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K. Zakosh. University of Alaska, Southeast.

Each presupposes different forms of ethical argu- ment which reflect various purposes buy 400 mg levitra plus amex erectile dysfunction freedom book. One of the few facts known for certain about the great Hippocrates was that he was pre- pared to teach medicine for a fee to anyone who could afford it order levitra plus 400 mg visa best erectile dysfunction pills over the counter... Miles founds his explanation on how oaths were used in Ancient Greeks in Thucydides account of the Poloponnesian W ar (Miles, 2004, p. For an overview of the debate between those who defend and those who object to the con- cept of an internal morality of medicine see the special issues of The Journal of Medicine and Philosophy co-edited by R. W hether oaths do not compel ethical behavior or are simply human instruments is debatable. As far as Ancient Greece, there is evidence that Greeks physicians acknowledged the gods and god- desses in their practice. The relationship between religion and medicine has always been present in tra- ditional cultures (e. From the beginnings of medical practice, religious aspects such as causation theories of illness have been incorporated into the understanding of disease. The Greeks transformed medicine into a rational system of analyzing diseases and removed, to some extent, the mythological and transcendental aspects. They organized medical practice through the Hippocratic Corpus that includes the Hippocratic Oath. Greek Hippocratic physicians, however, did not limit their practice exclusively to physiological phenomena. In their attempt to understand disease they retained a transcendental element in their practice. In Decorum, the author associates the practice of medicine with the acknowledgment of the gods: now with medicine a kind of wisdom is an associate, seeing that the physician has both these things and indeed most things. In Prognostic, the writer encourages physicians to determine the nature of disease and also to discern whether there is anything divine in it (Prognostic, I, n. Connelly regards American culture as a huge obstacle for medical professionalism in this country. She identifies six issues that are potential struggles for those who whish to enter the medi- cal profession: 1. The denial of personal and professional limitations continues to be modeled throughout medi- cine. Ongoing acceptance in medicine that emotional distance between patient and physician is par- amount. Professionalism is too often defined in terms of technical expertise in medicine, occulting the central feature of the patient-physician relationship. See Light (1993) for an account of the transformation of health care delivery in United States. For an analysis of the social transformation of American medicine see Starr (1982). Cruess there is increasing public discussion for a return of medical professionalism, with its core values of scientific expertise and altruism (2000, p. It has borrowed pieces from philosophy and theology In addition to these philosophical and theological pieces, fragments of law and the social sciences have been clumsily built onto the bioethical edifice (Jonsen, 1998, p. Caplan makes such distinction and points out that the philosophy of medicine is the study of the epistemological, metaphysical and methodological dimensions of medicine whereas bioethics aims at reflecting on how such knowledge raises moral questions. See, for instance, Engelhardt: To find that value judgments are core to our language of health and disease is not to deny that there are real causes of disease or real empirical factors important in maintaining health or causing disease. It is, rather, to recognize the obvious that to speak of being ill or being well turns on our value judgments about the world. Interestingly not all physicians in the United States are members of the American Medical Association. Countervailing power: The changing character of the medical profession in the United States (pp. Medical ethics and etiquette in the early Middle Ages: The persistence of Hippocratic ideals. On a new charter to defend medical professionalism: W hose profession is it anyway? Healers in the medical market place: Towards a social history of Graeco-Roman medicine (pp. Diagrammed Citation - Many people need to format a non-complex citation and want to know how to format a citation, without learning why it should be structured that way. General Rules and Examples - A smaller number of people will need to view the General Rules and Examples sections to get more information. They either will have a specific problem to solve or their work requires them to build a general knowledge of citation that they can later apply to specific cases. For this group we lay out why citations are structured the way they are and show them what types of citations exist (Examples) and what special, difficult cases they may encounter (Specific Rules). Specific Rules - A yet smaller number of people will need to enter the Specific Rules section to solve a specific problem, such as handling non-English citations. History This publication updates and supersedes two existing publications: National Library of Medicine Recommended Formats for Bibliographic Citation (1991). For example, we changed the number of authors taken to all and added a period at the end of the journal title abbreviation. We ask that you acknowledge this source in any x Citing Medicine published writing. Introduction xi Introduction Citing Medicine provides assistance to authors in compiling lists of references for their publications, to editors in revising such lists, to publishers in setting reference standards for their authors and editors, and to librarians and others in formatting bibliographic citations. National Library of Medicine recommended formats for bibliographic citation [Internet]. Be aware, however, that individual publishers may not accept references to all the types of items presented here. Papers that have been accepted for publication but not yet published, papers or abstracts of papers that were never published, and written personal communication such as letters or e-mails in particular may not be approved. Those familiar with the Manual are aware that its scope is limited to journal articles. However, if a precedent was established by the Manual, as for example with pagination and dates, this precedent is carried over into other types of bibliographic material. Structure Citing Medicine is divided into 26 chapters, each one representing a separate bibliographic format. Formats range from print publications such as books and journals to blogs and wikis on the Internet. Each chapter has three distinct sections: Sample Citation and Introduction, Citation Rules, and Examples of Citations. The sample citation is a diagram with labels for all of the parts of a citation and includes punctuation; the introduction provides information on the primary factors in citing the particular format.

