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Transoesophageal tw o- dim ensional echocardiography for the detection of left atrial appendage throm bus esomeprazole 20mg with mastercard. Accuracy of trans- oesophageal echocardiography for identifying left atrial throm bi purchase 20 mg esomeprazole fast delivery. Im aging of throm bi and assessm ent of left atrial appendage function: a prospective study com paring trans- thoracic and transoesophageal echocardiography proven 20mg esomeprazole. Diana Holdright Approxim ately 80% of strokes are ischaem ic in origin, of w hich 20–40% have a cardiac basis. Com m on cardiac abnorm alities associated w ith neuro- logical events include atrial fibrillation, m itral valve disease, left atrial enlargem ent, left ventricular dilatation, prosthetic valve abnorm alities and endocarditis. The aim of echocardiography is to confirm the presence of im portant predisposing cardiac abnorm alities and in younger patients, typically <50 years, to look for rare cardiac causes that m ight not be detected by other m eans. Consequently, echocardiography is particularly useful in patients at both ends of the age scale. Superiority of trans- oesophageal echocardiography in detecting cardiac source of em bolism in patients w ith cerebral ischaem ia of uncertain aetiology. It is a vestige of the fetal circulation, w ith an orifice varying in size from 1 to 19m m , allow ing right-to- left or bidirectional shunting at atrial level and the potential for paradoxical em bolism. The detection of venous throm bosis is not w ithout difficulty and venous throm bi m ay resolve w ith tim e, such that a negative study does not exclude prior throm bosis. There are no com pleted prospective trials com paring aspirin, w arfarin and percutaneous closure to guide m anagem ent of patients w ith an ischaem ic stroke presum ed to be cardioem bolic in origin. Aspirin therapy is an uncom plicated option, and easier and safer than life-long w arfarin. If there is evidence of m ore than one ischaem ic lesion, no indication for w arfarin (e. Atrial septal aneurysm and patent foram en ovale as risk factors for cryptogenic stroke in patients less than 55 years of age. Frequency of deep vein throm bosis in patients w ith patent foram en ovale and ischem ic stroke or transient ischem ic attack. Physical exam ination should include an assessm ent of blood pressure in the supine and erect position, a cardiovascular exam ination to look for the presence or absence of structural heart disease (including aortic stenosis, m itral stenosis, outflow tract obstruction, atrial m yxom a or im paired left ventricular function) and auscultation for carotid bruits. Kenny et al in 1986 w ere the first to dem onstrate the value of head up tilt testing in the diagnosis of unexplained syncope. Tilt table testing m ay also be of use in the assessm ent of elderly patients w ith recurrent unexplained falls and in the differential diagnosis of convulsive syncope, orthostatic hypotension, postural tachycardia syndrom e, psychogenic and hyper- ventilation syncope and carotid sinus hypersensitivity. W hat do you do if you make a diagnosis of vasovagal syncope on history and head up tilt test? As a result of the com plexity of the aetiology of vasovagal syncope and the lack of a single w ell evaluated therapeutic intervention there are m any treatm ents available. These have recently been review ed,2 and the follow ing algorithm for m anagem ent of vaso- vagal syncope suggested (Algorithm 75. The New castle protocols for head-up tilt table testing in the diagnosis of vasovagal syncope and related disorders. In older patients presenting to casualty this m ay be as high as 20% w hen evaluated w ith a full cardiovascular w ork up. Thus even after a thorough w ork up, the cause of syncope m ay rem ain unexplained in up to 40% of cases. At best, sym ptom s correlating w ith arrhythm ias occur in 4% of patients, asym ptom atic arrhythm ias occur in up to 13% , and sym ptom s w ithout arrhythm ias occur in up to a further 17%. In a follow up by Kapoor et al,11 only 5% of patients reported recurrent sym ptom s at 1 m onth, 11% at 3 m onths and 16% at 6 m onths. This variability is prim arily dependent on the char- acteristics of patients studied, in particular the absence or presence of co-m orbid cardiovascular disease. It should be considered in those w ho have already com pleted the above outlined investigations that have proved negative, and in those in w hom the external loop recorder has not yielded a diagnosis in one m onth. It has the ability to “freeze” the current and preceding rhythm for up to 40 m inutes after a spontaneous event and thus allow s the determ ination of the cause of syncope in m ost patients in w hom sym