D. Grok. Menlo College.
By that time he had alienated a number of his supporters because of his emphasis on the role of sex in the origins of neurosis purchase 100mg modafinil visa. Emotional abuse may involve encouragement to develop inappropriate behaviour (ranging from drug abuse to sexual acts) purchase modafinil 100mg visa, preventing wider societal experience order cheap modafinil on line, non-inclusion in family activities, not providing emotional warmth, humiliation, intimidation, and exposure to violence, and generally poor parenting (unreliable, inconsistent, unpredictably changing rules, etc). If an adult discloses a history of childhood abuse the doctor must assess current risk to others and if someone is likely to be at risk the clinician should report the revelation, preferably with the patient’s consent. This author was well aware of such events at the rumour level when a schoolboy, but it was not something one confided to adults at the time. These Irish scandals are not unique and such abuse of power and cover up by society in general have an international dimension. He is better known for his writings on battered child syndrome (Tardieu’s syndrome). Incest is variously defined by statute as a specific 1981 sexual act performed between persons who are prohibited to marry. It should not be forgotten that sexual abuse can occur at any age, including in old age, and childhood abuse of any variety may predispose to abuse as an adult. Under the Punishment of Incest Act 1908 a male perpetrator of incest can receive a life sentence whereas a female perpetrator can only be gaoled for up to 7 years. Under the Irish Criminal Law (Sexual Offences) Act 2006 the age for consent for sex for males and females is set at 17 years. Anyone defiling a person under 15 years of age will receive a life sentence; those defiling someone aged 15-17 years will receive up to 5 years in prison, double that period if the perpetrator is a person in authority over the victim. Consent is not a defence where the victim is less than 15 years old, but an honest belief that the victim was over 17 years may be allowed as a defence in the case of older children. Father-daughter incest, the most frequently reported form, often starts when the girl begins to develop adult sexual characteristics. Killing of a baby within a day of birth may involve mothers from problematic homes who hide their pregnant state from others. Abduction of a child may reflect custody disputes, sex slave traffic, kidnapping (e. Casey and Craven (1999) wondered if boys were really abused less often than girls, and pondered about the possibility that abused females might simply be more likely to disclose the abuse. Many if not most adult child abusers may start abusing children when they themselves are still adolescents. The long-absent man returning to an unfamiliar and aging wife and a teenage daughter, the bereaved husband, the overcrowded home, the socially or geographically isolated family, the rejected spouse, and psychopathy, increase the chances of father-daughter incest. Incest families compared to non- incest families demonstrate a rigid internal belief system, a dysfunctional parental coalition, parental neglect and emotional unavailability, and an inability to nurture autonomy in its members. Brother-sister incest is often the result of poor adult supervision, although, in the authors’ experience, the parent(s) may also be involved, as may, rarely, children living in the neighbourhood. It should be noted in passing that 1985 about 10% of paedophiliacs are bisexual in orientation. In the authors’ experience, this fact has attracted varying judicial interpretations, varying from compassion to condemnation. The act: Sexually abusive behaviours include genital exposure, fondling, masturbation, fellatio, and cunnilingus, digital penetration of the anus or vagina, or penile penetration of the vagina. The average length of such a relationship in one Northern Ireland study was eight years. Psychoanalysts stress a potential need of the child to subconsciously view the abuser as good, allowing a turning to the perpetrator for relief of distress; also, the abuser may find it essential to be seen as good by the child victim rather than as a predatory seducer. The former were more likely to be abused by a female and a non-relative (female baby-sitters were alleged perpetrators in several cases) whilst those from two-parent families were more likely to be abused by a male and a relative. The child psychiatrist should approach the interview with an open mind and, if a family interview has been conducted, an interview with the child should be conducted on his/her own. The psychiatrist should steer a course between the extremes of overly leading questioning and, on the other hand, being insufficiently enabling for the reluctant child. Use