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Rabies Rabies is one of the oldest and most feared diseases reported in medical literature buy generic levitra plus 400mg erectile dysfunction reasons. Rabies is a viral zoonosis (an animal disease transmissible to humans) caused by rhabdoviruses of the genus Lyssavirus levitra plus 400 mg low cost blood pressure erectile dysfunction causes. In terms of risks to human health, dogs are the most dangerous reservoir: more than 99. It is estimated that 50 000 persons die of rabies each year, mainly in Africa and Asia. Second-generation vaccines consisting of highly puried vaccines prepared on primary and continuous cell lines and in embryonating eggs are available, though expensive, to prevent the occurrence of the disease in persons exposed to an animal suspected of rabies. The vaccines are usually administered according to regimens involving fewer doses (usually ve or six) than those used for brain tissue vaccines. Control of rabies depends on education, vaccination of dogs, cats and farm animals and noti- cation of suspected cases to local authorities (14). Although tuberculosis most commonly affects the lungs (the usual site of primary infection), it can cause disease in any part of the body as a consequence of haematogenous spread from the lung. Among extrapulmonary cases, the most common sites involved are the lymph nodes and the pleura, but the sites of tuberculosis associ- ated with neurological disorders (meninges, brain and vertebrae) also constitute an important group. Meningeal tuberculosis has a high case-fatality rate, and neurological sequelae are com- mon among survivors. Cerebral tuberculoma usually presents as a space-occupying lesion with focal signs depending on the location in the brain. Vertebral tuberculosis usually presents with local pain, swelling and deformity, and there is risk of neurological impairment because of spinal cord or cauda equina compression. The diagnosis of nervous system tuberculosis is often difcult, because of its nature of great simulator and also because of limited access to methods to conrm it (17 ). There are important public health approaches to the primary prevention of these tuberculosis- related conditions and to the secondary prevention of their adverse consequences. The most important overall approach to primary prevention consists of cutting the chain of transmission by case-nding and treatment. The primary prevention of isoniazid-induced peripheral neuropathy is by routine administration of pyridoxine to tuberculosis patients. The main public health approach to the secondary prevention of the adverse consequences of tuberculosis disease of the meninges, brain and vertebrae is through promoting the application of the International Standards for Tuberculosis Care (19) to ensure prompt diagnosis and effective treatment. Leprosy neuropathy Leprosy is the cause of the most common treatable neuropathy in the world, caused by Myco- bacterium leprae. The incubation period of the disease is about ve years: symptoms, however, can take as long as 20 years to appear. The infection could affect nerves by direct invasion or during immunological reactions. In rare instances, the diagnosis can be missed, because leprosy neuropathy may present without skin lesions (neuritic form of leprosy). Patients with this form of disease display only signs and symptoms of sensory impairment and muscle weakness, posing difculties for diagnosis, particularly in services where diagnostic facilities such as bacilloscopy, electroneuromyography and nerve biopsy are not available. Delay in treatment is a major problem, because the disease usually progresses and the resulting disability if untreated may be severe, even though mycobacteria may be eliminated. Delay in treat- ment is, however, usually a result of delayed presentation because of the associated stigma. People with long-term leprosy may lose the use of their hands or feet because of repeated injury resulting from lack of sensation. Bacterial meningitis Bacterial meningitis is a very common cause of morbidity, mortality and neurological compli- cations in both children and adults, especially in children. It has an annual incidence of 4 6 102 Neurological disorders: public health challenges cases per 100 000 adults (dened as patients older than 16 years of age), and Streptococcus pneumoniae and Neisseria meningitidis are responsible for 80% of all cases (20). In developing countries, overall case-fatality rates of 33 44% have been reported, rising to over 60% in adult groups (21). Bacterial meningitis can occur in epidemics that can have a serious impact on large populations. The highest burden of meningococcal disease occurs in sub-Saharan Africa, which is known as the meningitis belt, an area that stretches from Senegal in the west to Ethiopia in the east, with an estimated total population of 300 million people. The hyperendemicity in this area is at- tributable to the particular climate (dry season between