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W ithdraw al of digoxin from patients w ith chronic heart failure treated w ith angiotensin- converting-enzym e inhibitors buy 100mg viagra super active erectile dysfunction reversible. Rakesh Sharma M ore than 25 years ago it w as proposed that beta blockers m ay be of benefit in heart failure1 and yet cheap viagra super active 50mg without prescription impotence restriction rings, until recently cheap viagra super active 100mg line impotence definition inability, there has been a general reluctance am ongst the m edical profession to prescribe them for this indication. This is not entirely surprising, as not too long ago heart failure w as w idely considered to be a m ajor contraindication for the use of beta blockers. Treatm ent should be initiated at a low dose and be increased gradually under supervised care. The patient should be m onitored for 2–3 hours after the initial dose and after each 100 Questions in Cardiology 119 subsequent dose increase to ensure that there is no deterioration in sym ptom s, significant bradycardia, or hypotension. In patients w ith suspected or know n renal im pairm ent, it is recom m ended that serum biochem istry is also m onitored. How ever, there are several im portant areas in w hich the effect of beta blocker therapy is unknow n. For exam ple, should w e be using beta blockers to treat asym ptom atic patients w ith evidence of systolic ventricular dysfunction and is there a role for beta blocker therapy in the patient post-m yocardial infarction w ho has ventricular im pairm ent? Evidence of a beneficial effect of beta blockers on the syndrom e of heart failure is accum ulating. The use of beta blockers in this context m ay prove to be one of the m ost im portant pharm aco- logical “re-discoveries” in cardiology in recent years. Double-blind, placebo-controlled study of the effects of carvedilol in patients w ith m oderate to severe heart failure. The ninth and latest edition, published in 1994,1 retains an assessm ent of the functional capacity of the patient w ith heart disease (see Table 57. Despite this it rem ains a quick, sim ple and repro- ducible evaluation of the patient w ith heart failure. Survival of just 33% at tw o year follow up has been reported for this group in a Canadian study. The Fram ingham Heart Study4 is probably the largest survey of cardiovascular disease undertaken and has data on over 9000 patients, spanning tw o generations, w ith a m edian follow up of 14. The overall five year m ortality rates w ere reported as 75% for m en and 62% for w om en w ith a m edian survival of 1. The authors of this study4 em phasise the grim prognosis of this disease by m aking com parison to the m ortality rate for all cancers, w hich, betw een 1979 and 1984 w as reported as 50%. The overall prognosis for a patient diagnosed w ith heart failure is therefore really rather w retched. M any objective prognostic variables w ith equal or greater w eight in predicting heart failure m ortality have been elucidated,5 how ever, and account of these should be acknow ledged. O rdinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain. O rdinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain. Less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain. Sym ptom s of heart failure or of the anginal syndrom e m ay be present even at rest. Criteria for diagnosis and treatm ent of heart disease, 9th edition, Little, Brow n and Com pany, 1994.

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It seems very likely that the Hippocratic authors regarded writing as an instrument for the organisation of knowledge concerning a great variety of phenomena buy generic viagra super active 100 mg line erectile dysfunction drugs trimix, that is generic viagra super active 50 mg visa doctor's advice on erectile dysfunction, not only in order to prevent knowledge from being forgotten – a desire they shared with cheap viagra super active 25mg with visa erectile dysfunction pump surgery, for example Herodotus – but also to keep knowledge available for 56 On Regimen in Acute Diseases 3 (2. And it seems entirely reasonable that medicine (rather than, say, mathematics or astronomy) should play this part: for, on the one hand, the empirical data reflected in case histories such as the Epidemics must soon have reached such unmanageable proportions and such a high degree of detail that it could not possibly be remembered; so there was a need for storage of information based on the belief that such information might remain useful. On the other hand, since medicine was incessantly confronted with new cases in which existing knowledge had to be applied or against which it had to be checked and, if necessary, modified, it had to be accessible in a conveniently retrievable form. If all this is plausible, the emergence of the Hippocratic writings and especially the variety of forms they display can be seen as a result of the need for organisation of knowledge and research – a need arising also from the fact that their authors must have formed a community of scholars rather than being single scientists working independently. This might also suggest an alternative explanation of why all the Hippocratic writings are anonymous (cf. In the course of the fourth century the collection and organisation of knowledge was further implemented and applied to a much broader area by Aristotle and his pupils (or colleagues), and a similar process of data preservation, common intellectual property and exchange of information evidently took place in the Lyceum. More could be said from