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code for dysfunctional uterine bleeding
Palace of blood the treatment of dysfunctional uterine bleeding (DUB short) is a common gynecological diseases, the incidence rate of approximately 10% of patients with gynecological clinic to 15%. The disease can be divided into clinical and non-ovulation ovulation DUB DUB to anovulatory dysfunctional uterine bleeding is more common, about 50% occur in the perimenopausal period. Perimenopausal dysfunctional uterine bleeding is to exclude organic disease reproductive organs, perimenopausal women because of ovarian dysfunction, endocrine disorders, menstrual cycle caused by the volume of irregular changes. Gradually as ovarian anovulation, resulting in endometrial hyperplasia, manifested as amenorrhea occurs after a period of time or completely irregular menstrual bleeding like bleeding, duration of different lengths, the number of bleeding different, and some showed only blood and more long period. Because long-term bleeding can cause anemia to varying degrees. Treatment of traditional Chinese medicine treatment of bleeding to kidney and spleen, the principle of stasis to stop bleeding, the use of solid red decoction. Prescription form: madder 10g, cuttlebone 20g, palm charcoal 12g, Panax Powder 3g (blunt), Puhuang carbon 10g (Pack fried), white peony root 10g, deer grass title 15g, calcined oyster 12g, Burnet carbon 15g, dogwood 12g, Astragalus 15g, Bai Zhu 10g, Codonopsis 15g. Yin blood deficiency add Schisandra, donkey-hide gelatin, and heat plus orientalis carbon, carbon skullcap, and cold plus Bao Jiang, Nepeta charcoal. Blood only after the treatment to liver and kidney and spleen, nourishing yin and clearing heat principle of menstruation, the use of two to two Decoction Pills. Recipe: Ligustrum lucidum 10g, Eclipta prostrata 20g, habitat, carbon 12g, Scrophularia 15g, Radix 12g, donkey-hide gelatin 12g (molten), fried moutan 10g, coke Gardenia 10g, wolfberry fruit 12g, white peony root 10g, to Bone Paper 12g, deer grass title 15g, angelica 10g, Chinese yam 12g. Deficiency increases Dodder, Curculigo and Epimedium, poor sleep soundly the night plus Polygala, Suanzaoren. Western medicine treatment of bleeding with high dose of progestin therapy, that is, medroxyprogesterone acetate 8mg, every 6 ~ 8h 1 oral dose, the blood after only 1 per 3d reduction, less the original dose of 1 1 / 3, maintaining the amount of 6 8mg / d, used in conjunction 20d after withdrawal, withdrawal 3 ~ 7d menstrual cramps. Each menstrual cycle after the first start taking medroxyprogesterone 15d 8mg, even serving 10d withdrawal, 3 months to 1 course of treatment. A lot of bleeding, the United testosterone propionate 25 ~ 50mg intramuscular injection. Following the above treatment did not significantly reduce the blood after 24h, the line of curettage and postoperative bleeding while serving on the herbs, the blood only after the dressing change. Curettage 15d after the first menstrual cycle after the 15d time to start taking progesterone 8mg / d, even serving
Classification of diseases into disease categories anovulatory and ovulatory DUB DUB two, the former is ovulation occurring disorders, occurs in puberty and menopause; the latter system luteal dysfunction, more common in women of childbearing age. The main symptoms of menstrual cycle disorders, the volume increased, prolonged bleeding, dripping dirty and so on. Anovulatory dysfunctional uterine bleeding of anovulatory dysfunctional uterine bleeding were more common, accounting for about 90% of the disease. Prevalent in the ovaries begin to mature
Normal endometrial hyperplasia and ovarian puberty began to decline in the menopause. Because ovarian function is low, the secretion of estrogen deficiency, and thus can not produce normal pituitary negative feedback, no luteinizing hormone peak, although it can develop follicles but not mature, there is no ovulation. Endometrium under the action of estrogen for a long time, showed hyperplasia. Clinical manifestations stop bleeding after a period of time, the amount of bleeding, long duration; it was also manifested by the volume, long menstrual period. Normal gynecological examination, basal body temperature was one-way, vaginal smears do not see the role of progesterone, endometrial biopsy did not change in the secretory phase. Treatment principle is to stop bleeding, to adjust and restore ovulation in the menstrual cycle. Zeyi of menopausal women to stop bleeding, reduce the amount based upon. Many hemostatic agents, commonly used class of synthetic progesterone, such as norethindrone, megestrol acetate and so on. Adolescent patients with sequential therapy of estrogen and progesterone used adjustment period, also known as artificial cycle. Commonly used drugs clomiphene ovulation, luteinizing hormone releasing hormone. Application of menopausal women can stop the bleeding curettage can be diagnosed, conservative treatment is poor resectability of the uterus. Hysteroscopic resection of endometrial laser or electrical new technology in recent years. There are ovulatory DUB DUB ovulation occurred in women of reproductive age. ~ ~ Hypothalamic pituitary ovarian axis feedback mechanisms have been established, ovarian ovulation, but the corpus luteum dysfunction. Is divided into luteal and luteal insufficiency atrophy two former scrape before menstruation secretory endometrium show poor clinical manifestations of premenstrual menstrual cycles or spotting; yellow atrophy showed endometrium incomplete incomplete on the fifth day of menstruation is still scraping the secretory endometrial changes, clinical manifestations of menstruation, basal body temperature was two-way, the treatment easier, can be used in the latter half of the menstrual progestogen-progestin therapy. Modern medicine, the body affected by external factors, such as psychological stress, the environment and climate change, impact of malnutrition or metabolic disorders, through the cerebral cortex, hypothalamus interference ~ ~ pituitary ovarian axis of mutual adjustment and constraints. Disorders such relations, he suddenly manifested in disorders of ovarian function, thus affecting the endometrium, resulting in dysfunctional uterine bleeding. TCM 1 that "the main reproductive kidney", "kidney is the source of life", "by this in the kidney", dysfunctional uterine bleeding and kidney more closely related with the liver and spleen, and blood stasis, also have some contact. Description of dysfunctional uterine bleeding disease called DUB for gynecological diseases. It is due to the neuroendocrine mechanisms regulating reproductive disorders caused by abnormal uterine bleeding, and internal and external genital systemic and there is no organic lesion. Ovulatory dysfunctional uterine bleeding and can be divided into two types of anovulatory, about 85% of the cases are anovulatory dysfunctional uterine bleeding. Dysfunctional uterine bleeding can occur in between menarche to menopause at any age, 50% in premenopausal patients, 30% of reproductive age, adolescents accounted for 21%. Signs and symptoms in patients with anovulatory dysfunctional uterine bleeding may have different clinical manifestations. The most common clinical symptom is irregular uterine bleeding, is characterized by menstrual irregularities. Period of varying lengths, amount of bleeding has been uneven, and even a lot of bleeding. Sometimes the first few
Dysfunctional uterine bleeding menopause weeks or months, and then place irregular vaginal bleeding, blood is often more, for 2 to 4 weeks or more, is not easy since only; sometimes it is the irregular vaginal bleeding started, but also can be expressed as similar to the normal cyclical menstrual bleeding. No abdominal pain or bleeding of other discomfort, often accompanied by bleeding or anemia in the elderly time. Gynecological examination was normal uterine size, uterine bleeding is relatively soft. Classification of abnormal uterine bleeding abnormal uterine bleeding according divided into: 1, menorrhagia: menstrual rules, more than 7 days or menstruation as excessive than 80ml. 2, irregular excessive uterine bleeding: irregular menstruation cycle, as excessive. 3, irregular uterine bleeding: irregular cycles, but by the amount of normal menstruation. 4 months after the frequency: frequent menstruation, cycle time, less than 21 days. Dysfunctional uterine bleeding type one anovulatory dysfunctional uterine bleeding by age into two groups. (A) adolescent dysfunctional uterine bleeding: seen in girls after menarche, as HPOU axis are not mature enough to establish regular ovulation due. After menarche, menstruation clinical manifestations thin hair, short hair after menopause irregular menstruation harmful, menstruation, dripping more than that may cause severe anemia. (B) menopause (perimenopause) DUB: a ≥ 40-year-old woman to DUB in women before and after menopause, during which the incidence of anovulatory dysfunctional uterine bleeding increased year by year. Clinical manifestations: frequent menstruation, irregular periods, as excessive, prolonged menstruation. 10 to 15% of patients were severely irregular menstruation, uterine bleeding and severe anemia. Endometrial biopsy showed different degrees of more endometrial hyperplasia, it curettage is necessary, particular attention should be excluded from gynecological tumors (uterine fibroids, endometrial cancer, ovarian cancer, cervical cancer) caused by hemorrhagic bleeding non-work . Second, the ovulatory function of blood found in most women of childbearing age, some found in adolescent girls and menopausal women. Clinically divided into the following types: (a) ovulatory menstrual disorders 1, ovulatory menstrual thin hair: seen in adolescent girls. After menarche, prolonged follicular phase, luteal phase normal cycle ≥ 40 days, and months after the menstrual thin hair less often the harbinger of polycystic ovary, rare in postmenopausal women near menopause, usually progressed to natural menopause. 2, ovulatory menstrual frequency: adolescent girls, leaving the ovary to increase follicular sensitivity to gonadotropins accelerate follicular phase shortened, frequent menstruation, but ovulation and luteal phase remains normal. If the patient was menopausal women are presented follicular phase and luteal phase were shortened and early menopause. (B) 1, luteal dysfunction, luteal not health: premature degradation of the corpus luteum, luteal phase shortening ≤ 10 days. Frequent clinical manifestations of menstruation, cycles, premenstrual bleeding and menorrhagia, infertility and early abortion. Irregular endometrial pathology for the mature (irregular ripening) or secretion of incomplete (imcomplete secretion). 