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Difficulty diagnosing this condition has made it difficult to anxiety headache generic 10mg atarax with visa develop treatments, many of which address symp to ms rather than the underlying cause. Before making a decision about treatment, you should be given full information about all the options including risks and benefits of each. Several fac to rs may influence your decision-making, such as: your age and how close you are to having the menopause whether you want to become pregnant treatments you have already tried how you feel about surgery. Sometimes treatments for another condition (for example, fibroids) have been found to improve symp to ms of adenomyosis. However, these treatments (for example, endometrial ablation and surgical excision during myomec to my) are not advised for the treatment of adenomyosis only. Complementary therapies such as yoga, meditation, and gentle exercise may help with painful periods. Useful sources of information Some women will have difficulty finding a treatment option that works for or suits their situation. Internet forums may be the first place you turn to for support, but the unregulated information needs to be interpreted with caution. Theories on the patho acetylation (lower levels of H3K9ac and H4K16ac) which further 30 genesis of endometriosis. Pathogenesis of endometriosis: the role of defec methylated at H3K4, H3K9, and H3K27. Another study showed that H3K27me3-positive nuclei (trimethylated his to ne 3 at lysine residue 27) are more prevalent in 5. Role of major his to compat endometriotic cells compared to eu to pic endometrial cells. Pathogenesis and pathophysiology of plain the pathogenesis of endometriosis: retrograde menstruation endometriosis. Abe W, Nasu K, Nakada C, Kawano Y, Moriyama M, Narahara roidogenic acute regula to ry protein expression and progesterone H. Trichostatin A, a his to ne deacetylase inhibi to r, attenuates invasiveness and reactivates E 28. If you have any concerns about taking this medicine, ask your doc to r or pharmacist. This means that it affects the levels of various hormones (natural chemicals produced by the body). In women, female hormones make the breasts grow, prepare the womb and other sex organs for pregnancy, and increase the sex drive. In men, male hormones make the testicles grow, assist an erection, and increase the sex drive. It is not a cure for prostate cancer, and does not work in every patient with prostate cancer. These fac to rs include: fi smoking fi having a slight build fi having a diet low in calcium fi having treatment with steroids for other conditions fi poor mobility (for example, confined to a wheelchair). A similar condition also happens after the change of life, when the natural production of female sex hormones falls. However, women who have a family his to ry of osteoporosis and other risk fac to rs should discuss the use of Zoladex 3. If you have had an allergy to any other medicines or any other substances, such as preservatives or dyes. If you have had any problems passing urine or if you have had any lower back problems. If you have any of the following: heart or blood vessel conditions, including heart rhythm problems (arrhythmia), or are being treated with medicines for these conditions. The risk of heart rhythm problems may be increased in such patients when using Zoladex 3. If you have not to ld your doc to r about any of the above, tell him/her before you receive any Zoladex 3. Taking Other Medicines Tell your doc to r if you are taking any other medicines, including medicines that you buy without a prescription from your pharmacy, supermarket or health food shop. Zoladex might interfere with some medicines used to treat heart rhythm problems or might increase the risk of heart rhythm problems when used with some other medicines that can cause heart rhythm abnormalities. The injection is often at the front of the s to mach (belly), or to the side of the s to mach. If longer courses of treatment are needed, the doc to r may need to consider possible side effects related to loss of calcium in bones. If You Miss A Treatment Tell your doc to r if you miss your monthly treatment with Zoladex 3. If you have missed a dose on purpose because you do not like a side effect of the medicine discuss this with your doc to r. If you are about to be started on any new medicine, tell your doc to r or pharmacist that you are receiving Zoladex 3. If you are unsure about any of these points or have further questions please tell your doc to r or pharmacist. Tell your doc to r or pharmacist as soon as possible if you do not feel well while you are using Zoladex 3. Injection site injury (including damage to blood vessels in the abdomen) has been reported following injection of Zoladex. Contact your doc to r immediately if you experience any of the following symp to ms: abdominal pain, abdominal distension, shortness of breath, dizziness, low blood pressure and/or any altered levels of consciousness. Therefore you should always tell your doc to r if you notice any possible side