Mark Corson

By T. Fedor. Southern Oregon State College. 2018.

The author of On Regimen appeals to a rather ‘dualistic’ conception of the relation between soul and body nicotinell 17.5mg sale, of the type referred to earlier on in this chapter: 49 SeetheinstanceslistedinvanderEijk(1994)279 buy cheap nicotinell 35mg online. Ross (1955) 56–7 52.5 mg nicotinell overnight delivery, who points out that Aristotle’s ‘comparison of the heart-lung system to a double bellows [in De respiratione 480 a 20–3] is clearly borrowed from Vict. Aristotle on sleep and dreams 199 For when the body is awake, the soul is its servant: it is divided among many parts of the body and is never on its own, but assigns a part of itself to each part of the body: to hearing, sight, touch, walking, and to acts of the whole body; but the mind is never on its own. However, when the body is at rest, the soul, being set in motion and awake, administers its own household and of itself performs all the acts of the body. For the body when asleep has no perception; but the soul, which is awake, cognises all things: it sees what is visible, hears what is audible, walks, touches, feels pain, ponders, though being only in a small space. Whoever, therefore, knows how to interpret these acts correctly, knows a great part of wisdom. It would be impossible for Aristotle to say – as the writer of On Regimen does – that in sleep the body is at rest but that the soul works. Sleep is for Aristotle an affection of the complex of soul and body due to the heating and cooling of food and preventing the animal from perceiving actual sense movements. It is obvious, therefore, that we cannot say that Aristotle is influenced here by the medical writer’s views on dreams. It would be more appropriate to say that the non-specialised student of nature gives a theoretical explanation or even a justification of the view held by the distinguished doctors; this justification is given entirely in Aristotle’s own terminology and based on his own presuppositions (the two principles mentioned above). This procedure is completely in accordance with his general views on the relation between natural science and medicine discussed above. However, the incorporation of the medical view on the prognostic value of dreams into his own theory of sleep and dreams does confront Aristotle with a difficulty which he does not seem to address very successfully. For, as we have seen above, in On Dreams Aristotle says that dreams are based on the remnants of small sensitive movements which we receive in the waking state but do not notice at the time, because they are overruled by more powerful movements which claim all our attention. Yet during sleep, when the input of stronger competing sensitive movements has stopped, the remnants of these small movements come to the surface and present themselves to us in the form of dreams. As I have already said, it is exactly this mechanism to which Aristotle seems to refer in Div. The experiences of hearing thunder, tasting sweet flavours and going through a fire are apparently the result of movements in the body which present themselves at the time of sleep. These movements are not the remnants of movements which have occurred during the daytime but which were overruled then, but they are actual movements which take place at the moment of sleep and which are noticed at the moment that they occur. Now, as we have seen, Aristotle in On Dreams acknowledges that this kind of perception may take place in sleep; but he immediately adds the qualification that this kind of perception is not a dream (an enhupnion)in the strict sense of the word, whereas that is the word he is using here in On Divination in Sleep. Moreover, in the present passage Aristotle states that we perceive these movements ‘more clearly’ in sleep than in the waking state, whereas the examples of the borderline experiences he gives in On Dreams are said to be perceived ‘faintly and as it were from far away’. There are several ways to cope with this problem, none of which, how- ever, are free from difficulties. In this respect the transition from line 10 to 11 may be understood – and paraphrased with some exaggeration – as follows: ‘for then it even happens that small movements (no matter whether they are remnants of earlier perceptions or actual impressions) appear stronger than they really are’. The word ‘even’ (kai) may then be taken as pointing to the fact that the examples which follow demonstrate more than is really necessary for Aristotle’s purpose. What is necessary for the argument is that the small movements which escaped our