2, yellow atrophy incomplete: extension of luteal function also known that the corpus luteum can not be completely in 3 to 5 days of degradation, or degradation of prolonged menstrual period or a certain amount of continued secretion of progesterone Erzhi detachable endometrial irregularities ( irregular shedding). Menstruation, dripping more than the merger early luteal degradation, then the performance of frequent menstruation, menorrhagia. More common in artificial abortion, induced abortion, the combination of uterine fibroids, endometrial polyps and adenomyosis are. Third, also known as menstrual bleeding mid-ovulation bleeding. Ovulation, often accompanied by pain (intermenstrual pain or mittelschmerz) Department of ovulation stimulation and a small amount of bleeding female hormone fluctuations (1 to 3 days) and abdominal pain. More individual and continues to menstrual bleeding and the formation of pseudo-period of frequency (pseadopolymenorrhea). Disease causes anovulatory dysfunctional uterine bleeding or ovarian hormones due to gonadotropin-releasing or adjusting the terms of the temporary changes in many factors, internal and external body, such as psychological stress, fear, sadness, sudden changes in environment and climate as well as systemic diseases , can affect the central nervous system through the cerebral cortex and the hypothalamus pituitary ~ ~ ovarian axis mutual adjustment, malnutrition, anemia and metabolic disorders may also affect hormone synthesis, transport, and the target organs caused by the effects of menstrual disorders. Regular ovulatory menstrual disorders caused by the lack of luteal function. Menstrual cycle in follicle development and ovulation, but the luteal phase progesterone secretion or luteal premature decline, leading to poor endometrial secretory response. Pathophysiology of anovulatory dysfunctional uterine bleeding or ovarian gonadotropin-releasing hormone, or regulation in respect of temporary changes in many factors, internal and external body, such as psychological stress, fear, sadness, sudden changes in environment and climate as well as systemic disease, can affect the central nervous system through the cerebral cortex and hypothalamus ~ ~ pituitary ovarian axis of mutual adjustment, malnutrition, anemia and metabolic disorders may also affect hormone synthesis, transport, and the target organs caused by the effects of menstrual disorders. Ovulatory menstrual disorders and more relevant with the corpus luteum. The development of a sound depends on luteal adequate level of FSH and LH, the ovary to LH also must have good enough reaction and secretion of steroid hormones. Now that luteal phase defect due to a variety of factors: regulation of neuroendocrine dysfunction that can lead to a lack of follicular phase FSH, follicle development to slow, reduce the secretion of female hormone Xi; LH pulse frequency, although increased, but the peak is not high, L
H less dysfunctional uterine bleeding after ovulation and luteal hypoplasia so, reduce the secretion of progesterone; LH / FSH ratio can also result in abnormal gonadal axis dysfunction, the follicular dysplasia, hypoplasia of corpus luteum after ovulation, resulting in inadequate endometrial secretory response . Sometimes the normal luteal secretory function, but maintain a short time. Some patients in the luteal phase defect at the same time, showing increased blood prolactin levels. In addition, physiological factors such as menarche, menopause and after childbirth before the hypothalamus may also occur ~ ~ pituitary ovarian axis dysfunction, leading to the occurrence of luteal insufficiency. Diagnostic tests based primarily on history, physical pick up the investigation, determination of ovulation and other examinations. History 1, the detailed history should note that children age, menstrual history, obstetrical history, and contraceptive measures, the body with or without chronic disease such as liver disease, blood disease and thyroid, adrenal or pituitary disease, with or without mental stress and emotional impact of combat, etc. normal menstrual factors. Understanding of the course through. Such as time of onset, the current bloodshed, bloodshed before the menopause, whether through the history and past treatment. Type of understanding of several types of abnormal uterine bleeding: (1) menstruation: Periodic rules, but as excessive (> 80m1) or prolonged menstrual period (> 7); (2) frequency of menstruation: Periodic rules, but short at 21; (3) irregular uterine bleeding: irregular periods, menstrual volume is not too much by a long face; (4) irregular excessive uterine bleeding: irregular periods, excess blood. 2 medical examination, physical examination, including body checks, gynecological examination, in order, except systemic diseases and reproductive tract organic disease. Auxiliary 3, the diagnosis (1) diagnostic curettage: to exclude endometrial lesions and to achieve hemostasis purposes, must be fully curettage, scraping the entire bureaucratic. Uterine curettage should pay attention to size, shape, palace wall is smooth, the nature and quantity of scrapings. In order to determine ovulation or luteal function, should be premenstrual or menstrual cramps curettage within 6 hours; irregular bleeding curettage may at any time. Pathological examination revealed endometrial proliferative changes or hyperplasia, non-secretory phase appears. (2) hysteroscopy: uterine endometrial thickness were observed under microscope, but also do not thickened, smooth and unstructured processes, but there is congestion. Choice in the uterus mirror the lesion under direct vision biopsy, the diagnosis of endometrial than the blind to take the high value, in particular, can improve the early
Dysfunctional uterine bleeding of intrauterine lesions such as endometrial polyps, uterine submucous fibroids, endometrial cancer diagnosis. (3) basal body temperature measurement: a simple and feasible method for determination of ovulation. Basal body temperature showed a single phase type, indicating no ovulation. (4) cervical mucus crystallization tests: The leaf-shaped crystals appeared before ferns suggest anovulation. (5) Vaginal smears examination: general performance of the smear, a high estrogen effect. (6) Hormone Determination: To determine whether ovulation, progesterone serum or urine may be pregnant diol. V. often shortened menstrual cycle history, infertility or early pregnancy when the abortion. Gynecological examination reproductive organs in the normal range. Basal body temperature bipolar, but after ovulation the body temperature rises slowly, low rise, rise time is only 9 to 10 days to maintain the decline. Secretory endometrium showed poor response. Treatment of dysfunctional uterine bleeding eggs: 1. General treatment of patients is often poor physical fitness, was anemic appearance, should enhance nutrition, improve the general condition, can add iron, vitamin C and protein, severe anemia, still need a blood transfusion. Bleeding during strenuous exercise to avoid fatigue and to ensure adequate rest. Bleeding time to give antibiotics to prevent infection in the elderly, proper use of clotting drugs to reduce bleeding. 2. Highly effective drug therapy endocrine therapy, but the object of different ages should be taken different ways. Adolescent girls to stop bleeding, adjust the cycle to promote ovulation-based treatment; bleeding in perimenopausal women after adjustment cycle, reduce by the amount of principle. Use of hormone therapy should be carefully planned to develop a reasonable program, use the lowest effective dose possible, and for close observation, so the application does not face of shock caused by bleeding orderly. (1) bleeding: bleeding of the large number of patients require effective hormone treatment for 6 hours, 24 to 48 hours to stop internal bleeding basic, if still bleeding 96 hours or more should consider organic disease exists. 1) progesterone: anovulatory dysfunctional uterine bleeding caused by a single stimulus of estrogen, progesterone added that in the proliferative phase or endometrial hyperplasia into the secretory phase, endometrial shedding after treatment, herbal withdrawal bleeding occurs. Since such endometrial shedding more thoroughly, so called "drug-induced dilatation and curettage." The body has a certain level for patients with estrogen. Two types of synthetic progesterone, used for 17 - hydroxyprogesterone derivatives (medroxyprogesterone acetate, megestrol acetate) and 19 - to methyl testosterone derivatives (norethindrone, norethindrone double vinegar, etc.) . Can choose the role of endometrial titer of norethindrone (Women Tablets) 5 ~ 7.5mg orally every 6 hours, usually after 4 times the amount of bleeding was significantly reduced or stopped, to 8 hours, then gradually reduced volume decrease every 3 1 / 3 volume, up to a daily maintenance dose 5mg, continued to use the blood of only about 20 days after drug withdrawal, drug withdrawal occurred after 3 to 7 days herbal withdrawal bleeding. 2) estrogen: high dose of estrogen can rapidly increase the concentration of estrogen in the blood to promote endometrial growth, wound repair and bleeding shortly. For insufficient endogenous estrogen, mainly for adolescent dysfunctional uterine bleeding. At present, many pregnant horses used estrone 1.25 ~ 2.5mg, every 6 hours, the blood only after the 3rd of each reduced by 1 / 3 of the amount until the maintenance dose of 1.25mg; also be used diethylstilbestrol 1 ~ 2mg, once every 6 to 8 hours, until the decreased after 3 days of each 1 / 3 the amount of daily maintenance dose lng. The disadvantage of oral diethylstilbestrol gastrointestinal reaction is heavy, slow drug absorption, easy to work quickly, if necessary, oral micronized 17β-estradiol, estrone pregnant horse, or estradiol benzoate intramuscularly. To achieve rapid hemostasis. Irrespective of whether the kind of estrogen, the blood just started 2 weeks after the addition of progesterone, the endometrial transformation, can be used oral medroxyprogesterone 10mg once a day, a total of 10 withdrawal. Estrogen and progesterone withdrawal at the same time, synchronization of endometrial shedding in favor, generally 3 to 7 days after treatment withdrawal occurred medicinal bleeding. 3) Androgen: Androgen amount of blood and reduce bleeding. However, when bleeding can not immediately change the male induced intimal Chapter shedding process, we can not fix it quickly, alone ineffective. 4) combination therapy: the combination of the hemostatic effect of sex hormones worry in a single drug, so ①DUB puberty bleeding in progestin at the same time compatibility of small doses of estrogen and progestin therapy to overcome the lack of one can reduce the amount of progesterone, and to prevent breakthrough bleeding. The specific use of progestin dominant oral contraceptives 1. Every 6 hours, the blood only on the law and press down to maintenance dose, a daily total of 20 withdrawal. ② perimenopausal dysfunctional uterine bleeding progesterone to stop bleeding in based on the compatibility of male and female hormones, specifically with the triple hormone (progesterone 12.5mg, estradiol 1.25mg, Gao ketone 25mg) 2ml intramuscular injection once every 12 hours, blood After only down to one every 3 days, a total of 20 withdrawal. 5) anti-prostaglandin drugs: bleeding during the taking of prostaglandin synthesis inhibitors such as fluoride fragrance that acid 200mg, 3 times a day, can reduce uterine bleeding endarterectomy. Mainly by changing the thromboxane A2 and prostacyclin balance between work. Thromboxane A2 for the synthesis of platelet aggregation and smooth muscle precursor substances, and prostacyclin is a potent smooth muscle relaxant and anti-platelet aggregation properties. 