ptom s are due to an arrhythm ia. The activation device, used by the patient, fam ily m em ber or friend freezes and stores the loop during and after a spontaneous syncopal episode. Hypotensive syndrom es including vasovagal syncope, orthostatic hypotension, post-prandial hypotension and vasodepressor carotid sinus hypersensivity m ay also cause syncope. An ability to record blood pressure variation in addition to heart rate changes during sym ptom s w ould be a very helpful and exciting addition to the investigation of people w ith syncope. Arrhythm ias detected by am bulatory m onitoring; lack of correlation w ith sym ptom s of dizziness and syncope. Increm ental diagnostic yield of loop electrocardiographic recorders in unexplained syncope. Detection of arrhythm ias; use of patient-activated am bulatory electrocardiogram device w ith a solid state m em ory loop. Simon Sporton Norm al activation of the ventricles below the bundle of His occurs by w ay of three “fascicles” – the right bundle branch and the anterosuperior and posteroinferior divisions of the left bundle branch. There have been no random ised trials of pacing vs no pacing in patients w ith chronic bi- or trifascicular block. Clinicians m ust therefore be guided by know ledge of the natural history of the condition w ithout pacing, and expert consensus guidelines. The largest prospective study of patients w ith bi- and tri- fascicular block follow ed 554 asym ptom atic patients for a m ean of 42 m onths. The five year m ortality from an event that m ay conceivably have been a bradyarrhythm ia w as just 6% , a figure that m ust inevitably include som e non-bradyarrhythm ic deaths. An im portant finding of this study w as a five year all cause m ortality of 35% reflecting the high incidence of underlying coronary heart disease and congestive cardiac failure. The available evidence w ould suggest that asym ptom atic patients w ith trifascicular block should not be paced routinely. A history of syncope should prom pt thorough investigation for both brady- and tachyarrhythm ic causes. If interm ittent second or third degree block is docum ented perm anent pacing is indicated. Bi- and trifascicular block are associated w ith a high incidence of under- lying coronary heart disease and heart failure. Attention should 100 Questions in Cardiology 165 therefore be directed tow ards the detection of these conditions and the use of therapies know n to im prove their prognosis. Dual cham ber pacing (or m ore accurately physiological pacing w hich m ay include single cham ber atrial devices) is the preferred m ode in m ost com m on indications for pacem aker im plantation. Physiological pacem akers can be recom m ended in sinus node disease on the basis of m any retrospective studies and one prospective study. M ortality is m inim al and occurs due to unrecognised pneum othorax, pericardial tam ponade or great vessel traum a. Com plications at im plant are those of subclavian puncture, particularly pneum othorax, although these can be avoided if the cephalic approach is used. There is som e long term evidence that the cephalic approach m ay avoid chronic lead failure in polyurethane leads due to subclavian crush injury. Acute lead displacem ent should be less than 1% for ventricular leads and 1–2% for atrial leads. Prospective random ised trial of atrial versus ventricular pacing in sick-sinus syndrom e. Alistair Slade Pacem akers have increasingly sophisticated circuitry to prevent dam age or interference from external m agnetic interference. Electric fences Nobody should touch an electric fence but should electric shock occur it w ould be w ise to have the system checked by form al interrogation in case electrical m ode reversion has occurred. Significant artefact w ould be obtained in regions close to an im planted pacem aker but m ore im portantly the pow erful m agnetic fields m ight interfere w ith the device. Airport metal detectors Airport m etal detectors have the potential to interfere w ith pacing system s. Patients should produce their pacem aker registration cards to bypass busy security queues. M obile phones M obile phones have been extensively investigated in term s of interaction w ith im planted devices. Analogue phones do not interact w ith im planted devices but m ore m odern digital devices have the potential to interfere w ith pacing system s w hen utilised w ithin a field of 10–15 cm. Pacem aker patients w ith m obile phones are therefore advised to carry m obile telephones on the opposite side 100 Questions in Cardiology 169 of the body from the site of the device im plant and should hold the device to the opposite ear. Safe perform ance of m agnetic resonance im aging on five patients w ith perm anent cardiac pacem akers.

