By Y. Myxir. University of Houston, Downtown. 2019.

The research done by Peju and Rajat has been referred to many times over the years by other researchers who studied and clinically applied the anti-bacterial properties of urea order vardenafil uk. S Kirk buy cheap vardenafil on line, published their report entitled "Urea as a Bactericide and Its Application in the Treatment of Wounds" order 10 mg vardenafil with visa. Symmers and Kirk were actually military doctors, so of course their work with urea centered around its use as an antiseptic for wounds. In their report, they comment that "all the wounded soldiers under our care in the Ulster Volunteer Force Hospital have been treated with urea, and it has been found that Duncan was the Attending Surgeon, Genito- Urinary Specialist and co-founder of the Volunteer Hospital, New York City. Duncan used the word Autotherapy, as have other doctors, to refer to the utilization of natural substances of the body to create a healing response. Duncan describes his clinical observations on the use of urine therapy in his medical practice, and discusses reports from other doctors who were using urine therapy at the time. Duncan was a practicing surgeon, founder of the Volunteer Hospital in New York City, a Genito-Urinary Specialist –and a supporter of natural urine therapy. Duncan observed: "There is scarcely a pathogenic (disease) condition which does not affect the urine contents. In the New York Medical Journal of December 14 and 21, 1912 and in the Therapeutic Record of January 1914, I reported that I was employing urine successfully in the treatment of many conditions. A teaspoonful of morning urine one-half hour before ineals completely cleared up the case within two days. Upon rising from a sitting posture it was necessary to void urine within a minute. He was instructed to take a drachm of early morning urine a half hour before each meal. Within twenty-four hours his improved condition was so marked that be became alarmed thinking his recovery was too quick. Moore was republished in the New Albany Medical Herald, February, 1915, from the Archives of Pediatrics: "I find diabetes mellitus an uncommonly difficult disease for the general practitioner to treat. They gave me a history of her having felt badly for a few days and of having had some fever. In a couple of days they informed me her temperature was normal and she was feeling all right, but she was passing a large (sticky) amount of urine frequently. Having tried all methods of treatment on several other patients whom I have had within the past few months suffering with glycosuria (sugar in the urine), I decided 77 to try Autotherapy, for I had known cases of icterus (jaundice) which had failed to respond to any medical treatment, but cleared up in a very short time when they were given their own urine to drink. I gave this little girl three ounces of her own urine three times daily and then examined for the sugar percentage and found that when she was taking the urine, the percentage of sugar dropped, and that when it was withdrawn, the percentage increased. The treatment consisted of a twenty minim injection of urine diluted 1 to 100 with distilled water. He improved with this to a certain point but did not entirely recover until I used a less diluted urine, after which he made a prompt recovery. Two months after he recovered a urinalysis showed absence of pus and renal cells and a normal volume of urine. Deachman comments: "These are but a few of the many cases I have successfully treated by this method, the value of which I consider inestimable. I make this statement after a wide experience in using urine] in treating many patients suffering with chronic diseases and particularly in the use of urine as an autotherapeutic agent. I am free to say that the results obtained with urine therapy are [far better] than the usual recognized methods. From the Departments of Pharmacology and Experimental Bacteriology, University of Cincinnati. The researchers in this study, Foulger and Foshay, found that urea was extremely effective in curing or preventing a wide variety of bacterial infections and, unlike sulfa drugs, which were widely used at the time, had no deleterious side effects: ". Ramsden (1902) made the very interesting observation that urea prevents putrefaction. In one case with a chronic staphylococcus blood infection, urea (powder) was sprinkled between the layers of tissue and the wound then. Infected wounds dressed with urea powder gave better results than similar wounds treated by other methods. F,) selected as material for a clinical study of urea a few cases of purulent otitis media (middle ear infection). The results so far obtained suggest that urea may be of considerable value in the treatment of purulent discharges of many types and in the treatment, also of suppurating