notice in the waking state become manifest to us in sleep. This interpretation, however, seems unlikely: the present participles gignomenon, katarrheontos, gignomenes¯ ¯ , as well as the fact that no example from the visual domain is given, surely indicate that the occurrence of the stimulus and its experience by the sleeper are simultaneous. Aristotle on sleep and dreams 201 However, a similar problem presents itself further down in the text, when Aristotle considers yet another possible explanation for the phenomenon of divination in sleep; and again the difficulty arises while accommo- dating the view of another thinker, in this case the atomist philosopher Democritus. Just as when something sets water in motion or air, and this moves something else, and when the one has stopped exercising motion, such a movement continues until it reaches a certain point where the original moving agent is not present, likewise nothing prevents a certain movement and sense- perception from arriving at the dreaming souls, proceeding from the objects from which Democritus says the idols and the emanations proceed, and in whatever way they arrive, [nothing prevents them from being] more clearly perceptible at night because during the day they are scattered more easily – for at night the air is less turbulent because there is less wind at night – and from bringing about sense-perception in the body because of sleep, for the same reason that we also perceive small movements inside us better when we are asleep than when we are awake. These movements cause appearances, on the basis of which people foresee the future even about these things. Furthermore, Aristotle says explicitly that the explanation offered for these ‘extravagant’ cases of foresight is built on the assumption that they are not due to coincidence (e« mŸ ˆp¼ sumptÛmatov g©netai t¼ proorŽn). Thus he is offering an alternative explanation for cases of foresight which earlier on he attributed to coincidence (463 b 1–11) – and this was apparently also what Democritus was doing. The experiences mentioned here are clearly derived from sources outside the dreamer’s body, which emit ‘movements’ that, after travelling over a great distance, reach the soul in sleep; and they can do so more easily at night because, Aristotle says, there is less wind 53 See van der Eijk (1994) 310–12 for a discussion and fuller references. Aristotle does not say to which category the dreams discussed here belong, but it seems that, if the category of ‘coincidence’ (sumptoma¯ ) is eliminated, these dreams stand to the events they predict in a relationship of signs (semeia¯ ), and that both the event and the dream go back to a common cause. It is difficult, however, to see how the experiences described here can be accommodated within Aristotle’s theory of sleep and dreams. They clearly do not fulfil the requirements for dreams as posited in On Dreams; nor do they seem to belong to the category of borderline experiences, because, again, Aristotle stipulates that they appear to us stronger than in the waking state. Unless we were to assume that Aristotle is contradicting himself, we might prefer to accept that in addition to dreams and to the borderline experiences of hearing faint sounds and suchlike, he recognises yet another kind of experience during sleep and that, by calling these experiences en- hupnia, he uses the term in a less specific, more general sense than the strict sense in which it was used in On Dreams. After all, as I have said, the word enhupnion basically means ‘something in sleep’, and this could be used both at a more general and at a more specific level. But in that case, very little is left of Aristotle’s initial, a priori assumption that sleep is an incapacitation of the sensitive part of the soul, for it turns out that we are perfectly well capable of perceiving these movements while asleep, provided that the at- mospheric conditions are favourable. Nor is it open here to Aristotle to say that these movements originating from remote places such as the Pillars of Heracles are perceived by us not ‘in so far as’ we are asleep but in so far as we are, in a certain way, already awake: in fact, Aristotle explicitly says that we receive these stimuli ‘because’ we are asleep – indeed, they ‘cause perception because of sleep’ (a­sqhsin poioÓsin di‡ t¼n Ìpnon), which seems in blatant contradiction to everything he has said in On Sleep. A different approach to this problem is to seek an explanation for these apparent inconsistencies in what Charles Kahn has called ‘the progressive nature of the exposition’ in Aristotle’s argument.