December and June, with dust winds) and social habits: overcrowded housing at family level and large population displacements for pilgrim- ages and traditional markets at regional level. Because of herd immunity (whereby transmission is blocked when a critical percentage of the population had been immunized, thus extending protection to the unvaccinated), the epidemics occur in a cyclical fashion. Meningitis is characterized by acute onset of fever and headache, together with neck stiffness, altered consciousness and seizures. Antibiotic treatment is effective in most cases but several neurological complications can remain, such as cognitive difculties, mo- tor disabilities, hypoacusia and epilepsy. In a recent review, treatment with corticosteroids was associated with a signicant reduction in neurological sequelae and mortality (22). Progress is more likely to come from investigations into preventive measures, especially the use of available vaccines and the development of new vaccines. Meningitis caused by Haemophilus inuenzae type B has been nearly eliminated in developed countries since routine vaccination with the H. The approval in 2005 of a conjugate meningococcal vaccine against serogroups A, C, Y and W135 is also an important advance that may decrease the incidence of this devastating infection. Local and nationwide surveillance, in- cluding the laboratory investigation of suspected cases, is critical for early detection of epidemics and the formulation of appropriate responses. Tetanus Tetanus is acquired through exposure to the spores of the bacterium Clostridium tetani which are universally present in the soil. The disease is caused by the action of a potent neurotoxin produced during the growth of the bacteria in dead tissues, e. Tetanus is not transmitted from person to person: infection usually occurs when dirt enters a wound or cut. At the end of the 1980s, neonatal tetanus was considered a major public health problem. A worldwide total of 213 000 deaths were estimated to have occurred in 2002, 198 000 of them concerning children younger than ve years of age (23). Unlike poliomyelitis and smallpox, the disease cannot be eradicated because tetanus spores are present in the environment. Once infection occurs, mortality rates are extremely high, especially in areas where appropriate medical care is not available. Neonatal tetanus can be prevented by immunizing pregnant women and improving the hygienic conditions of delivery. Adult tetanus can be prevented by immunizing people at risk, such as work- ers manipulating soil; others at risk of cuts should be also included in the prevention measures. The adult tapeworm (at, ribbon-like, approximately 2 4 m long) lives only in the small intestine of humans, who acquire it (taeniasis) by eating undercooked pork containing the viable larvae or cysticerci. A tapeworm carrier passes microscopic Taenia eggs with the faeces, contaminating the close en- vironment and contacts and causing cysticercosis to pigs and humans. Human beings therefore acquire cysticercosis through faecal oral contamination with T.

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One hypothesis is that the reaction is caused by an immunologic response to deposits on the lens surface levitra plus 400mg with amex erectile dysfunction exam what to expect. However purchase 400mg levitra plus amex erectile dysfunction treatment with viagra, the amount of deposits does not clearly correlate with the presence of giant papillary conjunctivitis, and all lenses develop deposits within 8 hours of wear (90). Evidence suggesting an immune mechanism in the production of giant papillary conjunctivitis is based on several observations. Patients with giant papillary conjunctivitis have elevated, locally produced tear IgE (91). Eosinophils, basophils, and mast cells are found in giant papillary conjunctivitis in greater amounts than in acute allergic conjunctivitis ( 45). Non IgE-mediated immune mechanisms have also been incriminated in the production of this disorder. IgG levels are elevated, but the IgG is bloodborne rather than locally produced (91). There is also evidence for complement activation, and there is decreased lactoferrin in the tears of patients with giant papillary conjunctivitis (59,60). Neutrophil chemotactic factor is present in tear fluids in amounts exceeding levels found in nonaffected soft contact lens wearers ( 94). Treatment of giant papillary conjunctivitis is usually carried out by the ophthalmologist. Early recognition is important because discontinuation of lens wear early in the stage of the disease and prescription of appropriate lens type and edge design can prevent recurrence. It is also important to adhere to a strict regimen for lens cleaning and to use preservative-free saline. Enzymatic cleaning with papain preparations is useful to reduce the coating of the lenses by antigens. Floppy Eye Syndrome Floppy eye syndrome is a condition characterized by lax upper lids and a papillary conjunctivitis