wounds producing foul odors. The cheapness and harmlessness of urea should encourage other investigations of its clinical use. As an added note, Foulger and Foshay also discovered, as did other urea researchers later, that destroying strong bacterial strains such as those which cause staph and strep infections required longer exposure to urea than some other types of bacteria, which is something to keep in mind when using urine therapy to combat staph and strep infections. Millar, 80 From the Department of Surgery, College of Medicine of the University of Cincinnati. Millar began using urea crystals to heal external cancerous ulcerations: "The peculiarly penetrating odor of a sloughing cancer is one of the horrible aspects of this disease. For the past year at the Tumor Clinic of the Cincinnati General Hospital, urea crystals have been advocated and prescribed in such cases. Although they dissolve in a few minutes, the offensive character of the ulcer becomes less with each application. The crystals are cheap, they possess a considerable antiseptic value, and there is no fear of a systemic reaction. Martin Krebs, (pediatri- Report #5 cian), from a lecture delivered at the Society of Pediatricians, Leipzig. Duncan and other practitioners, he referred to this practice as autourine therapy. The use of auto-urine therapy is also indicated in the treatment of muscular spasms caused by birth traumas to the brain. The boy immediately began breathing better, and in a few minutes the extreme redness of the eyes disappeared. Another child who had spent 31/2 months in a sanatorium for treatment of his asthma, received an injection of 4 cc. After the first injection of urine, he began to loosen and open his fists, his general movements were freer and he laughed, something which his parents had never seen him do. Also, the attacks of angina which he had experienced, stopped after the injection. I highly recommend the therapy in the treatment of hayfever and asthma, and I would like to see further follow-up clinical studies done on its application to the other conditions that were mentioned. Krebs undertook further clinical research studies in 1940 using natural urine in treating children.

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If severe hypothermia buy cheap vardenafil 10 mg online, (34 358C [93 958F]) safe 20 mg vardenafil, moderate (30 348C consider colonic/bladder irrigation best purchase vardenafil, peritoneal or [86 938F]), or severe (<308C[<868F]) pleural lavage, extracorporeal blood rewarming. Caution with hypothermia, arrhythmia (atrial fibrillation, brady 2 fluid overload (decreased cardiac output in hypother cardia, ventricular tachycardia), acidosis (meta mic patients) and vasopressors (arrhythmogenic bolic, respiratory), anoxic brain injury, cerebral potential). Chemotherapy Induced Nausea and Vomiting gastric electromechanical events are perceived as (p. If progressing from solids to liquids, con Parkinson’s, dementia, amyotrophic lateral sider structural disorders and proceed to step 4 sclerosis, Guillain Barre, myasthenia gravis, cer 3. For motility disorders, is the dysphagia pro ebral palsy, Huntington’s, tardive dyskinesia, gressive? If diverticulum, cervical webs, oropharyngeal intermittent, consider esophageal ring tumors, osteophytes and skeletal abnormality, 5. Consider non gastric causes of dyspepsia (car tory treatment (proton pump inhibitors more effec diac, pulmonary, hepatobiliary, colonic, musculos tive than H2 blockers for esophagitis. Use antacids as keletal, medications, and dietary indiscretion) and breakthrough). Promotility weight loss, Dysphagia), refer for gastroscopy to agent (domperidone) check for gastric cancer. Transfor ofgastriculcers,80% ofgastriccancers,and90%of mation to low grade dysplasia 4%/year, high gastric lymphomas grade dysplasia 1%/year and cancer 0. Rigidity, positive psoas sign, fever and rebound tenderness increase likelihood of appendicitis. If pain is defined and difficult to clearly differentiate on intra abdominal, the pain will not increase as tensed examination), ovary, uterus, fallopian tube rectus muscles protect the underlying viscus) (pelvic structures require bimanual examination), lymphoma (does not move with inspiration, usually more central) Related Topic Acute Pancreatitis (p. If biliary pain despite cholecys (70%), biliary colic (20%, intermittent obstruction), tectomy, consider possibility of a retained common acute cholecystitis (cystic duct obstruction), choledo bile duct stone, sphincter of Oddi dysfunction, or cholithiasis (common bile duct obstruction), ascend functional pain ing cholangitis (stasis and infection of biliary tract. For patients with suspected hypovolemia not due to blood loss, severe postural dizziness, postural pulse increment, or dry axilla can be helpful. Continue ing endoscopy (90% chance), non bleeding visible octreotide for 3 5 days. Repeat endoscopy every vessel (50% chance), adherent clot (25 30% 2 weeks until varices obliterated, then at 1 3 months chance). If failed, add metronidazole and of inflammatory bowel disease, infectious colitis ciprofloxacin. If failed, consider immunosuppressive ther ischemic colitis, and obstructive colon cancer apy. If plus one of the following (dehydration, delirium failed, add budesonide enemas. Patients with toxic with bowel rest, hydration, nutrition, parenteral megacolon who do not respond to therapy within steroids, and adjunctive rectal and oral therapy. Perform a rectal examination weeks, fecal leukocytes, semi formed stools, and test for fecal occult blood. Avoid use of antiperistaltic sens 73%, spc 84%), fecal lactoferrin (inflamma agents (opiates, loperamide). Antidiar stool assays after treatment unless patient has rheal agents if not inflammatory (bismuth subsalicy moderate or severe diarrhea. Perform a rectal spc 99%), antiendomysial IgA, antigliadin IgG examination and test for fecal occult blood (celiac patients with IgA deficiency may not be antitransglutaminase positive). Rate >3 months of abdominal pain relieved with defe amount of stool in each quadrant from 0 3. Symptoms include (1) abdominal pain, flatulence, or bowel irregularity for >2 years; (2) description of abdominal pain as ‘‘burning, cutting, very strong, terrible, feeling of pressure, dull, boring, or not so bad’’; and (3) alternating constipation and diarrhea. Patients with score >7 or any clinical signs usually resonant over the kidney of decompensation (variceal bleeding, ascites, ence 4. A friction rub may occasionally be heard over the phalopathy) should be considered for liver transplan liver, but never over the kidney because it is too tation. Alternative calculation is atotal score ofall five posterior parameters, grade A=5 6, grade B=7 9, grade 5. If nega ders), medication history (acetaminophen/paraceta tive, hepatomegaly is unlikely. It is often mistaken for a patho atrophy, proximal muscle weakness, peripheral logical enlargement of the liver or gallbladder. Most powerful findings for making diagnosis of ascites are positive fluid wave, shifting dullness, or peripheral edema. For pruritus, consider cannot be secreted into the biliary system) cholestyramine, rifampin, and naltrexone. Rectal examination for occult blood row response, <2% suggests hypoproliferative (i. May be associated with fever, swelling, ten or without fever) treat precipitating factor, fluids, derness, tachypnea, hypertension, nausea, and vomit pain control, transfusions (simple or exchange) ing. One prior to certain procedures (expect platelet rise of third of the total body platelets is found in the spleen $5/unit). Does not which may increase the platelet count within days respond to plasma exchange andlastsforafewweeks. With the excep observation if no bleeding and platelets tion of platelet inhibitors, there is usually 5 7 days >20Â103/mL. Otherwise, treat with romiplostim between initiation of drug therapy and platelet drop or eltrombopag if patient isreceiving themedication for thefirst time. Historically, anemia that usually affects children but occasionally sucrose hemolysis test used for screening, fol presents in adults. U/S of calf veins is not routinely $25% extend into proximal veins within a week performed because of lower sensitivity (70%). Particularly dermatan sulfate, and to plasma anti Xa level of important in renal failure chondroitin sulfate. Milder form Stop transfusion and check reaction minor antigen, 1/600,000 of above blood. Associated with autoimmune hemolytic anemia taining such inclusions are called siderocytes, due to (microspherocytes), hereditary spherocytosis, and hyposplenism, thalassemia, and sideroblastic disor Clostridium infections ders. The percussion note is dull over the spleen but is (Histoplasma), parasitic (malaria, Leishmania, usually resonant over the kidney trypanosomiasis) 6. Rather, the examination for splenomegaly is most useful to rule in the diagnosis of splenomegalyamong patients in whom there is a clinical suspicion of at least 10%. If no dullness is detected on percussion, there is no need to palpate as the results of palpation will not effectively rule in or rule out splenic enlargement. If the possibility of missing splenic enlargement remains an important clinical concern, then ultrasound or scintigraphy is indicated. If both tests are positive,thediagnosisofsplenomegaly isestablished(providing theclinical suspicionofsplenomegaly wasat least10% beforeexamination). Myeloid leukemia sel phages, eosinophils, basophils, mast cells, erythro dom presents in lymph nodes cytes, platelets, and their precursors. This gene product plete remission with induction chemotherapy, espe plays a key role in leukemogenesis.

