Hyzaar

By G. Gunock. Montana Tech.

This means that they were not intended to stand on their own buy discount hyzaar 12.5 mg on-line, and this fact may provide an explanation for some of the formal peculiarities they display and for some of the difficulties involved in their interpretation purchase hyzaar 50mg without prescription. Very similar instructions are found elsewhere in the Corpus, suggesting that this use of written information – probably in addition to oral information and the doctor’s own observations – is by no means something self-evident, but needs to be encouraged and to be done correctly. It is further noted at several points 51 In a comparison between legislation and medicine, Aristotle says: ‘Neither do men appear to become expert physicians on the basis of medical books. Yet they try to discuss not only general means of treatment, but also how one might cure and how one should treat each individual patient, dividing them according to their various habits of body; these [discussions] appear to be of value for men who have had practical experience, but they are useless for those who have no knowledge about the subject’ (Eth. And a report about Diocles’ reply to someone who claimed to have purchased a medical book (iatrikon biblion) and therefore to be no longer in need of instruction makes the same point: ‘Books are reminders for those who have received teaching, but they are gravestones to the uneducated’ (fr. Another remarkable reference to the use of written records is to be found at Epidemics 6. The significance of this for our understanding of these texts can hardly be overstated. Rather than claiming that in the case of Hippocratic medicine the transition from orality to literacy brought about a change in mental attitude and even in thinking, as has been suggested by Miller and Lonie,59 it seems more likely that, conversely, the development of prose writing, and the various forms in which the Hippocratic writers expressed themselves, is to be understood as a consequence of new ways of thinking – or rather as the result of a new attitude towards knowledge, resulting in a desire to store data gained by practical experience, to systematise them and to make them accessible for future use. It seems very likely that the Hippocratic authors regarded writing as an instrument for the organisation of knowledge concerning a great variety of phenomena, that is, not only in order to prevent knowledge from being forgotten – a desire they shared with, 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.

The Vd increased approximately 50% greater than normal for this population with one patient demonstrating a threefold increase buy 12.5mg hyzaar amex. Using individual patient pharmacokinetic parameters cheap 50mg hyzaar amex, adjustments in gentamicin doses ranged from 1. In this latter study, drug elimination rates were strongly influenced by the patient’s serum creatinine as a marker of clinical renal function. Despite larger doses that were required, doses of the aminoglycosides were given less frequently with patients having a creatinine above 1 mg/dL. They identified 59% of patients that had blood concentration of the antibiotic that was significantly below expected concentrations. The expanded Vd was considered to be responsible for the low blood concentrations. Dasta and Armstrong (10) studied aminoglycoside pharmacokinetics in 181 critically ill patients in a surgical intensive care unit. Additional studies have validated that the observations of increased Vd and highly variable T1/2 are applicable to all of the aminoglycosides in trauma (11) and intensive care unit patients (12). Understanding these changes of aminoglycosides under circumstances of trauma, fever, and critical illness should lead to pharmacokinetic dosing and changes in the management of these patients. Once-daily dosing of aminoglycosides has become very common at present, but again the pharmacokinetic observations have demonstrated that conventional doses will be inadequate, especially for the younger trauma patient with normal renal function. Vancomycin Like the aminoglycosides, the pharmacokinetics of vancomycin is highly variable among patients with normal renal function (14). They assumed and documented that the Vd of vancomycin was essentially that of total body water, or 0. In selected cases, the Vd was so high that it actually exceed the theoretical maximum of 1. Pharmacokinetic dosing required a 20% increase in the predicted dose of vancomycin, but a 50% increase in the interval between doses reflected a longer T1/2 than expected. Vancomycin clearance was 143 mL/min in the burn patient which was more than twice as great as that seen in control patients (68 mL/min). Vancomycin patients required larger and more frequent doses of the drug to achieve satisfactory peaks and troughs during therapy. The hyperdynamic circulation of the burn patient with normal kidney function was thought to be the basis for accelerated drug clearance. Garrelts and Peterie (17) made similar observations with respect to a reduced T1/2 in burn patients receiving vancomycin. Van Dalen and Vree (18) studied Vd and T1/2 in critically ill patients after the administration of ceftriaxone, the most commonly employed third-generation cephalosporin. They identified that the pharmacokinetics patterns were very similar to the aminoglycosides with an expanded Vd and wide inter-patient variability with T1/2. They concluded that unique nomograms needed to be developed to permit dosing of ceftriaxone that was consistent with each patient’s unique severity of disease profile. Yet another study demonstrated similar findings with a 90% increase in Vd and that drug clearance was increased in patients with normal renal function (19). Patients with diminished renal function demonstrated a very prolonged T1/2 and posed a serious problem of potential drug accumulation. They suggested that the expanded Vd could serve as a reservoir for the drug and result in slow return to the circulation, which would explain the reduced clearance. They concluded that continuous infusion would prove to use less total drug and would ensure reliable therapeutic drug concentrations. Cefepime is a commonly used antibiotic especially later in the trauma patient’s course when fever and nosocomial infection are significant issues. The pharmacokinetics of aztreonam were studied in 28 critically ill, mostly trauma patients, with gram-negative infections (27). The patients were a relatively young group (age ¼ 35 years) and received 2 g of aztreonam every six hours. The larger dose of aztreonam was the likely reason that adverse effects were not seen from the increase in Vd. Carbapenems The carbapenem antibiotics are a subgroup of the b-lactams that are commonly used to treat the most difficult of infected trauma patients, especially with hospital-acquired bacteria. Vd and T1/2 tended to be similar to normal adult measurements in surgical patients with intraabdominal infection and other surgical infections.

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