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Prevention of the second can be achieved with fastidious attention to hygiene particularly with hand washing and food preparation cholesterol vs triglycerides purchase cheap atorvastatin on line. If you are likely to be in a shelter for the short-term cholesterol test in singapore generic atorvastatin 10 mg on line, you should give consideration to using completely disposable plates and cutlery cholesterol in eggs bodybuilding atorvastatin 5 mg order. One of the biggest sources of gut infections in primitive situations is the inability to adequately clean plates and cooking utensils cholesterol test normal atorvastatin 20 mg buy without prescription. If you are planning for long-term shelter living you must ensure that the ability to hot wash your dishes with detergent is a priority cholesterol ratio evidence atorvastatin 5 mg order on line. There is no clear evidence daily wiping down of all surfaces with a dilute disinfectant reduces infection. Despite this it is a common submarine practice (those who remain undersea for months at a time) in some countries navies and they strong believe it reduces infections. Loss of a predictable light/dark patterns leads to sleep disturbance causing somatic symptoms (headaches, aches and pains), increased stress, reduced ability to concentrate, mood swings, and erratic behaviour. Shelter lighting should be set to follow a day-night cycle with a predictable length. Over prolonged periods the pattern should be adjusted to shortening and lengthening of the light time to simulate changing seasons. Light is also required for the activation of vitamin D which is required for proper bone growth. In the absence of exposure to sunlight or due to dietary deficiency adults develop osteomalacia (thin bones prone to fractures) and children develop Rickets which is characterised by weakness, bowing of the legs, and deformities of other bones. From a dietary point of view vitamin D is found primarily in fish oils and egg yolk. Supplementation with multivitamins is probably the best option for long-term shelter dwellers. In the face of confinement and limited activity physical condition rapidly decays. If it is at all possible give some consideration to the value of storing small items of exercise equipment such as a mini-tramp or some sort of stepping device to provide the ability to undertake some form of aerobic or cardiovascular exercise. One possible option is using an exercise bike to run an alternator producing electricity to charge batteries or directly powering the shelter ventilation fans. Killing two birds with one stone, serving a very useful survival purpose while providing aerobic exercise. Depending on the physical shape of the shelter other options for aerobic exercise include skipping or sprint starts against resistance (such as a bungy). Anaerobic exercise is much for easier to perform with limited space using free weights, press-ups, and chin-ups, etc. It should be built into the daily timetable as a scheduled activity and should be compulsory. The importance of exercise has to be balanced against the energy expended undertaking it. If you are relying on a very simple food storage programme with only the core staples then you will have problems quickly. If you have stored a broad range of items, and tinned, and bottled foods in addition to dry staples then it will be less of a problem. If you are in the former group as an absolute minimum you should ensure that you have an adequate supply of multivitamin supplements If you are planning long-term shelter living you should give serious thought to developing a system for gardening within your shelter. Hydroponics is the obvious solution and can be relatively easily grown in a shelter type environment, however, it still requires large amounts of light, water, and nutrients to grow. The nutrient value depends on the type of bean used, how long it is allowed to grow, and the - 88 - Survival and Austere Medicine: An Introduction amount of light it is exposed to . The more light and the longer the growth period the more vitamin A and C will be present with peak levels present at 8 days. In uncooked legumes (beans, peas, lentils) an enzyme which blocks the absorption of protein, is present. The Prudent Pantry, A T Hagan, 1999 – no out of print) - 89 - Survival and Austere Medicine: An Introduction Chapter 11 Long-term austere medicine Introduction Most of what is discussed in this book is related to a short to medium term disasters with serious disruption of medical services, but with a view to eventual recovery to a high technological level in the short to median term, certainly within a generation. The above paints a possible scenario for what may happen in a major long term disaster – a complete permanent collapse of society and, with that medical services; no hospitals, no new supplies or medications, no medical schools, and no prospect of a significant degree of technological recovery. Depending on your level of preparedness (or paranoia) possible scenarios include comet strike, massive climate change, global pandemic, or worldwide nuclear war any of which would result in complete disruption of infrastructure, and knowledge, and an inability to recover to today’s modern level. While all the principles discussed in other sections apply to the early stages of these sorts of disasters what happens when things run out for good, or the doctor/medic in your group is getting old, or dies raises a whole series of other issues. In this section we cover some of the main issues about long-term medical care in a primitive / austere environment. It is not a “how-to” chapter but more a discussion of likely scenarios and thoughts about what is possible and what is not. Despite the pessimistic picture painted in the scenario above with planning and thought it is possible to maintain a surprisingly high level of medical care. We are not talking heart transplants and high-level intensive care, but we are talking quality medical care which can manage even if it cannot cure common medical problems. While at first thought it may appear that the loss of modern technology and medication will place medical care back to the dark ages it is important not to forget that the knowledge underpinning modern medicine is still there. While there may be no antibiotics for your dirty wound you still have an understanding of what causes infection, basic hygiene measures, and good basic wound care so while you may not have antibiotics to prevent or treat infection you will still know how to minimise the chance of infection, and optimise healing, and hopefully a knowledge of other substances with antibacterial properties. For this reason it is extremely important that you have a comprehensive medical library to begin with and that there is a priority to preserve the knowledge the books contain. Having several people with detailed medical knowledge initially is ideal but this for many may not be possible. It is important that there is a degree of cross training within the group at least at a basic level. When it is apparent that a - 90 - Survival and Austere Medicine: An Introduction disaster is likely to be prolonged it is vital that you begin to train someone to the same level as yourself; the best way is probably using an apprenticeship model over several years. This was the way the majority of western doctors (Middle Eastern cultures th have had medical schools for the last 1500 years) were taught until the 17 century when the medical schools took over, and apprenticeships were still common up until early last century although they were considered inferior. Unfortunately learning medicine simply from a book is inadequate and having supervised experience in addition to books is the only real way to learn. For this reason if you are considering a long-term collapse ensure that you also have the resources to teach the basics of biological sciences first before moving onto medicine proper. It would be difficult to teach someone the complexities of medicine without a good understanding of the basics. In addition to modern medical knowledge, if you are planning for a multi-generational catastrophe then you need to study medical history. The practice of medicine in the th th 18 and 19 Century provides, in our opinion, what we may realistically expect in terms of a technological level in medicine with our modern knowledge superimposed over the top. Look at how things were done, and with what instruments, what medications where used, and how; what were the medical problems encountered? Much from that time is simply wrong and reflects the ignorance of physiology and pathology of the times but there is much to learn, and when approached with modern knowledge it is easy to identify what is useful information and what is not. An interesting way to appreciate the medical problems of the time is by looking at the causes of death during that period; this gives some insight into likely serious medical problems in this sort of scenario now. Below are some of the commonest causes of th death in early 19 Century in Australia. In addition to showing causes of death they also show some of the limited medical understanding of the time: • Trauma (including drowning and burns) – deaths from drowning and burns appear to have occurred with frightening frequency. There were also a large number of trauma deaths – both as a consequence of (mostly) farming accidents and violence. While covering a number of different diagnosis for the most part it referred to heart failure and commonly followed episodes of severe chest pain although at the time this wasn’t recognised for what it was – a myocardial infarction • Abdominal distemper – this was a syndrome characterised by severe abdominal pain, abdominal rigidity, fevers, and death. A significant number of cases were probably appendicitis although it is likely that pancreatitis, liver disease (from alcohol abuse), and gallbladder infections accounted for a number of cases. Again, more recently the term referred to typhoid fever, prior to this it referred to any dysentery. They divided them into one of three groups: • those conditions