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By I. Gancka. University of La Vernee. 2018.

There were cheap 100mcg ventolin with mastercard asthma symptoms hoarse voice, moreover discount ventolin 100mcg free shipping asthma nclex questions, as we shall see in more detail later, some women in Salerno who likewise engaged in medical practice; these women apparently could not avail themselves of the same educational privi- leges as men and are unlikely to have been ‘‘professionalized’’ in the same way as their male counterparts. There was, in any case, no regulation of medical practice in this period (licensing was still a thing of the future),59 so to that degree the ‘‘medical marketplace’’ was open. The context in which the three Salernitan texts on women’s medicine came into being thus was quite expansive and open to a variety of influences and practices. These texts share to varying degrees the characteristics of ‘‘main- stream’’ Salernitan medical writings, Conditions of Women with its attempts to assimilate Arabic medicine, Treatments for Women with its collection of tra- ditional local practices. Women’s Cosmetics is most interesting as an example of how traditional empirical practices could be adopted by learned physicians and deployed as another strategy in re-creating the ideal of the ancient city physician whose success lay largely in the reputation he was able to cultivate. Clearly, women were among the patients whose patronage these practitioners wanted to earn. The Lombard princess Sichelgaita seems to have had her own personal physician, Peter Borda, in the s,60 and there is ample evidence that women regularly figured in the clientele of male practitioners. Neverthe- less, as was noted above, gynecology and obstetrics were areas of medical prac- tice that saw relatively little innovation by male medical writers. Male physi- cians clearly diagnosed and prescribed for gynecological conditions, and they  Introduction recommended a wide variety of potions and herbs for difficult birth. But it is doubtful that they ever directly touched the genitalia of their female patients. This limitation of male gynecological and obstetrical practice left room for the existence of female practitioners whose access to the female body was less restricted. As we have seen, women had no higher social position here and they may well have been less literate than women in neighboring areas. Few specialized texts on women’s medicine existed in Arabic, and nonewere translated by Constantine. The larger intellectual currents of Salernitan medicine—the concern to system- atically analyze and explain, the eagerness to incorporate new pharmaceutical products, and, most important, the desire to capture all this new knowledge in writing—provided the spark that would make Salernitan women’s medicine different from anything that had gone before it. Women’s Medicine P-S G Had it been possible to draw up an inventory of European medical writings on women in the third quarter of the eleventh century, that list would have included at least two dozen different texts. But such an inventory would be insufficient to assess the varying im- Introduction  portance of these texts, for even though copies might be found in this library or that, an individual text’s usefulness may have been minimal, either because its Latin (often interlarded with Greek terminology) had been corrupted over the course of several centuries of copying or because its theoretical precepts were no longer adhered to or even understood. The gynecological literature in western Europe prior to the late eleventh century represented two ancient medical traditions. First was the Hippocratic tradition, embodied in a corpus of anonymous Greek writings composed be- tween the fifth and fourth centuries . The gynecologi- cal materials of the Hippocratic Corpus constituted as much as one-fifth of that vast collection of writings. The abbreviated translation of Diseases of Women  laid out the basic physiology of women (especially as it related to pregnancy), then moved on to alterations of the womb, impedi- ments to conception, disorders of gestation, causes of miscarriage, difficulties of birth, and subsequent problems. The longer version, called by its modern editor On the Diverse Afflictions of Women, addresses questions of etiology, diagnosis, and prognosis, as well as the more routine matters of basic pathology and ther- apy in its ninety-one subheadings. Three other texts (Book on the Afflictions of Women, Book on the Female Affliction, and Book on Womanly Matters) also derive from Diseases of Women ; these are fairly brief and often redundant recipe col- lections rather than organized medical treatises. Just as influential in dissemi- nating Hippocratic views of the female body were the Aphorisms, a collection of pithy verities about the nature of the physician’s craft, the symptoms of dis- ease, prognostic signs, and so forth. The fifth (or in some versions the sixth) of the seven sections of the Aphorisms was devoted primarily to women and their diseases; it was on occasion accompanied by an extensive commentary. Here, a reader would find such statements as ‘‘If the menses are deficient, it is a good thing when blood flows from the nostrils,’’ or ‘‘If in a woman who is pregnant the breast suddenly dries up, she will abort. Soranus of Ephesus, a Greek physician from Asia Minor who practiced in Rome in the late first and early second century . All the physician needed to know was that therewere three basic states of the human body: the lax, the con- stricted, and a combination of the two. Upon diagnosing which of the three states was manifest in any given case, the physician’s therapeutic response was to treat by opposites: to relax the constricted, constrict the lax, and do both in mixed cases, treating the more severe symptoms first. Soranus’s views of female physiology and pathology in particular seem to have been novel. He argued, for example, that menstruation, sexual activity, and pregnancy were harmful to women, in contrast to the Hippocratic tradition, which asserted (as we shall see in more detail later) that these three processes were not only salubrious but actually vital to women’s health. Soranus’s Greek Gynecology was adapted into Latin several times in the late antique period, in every instance (though to varying degrees) being stripped of its more theoretical elements. The most influential of these Latin Soranian texts was the Gynecology of Muscio, who had deliberately abbreviated and sim- plified his translation of Soranus (using, he says, ‘‘women’s words’’) so that he would not overburden the allegedly weaker minds of midwives, to whom the work was addressed.