of anatomically correct dolls requires special training, and video tape recording reduces the need for repeated interviews, although some children may find the latter inhibiting. Sequelae and adjustment: Abused females are at increased risk in adulthood for personality disorders (and 1988 earlier conduct disorder), anxiety (including panic: Goodwin ea, 2005) and depression (Kendler ea, 1989 1990 2004), self-harm , suicidal ideation, alcohol and/or substance abuse and dependence ,(Nelson ea, 2006) increased sensitivity to stressful life events,(Kendler ea, 2004) and frigidity or sexual aversion. One theory holds that women internalise their own abuse with resultant problems such as eating disorders, whereas men may externalise by abusing others. Non- forceful, non-intrusive, and rare or infrequent sexual contact, were the least likely to cause lasting harm. With more severe forms of sexual abuse, however, few women were able to avoid persistent ill effects. Those who experienced forceful, repeated, or prolonged abuse or severe physical violation, and especially those abused by much older men, especially at the hands of fathers or stepfathers, were very likely to report persistent sexual problems in adult life. Spataro ea (2004) conducted a prospective study of boys and girls to determine the subsequent levels of treatment by public mental health services for mental disorder. Victims of both sexes had higher rates of treatment than did general population controls (12. Abuse by fathers or stepfathers may have a more negative impact than abuse by other perpetrators. Only a small percentage of women subjected to severe abuse reported that these experiences had no lasting effects. Actual genital contact, especially if prolonged and penetrative, and the use of force seem more traumatic for the victim. When the families do not support the victim or if the victims were taken out of the home, the outlook may in fact be worse. Adult women sexually abused as children show increased rates of depression, self-destructive behavior, anxiety, low self-esteem, feelings of loneliness, drug abuse, and a tendency to re-victimisation. In one study, women who had been abused as children, when compared with controls, were more depressed, anxious, and fearful; fear and distrust of men, and difficulty with sexual functioning were the most common reported long-term difficulties. According to American follow-up research on abused children, data on whether they are removed from or returned to their parental is not often recorded. They may spend years in ‘temporary’ accommodation awaiting a judicial decision, and if they are offered up for adoption there are few families willing to accept them.
The ﬂuid can be either transudate in Lymphangitic carcinomatosis is seen with adeno- the initial phase with cardiac dysfunction or an carcinoma of the lung generic modafinil 200 mg amex, breast cheap 200 mg modafinil fast delivery, stomach buy generic modafinil pills, pancreas, exudate with vascular leak. A massive pleural effusion (occupying malignant pleural effusions, with lymphoma the entire hemithorax) is most commonly to representing approximately 10%. Bilateral malignant pleural effusions in lung cancer result from ipsi- effusions are most common with a nonlung pri- lateral tumor invasion into the pulmonary artery mary. The classic triad of lym- Malignant mesothelioma is the most common phangitic carcinoma is ipsilateral mediastinal primary malignant tumor of the pleura that arises adenopathy, Kerley B-lines, and a pleural from the mesothelial surfaces of the pleura. The latency period from asbestos expo- ogy, and poorer response to chemical pleurodesis sure to the development of mesothelioma varies than those with normal pH malignant pleural from 20 to 50 years. Immunohistochemistry has essen- advanced disease being associated with greater tially replaced electron microscopy as the gold sensitivities; therefore, the sensitivity of cytology standard for diagnosis. The most frequent presenting symptom is centesis for patients with far-advanced disease and nonpleuritic chest pain (60%) followed by dyspnea contralateral mediastinal shift is appropriate. Some patients are asymp- Chemical pleurodesis with talc poudrage or slurry tomatic at diagnosis with a unilateral pleural effu- for refractory effusions with dyspnea relieved by sion found on a routine chest radiograph. All patients with a suspected malignant effusion A small percentage of patients will show evidence should undergo pleural manometry to determine of asbestosis. In the later stages of disease, the whether the lung is completely expandable, mak- patient develops ipsilateral mediastinal shift ing the patient a candidate for pleurodesis. Other poor prognostic factors at the larger than if no radiographic infarct is present but time of diagnosis include