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By M. Luca. Apache University. 2019.

Vancomycin-resistant enterococci in intensive care units: high frequency of stool carriage during a non-outbreak period order citalopram 40 mg amex treatment centers. Effectiveness of gloves in the prevention of hand carriage of vancomycin-resistant Enterococcus species by health care workers after patient care cheap citalopram 20mg on line symptoms for pink eye. Risk of hand or glove contamination after contact with patients colonized with vancomycin-resistant Enterococcus or the colonized patients’ environment effective 10mg citalopram treatment for sciatica. Recovery of vancomycin-resistant enterococci on fingertips and environmental surfaces purchase citalopram 20 mg overnight delivery osteoporosis treatment. Long-term survival of vancomycin-resistant Enterococcus faecium on a contaminated surface. Hospital-acquired infection with vancomycin-resistant Enterococcus faecium transmitted by electronic thermometers. A case-control study to detect modifiable risk factors for colonization with vancomycin-resistant enterococci. A hospital epidemic of vancomycin-resistant Enterococcus: risk factors and control. Effect of gastrointestinal bleeding and oral medications on acquisition of vancomycin-resistant Enterococcus faecium in hospitalized patients. A comparison of the effect of universal use of gloves and gowns with that of glove use alone on acquisition of vancomycin-resistant enterococci in a medical intensive care unit. Prevalence and acquisition of vancomycin-resistant enterococci in a medical intensive care unit. Risk factors for new detection of vancomycin-resistant enterococci in acute-care hospitals that employ strict infection control procedures. Role of environmental contamination as a risk factor for acquisition of vancomycin-resistant enterococci in patients treated in a medical intensive care unit. Occurrence of co-colonization or co-infection with vancomycin- resistant enterococci and methicillin-resistant Staphylococcus aureus in a medical intensive care unit. Effect of antibiotic therapy on the density of vancomycin-resistant enterococci in the stool of colonized patients. The association between antecedent vancomycin treatment and hospital-acquired vancomycin-resistant enterococci. Vancomycin-resistant enterococci among chronic hemodialysis patients: a prospective study of acquisition. Clinical and molecular biological analysis of a nosocomial outbreak of vancomycin-resistant enterococci in a neonatal intensive care unit. Outbreak of vancomycin-resistant Enterococcus faecium in a neonatal intensive care unit. Laboratory-based surveillance for vancomycin-resistant enterococci: utility of screening stool specimens submitted for Clostridium difficile toxin assay. High rate of false-negative results of the rectal swab culture method in detection of gastrointestinal colonization with vancomycin-resistant enterococci. Comparison of rectal and perirectal swabs for detection of colonization with vancomycin-resistant enterococci. Control of vancomycin-resistant Enterococcus in health care facilities in a region. The effect of active surveillance for vancomycin-resistant enterococci in high-risk units on vancomycin-resistant enterococci incidence hospital-wide. Control of endemic vancomycin-resistant Enterococcus among inpatients at a university hospital. Active surveillance reduces the incidence of vancomycin- resistant enterococcal bacteremia. Surveillance for vancomycin-resistant enterococci: type, rates, costs, and implications. Persistent contamination of fabric covered furniture by vancomycin-resistant enterococci: implications for upholstery selection in hospitals. Reduction in acquisition of vancomycin-resistant Enterococcus after enforcement of routine environmental cleaning measures. Prior environmental contamination increases the risk of acquisition of vancomycin-resistant enterococci. Disinfection of hospital rooms contaminated with vancomycin-resistant Enterococcu faecium. Interventional evaluation of environmental contamination by vancomycin-resistant enterococci: failure of personnel, product, or procedure? Monitoring antimicrobial use and resistance: comparison with a national benchmark on reducing vancomycin use and vancomycin resistant enterococci. Manipulation of a hospital antimicrobial formulary to control an outbreak of vancomycin-resistant enterococci. Reduction of vancomycin-resistant enterococcal infections by limitation of broad-spectrum cephalosporin use in a trauma and burn intensive care unit. Association between antecedent intravenous antimicrobial exposure and isolation of vancomycin-resistant enterococci. Effect of the increasing use of piperacillin/tazobactam on the incidence of vancomycin-resistant enterococci in four academic medical centers. Impact of a formulary switch from ticarcillin-clavulanate to piperacillin-tazobactam on colonization with vancomycin-resistant enterococci. Acquisition of rectal colonization by vancomycin- resistant Enterococcus among intensive care unit patients treated with piperacillin-tazobactam versus those receiving cefepime-containing antibiotic regimens. Costs and savings associated with infection control measures that reduced transmission of vancomycin-resistant enterococci in an endemic setting. Cost-effectiveness of perirectal surveillance cultures for controlling vancomycin-resistant Enterococcus. A cost-benefit analysis of gown use in controlling vancomycin-resistant Enterococcus transmission: is it worth the price? Cunha Infectious Disease Division, Winthrop-University Hospital, Mineola, New York, and State University of New York School of Medicine, Stony Brook, New York, U. The main clinical problem with the “septic” patient is to determine whether the patient is septic or has a dis- order noninfectious mimic of sepsis by hemodynamic or laboratory parameters. In the intensive care setting, it is of critical importance to differentiate between sepsis and its mimics (1–6). The most important clinical consideration in determining whether a patient is septic is to identify the source of infection. Infections limited to specific infections in a few organ systems are the only ones with septic potential. Lower gastrointes- tinal tract perforations, intra-abdominal/pelvic abscesses, pylephlebitis, commonly result clinically in sepsis. In contrast, gastritis and nonperforating gastric ulcer are rarely associated with sepsis. Cholangitis in the hepatobiliary tract results in sepsis, but rarely, if ever, complicates acute/chronic cholecystitis (6–13). It is almost always possible to identify the septic source by physical exam, laboratory, or radiology tests. Disorders that mimic sepsis should be recognized to treat the condition and not to avoid inappropriate treatment with antibiotics. Fever should not be equated with infection since the chemical mediators of inflammation and infection, i. All that is febrile is not infectious, and most, but not all diseases causing sepsis are accompanied by temperatures! With the exceptions of drug fever and adrenal insufficiency, the disorders that mimic sepsis and Clinical Approach to Sepsis and Its Mimics in Critical Care 129 Table 1 Clinical Conditions Associated with Sepsis Associated with sepsis (fevers! Genitourinary source Sinusitis Renal Mastoiditis Pyelonephritis Bronchitis Intra/perinephric abscess Otitis Calculi. Skin/soft tissue source Total Osteomyelitis Prostate Uncomplicated wound infections Abscess.