that can be treated • those that can be contended with • those that cannot be treated It is simple but surprisingly useful because in an austere situation it gives a framework to classify what you can do for your patients; those you can treat and cure, those that you can palliate or make comfortable (until they die or get better), and those that you can do nothing for or where your intervention is likely to make things worse. You need to convey a realistic expectation to your patients of what you will be able to achieve and this provides a simple framework. Lifestyle/Public health Lifestyle: Prior to any disaster it is worth considering what you can do to improve your own and your group’s health. Prevention of diseases such as heart disease, strokes, and diabetes is much better than attempting to treat them in an austere survival situation. You should ensure that all members of your group have their vaccinations up to date especially tetanus, measles, diphtheria, and polio. Preventive medicine: A large proportion of the disease burden in the past is related to poor public health and preventive medicine. For the most part it was related to ignorance of the role of bacteria in causing disease. Key elements of preventive medicine and infection control include: • Clean drinking water – uncontaminated by sewage and waste water • Hand washing – soap production is a priority. Incineration is probably the best option, followed by deep burial – away from water sources. Adequate rubbish disposal and trapping are probably the best methods for rodent control. Depending on climate mosquitoes may be a problem; stagnant water and rotting soft wood are foci for the mosquito larvae. Although many illnesses are infectious before symptoms become apparent it is important that any person who becomes unwell, particularly with fever or diarrhoea, is isolated immediately in an attempt to minimise further infections. With diarrhoeal illness – simple hand washing is usually sufficient for the caregiver. With febrile illnesses or those with respiratory symptoms then barrier precautions should be used – gloves, gown, facemask (N95), and goggles should be used. If this level of protection is not possible then some form of face mask is needed when with the patient and hand-washing, changing clothes (hot wash), and showering before contact with the healthy. For strangers arriving particularly during a pandemic consider 10-14 days isolation, followed by clothes burning and a through wash with soap before entering the community. There are no current infectious diseases with longer incubation times than 10-14 days. Provided the newcomer is symptom free at the end of this period you should be safe. However, among the current potential pandemic causes there are not currently carrier states although this needs to be considered. The recent tsunami in southern Asia clearly demonstrates how quickly public health can break down. Despite widespread knowledge even in developing third world countries about the basic principles of public health and hygiene latrines have been dug next to water supplies, water wasn’t being boiled, and in some places no effort was made to burn or dispose of rubbish, and it was just allowed to accumulate. While you can argue that some of this was due to “shell shock” from the disaster itself it just goes to show how the fundamentals can go out the window in a stressful situation. At present there is a heavy reliance on investigations; in a long-term austere situation history and examination will come into their own again. History taking and Examination: With very limited access to investigations the importance of clinical examination will again take on enormous importance. While modern doctors are competent at physical examination there is heavy reliance on special tests, and many of the skills of accurate physical examination have faded. The basics are easily learned from any clinical skills textbook (We recommend Talley and O’Connor, Physical Examination) and with a little practice. It is almost certain that in long-term austere situations that physical examination will come into its own again. The history 95% of the time is all that is required to know exactly what is going on. The examination and investigations may be used to confirm your thoughts, but it’s the history that usually gives you the diagnosis. Investigations: Laboratory tests: Lab tests which are possible in an austere environment are discussed in the Laboratory chapter. These include basic urine analysis, blood typing, and cross matching, and simple cell counts. There are several low-tech ways that are reasonably accurate in diagnosing fractures. Fractures of the long bones (tibia, fibula, femur, humerus, clavicle, ribs, etc), can be diagnosed by either percussion, or a tuning fork, and a stethoscope. A bony prominence on one end of the bone in question is tapped, or the base of a vibrating tunning fork is placed against it, and the stethoscope is applied to the other end. If a fracture exists on one side and not the other the gap in the bone at the fracture site will result in less sound being transmitted so the sound will be somewhat muted on the side of the fracture. To diagnose a hip fracture the sound source is applied to the patella (knee cap) and the stethoscope applied over the pubic symphysis. The technique is less effective on the obese as fatty tissue will absorb sound waves. For long bones running near the surface of the body a fracture can be localized by drawing the tuning fork along the bone slowly (>30 sec, but <60 sec) until a very localized source of pain is identified (<3 cm). A cone formed from rolled paper can act as a substitute for a stethoscope but is less than ideal. Once again, the reality will be that the most useful method for diagnosing fractures will be clinical examination. This is also the case for the clinical chest examination in patients who would previously have had a chest x-ray. Treatment The trick to learn for patient care in a truly austere situation is to do what you can do extremely well. You may not have access to many medications or much equipment but do what you are able to do well and you will save lives. The classic survival cliché is a simple scratch could result in you dying from gangrene infection of the leg.

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Which of the following mechanisms helps maintain the patient’s core temperature during the period following her rescue? A 39-year-old woman comes to the physician for a follow-up examination because she recently was diagnosed with hypertension cholesterol test eyes order 5 mg atorvastatin with amex. A 24-hour urine collection shows three times the normal excretion of epinephrine and metanephrine cholesterol medication guidelines cheap generic atorvastatin canada. The excessive epinephrine production in this patient is most likely caused by which of the following cell types? The blood flow through an organ is measured while the perfusion pressure is varied experimentally natural cholesterol lowering foods herbs atorvastatin 10 mg purchase mastercard. An abrupt cholesterol test instructions atorvastatin 20 mg sale, sustained increase in perfusion pressure increases flow initially cholesterol definition in urdu buy 20 mg atorvastatin amex, but over the course of 1 minute, the flow returns nearly to the baseline level despite continued elevation of the perfusion pressure. After an overnight fast, a 52-year-old man undergoes infusion of acid through a catheter into the upper duodenum. This most likely will increase pancreatic secretion mainly through the action of which of the following substances? A 20-year-old woman is brought to the emergency department 20 minutes after being stung by a wasp. A demonstration is performed during a lecture on muscle physiology in which a student is asked to fully extend his right arm with the palm up. Which of the following facilitates the maximum amount of tension that allows the student to keep his arm extended in place under the increasing weight of the books? During an experiment on the cough reflex in humans, a volunteer inhales air containing different amounts of particles that will impact and adhere to mucus primarily in the trachea. Blockade of which of the following receptors would most likely prevent this volunteer’s reflex to initiate a cough? A female newborn delivered at 32 weeks’ gestation develops severe respiratory distress within hours of birth. Examination of the lungs at autopsy shows lung alveoli with radii of less than 50 μm (N=100). A 55-year-old woman who is obese has a greater risk for endometrial carcinoma than a 55-year-old woman with the same health history and status who is not obese. A 4-hour-old female newborn delivered at 30 weeks’ gestation has respiratory distress. The primary cause of this patient’s condition is a dysfunction of which of the following cell types? A 22-year-old man is brought to the emergency department because of a 6-hour history of severe, sharp, upper back pain. Which of the following best describes the primary genetic cause of this patient’s condition? A 25-year-old woman comes to the physician because of a 2-day history of muscle cramps and profuse, watery stools. Stool culture shows numerous curved, gram-negative bacteria; there are no erythrocytes or leukocytes. The oral hydration formula most likely promotes sodium absorption via the gut by allowing cotransport with which of the following? A 26-year-old woman is brought to the emergency department because of a 4-day history of flu-like symptoms accompanied by vomiting following each attempt to eat or drink. A 77-year-old man comes to the physician because of swelling of his legs and feet for 6 months. A decrease in which of the following most likely promotes edema formation in this patient? During a study of gastric parietal cells, an investigator attempts to elicit maximum hydrochloric acid secretion from the stomach of an experimental animal. Which of the following combinations of substances is most likely to lead to this desired effect? Acetylcholine Gastrin Histamine Secretin (A) Increased increased increased increased (B) Increased increased