effect. Very occasionally you may have trouble passing urine or experience lower back pain. Some women will have a menstrual period in the first 2 weeks after the first injection of Zoladex 3. Rarely, some women may enter their natural menopause when being treated with Zoladex 3. At the beginning of treatment, a worsening of symp to ms of your breast cancer such as an increase in pain and/or an increase in the size of the affected tissue may occur. These effects are usually short-lived and discontinue on continuation of treatment. In addition, if you experience excessive nausea, vomiting or thirst, you should tell your doc to r. This may indicate possible changes in the amount of calcium in your blood and your doc to r may have to do certain blood tests. If you experience abdominal pain, abdominal swelling, nausea or vomiting after receiving these drugs for such treatment you should let your doc to r know immediately. Important: this leaflet alerts you to some of the situations when you should call your doc to r. Nothing in this leaflet should s to p you from calling your doc to r or pharmacist with any questions or concerns you have about using Zoladex 3. A locked cupboard at least one and a half metres above the ground is a good place to s to re medicines. The pellet is made of a combination of two white or cream coloured substances called polyglactins. Date of preparation this leaflet was revised on 8 May 2020 Zoladex is a registered trademark of the AstraZeneca group of companies. It usually involves multiple healthcare providers and covers a range of institutions, both public and private. The optimal are pathways map this journey for specifc tumour types, aiming to foster an understanding of the whole pathway and its distinct components to promote quality cancer care and patient experiences. These pathways act as a reminder that the patient is the constant in this journey and that the health system has a responsibility to deliver the care experience in an appropriate and coordinated manner. The optimal care pathways are based on a revision of the original patient management frameworks (Department of Health 2007a) which had, for the frst time, attempted to map the cancer pathway in an easily understandable form. The purpose of this work is to improve patient outcomes by facilitating consistent cancer care based on a standardised pathway of care.
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No X (for other interventions) Are the expected values and preferences clearly in favour of the recommendationfi Yes X (for psycho-education) No X (for other interventions) Is there certainty about the balance between benefits and resources being consumedfi Yes X In the case of positive recommendations (recommending to anxiety medication names order atarax 25mg line do something) is there certainty that the benefits are (for psycho-education) worth the costs of the resources being consumedfi No X In the case of negative recommendations (recommending not to do something) is there certainty that the costs of the (for other interventions) resources being consumed outweigh any benefit gainedfi If the bedwetting persists for more than one month, the child should be reasssesed for other disorders that may need treatment. For adults with symp to ms of dissociative (conversion) disorders in the first month after a potentially traumatic event, do early psychological interventions, when compared to treatment as usual, waiting list or no treatment, result in reduction of symp to ms, improved functioning/quality of life, presence of disorder or adverse effectsfi This scoping question covers both psychological and soma to form dissociation in adults in the first month after a potentially traumatic event. A critical review of dissociative trance and possession disorders: etiological, diagnostic, therapeutic and nosological issues. Efficacy of treatment for soma to form disorders: a review of randomized controlled trials. Three studies met the inclusion criteria of the review, with al to gether 119 participants: fi One study (Ataoglu, 2003) compared paradoxical intention therapy (two sessions a day for three weeks) for inpatients with diazepam for outpatient adults (mean age 27 years) with non-epileptic seizures in Turkey. Outcomes were: no statistically significant differences for physical signs and drop-out, and better outcome for the psychological treatment for anxiety. Outcomes were: no statistically significant difference on drop-out (physical and mental variables not reported). Outcomes were: no statistically significant differences on mental state and drop-out, and treatment benefits for physical signs (no numerical data for physical disability). The studies were judged to be of poor methodological quality, and they were not combined in a statistical meta-analysis because of differences in intervention and control groups across studies. As such, making interventions (for which there is inconclusive evidence of effectiveness) available through formal health-care settings may not provide additional value to these existing community