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If steroids are r Babies develop eczema predominantly on the face and appliedunderwetwrapsthedose/potencymustbede- head buy ventolin 100 mcg fast delivery asthma treatment in toddlers; this may resolve or progress by 18 months to the creased as increased absorption may result in systemic childhood/adult pattern 100 mcg ventolin sale asthma symptoms night. Complications r Topical tacrolimus, an immunosuppressant, is being Staphylococcus aureus is found on the skin of 90%, which increasingly used in children prior to the use of high- may result in acute infection (impetigenised eczema). Itappearssafeandeffective;however, Primary infection with herpes simplex may give a very the long-term risks are unknown, as it is a relatively severe reaction known as eczema herpeticum, which in new preparation. Pimecrolimus is under study as a the young may cause dehydration and is life-threatening. Prognosis Eczemahasafluctuatingcoursewithapproximately50% Management resolving by 18 months, and few have problems beyond There is no curative treatment. In ba- bies it may be appropriate to either test for cow’s milk allergy or to perform a therapeutic trial with a cow’s Contact dermatitis milk protein free formula. Definition r Generalised dry skin (xerosis) requires regular fre- Contact dermatitis is an allergic or irritant-induced der- quent use of emollient moisturisers especially af- matitis arising from direct skin exposure to a substance. Cream preparations are water based with emulsifiers and preservatives and they tend Age todrytheskin. A balance has to be struck between application of sufficient grease and cosmetic satisfaction. Geography The lowest potency that is effective should be used Exposure is most common in the home or industrially and higher potency reserved for resistant cases. Chapter 9: Scaly lesions 387 Aetiology/pathophysiology commonest areas affected are the eyebrows and around r Irritant contact dermatitis (80%) is caused by over- the eyes extending into the scalp. In babies a Oncetheepidermalbarrierisdamagedasecondaryin- widespread lesion of the scalp (cradle cap) is seen, and flammatory response occurs. Psoriasis Definition Clinical features Psoriasisisachronic,non-infectious,inflammatorycon- Contact dermatitis often affects the hands or face. Le- dition of the skin, characterised by well-demarcated ery- sions may also affect the legs of patients with chronic thematous patches and silvery scaly plaques. Management Age The allergens can be identified by patch testing (see page Peak of onset in teens and early 20s and late onset 55–60 467) and avoided. Seborrhoeic The aetiology is not fully understood but genetic en- dermatitis is a chronic scaly inflammatory eruption af- vironmental and immunological components are sug- fecting areas rich in sebaceous glands. There is concor- rum ovale,ayeast that colonises the skin of patients with dance in monozygotic twins and a suggestion of genes seborrhoeic dermatitis; however, it is unclear if this is the located within the major histocompatibility complex cause or effect of the condition. The lesions appear pinkish due to mild erythema and r There is a suggestion of environmental components. The Group A streptococcal sore throat can lead to guttate 388 Chapter 9: Dermatology and soft tissues psoriasis, psoriatic lesions occur at sites of trauma a thin or absent granular layer. Dilated capillaries are and damage (the Koebner phenomenon) and certain¨ seen in the oedematous papillary dermis. Management Psoriasis is a chronic disorder that is managed rather Pathophysiology than cured. Treatments are chosen on the basis of dis- The epidermis is thickened with increased epidermal ease pattern and severity, patient preference and clinical stem cells and keratinocytes. There is a thick silvery scale, which when lifted off char- is a risk of rebound psoriasis on stopping treatment. These treatments are tiple small psoriatic lesions on the trunk often in a expensive and increase the risk of skin cancer. An al- child or young adult with no previous history of pso- ternative may be the use of a high-energy laser that riasis. There is acute onset of diffuse retinoids all of which have systemic toxicity requiring erythema and scaling with sheets of superficial non- monitoring. If the entire skin is affected, it is termed erythrodermic (the von Zumbusch variant). Prognosis This may be associated with systemic upset (malaise, Psoriasis is a lifelong disease with variability in severity fever, diarrhoea) and is potentially life-threatening. Localised forms of pustular psoriasis also occur, such as palmoplantar pustulosis.