It accounts for 5 to 15 percent of the total diabetics generic 10mg citalopram with amex treatment 11mm kidney stone, depending on what population you study purchase citalopram 40mg amex treatment for strep throat. Most importantly discount citalopram 20 mg fast delivery medicine quetiapine, the plant-based approach mentioned previously that can dramatically prevent and even reverse type 2 diabetes cheap 40mg citalopram overnight delivery medications nurses, helps protect against the consequences of lifelong high blood sugar and insulin levels, such as eye, kidney, nerve, and cardiovascular damage. While researching new ways to create insulin in the body are important, studying why type 1 diabetes occurs in the first place is equally if not more important. Three areas that I would like to see studied urgently are as follows: • The role of vitamin D deficiency during pregnancy, lactation, and early childhood, setting the stage for an autoimmune or infectious insult that might damage the pancreas in the first place, leading to lack of insulin production. Take vitamin D during pregnancy and start it immediately after birth in the child; avoid cow’s milk products in childhood; and possibly supplement with - 45 - staying healthy in the fast lane probiotics during pregnancy, lactation, and throughout childhood. Finding out how to prevent type 1 diabetes by modulation of envi- ronmental and dietary factors is critically important and should be a major research focus in diabetic industries and by public health institutions. That means that we can easily and effectively reduce our risk of cardiovascular disease by:35 • engaging in regular physical activity,36 • avoiding tobacco use and secondhand smoke,37 • choosing a diet rich in fruit and vegetables, and avoiding foods that are high in fat, sugar, refined carbohydrates, and salt, and38 • maintaining an ideal body weight. To profoundly reduce the risk of heart disease, I believe we have to emphasize a dramatic reduction (preferably elimination) in animal-based foods, which includes total meats and dairy products, and encourage the con- sumption of only whole-grain products when grains are consumed. We also need to eliminate added fats, oils, and sugars by eating whole foods only. And of course, eat lots more vegetables, fruit and beans, and small amounts of raw nuts or seeds. Heart disease reversal by aggressive diet and lifestyle change was shown over thirty years ago by the late Nathan Pritikin and fifty years ago by California cardiologist Dr. Dean Ornish’s Program For Reversing Heart Disease,43 has also shown that a very low-fat, unrefined, mainly plant-based diet, with exercise and stress management, can reverse heart disease. Ornish’s work really put the whole concept of a diet and life- style approach to reversing heart disease on the road to legitimacy with his published work in the Lancet. The China Project, one of the most comprehensive databases on the multiple causes of disease ever compiled, was initiated in 1983, and the book The China Study (2006), with key investigator and co-author T. Colin Campbell, PhD from Cornell University, showed virtually no heart disease in parts of rural China where cholesterol levels ranged from 90 to 170 mg/dl (average 125 to 130), and the diets of these individuals were predominantly plant-based. Castelli said the following when asked if he couldn’t use drugs, but he could get the average American to go on the diet of his choice to reverse heart disease, “I would do it (diet) and it would work better than the drugs. Castelli commented on two past diet trials that showed reversal of heart disease, the St. Now if I would have put everyone on a veg- etarian diet and drive their numbers down by diet, we would get rid of all the atherosclerosis in America. I therefore decided it would be more appropriate to look at the leading killer of women and men in Western civilization, which is cardiovascular disease and heart attacks because in this global research it was very apparent that there were many cul- tures where heart disease and heart attacks were virtually non- existent. I mean, even today if you’re a cardiac surgeon and you go to rural China or the Papua Highlands in New Guinea, or if you go to central Africa or the Tarahumara Indians in northern Mex- ico, forget it. You’d better plan on selling pencils because you’re not going to find cardiovascular disease there, and it’s largely be- cause of that plant-based nutrition, and that’s what made me feel - 48 - the good news: chronic disease is preventable and reversible that if we could get people to eat to save their hearts they would actually then be saving themselves from cancer as well, and I still think that’s true. Esselstyn, Ornish, Fleming, and Rip Esselstyn), if applied with diligence, will stop the progression of and reverse heart disease in many people. Heart disease, the world’s number one killer, can be relegated to a “toothless paper tiger,” as Dr. You might be wondering why I am taking so much time on type 2 diabetes and heart disease treatment by diet and lifestyle and using the word “reversible. The same diet will greatly - 49 - staying healthy in the fast lane reduce the incidence of both. With this will come the dramatic reduction of all chronic diseases and a new, sustainable era in healthcare where low-cost lifestyle changes are the most powerful medicines, and we are free of the self-inflicted shackles of healthcare reform, insurance companies, and pharma- ceutical and hospital expenses. Read the books and listen to the interviews and references I share if you don’t believe me. If you don’t want to edu- cate yourself, just do the 9 Simple Steps to Optimal Health strictly for three to six months and see what happens! Chronic Disease Prevention and our Children In order to adequately address the systemic health risks that threaten our children, parents must make a commitment to live and eat differently. Parents must create a lifestyle for the whole family that is centered predominantly on unrefined, nutrient-rich, and less calorie-dense whole plant foods and minimal amounts of processed and animal foods. Furthermore, we need to become engaged with our schools in order to ensure that they are providing healthy, whole foods (vegetables, fruit, whole grains, beans, nuts, seeds), especially whole-grain products, on their premises. There should also be vegetarian alternatives such as veggie burgers and chili, marinara sauces, and the like. When I say vegetarian, I don’t mean with lots of eggs and cheese or white flour, sugar, and fat-laden products. Although I would prefer a completely plant-based school meal program, if schools provided the foods described above, along with small amounts of lean animal protein (fish; lean fowl and meats; eggs, preferably free-ranged and grass-fed; and low- fat, non-sweetened yogurt—yes, leave out the cheese) this would be acceptable and beneficial as long as the meat consumption was kept to a minimum and vegetable and fruit intake was encouraged. Additionally, par- ents and educators alike should aim for eliminating soft drinks and caffeinated sports drinks from school cafeterias and vending ma- chines—period! Encourage water consumption or at least mineral waters or 100 percent non-sweetened natural juices as the “in” thing, and our children will benefit immensely. A successful model that should be replicated across the coun- try for healthy nutrition advocacy for school children, as well as educating the public and policy makers on the importance of whole-food, plant-based school nutrition, is the New York Coali- tion for Healthy School Foods (Healthyschoolfood. This group helped create the excellent illustration shown at the end of Chap- ter, 1 “U. Food Consumption as a % of Calories” for which I am very thankful, since it makes teaching about the problems of U. Diet and the Big Three: School Behavior, Criminality, and Work Productivity Another wonderful interview I had the privilege of conducting was with Barbara Stitt, former chief probation officer in Ohio for two decades; former co-owner of the whole-food bakery Natural Ovens; and book author, speaker, and child nutrition advocate. First, she discovered that feeding probationers whole-food, unrefined diets reduced their recidivism from getting into trouble again from 85 percent down to 15 percent. Second, she and her husband, Paul Stitt, fed their more than 120 employees daily at their Natural Ovens bak- ery only whole foods, resulting in marked reductions in healthcare claims, increased work productivity in their employees, and gen- eral enhanced employee contentment. Third, she and her husband - 51 - staying healthy in the fast lane showed that you can go into a problem school (in this case an alter- native high school in Appleton, Wisconsin), serve only whole food in their cafeteria, and turn around the students’ behavior. So much good would occur if Paul and Barbara’s professional examples of incorporating simple whole-food nutrition were du- plicated by other American businesses, schools, and governmental 54 agencies. Physical education has to be strongly encouraged, if not mandatory, even if it is just a walk- ing class. And though it likely goes without saying, controlling the hours a child sits behind a computer screen or in front of a televi- sion is critical. It is so obvious why we are sick and chronically ill in this coun- try (and the world). We have to stop thinking that “normal” is being overweight, stuffed after a meal, or taking multiple medications starting at the age of forty. Why do we think that three days per week of twenty minutes of exercise is something impressive when for millennia we foraged hours per day for food? Why do we allow highly processed foods to be the norm of our diet when for millions of years we ate whole, non-processed foods? We will fail because the number of people with chronic disease will keep growing and any new healthcare package will simply cover more unhealthy people with chronic diseases, not create fewer of them. If you read President Obama’s Fiscal 2010 Budget: Transforming and Modernizing America’s Health Care System from the Office of Bud- get and Management, it emphasizes prevention, which is good, but I think this following statement is grossly understated: “Over a third of all illness is the result of poor diet, lack of exercise, and smoking. Indeed, obesity alone leads to many expensive, chronic conditions including high blood pressure, heart disease, diabetes, and even cancer. These highly preventable chronic diseases account for 75 percent of our healthcare expenditures. It’s you looking in the mirror, taking the information from this book and others, and changing your lifestyle so you dramatically reduce your chronic disease risk and stay away from the medical-indus- trial complex. There is no healthcare reform that will do more for you than getting off your behind and exercising and putting whole unprocessed food into your mouth. An act of patriotism in the twenty-first century is eating good food, getting exercise, reduc- ing your weight, and preventing chronic disease.

