By N. Irhabar. Houghton College.

Note on Methodology: We also drew on the conclusions of a study written by eminent researchers Peter Reuter and Franz Trautmann2 quality 100mg zyloprim, and commissioned by the European The data in table 1 has been obtained from the following publications of the Union purchase 300mg zyloprim otc, that examined global trends across this period purchase zyloprim 100 mg. Such a wide range of estimation indicates high to ‘eradicate or signifcantly reduce’ the scale of global drug markets generic 300 mg zyloprim with visa, levels of uncertainty regarding the data. We should end the should be the reduction of harm to the health, stigmatization and marginalization of people who security and welfare of individuals and society. These are enshrined been understandable that the architects of the system in the Universal Declaration of Human Rights and many would place faith in the concept of eradicating drug international treaties that have followed. Of particular production and use (in the light of the limited evidence relevance to drug policy are the rights to life, to health, available at the time). There is no excuse, however, for to due process and a fair trial, to be free from torture ignoring the evidence and experience accumulated or cruel, inhuman or degrading treatment, from slavery, since then. These rights are inalienable, often continue to be driven by ideological perspectives, and commitment to them takes precedence over other or political convenience, and pay too little attention international agreements, including the drug control to the complexities of the drug market, drug use and conventions. Rights, Navanethem Pillay, has stated, “Individuals who use drugs do not forfeit their human rights. Too Effective policymaking requires a clear articulation of the often, drug users suffer discrimination, are forced to policy’s objectives. These improving the health of people who use drugs, they indicators may tell us how tough we are being, but they are undermining a ‘tough on drugs’ message. This is do not tell us how successful we are in improving the illogical – sacrifcing the health and welfare of one group ‘health and welfare of mankind’. Many people taking part in the drug market are themselves the victims of violence and intimidation, or are Germany dependent on drugs. An example of this phenomenon are the drug ‘mules’ who take the most visible and risky roles in Australia the supply and delivery chain. We should not treat all those arrested for Sample of countries that have introduced harm traffcking as equally culpable – many are coerced into their reduction strategies partially, or late in the actions, or are driven to desperate measures through their progress of the epidemic: own addiction or economic situation. Portugal Finally, many countries still react to people dependent on drugs with punishment and stigmatization. In reality, drug Malaysia dependence is a complex health condition that has a mixture of causes – social, psychological and physical (including, for France example, harsh living conditions, or a history of personal 0 5 10 15 20 25 30 35 40 45 trauma or emotional problems). Countries that have Sample of countries that have consistently treated citizens dependent on drugs as patients in need of resisted large scale implementation of harm treatment, instead of criminals deserving of punishment, have reduction strategies, despite the presence of demonstrated extremely positive results in crime reduction, drug injecting and sharing: health improvement, and overcoming dependence. The consistent implementation researchers in this case also referred to police of this policy has led to an overall reduction in criminal records data. The research shows the number of people addicted to heroin as well that the numbers of charges brought against as a range of other benefts. A key study14 1,476 drug users in the years before and after concluded that: entering treatment reduced by 48 percent. Heavily engaged in Heroin has lost its appeal to the mainstream youth both drug dealing and other forms of crime, they and is considered a ‘dead-end street drug’. The number of problematic heroin users has As these hard-core users found a steady, legal dropped signifcantly and the average age of users means for their addiction, their illicit drug use was has risen considerably. Large-scale, low-threshold reduced as well as their need to deal in heroin drug treatment and harm reduction services and engage in other criminal activities. The heroin substitution program had three effects on the drug market: Medically prescribed heroin has been found • It substantially reduced the consumption among in the Netherlands to reduce petty crime and the heaviest users, and this reduction in demand public nuisance, and to have positive effects on affected the viability of the market. The development and implementation of drug A current example of this process (what may be described policies should be a global shared responsibility, as ‘drug control imperialism’), can be observed with the but also needs to take into consideration diverse proposal by the Bolivian government to remove the political, social and cultural realities. Policies should practice of coca leaf chewing from the sections of the respect the rights and needs of people affected 1961 Convention that prohibit all non-medical uses. As with all multilateral agreements, the However, the idea of shared responsibility has too often drug conventions need to be subject to constant review become a straitjacket that inhibits policy development and modernization in light of changing and variable and experimentation. This analysis strenuously over the last 50 years to ensure that all and exchange of experiences is a crucial element of the countries adopt the same rigid approach to drug policy process of learning about the relative effectiveness of – the same laws, and the same tough approach to their different approaches, but the belief that we all need to have enforcement. As national governments have become exactly the same laws, restrictions and programs has been more aware of the complexities of the problems, and an unhelpful restriction. When these involve a more tolerant approach to drug use, governments have faced international diplomatic pressure to ‘protect the integrity of the Conventions’, even when the policy is legal, successful and supported in the country.