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The interaction between microorganisms and the host determines the systemic response rather than the origin of the infection discount esomeprazole 20 mg visa. The clinical diagnostic approach is to identify systemic disorders or urinary tract abnormalities that predispose to urosepsis cheap 40mg esomeprazole overnight delivery, i cheap esomeprazole 40mg without prescription. Gram stain and culture of the urine with urinalysis plus blood cultures are the definitive diagnostic tests. Indwelling (short-term) Normal Low No antibiotics Remove Foley catheter as non-obstructed Foley soon as possible. Urosepsis due to cystitis in compromised hosts has no localizing signs (1,4,5) (Table 4). Table 4 Differential Diagnosis of Acute Cystitis, Rental Stone, Acute Pyelonephritis Clinical findings Acute cystitis Rental stone Acute pyelonephritis. Symptoms Abdominal pain Suprapubic discomfort Unilateral back pain Unilateral back pain Dysuria þ À þ. Urosepsis in Critical Care 291 Nosocomial urosepsis follows recent urologic instrumentation usually <72 hours. The diagnosis should be considered when a patient becomes septic after a urologic procedure. Patients presenting from the community with urosepsis often have stone or structural ureteral, bladder, or renal abnormality, acute prostatitis/prostatic abscess, or acute pyeloneph- ritis. In acute pyelonephritis, the Gram stain provides a rapid, presumptive, otherwise unexplained microbiologic diagnosis, which should guide antibiotic selection. Patients with acute prostatitis may become septic, but urosepsis often accompanies prostatic abscesses (3–8) (Table 5). Prostatic abscess is a difficult diagnosis in a septic patient without any localizing signs. Similarly, in a patient who has a history of prostatitis and no other explanation for fever/hypotension sepsis, a prostatic abscess should be considered in the differential diagnosis. Gram-positive cocci in chains are group B or D streptococci, since gram-positive cocci in clusters represent S. With the exception of epididymitis in the elderly, community- acquired urosepsis does not require P. Table 6 Community-Acquired Urosepsis: Therapeutic Approach Urosepsis- associated syndrome Microorganisms Urine Gram stain Empiric coverage. Urosepsis in Critical Care 293 Table 7 Nosocomial Urosepsis: Therapeutic Approach Urosepsis- associated syndrome Usual uropathogens Urine Gram stain Empiric coverage. The importance of pre-existing urinary tract disease and compromised host defenses. Role of fluoroquinolones in the treatment of serious bacterial urinary tract infections. Efficacy and safety of colistin (colistimethate sodium) for therapy of infections caused by multidrug-resistant Pseudomonas aeruginosa and Acinetobacter baumannii in Siriraj Hospital, Bangkok, Thailand. Polymyxin B for the treatment of multidrug-resistant pathogens: a critical review. Pseudomonas aeruginosa susceptible only to colistin in intensive care unit patients. Once daily tigecycline therapy of multidrug-resistant and non-multidrug resistant gram- negative bacteremias. Polymyxin B and doxycycline use in patients with multidrug-resistant Acinetobacter baumannii infections in the intensive care unit. In vitro activity of tigecycline and comparators against carbapenem-susceptible and resistant Acinetobacter baumannii clinical isolates in Italy. Treatment with tigecycline of recurrent urosepsis caused by extended-spectrum-beta-lactamase-producing Escherichia coli. Considerations in control and treatment of nosocomial infections due to multidrug-resistant Acinetobacter baumannii. Severe Skin and Soft Tissue Infections 17 in Critical Care Mamta Sharma and Louis D. John Hospital and Medical Center, and Wayne State University School of Medicine, Detroit, Michigan, U. Most of these infections are superficial and treated with regimens of local care and antimicrobial therapy. However, others like necrotizing infections are life-threatening and require a combined medical and surgical intervention. Prompt recognization and treatment is paramount in limiting the morbidity and mortality associated with these infections, and thus a thorough understanding of the various etiologies and presentation is essential in the critical care setting. It is also important to discriminate between infectious and noninfectious causes of skin and soft tissue inflammation. A detailed history and examination are necessary to narrow the possible etiologies of infection. In many instances, surface cultures are unreliable and misleading because surface-colonizing organisms can be mistaken for pathogens. In instances in which the diagnosis is in doubt, aspiration, biopsy, or surgical exploration of the skin can be considered. Typically, soft tissue infections result from disruption of the skin by exogenous factor, extension from subjacent infection, or hematogenous spread from a distant site of infection. Physiological factors that control the bacterial skin flora include humidity, water content, skin lipids, temperature, and rate of desquamation. Besides containing secretory immunoglobulin (IgA), sweat also possesses sufficient salt to create a high osmotic pressure, which may be responsible for inhibiting many microbial species. In spite of these barriers to colonization, the skin provides an excellent venue of various microenvironments. Differences in cutaneous microflora may relate to variability in skin surface temperature and