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Recent studies have examined the issue of lifetime cumulative effective doses received by patients attending hospital with gastrointestinal disorders and have shown potential for substantial radiation exposures from gastrointestinal imaging effective ventolin 100 mcg asthma treatment 1 year old, especially in small groups of patients with chronic gastrointestinal disorders such as Crohn’s disease cheap ventolin 100mcg with mastercard asthma definition eloquent. In these patients, radiation dose optimization is necessary and should follow the principles of justification, optimization and limitation. Currently, there are increasing numbers of medical specialists using fluoroscopy outside imaging departments and the use of fluoroscopy is currently greater than at any time in the past. This is partly explained by lack of education and training in radiation protection in this setting, and can result in increased radiation risk to patients and staff. Radiation protection and fluoroscopy facilities separate from radiology departments The extent of the problem with radiation protection in endoscopy suites can vary greatly from one jurisdiction to another [1, 2]. In some countries, there is no database of fluoroscopic equipment located outside radiology departments. As a result, staff in endoscopy suites need enhanced radiation protection education and need to routinely utilize radiation protection tools (e. There is huge variation, between institutions and between countries, in the level of involvement of radiologists and medical physicists in radiation protection for endoscopic procedures. Potential risk areas In some hospitals and in some jurisdictions, there may be a lack of radiation protection culture, with a paucity of patient and staff dose monitoring [1, 2]. There may be poor quality control of fluoroscopic equipment with risk for incidental accidental high exposures or routine overexposures affecting patients and staff. Poor radiation shielding, including lead flaps and poor maintenance of radiation protection equipment, can also be associated with additional risks. Radiation dose to patients in endoscopic procedures Shielding systems to protect staff should be optimized to reduce dose, but must not interfere with performance of clinical tasks. Scheduled periodic testing of fluoroscopic equipment can provide confidence in equipment safety [1, 2]. Equipment factors — Under-couch tubes reduce scattered radiation and exposure to operators, staff and patients. Image hold and image capture options also represent very important features of modern fluoroscopy which can reduce dose and should be used where feasible. Procedure related factors There are many important steps which can be taken to reduce radiation exposure, including the careful use of collimation to reduce area of exposure, limiting the number of radiographic images, using magnification only when really necessary and avoiding steep angulations of the X ray tube [1, 2]. The X ray tube should be as far as possible and image receptor as close as possible to the patient. In addition, the radiation field should be limited carefully to the parts of the body being investigated. Staff doses at endoscopic retrograde cholangiopancreatography Average effective doses of 2–70 μSv per procedure have been reported for endoscopists wearing a lead apron [1, 2]. Lead aprons provide protection; however, there can be substantial doses to unshielded parts such as the fingers and eyes. Use of ceiling mounted shielding, and lead rubber flaps mounted on pedestals that are mobile, should be mandatory and staff should be educated in how to use them effectively. Procedures performed by highly experienced and trained staff usually result in much lower patient and staff exposures — every 10 years of experience has been reported to be associated with 20% reduced fluoroscopy time. There has been continued high utilization of plain radiographs, in spite of the fact that other studies have questioned the diagnostic value of these studies and their ability to influence patient management [3]. Small groups of patients (and especially subgroups of Crohn’s patients) can be exposed to substantial cumulative effective doses of ionizing radiation [3]. In addition, limiting the use of plain abdominal radiography in Crohn’s disease and other chronic gastrointestinal disorders should be considered, as performance of these studies usually has little impact on patient management. There is, therefore, a fine balance between reducing radiation exposure and maintaining sufficient image quality to ensure accurate detection of pathology. Each of these systems has different specifications and operates somewhat differently. Iterative reconstruction is a method which models photon statistics and, thus, extracts noise in the final image. Patient dose tracking Radiation dose tracking is a new development, which has recently been made available by the industry [14].