thrombocytosis, leuko- its volume is still less than onethird of the hemi- cytosis, anemia, fever, sarcomatoid or mixed histol- thorax. There are some long-term survi- classic bloody, neutrophil-predominant exudate is vors after extrapleural pneumonectomy, when present in only approximately one third of patients. Immediate anticoagulation with heparin Pleural effusions occur in 40 to 50% of patients should be instituted when the diagnosis is highly with angiogram-documented pulmonary embo- likely or deﬁnitively established. A pleural effusion results from ischemia, effusion or minimal hemoptysis is not a contrain- leading to increased capillary permeability and the dication to anticoagulation. The of hemothorax developing during heparin therapy effusion can also be the result of atelectasis second- in the setting of a large hemorrhagic infarction. A large, hemorrhagic pulmonary speciﬁc treatment is required for the pleural effu- infarction can rarely result in a hemothorax in a sion of pulmonary embolism. Patients with a radiographic infarction and a larger Ipsilateral pleuritic chest pain, acute onset of dys- pleural effusion usually require 14 to 21 days for pnea, tachypnea, and tachycardia are the typical resolution. These effusions Tests Sensitivity, % develop when a subpleural focus of tuberculosis ruptures into the pleural space followed by a cell- Percutaneous pleural biopsy mediated immune response to the tuberculous Histology 63–85 antigens. The major drainage, bowel rest, and hyperalimentation; how- symptom with a chronic pancreatic effusion is ever, conservative therapy is only successful in 50% dyspnea attributable to the large pleural effusion; of patients. In those with refractory chronic pan- chest discomfort and cough are typical in these creatic effusions, percutaneous catheter drainage patients who do not have abdominal symptoms of somatostatin, the pseudocyst, or surgery are but have a long history of alcohol abuse. In the set- in approximately 5% of patients; however, at ting of a chronic pancreatic effusion, the effusion autopsy, 50% of patients will have pleural ﬁbrosis is large or massive in size and typically unilateral or an effusion (Table 13). Small ﬁbrous plaques, ally recurs rapidly after thoracentesis because the rheumatoid nodules, or extensive fibrosis can ﬂuid is rapidly generated from the pseudocyst involve the visceral pleura. Tests Useful in the Differential Diagnosis of Amylase-Rich Pleural Effusions Tests Acute Pancreatitis Chronic Pancreatic Effusion Esophageal Rupture Malignancy Pleural ﬂuid amylase Moderate Extremely elevated Minimal Minimal concentration Pleural ﬂuid /serum amylase 10:1 20:1 (mean 63,000) 5:1 3:1 Pleural ﬂuid amylase Pancreatic Pancreatic Salivary Salivary isoenzyme Pleural ﬂuid pH 7. Causes of Amylase-Rich Pleural Effusions Diagnosis Type of Amylase Isoenzyme Pancreatitis, pancreaticopleural ﬁstula Pancreatic Carcinoma of the lung (usually adenocarcinoma) Salivary (most common cause of salivary amylase-rich effusion) Adenocarcinoma of ovary Salivary Lymphoma Macroamylase/salivary Esophageal rupture Salivary Chronic lymphatic leukemia Salivary Pneumonia Salivary Ruptured ectopic pregnancy Probably salivary chest pain and dyspnea or may be asymptomatic, appearance suggests that the patient has long- usually without fever. The chest radiograph typically shows a if there is an unexpandable lung without active small-to-moderate unilateral effusion with a nor- disease, up to 15,000 mostly neutrophils/ L in mal cardiac silhouette. However, in one third of acute rheumatoid pleurisy or with a cholesterol patients, another manifestation of rheumatoid lung effusion with chronic inflammation. There are anecdotal tomatic with pleuritic chest pain (86 to 100%), reports of responses to corticosteroids; however, pleural rub (71%), cough (65%), dyspnea (50%), the course is variable, and it is uncommon for the and fever. Pleural thickening may be a residual in sions; however, unilateral massive pleural effu- some patients evolving into a trapped lung that sions have been reported. In refractory cases, Patients usually require antiinflammatory immunosuppressive agents, such as azathioprine, therapy for relief of symptoms, including predni- added to corticosteroids are sometimes but not sone in some cases. However, persistent pleuritic pain corticosteroids because their withdrawal often appears to be an adverse prognostic marker with results in recurrence. The chest radio- elevated left hemidiaphragm in the early postop- graph is abnormal in 95% of patients, with pleural erative period associated with phrenic nerve injury. A trapped lung may develop after 6 increased cardiac silhouette, most likely from a months and typically is a small, unilateral effusion pericardial effusion. In contrast, medium-chain triglycerides (con- Lymphocytic