moisture content as well as the presence of different concentrations of skin surface lipids that may be inhibitory to various microorganisms. Colonization with organisms sensitive to desiccation, such as gram-negative bacilli, is not favored. The predominant bacterial flora of the skin is the various species of coagulase-negative staphylococci (Staphylococcus epidermidis, S. Colonization of the anterior nares, perineum, or skin, particularly if the cutaneous barrier has been disrupted or damaged, may occur shortly after birth and may recur anytime thereafter (1–4). Approximately 20% of individuals always carry one type of strain and are called persistent carriers. Carriage rates are higher than in the general population for injection drug users, persons with insulin-dependent diabetes, patients with dermatological conditions, patients with long-term indwelling intravascular catheters, and those with human immunodeficiency virus infection. Other gram-negative bacilli are found more rarely on the skin, and these include Proteus and Pseudomonas in the toe webs and Enterobacter and Klebsiella on the hands. Antibiotics disturb the balance within commensal flora and leave the surface vulnerable to colonization by exogenous gram-negative bacilli and fungi. The principal fungal flora is lipophilic yeasts of the genus Malassezia, and nonlipophilic yeasts such as Candida spp. Primary skin infections occur in otherwise normal skin and are usually caused by group A streptococci or S. A deficiency in the expression of antimicrobial peptides may account for the susceptibility of patients with atopic dermatitis to skin infection with S. Other factors predisposing to skin infections include vascular insufficiency, disrupted venous or lymphatic drainage, sensory neuropathies, diabetes mellitus, previous cellulitis, foreign bodies, accidental or surgical trauma, burns, poor hygiene, obesity, and immunodeficiencies. Extension into the superficial dermis with involvement of lymphatic is typical of erysipelas, whereas cellulitis is an extension into the subcutaneous tissue. A clinically useful distinction with important management implications subdivides soft tissue infections into nonnecrotizing and necrotizing processes (9). The Center for Drug Evaluation and Research for development of antimicrobial drugs has classified skin and soft tissue infection as uncomplicated or complicated. The uncomplicated category included simple abscesses, impetiginous lesions, furuncles, and cellulitis. Compli- cated category included infection involving the deeper layer or requiring significant surgical intervention. Superficial infection in an anatomical site with a risk of gram-negative pathogen or anaerobes such as the rectal area was also considered to be complicated (10). DiNubile and Lipsky classified skin and soft tissue infections to assist clinician in recognizing uncomplicated and complicated infections (11).

It is difficult order 40mg esomeprazole with amex, however buy 40mg esomeprazole visa, to see how the experiences described here can be accommodated within Aristotle’s theory of sleep and dreams generic esomeprazole 40 mg otc. 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. Instead, he simply goes on, eager to explain as much as he can and carried away by the sub- tlety and explanatory power of his theories, but without bothering to tell us how these explanations fit in with what he has said earlier on. Aristotle on sleep and dreams 203 an argumentative, ‘dialectic’ or perhaps even didactic strategy (we should not forget that Aristotle’s extant works derive from the teaching practice, and that they are very likely to have been supplemented by additional oral elucidation). However this may be, it is undeniable that Aristotle in his works on sleep and dreams, as in his biological works at large, sometimes shows himself an improviser of ad hoc explanations, constantly prepared to adapt his theories to what the phenomena suggest. This inevitably means a lower degree of systematicity than we would perhaps regard as desirable; on the other hand, the elasticity of his explanations, and his readiness to accommodate new empirical observations, are things for which he is to be commended. Lack of systematicity is, to a varying extent, characteristic of many Aris- totelian works and can also be observed in other parts of the Parva naturalia, both within and between the individual treatises that make up the series. But it seems to obtain particularly to On Divination in Sleep,55 which is in general a less technical treatise whose degree of accuracy, both in scien- tific terminology56 and in the description of psycho-physiological details, is rather low in comparison with the other two works. Aristotle approaches the problem of divination in sleep from different perspectives, but he offers neither a definition nor a comprehensive explanatory account. The text has a strongly polemical tone and is for a substantial part devoted to an assessment of current views on the subject, such as the view (referred to and criticised three times) that dreams are sent by the gods, or the view held by the ‘distinguished doctors’, or the theory of Democritus. Yet not too much weight should be attached to these cross-references, as they may easily have been added at a later, editorial stage;besides,theprefacetoOnSleepandWakingpresentsaprogrammeofquestionsthatissomewhat different from what is actually being offered in what follows, and this