Clostridium difficile colitis associated with inflammatory pseudotumor in a liver transplant recipient buy nicotinell 52.5 mg on line. Clinical manifestations purchase nicotinell 17.5 mg without a prescription, treatment and control of infections caused by˜ Clostridium difficile cheap 52.5mg nicotinell fast delivery. Cytomegalovirus and Clostridium difficile ischemic colitis in a renal transplant recipient: a lethal complication of anti-rejection therapy? Infectious enteritis after intestinal transplantation: incidence, timing, and outcome. Incidence and risk factors for diarrhea following kidney transplantation and association with graft loss and mortality. Simultaneous occurrence of Clostridium difficile and Cytomegalovirus colitis in a recipient of autologous stem cell transplantation. Two cases of Norwalk virus enteritis following small bowel transplantation treated with oral human serum immunoglobulin. Rotavirus enteritis in solid organ transplant recipients: an underestimated problem? Benign transient hyperphosphatasemia associated with Epstein-Barr virus enteritis in a pediatric liver transplant patient: a case report. Cryptosporidium parvum-associated sclerosing cholangitis in a liver transplant patient. Encephalitis caused by human herpesvirus-6 in transplant recipients: relevance of a novel neurotropic virus. The impact of human herpesvirus-6 and -7 infection on the outcome of liver transplantation. Human herpesvirus-6 in liver transplant recipients: role in pathogenesis of fungal infections, neurologic complications, and outcome. Early diagnosis and successful treatment of acute cytomegalovirus encephalitis in a renal transplant recipient. Naturally acquired West Nile virus encephalomyelitis in transplant recipients: clinical, laboratory, diagnostic, and neuropathological features. West Nile virus encephalitis in organ transplant recipients: another high-risk group for meningoencephalitis and death. Listeria infection after liver transplantation: report of a case and review of the literature. Listeria monocytogenes-associated acute hepatitis in a liver transplant recipient. Cryptococcus neoformans infection in organ transplant recipients: variables influencing clinical characteristics and outcome. Clinical spectrum of invasive cryptococcosis in liver transplant recipients receiving tacrolimus. Cutaneous cryptococcosis mimicking bacterial cellulitis in a liver transplant recipient: case report and review in solid organ transplant recipients. Cryptococcal necrotizing fasciitis with multiple sites of involvement in the lower extremities. Central nervous system cryptococcosis in solid organ transplant recipients: clinical relevance of abnormal neuroimaging findings. First report of Cryptococcus albidus–induced disseminated cryptococcosis in a renal transplant recipient. Pulmonary cryptococcosis in solid organ transplant recipients: clinical relevance of serum cryptococcal antigen. Central nervous system lesions in liver transplant recipients: prospective assessment of indications for biopsy and implications for management. Invasive pulmonary aspergillosis in solid organ and bone marrow transplant recipients. Pseudallescheria boydii brain abscess in a renal transplant recipient: first case report in Southeast Asia. Infections due to dematiaceous fungi in organ transplant recipients: case report and review. Rhinocerebral zygomycosis: an increasingly frequent challenge: update and favorable outcomes in two cases. Invasive gastrointestinal zygomycosis in a liver transplant recipient: case report and review of zygomycosis in solid-organ transplant recipients. Successful toxoplasmosis prophylaxis after orthotopic cardiac transplantation with trimethoprim-sulfamethoxazole. Sulfadiazine-related obstructive urinary tract lithiasis: an unusual cause of acute renal failure after kidney transplantation. Nocardiosis in renal transplant recipients undergoing immunosuppression with cyclosporine. Bacteremias in liver transplant recipients: shift toward gram-negative bacteria as predominant pathogens. Gram-negative bacilli associated with catheter-associated and non-catheter-associated bloodstream infections and hand carriage by healthcare workers in neonatal intensive care units. Critical care unit outbreak of Serratia liquefaciens from contaminated pressure monitoring equipment. Internal jugular versus subclavian vein catheterization for central venous catheterization in orthotopic liver transplantation.