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Since the discovery of radium purchase 10 mg citalopram visa medications jamaica, many radioactive isotopes have been random mating Totally haphazard mating generic citalopram 20 mg on-line chapter 9 medications that affect coagulation, with used for both the diagnosis and the treatment of no regard to the genetic makeup (genotype) of the diseases generic citalopram 40 mg amex medicine 377. The skin discoloration occurs example generic citalopram 10mg overnight delivery treatment 5th metatarsal shaft fracture, if five premature infants are born, weigh- because an abnormal spasm of the blood vessels ing 2, 3, 4, 5, and 6 pounds, respectively, the range causes a diminished blood supply. Raynaud’s phenomenon A condition that For example, a knee might lack 10 degrees of full results in discoloration of fingers and/or toes when extension due to an injury. A rash lupus erythematosus; hormone imbalance, includ- can be caused by an underlying medical condition, ing hypothyroidism and carcinoid imbalances; hormonal cycles, allergies, or contact with irritating trauma, such as from frostbite or the use of vibrat- substances. Treatment depends on the underlying ing tools; medications, particularly propranolol cause of the rash. Medically, a rash is referred to as (brand name: Inderal), estrogens, nicotine, and an exanthem. When the discoloration occurs alone, it is called Raynaud’s Rasmussen syndrome A rare brain disorder that is caused by inflammation of brain cells in one disease. For exam- unknown, features seizures that can be difficult or ple, the kidney selectively reabsorbs substances it impossible to control with medication, and it even- has already secreted into the renal tubules, such as tually results in brain shrinkage (atrophy). The narrowing limits the ability of air to be expelled from the lungs rattlesnake bite A poisonous bite from a mem- ber of the pit viper family. The affected body the eyes (conjunctivitis), and inflammation of the part should be kept immobile and below the level of genital, urinary, or gastrointestinal systems. Reactive the heart, and the bite victim should be taken to the arthritis is the preferred name for what was formerly nearest hospital. Reactive arthritis seems to not be used, and no one should attempt to suction involve an immune system that is “reacting” to the out the wound by mouth. Treatment includes use of presence of a bacterial infection in the genital, uri- antivenom and care for the puncture wound itself nary, or gastrointestinal system. Accordingly, certain and any symptoms that emerge, such as respiratory people’s immune systems are genetically primed to distress. Reading retardation may reflect mental disability, recombinant A person with a new combination cultural deprivation, or learning disability. Key features of recombination include the point-to-point associa- receptor 1 In cell biology, a structure on the sur- tion of paired chromosomes (synapsis), followed by face of a cell or inside a cell that selectively receives the visible exchange of segments (crossing over) at and binds a specific substance. There are two types of recessive diseases—autosomal recessive and X- rectal cancer See cancer, rectal. The rectum stores solid waste until it leaves the orblindness, deuteranopia, and Daltonism. In rectus abdominis A large muscle in the front of reduction division, the chromosome number is the abdomen that assists in regular breathing move- reduced from diploid (46 chromosomes) to haploid ments, supports the muscles of the spine while a (23 chromosomes). Also known as first meiotic divi- person lifts something, and keeps the intestines and sion and first meiosis. Reed-Sternberg cell A type of cell that is seen recuperate To recover health and strength. If one gets a referral to recurrence The return of a sign, symptom, or ophthalmology, for example, the person is being disease after a remission. The recur in that family, affecting another person or term referral can pertain both to the act of sending persons. For example, a recurrent fever is a fever that has referred pain Pain felt at a site other than where returned after an intermission, a recrudescent fever. For example, the recurrent respiratory papillomatosis See corneal reflex is the blink that occurs upon irritation of the eye. Reflex between laboratories, but is generally in the range sympathetic dystrophy syndrome is associated with of 4. Red cell count can be varying degrees of sweating, warmth and/or cool- expressed in international units as (4. Refractive who has suffered an illness or injury restore lost errors include nearsightedness (myopia), farsight- skills and so regain maximum self-sufficiency. Lenses can be example, rehabilitation work after a stroke may used to control the amount of refraction and correct help the patient walk and speak clearly again. Refsum disease A genetic disorder that affects the metabolism of the fatty acid phytanic acid. For example, a transplanted kid- caused by damage to the cerebellar portion of the ney may be rejected. For example, after an injury, the liver often administered during abdominal surgery to has the capacity to regenerate. A low-salt diet is one type of dietary nancy that facilitates the birth process by causing a regimen. Relaxin also inhibits contractions of the uterus and may play a role in determining the regional lymphadenitis See cat scratch fever. A registry is release, carpal tunnel See carpal tunnel usually organized so that the data in it can be ana- release. For example, analysis of data in a tumor reg- istry maintained at a hospital may show a rise in lung rem In radiation, an international unit of X-ray or cancer among women. These periods occur at intervals of 1 to 2 hours and can vary in regurgitation A backward flowing. A remission can be ate goal is to quickly open blocked arteries and temporary or permanent. Early reperfusion min- imizes the extent of heart muscle damage and pre- remission induction chemotherapy See serves the pumping function of the heart. One of carried out from a great distance using computer the best-known repetitive stress injuries is carpal and robotic technology. For example, supermarket checkers, assembly-line workers, typ- renal cancer is cancer of the kidneys. Common causes of renal artery stenosis include atherosclerosis and thicken- replication A turning back, repetition, duplica- ing of the muscular wall (fibromuscular dysplasia) tion, or reproduction. Reproduction need not be sexual; for example, renal cell carcinoma See cancer, renal cell. This idea has stirred great controversy and has met with almost uniform disapproval. Rendu-Osler-Weber syndrome See hereditary research, controlled A study that compares hemorrhagic telangiectasia. Board certification in all near drowning, heart failure, severe infection, and medical and surgical specialties requires the satis- extreme obesity. In practice, the respiratory rate is usually determined resistance Opposition to something, or the abil- by counting the number of times the chest rises or ity to withstand something. The aim of measuring respiratory forms of the staphylococcus bacterium are resistant rate is to determine whether the respirations are to treatment with antibiotics. Resolution may annual community outbreaks, often lasting 4 to 6 range from low to high. For having a continuous, solid level of antibodies example, when bone is surgically reshaped, it against the virus. Respiratory failure occurs because of the failure of the exchange of oxygen and carbon restless leg syndrome An uncomfortable dioxide in tiny air sacs in the lung (alveoli), failure (creeping, crawling, tingling, pulling, twitching, of the brain centers that control breathing, or fail- tearing, aching, throbbing, prickling, or grabbing) ure of the muscles required to expand the lungs that sensation in the calves that occurs while sitting or can cause respiratory failure. The result is an uncontrollable ical conditions can lead to respiratory failure, urge to relieve the uncomfortable sensation by including asthma, emphysema, chronic obstructive moving the legs. The leg pain typically eases medication, such as cyclosporine, chlorambucil, and with motion of the legs and becomes more notice- cyclophosphamide. A small area called the macula in the retina contains special retinoblastoma A malignant eye tumor usually light-sensitive cells that allow clear perception and seen in children, that arises in cells in the develop- central vision. The retina is filled with tiny blood ing retina that contain cancer-predisposing muta- vessels. The sporadic form of retina has torn, the vitreous liquid can pass through retinoblastoma has later onset and typically leads to the tear and accumulate behind the retina. Retinal vasculitis ranges in sever- often requires removal of the eye (enucleation).