increased decreased (C) Increased decreased decreased increased (D) Decreased increased increased increased (E) Decreased decreased increased increased (F) Decreased decreased decreased decreased (G) Decreased decreased decreased decreased - 66 - 19. A 30-year-old woman comes to the physician for a routine health maintenance examination. An increase in which of the following substances is the most likely cause of the serum finding in this patient? A 28-year-old woman comes to the physician because of a 3-month history of shortness of breath with exertion. Cardiac examination shows a regular rate and rhythm; S2 is slightly louder than S1. Cardiac catheterization shows a pulmonary artery pressure of 78/31 mm Hg (N=15–30/3–12) with a normal left ventricular end-diastolic pressure. E - 69 - Adult Ambulatory Medicine Systems General Principles, Including Normal Age-Related Findings and Care of the Well Patient 5%–10% Immune System 5%–10% Diseases of the Blood 5%–10% Diseases of the Nervous System 1%–5% Cardiovascular Disorders 15%–20% Diseases of the Respiratory System 10%–15% Nutritional and Digestive Disorders 10%–15% Gynecologic Disorders 1%–5% Renal, Urinary, & Male Reproductive Systems 8%–12% Diseases of the Skin 1%–5% Musculoskeletal and Connective Tissue Disorders 5%–10% Endocrine and Metabolic Disorders 8%–12% Physician Task Promoting Health and Health Maintenance 10%–15% Understanding Mechanisms of Disease 15%–20% Establishing a Diagnosis 40%–45% Applying Principles of Management 20%–25% Patient Age 18 to 65 80%–90% 66 and older 10%–20% - 70 - 1. A 19-year-old man has had fever, headache, sore throat, and swelling of the cervical lymph nodes for 5 days. His temperature is 40°C (104° F), pulse is 120/min, respirations are 20/min, and blood pressure is 125/85 mm Hg. There is tender cervical adenopathy and palpable lymph nodes in the axillary and inguinal areas. Leukocyte count is 14,000/mm3 (25% segmented neutrophils, 60% atypical lymphocytes, and 15% monocytes). An asymptomatic 37-year-old African American man comes to the physician for a preemployment examination. A 32-year-old woman comes to the physician because of lethargy and boredom since the birth of her son 5 months ago. The most appropriate next step in diagnosis is measurement of which of the following serum concentrations? She has microalbuminuria; her hemoglobin A1c is 7%, and serum creatinine concentration is 1. A previously healthy 27-year-old woman comes to the physician because of a 3-month history of moderate abdominal pain that improves for a short time after she eats. B - 73 - Clinical Neurology Systems General Principles, Including Normal Age-Related Findings and Care of the Well Patient 1%–5% Behavioral Health 3%–7% Nervous System & Special Senses 60%–65% Infectious, immunologic, and inflammatory disorders Neoplasms (cerebral, spinal, and peripheral) Cerebrovascular disease Disorders related to the spine, spinal cord, and spinal nerve roots Cranial and peripheral nerve disorders Neurologic pain syndromes Degenerative disorders/amnestic syndromes Global cerebral dysfunction Neuromuscular disorders Movement disorders Paroxysmal disorders Sleep disorders Traumatic and mechanical disorders and disorders of increased intracranial pressure Congenital disorders Adverse effects of drugs on the nervous system Disorders of the eye and ear Musculoskeletal System 10%–15% Other Systems, Including Multisystem Processes & Disorders 15%–20% Social Sciences, Including Death and Dying and Palliative Care 1%–5% Physician Task Applying Foundational Science Concepts 10%–15% Diagnosis: Knowledge Pertaining to History, Exam, Diagnostic Studies, & Patient Outcomes 55%–60% Health Maintenance, Pharmacotherapy, Intervention & Management 25%–30% Site of Care Ambulatory 60%–65% Emergency Department 25%–30% Inpatient 5%–15% Patient Age Birth to 17 10%–15% 18 to 65 55%–65% 66 and older 20%–25% - 74 - 1. A 39-year-old man is admitted to the hospital by his brother for evaluation of increasing forgetfulness and confusion during the past month. His brother reports that the patient has been drinking heavily and eating very little, and has been slightly nauseated and tremulous. On admission to the hospital, intravenous administration of 5% dextrose in water is initiated. He has had progressive difficulty with daytime sleepiness and has intermittently fallen asleep at work. He has no difficulty falling asleep or staying asleep at night but awakens in the morning not feeling well rested. Examination of the throat shows no abnormalities except for hypertrophied tonsils. A 45-year-old man has had a 1-week history of increasing neck pain when he turns his head to the right. He also has had a pins-and-needles sensation starting in the neck and radiating down the right arm into the thumb. His symptoms began 3 months ago when he developed severe pain in the neck and right shoulder. Neurologic examination shows limitation of motion on turning the neck to the right. There is 4+/5 weakness of the right biceps and decreased pinprick over the right thumb. Deep tendon reflexes are 1+ in the right biceps and brachioradialis; all others are 2+. A 29-year-old man is brought to the emergency department because he has a severe bilateral headache and irritability. His pulse is 120/min, respirations are 30/min, and blood pressure is 200/120 mm Hg. A 29-year-old woman with an 11-year history of bipolar disorder comes to the physician because she is concerned about memory loss during the past 2 weeks. She has had difficulty remembering appointments that she has made, and on one occasion, she got lost going to the health club where she has been a member for years. She has taken lithium carbonate for 8 years, and she has been taking a friend’s diuretic for perimenstrual weight gain during the past 3 months. On mental status examination, she is oriented to person, place, and time, but she recalls only one of three objects after 5 minutes. A 63-year-old man is brought to the physician by his daughter because she is concerned about his memory loss during the past year. Although he denies that there is any problem, she says he has been forgetful and becomes easily confused. He is oriented to person and place but initially gives the wrong month, which he is able to correct. He recalls memories from his youth in great detail but only recalls one of three words after 5 minutes. Physical examination, laboratory studies, and thyroid function tests show no abnormalities. A 65-year-old man has had increasingly severe headaches and diffuse muscle aches during the past 3 months. He also has a 1-month history of jaw pain when chewing food and decreasing visual acuity in his left eye. Visual acuity in his left eye is 20/100, and the left optic disc is slightly atrophic. A 19-year-old woman comes to the physician because of a 3-month history of intermittent drooping of her left eyelid each evening and occasional difficulty chewing and swallowing. She also has had two episodes of double vision that occurred in the evening and resolved by the following morning. A 72-year-old man is brought to the physician by his daughter because of a 2-day history of confusion, disorientation, and lethargy. He had a cerebral infarction 1 year ago and has been treated with daily aspirin since then. A 21-year-old college student comes to student health services requesting medication to help her sleep. Four days ago, she returned from a 1-year trip to India where she studied comparative religions. She constantly feels tired, has difficulty concentrating, and does not feel ready to begin classes. Her appetite has not decreased, but she has an aversion to eating meat since following a vegetarian diet in India. When asked to subtract serial sevens from 100, she begins accurately but then repeatedly loses track of the sequence. Today, she says she has had a persistent sensation of tingling and numbness of her left thigh that she did not report in the hospital because she thought it would go away; the sensation has improved somewhat during the past week. Sensation to light touch is decreased over a 5 × 5-cm area on the lateral aspect of the left anterior thigh. Which of the following is the most likely cause of this patient’s decreased sensation? She has a history of mild hypertension treated with hydrochlorothiazide and hypothyroidism treated with thyroid replacement therapy. Neurologic examination shows decreased ankle jerk reflexes bilaterally and decreased vibratory sense and proprioception in the lower extremities. Laboratory studies show: Hemoglobin 10 g/dL Leukocyte count 11,000/mm3 with a normal differential Mean corpuscular volume 106 µm3 Serum K+ 4. An 82-year-old man is admitted to the hospital because nursing staff in his skilled nursing care facility report that he has appeared sad and depressed during the past 2 months. It is reported that he has a history of psychiatric illness, but details are not provided. Which of the following is the most likely cause of this patient’s current symptoms? A 25-year-old butcher has had severe episodic pain in his right thumb and right second and third digits for 2 months. He has decreased sensation over the palmar surface of the thumb and index and long fingers of the right hand and atrophy of the thenar muscle mass. A 27-year-old woman comes to the physician because of a 3-week history of fatigue and blurred vision. For the past year, she has had 3- to 4-day episodes of numbness and tingling of her arms and legs. Sensation to light touch is decreased over the hands and feet; sensation to pinprick is increased over the fingers and toes bilaterally. A 57-year-old woman comes to the physician because of a 2-year history of difficulty sleeping. After she gets into bed at night, her legs feel cold and crampy, and she cannot settle into a comfortable position. A 77-year-old man comes to the emergency department 1 hour after a 15-minute episode of right arm weakness and an inability to speak in sentences; the symptoms have now resolved. Examination, including cardiopulmonary and neurologic examinations, shows no other abnormalities. Which of the following is the most appropriate next step to prevent cerebral infarction in this patient?