resources. Any (including additional training in paradoxical intention therapy and hypnosis would require resources, including supervision. No X In the case of negative recommendations (a recommendation not to do something), do the harms outweigh benefitsfi Therefore, as no further specific recommendation can be made, psychological first aid should be considered in adults with symp to ms of dissociative (conversion) disorders in the first month after a potentially traumatic event. For children and adolescents with symp to ms of dissociative (conversion) disorders in the first month after a potentially traumatic event, do early psychological interventions, when compared to treatment as usual, waiting list or no treatment, result in reduction of symp to ms, improved functioning/quality of life, presence of disorder or adverse effectsfi This scoping question covers both psychological and soma to form dissociation in children and adolescents in the first month after a potentially 38 traumatic event. Does not list inclusion/exclusion criteria, quality appraisal or formal meta-analysis for evaluation studies. Harms There is no systematic review on the potential harms of psychological interventions for children and adolescents with dissociative (conversion) disorders in the first month of a potentially traumatic event. Value and preferences In favour Against It has been argued that dissociative symp to ms. People suffering dissociative symp to ms often seek care in the non-formal health sec to r. Psychological interventions require time to be delivered, which is important in the context of constrained human resources. Yes In the case of positive recommendations (a recommendation to do something), do the benefits outweigh harmsfi In the case of negative recommendations (recommending not to do something) is there certainty that the costs of the resources being consumed outweigh any benefit gainedfi Therefore, as no further specific recommendation can be made, psychological first aid should be considered in children and adolescents with symp to ms of dissociative (conversion) disorders in the first month after a potentially traumatic event. The use of culturally specific interventions that are not harmful may be considered. For adolescents and adults with hyperventilation in the first month after a potentially traumatic event, does rebreathing in to a paper bag, when compared to treatment as usual, waiting list or no treatment, result in reduction of symp to ms, improved functioning/quality of life, presence of disorder or adverse effectsfi Background on the scoping question Exposure to potentially traumatic events is common, and symp to ms of acute stress in the aftermath of such events are frequently reported. This scoping question covers hyperventilation in adolescents and adults in the first month after a potentially traumatic event. Around half of 40 populations exposed to potentially traumatic events have been reported to experience panic symp to ms during the first month after the event. We included studies if they were systematic reviews of treatment studies published from 2001 onwards that included studies with adolescents (10-19 years) and adults (>18 years). Given that no systematic reviews were identified, a systematic review was conducted in week 24 of 2012. Harms No studies were available to evaluate whether rebreathing in to a paper bag for adolescents and adults with hyperventilation in the first month after exposure to traumatic stress may do harm. Against Clinical guidelines recommend not rebreathing in to a paper bag in pre-hospital settings. Strength of recommendation: not applicable Quality of evidence: very low Remarks There are significant risks if this technique is used in specific populations. For children with hyperventilation in the first month after a potentially traumatic event, does rebreathing in to a bag, when compared to treatment as usual, waiting list or no treatment, result in reduction of symp to ms, improved functioning/quality of life, presence of disorder or adverse effectsfi This scoping question covers hyperventilation in children in the first month after a potentially traumatic event. Around half of populations 41 exposed to potentially traumatic events have been reported to experience panic symp to ms during the first month after the event. Indeed, clinical experience suggests that in the immediate aftermath of potentially traumatic events, help-seeking for hyperventilation is common. We included studies if they were systematic reviews of treatment studies published from 2001 onwards that included studies with children (<10 years). Harms No studies were available to evaluate whether rebreathing in to a bag for children with hyperventilation in the first month after exposure to traumatic stress may do harm. Value and preferences In favour A common approach to dealing with hyperventilation caused by stress may be rebreathing in to a paper bag. Feasibility Making a recommendation not to carry out a specific intervention is feasible. Yes No X Is there certainty about the balance between benefits and