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Isosorbide dinitrate/angiotensin receptor blockers worsen heart failure in patients with left ventricular sys- D cheap citalopram 20mg medications similar buspar. Epidemiologic factors that have poorer prognosis include African- American race purchase citalopram 40 mg on line medicine 627, male sex purchase citalopram 10 mg online medicine app, and onset of hypertension in youth generic citalopram 20mg fast delivery symptoms quivering lips. In addition, comorbid fac- tors that independently increase the risk of atherosclerosis worsen the prognosis in pa- tients with hypertension. These factors include hypercholesterolemia, obesity, diabetes mellitus, and tobacco use. Physical and laboratory examination showing evidence of end organ damage also may portend a poorer prognosis. This includes evidence of retinal damage or hypertensive heart disease with cardiac enlargement or congestive heart fail- ure. Furthermore, electrocardiographic evidence of ischemia or left ventricular strain but not left ventricular hypertrophy alone may predict worse outcomes. A family history of hypertensive complications does not worsen the prognosis if diastolic blood pressure is maintained at less than 110 mmHg. In- dications for proceeding to surgery include any patient with symptoms or an aneurysm that is growing rapidly. Pre- operative cardiac evaluation before elective repair is imperative as coexisting coronary artery disease is common. The physical examination suggests mitral valve stenosis with a positional low-pitched sound heard when the patient is in the upright position. This is characteristic of a “tumor plop,” which should alert the physician to the possibility of a cardiac tumor. This is confirmed by the echocardiogram revealing a large left atrium tumor, which is most likely an atrial myxoma. Myxomas are the most common type of benign primary cardiac tumors, accounting for over three-quarters of surgically resected cardiac tumors. Myxomas generally present in between ages 20 and 50 and are seen more commonly in women. The clinical presentation of myxomas resembles that of valvular heart disease due either to obstruction of flow from the tumor obscuring valvular flow or to regurgitation due to abnormal valve closure. The tumor plop is heard in mid-diastole and results from the impact of the tumor against the valve or ventricular wall. Histologically, they appear as gelati- nous structures with scattered myxoma cells embedded in a glycosaminoglycan stromal matrix. They may embolize and can be mistaken for endocarditis, particularly as systemic 202 V. However, cardiac catheterization is no longer considered manda- tory prior to tumor resection, especially as catheterization of the chamber containing the tumor increases the likelihood of embolization. Primary surgical excision is the treatment of choice and should be performed regardless of tumor size as even small tumors can cause embolization or valvular obstruction. Surgical resection is generally curative with only a 1–2% recurrence rate in sporadic cases. Tumors metastatic to the heart are more common than primary cardiac tumors and occur with the highest incidence in metastatic melanoma. However, by absolute numbers of cases, breast and lung cancer account for the largest number of cases. Cardiac metastases usually occur in patients with known malig- nancies, are usually not the cause of presentation, and are found incidentally. Only 10% are clinically apparent at the time of presentation, and most are found at autopsy. A normal oxygen supply to the myocardium requires adequate inspired oxygen, intact lung func- tion (including diffusion capacity, which is abnormal in emphysema), normal hemoglo- bin concentration and function, and normal coronary blood flow. The resistance to coronary blood flow is determined by three vascular regions: large epicardial arteries, pre-arteriolar vessels, and arteriolar and intramyocardial capillaries. In the absence of significant flow-limiting atherosclerosis, the resistance in the epicardial arteries is negligi- ble. The major determinant of coronary-resistance is due to the pre-arteriolar, arteriolar, and intramyocardial capillary vessels. Although myocardial ischemia and subendocardial infarction can produce deep, symmetric T-wave inversions which would result in tachy- arrhythmias and syncope, noncardiac phenomena such as intracerebral hemorrhage can similarly affect ventricular repolarization. The average time to death after onset of symptoms is as follows: angina pectoris, 3 years; syncope, 3 years; dyspnea, 2 years; con- gestive heart failure, 1. In addition, surgery is advocated when the ejection frac- tion falls below 50% or when severe calcification, rapid progression, or expected delays in surgery are present. There is no specific age cut-off or degree of left-ventricular function that precludes surgical correction. This is, in part, due to the fact that there are no good medical therapies to treat aortic stenosis. Percutaneous balloon valvuloplasty has been used as a bridge to surgery and in patients with severe left-ventricular dysfunction or who are otherwise too ill to tolerate surgery. After birth, the ductus arteriosus closes as blood now circulates through the low-resistance pulmonary vascular bed. If the ductus arterio- sus fails to close after birth, a left-to-right shunt develops between the aorta and the pul- monary vasculature. Because the pressure in the aorta is greater than that of the pulmonary artery through all portions of the cardiac cycle, the murmur of a patent duc- tus arteriosus is a continuous murmur. There is late systolic accentuation of the murmur at the upper left sternal angle. The murmur is described as “machinery”-like, and often a palpable thrill is present. If Eisenmenger syndrome occurs, as in this patient, the shunt changes directional flow and becomes a right-to-left shunt as a result of pulmonary hy- pertension. Because of the anatomic location of the ductus arteriosus below the level of the left subclavian artery, a characteristic of Eisenmenger syndrome in those with patent ductus arteriosus is cyanosis and clubbing of the toes but not the fingers. Total anomalous pulmonary venous return occurs when all four pulmonary veins drain into the systemic venous circulation. This condition is fatal soon after birth if there is not also an atrial or ventricular septal defect or a patent fora- men ovale. Most patients with this condition are identified shortly after birth because of cyanosis. Coarctation of the aorta is a relatively common congenital abnormality that is associated with a stricture of the aorta near the insertion site of the ligamentum arterio- sus (the remnant of the ductus arteriosus). Upper extremity hypertension is present in association with low blood pressures in the lower extremities. Tetralogy of Fallot is a congenital heart disease syndrome with ventricular septal defect, right-ventricular outflow obstruction, aortic override of the ventricular septal defect, and right-ventricular hypertrophy. Ventricular septal defect results in left- to-right shunt and a holosystolic murmur rather than a continuous murmur. The musical quality of the murmur has been described when the cause is a flail leaflet. These patients usually have hypoten- sion and rapidly develop pulmonary hypertension and signs of cardiogenic shock. Respiratory variation in mitral inflow velocity is an echocardiographic sign of tamponade physiology. High-frequency fluttering of the ante- rior mitral leaflet is the characteristic echocardiographic finding of acute aortic regurgi- tation, seen most commonly in primary aortic valvular disease, aortic dissection, infective endocarditis, or chest trauma. These symptoms should raise the con- cern for aortic dissection as the cause of the chest pain, and prompt evaluation and treatment are essential to decrease mortality from this often fatal condition. Aortic dissections are classified by either the DeBakey or Stan- ford classifications. Type I is caused by an intimal tear in the ascending aorta and has propagated to include the descending aorta.