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Temporary disability cholesterol from shrimp is it good buy discount atorvastatin 40 mg line, as in the case where a diabetic is withdrawn from the workforce for a short period cholesterol levels in kerala order 20 mg atorvastatin mastercard, is not accounted cholesterol egg white cheap atorvastatin 5 mg visa. The lack of inclusion for this form of income may cause overestimation in the lost income estimates cholesterol levels how to read atorvastatin 40 mg purchase without a prescription. However cholesterol levels in king crab buy cheap atorvastatin 40 mg on-line, the households with diabetics receiving remittances may use this income to ease the burden of diabetes i. These remittances, used to ease financial burden associated with disease, can then be considered an indirect cost of morbidity. Third, tax rates are often changed intermittently and, for some countries, the tax rate is a fixed fee within an income range, plus a proportion out of every unit over the lower bound of the bracket. O) Papua New Guinea Samoa 35 Solomon Islands Tonga Vanuatu Source: International Health Metric and Statistics. The burden and costs of chronic diseases in low-income and middle-income countries. An estimation of the economic impact of chronic noncommunicable diseases in selected countries World Health Organization Working Paper, 1-21. The Economic Costs of Noncommunicable Diseases in the Pacific Islands: A Rapid Stocktake of the Situation in Samoa, Tonga, and Vanuatu. The costs and affordability of drug treatments for type 2 diabetes and hypertension in Vanuatu. The fetal and infant origins of adult disease: the womb may be more important than the home. Maternal and child undernutrition: global and regional exposures and health consequences. Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990– 2013: a systematic analysis for the Global Burden of Disease Study 2013. Mortality displacement of heat- related deaths: a comparison of Delhi, Sao Paulo and London. Determinants of Tobacco Consumption in Papua New Guinea: Challenges in Changing Behaviours. Changing patterns of under- and over-nutrition in South African children—future risks of non-communicable diseases Annals of Tropical Peadiatrics, 25(1), 3-15. Public health impact of global heating due to climate change: potential effects on chronic non-communicable diseases. The 2006 California heat wave: impacts on hospitalizations and emergency department visits. Sugar-sweetened beverages and risk of metabolic syndrome and type 2 diabetes a meta-analysis. Evidence for impaired insulin production and higher sensitivity in stunted children living in slums. A survey of macro damages from Non-communicable chronic diseases: another challenge for global governance. Socioeconomic status and obesity in adult populations of developing countries: a review. The World Health Report 2001: Mental Health: New Understanding, New Hope: World Health Organization. Human Thermal Environments: The Effects of Hot, Moderate, and Cold Environments on Human Health, Comfort and Performance (2nd ed. Effect of socioeconomic deprivation on waiting time for cardiac surgery: retrospective cohort study. The link between childhood undernutrition and risk of chronic diseases in adulthood: a case study of Brazil. Forum Leaders’ Statement on Non-Communicable Diseases: Pacific in an Crisis, Leaders Declare: Secretariat of the Pacific Islands Community. Prevention and Control of Noncommunicable Diseases Regional Committee 51st Session, Manila, Philippinesn 18-22 September (Vol. A summary of the findings of the Commission on Macroeconomics and Health: investing in health for economic development Report of the Commission on Macroeconomics and Health. Noncommunicable Disease and Poverty: The Need for Pro-poor Strategies in the Western Pacific Region - A Review Regional Office for the Western Pacific World Health Organization,. Pacific Islanders pay heavy price for abandoning traditional diet Bulletin of the World Health Organization (Vol. Noncommunicable Disease and Poverty: The Need for Pro-poor Strategies in the Western Pacific Region - A Review. Noncommunicable Disease and Poverty: The Need for Pro-poor Strategies in the Western Pacific Region - A Review. Leaving No One Behind Public health—the practice of preventing disease and promoting health—effectively targets environmental factors and health behaviors that contribute to chronic conditions. The health risk factors of physical inactivity, tobacco use and exposure and poor nutrition are the leading causes of chronic disease. With even a small reduction in the prevalence of chronic disease, the combined health and productivity cost savings of prevention lead to a positive return on investment within a short time. Nearly 70% of frst heart attacks and 77% of frst strokes occur in people with hypertension. Cardiovascular disease is the estimation tool, which uses the leading cause of morbidity and mortality in the United States, Pooled Cohort Equations from accounting for 1 of every 3 deaths among adults. There is high certainty that the net benefit is moderate, or Offer or provide this service. There is at least moderate certainty patients depending on individual that the net benefit is small. There is moderate or high certainty that the service Discourage the use of this service. If the service is offered, I statement patients should understand the uncertainty about the balance of benefits and harms. This conclusion is therefore unlikely to be strongly affected by the results of future studies. The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by such factors as the number, size, or quality of individual studies. As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion. The calculator Risk Assessment derived from these equations takes into account age, sex, race, cholesterol levels, systolic blood pressure level, antihypertension treatment, presence of diabetes, and smoking status as risk factors. Statins are a class of lipid-lowering medications that function by inhibiting the enzyme 3-hydroxy-3-methyl-glutaryl coenzyme A Preventive reductase. For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please go to https://www. Aseparaterecommendationstatementalso bloodpressurelevel,antihypertensiontreatment,presenceofdia- found insufficient evidence to assess the balance of benefits and betes,andsmokingstatusasriskfactorsinthepredictionmodeland harms of screening for dyslipidemia in children and adolescents. Specific recommendations from other organiza- ofbenefitthataninterventionwithdemonstratedefficacycanhave tions for such individuals are discussed in the “Recommendations in a specific population directly depends on the incidence of dis- of Others” section. This is one of optimal intervals for cardiovascular risk assessment are uncertain. StatinRegimensUsedinAvailableTrials Dose, mga Statin Low Moderate High Atorvastatin 10-20 40-80 Fluvastatin 20–40 40 twice daily Fluvastatin extended release 80 Lovastatin 20 40 aDosecategoriesarefromthe AmericanCollegeof Pitavastatin 1 2-4 Cardiology/AmericanHeart Pravastatin 10-20 40-80 Association2013guidelinesonthe Rosuvastatin 5-10 20-40 treatmentofbloodcholesterolto reduceatherosclerotic Simvastatin 10 20-40 24 cardiovascularriskinadults. Thedegreeofcholesterolreductionmaybeattributable, shared decision making that weighs the potential benefits and in part, to interindividual variability in response to statins, not just harms, the uncertainty about risk prediction, and individual statin dosage. There Suggestions for Practice Regarding the I Statement may be individual clinical circumstances that warrant consider- for Initiating Statin Therapy for Primary Prevention ation of use of high-dose statins; decisions about dose should be based on shared decision making between patients and clinicians. Anotherstudyusing Burden of Disease datafromtheMedicalExpenditurePanelSurvey,whichdidallowfor In 2011, an estimated 375 000 adults died of coronary heart dis- thedifferentiationofindividualswithandwithoutvasculardisease easeand130 000diedofcerebrovasculardisease. Themediandurationoffollow-upwas3years, Other Considerations and 3 trials were stopped early because of observed benefits in the Research Needs and Gaps interventiongroup. Research is needed to Scandinavian Cardiac Outcomes Trial—Lipid Lowering Arm) evaluate the optimal frequency of cardiovascular risk assessment, trials10,40 because of their large sample sizes, the estimate was including serum lipid screening. After6months harms of initiating statin use for the primary prevention of cardio- to 6 years of follow-up, statin use was associated with a decreased vascular events in adults 76 years and older. However, in the available estimates when trials were stratified according to dose. Nostudieswere tent across different clinical and demographic subgroups (even identifiedthatdirectlycomparedtreatmentwithstatinstitratedto among adults without marked dyslipidemia). Becausetheab- Harms of Statin Use soluteunderlyingriskislower,feweradultswhosmokeorhavedys- In randomized trials of statin use for the primary prevention of lipidemia,diabetes,orhypertensionanda7. As such, any decision to ini- withdrawal because of adverse events compared with placebo, tiateuseofalow-tomoderate-dosestatininthispopulationshould and there were no statistically significant differences in the risk of involve shared decision making that weighs the potential benefits experiencing any serious adverse event. It should also take into consideration the personal prefer- levels with statin use. Some comments requested clarification regarding the op- foundnoassociationwithstatinuse,41butananalysisfromtheWo- timal dose of statins. Thesepersonsshouldbescreenedandtreatedinaccordancetoclini- Recommendations of Others cal judgment for the treatment of dyslipidemia. Thetreatmentstrat- ment is no longer relevant and has been replaced by a preventive egy is treatment-to-target rather than by therapy dose (eg, 50% medication framework. Total cardiovascularrisk:areportoftheAmerican