Bupropion
By G. Sobota. Georgia Southern University.
The clinical approach utilizes not only the height of the fever but the abruptness of onset purchase bupropion 150 mg with visa depression of 1873, the characteristics of the fever curve 150 mg bupropion depression blood test biomarkers, the duration of the fever, and defervescence pattern, all of which have diagnostic importance (Table 5) (5). The causes of single fever spikes include insertion/removal of a urinary catheter, insertion/removal of a venous catheter, suctioning/manipulation of an endotracheal tube, wound packing/lavage, wound irrigation, etc. Pleural effusions l Bilateral effusions are never due to infection: look for a noninfectious etiology Uncomplicated wound infections l Except for gas gangrene and streptococcal cellulitis, temperatures are usually low grade l “Wounds” with temperatures! Such transient bacteremias are unsustained and because of their short duration, i. Single fever spikes of the transient bacteremias are a diagnostic not a therapeutic problem. Fever secondary to blood products/blood transfusions are a frequent occurrence, and are most commonly manifested by fever following the infusion. Most reactions occur within the first 72 hours after the blood/blood product transfusion, and most reactions within the 72-hour period occur in the first 24 to 48 hours. There are very few reactions after 72 hours, but there is a smaller peak five to seven days after the blood transfusion, which although very uncommon, may occur. The temperature elevations associated with late blood transfusion reactions are lower than those with reactions occurring soon after blood transfusion. The fever subsequent to the transient bacteremia results from cytokine release and is not indicative of a prolonged exposure to the infecting agent, but rather represents the post-bacteremia chemokine-induced febrile response. The temperature 8 Cunha elevations from manipulation of a colonized infected mucosal surface persist long after the bacteremia has ceased (1,3–5,24–27). In patients with fever spikes due to transient bacteremias following manipulation of a colonized or infected mucosal surface, or secondary to a blood/blood product transfusion, may be inferred by the temporal relationship of the event and the appearance of the fever. In addition to the temporal relationship between the fever and the transient bacteremia or transfusion-related febrile response is the characteristic of the fever curve, i. The clinician must rely upon associated findings in the history and physical, or among laboratory or radiology tests to narrow down the cause of the fever. Pulse–temperature relationships are also of help in differentiating the causes of fever in patients with multiple temperature spikes over a period of days (1–5,10). Assuming that there is no characteristic fever pattern, the presence or absence of a pulse–temperature deficit is useful. The diagnostic significance of relative bradycardia can only be applied in patients who have normal pulse–temperature relationships, i. Any patient on these medications who develop fever will develop relative bradycardia, thus eliminating the usefulness of this important diagnostic sign in patients with relative bradycardia (Table 6) (1,5,33–35). Fever secondary to acute myocardial infarction, pulmonary embolus, acute pancreatitis, are all associated with fevers of short duration. If present in patients with these underlying diagnoses, a fever >1028F or one that lasts for more than three days should suggest a complication or an alternate diagnosis. Clinicians should try to determine what noninfectious disorder is causing the fever so that undue resources will not be expended looking for an unlikely infectious disease explanation for the fever (1–10,24–30). Prolonged fevers that become high spiking fevers should suggest the possibility of nosocomial endocarditis related to a central line or invasive cardiac procedure. Prolonged high spiking fevers can also be due to septic thrombophlebitis or an undrained abscess. Physicians should always be suspicious of the possibility of drug fever when other diagnostic possibilities have been exhausted. Drug fever may occur in individuals who have just recently been started on the sensitizing medication, or more commonly who have been on a sensitizing medication for a long period of time without previous problems. Patients with drug fever do not necessarily have multiple allergies to medications and are not usually atopic. However, the likelihood of drug fever is enhanced in patients who are atopic with multiple drug allergies. Other conditions aside, patients look “inappropriately well” for the degree of fever, which is different from that of the toxemic patient with a serious bacterial systemic infection. Relative bradycardia is invariably present excluding patients on b-blocker therapy, those with arrhythmias, heart block, or pacemaker-induced rhythms (1,5,41,42). Eosinophils are often present early in the differential count, but less commonly is their actual eosinophilia. The sedimentation rate also is increased after surgical procedures, negating the usefulness of this test in the postoperative fever patient.