6) other hemostatic agents: An Min network can reduce the blood and stop bleeding microvascular permeability, aminocaproic acid, toluene, ammonia acid, tranexamic acid can inhibit plasmin, a supporting role to reduce the amount of bleeding, but can not rely on to stop the bleeding. (2) adjusting the menstrual cycle: the use of hemostatic effect of sex hormones generally good, if a sudden withdrawal bleeding caused by the withdrawal effects of the medicine will make the blood of patients has long been added, resulted in the bleeding should continue after the medication to control the cycle, so that no Ting-long bloody period of 20 days or so. To this end, appropriate to stop the bleeding when higher doses of hormones used in the blood only gradually reduce, reduction can not be too fast, or localized endometrial shedding bleeding can happen again, until then wish to stop the bleeding, the drug required greater than the amount of bleeding before, and the results would be poor. Use of artificial hormones to control blood loss and the formation of the treatment cycle is a transitional measure, for the purpose on the one hand temporarily suppress the hypothalamus in patients with itself ~ ~ pituitary ovarian axis, enabling the secretion of normal menstrual regulation, on the other hand direct role in the reproductive organs, so that endometrial changes periodically, according to the expected time off, the blood loss associated with not too much. General continuous medication for 3 cycles. Always active in this process to correct anemia, improve nutrition, to improve the physique. Menstrual cycle adjustment methods commonly used are: 1) estrogen and progesterone sequential therapy: the artificial cycle, to simulate the natural menstrual cycle changes in ovarian endocrine, will estrogen and progesterone sequential, so that corresponding changes occur in endometrial , causing periodic shedding. For adolescent or child-bearing age DUB DUB endogenous estrogen levels lower. DES lmg (Novo Kun Fu lmg or pregnant horses estrone 0.625mg), the bleeding from the 5th day, 1 night, and even serving a 20-day, to taking the first 11, a daily 10mg intramuscular injection with progesterone (or 8 ~ 10mg medroxyprogesterone oral), two drugs used at the same time, 3 to 7 days after stopping bleeding. 5th day on repeated bleeding medication, usually 3 cycles of continuous use. 2 to 3 cycles of treatment, the patient can often be spontaneous ovulation. 2) estrogen and progesterone combined application: estrogen to endometrial regeneration and repair, estrogen and progesterone to limit intimal hyperplasia within the index. For reproductive function of blood levels of endogenous estrogen higher. Available compound norethisterone tablets (oral contraceptives 1) full amount or half the amount of bleeding on the 5th day on, the night one, and even serving a 20-day, after the withdrawal bleeding, less blood. Qd for 3 cycles. 3) after the half-cycle therapy: for menopausal uterine bleeding. In the latter half of the menstrual cycle taking medroxyprogesterone 8 ~ 10mg / d, even serving 10 to adjust the cycle. For a total of three cycles of treatment. If the effect of not satisfied with the compatibility of estrogen (Novo Kun Fu lmg or pregnant horses estrone 0.625mg / d) and / or androgen (methyltestosterone 5mg / d). (3) to promote ovulation: DUB for adolescent and reproductive success directly, especially infertility. 1) clomiphene citrate (CC): non-steroidal compound, a weak estrogen effect. It combines the hypothalamus of estrogen receptor competitive production of anti-estrogen effect. By inhibiting endogenous estrogen negative feedback on the hypothalamus to induce the release of gonadotropin-releasing hormone induced ovulation. For a certain level in the body of estrogen DUB patients. Bleeding from the 5th day in, night clothes 50mg, for 5 days. If ovulation fails, you can repeat the medication, CC dose was gradually increased to 100 ~ 200mg / d. If lack of endogenous estrogen, estrogen may be a small amount of compatibility. General Used 3 months, not long-term use, in order to avoid ovarian hyperstimulation syndrome or cause multiple pregnancy. Ovulation rate was 80%, pregnancy rate was only half of its. 2) HCG (HCG): LH has a role similar to ovulation for a certain level of FSH in the body, estrogen levels are moderate. Generally combined with other ovulation induction drugs, B-monitoring of follicular development close to maturity, can be high-dose intramuscular injection HCG 5000 ~ 10000U to induce ovulation. 3) Cable urinary gonadotropin (HMG): FSH and LH per ampoule with the 75U. FSH to stimulate follicular development and maturation, estrogen produced by the pituitary gland through the positive feedback so that sufficient quantities of LH and ovulation induction. Daily intramuscular injection of bleeding after a clean HMG1 ~ 2 sticks until the heat into the follicle development, disable HMG, plus HCG5000 ~ 10000U, intramuscular injection, to increase ovulation rate. Applications should be noted that when HMG ovarian hyperstimulation syndrome complicated by, the only effect of clomiphene used for poor patients required blood fertility work. 4) The gonadotropin-releasing hormone agonist (GnRHa): the last application of low-dose pulse administration of GnRHa from the incremental regulation to promote ovulation follicle development, now more advocate for first with GnRHa pre-treatment, to reach about 8 weeks state of pituitary desensitization, leading to gonadotropin were low, followed by hypogonadism, this time of giving GnRHa pulse treatment or application of HMG and HCG, can reach 90% of the ovulation rate. Citrate only poor efficacy of oxygen, requiring fertile men. 3. Curettage surgery to the most commonly used, both to confirm the diagnosis, and can quickly stop the bleeding. Menopausal hormone therapy in patients with bleeding before curettage should be routine, the best line in the sub-microscopic diagnosis of uterine curettage to rule out organic disease in utero fine. Curettage of adolescent dysfunctional uterine bleeding should be cautious about. Little hysterectomy for the treatment of dysfunctional uterine bleeding, for patients over the age of 40 years, pathological diagnosis of endometrial complex hyperplasia, and even has developed endometrial atypical hyperplasia. Line by electric coagulation or laser endometrial ablation, only 40 years older than the persistence of dysfunctional uterine bleeding, or the purposes of hysterectomy who have contraindications. The treatment of ovulatory DUB: 1. Promote follicular development luteal phase defect treatment more for their causes should first adjust the gonadal axis to promote follicular development and ovulation, in order to facilitate the formation of the normal corpus luteum. The drug of choice is the CC, for luteal phase defect who follicular phase is too long. Poor efficacy, especially infertility CC consider HMG ~ HCG therapy, to enhance follicular development and induce ovulation, to promote the normal corpus luteum formation. Luteal phase defect elevated prolactin levels, to use bromocriptine in the treatment. With the reduction in the level of prolactin can regulate the secretion of pituitary gonadotropin and ovarian estrogen and progesterone increase, thereby improving luteal function. 2. Luteal HCG stimulation usually used to promote and support the luteal phase. After the rise in basal body temperature every other day intramuscularly HCG2000 ~ 3000U, a total of 5 times, can significantly increase plasma progesterone, followed by resumption of normal menstrual cycle. 3. Luteal progesterone replacement therapy is generally used in the natural preparations, due to the majority of synthetic progesterone luteal function with a solution, may also be taken during pregnancy fetal maid masculine. Since the daily intramuscular injection of progesterone after ovulation 10mg, 10 to 14 days, to supplement the inadequate luteal progesterone secretion. The normal menstrual cycle after treatment can, reduce the amount of bleeding. Dysfunctional uterine bleeding treatment of Chinese medicine, Chinese medicine, blood, organs and systems in the spleen, liver blood, spleen qi can not control blood, liver Qi is not hidden blood, both of which can cause bleeding. Closely related to both gas and blood. Blood is the mother of qi, qi is the commander of blood; gas line is the blood line, gas is blood stasis. Qi falling into the fire, blood, blood heat then forced Wang Xing and bleeding. "Righteousness deposit, evil can not be dry," "evil of the hash, the gas will empty." Chinese medicine, disease occurs is due to a common result of internal and external causes. On the one hand is whether the substantial body of righteousness, on the other lies in the strength of evil. The upright body is enriched by a variety of factors, such as genetic endowment, climate change, food Laojuan, emotional changes and so on. Therefore, Chinese medicine treatment of disease must be due to people, time, place treatment. This is also in Chinese medicine, "Heaven corresponding" doctrine. Depending on the disease causes and the different organs involved, dysfunctional uterine bleeding can be divided into the following disease types: 1, spleen deficiency type: common symptoms are: the amount of bleeding, shortness of breath, weakness, pale, abdominal distension, loose stools , eat less sodium, pale tongue, white coating, thready pulse. 2, heart deficiency type: Zheng Jian pale complexion, palpitations, insomnia, dizziness, the amount of bleeding and pale, pale tongue, white coating, thready pulse. 3, kidney yang: common symptoms are: waist and knee pain, cold extremities, urine long. Continuous bleeding, pale or dark, pale tongue, white coating, the pulse was fine and so on. 4, kidney by: Zheng Jian facial flushing, tinnitus, backache, heel pain, night sweats, five upset hot, menstrual volume and red, red tongue, pulse imaginary; 5, blood heat Wang Xing-type: patients met red, hi cold dry mouth, bleeding multicolor dark red, yellow tongue coating, rapid pulse. 6, liver Qi stagnation: Zheng Jian had flank pain, breast tenderness, good heave a deep sigh, more or dripping blood than, yellow tongue fur, pulse string. 7, blood stasis type: Zheng Jian abdominal pain and fullness, the amount of bleeding, color Zihei a block, dark tongue, pulse string astringent. Clinical medicine more than a few are common type of blood work, clinical work on the commonly used conventional treatment with prescription blood consolidate the Palace bleeding soup Dangguibuxuetang and so on, need to dialectical therapy based on the addition and subtraction medication, patients In addition to medical treatment, should also pay attention to the spirit of photo transfer, and strive to Diet, living there often do not make any rash labor, tranquil and empty, keep within the spirit. This would achieve the dual role of medical treatment and health care to improve their quality of life. Health Tips 1. Should light diet; should eat fresh fruits rich in vitamin C, vegetables. 2. Avoid eating and drinking, so as not to damage the spleen and stomach; not eat spicy and too cold of the product. 