resources being consumedfi Strength of recommendation: standard Quality of evidence: very low Remarks Health-care providers should always rule out physical causes before considering psychological intervention. They should maintain a calm approach, where possible remove sources of anxiety and coach respirations. We included studies if they were systematic reviews of treatment studies published from 2001 onwards that included studies with adults (>18 years), focusing on psychological treatments. Internet-based interventions for traumatic stress-related mental health problems: A review and suggestion for future research. A systematic review of treatments for post-traumatic stress disorder among refugees and asylum seekers. Department of Veterans Affairs Health Services Research and Development Service (2009).
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In addition to anxiety essential oils cheap atarax 10mg on-line being responsible for the symp to ms, these excluded clinical scenarios, diseases and/or conditions may affect treatment in a manner outside the purview of this Guideline. The full description of the methodology presented in Chapter 2 can be accessed at. As in the previous Guideline, statements were graded using three levels with respect to the degree of flexibility in their application. Standard: A guideline statement is a standard if: (1) the health outcomes of the alternative interventions are sufficiently well known to permit meaningful decisions and (2) there is virtual unanimity about which intervention is preferred. Option: A guideline statement is an option if: (1) the health outcomes of the interventions are not sufficiently well known to permit meaningful decisions, or (2) preferences are unknown or equivocal. Diagnostic Evaluation the Panel decided that the diagnostic section of the 2003 Guideline required updating. In general, optional tests are performed during a detailed evaluation by a urologist. The physician can discuss with the patient treatment alternatives based on the results of the initial evaluation with no further tests being needed (See Figure 1. There should be a discussion of the benefits and risks involved with each of the recommended treatment alternatives. Then the choice of treatment is reached in a shared decision-making process between the physician and patient. If the patient has predominant significant nocturia and is awakened two or more times per night to void, it is recommended that the patient complete a frequency volume chart for two to three days. The frequency volume chart will show 24-hour polyuria or nocturnal polyuria when present, the first of which has been defined as greater than three liters to tal output over 24 hours. In practice, patients with bothersome symp to ms are advised to aim for a urine output of one liter per 24 hours. Nocturnal polyuria is diagnosed when more than 33% of the 24-hour urine output occurs at night. If symp to ms do not improve sufficiently, these patients can be managed similarly to those without predominant nocturia. If the patient has no polyuria and medical treatment is considered, the physician can proceed with therapy by focusing initially on modifiable fac to rs such as concomitant drugs, regulation of fluid intake (especially in the evening), lifestyle (increasing activity) and diet (avoiding excess of alcohol and 14 highly seasoned or irritative foods). If pharmacological treatment is necessary, it is recommended that the patient be followed to assess treatment success and possible adverse events. The time from initiation of therapy to treatment assessment varies according to the pharmacological agent prescribed. If treatment is successful and the patient is satisfied, once yearly follow-up should include a repeat of the initial evaluation. The urologist may use additional testing beyond those recommended for basic evaluation (Figure 1. It is the expert opinion of the Panel that some patients may benefit using a combination of all three modalities. Should improvement be insufficient and symp to ms severe, then newer modalities of treatment such as botulinum to xin and sacral neuromodulation can be considered. The patient should be followed to assess treatment success or failure and possible adverse events according to the section on basic management above. Interventional Therapy If the patient elects interventional therapy and there is sufficient evidence of obstruction, the patient and urologist should discuss the benefits and risks of the various interventions. Transurethral resection is still the gold standard of interventional treatment but, when available, new interventional therapies could be discussed. Some patients with bothersome symp to ms might opt for surgery, while others might opt for watchful waiting or medical therapy depending on individual views of benefits, risks and costs. The treatment choices (Table 1) are discussed in this chapter with the supporting evidence presented in Chapter 3. Symp to m distress may be reduced with simple measures such as avoiding decongestants or antihistamines, decreasing fluid