AspirinUsetoPreventCardiovascularDiseaseand cholesterol and risk of mortality in the oldest old. The tables and figures in this Pocket Guide follow the numbering of the 2017 Global Strategy Report for reference consistency. These include genetic abnormalities, abnormal lung development and accelerated aging. These comorbidities should be actively sought and treated appropriately when present as they can influence mortality and hospitalizations independently. Spirometry is the most reproducible and objective measurement of airflow limitation. Despite its good sensitivity, peak expiratory flow measurement alone cannot be reliably used as the only diagnostic test because of its weak specificity. Spirometry should be performed after the administration of an adequate dose of at least one short-acting inhaled bronchodilator in order to minimize variability. Spirometry in conjunction with patient symptoms and exacerbation history remains vital for the diagnosis, prognostication and consideration of other important therapeutic approaches. In the refined assessment scheme, patients should undergo spirometry to determine the severity of airflow limitation (i. Finally, their history of exacerbations (including prior hospitalizations) should be recorded. This classification scheme may facilitate consideration of individual therapies (exacerbation prevention versus symptom relief as outlined in the above example) and also help guide escalation and de-escalation therapeutic strategies for a specific patient. Pharmacotherapy and nicotine replacement reliably increase long-term smoking abstinence rates. However, individual patient factors must be considered when evaluating the patient’s need for supplemental oxygen. If effective resources and time are dedicated to smoking cessation, long-term quit success rates of up to 25% can be achieved. Counseling delivered by physicians and other health professionals significantly increases quit rates over self-initiated strategies. Stimulation of beta2-adrenergic receptors can produce resting sinus tachycardia and has the potential to precipitate cardiac rhythm disturbances in susceptible patients. Exaggerated somatic tremor is troublesome in some older patients treated with higher doses of beta2-agonists, regardless of route of administration. Antimuscarinic drugs  Antimuscarinic drugs block the bronchoconstrictor effects of acetylcholine on M3 muscarinic receptors expressed in airway smooth muscle. Inhaled anticholinergic drugs are poorly absorbed which limits the troublesome systemic effects observed with atropine. Toxicity is dose-related, which is a particular problem with xanthine derivatives because their therapeutic ratio is small and most of the benefit occurs only when near-toxic doses are given. Results from withdrawal studies provide equivocal results regarding consequences of withdrawal on lung function, symptoms and exacerbations. Reduction of total personal exposure to occupational dusts, fumes, and gases, and to indoor and outdoor air pollutants, should also be addressed. Key points for the use of other pharmacologic treatments are summarized in Table 4. Symptoms, exacerbations and objective measures of airflow limitation should be monitored to determine when to modify management and to identify any complications and/or comorbidities that may develop. These changes contribute to increased dyspnea that is the key symptom of an exacerbation. Other symptoms include increased sputum purulence and volume, together with increased cough and wheeze. More than 80% of exacerbations are managed on an outpatient basis with pharmacologic therapies including bronchodilators, corticosteroids, and antibiotics. Acute respiratory failure — non-life-threatening: Respiratory rate: > 30 breaths per minute; using accessory respiratory muscles; no change in mental status; hypoxemia improved with supplemental oxygen via Venturi mask 25-30% FiO2; hypercarbia i. Acute respiratory failure — life-threatening: Respiratory rate: > 30 breaths per minute; using accessory respiratory muscles; acute changes in mental status; hypoxemia not improved with supplemental oxygen via Venturi mask or requiring FiO2 > 40%; hypercarbia i. The management of severe, but not life threatening, exacerbations is outlined in Table 5. Respiratory Support Oxygen therapy  This is a key component of hospital treatment of an exacerbation. Supplemental oxygen should be titrated to improve the patient’s hypoxemia with a target saturation of 88- 92%. The indications for initiating invasive mechanical ventilation during an exacerbation are shown in Table 5. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.

Diseases

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The last major version of the ensemble (and that edited here) cholesterol lowering vegetarian diet discount atorvastatin online, the standardized ensemble offers no substantive additions or deletions cholesterol in large shrimp discount atorvastatin 10 mg otc; the content of the text is entirely identical to the revised ensemble cholesterol in raw eggs purchase atorvastatin with a visa. Its editor chose to replace the assertion that Nature wished ‘‘to recuperate’’ women’s de- fective heat by the more poetic phrase ‘‘to temper the poverty of their heat’’ (¶) good cholesterol definition cheap 40 mg atorvastatin visa. This editor had a particular taste for synonymy xenical cholesterol buy discount atorvastatin 20 mg online, that is, introducing a sec- ond term to more fully convey breadth of meaning: the veins of the womb are both ‘‘wide and open,’’ not simply ‘‘open’’ (¶); pain occurs in the ‘‘more prominent’’ or the more anterior part of the womb (¶). This editor was also not averse to what apparently passed for ethnic humor in the thirteenth Introduction  century: s/he was responsible for the suggestion that the language of Lom- bards is particularly noxious to the newborn (¶). Finally and more positively, to this editor can be attributed regularized chapter divisions and rubrics. True, there should have been quite a few more chapter headings than were actually added. For example, in the Treatments for Women section, the chapter on cancer of the nose is followed immediately by one on provoking the menses (¶¶ and ), with no chapter division to signal the separation of two such obviously distinct topics. Still, the addition of the regularized rubrics undoubtedly increased the utility of the text for ref- erence purposes. Perhaps the most important of these rubrics was the open- ing one: ‘‘On the Diseases of Women According to Trotula’’ (De passionibus mulierum secundum Trotulam), yet another reinforcement of the attribution of this wide-ranging collection of texts on women’s medicine to the single author ‘‘Trotula. Many of the changes that the texts underwent between their com- position and the mid-thirteenth century were subtle and insignificant for the works’ actual theoretical or therapeutic content. Some changes might be con- sidered real improvements: the transposition of several of Treatments for Women’s cosmetic chapters into the Women’s Cosmetics section rendered them more accessible, while additions like the precise instructions for the prepara- tion of starch (¶) must have been genuinely helpful. But some changes were not calculated emendments but accidental errors that crept into the texts. The loss of the negative in the opening sentence of ¶ in Treatments for Women, for example, had the result of encouraging treatment of old women suffer- ing from a sanious flux, whereas the original text had said it was pointless to treat them because they were already incapable of bearing children. Many errors or corruptions, of course, would not have been obvious to readers without multiple copies of the texts at hand. Yet the failure of later scribes or readers to correct some of the more glaring errors must give us pause when imagining how actively the standardized ensemble in particular might  Introduction have been used in any kind of clinical setting. Not a single reader of the extant standardized ensemble manuscripts seems to have noticed, for example, the obvious logical inconsistency within a recipe in Women’s Cosmetics for redden- ing the skin and lips, where an accidental misreading changed a prescription to use a violet dye into one for a green dye (¶). And one wonders how even the most dedicated occultist could have made sense of the garbled magical passages in ¶¶ and . It is likely, however, that the standardized ensemble became the preferred version of the Trotula texts, not because it was scrutinized in de- tail for every possible remedy for women’s conditions (there are, after all, over three hundred different prescribed therapies), but because it could serve a more general function as a basic referencework on fertility—a subject on which there was increasing concern from the thirteenth century on. L D The standardized ensemble is today found in twenty-nine manuscripts from all parts of Latinate Europe. In the fifteenth century, even though other forms of the texts were still being tran- scribed in many parts of Europe, the standardized ensemble seems to have been rarely copied in Italy, England, or even in France, where the text had earlier achieved its greatest popularity. Most of the extant fifteenth-century manu- scripts come from central and eastern Europe. The standardized ensemble seems always to have been closely associated with university circles and in this context manuscripts preserved their utilityas reference texts for years after their initial composition. At his death (sometime between  and ), the theo- logian Gérard of Utrecht left his copy to the College of the Sorbonne in Paris, where it was to remain until the modern period. Caillau then gave the manuscript to his patron the duke in exchange for another book. A final indication of the standardized ensemble’s utility was its translation in the fifteenth century into the vernacular, once into Dutch, once, perhaps twice into French, and twice into German. Copy after copy reproduced