Empiric therapy is appropriate if clinical suspicion is high and the initial diagnostic assay is pending or negative buy generic nicotinell 35 mg online. One study showed increased mortality among patients who had an initial false-negative toxin (40) discount nicotinell 35 mg on line. The recommended dose for severe disease is 125-mg oral vancomycin four times daily buy nicotinell 35 mg amex. Response to treatment is generally rapid, with decreased fever within one day and improvement of diarrhea in four to five days. Patients who fail to respond may have alternate diagnoses, lack of compliance, or the inability of drug to reach the colon such as with ileus or megacolon (26). Yet, all studies have shown failures with both metronidazole and vancomycin (*15% failure rates in the randomized controlled trials). Surgery is indicated for patients with peritoneal signs, systemic toxicity, toxic megacolon, perforation, multiorgan failure, or progression of symptoms despite appropriate antimicrobial therapy and Clostridium difficile Infection in Critical Care 283 recommended before serum lactate >5 (54). Select patients with disease clearly limited to the ascending colon have been treated successfully with right hemicolectomy, but intraoperative colonoscopy should be performed to rule out left-sided disease (40). Among patients requiring surgery, mortality rates after colectomy have ranged from 38% to 80% in small series (40). In a study of patients with fulminant colitis requiring colectomy, the need for preoperative vasopressor support significantly predicted postoperative mortality (40). Teicoplanin may be at least as effective as oral vancomycin or metronidazole but is expensive and not available in the United States. Both fusidic acid, also not available in the United States, and bacitracin have been shown to be less effective than vancomycin (54). Anion exchange resins, such as colestiol and cholestyramine, assert their effect on C. The anion exchange resins are not as effective as oral vancomycin and metronidazole and should not be used as the single agents. Resins must be taken at least two hours apart from oral vancomycin since it binds vancomycin as well as toxins. However, in the first of two subsequent phase 3 trials, tolevamer demonstrated significantly worse outcomes compared with standard therapy with oral vancomycin and metronidazole (57). It has wide antibacterial activity and poor absorption, leading to high intraluminal concentrations. Although it usually develops within 15 days after discontinuing the antibiotic, it can develop after as much as two months. Patients with at least one recurrence have 50% to 65% risk of experiencing an additional episode. It is not recommended to repeat stool assays after therapy unless the patients has moderate to severe diarrhea. Metronidazole should not be used beyond the first recurrence and duration should not be longer than 14 days. Tapered or pulsed dosing of vancomycin allows resistant 284 Hjalmarson and Gorbach spores to develop into vegetative cells between doses, making them susceptible to killing by antibiotics. Recovery of normal fecal flora may take days to weeks after discontinuation of antibiotics (61). Aside from cost, repeated courses of anticlostridial therapy have the disadvantage of perpetuating this disruption in intestinal flora. To break this cycle, alternate treatments have been attempted, including probiotics, administration of nontoxigenic C. Probiotics, including lactobacillus species and Saccharomyces boulardii, are nonpathogenic microorganisms that, when ingested, may benefit the health or physiology of the host. Stool transplantation, administration of feces or fecal flora via enema, or nasogastric tube has been found effective in small case series of patients with at least two relapses (61); the method remains unpopular for practical and aesthetic reasons. Among patients requiring surgery, mortality rates after colectomy have ranged from 38% to 80% in small series (40). During epidemics or if private rooms are not available it may be necessary to cohort patients to certain designated rooms. Each patient should have a dedicated commode, and privacy curtains should be used to decrease direct contact between beds. As the patient’s symptoms resolve, they should be Table 4 Infection Control Antimicrobial stewardship. Use designated individual thermometers, blood pressure cuffs and stethoscopes for infected patients Single-room isolation/cohorting Clostridium difficile Infection in Critical Care 285 moved to another room to avoid reinfection. Alcohol-based hand washing agents appear less able than soap and running water to remove spores from the hands. Particular emphasis must be given environmental cleaning and disinfection due to the C. Only chlorine-based disinfectants and high concentrations of vaporized hydrogen peroxide have been shown to be sporicidal (45,64). Generic bleach (containing at least 1000 ppm available chlorine) should be used to address environmental contamination. The spectrum of pseudomembranous enterocolitis and antibiotic-associated diarrhea. Narrative review: the new epidemic of Clostridium difficile-associated enteric disease. Severe Clostridium difficile-associated disease in populations previously at low risk—four states, 2005,. Clostridium difficile-associated diarrhea in a region of Quebec from 1991 to 2003: a changing pattern of disease severity.

