, men are not going to get excited or have orgasms. The inability to reach orgasm and ejaculation during any kind of sexual activity, in spite of normal erections, normal hormones, and full development of secondary sex characters, is known as 'Primary absolute anorgasmia'. Several factors might interfere with reaching full sexual excitement and thus failure to reach orgasm. Suggested psychological factors include obsessive-compulsive personality, interpersonal factors and various fears. However, in most cases there is no clear-cut cause, and anorgasmia may puzzle both the patient and physician. Patients might fall into a performance anxiety trap. Instead of relaxing and enjoying the sexual experience they might focus on their performance and on reaching orgasm. Performance anxiety would thus inhibit sexual excitement and orgasm. Suggested physical factors include hypnotic abuse, narcotic & alcohol abuse and nerve disorders or spinal cord injuries. An absent glandipudendal ('bulbocavernosus') reflex has been correlated with treatment failure. However, many healthy men have an absent 'bulbocavernosus' reflex. Various treatment approaches have been used with varying success. Reduction of performance anxiety and providing a high level of stimulation might be achieved through the sensate focus exercises (relaxed sensual massage). These exercises are prescribed by a sex therapist and include both partners taking turns at giving and receiving stimulation while forbidding genital touching, vaginal penetration and orgasm. If the patient is able to ejaculate outside the vagina, sex therapists attempt desensitization by prescribing a series of exercises where the patient masturbates up to ejaculation on his own first, then with his wife, then outside the vagina, and finally intravaginally. Electrovibratory stimulation and sexual fantasies might also be helpful. The other aspect of the Anorgasmia problem is infertility. Several approaches for sperm retrieval and assisted reproduction have been successful. These include electrovibratory stimulation, transrectal electroejaculation, and testicular sperm retrieval. Patients who occasionally ejaculate outside the vagina may collect sperm after night emissions and deliver it to the Andrology laboratory for freezing. The general advice given to patients with primary or secondary failure of reaching orgasm is not to concentrate on the outcome of the sexual experience but rather to relax and enjoy giving and receiving stimulation. Best wishes, Hussein Ghanem MD Response from Dr: Juhana Piha I have treated several patients with ejaculation problems successfully using intensive testosterone therapy. As the patient told, his testosterone level is only 3.63 nmol/l, which is very low value in 19 years old man. Most of my patients have normal male habitus although the testosterone level is low. The patient told that he have had Syntacinon injections. Is this a testosterone drug? I suggest intensive testosterone therapy both i.m and p.o. for few months. There are also few reports that yohimbine could improve ejaculatory capacity. Best regards Juhana Piha, M.D., Ph.D. Last update : 03/15/2002 |
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