The impact on energy expenditure of weight loss regimens involving lesser or greater reductions in energy intake need to be assessed before rates of weight reduction can be more precisely predicted zyloprim 300 mg with amex. However 300mg zyloprim overnight delivery, it must be appreciated that reduction in resting rates of energy expenditure per kilo- gram of body weight have a small impact on the prediction of energy deficits imposed by food restriction buy 100mg zyloprim otc, and the greatest cause of deviation from projected rates of weight loss lies in the degree of compliance zyloprim 100mg generic. In addition, children under 2 years of age should not be placed on energy-restricted diets out of concern that brain development may inadvertently be compromised by inadequate dietary intake of fatty acids and micronutrients. Mean of the residuals did not differ from zero, and the standard deviation of the residuals ranged from 74 to 213. The mean of the residuals did not differ from zero and the standard deviation of the residuals ranged from 73 to 208. The spe- cific equation for the overweight and obese boys was statistically different from the equation derived solely from normal-weight boys (P > 0. The specific equation for the overweight and obese girls was statistically different from the equa- tion derived solely from normal-weight girls (P > 0. The equations for the normal-weight boys and girls differed from the combined equation (P = 0. Weight Reduction in Overweight Children Ages 3 Through 18 Years Weight reduction at a rate of 1 lb/m (15 g/d) is equivalent to a body energy loss of 108 kcal/d (assuming the energy content of weight loss averages 7. This lack of data makes it impossible to describe the rela- tionship between change in energy intake and change in body energy for children in whom weight loss is indicated. However, if the negative energy balance is achieved by a reduction in energy intake alone, at least a 108 kcal/d decrease in energy intake (i. Small reductions in energy intake of the magnitude required to resolve childhood overweight gradu- ally over time are within the potential for ad libitum changes induced by improvements in dietary composition. When energy intake is unable to match energy needs (due to insufficient dietary intake, excessive intestinal losses, or a combination thereof) several mechanisms of adaptation come into play (see earlier section, “Adaptation and Accommodation”). Reduction in vol- untary physical activity is a rapid means of reducing energy needs to match limited energy input. In children, reduction in growth rates is another important mechanism of accommodation to energy deficit. Under condi- tions of persistent energy deficit, the low growth rate will result in short stature and low weight-for-age, a condition termed stunting. A chronic energy deficit elicits mobilization of energy reserves, pro- gressively depleting its main source: adipose tissue. Thus, an energy deficit of certain duration is associated with changes in body weight and body composition. As body weights decrease, so do energy requirements, although energy turnover may be higher when expressed per kg of body weight due to a predominant loss of fat tissue relative to lean tissue. In healthy, normal-weight individuals who face a sustained energy deficit, several hormonal mechanisms come into play, including a reduction in insulin release by the pancreas, a reduction in the active thyroid hormone T3, and a decrease in adrenergic tone. These steps are aimed at reducing cellular energy demands by reducing the rates of key energy-consuming metabolic processes. However, there is less evidence that similar mecha- nisms are available to individuals who already have a chronic energy deficit when they are faced with further reductions in energy input (Shetty et al. The effects of chronic undernutrition in children include decreased school performance, delayed bone age, and increased susceptibility to infections. Although estimates of energy needs can be made based on the initial deficit, body weight gain will include not only energy stored as fat tissue, but also some amount in the form of skeletal muscle and even visceral tissues. Thus, as recovery of body weight proceeds, the energy requirement will vary not only as a function of body weight but in response to changes in body composition. The energy needs for catch-up growth for children can be estimated from the energy cost of tissue deposition. However, in practical terms, the target for recovery depends on the initial deficit and the conditions of nutri- tional treatment: clinical unit or community. Under the controlled condi- tions of a clinical setting, undernourished children can exhibit rates of growth of 10 to 15 g/kg body weight/d (Fjeld et al. Undoubtedly, this figure would be highly dependent on the magnitude and effectiveness of the nutritional intervention. Dewey and coworkers (1996) estimated the energy needs for recovery growth for children with moderate or severe wasting, assuming that the latter would require a higher proportion of energy relative to protein. If a child is stunted, however, weight may be adequate for height, and unless an increased energy intake elicits both gains in height and in weight, the child may become over- weight without correcting his or her height.