3. The early health food rice, cabbage, leeks, celery, oranges, etc.; by the late health food are milk, pig pancreas, carrots, safflower, etc.; by the former, the food can be consumed after a seaweed, dried dates, tofu skin, sorghum, Coix Seed, lamb, apples and so on. 4. Sydney menstrual taboo foods, banana, chestnut, Umbilicaria, stone flowers, to the ear and other cold food; cinnamon, pepper, cloves, pepper, pepper and other spicy foods; water chestnuts, wild rice shoots, melon, broccoli, fern , black fungus, stomach or kidney damage and other rabbit food. 5. Strengthen health education, bleeding after menopause, menopause menstrual disorders should be to rule out the possibility of cancer for young women with menorrhagia and treatment 2 to 3 months with no response, should be done and endometrial cytology and neck lining Check. Confirmed as endometrial hyperplasia or atypical adenomatous hyperplasia of precancerous lesions, the situation should be based on the patient with total hysterectomy. 6. Strict indications estrogen and rational use; of menopause and postmenopausal women should be used with caution, the application time should not be too long, the amount should not be large, and should be closely observed response. 7. Surgical treatment should be taken to avoid spread of cancer cells or direct planting, resulting in failure to cure, to promote relapse. Precautionary measures. 8. Should be regularly followed up after treatment. Bleeding to the attention of genital cleansing, frequently changes and menstrual underwear menstrual pads and other supplies; do not clean the vulva due to bleeding rather than the contrary, menstruation must be cleaned daily to remove blood. Some genital cleansing agent available, can also be used warm water washing, but should avoid basin margin; married women to avoid sexual life of the bleeding. If large amount of bleeding can cause anemia and lower body resistance, should strengthen measures to stop bleeding and, where appropriate antibiotics to prevent inflammation and acute diseases. Efficacy criteria of 1 and healing: by volume, menstrual, cycle back to normal, adolescent, child-bearing age 2 of a continuous ovulation, the luteal phase of 12 to 14 days after treatment remained more than 3 menstrual cycles; menopausal patients with menstruation, after more than 3 times the normal amount of maintenance, or thin hair to menopause, hysterectomy or other treatment, symptoms disappeared persons. 2, effective: reduction by 1 / 3 to 1 / 2, within 10 days period, 1 or 2 normal menstrual cycle. 1 child-bearing age ovulation, corpus luteum insufficient improvement; no ovulation, there change in the luteal phase; menopause period shortened, the volume has decreased. 3, invalid: by volume, period, period no better. Books of related book information: Juan editor
Related Books Publisher: Medical Science and Technology Publishing House Time: 2010-1-1 Folio: Big 32 opening ISBN: 9787506742979 Price: ¥ 18.00 Introduction This book describes the dysfunctional uterine bleeding in the physiology and pathology, pathogenesis, clinical examination, classification and differential diagnosis, treatment and care and prevention, highlighting the systematic, advanced, scientific and practical, reflecting the dysfunctional uterine bleeding clinic new results, new progress. The book is rich in content, informative, clinicians and medical colleges for students to read for reference. Directory Chapter physiological basis of female reproductive system anatomy female reproductive system physiology Section II Section III physiological menstrual cycle in female reproductive physiology in the etiology and pathology of medical knowledge Chapter II Section etiology and pathology of the incidence of Etiology and Pathogenesis of Medicine III Chapter IV Section TCM four diagnostic clinical examination differentiation Check Chapter II clinical examination Western General Inspection Section II Section III gynecological routine examination of dysfunctional uterine bleeding secondary Check the fourth common gynecologic diagnosis diagnosis and differential diagnosis of Chapter VI of Section II Western Western diagnosis differential diagnosis combined with other gynecological disease diagnosis III clinical study of the analysis of Section V of misdiagnosis and Syndrome TCM diagnosis elements of Chinese medicine treatment of Chapter VII Section II acupuncture treatment of traditional Chinese medicine prescription point injection therapy III IV V skin and ear acupuncture therapy acupuncture cupping therapy VI VII VIII other commonly used acupuncture Section IX of Chinese Acupuncture and Traditional Chinese dietary therapy combination therapy of Chapter VIII of the general treatment of Section II Western medicine therapy psychotherapy III IV V in the surgical treatment of Western medicine therapy Nursing Section IX General Section III stage nursing care of dysfunctional uterine bleeding in surgical nursing care and rehabilitation of Chapter IV Section prevention prevention of dysfunctional uterine bleeding dysfunctional uterine bleeding Section importance of prevention of the tenth a chapter on health education and management education in Section II how to prevent adolescent health management of dysfunctional uterine bleeding First of all, should be a proper understanding of adolescent development process, reasonable arrangements for learning and life. Second, adolescent girls should know about adolescent growth and development, menstruation is how the case, what factors can cause menstrual abnormalities, how should I do. Girls generally 13 to 16 years of age to menstruation. Most of them soon after passing the initial establishment of the normal menstrual cycle, on a monthly basis via; and a few because of its endocrine function has not yet fully mature, the phenomenon of menstrual disorders may occur. Again, to avoid psychological stress, fatigue, malnutrition can be induced by this phenomenon. Thus, adolescent girls must be studying and living arrangements, pay attention to work and rest, exercise, enhance physical fitness, to ensure adequate nutrition (protein, vitamins, iron) intake, avoid cold food. Bleeding inside and outside the uterine cavity in the same, the growth of bacteria in the environment due to good will multiply rapidly and cause disease. Therefore, bleeding should pay attention to genital cleansing, frequently changes and menstrual underwear menstrual pads and other supplies; do not clean the vulva due to bleeding rather than the contrary, menstruation must be cleaned daily to remove blood. Some genital cleansing agent available, can also be used warm water washing, but should avoid tub baths.
Dysfunctional uterine bleeding
Dysfunctional Uterine Bleeding DUB referred for gynecological diseases. It is due to the neuroendocrine mechanisms regulating reproductive disorders caused by abnormal uterine bleeding, and internal and external genital systemic and there is no organic lesion. Ovulatory dysfunctional uterine bleeding and can be divided into two types of anovulatory, about 85% of the cases are anovulatory dysfunctional uterine bleeding. Dysfunctional uterine bleeding can occur in between menarche to menopause at any age, 50% in premenopausal patients, 30% of reproductive age, adolescents accounted for 20%.
One anovulatory dysfunctional uterine bleeding
"Cause" because of dysfunctional uterine bleeding or ovarian gonadotropin-releasing hormone, or regulation in respect of temporary changes in many factors, internal and external body, such as psychological stress, fear, sadness, sudden changes in environment and climate as well as systemic diseases, were can affect the central nervous system through the cerebral cortex and the hypothalamus - pituitary - ovarian axis of mutual adjustment, malnutrition, anemia and metabolic disorders may also affect hormone synthesis, transport, and the target organs caused by the effects of menstrual disorders.
"Pathophysiology" anovulatory uterine bleeding occurs mainly in adolescent and perimenopausal women, but not identical to the pathogenesis of the two. In puberty, the regulation of the hypothalamus and pituitary function are not matured, they are yet to be established between the stability of ovarian cyclical adjustment, especially for the positive feedback effect of estrogen deficiencies. This period was sustained low levels of pituitary FSH secretion, and no peak formation. Thus, although the bulk of follicular growth, but no ovulation, follicular development that occurs to a certain degree of degeneration, the formation of atretic follicles. And perimenopausal women, because ovarian function decline, a few follicles have been depleted, particularly in the remaining follicles of the low reactivity of the pituitary gonadotropin, estrogen secretion dropped sharply negative feedback on pituitary weak, so the level of gonadotropin increased, but can not form the peak before ovulation, and finally to the occurrence of anovulatory uterine bleeding.
Is based on the occurrence of normal menstruation after ovulation and the end of the luteal phase of life, the withdrawal of estrogen and progesterone, so that shrinkage necrosis and shedding of endometrial bleeding. Anovulatory DUB is due to estrogen stimulation without a single confrontation progesterone withdrawal bleeding caused by estrogen or estrogen breakthrough bleeding. In a single persistent estrogen stimulation, endometrial hyperplasia, if a group of follicular atresia, a sudden drop in estrogen levels may be, the loss of hormonal support of endometrial bleeding stripping, as the application of exogenous estrogen caused after the withdrawal of bleeding, estrogen withdrawal is bleeding. Estrogen breakthrough bleeding, there are two types of estrogen concentrations with the existence of a semi-quantitative relationship. Low levels of estrogen to maintain the threshold level, intermittent bleeding can occur, endometrial repair slow to prolonged bleeding; and maintain high levels of estrogen in the effective concentration is caused by prolonged amenorrhea, due in no progesterone, endometrial thickened but not firm, high incidence of acute breakthrough bleeding, and blood surging.
Normal menstrual cycle, duration and amount of blood, showing apparent regularity and self-limiting, and most patients with anovulatory dysfunctional uterine bleeding does not have these characteristics. Severe anovulatory bleeding-prone more than the amount of estrogen secretion or long duration cases, the lack of progesterone antagonist, endometrial hyperplasia without restriction, at the same time, but no dense interstitial solid support, resulting in such organizations vulnerable and easy to spontaneous ulceration bleeding; no effect of progesterone in endometrial blood vessels of the lack of spiral, segmental contraction and relaxation does not occur, the endometrium can not sync off, resulting in a repair, another and bleeding; irregular vascular tissue damage and multiple fracture, because of contraction of the spiral arteries ineffective, resulting in bleeding for a long time, blood loss from multiple and difficult to stop. In addition, several organizations within the damaged blood activation of plasmin, causing more fiber protein cleavage, not easy to form blood clots, further exacerbating the bleeding.