Those who have read the fragment in this way not only seem to have extrapolated Diocles’ re- marks about dietetics to all other branches of medicine (on the question whether this is justified discount bupropion 150 mg with mastercard mood disorder social security disability, see above) discount bupropion 150mg otc kindling depression definition, but also, as far as dietetics itself is con- cerned, to have been guided by Galen’s presentation of it, that is, as propa- ganda for an exclusively empirical approach to the search for the powers of 50 It has been argued by von Staden (1992, 253) that there is no independent evidence of mineralogist interest by Diocles. The fragment is quoted by Galen in the context of embryology, but there is no evidence that in its original context it just served the purpose of analogy (as it does for Galen). Moreover, as von Staden concedes, in the immediate context of the Diocles fragment in On Stones, Theophrastus mentions dietetic and physiological factors affecting the magnetic force of the lyngourion – although I agree that this does not prove that the Diocles mentioned was Diocles of Carystus. In fact, when reading Galen’s own discussion of the right method of dietetics in the pages following on the fragment, it turns out that Diocles’ position as reflected in the fragment (especially in his crit- icism of claims one and two) perfectly meets the requirements of what Galen himself calls ‘qualified experience’ (diwrismnh pe±ra; see chapter 10 below). By this concept, which Galen presents as his own innovation, he means an empirical approach which takes into account the conditions un- der which a dietetic statement like ‘rock fish are difficult to digest’ is true. All these should be considered, Galen points out, before any generalising statement about the power of a particular foodstuff is allowed. Galen represents Diocles as being completely unaware of these factors and as being more one-sided than he actually was – and it would seem that Galen is doing so not for lack of understanding but in order to articulate his own refined position as against Diocles’ unqualified acceptance of experience as the only way to get to know the powers of foodstuffs. But here too there is a highly useful qualification, itself, too, not mentioned by Diocles, just as also none of the others we have discussed until now [was mentioned by him]’ (t to©nun msa ta±v krsesin oÉdem©an pikratoÓsan conta poi»thta Diocles of Carystus on the method of dietetics 99 the ‘highly useful distinction’ (diorism»v) between ‘foodstuffs’ (trofa©) and ‘drugs’ (frmaka) – that is to say, for not having pointed out under what circumstances a particular substance acts like a foodstuff (which only preserves the state of the body) or as a drug (which changes the state of the body) – just as he failed to deal, Galen adds maliciously, with the other distinctions discussed by him in the previous paragraphs. In fact, in the context of another treatise, namely On Medical Experience (De experientia medica, De exp. For if everything which is ascertained is ascertained only by reasoning, and nothing is ascertained by experience, how is it possible that the generality, who do not use reason, can know anything of what is known? And how was it that this was unanimously asserted among the elder doctors, not only by Hippocrates, but also by all those who came after him, Diogenes, Diocles, Praxagoras, Philotimus, and Erasistratus? For all of these acknowledge that what they know concerning medical practice they know by means of reasoning in conjunction with experience. In particular, Diogenes and Diocles argue at length that it is not possible in the case of food and drink to ascertain their ultimate effects but by way of experience. In this testimony, the view of Diocles and the other ancient authorities is obviously referred to in order to support Galen’s argument against an exclusively theoretical approach to medicine. And although we should not assign much independent value to this testimony – which, apart from its vagueness, is a typical example of Galen’s bluffing with the aid of one of his lists of Dogmatic physicians – it is compatible both with the picture of Diocles’ general medical outlook that emerges from the collection of fragments as a whole and with his approach to dietetics as reflected in our fragment 176. Diogenes and Diocles are mentioned by Galen in particular trofaª m»non e«s©n, oÉ frmaka, mqì Ëpgonta gastra... This reference to the ‘ultimate effects’58 is in accordance with the in- terpretation of section 8 given above: this ultimate effect does not admit of further causal explanation; we can only make sure what it is by experience, by applying the foodstuff in a given case and seeing how it works out. Postscript Discussions of this fragment that came out after the original publication of this paper can be found in Hankinson (1998a), (1999) and (2002), in van der Eijk (2001a) 321–34, and in Frede (forthcoming). But a re-examination of the Arabic would seem to make this interpretation less plausible. A literal translation of the Arabic would read as follows: ‘It is not possible to ascertain in the case of food and drink where their last things (akhiriyatuha? The idea is then that although a Dogmatist might speculate theoretically about the power (dÅnamiv)ofa particular foodstuff, e. Thus the position attributed to Diocles here corresponds closely with that attributed to him by Galen in fr. This would suggest that Galen is referring to how foods and drinks are ultimately disposed of; but this would seem to be quite inappropriate to the context. Principles and practices of therapeutics in the Hippocratic Corpus and in the work of Diocles of Carystus 1 introduction In a well-known passage from the Hippocratic Epidemics, the doctor’s duties are succinctly characterised as follows: [The doctor should] declare what has happened before, understand what is present, and foretell what will happen in the future. As to diseases, he should strive to achieve two things: to help, or to do no harm. The (medical) art consists of three components: the disease, the patient, and the doctor. It is succinctly summarised here in the words ‘to help, or to do no harm’ (Ýfele±n £ m blptein), a formula which is often quoted or echoed both in the Hippocratic Corpus and in later Greek and Roman medical literature. The Hippocratic Oath, which explicitly mentions the well-being of the patient as the doctor’s This chapter was first published in slightly different form in I. Thus, according to the Oath, the doctor is not allowed to give a woman an abortive, nor to administer a lethal poison, not even when being asked to do so; and the doctor is instructed to refrain from every kind of abuse of the relation of trust that exists between him and the patient. Yet it is also possible – as the word ‘or’ suggests – to take the formula in the sense of unintended harm: ‘To help, or at least to cause no harm’, that is to say, the doctor should be careful when treating the patient not to aggravate the patient’s condition, for example in cases that are so hopeless that treatment will only make matters worse, or in cases which are so difficult that the doctor may fail in the execution of his art; and as we shall see, there is evidence that Greek doctors considered this possibility too. In this chapter I will examine how this principle ‘to help, or to do no harm’ is interpreted in Greek medical practice and applied in cases where it is not immediately obvious what ‘helping’ or ‘causing harm’ consists in.