intake at bedtime and decreasing caffeine and alcohol intake generally. Watchful waiting patients usually are reexamined yearly, repeating the initial evaluation as previously outlined in Figure 1. Measures to reduce the risk, such as medical intervention, may be offered depending on the circumstances. Although there are slight differences in the adverse events profiles of these agents, all four appear to have equal clinical effectiveness. As stated in the 2003 Guideline, the effectiveness and efficacy of the four alpha blockers under consideration appear to be similar. Although studies directly comparing these agents are currently lacking, the available data support this * contention. Noradrenergic sympathetic nerves have been demonstrated to effect the contraction of prostatic 15 smooth muscle. Ninety-eight percent of alpha-blockers are associated with the stromal elements of 16 the prostate and are thus thought to have the greatest influence on prostatic smooth muscle to ne. For the purposes of this Guideline, the specific agents reviewed included alfuzosin, doxazosin, tamsulosin and terazosin as they theoretically act in the location that will have the greatest benefit for symp to ms with the fewest side effects. Alpha-blockers produce a significant symp to m improvement compared to placebo, which the average patient will appreciate as a moderate improvement from baseline. The minor differences in efficacy noted between the different alpha blockers are not statistically (when tested) or clinically significant. The 2003 Guideline suggested that some patients treated with tamsulosin require the 0. However, during guideline development (March 2010), the Panel became aware that tamsulosin was available as a generic product which may have obviated this problem. In clinical studies, rates for specific adverse events were low and similar between treatment and placebo groups. Dizziness was the most common adverse event, with rates reported between 2% and 14% in patients receiving alpha-blockers and somewhat lower rates with placebo. With regard to tamsulosin, the ~10% risk of ejacula to ry disturbance cited in the 2003 Guideline appears to be lower in a more recent study noted in this review, understanding that this study used alternate metrics to gauge 17 ejaculation alterations. Although doxazosin and terazosin require dose titration and blood pressure moni to ring, they are inexpensive, are dosed once daily, and appear to be equally effective to tamsulosin and alfuzosin. In addition, they have generally similar side effect profiles, except ejacula to ry dysfunction which has been reported less frequently with alfuzosin. It was the opinion of the Panel that there is insufficient information to gauge the utility of alpha-blocker withdrawal among men initially treated with combination therapy. Although not an unreasonable strategy, clinicians need to recognize that the optimal duration of combination therapy prior to discontinuation of the alpha-blocker remains in doubt. A significantly greater improvement from baseline in peak urinary flow for combination therapy vs. There was a significant increase in drug-related adverse events with combination therapy vs. Men with planned cataract surgery should avoid the initiation of alpha-blockers until their cataract surgery is completed. Operative complications in some cases included posterior capsule rupture with vitreous loss and pos to perative intraocular pressure spikes, though visual acuity outcomes appeared preserved. The original report linked this condition with the preoperative use of tamsulosin; iris dila to r smooth muscle inhibition has been suggested as a 20, 21 potential mechanism.
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Progress made in healing can aware of his treatment efectiveness as well as of its cer and therefore a decrease of the fear of diagnosis to anxiety symptoms following surgery purchase atarax with visa xic potential, and the oncological board should may be convincing fac to rs of this change of attitude in co-decide with the patient for the treatment options. Further research on the impact of pa Conclusions tient decision would improve the structure and the Oncology boards should be part of the routine func functionality of oncologic boards. The Greek Ministry of Health and Social Solidar ity (Ministerial decree 141758/12. On the diagnosis and treatment, refers also to submitted formation and operation of the oncology committee; Decem proposals with respect to the restructure of oncologic ber 24, 2003; article 29: p 5206. Medical Code of Deon to logy, Law 3418/2005, Furthermore, the above amendments make refer Panhellinic Medical Association, 2006 Athens. Crimes against life: articles 300, In addition, the responsibility of the function the 301,302. Surbone A, Zwitter M (Eds): Communication with the cancer With the current mentality, hiding the truth from patient. Psycological reac relatives is ambiguous but on the other hand the con tions of cancer patients and the communication between the tinuation of this informational policy is wrong. The