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All studies have some degree of useful information cheap generic vardenafil canada, and the aforementioned articles are useful for reviewing and relearning background information order 10 mg vardenafil mastercard. A partial list of common and important medical journals is included in the Bibliography buy vardenafil amex. Usually, when asked about articles in the medical literature, one thinks of clini- cal research studies. These include such epidemiological studies as case–control, cohort or cross-sectional studies, and randomized clinical trials. These are not the only types of articles that are important for the reader of the medical liter- ature. There are several other broad types of articles with which you should be familiar, and each has its own strengths and weaknesses. We will discuss studies other than clinical research in this chapter, and will address the common types of clinical research studies in Chapter 6. Basic science research Animal or basic science research studies are usually considered pure research. They may be of questionable usefulness in your patients since people clearly are not laboratory rats and in vitro does not always equal in vivo. However, they are useful preliminary stud- ies, and they may justify human clinical studies. It is only through these types 26 Essential Evidence-Based Medicine of studies that medicine will continue to push the envelope of our knowledge of physiological and biochemical mechanisms of disease. Animal or other bench research is sometimes used to rationalize certain treat- ments. This leap of faith may result in unhelpful, and potentially harmful, treat- ments being given to patients. An example of potentially useful basic science research is the discovery of angiostatin, a chemical that stops the growth of blood vessels into tumors. The publication of research done in mice showing that infu- sion of this chemical caused regression of tumors resulted in a sudden increase in inquiries to physicians from family members of cancer patients. These fam- ily members were hoping that they would be able to obtain the drug and get a cure for their loved ones. When the drug was given to patients in a clinical trial, the results were much less dramatic. This is not the only clinical trial that diplayed less dramatic results in humans. In another example, there were similar outcomes when bone-marrow transplant therapy was used to treat breast cancer. These had anti-inflammatory action without causing gastric mucosal irritation and gastrointestinal bleeding. However, extending the use of this class of drug to rou- tine pain management was not warranted. Finally, more recently, the drugs were found to actually increase the rate of heart attacks. Basic science research is important for increasing the content of biomedical knowledge. For instance, recent basic science research has demonstrated the plasticity of the nervous system. Prior to this discovery, it was standard teach- ing that nervous system cells were permanent and not able to regenerate. Cur- rent research now shows that new brain and nerve cells can be grown, in both animals and in humans. While not clinically useful at this time, it is promis- ing research for the future treatment of degenerative nerve disorders such as Alzheimer’s disease. Because these basic science studies seem to be more reliable given that they measure basic physiologic processes, the results of these studies are sometimes accepted without question. These studies used basic science The medical literature: an overview 27 techniques in clinical settings. Editorials Editorials are opinion pieces written by a recognized expert on a given topic. Editorials are the vehicle that puts a study into perspective and shows its use- fulness in clinical practice. They give contextual commentary to the study, but, because they are written by an expert who is giving an opinion, the piece incor- porates that expert’s biases. Editorials should be well referenced and they should be read with a skeptical eye and not be the only article that you use to form your opinion. Clinical review A clinical review article seeks to review all the important studies on a given sub- ject to date. It is written by an expert or someone with a special interest in the topic and is more up to date than a textbook. Clinical reviews are most useful for new learners updating their background information. Because a clinical review is written by a single author, it is subject to the writer’s biases in reporting the results of the referenced studies. However, if you are familiar with the background literature and can deter- mine the accuracy of the citations and subsequent recommendations, a review can help to put clinical problems into perspective. The overall strength of the review depends upon the strength (validity and impact) of each individual study. Meta-analysis or systematic review Meta-analysis or systematic review is a relatively new technique to provide a comprehensive and objective analysis of all clinical studies on a given topic. It attempts to combine many studies and is more objective in reviewing these stud- ies than a clinical review. The authors apply statistical techniques to quantita- tively combine the results of the selected studies. Components of a clinical research study Clinical studies should be reported upon in a standardized manner. Clinical epidemiological quality in molecular genetic research: the need for methodological standards. Components of reported clinical studies (1) Abstract (2) Introduction (3) Methods (4) Results (5) Discussion (6) Conclusion (7) References/bibliography Introduction, Methods, Results, and Discussion. First proposed by Day in 1989, it is now the standard for all clinical studies reported in the English-language literature. Its purpose is to give you an overview of the research and let you decide if you want to read the full article. These include the introduction, study design, population studied, interventions and comparisons, outcomes measured, primary or most important results, and conclusions. The abstract may not completely or accurately represent the actual findings of the article and often does not contain important information found only in the arti- cle.