effusion of taining 12 carbon units) are directly absorbed uncertain origin into the portal vein without entering intestinal Constrictive pericarditis lymphatics. Approximately 60% of the dietary fat Lung entrapment enters the lymphatics, and 1,500 to 2,500 mL of Persistent ( 6 mo) Trapped lung chyle travels daily through these vessels. If the mediastinal pleura remain intact, node hyperplasia), sarcoidosis, Kaposi sarcoma, chyle ﬁlls the mediastinum and forms a “chyloma” yellow nail syndrome, Noonan syndrome, multiple over the next several days before rupturing into myeloma, Waldenström macroglobulinemia after the pleural space, usually on the right at the base thoracic radiation, and goiter. The thoracic duct, Patients with chylothorax present with sub- which has its origin in the cisterna chyli, is situated acute or insidious onset of dyspnea. The thoracic duct travels through tion, a number of chylothoraces are termed idio- the aortic hiatus of the diaphragm approximately pathic; these are most likely caused by innocuous at the level of the tenth to twelfth thoracic vertebrae hyperextension of the spine or an occult malig- to the right of the aorta. Patients with chylothorax are usually not to sixth thoracic vertebrae, the duct enters the left febrile and do not have chest pain because chyle posterior mediastinum and eventually joins the does not tend to invoke an inﬂammatory response. Sputum triglyceride concentrations have below T5 to T6 causes a right-sided chylothorax, been reported to range from 662 to 2,600 mg/dL, whereas injury to the duct above this level re- which is greater than concurrent serum values. Second, pro- opalescent if fat is present; however, the ﬂuid can longed drainage of a chylothorax should be be clear and yellow in the adult who has not eaten avoided to prevent immunosuppression and mal- for 12 h or hemorrhagic if there is concomitant nutrition. The primary cells in chyle bowel rest, and parenteral nutrition to minimize are T lymphocytes, which typically represent 80% the ﬂow of chyle and maintenance of ﬂuid and of the cellular population. If In contrast to a cholesterol pleural effusion, the drainage is persistent after 2 weeks, 1,500 mL for cholesterol levels in chyle are substantially lower 5 days, or if the patient develops signiﬁcant weight and range from 65 to 220 mg/dL. Conversely, if the There are recent reports of percutaneous catheter- triglyceride level is 50 mg/dL, it is highly ization and embolization of the thoracic duct in unlikely that a chylothorax is present. If have been reported to decrease chyle production chylomicrons are present, the diagnosis is estab- in postoperative chylothorax in small case lished deﬁnitively. There are studies recurrences were ipsilateral (71%) and contralateral that have evaluated the outcomes of lung trans- (74%), occurring at an average of 21. Thirteen (38%) of Foundation study identiﬁed 8 (4%) of 193 patients 34 patients had previous pleurectomy or pleurode- who developed bilateral simultaneous pneumo- sis.
Recovery management and recovery-oriented systems of care: Scientific rationale and promising practices order 200 mg modafinil with mastercard. Addiction as a chronic disorder: Key messages for clients purchase modafinil on line amex, families and referral sources discount 100 mg modafinil mastercard. The varieties of recovery experience: A primer for addiction treatment professionals and recovery advocates. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: A summary of the evidence for the U. Comparison of acamprosate and placebo in long-term treatment of alcohol dependence. The effect of substance abuse treatment on Medicaid expenditures among general assistance welfare clients in Washington state. Work stress, substance use, and depression among young adult workers: An examination of main and moderator effect model. Further evidence of an association between adolescent bipolar disorder with smoking and substance use disorders: A controlled study. New research is redefining alcohol disorders: Does the treatment field have the courage to change? Preparing pharmacy students and pharmacists to provide tobacco cessation counseling. Family risk factors and adolescent substance use: Moderation effects for temperament dimensions. Behavioral and emotional self-control: Relations to substance use in samples of middle and high school students. Depressive symptoms and cigarette smoking among middle adolescents: Prospective associations and intrapersonal and interpersonal influences. Adolescent temperament and lifetime psychiatric and substance abuse disorders assessed in young adulthood. Assertive community treatment for patients with chronic and severe mental illness who abuse drugs. Motivational enhancement therapy to improve treatment utilization and outcome in pregnant substance users. Behavioral couples therapy for female substance-abusing patients: Effects on substance use and relationship adjustment. Treating adolescents with substance use disorders: An overview of practice issues and treatment outcome. Simple screening instruments for outreach for alcohol and other drug abuse and infectious diseases. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Childhood sleep problems, early onset of substance use and behavioral problems in adolescence. Extended vs short-term buprenorphine-naloxone for treatment of opioid-addicted youth: A randomized trial. Self-help organizations for alcohol and drug problems: Towards evidence-based practice and policy. Service utilization during and after outpatient treatment for comorbid substance use disorder and depression. Treatment use and barriers among adolescents with prescription opioid use disorders. The multidimensional structure of internal barriers to substance abuse treatment and its invariance across gender, ethnicity, and age. Encouraging physicians to screen for and intervene in substance use disorders: Obstacles and strategies for change. A comprehensive review of the psychometric properties of the Drug Abuse Screening Test. Search for genetic markers and functional variants involved in the development of opiate and cocaine addiction and treatment. Dietary choices and likelihood of abstinence among alcoholic patients in an outpatient clinic. Determinants of alcohol use and abuse: Impact of quantity and frequency of patterns on liver disease. Brief assessment oral health screening increase smokeless tobacco user enrollment. Improving the care of individuals with schizophrenia and substance use disorders: Consensus recommendations. Tobacco use and cessation in psychiatric disorders: National Institute of Mental Health report. Mental health professionals with a specialty in anxiety disorders: Knowledge, training, and perceived competence in smoking cessation practices. As an energy source, fat contains over twice the energy per gram as does carbohydrate. Carbohydrates (in the form of glucose) are typically used to provide rapid energy, while fat is burned during sustained exercise. Fat is the primary fuel of choice during slow aerobic exercise, while glucose is used during fast aerobic or anaerobic exercise. Lipids include fats and oils; oils tend to be liquid at room temperature, fats tend to be solid. A fat molecule consists of one molecule of glycerol, bonded by dehydration synthesis (the loss of water) to three fatty acid molecules (this is a triacylglycerol, Figure 1. In a phospholipid molecule, one fatty acid is replaced with a phosphate group, to which is attached (X) a nitrogen-containing molecule, for example choline, ethanolamine, serine or inositol (giving the phospholipid phosphatidylcholine, phos- phatidylethanolamine, phosphatidylserine or phosphatidylinositol, respectively). The amphipathic phospholipid molecule contains a polar head group and non-polar tail; this is crucial to the ability of such molecules to self assemble in water to form lipid membranes. Consisting of a polar (charged) head group and a pair of non-polar fatty acid tails, they are amphipathic molecules (Figure 1. Lipids may be saturated or unsaturated (or polyunsaturated), depending on whether their fatty acids contain carbon–carbon double bonds (Figure 1.
Because of the rapid spread 33 of bacteria and molds modafinil 200mg without prescription, teas prepared by maceration may be briefly boiled 34 before consumption buy modafinil in india, though the use of sanitary utensils and refrigeration 35 of the tea mixture for up to 3 days in the refrigerator makes this mostly un- 36 necessary generic 200 mg modafinil amex. Half the required amount of water is poured onto the full dose of the tea 43 mixture, which is then left to steep for 5 to 8 hours and finally strained. The 44 other half of the water is later boiled and poured onto the herbs caught in 45 the tea strainer, then added to the cold extract. Use only as much sweetener for these herbs as is necessary to take 3 them regularly, because tasting the bitter enhances the therapeutic action. The 14 specific instructions for use of a given product are found on the product label. The patient 16 or guardian should always read the product label and, if uncertain, ask a phar- 17 macist or herbalist. Afterwards, the pa- 21 tient should discontinue the tea for 4 weeks or switch to another tea with 22 similar effects. Many “tonic” teas recommended by a licensed tradition- 25 al Chinese medicine practitioner are taken for several months or more, 26 depending on the patient’s response, although the formula is often 27 changed regularly. Applying herbs or herbal teas externally in this way is safe when a few 5 cautions are observed. Local anti-inflammatory effects and stimulation of cir- 6 culation and