"The pathological changes of the endometrium," according to the concentration of the blood level of estrogen and the role of the length of time, and endometrial sensitivity to estrogen, the endometrium may show hyperplastic changes in different degrees, a few shrinking of change.
1. Endometrial growth is too long categorized as follows.
(1) simple hyperplasia: the glandular cystic hyperplasia. Refers to the glands had mild to moderate structural abnormalities. Endometrial thickening in part or in whole, or showed polypoid hyperplasia. Gland is characterized by an increase in the number of microscopic, glandular cystic expansion of large and small, like a Swiss cheese-like appearance, it is also called the Swiss cheese-like hyperplasia. High columnar epithelial cells, can form a pseudostratified proliferation, non-secreted. Regular interstitial edema, necrosis, with a small amount of bleeding and leukocyte infiltration.
(2) complex hyperplasia: the adenomatous hyperplasia. Gland hyperplasia refers to the crowded and complex structure. A high degree of endometrial glandular hyperplasia were sprouting like growth, the formation of the sub-glandular or glandular sudden, significant increase in the number of glands, appeared back to back, resulting in significantly reduced interstitial. Epithelium was stratified or pseudostratified arrangement, large nuclei, stained with nuclear fission, but all typical changes.
(3) atypical hyperplasia: the pre-cancerous lesions, 10% -15% can be converted to endometrial cancer. Epithelial atypia that appear to change, showing glandular epithelial cells, the level of increased disorder, a large dark stained nuclei atypia. Whether a simple type or complex hyperplasia, glandular epithelial cells as long as dysplasia changes should be classified as atypical hyperplasia. Such change has been the blood does not belong to the scope of work.
2. Proliferative endometrium and normal endometrium seen in menstrual cycle, no difference in proliferative phase endometrium, but in the latter half of the menstrual cycle or menstrual period, still showed proliferation of forms.
3. Atrophic endometrium meager endometrial atrophy, glands few and small, duct narrow and straight, for the single cubic epithelium or low columnar cells, small and dense interstitial collagen fibers relative increase.
"Clinical" patients with anovulatory dysfunctional uterine bleeding may have different clinical manifestations. The most common clinical symptom is irregular uterine bleeding, is characterized by menstrual cycle disorders, menstrual period of varying lengths, amount of bleeding has been uneven, and even a lot of bleeding. Sometimes several weeks or months before menopause, and then irregular vaginal bleeding, blood is often more, for 2-3 weeks or more, is not easy since only; sometimes it is the irregular vaginal bleeding started, but also the performance of is similar to the normal cyclical menstrual bleeding. No abdominal pain or bleeding of other discomfort, often accompanied by bleeding or anemia in the elderly time. Gynecological examination was normal uterine size, uterine bleeding is relatively soft.
"Diagnosis" based primarily on history, physical examination, determination of ovulation and other examinations.
1. Detailed history should be noted that the patient's age, menstrual history, obstetrical history, and contraceptive measures, the body with or without chronic disease such as liver disease, blood disease and thyroid, adrenal or pituitary disease, with or without mental stress and emotional impact of combat and other normal menstrual factor. Understand the course of the disease through, such as time of onset, the current bloodshed, bloodshed before the menopause, whether through the history and past treatment. Understanding of several types of abnormal uterine bleeding: â' menorrhagia: periodic rules, but as excessive (> 80ml) or prolonged menstrual period (> 7); â'¡ menstrual frequency: periodic rules, but less than 21; â'¢ irregular uterine bleeding: irregular periods, menstrual volume not too long after; â'£ irregular excessive uterine bleeding: irregular periods, excess blood.
2. Physical examination including complete physical, gynecological examinations, etc., to exclude systemic diseases and reproductive tract organic disease.
3. Aided diagnosis
(1) diagnostic curettage: to exclude endometrial lesions and to achieve hemostasis purposes, must be fully curettage, scraping the uterine cavity. Uterine curettage should pay attention to size, shape, palace wall is smooth, the nature and quantity of scrapings. In order to determine ovulation or luteal function, should be premenstrual or menstrual cramps curettage within 6 hours; irregular bleeding curettage may at any time. Pathological examination revealed endometrial proliferative changes or hyperplasia, non-secretory phase appears.
(2) hysteroscopy: uterine endometrial thickness were observed under microscope, but also do not thickened, smooth and unstructured processes, but there is congestion. Choice in the uterus mirror the lesion under direct vision biopsy, the diagnosis of endometrial than the value of the blind to take the high, in particular, to improve early intrauterine lesions such as endometrial polyps, uterine submucous fibroids, endometrial cancer diagnosis.
(3) basal body temperature measurement: a simple and feasible method for determination of ovulation. Basal body temperature showed a single phase type, indicating no ovulation.
(4) cervical mucus crystallization tests: The leaf-shaped crystals appeared before ferns suggest anovulation.
(5) Vaginal smears examination: general performance of the smear, a high estrogen effect.
(6) Hormone Determination: To determine whether ovulation, pro
"Differential diagnosis" must be excluded from the local genital tract disease or systemic disease caused by the reproductive tract, particularly in adolescent girls, vaginal or cervical malignancy, submucosal fibroids and women of childbearing age trophoblastic tumor, and the perimenopausal period, women in old age endometrial cancer misdiagnosed as dysfunctional uterine bleeding, should pay attention to identification.
1. Systemic diseases such as blood disorders, liver damage, such as hyperthyroidism or lower.
2. Abnormal pregnancy or pregnancy complications such as miscarriage, ectopic pregnancy, hydatidiform mole, uterine involution poor residual placenta, placental polyp.
3. Reproductive tract infections such as acute or chronic endometritis, uterine myositis.
4. Reproductive tract tumors such as endometrial cancer, cervical cancer, choriocarcinoma, uterine fibroids, ovarian tumors.
5. Improper use of hormone drugs.


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Rear Admiral Russell Allen, a Southern Illinois native, began his military career in 1978 when he enlisted in the U.S. Navy Nuclear Power Program. He was commissioned an ensign upon graduation in December 1984 from the University of Texas and was designated a Naval Aviator in 1986.
Following pilot training at Helicopter Combat Support Squadron (HC) 3 in San Diego, California, he reported to his first operational assignment as a CH-46 pilot with the "Dragonwhales" of HC-8 at NAS Norfolk. He completed three deployments to the Mediterranean as a VERTREP pilot aboard the USNS Saturn (T-AFS-10) and USS Concord (T-AFS-5), and then returned to HC-3 as a flight instructor until he voluntarily resigned his regular commission in June 1992.
In July 1992, Allen began his tour with the Helicopter Combat Support Special Squadron (HCS) 5 "Firehawks" as a Selected Reservist, flying the HH-60H as a Combat SAR and Special Operations mission commander. Mobilized for Operation Iraqi Freedom in March 2003 while executive officer, he served as deputy commander, Joint Special Operations Air Detachment—Arabian Peninsula. He assumed duties as HCS-5 commanding officer in June 2004 until October 2005 and led the squadron's second major deployment to Iraq.
Additional Command tours include Navy Reserve, Strike Force Training, Pacific, including an active duty tour as chief of staff from May through September 2007. He later served as deputy commander, Naval Air Force Reserve from June through August 2008 and 3rd Fleet Joint Force Maritime Component Commander (JFMCC) as commanding officer from December 2008 to December 2010.
Previous staff tours were with U.S. Pacific Fleet's Joint Contingency Unit, 3rd Fleet JFMCC, Navy Region Southwest Reserve Component Command as deputy commander, and 7th Fleet deputy commander from October 2013 to February 2015.
In his current assignment since February, 2015, he is responsible for the Undersea Domain mission of Anti-Submarine Warfare.
Allen's military decorations include the Legion of Merit (three), Bronze Star, Meritorious Service Medal (two), Combat Action Ribbon, Navy Unit Commendation, Meritorious Unit Commendation and the Battle "E."

subset: commoncrawl


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For many years the idyllic qualities of Anna Maria Island off the Central Gulf coast in Florida remained a well hidden secret to the people of the 'Sunshine State'. But following the first inhabitants of the island at the beginning of the 20th century, it soon became a glorious hideaway for locals and visitors to enjoy the beauty of the Gulf Coast in all its glory.
The sanctuary of this sun-kissed island is that there is no need to beat the crowds for your spot on the beach as there simply aren't any crowds to beat! Take to the crystal blue seas and take your adrenaline fill with a parasailing ride, or marvel at the spectacular catch of the day on a deep sea fishing charter boat.
Take things at your own pace on this magical island, but by all means explore the rest of what the Western Florida coastline has to offer. With its relative proximity to the Everglades National Park, engulf yourselves in over 1.5 million acres of serenity and natural beauty. A host of luxurious, self-catered rental accommodation is available to select from, providing a magical base for the perfect leisure vacation.
A vacation rental on Anna Maria Island gives you great access to it's many beaches. You could try a short term rental holiday home on Anna Maria Beach, or even a privately owned Condominium on Holmes Beach.


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(based on 1 review)
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Awesome size for a first board
By onefish
from Sabattus, Maine
About Me Intermediate
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Comments about Liquid Force Nemesis Grind Wakeboard - Boy's 2013:
My 4 year old really wanted to wakeboard and the 124 we had was just too big and had too wide a stance. Picked the 111 nemesis up and he popped up out of the water and was riding. He should be using this for several years to come.
Bottom Line Yes, I would recommend this to a friend
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A supplement like Nutritional Support for Dogs & Cats Powder by Rx Vitamins for Pets could potentially help your pet stay healthy.
First' this powdered supplement provides several vitamins and minerals that may work to maintain overall well-being. For example' vitamin E might play a role in regulating cardiovascular and immune function' while biotin may act to preserve a healthy-looking skin and coat.