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But if it has been made without the juice of opium poppy and you wish to make a laxative buy 100 mcg ventolin amex asthmatic bronchitis 8 month, give two drams with two scruples of Levant scam- mony made into pills cheap ventolin 100 mcg free shipping asthma pregnancy. It purges the head and stomach of phlegm and foulness, and it takes away heaviness of the eyes. The fourth part is one pound because in each dose they put a pound and half of skimmed honey. Take eleven drams and fifteen grains of aloe; four and a half drams each of saffron, costmary, mark- ing nut, agaric, coral, myrrh, ammoniacum, turpentine, galbanum, serapinum gum, opoponax, confected cleavers, calamite storax, and Florentine iris; two drams and fifteen grains each of juice of opium poppy, frankincense, mastic  Appendix gum, bdellium, and cozumbrum; one dram and a half each of balsam and cloves; [and] two drams of balm. Take the gums—galbanum, serapinum gum, ammoniacum, and opoponax—and grind them a little bit, and let them be placed in white and moderately sweet-smelling wine for one night. Afterward, add four ounces of skimmed honey and let them continue to boil until they begin to thicken. Then, having ground thoroughly the cala- mite storax, confected cleavers, and cozumbrum with a hot pestle, let them be placed in a cauldron, stirring constantly with a spatula until they liquefy. And if you wish to test whether it is cooked, place a little bit on some marble, and if it immediately congeals into the consistency of honey, [then it is cooked]. A little later, the cauldron having been placed on the ground, let the myrrh, together with the bdellium, be added. Then the costmary, marking nut, agaric, coral, Florentine iris, juice of opium poppy, cloves, and balm. Having ground all these together and pulverized them, let them be placed in the cauldron. Then spread this whole mixture onto a slab of marble that has first been covered with oil of laurel. And let this be softened with the powder of aloe, while the saffron is ground with the spices. Populeon (¶): Unguentum populeon is so called because it is made from poplar buds [oculus populi]. It is good against the heat of an acute fever and for those who are unable to sleep if it is anointed on the temples and the pulse points and the palms of the hands and soles of the feet. This same unguent, when mixed with oil of roses or violets and anointed above the kidney, takes the heat away marvelously; when anointed on the abdomen, it provokes sweat- ing. Take one and a half pounds of poplar buds; three ounces each of red poppy, leaves of mandrake, the tips of the most delicate leaves of bramble, henbane, black nightshade, common stonecrop, lettuce, houseleek, burdock, violet, and scantuncelus (i. On the third day, gatherall the above- mentioned herbs and let them be ground well by themselves. Afterward, let the lozenges be put piece by piece in a cauldron with one pound of excellent,odoriferous wine. Afterward, Compound Medicines in the Trotula Ensemble  having squeezed it all out in a sack, drain [the mixture] well. Potio Sancti Pauli (¶): Potio Sancti Pauli is called potio from potando [drink- ing], sancti Pauli because Saint Paul created it. This is the same potion which the Romans called potio maior, because Paul the Great modified it. Properly it is given to epileptics, cataleptics, analeptics, and those suffering in the stom- ach; it is given with wine in which incense or mixed peony has been cooked. This potion is given with Esdra11 in the wintertime and in the springtime to those suffering from quartan fever. It cures when given before the hour of crisis with wine in which felwort or golden gorse and castoreum have been cooked. It likewise heals those suffering from diseases of the windpipe and paralytics when given with wine in which sage or castoreum has been cooked. Take three drams and one scruple of natron; one dram and one scruple each of castoreum, antimony, houseleek, cloves, laurel berry, willow, wild celery, parsley, fennel, wild carrot, and stavesacre; three scruples each of sweet flag, myrobalans, licorice, vitriol, peony, and pellitory; one scruple and eighteen grains of costmary, colocynth, agaric, mastic, both long and round aristolochia, roses, juice of wild cabbage, hazelwort, wood sage, cuckoopint, dittany, basil, bear’s breech, horsemint, oregano, penny- royal, wall germander or hyssop, savory, white pepper and black pepper and long pepper, and rue seed; one scruple and four grains each of watercress and frankincense; one scruple each of balsam, spikenard, saffron, camel grass, Chi- nese cinnamon, myrrh, opoponax, sulfur, mandrake, felwort, malt, spurge, poppy, and cormorant blood; one scruple minus four grains each of cinnamon, cloves, ginger, marking nut, bark of the balsam tree, rhubarb, hog’s fennel, fruit of the balsam tree, calamite storax, serapinum gum, hazelwort, dragon’s blood, hare’s rennet, sheep’s and goat’s and veal rennet, bear’s gall, goose blood, and petroleum; seven drams and four grains of cowslip; and honey as needed. This is given in the evening, in the amount of a hazelnut, or with the above- mentioned decoctions, to those suffering from diseases of the head.