The Renaissance editor cheap zyloprim 300mg mastercard, undoubtedly with the best of intentions zyloprim 300mg with amex, added what was to be the last of many layers of editorial ‘‘improvements discount 300mg zyloprim amex. True order zyloprim 100 mg with mastercard, they were all probably of twelfth-century Salernitan origin, but they reflected the work of at least three authors with distinct perspectives on women’s diseases and cosmetic concerns. The first and third of these texts, On the Conditions of Women and On Women’s Cosmetics, were anonymous. The sec- ond, On Treatments for Women, was attributed even in the earliest manuscripts to a Salernitan woman healer named Trota (or Trocta). Each of the texts went through several stages of revision and each circulated independently through- out Europe through the end of the fifteenth century, when manuscript culture began to give way to the printed book. By the end of the twelfth century, an anonymous compiler had brought the three texts together into a single ensemble, slightly revising the wording, adding new material, and rearranging a few chapters. This ensemble was called the Summa que dicitur ‘‘Trotula’’ (The CompendiumWhich Is Called the ‘‘Tro- tula’’), forming the title Trotula (literally ‘‘little Trota’’ or perhaps ‘‘the abbre- viated Trota’’) out of the name associated with the middle text, On Treatments for Women. The appellation was perhaps intended to distinguish the ensemble from a general, much longer medical compilation, Practical Medicine, com- posed by the historical woman Trota. The Trotula ensemble soon became the leading work on women’s medicine, and it continued to be the object of ma- nipulation by subsequent medieval editors and scribes, most of whom under- stood ‘‘Trotula’’ not as a title but as an author’s name. He rewrote certain passages, suppressed some material and, in his most thorough editorial act, reorganized all the chapters so as to eliminate the text’s many redundancies and inconsis- tencies (due, we know now, to the fact that several authors were addressing the same topics differently). There is no way that a reader of this emended printed text could, without reference to the manuscripts, discern the presence of the three discrete component parts. Hence when some twenty years later a debate over the author’s gender and identity was initiated (and it has continued to the present day), it was assumed that there was only one author involved. What can they reveal about the impact of the new Arabic medicine that began to infiltrate Europe in the late eleventh century? Is there, in fact, a female author behind any of the texts and, if so, what can she tell us about medieval women’s own views of their bodies and the social circumstances of women’s healthcare either in Salerno or elsewhere in Europe? Answering these questions calls for close textual analysis that pulls apart, layer by layer, decades of accretion and alteration. Such analysis shows us not simply that there are three core texts at the heart of the Trotula but also that the ensemble became a magnet for bits and pieces of material from entirely unrelated sources. We cannot, for example, attribute the neonatal procedures described in ¶¶– to local southern Italian medical practices but must rec- ognize them instead as the work of a ninth-century Persian physician named Rhazes. Such analysis shows us, in other words, that the Trotula ensemble is a patchwork of sources. There is, consequently, no single (or simple) story to be told of ‘‘Trotula’’ or women’s medicine at Salerno. Knowledge of the multiplicity of the Trotula may resolve certain ques- tions (about the redundancies and inconsistencies that so troubled the Renais- sance editor Georg Kraut, for example), but it raises others. Particularly, if the texts are so protean (a total of fifteen different versions of the independent texts and the ensemble can be identified in the medieval manuscripts),8 howdowe choose any single version to study? Obviously, the authors of the three origi- nal, independent works had their own unique conceptions of the content and intended uses of their texts. On the basis of my reconstructions of these origi- nal forms of the texts, I describe in the Introduction their more distinctive medical theories and practices; I also summarize what is now known about the medical practices of the women of Salerno—including, most important, Trota. Nevertheless, the three original twelfth-century works often bore only an oblique resemblance to the text(s) that later medieval readers would have had in front of them. The Trotula ensemble, ragged patchwork though it is, has a historical importance in its own right, since it was this version of the texts that the largest proportion of medieval readers would have seen, and it was this assembly of theories and remedies (whatever their sources or however incon- xiv Preface gruous the combination originally may have been) that would have been most commonly understood throughout later medieval Europe as the authoritative Salernitan teachings on women and their diseases. One of the several versions of the ensemble was particularly stable in form and widespread in circulation: this is what I have called the ‘‘standardized en- semble,’’ which, with twenty-nine extant copies, ranks as the most popular ver- sion of the Salernitan texts in any form, circulating either independently or as a group. The standardized ensemble is a product of the mid-thirteenth cen- tury (whether it was produced at Salerno itself I cannot say) and it reflects the endpoint of what had been an active first century of development for the three texts. I have based the present edition on the earliest known complete copy of the standardized ensemble, an Italian manu- script from the second half of the thirteenth century, and I have collated it in full with eight other manuscripts coming from various parts of Europe and dating from the later thirteenth century through the turn of the fourteenth century. The edition and translation presented here, then, reflect the standardized Trotula ensemble text as it was known and used up through about . To facilitate a historically nuanced understanding of the ensemble, I have anno- tated the edition to highlight its major points of divergence from the three original Salernitan texts on women’s medicine. Inevitably, many nuances— anatomical, nosological, and botanical—can never be adequately recaptured.