the text with hardly any variation, in stark contrast to earlier versions, which copyists often felt free to abridge or emend as they liked. One scribe re- interpreted the title as ‘‘The Good TreatiseWhich Is Entitled ‘The Old Woman on the Sufferings [of Women]. Kraut’s major editorial innova- tion was to reorganize all the material from the ensemble into one smoothly ordered summa, rearranging the ensemble’s disparate parts into sixty-one chap- ters. Gone, too, of course, were any remaining hints that the Trotula was a concretion of a variety of sources from a variety of differ- ent authors. While in general Kraut seems to have been concerned to preserve most of the material he found in the standardized ensemble, humanist that he was he could not refrain entirely from tidying up the text. He suppressed the two references to magical practices to aid birth in Conditions of Women (¶¶ and ), he clarified that the contraceptives were to be used only if out of fear of death the woman did not dare conceive,221 and he apologized for the in- clusion of mechanisms to ‘‘restore’’ virginity, saying that he would not have included them were they not necessary to aid in conception. Kraut was apparently motivated by the desire to make both the femininity and the originalityof ‘‘Trotula’’ more apparent. Whereas neither the original Condi- tions of Women nor the standardized ensemble had offered any direct hint of the author’s gender, Kraut, presuming the whole of his newly unified text to be the work of a single feminine author, altered the preface to stress her gender. He also omitted the names of Hippocrates and Galen and even the author’s clear admission that the work was a compilation of excerpts from other writings. Kraut’s artificial text with his artificially unified and gendered author proved to be authoritative; all subsequent Renaissance editors reprinted this humanist fabrication rather than returning to the medieval manuscripts. Kraut’s edition thus occluded the medieval history of the texts from view, with the result that most of the modern controversy about the authoress ‘‘Trotula’’ has produced little more than idle speculation. The Trotula texts, whoever their authors may have been, were very real and very influential throughout Europe for nearly half a millennium. What- ever their relationship to Trota or the other women of Salerno, the Trotula were one of the pillars on which later medieval culture was built, being present in the libraries of physicians and surgeons, monks and philosophers, theolo- gians and princes from Italy to Ireland, from Spain to Poland. When Latin- ate physicians or surgeons (such as the anonymous surgeon who owned the Laon manuscript used in the edition here) wanted a handbook on women’s medicine, they used the Trotula. When medieval translators looked for gyne- cological material to render into the vernacular, it was to the Trotula texts that they most frequently turned. Of ten gynecological texts composed in Middle English between the fourteenth and fifteenth centuries, for example, five are renditions of the Trotula. The Latin texts probably only rarely made their way into women’s hands in the early years after their composition, perhaps not at all after the thirteenth century. The Laon manuscript just mentioned, for example, passed from that anonymous male surgeon into the holdings of the cathedral of Laon, where it was annotated and used by the canons of the cathedral for the rest of the Middle Ages. Every other manuscript whose provenance is known is similarly found passing exclusively through the hands of men. Its early provenance is not known, but it has the distinction among the Latin Trotula manuscripts in being the smallest codex, a handbook less than six by four inches in size. It also contains only one other text: a brief tract on useful and harmful foods, which could, conceivably, be used for self-medication by controlling diet. There are no contemporary annotations to confirm owner- ship by a woman, but its small size (similar to that of the books of hours owned by many upper-class women in this period) and the absence of any other, more technical medical literature may suggest use by a layperson and so, perhaps, by a woman. The author of the earliest English translation, writ- ing in the late fourteenth or early fifteenth century, went so far as to demand of any male reader who happened upon the text that ‘‘he read it not in spite nor [in order to] slander any woman nor for any reason but for healing and helping them. It seems, then, that relative to their widespread popularity among male practitioners and intellectuals, it was only very infrequently that the Trotula found their way into the hands of women. Despite the recognition by the author of Conditions of Women that women often did not want to turn to male physicians, the Trotula seem to have functioned as a prime tool by which male practitioners did, in fact, come to have significant control over the practice of gynecology and cosmetics. Note on This Edition and Translation T E The following edition of the Trotula ensemble represents the standardized text as it circulated in the latter half of the thirteenth century through the turn of the fourteenth century. The nine manuscripts collated here were chosen on the basis of their early date and the integrity of their text. The text, including orthography, reflects that of the Basel manuscript, including the hand of the original scribe (B), that scribe’s own corrections (B1), and the corrections of a second, slightly later hand (B2). I have deviated from B’s text only in those cases where the orthography seemed misleading, or where the unanimous agreement of the other manuscripts suggested a lacuna or an error in B. Where B’s reading is unique but not necessarily erroneous, however, I have retained it despite the unanimity of the other manuscripts. All variants are noted in the apparatus with the following two exceptions: varia- tions in word order and orthography, except in those cases where they seemed potentially meaningful, and the presence orabsence of et except, again, in those cases where it might be important to the sense. Corrections or expunctions in the hand of the original scribes have not been specially flagged; the text has simply been read as corrected. It is meant not only to indicate the obvi- ous grammatical and topical breaks (and in this I have respected the manu- scripts’ readings as much as possible) but also to reflect the original compo- nent parts of the texts. Thus, strings of recipes will often be separated except in those instances (such as ¶) where they all come uninterrupted from a single source. More detailed information on when, exactly, this material entered the ensemble and on internal transpositions of material within the texts can be found in my  essay on the subject. B’s orthography displays certain Italianate features, such as a characteristic doubling of consonants (e. The text has been carefully corrected by a contemporary hand (B2), who notes a few omissions in the margins or interlinearly. The original scribe entered the text of the rubrics at the bottom of the page; these were then written in by the same hand. Contents: Johannes de Sancto Paolo, De simpli- cium medicinarum virtutibus; treatise on preparation of colors; Petrus His- panus, Liber de egritudinibus oculorum; idem, Tractatus secundus, i. Zacharias, Tractatus de passionibus oculorum; Trotula, standardized ensemble; Magister Petrus Lumbardus, Cure. Owner: original owner(s) unknown; apparently owned in the late fif- teenth century by Henricus de Sutton, who added some additional reme- dies at the end of the book, including one that he claims to have employed for pain in the penis and breasts. Contents: Isaac Israeli, De dietis particularibus; list of prebends in Laon, held predominantly by Italian canons, between  and ; Trotula, standardized ensemble; Richardus Anglicus, Anathomia. Owners: an unidentified male surgeon (partially erased owner’s mark: Iste liber est. Contents: Bernard de Gordon, Lilium medi-  Introduction cine; table of contents of whole codex; Alphita; Nicholaus, Synonima; Quid pro quo; Tabule Salerni; Nicholaus, De dosibus; Walter, De dosibus; Johannes Stephanus, De medicinis purgantibus; Trotula, standardized en- semble; Thadeus, Experimenta; idem, Practica disputata (an. Contents: Antidotarium Nicolai; Additiones Anthidotarii; Walter, De dosibus; Johannes Stephanus, De dosibus; Walter, De febribus; De conferentibus et nocentibus; He ben Mesue, De simplicibus medicinis; De medicinis solutivis in speciali; He ben Mesue, Liber graduum, followed by list of Arabic words and their definitions; Johannes Damascenus Nafra- nus, filius Mesuhe Calbdei, Agregatio vel antidotarium electuorum con- fectionum; Avicenna, Flebotomia; Rhazes, Flebotomia; Constantinus Afri- canus, Flebotomia; Lectura Johannis de Sancto Amando supra Antidotarium Nicolai; Ricardus Anglicus, De signis pronosticis; Rogerina maior; Rogerina minor; Trotula, standardized ensemble; Practica puerorum (inc. Contents: Mattheus Platearius, Circa instans;WalterAgi- lon, Conferentibus et nocentibus; Gerard of Montpellier, Summa de modo medendi; Walter Agilon, De dosibus; Trotula, standardized ensemble; Rhazes, Passiones sive Practica puerorum;RogerBaron,Rogerina maior; idem, Rogerina minor; Johannes de S. Because they reflect nothing about the thirteenth-century uses of the text, the rubrics of this Introduction  manuscript (which frequently agree little with the sense of the chapters) have not been noted in the apparatus. Contents: consists of five separate manuscripts, brought together by the fifteenth century at the latest. Owner: whole codex of five manuscripts owned in the fifteenth century by Johannes Spenlin of Rothenburg (d. Many rubrics illegible on film; upper parts of several folios damaged by water or acid, thus occasionally obscuring the text of the top – lines. Codex composed of two sepa- rate sections that were brought together by Johannes Medici alias Patz- ker, master of arts from