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Excessive parathormone paraphimosis An emergency condition in which leads to elevated calcium levels in the blood and the foreskin of the penis order citalopram 40 mg with visa medications going generic in 2016, once retracted generic citalopram 20 mg medications hypertension, cannot calcium deposition in cartilage order citalopram 40mg amex symptoms diabetes type 2. Treatment involves parathyroid gland The gland that regulates cal- reduction of the foreskin using anesthetics and pain cium metabolism buy 40 mg citalopram mastercard treatment plan for anxiety. It secretes a hormone called parathormone that is critical to the paraplegia Paralysis of the lower part of the metabolism of calcium and phosphorus. The parathyroid glands appear as paraquat lung Lung disease caused by the con- a pair, one above the other, on each side of the thy- tact herbicide paraquat, which selectively accumu- roid gland, and they are plastered against the back lates in the lungs and is highly toxic. Paraquat risk for being accidentally removed during thy- lung is rare because the herbicide must be directly roidectomy. Paraquat lung emerged as a health concern in the 1970s, when the parathyroid hormone See parathormone. Some of the sprayed plants parathyroids, hypoplasia of the thymus and survived and were sold, causing paraquat lung in See DiGeorge syndrome. For example, malaria is caused by parenteral Not delivered via the intestinal tract. In malaria, a measure called the parasitemia parenteral nutrition Intravenous feeding. Parkinson’s disease A slowly progressive neu- partial syndactyly See syndactyly, partial. Treatment involves use of passive immunity Immunity produced by the medication, such as levodopa (brand name: transfer to one person of antibodies that were pro- Larodopa) and carbidopa (brand name: Sinemet). Protection from passive A surgical procedure known as deep brain stimula- immunity diminishes in a relatively short time, usu- tion, in which externally controlled electrodes are ally a few weeks or months. For example, antibod- implanted into the brain, has also been shown to be ies passed from the mother to the baby before birth helpful. There are no blood or laboratory tests to confer passive immunity to the baby for the first 4-6 diagnose the condition. Also known as paralysis passive smoking Inhalation of smoke that agitans and shaking palsy. Passive smok- ing is associated with the same array of diseases as paronychia Inflammation of the folds of tissue actual smoking, with an elevated risk of lung can- surrounding the nail due to infection. Pasteur, Louis A French chemist and biologist who invented pasteurization, developed the germ parotid gland One of the largest of the three theory, founded the field of bacteriology, and cre- major salivary glands. Normally, the pathophysiologic alteration is a change in function quadricep muscle pulls the kneecap over the end of as distinguished from a structural defect. This off- -pathy Suffix indicating suffering or disease, as in kilter path permits the underside of the kneecap to neuropathy (disease of the nervous system). Treatment involves pain management, Pavlovian conditioning A method to cause a and rehabilitation is designed to create a straighter reflex response or behavior by training with repeti- pathway for the patella to follow during quadriceps tive action. For example, when he patent 1 A legal device that gives exclusive con- customarily rang a bell before feeding them, the dogs trol and possession of a device, an invention, or a would begin to salivate whenever the bell rang. Therefore, these mother after delivering her baby in the delivery genes are pathogenetic. Patients can use peak flow meters at home to measure their own air flow pathognomonic A sign or symptom that is so regularly. The pectoral muscles are famil- pathologist A physician who identifies diseases iarly known as the pecs and are the muscles under- and conditions by studying abnormal cells and neath the breasts. For example, “The physi- cian found no pathology” would mean the physician pectoralis muscle absence with syndactyly found no evidence of disease. During a pelvic exam, a physician feels pedigree In medicine, a family health history that the uterus (womb) and ovaries with the fingers to is diagrammed with a set of international symbols to detect swellings or other abnormalities. A pedigree is a basic tool of by bacteria migrating upward from the urethra and clinical genetics that is used to determine that a dis- cervix into the upper genital tract. Symptoms include fever, foul- smelling discharge, extreme pain, pain during inter- pedophilia Adult sexual fondness for and activity course, and bleeding. If acted out, pedophilia involves use of antibiotics for the patient as well as is legally defined as sexual child abuse. Structures in the male require intense psychological and pharmacological pelvis include the bladder, rectum, prostate, testi- therapy prior to release into the community because cles, and penis. It is essential that pedophilia be reported so that appropriate steps pelvis, gynecoid See female pelvis. Pendred syndrome members of the biomedical community before is inherited in an autosomal recessive manner and publication. Also known as deafness with goiter, putting a needle through the skin in order to obtain goiter-deafness syndrome, and thyroid hormone tissue within the body for examination. The urologist then inserts instruments into however, and specific penicillin types may be the kidney via the access port to break up the stone needed for certain bacteria. The rise of penicillin- percutaneous umbilical blood sampling A resistant bacteria is due to overuse of penicillin procedure in which a needle is inserted through the drugs, including their ineffective but nonetheless fre- mother’s abdominal wall and then through the uter- quent use against colds and viral infections. Also known as umbilical vein sampling, cordocen- penis The external male sex organ. These chambers peri- Prefix meaning around or about, as in peri- are filled with spongy tissue and surrounded by a cardial (around the heart) and periaortic lymph membrane called the tunica albuginea. The urethra, which is the perianal Located around the anus, the opening channel for urine and ejaculate, runs along the of the rectum to the outside of the body. For example, periaortic lymph nodes are lymph nodes around the penis, hypospadias of the See hypospadias. For example, the fiftieth the heart (the pericardium) that causes chest pain percentile for walking well is 12 months of age. There are many causes of peri- is concerned with the care of the mother and fetus carditis, including infections, injury, radiation when there is a higher-than-normal risk of compli- treatment, and chronic diseases. A high-risk baby is often cared for by a perinatologist pericardium The conical sac of fibrous tissue