also applies to On Dreams. Thus the beginning of On Sleep and Waking announces a discussion of the question ‘why people who sleep sometimes dream and sometimes do not dream, or, alternatively, if they always dream, why they cannot always remember their dreams’ (453 b 18–20); but these questions can hardly be regarded as central to On Dreams, where they are addressed only in passing (in 461 a 13) and incompletely (in 462 a 31–b 11, a passage that itself, too, shows signs of a hastily added appendix). Such discrepancies between programme and execution need not, however, be due to later editorial additions, for it is, again, not uncharacteristic of Aristotle’s works for there to be discrepancies between programme and execution. As his discussion shows, and in particular the passage from 463 b 12–18 quoted above, dreams do not have any cognitive or moral significance and do not contribute in any way to the full realisation of human virtues. True, Aristotle concedes that in some cases foresight in sleep is possible, but this is not to be taken in the sense of a special kind of knowledge which some people possess, but rather in the straightforward sense of ‘foreseeing’, in a somewhat accidental and uncontrollable manner, what later actually happens. He does not assign a final cause to dreaming, and the answer to the question of the purpose of dreams is only given in a negative way. In the passage 463 b 14 discussed above, Aristotle says that dreams ‘do not exist for this purpose’, to serve as a kind of medium for divine messages. This lack of a teleological explanation is not something to be surprised at, for as Aristotle himself says, one should not ask for a final cause with everything, for some things simply exist or occur as a result of other things or occurrences. Foresight in sleep is not an intellectual or cognitive virtue in the sense of the Aristotelian notion of excellence (arete¯ ); on the contrary, it occurs with people whose intellectual powers are, for some reason, weakened or inactive. Prophecy in sleep is a matter of luck and belongs to the domain of chance: it escapes human control, and its correctness can only be established afterwards, when the event that was foreseen has actually taken place. Mantic knowledge is not knowledge in the strict sense (for many dreams do not come true, 463 b 22–31), and the insights gained by it, if correct, are at best ‘accidental insights’, which only concern the ‘that’, not the ‘because’: they only point to the existence or occurrence of something without providing an explanation for this. This low estimation provides an additional reason why Aristotle shows so little interest in the contents and the meaning of dreams, which was one of the questions with which this investigation started. It will have become clear that the ‘omissions’ in Aristotle’s discussion of dreams that I mentioned at 57 Part. Aristotle on sleep and dreams 205 the beginning can better be understood both in the light of the framework of the study of nature in which his discussion takes place and in the light of his overall attitude towards the phenomenon in the wider context of his psychology and ethical theory. From this point of view, we can arrive at a more appropriate assessment of Aristotle’s achievement in the study of sleep and dreams. The strength of Aristotle’s treatment lies, in my view, in his highly intelligent and systematic approach, as it is reflected in the shrewd and original questions he asks. His use of empirical material does not, to be sure, always concord with all criteria that we, from a modern point of view, might think desirable for a truly scientific investigation; and his optimistic tone throughout both treatises, suggesting that everything is clear and only waiting to be explained by the master, does not quite do justice to his struggle with the perplexing phenomenon of prophecy in sleep – which he, not surprisingly, is unable to explain satisfactorily. Yet when measuring Aristotle’s achievement in comparison with what was known and believed in his own time, we have good reasons to be impressed. His works on sleep and dreams are without any doubt the most intelligent extant treatment of the subject in classical literature. There also seems to be a general agreement as to the basic consistency of Aristotle’s psychological theory, or at least a tendency to explain apparent contradictions between On the Soul and the Parva naturalia on the one hand, and statements related to the soul in the zoological writings on the other (or between On the Soul and the Parva naturalia, or between different sections of the Parva naturalia) as the result of differences of method, approach, or argumentative strategy of particular treatises or contexts rather than in terms of a development in Aristotle’s psychological ideas. The compatibility of ‘instrumentalism’ and ‘hylomorphism’ was stressed by Kahn (1966); Lefevre (` 1972) and (1978); and for the Parva naturalia by Wiesner (1978); and Wijsenbeek-Wijler (1976). See also 206 Aristotle on the matter of mind 207 This consensus might easily give rise to the view that there is no such thing as an Aristotelian ‘psychology’, or at least that psychology more or less coincides with, or forms part of, biology in that it represents an investigation of animals (and plants) qua living beings, that is, ensouled natural things. Although this view is, in my opinion, not entirely correct (see below), it is in general accordance with Aristotle’s