In addition' this Rx Vitamins for Pets supplement contains antioxidants like superoxide dismutase (SOD). As a result' Nutritional Support for Dogs & Cats Powder might work to protect your pet's cells from free radical damage.
Finally' every serving of Nutritional Support for Dogs & Cats Powder provides a wide array of herbs. For instance' horsetail extract could potentially work to alleviate mild incontinence as well as other symptoms associated with minor urinary tract infections.
Each container of Rx Vitamins for Pets' Nutritional Support for Dogs & Cats Powder provides over nine ounces of powder' which is easy to mix with the cat or dog food of your choice.
These statements have not been evaluated by the Food and Drug Administration (FDA). These products are not meant to diagnose' treat or cure any disease or medical condition. Please consult your doctor before starting any exercise or nutritional supplement program or before using these or any product during pregnancy or if you have a serious medical condition.
Ingredients per 2 teaspoons:
Lecithin 1000 MG
Liver powder 1000 MG
Salmon meal 1000 MG
Flaxseed meal 500 MG
Spirulina 500 MG
Bee Pollen 100 MG
Kelp 100 MG
Tang kwei 100 MG
Burdock root 50 MG
Catnip 50 MG
Dandelion 50 MG
Ginger 50 MG
Horsetail 50 MG
L-glutamine 50 MG
L-taurine 50 MG
Milk thistle seed 50 MG
Oregon Grape Root 50 MG
Rose Hips 50 MG
Siberian Eleuthero 50 MG
Sodium Ascorbate 50 MG
Turmeric 50 MG
Yucca 50 MG
Zinc (monomethionine) 2 MG
Vitamin E (d-alpha-tocopherol succinate) 10 I.U.
Biotin 50 MCG
Selenium (Selenomethionine) 3 MCG
Suggested use:
20-50 lbs. - 1 teaspoon
50-100 lbs - 2 teaspoons
Over 100 lbs. - 1 tablespoon
Administer once or twice daily
Dosaging Tips: The above dosages are recommended for the initial 2 months of administration. After 2 months' dosage may be halved. To amplify or increase the benefit of the food-bound nutrients' dosage may be increased safely 2 or 3 times.
Consult your veterinary
Allergy / Dietary Needs
- Hypoallergenic
Ratings & ReviewsReview This Item
Overall Rating for Nutritional Support for Pets (Dogs & Cats) Powder - 9.07 oz (257 Grams)
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By Nelson
from NYC
Finally pets get their veggies!
A holistic vet had me use Nutritional Support for Pets by RX Vitamins for my pooch & was looking forever without a 'prescription'......finally with a google search, I found it!! My dogs are not veggie eaters(one of my angels likes avocado!!) & they all need their phyto nutriients, like humans, & this is the best formula on the market!!! Strengthen them with this you will see a drop of health issues & less visits to the vet!!!
Veggie formula which all pets must have.
What's to dislike.
√ I would recommend this item to a friend.
By Lynne Parisi
from Nevada
Multi vitamin for Pets
I was given a recommendation by my local pet store owner to Nutritional Support for Pets by Rx Vitamins, the Probiotic and the Enzyme. I just sprinkle it on their food, both wet and dry, and they gobble it up. Now that I have moved, I order online.
Easy to administer to my dogs.
√ I would recommend this item to a friend.
By Nancy
from Milford, DE
I'm back to reorder!
Nutritional Support by Rx Vitamins got rid of my dog's black scabs after trying everything. Vet said it was thyroid but tests said no. Three vets just shrugged and said it was fungus, or yeast or whatever. Was prescribed steroids and iodine shampoos which helped. I tried diet changes and very expensive food and whole foods but it wouldn't go away just change a bit. After a month on Nutritional Support, he's go no lesions on him!
Easy to put into food. Picky dog seems to like it fine.
Should come in larger container so I can give to all three dogs.
√ I would recommend this item to a friend.
Displaying reviews 1-3 of 3
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Your question(s) and our corresponding answer(s) will not be confidential and will be posted publically on this specific product page.
Additionally, PureFormulas is unable to directly recommend products in relation to specific health conditions. Please contact your trusted healthcare practitioner for direct product recommendations.
If you have any general questions regarding orders or our policies and programs, please contact our Customer Happiness Team @ 1.800.383.6008
If you are pregnant, nursing, taking any medications or have any medical condition, consult your doctor before use. Your healthcare professional is the best source for guidance before beginning an exercise or nutritional supplement program.


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COVENTRY – Resident Pedro Grondin met with the select board Tuesday evening in an attempt to get Coventry to start its own fire department.
Last month, select board chair Mike Marcotte and selectman Brad Maxwell met with the Newport City Council to see if there is interest in getting in a contract for fire coverage. As it is now, Coventry pays per call. A contract would mean Coventry pays a flat fee, which would make budgeting easier for fire coverage.
After a brief discussion, the Newport City Council gave the okay for representatives to start discussions.Â
KILLINGTON–"That was probably the most solid 18 holes of tournament golf I have played in quite a while."
That is what Matt Morin said of his first round at the Vermont State Amateur Championship on Tuesday.
The recent Lake Region graduate, along with Matt Stakus, shared the lead with a one under par 70 heading into Wednesday's 2nd round at the Green Mountain National Golf Course.
Said Morin of the keys to his success on Tuesday, "I did not make any big numbers.
"I was calm and cool on the course, I did not three-putt and I did not shoot anything higher than a bogey."
CASTLETON–The Vermont Softball Coaches Association, partnering with Castleton State College, gave the opportunity of a lifetime to thirty-six of the top softball players and coaches in the state when the group gathered for a weekend of softball at the North-South All-Star Series.
Catcher Chelsey Thibeault from Lake Region was the sole representative from Orleans County at the event.
The best of three series got underway on Friday as the players battled not only each other, but the gruelling heat as well.
The North swept the double-header, winning by the scores of 9-7 and 6-4.
NEWPORT CITY – A boat ride can be a very tranquil thing to do on a warm sunny day, but don't let a delightful trip have a tragic ending.
"You have to be safe when you're boating," said Newport City Fire Chief Jamie LeClair Monday.
Boaters should know the water they are in and should tell someone where they are going. Boaters should not go out alone. They should be aware of the weather, which includes having a radio that receives broadcasts from the National Weather Service.
DERBY – Another discussion over the Derby Line Ambulance quickly grew heated and led to foul and vulgar language at the Derby Select Board's regular meeting Monday.
A group of people formerly associated with the ambulance service have shown up several times at select board meetings to express their concerns over how the ambulance is run. Leading the charge is Roger Gosselin, a former member of the ambulance service, and Nathan Pickard, who went on a few calls with Gosselin.
ALBANY – Republican Rep. Vicki Strong (Orleans-Caledonia-1) hopes that voters in her district will send her back to Montpelier.Â
Strong, who is seeking her second term, called her first year a learning experience.
Part of her education in Montpelier included learning about the legislative process, what it takes to see a bill happen and why Vermont even needs a legislature.
"Learning the whole process was a big, big step for me," she said. "I still have a lot to learn. Just being part of that was exciting and interesting."
The Lake Region Sun Devils 16-U girls softball squad continued their summer season with three thrilling games this past week.
On Friday evening, the Sun Devils traveled to the campus of Lyndon State College for a twi-night doubleheader against the Lyndon Orioles.
In the opener, each club battled back and forth in a tightly contested game, with Lake Region eventually pulling out an 8-7 victory.
Kahlstrom–– Douglas McArthur, age 70, of Lampasas, TX, died Friday, July 6, 2012 at his home. A memorial service for Mr. Kahlstrom will be held at a later date. Sign our online guest book at sneedfuneralchapel.com. Sneed Funeral Chapel is in charge of arrangements.
For the full obituary see Tuesday's Express.
NEWPORT CITY, VT – A sailing trip on Lake Memphremagog turned tragic for 58-year-old John Connell of Calais, VT, Sunday afternoon.
Connell jumped off the sailboat he was on in an attempt to retrieve a canoe his boat had in tow, Police Chief J. Paul Duquette said. Duquette said Connell took a few strokes away from the boat and hollered back to his friend that he was having breathing difficulties. Connell's friend, who was still on the boat in clothes, went below to change but, by the time he returned to the main deck, Connell had disappeared.


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Disability Support Services
Disability Support Services (DSS) works with qualified students with disabilities in a confidential, respectful, and safe environment to identify and develop reasonable classroom accommodations; to ensure equal opportunity and access of academic and professional goals; and to promote an accessible community where students with disabilities have equal opportunity to participate in college programs and activities.
You are welcome to visit our office at any time during your enrollment at Grays Harbor College (GHC), but we recommend that you come to our office at least one month prior to starting classes.
Rehabilitation Act of Congress, 1973 Title V; Section 504
"No otherwise qualified individual with a disability in the United States, shall, solely by reason of her or his disability, be excluded from the participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance."
Who is eligible for services?
Disabilities (physical, learning, psychological, cognitive and/or sensory) that substantially limit one or more of an individual's life activities (i.e. learning) may qualify a student for services. Examples may include, but are not limited to:
- Learning Disabilities
- Psychological Conditions
- Medical Conditions
- Visual Impairments
- Hearing Impairments
Examples of services provided, but not limited to:
- Special location for testing
- Note-taking assistance
- Alternatively-formatted books
- Sign Language Interpreters
- Extended time on tests
- Supportive Chairs
- Medical Reserve Parking
- Referrals to campus and community resources
Steps for requesting services:
- Contact DSS for orientation of services
- Obtain historical and/or recent documentation of your disability
- Schedule Intake Interview with DSS Specialist
- Develop Letter of Accommodation with DSS Specialist
- Discuss Letter of Accommodation with Instructors
Information regarding your disability is considered confidential. No information will be released outside of GHC without your written permission. Transcript and records do not identify whether or not a student received accommodations from DSS.