Hepatitis C is the major cause of morbidity and the second leading cause of death in patients exposed to older factor concentrates discount 35mg nicotinell amex. Patients develop cirrhosis and the complications including as- cites and variceal bleeding generic nicotinell 35mg visa. Hepatitis B was not transmitted in significant numbers to patients with hemophilia generic nicotinell 52.5 mg mastercard. Diverticular dis- ease or peptic ulcer disease would not explain the prolonged prothrombin time. In contrast, these tests should not fluctuate as much in patients with severe liver disease. This step may be not necessary however in those individ- uals with hemoglobin greater than 20 g/dL. Once absolute erythrocytosis has been deter- mined by measurement of red cell mass and plasma volume, the cause of erythrocytosis must be determined. If there is not an obvious cause of the erythrocytosis, an erythropoi- etin level should be checked. An elevated erythropoietin level suggests hypoxia or auton- omous production of erythropoietin as the cause of erythrocytosis. When symptoms are present, the most common complaints are related to hyperviscosity of the blood and include vertigo, headache, tinnitus, and transient ischemic attacks. Molluscum contagiosum gency room with a transient ischemic attack characterized B. She calls your office 2 weeks later slightly distressed man with disheveled appearance. Cardiac examination reveals an early diastolic murmur over the left 3d intercostal space. Write her a prescription for oseltamivir and call her right hand and on the fourth finger of his left hand that are in 24 h to ensure improvement. A 56-year-old man with a history of hypertension cells coated with coccobacillary organisms. Which of the and cigarette smoking is admitted to the intensive care following therapies is indicated? Minority women aged 13–19 from the southeastern mens is recommended as first-line treatment for her United States account for a growing proportion of malarial infection? Which of the following is true years ago and is maintained on prednisone, 5 mg, and cy- regarding enteroviruses as a cause of aseptic meningitis? A 38-year-old female pigeon keeper who has no sig- trichomonal parasites are identified. Which of the follow- nificant past medical history, is taking no medications, has ing statements regarding trichomoniasis is true? When given as a first-line agent for invasive As- her shoulder presents with fever and severe low back pain. Bilirubin, lactose dehydrogenase, as well as gram-negative coverage and haptoglobin are all within normal limits. White blood cell count is 4300, with an of friends go on a 5-day canoeing and camping trip in ru- absolute neutrophil count of 2500. Which of the following tests is most likely to ers develops a serpiginous, raised, pruritic, erythematous produce a diagnosis? Treatment only for symptomatic illness ioides infection in an immunocompetent host? Asymptomatic seroconversion not been compliant with his physician’s request to off- C. A metal probe is used to probe the wound and it detects bone as well as a 3-cm deep cavity. You are a physician working on a cruise ship travel- Gram stain of the pus shows gram-positive cocci in ing from Miami to the Yucatán Peninsula. In the course of chains, gram-positive rods, gram-negative diplococci, 24 h, 32 people are seen with acute gastrointestinal illness enteric-appearing gram-negative rods, tiny pleomor- that is marked by vomiting and watery diarrhea. The phic gram-negative rods, and a predominance of neu- most likely causative agent of the illness is trophils. Isolation in cell culture health care provider after an accidental needle stick from E. The patient whose blood is on the contaminated therapeutic regimen for mono-infection with hepatitis B? Adequate therapy that allows for eradication of in- with severe dyspnea, confusion, productive cough, and fe- fection in index cases before person-to-person vers. She had been ill 1 week prior with a flulike illness spread can occur characterized by fever, myalgias, headache, and malaise. Earlier diagnosis due to a new culture assay Her illness almost entirely improved without medical in- C. Federal laws limiting the import of foreign cattle tervention until 36 h ago, when she developed new rigors D. Laws prohibiting the feeding of uncooked garbage followed by progression of the respiratory symptoms. On examination she is clammy, confused, and very cells, moderate gram-positive cocci in chains, and yeast dyspneic. Patient X > patient Y > patient Z resistant to which of the following antibiotics? Two weeks earlier she had a self-limited febrile ill- ness notable for a red facial rash and lacy reticular rash on A.