belief that the study of soul ‘contributes greatly’ to the study of nature,3 his definition of soul as ‘the form of the body’4 and his programmatic statement that all psychic ‘affections’ (paqžmata) are ‘forms embedded in matter’ (l»goi ›nuloi). The fact that in On the Soul itself we hear relatively little of these bodily aspects6 might then be explained as a result of a deliberate distribution and arrangement of information over On the soul and the Parva naturalia, which should be seen as complementary parts of a continuous psycho-physiological account which is in its turn complementary to the zoological works. Thus the present chapter will deal with Aristotle’s views on the bodily aspects of think- ing, and it will attempt to show that although thinking, according to Aristotle, is perhaps itself a non-physical process, bodily factors have a much more significant part to play in it than has hitherto been recognised. In their turn, students of Aristotle’s zoological writings might feel an in- creasing need to relate Aristotle’s views on bodily parts and structures of organisms explicitly to the psychic functions they are supposed to serve, Hardie (1964); Tracy (1969) and (1983); Verbeke (1978); Hartman (1977); Modrak (1987). This is not to say that developmental approaches to Aristotle’s psychology have entirely disappeared; on certain specific topics, such as the various discussions in On the Soul and the Parva naturalia of the ‘common sense’ and its physiological aspects, there is still disagreement about how to account for the discrepancies; a developmental explanation is offered by Welsch (1987), a very important book which seems to have gone virtually unnoticed by Anglo-American scholarship on Aristotle’s psychology, and by Block (1988). For, as Aristotle himself indicates, a purely formal description of psychic powers and pro- cesses is insufficient for at least two reasons. First, as he repeatedly stresses (apparently in polemics against the Pythagoreans), the connection of a cer- tain psychic function with a certain bodily structure (an organ such as the eye, a process such as heating) is by no means coincidental; on the contrary, the bodily basis should have a certain nature or be in a certain condition in order to enable the exercise of a certain psychic power (e. These variations may exist, or occur, among different species, but also among in- dividual members of one species, or among types of individuals within one species, or even within one individual organism at different moments or states (e. As this chap- ter will try to show, variations in intellectual capacities and performances among different kinds of animals, among different members of one kind or even within one individual on different occasions are explained by Aristotle with a reference to bodily factors. Are the variations to be explained mechanically or teleologically, and are defects compensated for by other skills? In spite of this pronouncedly biological context, however, there are indi- cations that the study of the soul has, for Aristotle, a special status and is 8 See Part. Aristotle on the matter of mind 209 not completely reducible to the study of nature. His consideration of the – perhaps no more than potential – existence of ‘affections that are peculiar to the soul’ (­dia t¦v yuc¦v) in De an. Likewise unclear is the status of the Parva naturalia, which seem to oc- cupy a kind of middle position between On the Soul and the zoological works and which, as a result, have traditionally, although rather unfortu- nately, been divided into a ‘psychological’ and a ‘biological’ section. Hence it would perhaps be more appropriate to say that for Aristotle psychology and biology, as far as their subject matter is concerned, overlap 11 De an. On the method and scope of the Parva naturalia see van der Eijk (1994) 68–72; for a different view see G. Ross (1906) 1: ‘They [the Parva naturalia] are essays on psychological subjects of very various classes, and there is so much detail in the treatment that, if incorporated in the De Anima, they would have detracted considerably from the unity and the plan of that work. Consequent on the separateness of the subjects in the Parva Naturalia, the method of treatment is much more inductive than in the De Anima. There, on the whole, the author is working outwards from the general definition of soul to the various types and determinations of psychic existence, while here, not being hampered by a general plan which compels him to move continually from the universal to the particular, he takes up the different types of animate activity with an independence and objectivity which was impossible in his central work. In spite of Aristotle’s own characterisation of the scope of the Parva naturalia in the beginning of On Sense Perception, it is not easy to characterise the difference with regard to On the Soul in such a way as to account for the distribution of information over the various treatises. Even if one is prepared to regard On the Soul and Parva naturalia as a continuous discussion of what it basically means for a living being (an animal or a plant) to live and to realise its various vital functions, or to explain the relative lack of physiological detail in On the Soul as the result of a deliberate argumentative strategy, it remains strange that some very fundamental formal aspects of the various psychic functions are dealt with at places where one would hardly expect them (e.