Paris, provost and canon of Sanctus Johannes Maior, and cantor of the Church of the Holy Cross in Wrocław in the fif- teenth century. T T In the translation that follows, I have aimed for clarity above all. I have resisted the temptation to ‘‘diagnose’’ the conditions described and have preferred to replicate the sometimes loose phrasing of the Latin rather than offer more pre-  Introduction cise readings that presume the ideological framework of modern western bi- ology and medicine. Readers can decide for themselves if, for example, they wish to interpret infertility accompanied by dry lips and incessant thirst (¶) as a description of diabetes. I have also retained the grammatical voice of most instructions—that is, I have rendered passive constructions passivelyand active actively. Although admittedly this results in a somewhat uneven text, it has the virtue of reflecting some remnants of the distinctive tone of address of the three original texts. On the one hand, the names used by the authors of the origi- nal Trotula texts in twelfth-century southern Italy often became deformed in transmission (I have flagged only the major deviations in the notes to the edi- tion), or they may have referred to several different plants. Some species may now be extinct or their chemical properties may have changed slightly over the past eight hundred years. On the other hand, there are instances when mul- tiple Latin names seem to refer to the same plant, for example, altea, bismalua, euiscus, malua, and maluauiscus, all of which seem to refer to marsh mallow (Althaea officinalis L. Having said this, I also feel my objective as translator is to attempt to bring a world long since disappeared back to life for the reader. This, it seems to me, can best be accomplished byattempting to identify plants, animals, and other materia medica by signifiers we use today. Since I am neither a botanist nor a phytopharmacologist, I have availed myself of the work of linguists and historical botanists in translating the medieval Latin terms with modern English common names (and, for the sake of readers whose native language may not be English, in cross-identifying those common names with their Linnaean classifications in the Index Verborum). Any investi- gators, either historical or pharmaceutical, who wish to use these texts as the basis for scientific research should refer to the Latin text. Needless to say, I can in no sense endorse the therapeutic use of these prescriptions by lay readers. The Appendix provides full descriptions of their ingredients and preparations as described in the major twelfth-century Salernitan collection of compound medicines, the Antido- tarium Nicholai. As for weights and measures, I have not attempted to modern- Introduction  ize them. The description in the Antidotarium Nicholai can serve for the present purposes: ‘‘The following are the weights or measures which are used in the medicinal art and through subtle, ingenious, and clever study we have ordered them with the greatest diligence for the needs of those wishing to study the medical art Ascrupleistheweight of twenty grains;241 two scruples equal forty grains, and three scruples equal sixty grains. Those accompanying the Latin edi- tion are devoted to highlighting the most historically significant deviations of the standardized ensemble from earlier forms of the texts. These annota- tions are by no means exhaustive, though all points where the sense of the text was significantly altered have received some comment. The annotations to the translation discuss particular aspects of medieval medical theory or therapeu- tics and comment on other issues of historical interest. In several instances where textual corruption oralteration affects the sense of the translation, I have cross-referenced to the notes to the Latin edition. Edition and Translation of the Standardized Trotula Ensemble [Liber de Sinthom atibus ulierum ] a <Incipit liber de passionibus mulierum secundum Trotulam> [] Cum auctorb uniuersitatisc deus in prima mundi constitutione rerum natu- ras singulas iuxta genus suum distingueret, naturam humanamd supra cetera dignitate singulari consecrauit, cui super aliorum animalium conditionem ra- tionis et intellectuse libertatem dedit, eiusque perpetuam uolens subsistere generationem,f in sexu dispari ordinans principium future sobolis propaga- tioneg prouida dispensanteh deliberatione, masculum et feminam creauit eos. Sed ne nimis in alterutram naturam masculus habundaret, opposita frigiditate et humiditatek mulieris ab excessu nimiol uoluit cohercere utm qualitates for- tiores, scilicetn caliditas et siccitas, uiro tamquam fortiori et dignio[rb]ri persone, debiliores,o scilicetp frigiditas et humiditas, utpote debiliori, scilicet mulieri,q dominarentur. Et ipse condicione sue fragili- tatis propter uerecundiam et faciei ruborem egritudinum suarum, qued ine secreciori loco accidunt,f angustias non audent medico reuelare. Earum igitur miseranda calamitas et maxime cuiusdamg mulieris gratia animum meum solli- citansh inpulit, ut circa egritudines earumi euidentius explanaremj earum sani- ¶a. And wishing to sustain its generation in perpetuity, He created the male and the female with provident, dispensing deliberation, laying out in the separate sexes the foundation for the propagation of future offspring.

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Birds can die from lead poisoning throughout the year but mortality is more likely after waterfowl hunting seasons cholesterol levels ldl hdl buy generic atorvastatin line. Lead exposure may also cause a variety of health effects in humans cholesterol levels by country purchase atorvastatin uk, particularly for children cholesterol lowering foods wikipedia atorvastatin 10 mg amex, foetuses and pregnant women cholesterol levels red yeast rice buy cheap atorvastatin 10 mg line. Species affected Many species of birds lowering good cholesterol foods list atorvastatin 20 mg buy without prescription, particularly waterbirds, birds of prey, scavenging birds, and mammals. Any species using an area where shooting with lead ammunition occurs or has occurred previously is at some risk of exposure and, potentially, poisoning. Lead-based paint, mine wastes, lead contaminated industrial effluents and other objects provide additional sources of contamination. How are animals exposed Waterfowl usually become poisoned after ingesting spent lead shot, mistaking to lead? Predators or scavengers may become poisoned after consuming animals that have been shot with lead ammunition. Lead from ammunition and fishing weights may slowly dissolve and enter groundwater, making it potentially harmful for plants, animals and perhaps humans if it enters water bodies or is taken up in plants. Lead poisoning in livestock often occurs after swallowing point sources of lead such as lead from inside vehicle/machine batteries or lead paint, but also through consuming contaminated water and food supplies. Cattle are at most risk due to their inquisitive natures and they often ‘taste-test’ objects. How are humans exposed Exposure to lead may occur through ingestion of contaminated food, such as to lead? Signs include weakness, lethargy, reluctance to fly or inability to sustainweakness, lethargy, reluctance to fly or inability to sustain flight, weight lossweakness, lethargy, reluctance to fly or inability to sustain causing emaciation (the breast-bone becomes prominent), greencausing emaciation (the breast bone becomes prominent), green-stained faeces and vent and fluid discharge from the bill. Those suffering from acute poisoning do not attempt to escape but will often seek isolation and protective coverattempt to escape but will often seek isolation and protective coverattempt to escape but will often seek isolation and protective cover making them difficult to find. In some species, the head and neck position may appear ‘crooked’ or bent during flight. A lot of green faeces in areas used by waterfowl may suggest lead poisoned birds and warrantsareas used by waterfowl may suggest lead poisoned birds and warrants further searches. Those suffering from acute poisoning may die with few clinical signs or lesions, but there are usually several weeksclinical signs or lesions, but there usually several weeks between exposure and death. Lead poisoned mute swanLead poisoned mute swan Cygnus olor with typical kinked neck and drooped wingstypical kinked neck and drooped wings (Martin Brown). Radiograph of dense pieces of lead shot inRadiograph of dense pieces of lead shot in the gizzard of a lead poisoned swan (the gizzard of a lead poisoned swan Martin Brown). These symptoms may be accompanied by muscle twitches (which may be more obvious around theaccompanied by muscle twitches (which may be more obvious around the face), blindness, staggeringblindness, staggering and gazing at the sky (‘star-gazing’)gazing’). Obvious symptoms in humans usually don’t appear untilObvious symptoms in humans usually don’t appear until sufficient amounts of lead have accumulated. Symptoms in children include: loss of appetite, weight loss, fatigue, abdominal pain, vomiting, constipation and learning difficulties. Symptoms in adults may include pain and numbness, muscular weakness,Symptoms in adults may include pain and numbness, muscular weakness,Symptoms in adults may include pain and numbness, muscular weakness, headache, abdominal pain, memory loss, miscarriage or premature birth inheadache, abdominal pain, memory loss, miscarriage or premature birth inheadache, abdominal pain, memory loss, miscarriage or premature birth in pregnant women and fatigue. A blue line around the gums and a metallic taste in the mouth may indicate lead poisoning. Other less ‘identifiable’ symptoms include affects on cognitive function, blood pressure and kidneysymptoms include affects on cognitive function, blood pressure and kidneysymptoms include affects on cognitive function, blood pressure and kidney function. Depending on local arrangements, suspected cases in livestock should be