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Chronic Disease & Injury
Each year in the United States, there are more than 780,000 strokes. Stroke is the fourth leading cause of death in the country and causes more serious long-term disabilities than any other disease. Nearly three-quarters of all strokes occur in people over the age of 65 and the risk of having a stroke more than doubles each decade after the age of 55.


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Maggie Valley, North Carolina Pet Friendly Hotels & Lodging
United States » North Carolina » Maggie Valley
Looking for a hotel in Maggie Valley, NC that you can bring your pet to? We made sure that each one of the hotels below are pet friendly, so you can enjoy your trip with your pet by your side! Once you have found a pet friendly hotel, you can book your stay instantly from our website or call 866-212-1803 to speak with a pet travel agent.
Browse Pet Friendly Hotels In Maggie Valley, North Carolina
Rates from
3811 Soco Road Route 19 - Maggie Valley, NC (Map)
Best Western pet friendly properties will allow up to two domestic dogs in a rented room, with a maximum size of 80 lbs per animal. Other pet types such as cats, birds, monkeys, snakes, or other animals are allowed at the discretion of each property and require prior approval from the property. There may be a maximum $20 per day charge for each room with a pet or multiple pets or a maximum per wee...
Overview | Pet Policy | Map
Rates from
3777 Soco Road Rt 19 - Maggie Valley, NC (Map)
Microtel Inn & Suites by Wyndham Maggie Valley welcomes pets at their pet friendly accommodation. The pet weight limit is 20 pounds and the pet fee is $10 per night.
Overview | Pet Policy | Map


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Leave a Review
For a great variation, I add a tsp of almond extract and substitute crushed almonds for the walnuts and dust the top with crystal sugar. Soooo good.flag if inappropriate
So good my grandmother (who normally does all of the biscotti baking) asked me for my recipe!flag if inappropriate
Sorry about the size issue in my yesterday's review as I just printed the recipe out and saw that it was not 3-4" but 3/4" slices!flag if inappropriate
These are very good and no more difficult to slice without breaking than any other biscotti I have made. I followed the recipe exactly except I only had 5 Tbs butter so added 1 of oil. I used dutch process cocoa as that was all I had. The slicing instructions are a little ambiguous- at first I thought that the slices should be 3-4" thick but I sliced them my usual 1".I then realized that the 3" probably was the length which you have little control over once you have made the logs and cut on the bias. Giving the thickness would have been more helpful. But overall a very good recipe.flag if inappropriate
My first time making Biscotti and I now wonder what took me so long, as this was soooo easy and so delicious! Got rave reviews at the office and also sent away as a gift. Beautiful and delicious!!! Superb deep chocolate flavor..flag if inappropriate
I have made these biscotti SO many times. So easy and very addictiveflag if inappropriate
I have made this recipe many times because it is excellent. My newest variation was to use roasted pistachios and 1l2 tsp orange oil. Yum! I also routinely add 1 tsp espresso powder with the eggs and 1 tsp vanilla. These additions just improve the flavor. Before I cut them, I lightly spritz with water so they do not crack as much.flag if inappropriate
I am a caterer and have been making these for a long time. Often I'll add a touch of cayenne pepper or mixed spice (an english spice mix like allspice) which adds a depth of flavour. Or, I'll add a a tsp of vanilla and use dark chocolate cocoa although they are good whether using premium cocoa or regular Hersheys. I dip the ends in white chocolate and often add chopped hazelnuts or forego nuts entirely for the nut-allergic. Often I'll score them before I bake, makes cutting easier but agree easier to cut when warm out of oven as they will break if not careful. Hands down best recipe for biscotti!flag if inappropriate
this was the first biscotti i ever made and it was really good and crunchy. i didn't have any chocolate chips or walnuts on hand so i just left them out. they were still really chocolatey and flavorful! i added a teaspoon of vanillaflag if inappropriate
I have been baking almond biscotti for 20 years and after many requests for chocolate I tried these. Wow is all I can say. You can not eat just one.flag if inappropriate


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The first question that comes to mind is: How Main is Washington and how Main is U.S. 31, and where is the promotional scheme for that area as well as for the rest of Grand Haven? I am not saying that MSDDA can't or should not promote themselves, but should the city government take sides by promoting one area while forgetting the other areas, while they are supposed to be representing all of us.
Eric Brennberger, planning commissioner, had it right when he suggested that it would be more fun if we let a few more people into the game. In good schools, kids get taught this at an early age, but either someone didn't go to one of the good schools or they just don't play well with others.
City Planner Kristin Keery said that opening up the PSD to a larger area would be a challenge for the DDA because they want to market the core downtown and Centertown area. Too bad, this is our city and we all live here together; so, if you want us to pay the city planners to help you make this happen, then you should open up the area to include the land from approximately the Bil-Mar to Kirby's to U.S. 31 to the bridge and back to the Bil-Mar. Later, the city can make one or two more PSDs for other areas if they can prove they know what they are doing. (No more Grand Landings that we have to pay for).
The current MSDDA can be the center of the new group and show them the ropes so to speak and at the same time this arrangement will keep the DDA people from stepping on as many toes as they might if they acted alone.
While we are talking about this, let's tell the city government that we don't want to see any city-backed bonds issued without the approval of the voters, including a stated worst-case millage limit in the case we end up paying them back out of our taxes (again).
I am stuck at a second-shift job so maybe some of you fine people can attend whatever meetings are held and try to keep things going in a healthy direction.
— Dale Freye, Grand Haven


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Hawaiian Regional Cuisine
Posted 03 February 2004 - 09:57 AM
Along with others in this forum, I've been arguing that Hawaiian Regional Cuisine has lost its edge, that it has become cliched, and that the same dishes are being recycled over and over again. It's hard to measure what effect, if any, this has had on the commercial side of things. However, there's no question that some of the excitement that characterized the food community here in the early 90s is starting to wear off. . .
What can be done to revitalize the local food scene? IMHO, the one thing that needs to be done is to tie the efforts of high-end restaurants more intrinsically to Hawai`i's popular cuisine. No, I don't mean that HRC places should start to serve chicken katsu, teri beef, and loco moco! At any rate, Wayne Hirabayashi's foie gras, unagi, lobster, and quail egg "loco moco" shows that even that kind of "grass-roots" cuisine can be bent totally out of shape if the only thing that is maintained is name and the outward form. Instead, local high-end chefs should try to do more to inhale the spirit of local cooking, and the kind of blending that comes less from a conscious attempt to fuse East and West and to mark off culinary territory, and more of an attempt to create what tastes good, regardless of provenance, based upon the extremely wide range of ingredients that are available locally.
If I would cite a historical precedent for HRC, it would be Trader Vic's "Tiki" Cuisine from the 1950s. Contemporary foodies may view Tiki Cuisine, with its psychedelic cocktails and flaming pupu platters, as kitchy retro, but during its peak era it was considered the height of fashionable eating not only in Hawai`i but throughout the American West Coast. And like HRC, it came out of a conscious attempt to fuse East and West, creating something that was labeled "Polynesian" for a global audience. And, if you'd actually ever eaten at a Trader Vic's, you'd know that some of results do taste very good. However, like much of HRC, it was essentially built upon creating a fantasy vision of Pacific cuisine, once based upon upscaled and Westernized dishes from various parts of East and Southeast Asia. The actual cuisine of the Pacific Islands, while not exactly ignored, was not taken seriously as the basis for something that would be acceptable to the mainland gourmands towards whom the cuisine was aimed. Hence once the novelty faded, there was little to fall back upon to renew the vision and innovation. HRC people may not enjoy the comparison, but in 20 years will "Seared Ahi" and such be viewed with the same mixture of nostalgia and condescension as the Pupu Platter?
What do you think? What can be done to create a local high-end cuisine with staying power?
Posted 05 February 2004 - 02:25 AM
First I wanted to say...Trader Vic's is alive and well in some far-flung parts of the world. My father and brother live in Dubai and the first time i went to visit in 1992, boy was I surprised to find Trader Vic's is one of the city's most popular restaurants. My Dad loves it, cause he can swill maitais and it's a nostalgia trip for him—he loved Trader Vic's here back in the 60s. He's a sweet-and-sour-loving haole. They keep the tiki torch burning, with the addition of some seminal 80s culinary additions like chicken satay and the like. (As a kid living in Jakarta in the seventies, I never guessed the peanut sauce I ate at street stalls would go on to conquer the world.)
I agree there is a certain strata within HRC that is becoming humdrum—the requisite mahimahi with mango salsa, and "crisp" moi and now seems to be taking its place. (The plus side is that while that may seem boring, it's cool that it's trickled down to budget operations like Diamond Head Market and Grill...it's nice to be able to get mahi-mango for 7 dalah.)
But as I said, in the Hale Aina Awards topic, I think a few chefs are going to be changing things, like chef Etsuji at Brown's Beach House at the Fairmont Orchid on the Big Island. He's so excited about getting to know the famer's in nearby Waimea. I ate there and he specially made a dish of sliced hamachi topped only by sweet locally grown tomato slices and a light shiso vinaigrette. He also did something extraordinary: baked baby (also locally grown) potatos in ala'ea. He said "Taste these potatoes, they have so much flavor you can just eat them plain." And he was right. Trained in Japanese and French technique, his way with seafood is masterful, highlighting pure flavors. The hotel just built him a new open kitchen.
Also, although his regular menu is often criticized, chef Hiroshi at L'Uraku really does some outstanding cooking for his contemporary kaiseki dinners. Uni risotto, kahala sashimi, gosh, there were other memorable little plates. They highlighted local ingredients but never fell into a HRC rut. I highly recommend trying to get a reservation at his next kaiseki event this spring.