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For example purchase 100 mcg ventolin visa asthma symptoms lungs, eating a breakfast supplemented with 29 g of sugar beet fiber resulted in 14 per- cent less energy consumption at the subsequent lunch (Burley et al trusted 100 mcg ventolin asthma symptoms after endoscopy. In contrast, other investigators have failed to demonstrate any postingestive effect of fiber on food intake (Delargy et al. One study found that there was no difference between a high fiber and a low fiber diet on later food intake if the energy content of the initial diets was similar (Delargy et al. These authors used 20 g of Dietary Fiber for their test breakfast meal, which is much lower than the 29 g used by Burley and coworkers (1993). Similar findings of no effect of a test meal on appe- tite throughout the day have been found for substituting resistant starch for digestible starch (Raben et al. In addition, much of the data on chitin and chitosan in promoting weight loss have been negative (see earlier section, “Physiological Effects of Isolated and Synthetic Fibers”). Efforts to show that eating specific fibers increases satiety and thus results in a decreased food intake have been inconclusive. In terms of the attribute of fiber that may result in decreased food intake, some have suggested that viscosity is important as it delays gastric empty- ing and may lead to feeling more full for a longer period of time. For humans, there is no over- whelming evidence that Dietary Fiber has an effect on satiety or weight main- tenance, therefore this endpoint is not used to set a recommended intake level. Those with energy intakes significantly above or below the refer- ence intakes for their age and gender may want to consider adjusting their total fiber intake accordingly. Infants Ages 0 Through 12 Months There are no functional criteria for fiber status that reflect response to dietary intake in infants. During the 7- through 12-month age period, the intake of solid foods becomes more significant, and Dietary Fiber intake may increase. National pediatric dietary goals are targeted for children older than 2 years of age, with a suggestion that age 2 to 3 years be a transition year (National Cholesterol Education Program, 1991). Constipation is a common problem during childhood, as it is in adults, and accounts for 25 percent of visits to pediatric gastroenterology clinics (Loening-Baucke, 1993). As discussed in the earlier section, “Dietary Fiber, Functional Fiber, and Colon Health,” there are strong data showing the contribution of high fiber diets, along with adequate fluid intake, to lax- ation in adults. Two studies by the same research group addressed fiber intake in American children and found that chil- dren with constipation consumed, on average, about half as much fiber as the healthy control group (McClung et al. Morais and co- workers (1999) reported that children with chronic constipation ingested less Dietary Fiber than age-matched controls. The median energy intake for 1- to 3-year-old children is 1,372 kcal/d (Appendix Table E-1). It should be kept in mind that recommendations for fiber intake are based on a certain amount of total fiber as a function of energy intake. This means that those who consume less than the median energy intake of a particular category need less fiber than the recommendation (which is based on the mean energy intake). For example, the median energy intake for 1- to 3-year-old children is 1,372 kcal/d and the recommendation for total fiber is 19 g/d. However, 1-year-old children not meeting this energy consumption level will not require 19 g/d and their intake should be scaled back accordingly. The median energy intake for 4- to 8-year-old children is 1,759 kcal/d (Appendix Table E-1). A more important consideration for establishing a requirement for fiber is the fact that the dietary intake data from epidemiological studies are on fiber-containing foods, which are considered Dietary Fiber. Certain investigators specifically analyzed diets for Dietary Fiber (Burr and Sweetnam, 1982; Hallfrisch et al. Both men and women appear to benefit from increasing their intake of foods rich in fibers, particularly cereal fibers, with women appearing to benefit more from increasing fiber consumption than men. Because the prospective studies of Pietinen and coworkers (1996), Rimm and coworkers (1996), and Wolk and coworkers (1999) are ade- quately powered, divide fiber intake into quintiles, and provide data on energy intake (Table 7-2), it is possible to set a recommended intake level. Data from 21,930 Finnish men showed that at the highest quintile of Dietary Fiber intake (34. The Health Professionals Follow-up Study of men reported a Dietary Fiber intake of 28. In the Nurses’ Health Study of women, the median Dietary Fiber intake at the highest quintile was 22. Taken collectively and averaging to the nearest gram, these data suggest an intake of 14 g of Dietary Fiber/1,000 kcal, particularly from cereals, to promote heart health.

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