reported to national authorities. Diagnosis Confirmation of lead poisoning as a cause of death can only be determined by a combination of pathology, toxicological findings, clinical signs and field observations. It is useful to record whether dead birds have lead shot or lead particles in the gizzard although this does not provide a confirmative diagnosis. For dead birds, whole carcases should be submitted to a diagnostic laboratory but if this is not possible, liver and/or kidneys can be submitted, frozen and wrapped separately in aluminium foil. Lead levels in live birds can be determined through blood screening and through indirect measurements using blood enzymes. Post mortem examination should confirm lead poisoning through the detection of toxic levels of lead in kidney and/or liver tissue of affected animals. Blood samples can be taken from live animals suspected of having lead poisoning to confirm diagnosis. For humans, a blood test can screen for harmful levels of lead in the body and confirm diagnosis. Livestock Ensure that livestock do not have access to potential sources of lead such as old batteries, broken battery cases and spilled contents, lead paint, sump oil, contaminated soil from lead mining, and other farm machinery/rubbish. Check for these sources before putting stock onto new land and by checking areas ahead when driving stock. Animals in the early stages of poisoning are more likely to respond to treatment than those severely affected. This is the only long-term solution for significantly reducing wild bird mortality from lead poisoning. Pick up and safely dispose of birds known, or suspected to be, contaminated by lead so that scavenging species do not ingest them. Habitat management to temporarily reduce the availability of lead shot: - Lower water levels in feeding grounds after the hunting season to deter waterfowl from an area or increase water levels so that shot is out of reach of certain waterfowl species. These methods require knowledge of where the birds are picking up lead and knowledge of the wetlands’ hunting history and historical lead exposure. Differences in feeding habitat should be considered for the broad spectrum of wildlife using the area. Treatment of poisoned birds is generally impractical but endangered species or those of high value may warrant treatment, which involves the use of lead-chelating chemicals under veterinary supervision. Humans Humans should reduce their exposure to lead by whatever means including reducing the amount of food consumed containing lead shot or other ammunition. Hunters should be encouraged by whatever means (legislation or education) to only use non-toxic shot when hunting. Lead poisoning is a particular problem in dabbling ducks, diving ducks and grazing species and accounts for an estimated 9% of waterfowl mortality in Europe alone. Morbidity and mortality also occurs in bird species that predate and scavenge animals shot with lead ammunition and has also been reported in upland bird species, reptiles and small mammals. The impacts of lead poisoning on threatened animal species and populations are also a great cause for concern. Effect on livestock Lead is a common cause of morbidity and mortality in cattle but is less frequently reported in sheep, goats and other livestock. Domestic animals are most vulnerable when they have access to the sources of lead listed above. Mortality in exposed groups can be high if animals are not removed from the source promptly. Effect on humans Lead can cause damage to various body systems including the nervous and reproductive systems and the kidneys and can cause anaemia and high blood pressure. Children, foetuses and pregnant women are particularly vulnerable to its toxic effects and there is now considered to be no safe level of lead exposure below which toxic effects do not occur. Economic importance There is potential for significant economic losses to the livestock industry due to death and illness of poisoned animals and restrictions on the sale of produce. Even low levels of exposure, which may not cause clinical illness, can cause concentrations of lead residues in milk, offal and meat to exceed residue limits and be deemed unfit for human consumption. The effects of lead on cognitive function of humans, together with other health impacts, have socioeconomic impacts. In: Field manual of wildlife diseases: websites general field procedures and diseases of birds. A bacterial infection that affects humans and animals following exposure to species of Leptospira spp. Bacteria are excreted into the environment in the urine of infected animals and can survive for up to several months in contaminated soil and for several weeks in contaminated mud slurries, although they do not survive well in river water. The primary reservoir hosts for most Leptospira species are wild mammals, particularly rodents, in which they cause little or no clinical disease. Leptospirosis is most commonly transmitted indirectly through contact with contaminated water or soil but can also be transmitted directly between mammalian hosts. It is mainly endemic in countries with humid subtropical or tropical climates and is a notable cause of morbidity and mortality in humans and animals in the western hemisphere. It occurs most commonly during the rainy season in the tropics and in the summer and autumn in temperate regions. Conditions leading to an increase of contaminated surface water or soil, such as rain, floods and disasters increase the risk of leptospirosis and may result in epidemics. In addition, during periods of drought, risks of infection may increase in association with the attraction of both humans and animals to water bodies. In humans, the range of symptoms is very wide and variable, from mild non- specific signs to lethal infection. There are over 200 pathogenic serovars with many being host adapted to wildlife species in which they cause little clinical disease. Most commonly found in many species of wild and domestic animals including rodents, cattle, sheep, goats, pigs, horses and dogs. Humans, particularly those working in or close to water, are very susceptible to illness caused by certain strains. Geographic distribution Occurs worldwide but most commonly in temperate or tropical climates with high rainfall. The highest concentrations of cases are often in developing countries where wet farming and rodent populations combine and where freshwater floods may occur. Leptospirosis is particularly prevalent in warm and humid climates, marshy or wet areas, and in regions with an alkaline soil pH. How is the disease Infection is acquired through direct contact with infected urine or indirect transmitted to animals? Occasionally, infection can spread through the inhalation/ingestion of aerosolised urine or water. Transmission may also occur through contact with infected normal, aborted or stillborn foetuses, or vaginal discharge and placental fluids. How does the disease Infection is spread from one animal group to another by an infected animal spread between groups of which will shed the bacteria into the environment, most commonly in urine. Infection is maintained through survival of bacteria in the kidney of a reservoir host, where they are protected from the host’s immune response. How is the disease Infection is acquired through contact with water, food or soil contaminated transmitted to humans? Bacteria may be ingested or may gain entry across intact mucous membranes or broken skin. In accidental hosts symptoms may be very variable, and depend, in part, on the bacterial strain involved. Initial clinical signs are generally non-specific and include lethargy and anorexia, associated with fever. Disease may progress to septicaemia and in some cases may result in death of the host. Infection during pregnancy may result in abortion, still-birth, weak offspring or infected but healthy offspring. In horses, many infections are subclinical and eye disease is the most common symptom. During the initial incubation period of roughly seven days (range 2-19), signs are non-specific and include fever, headache, chills, a rash and muscular pain. The kidneys and liver are common target organs and symptoms might include vomiting, anaemia and jaundice. Recommended action if Contact and seek assistance from human and animal health professionals suspected immediately if there is any illness in people and/or livestock. Diagnosis Clinical diagnosis is not straightforward due to the non-specific nature and wide variability in symptoms observed. Demonstration of the presence of the organism or an antibody response to the organism are required. In dead animals, the liver, lung, brain, kidney, genital tract and the body fluid of foetuses can be used for detecting bacteria. Monitoring of outbreaks in animals and humans can also help assess the contribution of animals to human illness. Selective rodent control can prevent infections in livestock and humans, particularly in urban areas. Minimise contact with reservoir host species, rodents in particular, and minimise contact with potentially contaminated food/water/bedding. Livestock Good sanitation and the prevention of contact with contaminated environments or infected wildlife, particularly rodents, can decrease the risk of infection. Fence stream banks and watering holes, to limit access by livestock to water bodies contaminated by urine from infected animals, and to reduce contamination of water courses. Provide clean drinking water in separate watering tanks located away from potentially contaminated water sources. Chlorinate contained drinking water sources and prevent urine contamination of food and water where possible. Do not chlorinate natural water bodies as this will have an adverse effect on the wetland ecosystem. Keep livestock wastes away from pastures, animal housing and feeding sites and away from water courses in so far as possible. Replacement stock should be selected from herds that have tested negative for leptospirosis.

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