Seared ahi is much more than a HRC dish...it already is a classic. You'll find versions of it as the chicest restaurants in Manhattan, along with some kind of tuna tartare. I think you'd be surprised to find how far HRC's reach has gone in subtle ways. Rocco DiSpirito (yes, the chef from that lame Restaurant reality show) made his name not with Italian food, but with his Pan-Asian-inflected contemporary cooking at his restaurant Union Pacific. It opened in 1997, and is just phenomenal. Roy's, Alan Wong's and Chef Mavro will never reach this level of cooking. But I don't know if he was influenced by what was happening in the Pacific Rim, or vice versa, or if there was no influencing going on at all. The fact is, Hawaii kitchens COULD be doing his kind of cooking: Halibut cooked in its own fat, covered in tangled scales of caramelized young ginger (just substitute the halibut for a luscious local fish), curried baby calamari in a Madras sauce set off by marinated dried blueberries (substitute the berries with dried strawberry guava or something). There is so much room for innovation and experimentation.
I think as new crops of Hawai'i born chefs graduate from places like Maui Community College's revamped $17 million culinary center and go out in the world and discover new flavors and techniques then return home, we'll see a natural evolution out of our mahi-and-mango culinary holding pattern. (I hope!)
Posted 05 February 2004 - 04:18 PM
Along the same lines, the commercialization and mega-"branding" of products that seems rampant among Hawai`i's celebrity chefs too is perhaps understandable given the financial precariousness and overwork that is endemic to the restaurant business. Interesting that you mention Rocco in that light. People who are only familiar with his cheesy on-screen persona (or that of Emeril for that matter) may not realize that they got into a position to ruin their good names by being genuine innovators for many years. BTW, though this is off the point, perhaps the most popular eGullet thread of all time was the one in which seemingly about half of the staff of "Rocco's" registered and posted various insults directed at their boss and the network (and Tony Bourdain posted to quasi-defend - or put in context - his appearance on the show). Not that enlightening but a lot of fun. . .
But back to HRC. . . I guess my main question is an "identity" one - once they decide that self-conscious East-West fusion is no longer the paradigm around which want to define local high-end cuisine, is it going to be replaced by a new paradigm, or just a collection of disparate individual styles? And does it matter from a gastronomical point of view? From a commerical point of view?
I also had a Trader Vic experience about six or seven years ago - there was one in the basement of the Palmer House Hilton in Chicago, where the American Political Science Association conference was going on. Went with a friend of mine from Vancouver, who told me that Trader Vic's was considered the happening place there. Anyway, the tikis were burning brightly that night, and I ordered the pressed duck with almonds and plum sauce. Very sweet, as you might expect (shades of HRC!), but crunchy and addictive. The shadows cast by the heathen idols urged me on, and I couldn't stop eating it. . .
BTW, Irwin ("wesza") on this forum (Hawai`i's "Mr. Restaurant" of the 70s and early 80s) has regaled us with his recollections of Vic Bergeron himself. The Trader was quite a colorful fellow, and quite knowledgable about "authentic" traditional Polynesian food - his chapter on lua`u food in this Pacific Islands Cookbook is very well-researched - he just never served it at his restaurants.
Sorry for all the digressions. . .
Posted 10 February 2004 - 01:57 PM
I guess my main question is an "identity" one - once they decide that self-conscious East-West fusion is no longer the paradigm around which want to define local high-end cuisine, is it going to be replaced by a new paradigm, or just a collection of disparate individual styles? And does it matter from a gastronomical point of view? From a commerical point of view?
Interesting question. It seems to me simply the make up of our population will always lend itself to a blending of East and West in all avenues of life here. A local-born poet, Gary Chang, has his first book out. In one poem, a line describes him, a Chinese American, hunting on Maui and makes a reference to Hemingway's Francis Macomber. It's the literary version of L'Uraku's ikura panna cotta. I feel like that will always be the base, with "disparate individual styles" arising out of that.
But, as you say, this HRC has become such an identifiable brand, a wave that I think Yamaguchi et al will ride until the bitter end. It may fall out of fashion, like Calvin Klein jeans. And magazines and newspapers will come up with another convenient term to group a small school of chefs together.
Posted 11 February 2004 - 01:59 PM
While I don't agree with declaring a school, who the practitioners are, etc, I think HRC served a purpose. But the flip side of the way they invented it and handled it is that now that it seems a bit tired and there are some connotations to the name HRC, the other chefs who would have taken up the torch don't identify with the name, and so it doesn't go on indefinitely - it becomes associated with a particular span of time.
I'm not a fan of labels, but labels serve a purpose. So if I was a chef trying to differentiate myself from HRC now, I'd have to invent my own term, like Contemporary Hawaiian Global Cuisine or New Hawaiian Cuisine or whatever. The problem with those is that there's a reference to time there as well. Perhaps something more poetic would be better - Trade Wind Cuisine or Volcano Cuisine.
For the sake of discussion, let's say that the vast majority of all ingredients and techniques are now global. Everything is available, just about everywhere. How do you make that work within a context? How do you make the globally influenced food from Hawaii taste and SEEM identifiably different from the globally influenced food of Australia or Spain or New York or Tokyo? Clearly, it's not just the names - calling something lau lau or loco moco is only a small part of it.
In terms of food, I think Hawai`i can legitimately be a player among food destinations, but it faces the same challenges of being at the highest level. Beyond being delicious and technically well prepared, the best food conveys a sense of place, shows a recognizable aesthetic, and is memorable.
The advantage Hawai`i has over some places is hospitality - the Aloha spirit. But that doesn't come across automatically - it has to be fostered and encouraged.
I guess what I'm getting at is have to put yourself in the mindset of creating an experience for your guests, with emotions and memories attached, not just tasty and pretty food. And if you're doing it for real, it shouldn't be done with declarations and press releases.
Posted 22 February 2004 - 03:24 AM
For the sake of discussion, let's say that the vast majority of all ingredients and techniques are now global. Everything is available, just about everywhere. How do you make that work within a context? How do you make the globally influenced food from Hawaii taste and SEEM identifiably different from the globally influenced food of Australia or Spain or New York or Tokyo? Clearly, it's not just the names - calling something lau lau or loco moco is only a small part of it.
In terms of food, I think Hawai`i can legitimately be a player among food destinations, but it faces the same challenges of being at the highest level. Beyond being delicious and technically well prepared, the best food conveys a sense of place, shows a recognizable aesthetic, and is memorable.
That's a good question, and one that is arguably harder to answer at the higher end of the restaurant scene.
Indeed, in your larger cities, there's really little attempt by high-end restauranters to clearly define a regional style. They can afford to be eclectic and idiosyncratic. That's why it's very difficult to identify a coherent "New York", "Paris", or "Tokyo" style of high-end restaurant cooking - styles are associated with specific chefs or restaurants rather than a geographical area.
On the other hand, being a smaller population center dependent on tourism, Hawai`i has to provide a clear identity in order to draw in customers who may very well be from New York, Paris, or Tokyo; or at least have regular access to such cities. The question for such customers is "Why should I spend $100 to eat in Hawai`i when I could save this money to eat anywhere I want in <big culinary captital X>?" The answer is not going be - "Because our choice is so much wider and our technique so much better", so it has to be "Because we can provide you with a distinctive dining experience that you can't get anywhere else".
And the simplest way to convince people of that is to mark out a clearly recognized, distinctive regional style of high-end cuisine. There's no strict requirement that such a distinctive cuisine have a strong relationship with the traditional foods of the region. Indeed many high-end regional styles, HRC being only one, tend to stretch the plausibility a bit on that and risk accusations of "inventing tradition". Nonetheless, it does help to create at least a putative connection, however, since the tourist/customer to some extent is likely to viewing his/her dining experience as a kind of cultural adventure.
And here's where things get very difficult, as you mention. Since traditional ingredients associated with nearly every traditional food culture are now available throughout the world, local chefs cannot rely on a monopoly on such ingredients as their means to creating a distinctive style. Hence, the solution is to define local high-end cuisine not so much in terms of ingredients but rather in terms of some sort of local culinary aesthetic, not so much as a fancification of local traditional cuisine but as an expression of where a combined aesthetic embodying our particular mix of cultures would take things given an expanding range of ingredients and techniques. Obvious, defining that aesthetic is very difficult - simply calling it "East-West" puts us in the some culinary bin with dozens of other destinations that are attempting to exploit a similar niche.
To me, the most notable attribute that we can exploit culturally, and also culinarily, is sheer intensity which which national styles and attitudes are pushed and kneaded together. There is nowhere else in the world with as much ethnic diversity in such a tiny land space, and with regards to food this means that it is very difficult to respect national boundaries. Hybrid dishes that take their inspiration from multiple parts of the Pacific are a common occurence in local popular cuisine, and the blending of traditional foods is so seamless that it is often difficult to guess the national origins such of dishes.
If we can harness this in some way into high-level cuisines, it could really set Hawai`i apart from the rest. IMHO, the main weakness of most East-West cooking, including HRC, is that cultural borrowings are too visible and blatant. "Eastern" and "Western" cuisines are not so much combined as juxtaposed, often by combining classic French cooking techniques with putatively local ingredients. A smooth integration of cuisines has yet to make place, and Hawai`i is as well-equipped as anywhere in the world to generate this integration.


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The Powder Horn Golf Club, Stag Course
- 23 Country Club Ln, Sheridan, WY 82801
- (307) 673-4800
- www.thepowderhorn.com
|27 total holes at facility
|Green fees - $39 to $98 (estimate)
|Designed by Dick Bailey
|Built in 1997
|Blue Grass
|Driving Range: Yes
|Public Community golf course
The Stag Course at The Powder Horn Golf Club is a 9-hole regulation length golf course in Sheridan, Wyoming. This medium-length layout provides for a fun golf experience for golfers of all skill levels. Difficulty level of the course is unknown at this time, but will be provided soon. There are 2 other courses at this same golf club, the Eagle Course, and the Mountain Course. Online tee times may be available at The Powder Horn Golf Club or at nearby golf courses, often at a substantial discount from the going green fees rate.
|Course Rating
|Back Tees
|Golf Pro: Mark Metzger
|Course Superintendent: Derek Lowe
|Manager: Dale Volker
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