enhanced tissue repair can be expected because of constituents 7 such as the gingerols from ginger, which are absorbed transdermally. The prepared herbs are placed in the innermost cloth, which 10 serves as the carrier. When using fomentations, poultices, and compresses, the 11 cloth bearing the herbal preparation is placed in direct contact with the affect- 12 ed body part. When the preparation is in place, the patient should be allowed to 43 rest without unnecessary distractions. It is also important to monitor each patient in accord- 47 ance with their age, general health condition, and body temperature. Special attention should be paid to keeping the feet warm 2 (place a hot water bottle under the feet, if necessary). The amount of time the wrap should be left on depends on the type 7 of wrap used (see Section Four, p. This can be prevented by rinsing the feet with lukewarm water after the 31 footbath. Herbal tea infusions, essential oils, or salt-water solu- 45 tions can constitute the herbal additive. The hair should be covered with a towel to ensure that the vapors 49 are trapped between the head and the vessel. If essential oils are used, it is important to add 10 a natural emulsifying agent such as milk, cream, or honey. This 19 procedure stimulates receptors in the hair bulbs and increases central 20 lymph and blood volume, both generating a slight arousal reaction. For gastro- 31 intestinal complaints: 1 tablespoon daily (adults), 1 teaspoon in bottle 32 (infants). Health hazards in conjunction with proper administra- 37 tion of the designated therapeutic doses of the drug are not known. Topical arnica has antiphlogistic, analgesic, 17 and antiseptic action (due to the sesquiterpene lactones). Concentrated tincture can cause irritation 42 of the gastrointestinal mucosa accompanied by nausea, vomiting, diarrhea 43 and bleeding, and in high enough doses can lead to respiratory stimulation, 44 paralysis of the heart, and death. Frequent use of the 47 undiluted tincture can lead to sensitization (allergic skin rashes, itching, blis- 48 tering, ulcers/superficial gangrene). The external application of very high con- 49 centrations of the drug can cause primary toxic blister formation and necrosis. Biol Chem, 378(1997), 951–961; Willuhn G, Leven 16 W: Qualität von Arnikazubereitungen. The herb was shown to reduce cho- 32 lesterol levels in rats (luteolin inhibits cholesterol synthesis), as well as to 33 increase choleresis and reduce symptoms of dyspepsia, compared with 34 controls, in randomized double-blind studies with healthy human volun- 35 teers. In a small trial (n = 44), artichoke extract reduced total cholesterol in 36 volunteers with baseline values above 220 mg/dL, compared with controls. Atherosclerosis 129 (1997), 147; Fintelmann V: 9 Antidyspeptische und lipidsenkende Wirkung von Artischockenblätterex- 10 trakt. Toxicol Appl Pharmacol, 144(1997), 279–286; Wasielewski 14 S: Artischockenblätterextrakt: Prävention der Arteriosklerose. The herb consists of the dried pri- 20 mary roots (tap roots), secondary roots, and hair roots of four- to seven- 21 year-old Panax ginseng C. Stress models demonstrated that Asian ginseng increased the ani- 28 mals’ ability to cope with psychological and physical pressure. In addition, 29 ginseng increases, shortens the recovery phase, and enhances coordination 30 and memory in humans. If only larger root pieces and whole roots are available, 42 the patient should crush or cut the roots into coarse pieces before use; pre- 43 crushed roots may also be available. For a usual 5 : 1 extract, the dose would be 45 about 1 g, equivalent to 2 “0” caps or usually 2 tablets/day. Standardized 46 extract (5–10% ginsenosides, typically 200 mg per unit); 1–2 capsules or 47 tablets twice daily. Treatment should be 48 continued for 3 months followed by a break, after which treatment can be 49 re-initiated. Use of teas from whole roots chopped or ground at home 7 are acceptable; other use should be restricted to standardized preparations. Deutsche Apotheker Ztg 135 (1995), 2136–2138; 13 Pfister-Hotz G: Phytotherapie in der Geriatrie. Ex- 40 pressed orange oil also contains lipophilic flavonoids and furanocoumarins. They stimulate phagocytosis and have hemolytic, cyto- 28 toxic, antiviral, anticholinergic, and local anesthetic effects. The constituent 29 solasodine has a cortisone-like effect in individuals with rheumatic poly- 30 arthritis and Bekhterev’s arthritis, and it has a desensitizing effect. Toxic effects are not to be expected when doses less than approximately 43 25 g per day are used. Unstandard- 9 ized liquid and standardized powdered extracts in capsules and tablets are 10 widely available. The phytoestrogens in the rhizome ofAc- 16 taea racemosa bind to the estrogen receptors, and have selective estrogen 17 receptor modulator properties.