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The city had at least two dozen churches and nine monasteries proven vardenafil 10mg, three of which were female houses buy vardenafil 10mg overnight delivery. One of the earliest documents we have records the gift of a vineyard whose profits are to be used to support the monastery’s infirmary purchase genuine vardenafil on-line; the intent is that the sick nuns will pray for the donor’s soul. Three aqueducts, originally constructed in Roman times and later restored by the Lombard princes, brought water to the city; these waters were supplemented by spring water coming down from the hills, plus wells and cisterns (to collect rainwater) in private courtyards. The nuns of San Giorgio had such a bathhouse, and while we do not have specifics about its construction, documents from the male house of Santa Sofia suggest what it may have looked like. The latter seems to have been a substantial establish- ment, with at least two levels, furnaces and bronze cauldrons for providing hot water, and a pool. It was so luxurious, in fact, that contracts were drawn up allowing monastics from other houses (male and female) and secular clerics to come bathe there as well. Naples, on the Tyrrhenian coast north of Salerno, and Bari, on the eastern coast of the peninsula, were larger;21 nearby Amalfi was a more important center of international trade. The whole region of southern Italy shared in a relative bounty of grains, fruits, nuts, and other foodstuffs,22 with increasing surpluses of raw materials and textile goods to export to other lands. It was made the capital of the newly created Lombard principality of Salerno in . The city’s fortunes immediately took off, for it became the main supply center for the Amalfitan merchants, whose own hinterland was insuffi- cient to feed them and whose port was inadequate to sustain traffic in the heavy goods theyexported from southern Italy to north Africa. Norman pilgrims passing through southern Italy at the end of the tenth century had been asked to aid the city of Salerno in repelling an attack of Muslim invaders. Hired as mercenaries (by Christians as well as Muslims) during subsequent years, these Norman knights gradually became invaders themselves and bit by bit expanded their control over several southern Italian duchies. Their extended siege of Salerno in  took its toll on the city, but Robert Guiscard immediately made it the capi- tal of the newly united Norman duchy of Apulia and Calabria. In , when the Normans consolidated most of the fragmented Norman duchies into a single kingdom, they moved their capital to Palermo, in Sicily, which they had seized from Muslim control. It had become an archepiscopal see in the mid-s, and so was of some importance for local ecclesiastical administration. The Lombards, a Germanic people who had immigrated into the area in the late sixth century, controlled the duchies of Benevento,Capua, and Salerno up through the eleventh century, and they remained numerically dominant in the population afterward. Therewere also enclaves of Greek-speaking commu- nities in southern Italy, and whole principalities (such as Gaeta, Naples, and Amalfi) continued to follow Byzantine (Roman) law throughout this period. In the far south, Byzantium had reconquered Calabria, Lucania, and Apulia in the ninth century, and these remained under loose Byzantine authority until the Normans began to wrench control away in . Contact with Byzantium remained frequent even after its political control faded, and individuals such as Archbishop Alfanus of Salerno are known to have traveled to Constanti- nople. Although there were no resident Muslim communities on the southern Italian mainland during the eleventh and twelfth centuries, commercial inter- change with Sicilian, North African, and other Muslim merchants throughout the period would have kept southern Italians aware of Muslim culture. All of these communities, of course, had their respective notions of how the genders should function and what rights and responsibilities they had. Most of the Normans who came were male, and they quickly intermarried with local Lombard women. Lombard women spent their whole lives under the guardian- ship (mundium) of a male: their father was their guardian until they married,  Introduction then their husband, and then (if widowed) their adult sons, brothers, or other male relatives. Never- theless, even though wives technically retained their right over alienating this property (always, of course, with the permission of their guardian), charter evidence suggests that they more often merely consented to their husband’s actions than initiated such transactions themselves. Salernitan society has been characterized as having ‘‘an acute consciousness of nobility or aspirations to noble status,’’31 a sensitivity