before birth and by a neonatologist after birth. The pericardium consists of an outer perinatalogy A subspecialty of obstetrics that coat (the parietal pericardium) attached to the cen- is concerned with the care of the mother and tral part of the diaphragm and the back of the fetus when there is a higher-than-normal risk for breastbone and a double inner coat (the visceral complications. One layer of the visceral peri- destroys the attachment fibers and supporting bones cardium closely adheres to the heart, and the other that hold the teeth in the mouth. Left untreated, lines the inner surface of the outer (parietal) peri- periodontal disease can lead to tooth loss. The intervening space is filled with peri- cause of periodontal disease is bacterial plaque, a cardial fluid. More specifically, the period of time posed of fibrous connective tissue that closely wraps extending from when the patient goes into the hos- all cartilage except the cartilage in joints, which is pital, clinic, or doctor’s office for surgery until the covered by a synovial membrane. The perinatal period is fibrous connective tissue that closely wraps all bone defined in diverse ways. Depending on the defini- except that of the articulating surfaces in joints, tion, it starts at the 20th to 28th week of gestation which is covered by a synovial membrane. For example, peripheral vision is the type of vision that allows a person to see objects that are peritoneum The membrane that lines the not in the center of his or her visual field. Peritonitis can result from infection, as nervous system that is outside the brain and spinal by bacteria or parasites; injury and bleeding; or dis- cord. The peritonitis, acute Sudden inflammation of the peripheral nerves include the 12 cranial nerves, the peritoneum that results in abrupt abdominal pain spinal nerves and roots, and the autonomic nerves. The most serious causes of acute The autonomic nerves are concerned with auto- peritonitis include perforation of the esophagus, matic functions of the body, specifically with the reg- stomach, duodenum, gallbladder, bile duct, bowel, ulation of the heart muscle, the tiny muscles that appendix, colon, rectum, and bladder; trauma; line the walls of blood vessels, and glands.

Drug therapy is now the mainstay of treatment both prophylactically and during acute exacerbations citalopram 40 mg overnight delivery symptoms esophageal cancer. Dental management of asthma Dental treatment itself can cause emotional stress generic citalopram 10mg on-line treatment 6th february, which may precipitate an attack citalopram 20 mg low price symptoms ruptured spleen. Routine dental care with local anaesthesia is not usually a problem; if in doubt purchase citalopram 20 mg with mastercard symptoms of high blood pressure, invite the child to take a puff of their inhaler before commencing. Steroid inhalers for asthma do not generally cause adrenal suppression and insufficiency. However, there is recent evidence that some of the newer generation of steroid inhalers may cause suppression. General anaesthesia for severe asthmatics usually requires in-patient hospital admission. Key Points Of relevence to the dental management of asthma: • Erosion due to ⎯reflux; ⎯increase consumption of acidic beverages. Thick viscid mucus is produced, particularly in the lungs, which leads to chronic obstruction and infection of the airways and to malabsorption. It is the most common genetic condition in Caucasians, with approximately 5% of the population being carriers and 1 in 2000 of live births affected. The clinical manifestations of the condition are variable and some patients remain asymptomatic for long periods. Coughing is the most constant symptom of pulmonary involvement and this may lead to recurrent respiratory infections and bronchiolitis. Lung disease progresses leading to exercise intolerance and shortness of breath (Fig. More than 85% of affected children show evidence of malabsorption due to exocrine pancreatic insufficiency. Symptoms include frequent, bulky, greasy stools and a failure to thrive despite a large food intake. Dental management of cystic fibrosis There are reports of decreased caries prevalence attributable not only to the long term use of antibiotics and pancreatic enzyme supplements but also to increased salivary buffering. Nevertheless, these children suffer from delayed dental development; more commonly have enamel opacities and are more prone to calculus. Moreover, they need to have a very high calorific intake and may have frequent refined carbohydrate snacks. As such, children with cystic fibrosis are an important priority group for dental health education and care. A significant proportion of affected children also have cirrhosis of the liver, with resultant clotting defects and a liability to haemorrhage following surgical procedures. Children with cystic fibrosis sometimes still may be prescribed tetracycline to prevent chest infections, as a result of the development of multiple antibiotic sensitivities, even though it causes intrinsic dental staining (Fig. This has resulted in its incorporation into the mineral matrix with marked discoloration⎯alternative antibiotics are now used. Recent improvements in the management of people with cystic fibrosis have meant that an increasing number are not maintained on long-term antibiotic prophylaxis. The vast majority of these are febrile convulsions and are associated with illnesses that cause high fever late in infancy such as otitis media. The seizures are usually tonic-clonic with loss of consciousness followed by sustained muscle contractions. This tonic phase is followed by the clonic phase of intermittent muscular contraction. These convulsions usually occur early in the illness during the period of rapid temperature rise and may be the first indication that the child is ill. It is most important to eliminate the possibility of central nervous system infection; therefore examination of the cerebrospinal fluid is essential if there is persistent drowsiness following the attack. Epilepsy is not a disease in itself but a term applied to recurrent seizures, either of unknown origin (idiopathic epilepsy) or due to congenital or acquired brain lesions (secondary epilepsy). The choice of drug depends on the seizure type, but the dosage needs to control the seizures with minimal side effects. New generation anti-epileptic drugs have become available, for example, Lamotrigine, Gabapentin, Oxcarbazepine, Tiagabine, and Topiramate but even these are not without problems, for example, hyperexcitability, dizziness, depression, weight loss, and abdominal problems. The most familiar anti-epileptic drugs are Sodium Valproate, Phenytion, and Carbamazepine. Dental management of epilepsy If possible, any liquid anti-epileptic medication should be sugar-free (Fig. Sodium Valproate is not associated with gingival enlargement and like Carbamazepine, Lamotrigine, and Oxcarbazepine is available as a sugar-free liquid. The child with good control of seizures needs a minimum of restrictions, although the possibility of an attack occurring in the dental chair should be considered. A very high standard of oral hygiene is required to minimize the development of gingival enlargement and gingival surgery should never be contemplated unless the oral hygiene is good. Trauma to anterior teeth is often encountered in people with epilepsy who may have frequent, unpredictable falls. Reimplantation of avulsed teeth is usually contraindicated in those with severe learning difficulties. If prostheses are required then they should be well retained with clasps and unlikely to break or be inhaled during subsequent attacks. The child had been on long-term, sucrose-based medication but has now changed to the sugar-free sodium valproate liquid. It is age-related with peaks of presentation between 5 and 7 years and at puberty. Although there is a genetic predisposition, there may well be a triggering effect from viral infections