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The patient m ust be fully inform ed generic esomeprazole 40 mg otc, and involved in deciding her m ode of anticoagulation (m edicolegal im plications) buy esomeprazole 20mg visa. Failure of adjusted doses of sub- cutaneous doses of heparin to prevent throm boem bolic phenom ena in pregnant patients w ith m echanical cardiac valve prostheses order esomeprazole 20mg on line. The key here is to leave the m other off w arfarin for the m inim um tim e possible. An elective section is perform ed at 38 w eeks’ gestation, replacing the w arfarin w ith unfractionated heparin for the m inim um tim e possible • Severe aortic or m itral stenosis. If the m other’s life is at risk, section follow ed by valve replacem ent m ay be necessary. Controversy rem ains over w hether the follow ing patients should undergo elective Caesarean section: 1 Cyanotic congenital heart disease w ith im paired fetal grow th. Section m ay help to avoid further fetal hypoxaem ia, but at the 100 Questions in Cardiology 199 expense of excessive m aternal haem orrhage to w hich cyanotic patients are prone. A balance has to be m ade betw een a spontaneous vaginal delivery w ith the m other in the lateral decubitus position to attenuate haem odynam ic fluctuations, forceps assistance and the sm aller volum e of blood lost during this type of delivery, and the controlled tim ing of an elective section. Probably m ore im portant than the route of delivery is peri-partum planning and team w ork: delivery m ust be planned in advance, and the patient intensively m onitored, kept w ell hydrated and not allow ed to drop her system ic vascular resistance. Consultant obstetric and anaesthetic staff experienced in these conditions should be present, and the cardiologist readily available. Rachael James All anticoagulant options during pregnancy are associated w ith potential risks to the m other and fetus. Any w om an on w arfarin w ho w ishes to becom e pregnant should ideally be seen for pre- pregnancy counselling and should be involved in the anti- coagulation decision as m uch as possible. Potential risks to the fetus need to be balanced against the increased m aternal throm - botic risk during pregnancy. Anticoagulation for m echanical heart valves in pregnancy rem ains an area of som e controversy. The use of w arfarin during pregnancy is associated w ith a low risk of m aternal com plications1 but it readily crosses the placenta and em bryopathy can follow exposure betw een 6–12 w eeks’ gestation, the true incidence of w hich is unknow n. A single study has reported that a m aternal w arfarin dose 5m g is w ithout this em bryopathy risk. Conversion to heparin in the final few w eeks of pregnancy is recom m ended to prevent the delivery of, w hat is in effect, an anticoagulated fetus. Studies have been criticised for the use of inadequate heparin dosing and/or inadequate therapeutic ranges4 although a recent prospective study w hich used heparin in the first trim ester and in the final w eeks of pregnancy reported fatal valve throm boses despite adequate anticoagulation. Use in pregnancy is m ainly for throm boprophylaxis rather 100 Questions in Cardiology 201 than full anticoagulation but experience is increasing. M anagement W om en w ho do not w ish to continue w arfarin throughout preg- nancy can be reassured that conceiving on w arfarin appears safe but conversion to heparin, to avoid the risk of em bryopathy, needs to be carried out by 6 w eeks. Possible regim es include: • W arfarin throughout pregnancy until near term and then conversion to unfractionated heparin. Coum arin anticoagulation during pregnancy in patients w ith m echanical valve prostheses. Guidelines on the prevention, investi- gation and m anagem ent of throm bosis associated w ith pregnancy. Failure of adjusted doses of subcutaneous heparin to prevent throm boem bolic phenom ena in pregnant patients w ith m echanical cardiac valve prostheses. Matthew Streetly M echanical heart valves are associated w ith an annual risk of arterial throm boem bolism of <8%. This constitutes an unacceptable risk for patients undergoing m ajor surgery, and it is necessary to tem porarily institute alternative anticoagulant m easures. If surgery cannot be delayed, the effect of w arfarin can be reversed by fresh frozen plasm a (2–4 units) or a sm all dose of intravenous vitam in K (0. Recom m encing intravenous heparin in the im m ediate post- operative period m ay increase the risk of haem orrhage to greater levels than the risk of throm boem bolism w ith no anticoagulation. Heparin