These new technologies are meant to bring substantial improvement to radiation therapy generic zyloprim 300 mg visa. However order zyloprim 100mg with amex, this is often achieved with a considerable increase in complexity buy zyloprim 100 mg without a prescription, which cheap 100 mg zyloprim free shipping, in turn, brings with it opportunities for new types of human error and problems with equipment. It is based on lessons learned from accidental exposures, which are an invaluable resource for revealing vulnerable aspects of the practice of radiotherapy, and for providing guidance for the prevention of future occurrences. Dissemination of information on errors or mistakes as soon as they become available is crucial in radiation therapy with new technologies. In addition, information on circumstances that almost resulted in serious consequences (near misses) is also important, as the same type of event may occur elsewhere. Sharing information about near misses is, thus, a complementary and important aspect of prevention. Disseminating the knowledge and lessons learned from accidental exposures is crucial in preventing recurrence. This is particularly important in radiation therapy; the only application of radiation in which very high radiation doses are deliberately given to patients to achieve cure or palliation of disease. Notwithstanding the above, disseminating lessons learned from serious incidents is necessary but not sufficient when dealing with new technologies. It is of the utmost importance to be proactive and continually strive to answer questions such as: ‘What else can go wrong? While the recommendations specifically apply to new external beam therapies, the general principles for prevention are applicable to the broad range of radiotherapy practices in which mistakes could result in serious consequences for the patient and practitioner. The recommendations provide elements for mobilizing for future effective work as outlined below. Independent verification should be performed of beam calibration in beam radiation therapy. Independent calculation should be performed of the treatment times and monitor units for external beam radiotherapy. Prospective safety assessments should be undertaken for preventing accidental exposures from new external beam radiation therapy technologies, including failure modes and effects analysis, probabilistic safety assessment, and risk matrix, in order to develop risk informed and cost effective quality assurance programmes. Moderated electronic networks and panels of experts supported by professional bodies should be established in order to expedite the sharing of knowledge in the early phase of introducing new external beam radiation therapy technologies. A collaborating team of specifically trained personnel following quality assurance procedures is necessary to prevent accidents. Maintenance is an indispensable component of quality assurance; external audits of procedures reinforce good and safe practice, and identify potential causes of accidents. Accidents and incidents should be reported and the lessons learned should be shared with other users to prevent similar mistakes. The available data on doses received by people approaching patients after implantation show that, in the vast majority of cases, the dose to comforters and carers remains well below 1 mSv/a. Moreover, due to the low activity of an isolated seed and its low photon energy, no incident/accident linked to seed loss has ever been recorded. A review of available data shows that cremation can be allowed if 12 months have elapsed since 125 103 implantation with I (3 months for Pd). If the patient dies before this time has elapsed, specific measures must be undertaken. However, although the therapy related modifications of the semen reduce fertility, patients must be aware of the possibility of fathering children after such a permanent implantation, with a limited risk of genetic effects for the child. Patients with permanent implants must be aware of the possibility of triggering certain types of security radiation monitor. Considering the available experience after brachytherapy and external irradiation of prostate cancer, the risk of radio-induced secondary tumours appears to be extremely low, but further investigation might be helpful. Only the (rare) case where the patient’s partner is pregnant at the time of implantation may need specific precautions.

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