a contextual point of view about these and other features of medical and philosophical ‘discourse’. For example, there is the formation of a scientific terminology and its relation to ordinary language, with stylistic and syntactic anomalies such as the use of ‘shorthand’ (brachylogy), ‘aphoristic’ style and formulaic language, or structural characteristics such as ring composition, paragraph division, use of introductory and concluding formulae and other structuring de- vices. Particularly interesting is the presence or absence of the author in 60 See Ostwald and Lynch (1992). Furthermore, of great interest are the use of rhetorical questions, formulae for fictional objections, modes of argument used by the Hippocratic writers, Diocles and Aristotle, the use of metaphors and analogies, and patterns of thought, such as antithesis, binary or quaternary schemata, the various forms of overstatement, or the ways in which ancient scientific writers, just like orators, tried to convey a certain ¯ethos (in the ancient rhetorical sense of ‘personality’) to their audiences, for example by presenting themselves in a certain way or assuming a certain pose with re- gard to their audience and their subject matter. Alternatively, the author may present himself as a venerable authority, as a schoolmas- ter ready to praise good suggestions and to castigate foolish answers, as a dispassionate self-deprecating seeker of the truth, or a committed human being who brings the whole of his life experience to bear on the subject he is dealing with, and so on. As many readers of this volume will be aware from their own experience with communication to academic audiences, these are different styles of discourse, with different stylistic registers, types of ar- gument, appeals to the audience, commonplaces, and suchlike; what they were like in the ancient world deserves to be described, and the attempt should be made to detect patterns, and perhaps systematicity, in them. Ancient scientists, like orators, had an interest in captatio benevolentiae and were aware of the importance of strategies such as a ‘rhetoric of modesty’, a ‘rhetoric of confidence’. In this respect the dialogues of Plato provide good examples of these attitudes, and they may serve as starting-points for similar analysis of scientific writing which is not in the form of a dialogue. The works of Galen present a particularly promising area of study, for one can hardly imagine a more self-conscious, rhetorical, argumentative, polemicising and manipulating ancient scientific writer than the doctor 61 In chapter 1 we shall see an interesting example of a significant alternation of singular and plural by the author of On the Sacred Disease, where the author cleverly tries to make his audience feel involved in a course of religious action which he defends and indeed opposes to the magical one advocated by his opponents. And, as I have shown elsewhere, the works of Caelius Aurelianus present a further example of medical literature full of rhetorical and argumentative fireworks. At the same time, it will have become clear that these formal aspects of Greek and Latin medical writing are of great significance when it comes to the use of these texts as sources for what used to be seen as the primary jobs of the medical historian, namely the reconstruction of the nosological reality of the past and of the human response to this reality. I have dealt with this area more elaborately in a separate collaborative vol- ume on medical doxography and historiography. Many ancient medical writers, philosophers and scientists (as well as historians) regarded themselves as part of a long tradition, and they explicitly discussed the value of this tradition, and their own contribution to it, in a prominent part of their own written work, often in the preface. Yet, more recently, scholarship has drawn attention to the large variety of ways in which ancient scientific and philosophical discourse received and reused traditional material and to the many different purposes and strategies the description of this material served. Ancient writers on science and philosophy received and constructed particular versions of the 63 See van der Eijk (1999c). The modalities of these processes have turned out to be very complicated indeed, and it has become clear that the subject of ‘tradition’ in ancient thought comprises much more than just one authoritative thinker exercising ‘influence’ on another. Our understanding of ‘doxography’ and other genres of ancient ‘intel- lectual historiography’ has been significantly enhanced over the last two decades, and it has contributed to a greater appreciation of the various dimensions – textual, subtextual and intertextual – of much Greek and Roman philosophical and medical discourse. In particular, it has shed further light on the possible reasons behind the ways in which ideas are presented in texts and the modes in which ancient authors contextualise themselves, aspects which are of great relevance to the interpretation and evaluation of these ideas. He has been credited with attempting a ‘natural’ or ‘rational’ explanation of a disease which was generally believed to be of divine origin and to be curable only by means of apotropaeic ritual and other magical instruments. The identity, claims and practices of the magicians have also been studied by Lanata (1967); Temkin (1971) 10–15;Dolger (¨ 1922) 359–77; Moulinier (1952) 134–7; Nilsson (1955) 798–800. Miller (1953) 1–15; Nestle (1938) 1–16;Norenberg (¨ 1968); Thivel (1975); Vlastos (1945) 581.

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