is usually restarted 12–24 hours after surgery, depending on the type of surgery and the cardiac reason for w arfarin. W arfarin should be restarted as soon as the patient is able to tolerate oral m edication. Marc R Moon The indications for surgical m anagem ent of endocarditis fall into six categories. Congestive heart failure Patients w ith m oderate-to-severe heart failure require urgent surgical intervention. W ith m itral regurgitation, afterload reduction and diuretic therapy can im prove sym ptom s and m ay m ake it possible to postpone surgical repair until a full course of antibiotic therapy has been com pleted. In contrast, acute aortic regurgitation progresses rapidly despite an initial favourable response to m edical therapy, and early surgical intervention is im perative. Persistent sepsis This is defined as failure to achieve bloodstream sterility after 3–5 days of appropriate antibiotic therapy or a lack of clinical im provem ent after one w eek. Recognised virulence of the infecting organism • W ith native valve endocarditis, streptococcal infections can be cured w ith m edical therapy in 90%. Fungal infections invariably require surgical intervention • W ith prosthetic valve endocarditis, streptococcal tissue valve infections involving only the leaflets can be cleared in 80% w ith antibiotic therapy alone; how ever, m echanical or tissue valve infections involving the sew ing ring generally require valve replacem ent. If echocardiography dem onstrates a perivalvular leak, annular extension, or a large vegetation, early operation is necessary 100 Questions in Cardiology 205 4. Extravalvular extension Annular abscesses are m ore com m on w ith aortic (25-50% ) than m itral (1-5% ) infections; in either case, surgical intervention is preferred (survival: 25% m edical, 60-80% surgical). Peripheral embolisation This is com m on (30-40% ), but the incidence falls dram atically follow ing initiation of antibiotic therapy. Surgical therapy is indicated for recurrent or m ultiple em bolisation, large m obile m itral vegetations or vegetations that increase in size despite appropriate m edical therapy. Cerebral embolisation O peration w ithin 24 hours of an infarct carries a 50% exacerbation and 67% m ortality rate, but the risk falls after tw o w eeks (exacer- bation <10% , m ortality <20% ). Follow ing a bland infarct, it is ideal to w ait 2–3 w eeks unless haem odynam ic com prom ise obligates early surgical intervention. Follow ing a haem orrhagic infarct, operation should be postponed as long as possible (4–6 w eeks). Peter Wilson Despite progress in m anagem ent, m orbidity and m ortality rem ain m ajor problem s for the patient w ith endocarditis, both during the acute phase and as the result of long term com plications after a bacteriological cure. Im provem ents in m icrobiological diagnosis, types of antibiotic treatm ent and tim ing of surgical intervention have im proved the outlook for som e patients but the im pact has been m inor w ith som e of the m ore invasive pathogens. Healed vegetations m ay leave valvular function so com prom ised that surgery is required. In 140 patients w ith acute infective endocarditis, 48 (34% ) required valve replacem ent during treatm ent. Recurrence w as observed in 5 (4% ) patients betw een 4 m onths and 15 years after the first episode. In the follow up period, another 16 patients died of cardiac causes, m ost w ithin five years. O f 34 patients w ith late prosthetic valve endocarditis, 27 (79% ) survived their hospital adm ission but 11 had further surgery during the next five years, usually follow ing cardiac failure. Effects of changes in m anagem ent of active infective endocarditis on outcom e in a 25 year period. Peter Wilson The great m ajority of patients w ith endocarditis have positive blood cultures w ithin a few days of incubation and only a few cases w ill becom e positive on further incubation for 1–2 w eeks. The proportion of culture-negative cases depends on the volum e of blood and m ethod of culture but a com m on estim ate is 5% w ith a range from 2. If antibiotics have been given, w ith- draw al of treatm ent for four days and serial blood cultures w ill usually dem onstrate the pathogen. Nutritionally-deficient streptococci m ay fail to grow in ordinary m edia and yet are part of the norm al m outh flora and can cause endocarditis. After four negative cultures there is only a 1% chance of an organism being identified by later culture. Endocarditis due to nutritionally deficient strepto- cocci: therapeutic dilem m a.

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