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Several studies have been performed using ambulatory electrocardiogram (ECG) and blood pressure (BP) monitoring, comparing the heart rate, ECG, and BP response to sexual activity with other normal daily activities [1] The energy requirement during sexual intercourse is not excessive for couples in a longstanding relationship The average peak heart rate is 110 130 beats per minute and the peak systolic BP is 150 180 mmHg, resulting in a rate pressure product of 16,000 22,000 Expressed as a multiple of the metabolic equivalent (MET) of energy expenditure expanded in the resting state (MET = 1), sexual intercourse is associated with a work load of 2 3 METs before orgasm and 3 4 METs during orgasm Younger couples, who are not usually the individuals we advise, may be more vigorous in their

First, the network needs to protect itself Routing updates, keepalive messages, and critical network management information must get through Routing protocol time-outs are one set of limits Real-time voice and video applications begin to suffer when the end-to-end delay exceeds 150 to 200 ms Poor-quality conversations, reminiscent of CB radio, are still possible within 400 ms, and may be acceptable for some applications Delay of 200 to 400 ms will remove the nuances of emotion, but one rarely needs to give poetic directions to the warehouse on what part number to pull from the shelf People begin to notice delay at approximately 200 ms Fast typists who key 120 words per minute press a key approximately every 400 ms, so a delay of more than 600 ms would lose the illusion of local typing Delay limits for transaction processing are far more subtle Human factors studies on forms-oriented data entry have shown that productivity was not maximized by minimizing response time For reasons not immediately apparent, clerks doing insurance data entry with a forms-oriented mainframe application were most productive when response time was between 1 and 3 s The

activity, expending 5 6 METs The average duration of sexual intercourse is 5 15 minutes Therefore, sexual intercourse is not an extreme or sustained cardiovascular stress for patients in a longstanding relationship who are comfortable with each other Casual sexual intercourse, which must be separated from extramarital sexual intercourse with a longstanding other partner, may involve a greater cardiac workload because of lack of familiarity and age mismatch (usually an older man with a younger woman), with different activities and expectations [2] The incidence of ED increases with age as does the prevalence of coronary artery disease (CAD) [2,3] The heart rate response to exercise decreases with age and the presence of heart rate lowering antiischemic drugs such as the beta blockers The elderly remain sexually active with no evidence of increased cardiovascular risk from sexual activity or treatment with sildena l, providing the relationship is longstanding [38] While sildena l does not have any adverse effect on exercise-induced arrhythmias, cardiopulmonary responses during activity, or QT intervals on the ECG, by facilitating sexual activity sildena l may encourage elderly patients to seek a more challenging casual younger partner [30] Elevated catecholamine levels may result and adversely affect myocardial oxygen demand or overcome the protective action of beta blockers (which work on the basis of competition) and thereby increase the potential for an ischemic event By using our knowledge of MET equivalents in the clinical setting we can advise on sexual safety by comparing sexual intercourse to other activities Some of the daily activities and MET equivalents are shown in Table 281

3

Using a line of credit is another form of getting cash If you have a home, you can get a home equity loan Depending on the amount of the loan, if you provide the lender with an additional mortgage to provide security for the loan you will receive the very best rate maybe even the prime rate, or less than prime That is all negotiable Remember, if you don t ask, you won t receive! Depending on how many mortgages you already have on your home, the home equity loan would rank last in priority for example, it may be the third debt registered against the property, which would make it a third mortgage and rank it after the previous two mortgages in terms of priority for repayment from any sale of the property (should the sale of the property be required to satisfy your debts)