in the aetiology of diabetes. The clinical manifestations are polydipsia (increased thirst), polyuria (increased urination), polyphagia (increased appetite), and weight loss. The diagnosis is dependent on the demonstration of hyperglycaemia in association with glucosuria. The aims of treatment are to control the symptoms, prevent acute metabolic crises of hypo- and hyperglycaemia, and to maintain normal growth and body weight, with an active life-style. If there is good control of blood sugar levels with insulin therapy and nutritional management, then diabetic complications are minimized. One of the major hazards of insulin treatment is the development of hypoglycaemia. It is usually of rapid onset (unlike hyperglycaemia) with sweating, palpitations, apprehension, and trembling. Hypoglycaemia in a diabetic child indicates too much insulin relative to food intake and energy expenditure. Another problem, particularly in adolescents, is the psychological adjustment to the condition; the rebellious teenage years may lead to non-compliance with insulin therapy and nutritional management. Dental management of diabetes The well-controlled diabetic child with no serious complications can have any dental treatment but should receive preventive care as a priority. Uncontrolled diabetes can result in varied problems, which mainly relate to fluid imbalance, an altered response to infection, possible increased glucose concentrations in saliva, and microvascular changes. There may be decreased salivary flow, and an increased incidence of dental caries has been reported in uncontrolled young diabetics. There is also well- documented evidence of increased periodontal problems and susceptibility to infections, particularly with Candida sp. Dental appointments should be arranged at times when the blood sugar levels are well controlled; usually a good time is in the morning immediately following their insulin injection and a normal breakfast. General anaesthetics are a problem because of the pre-anaesthetic fasting that is required, and so these are normally carried out on an in-patient basis to enable the insulin and carbohydrate balance to be stabilized intravenously. However, problems in the dental management of patients with steroid insufficiency are more likely to occur in children who are being prescribed steroid therapy for other medical conditions; for example, in the suppression of inflammatory and allergic disorders, acute leukaemia, and to prevent acute transplant rejection.

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The very young and the very old have poor memories because of the movement: the latter are in a state of decay buy cheap citalopram 20mg online medications with weight loss side effect, the former in rapid growth; and small children are also dwarfish until they have advanced in age discount 40mg citalopram with mastercard symptoms of kidney stones. Again discount citalopram 10 mg otc treatment kennel cough, the thesis (that recollection is a physical process) is demonstrated with a reference to a disturbance in the act of recollection cheap 20mg citalopram treatment arthritis. The word di†noia is used in a context which deals with mental concentration, and also the melancholics make their appearance; reference is made to moisture around the ‘perceptive place’; and in the following section, which again deals with special groups, dwarfs, the very young and the very old are mentioned. So we have a rational process (although Aristotle, perhaps significantly, does not say that it is an affection of the intellectual part of the soul) which takes place in a bodily part and which is susceptible to influences and disturbances of bodily conditions. Again, it remains unclear what the normal physical conditions for a successful operation of recollection (searching ‘along a straight course’, eÉqupore±n)77 are. The passages that I have discussed clearly suggest that, according to Aristotle, bodily conditions can be of influence on intellectual activities 77 On this expression see above, n. It is clear, however, that apart from incidental bodily states such as drunkenness or sleep (which may be characterised as disturbing agents, although the former is par‡ fÅsin, the latter kat‡ fÅsin), there are also more structural conditions such as the quality of the blood, age, the overall balance between warm and cold in the body and the quality of the skin. Variations in these structural conditions account for variations in intellectual capacities. The variations exist among different species, but also among individual members of one species or types within a species, such as dwarfs or melancholics. For the most part, these types represent ‘imperfect’ (ˆtele±v) or ‘deformed’ (pephrwm”noi) groups of human beings with spe- cial characteristics due to their physical aberrations. However, some types (such as the malak»sarkoi) seem to represent special classes of humans whose distinctive characteristics are not to be regarded as deformations, but as variations within one species that may be either conducive, or harmful, or just neutral to the exercise of certain psychic powers. We hear very little about what the bodily conditions of a normal, success- ful operation of the intellectual powers are, but, as I have already said, there is good reason to assume that this is just because, in the writings that have survived, Aristotle simply does not have much reason to dwell on them. Our picture of Aristotle’s psycho-physiology is likely to remain very incom- plete – as is also indicated by the difficulties involved in piecing together his scattered remarks about physiological conditions such as pneuma, blood, and so forth. This has perhaps to do with his indebtedness to a medical tradition which supplied a lot of material which he could simply take for granted. As has already been demonstrated by Tracy – and is confirmed by more recent work on Aristotle’s acquaintance with medical literature79 – this indebtedness is probably much greater than the scanty references to medical authorities in Aristotle’s works suggest. In this particular context, the Hippocratic work On Regimen comes to one’s mind, which in chapters 35 and 36 has an extremely interesting discussion on variations in intellectual performance due to variations in the proportion between fire and water in 78 Other, more peripheral evidence (dealing less explicitly with intellectual capacities) is discussed in ch. Aristotle on the matter of mind 231 the body;80 and there may be other medical influences as well,81 especially of dietetics, for it was certainly one of the claims of dietetics in Aristotle’s time to provide a physiologically founded doctrine of ‘the good life’. Now it is certainly true that Aristotle’s psychology is much richer and much more sophisticated than that of the medical literature, but it should not be overlooked that there is also a ‘technical’ side to Aristotle’s psychology, an interest in the ‘mechanics’ of cognition and in modalities of thinking such as concentration, analytical powers, creativity, quickness (tacutžv) of thinking and intuition (ˆgc©noia, eÉstoc©a),83 habituation and repetition, and degrees in capacities to all these activities. It very rarely comes to the surface in On the Soul, but it figures more prominently in the Parva naturalia and in the zoological works, mostly when one species of animals is compared with another or when different members of one species are compared with one another, and mostly in contexts in which some sort of disturbance or aberration in cognitive behaviour is discussed. It is in these contexts that bodily factors are made responsible for these dis- turbances or aberrations; Aristotle does not explain what the normal bodily conditions for a normal functioning of thinking are, and they can only be deduced indirectly. However, it is very likely that the concept of ‘the mean’ plays an important part here. Here, too, there seems to be a tension between a ‘relativistic’, biological