that manifests itself in Women’s Cosmetics as well as in the medical writings of other Salernitan practitioners. There may have always been some level of awareness among Christian women in southern Italy of the differing cultural practices of Muslim women; a Muslim slave woman is listed as part of a Christian woman’s dowry in Bari in ,34 and it is likely that there were others. The Spanish Muslim historian Ibn Jubayr, who described his travels through the Mediterranean in –, noted with some surprise how eagerly Christian women in Palermo adopted the customs of local Muslim women: ‘‘The Christian women of this city follow the fashion of Muslim women, are fluent in speech, wrap their cloaks about them, and are veiled. They go forth on this Feast Day [Christmas] dressed in robes of gold-embroidered silk, wrapped in elegant cloaks, concealed by coloured veils, and shod with gilt slippers. Indeed, the attribution of a certain cosmetic preparation to Muslim noblewomen suggests Christian women’s turning to this neighboring culture forany symbols that would help secure theirown class aspirations. Yet the exchanges between these cultures were as real as their mutual antagonisms. The recogni- tion by Christians that the Muslims had intellectual goods to offer as valuable as their spices and perfumes is at the heart of what made Salernitan medicine unique. M In  or early in , the Salernitan writer Alfanus reminisced that in his youth ‘‘Salerno then flourished to such an extent in the art of medicine that no illness was able to settle there. At the time he made his claim, many other parts of southern Italy were richly supplied with practitioners; indeed, the neighboring city of Naples was particularly notable for its large number of lay healers. These features also con- tributed to the support of a population wealthy enough to afford the services of these increasingly sophisticated practitioners. Salerno’s growing reputation, in turn, attracted visitors from distant lands, including a significant number of English people who themselves contributed to the further dissemination of Salernitan medicine. But it is only in the second quarter of the eleventh century, in the figure of a physician by the name of Gariopontus, that we find the beginnings of the intellectual transformation that would not simply give shape to the distinctive teachings of Salernitan masters but would also serve as the foundation for medical instruction throughout all of western Europe for the next several centuries. Gariopontus, apparently frustrated with the disorga- nized and often indecipherable texts then circulating in southern Italy, decided to rework them into usable form. His resulting compilation, the Passionarius, would become a popular resource for physicians both near and far and initiate the first teaching glosses and commentaries that marked the revival of medical pedagogy in early-twelfth-century Salerno. Sometime before the mid-s, Alfanus translated Nemesius of Emesa’s Greek On the Nature of Man into Latin; he also composed two medical works in his own right, at least one of which shows Byzantine influence. Constantine came from North Africa, perhaps from Tunis, and was thus a native speaker of Ara- bic. Constantine arrived in Salerno around the year  but soon, at the recommendation of Alfanus, moved to the Benedic- tine Abbey of Monte Cassino, with which Alfanus had intimate ties. Constan- tine became a monk and spent the rest of his life in the rich, sheltered confines of the abbey, rendering his valuable cache of Arabic medical texts into Latin. He translated at least twenty works, including the better part of ‘Alī ibn al- ‘Abbās al-Majūsī’s Pantegni (a large textbook of general medicine) plus smaller, more specialized works on pharmaceutics, urines, diets, fevers, sexual inter- course, leprosy, and melancholy. Written by a physician from Qayrawān (in modern-day Tunisia) Introduction  named Abū Ja‘far Aḥmad b. Its sixth book was devoted to diseases of the reproductive organs and the joints, and it was upon this that the author of the Salernitan Conditions of Women would draw most heavily. Beyond their length, they had introduced into Europe a rich but difficult vocabulary, a wealth of new pharmaceuticals, and a host of philo- sophical concepts that would take medical thinkers years to fully assimilate. Yet ultimately, the availability of this sizable corpus of new medical texts would profoundly change the orientation of Salernitan medicine. The medical writings of twelfth-century Salerno fall into two distinct categories. Embodying the dictum that ‘‘medicine is divided into two parts: theory and practice,’’ twelfth-century Salernitan writings can be classified as either theoretical or practical. Salernitan medicine was distinguished by its em- phasis on what can properly be called a ‘‘philosophical medicine.