resembling giant papillary conjunctivitis. The condition is thought to result from chronic traction on the lax lid produced by the pillow at sleep. These include conditions such as acute keratitis, uveitis, acute angle-closure glaucoma, and endophthalmitis. The two most important symptoms pointing to a threatening condition are a loss in visual acuity and pain. These are signs that the patient could have an elevated intraocular pressure, keratitis, endophthalmitis, or uveitis. This contrasts with the pattern of vasodilation seen in acute allergic conjunctivitis, which produces erythema that is more pronounced in the periphery and decreases as it approaches the cornea. If the physician believes that the patient does not have a threatening eye disease, the next step is to differentiate between allergic and nonallergic diseases of the eye (Table 11. The differential diagnosis between allergic and nonallergic diseases of the eye can usually be made by focusing on a few key features. This is the most important distinguishing feature between allergic and nonallergic eye disorders. The physician must be certain that the patient understands what is meant by itching because burning, scratching, sandy eyes are often described as itchy by the patient. A purulent discharge with early morning matting is not a feature of allergic disease and points toward infection. Lid involvement indicates the presence of atopic dermatitis, contact dermatitis, or occasionally seborrhea or rosacea. Otitis media is a general term defined as any inflammation of the middle ear with or without symptoms and usually associated with an effusion. It is one of the most common medical conditions seen in children by primary care physicians ( 97). It is estimated that total costs for otitis media in the United States range from $3 to $4 billion dollars and $600 million in Canada ( 98). The First International Symposium on Recent Advances in Middle Ear Effusions (99) includes the following types of otitis media: (a) acute purulent otitis media, (b) serous otitis media, and (c) mucoid or secretory otitis media. Chronic otitis media is a condition displaying a pronounced, retracted tympanic membrane with pathologic changes in the middle ear, such as cholesteatoma or granulation tissue. The acute phase of otitis media occurs during the first 3 weeks of the illness, the subacute phase between 4 and 8 weeks, and the chronic phase begins after 8 weeks. It has been theorized that chronic conductive hearing loss in the child may lead to poor language development and learning disorders. The study further showed that after the first episode, 40% of the children had middle ear effusion that persisted for 4 weeks, and 10% had effusions that were still present after 3 months. In this study, spontaneous resolution of bilateral effusion by 2 years of age was typical. Eustachian Tube Anatomy and Physiology The nasopharynx and middle ear are connected by the eustachian tube. The production of middle ear effusions appears to be related to functional or anatomic abnormalities of this tube. Under normal conditions, the eustachian tube has three physiologic functions: (a) ventilation of the middle ear to equilibrate pressure and replenish oxygen; (b) protection of the middle ear from nasopharyngeal sound pressure and secretions; and (c) clearance of secretions produced in the middle ear into the nasopharynx. The eustachian tube of the infant and the young child differs markedly from that of the adult. These anatomic differences predispose infants and young children to middle ear disease. As growth occurs, the tube narrows, elongates, and develops a more oblique course (Fig. Usually after the age of 7 years, these physical changes lessen the frequency of middle ear effusion ( 116). In the normal state, the middle ear is free of any significant amount of fluid and is filled with air. This tube is closed at the pharyngeal end except during swallowing, when the tensor veli palatini muscle contracts and opens the tube by lifting its posterior lip ( Fig. When the eustachian tube is opened, air passes from the nasopharynx into the middle ear, and this ventilation system equalizes air pressure on both sides of the tympanic membrane (Fig. Illustration showing difference in angles of eustachian tubes in infants and adults. This results in the formation of negative pressure within the middle ear and subsequent retraction of the tympanic membrane ( Fig. High negative pressure associated with ventilation may result in aspiration of nasopharyngeal secretions into the middle ear, producing acute otitis media with effusion ( Fig. Prolonged negative pressure causes fluid transudation from the middle ear mucosal blood vessels ( Fig. Also, there is an increased density of goblet cells in the epithelium of the eustachian tube. It is thought that many children with middle ear effusions, without a demonstrable cause of eustachian tube obstruction, have a growth-related inadequate action of the tensor veli palatini muscle.