view of man as a zä on at the end of a scale which 80 For a discussion of these chapters see the commentary by Joly and Byl (1984). The doctrine of pneuma may be inspired by Diocles of Carystus (see Longrigg (1995) 441). On the claims of dietetics, and its relation to philosophy in the fourth century see also G. I should suggest that this difficulty is to be related to Aristotle’s endeav- ours to account for variations in psychic capacities and their performance by reference to variable bodily (anatomical, physiological, pathological) fac- tors – although it is not quite clear how these factors are to be accommodated within the ‘canonical’ doctrine of the incorporeality of the intellect and the changelessness of the soul. It is certainly to Aristotle’s credit as a scientist that he recognises the existence of these variations, most of which are prob- ably to be classified as belonging to the category of ‘the more and the less’ (diaforaª kaq’ Ëperocžn). Moreover, when it comes to physical defects, he also seems to apply a sort of principle of natural compensation, which manifests itself in his belief that nature (i. Aristotle on the matter of mind 233 but whose existence, however marginal their importance may be, Aristotle recognises as interesting and in need of explanation89 – an explanation which invokes the principle that even within the category of ‘what is con- trary to nature’ (t¼ par‡ fÅsin) there is such a thing as ‘according to nature’ (t¼ kat‡ fÅsin). However much this may seem to be applauded, it remains unclear how these gradualist and compensatory explanations should be accommodated within the ‘normative’ theory of De an. To be sure, it may be asked whether there is actually such a tension, for it might be argued that all instances of bodily influence on intellectual activ- ity discussed above can be classified under the rubric of the ‘dependence of the intellect on appearances’. Whether this affects the thesis of the incorporeality of the intellect, remains to be seen. The only terminological point we can make is that a number of passages assign an important role to dianoia, and it may be that this is Aristotle’s favourite term for intellectual activity on the borderlines between sense-perception and thinking; one sometimes gets the impression that it refers to a particular kind of thinking, a sort of attention, in any case a directed and concentrated intellectual activity (or the capacity to this). Neuhauser, however, rejected Baumker’s view by pointing¨ ¨ to a number of passages in which the verb dianoeisthai seems to be used as a general, non-specific term for any intellectual activity, including that of nous. There is, indeed, abundant evidence that in the border area between sense-perception and thinking, where elu- sive faculties such as ‘incidental perception’ (the perception that that white thing over there is the son of Diares), ‘common sense’ and imagination are at work, Aristotle is not always clear whether we are dealing with operations of the sensitive or the intellectual part of the soul. The question whether the judgement of images is a sensitive or an intellectual activity presents itself very strongly in On Dreams, where sometimes one sense (sight) corrects the other (touch), as in 460 b 21–2, but sometimes also an intellectual faculty is at work (as in 460 b 18–19), and sometimes it is unclear which faculty is judging (461 b 3ff. Aristotle on the matter of mind 235 Let us finally turn to the question of the kind of connection or corre- spondence between the bodily conditions referred to and the intellectual activities they are said to accompany or influence. Of course, Aristotle has appropriate language at his disposal: on a structural level (where bodily influences are related to constitution types such as the melancholic nature, to deformations such as dwarfs, or to natural conditions such as hardness of the flesh) he may say (as he often does in Parts of Animals and Genera- tion of Animals) that form does not completely ‘master’ (krate±n) matter, which results in deformed (pephrwm”na) or ‘imperfect’ (ˆtel¦) struc- tural capacities, or that material natural factors ‘impede’ (–mpod©zein) the full realisation of the formal nature. Thus apart from saying that bodily changes ‘correspond with’ or ‘accompany’ psychic activities, which does not com- mit itself to a specific type of causal relationship,99 we may go further and say that bodily states and processes act on psychic powers or ac- tivities just as well as psychic powers may be said to ‘inform’ bodily structures. Tobe sure, in the Physiognomonica intellectual capacities are rarely referred to,101 and the author mainly deals with moral dispositions and characteristics. He refers to stock examples such as drunkenness and illness, and he also uses love, fear, pleasure and pain as examples of how emotional states may influence the condition of the body, thus indicating that there is a reciprocal relationship between body and soul. In particular, it should be asked to what extent these passages present a challenge to the doctrine of the 100 Phgn. Aristotle on the matter of mind 237 changelessness of the soul and the incorporeality of the intellect; for it seems that the variety of psychic performances, including the intellec- tual ones, which the animal kingdom displays makes Aristotle acknowl- edge that there is a material aspect to thinking as well, which he, in the ‘canonical’ theory of nous in De an. Yet there seems to be a consensus among modern interpreters concerning the conclusion of the chapter. The principal question was whether eutuchia is caused by nature or not (1247 a 2), and Aristotle’s answer to this question, briefly summarised in 1248 b 3–7, is as follows. There are two forms of eutuchia, the first of which is both ‘divine’ (theia) and ‘by nature’ ( phusei ),2 and the second of which is caused by ‘chance’ (tuche¯ ); both forms are ‘irrational’ (alogoi), but the first form is ‘continuous’ (suneches¯ ), whereas the latter is not. The first form is the one which Aristotle has been trying to explain from the beginning; the existence of the second form he was compelled to recognise in the course of his argument. It appears that this first form of eutuchia is based on a kind of interaction between a principal divine movement (1248 a 25ff. Thus the explanation of eutuchia involves a rather specific conjunction of two factors, nature (phusis) and God (ho theos), which at an earlier stage of the argument (1247 a 23–31) – and also in the first chapter of the Eudemian Ethics (1214 a 16–24) – were distinguished among others as two different possible causes of eutuchia. On ‘chance’ (tÅch) as the cause of the second form see Dirlmeier (1962a) 492; Gigon (1969) 211. Aristotle suggests as a possible explanation of eutuchia that it is caused not by nature (phusis) but by a god or demon: or because they [i. That it is a genuine problem is further shown by the fact that the same objection as that raised in 1247 a 28–9 concerning the distribution of the phenomenon ascribed to divine dispen- sation (and which I shall henceforth refer to as the ‘distribution argument’) is found in two other Aristotelian writings which are closely parallel to Eth. And if we attribute such a thing to God, we shall make him a poor judge, or at least not a just one; and that is not befitting for God. For it would happen during the daytime and in intelligent people, if it were a god who sent it. I am aware that the authorship of the Magna moralia still is, and probably always will be, a matter of dispute, but the arguments in favour of an Aristotelian origin of much of the philosophical contents, at least, are so strong that I have thought it desirable to include Mag. At first sight there seems to be a discrepancy between, on the one hand, the conclusion of Eth. On any interpretation it is clear that developmental arguments, such as those used 17 See also the discussion in ch.

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