Population-w ide m ortality trends am ong patients hospitalized for acute m yocardial infarction: the O ntario experience cheap nicotinell 35 mg, 1981 to 1991 buy cheap nicotinell 52.5 mg on line. Trends in the incidence of m yocardial infarction and in m ortality due to coronary heart disease purchase nicotinell 52.5 mg overnight delivery, 1987 to 1994. Short and long term prognosis of acute m yocardial infarction since introduction of throm bolysis. Michael Schachter At least half the patients w ho suffer an acute infarct w ill survive at least one m onth, though 10–20% w ill die w ithin the next year. It is to be hoped and expected that m ore active early intervention w ill bring about further im provem ents in short term survival. There is therefore a large and grow ing num ber of patients w here there is a need to prevent further cardiovascular events and to m aintain and im prove the quality of life. Aspirin Aspirin at low to m edium doses (75–325m g daily) reduces m ortality, reinfarction and particularly stroke by 10–45% after m yocardial infarction. It has been estim ated that there is about one serious haem orrhage, gastrointestinal or intracerebral, for every event prevented. At the m om ent there is no com parable evidence for dipyridam ole, ticlopidine or clopidogrel. Beta blockers There is overw helm ing evidence for the beneficial effect of beta blockers, both w ithin the first few hours of m yocardial infarction and for up to three years afterw ards. Reduction in m ortality ranges from 15 to 45% , alm ost all of it accounted for by few er instances of sudden death. All beta blockers appear equally suitable, except those w ith partial agonist activity. The contraindi- cations are controversial, but m ost w ould include asthm a, severe heart block and otherw ise untreated heart failure, but patients w ith poor left ventricular function benefit m ost. In asthm atic patients, particularly, heart rate lim iting calcium channel blockers (verapam il or diltiazem ) m ay be useful alternatives to beta blockers in the absence of uncontrolled heart failure. The previous practice of only m easuring cholesterol levels som e m onths after an infarct should be abandoned and the levels assayed on admission at the sam e tim e as cardiac enzym es. This gives a reliable figure for usual cholesterol levels: a delay of a couple of days in sam pling w ill not. This is associated w ith significant decreases in m ortality (20–30% ) and in sudden death, as w ell as in reinfarction. Treatm ent should be started w ithin 1–2 days of the infarct and should be continued indefinitely. W hether all patients should be given these drugs post-infarction, in the absence of contraindications, is a m ore difficult issue. Other action In addition to these relatively specific m easures, diabetes and hypertension m ust of course be treated as required, and sm oking discouraged. Som e have advocated the use of fish oils especially in dyslipidaem ic patients, either as supplem ents or as fish. It is highly effective in preventing cardiovascular events, particularly stroke, but at the cost of m ore adverse effects than aspirin and the inconvenience of m onitoring. Evidence-based m edicine w ill lead to the prescription of 4 or m ore drugs, usually indefinitely. W e m ust be prepared to m ake a case for the patient to accept that it really is w orthw hile. At the m om ent, for w hatever reasons, m ost of these proven m easures are underused. Secondary prevention of m yocardial infarction: role of beta-adrenergic blockers and angiotensin converting enzym e inhibitors. Atherosclerosis 1999;147 (suppl 1): S39–44 66 100 Questions in Cardiology 31 W hat advice should I give patients about driving and flying after m yocardial infarction? John Cockcroft Com pared to other form s of international travel, flying presents few er dem ands on the invalid passenger than the alternative m odes of travel. Airlines have a duty of care to other passengers w ho m ay be inconvenienced by em ergency diversions, unscheduled stops and delays in the event of a m edical em ergency. Recertification of drivers and pilots follow ing m yocardial infarction depends upon their subsequent risk of incapacitation w hilst at the controls. All pilots and all professional drivers have a duty to inform the relevant licencing authority as soon as possible follow ing m yocardial infarction. There are no international regulations governing the prospective passenger w ho has recently suffered a m yocardial infarction and no statutory duty to inform the airline concerned. M ost w ill be guided in the decision w hether to fly or not by their cardiologist or fam ily doctor. M odern passenger aircraft have a cabin atm ospheric pressure equivalent to 5–8,000 feet, and alveolar oxygen tension falls by around 30%. This m ay exacerbate sym ptom s in any patient w ho experiences angina or shortness of breath w hilst w alking 50 m etres or clim bing 10 stairs. The enforced im m obility of the passenger on a long flight, airport transfers and the crossing of tim e zones should be considered. If few er than 10 days have elapsed since m yocardial infarction, or if there is significant cardiac failure, angina or arrhythm ia the patient m ay require oxygen or suitable accom panim ent. Private pilots are subject to the sam e regulations but m ay fly w ith a suitably qualified safety pilot in a dual control aircraft w ithout undergoing angiography. Sym ptom atic or treated angina, arrhythm ia or cardiac failure disqualifies any pilot from flying.