recent code of medical de riers in information disclosure between health care professio on to logy, the cancer patient informing process and the in nals and relatives with cancer patients in Greek society. Informing cancer patient in relation his type of gnostic information to cancer in Greece. Informing cancer patient in relation to his type rative survey of Greek and British nurse percep to rs beliefs to of personality: the emotional-hyperthymic (dramatizing) pa informed consent. Attitudes of cancer specialists to wards of personality: the controlling-orderly (obsessive) patient. Most endometrial cancers are low-grade, early-stage and carry an excellent References prognosis. The lifetime risk for breast cancer in impact of eliminating socioeconomic and racial disparities on pre the United States is usually about 1 in 8 (12%) of women mature cancer deaths. His protein overexpression is known as the triple negative to pathology 2008; 52: 108-118. Platinum-based chemotherapy in sive, have a high proliferation rate, high nuclear grade, triple-negative breast cancer. This is largely due to for neutrophils engrafment was 10 days, and for their chemosensitivity. The most frequent grade 3 / 4 to xicities were motherapy, patients who experience more than two febrile neutropenia (100% of patients), thrombocy to relapses, or are refrac to ry to all therapy lines, usually penia (100%), colitis / diarrhea (63%), nausea (54%) die from this disease. The fnal group of patients is poor, so earlier intensifcation is confrmation of the activity of high-dose chemother manda to ry. European Consensus Conferen ogous hema to poietic stem cell transplantation leads ce on Diagnosis and Treatment of Germ Cell Cancer: A Report of to longer survival when compared to conventional the Second Meeting of the European Germ Cell Cancer Consen chemotherapy. Einhorn L, Williams S, Chamness A, Brames R, Perkins S, Abono tions in 8 heavily pretreated patients who were previ ur R High-dose chemotherapy and stem cell rescue for metastatic ously administered a median of 4 (range 3-4) chemo germ-cell tumors. Afer mobilization, a large-volume apheresis followed by three high-dose chemotherapy regimens supported by was performed until the harvested number of cells au to logous stem cell transplantation. High-dose chemotherapy with au to logous stem cell support for heavily pretreated patients with germ cell tumors: a Serbian sin gle-centre frst-experience report. Lab tests revealed white blood cell count cal specimens revealed lymphocytic leukemia in the ile 25890 mmfi, lymphocyte count 18290 mmfi, hemoglo um and colon. In colonoscopy, the transverse colon transformation, can cause signs and symp to ms sugges mucosa was, in general, minimally edema to us, granular tive of chronic infamma to ry bowel disease. The his to pathologic dif References ferential diagnosis of common benign lymphatic hyper 1. Chronic Lymphocytic Leukemia: Prognos plasias and various malignant lymphoid disorders of the tic fac to rs and natural his to ry. Gastroduodenal com phenotype, whereas mucosa-associated marginal zone plications in patients with adult T-cell leukemia. Jpn J Clin Oncol lymphoma lacks specifc phenotypic markers and its 1988;18: 335-342. Lymphoepithelial lesions and plasmacytic difer Opin Gastroenterol 2005; 21:80-84. Between January 2005 to December 2010, 6 patients In cancer patients, any anas to mosis along the gastro who were operated on either electively or as an emergen intestinal tract carries the risk of an anas to motic leak, the cy for gastrointestinal tract malignancies and developed incidence of which can be as high as 20%, depending on gastrointestinal anas to motic leak, were treated with a several and specifc local and systematic fac to rs . Fol simple technique for vacuum drainage of the peri to neal lowing an anas to motic leak, the content of the gastroin cavity afer the diagnosis of gastrointestinal leak. Sometimes gravity is not enough for sure was chosen, since we noticed that greater pressures the drainage of the accumulated content and the applica collapsed the lumen of the silicon tubes. All fstulae were healed spontane tent drainage through the surgical incision we preferred ously within 3-14 weeks (median 6). A single fstula was successfully crated to the dermal gap and connection of the drain tubes to in all patients and none of the patients developed adverse the vacuum system. With this technique the infamed, events while all abdominal wounds were healed unevent ischemic or necrotic tissues of the abdominal wound fully. The vacuum was applied continuously ment of infected wounds, traumatic open abdominal throughout the day and the gastrointestinal content out wounds, wounds with bone exposure, pressure ulcers, put was recorded every 24 hours. The vacuum was dis diabetic foot ulcers and ulcers arising from venous ecta connected when less than 30mL of gastrointestinal tract sia in the extremities. The method is contraindicated or content drainage was recorded within 24 hours and when should not be applied in unexplored or non-enteric fs obvious improvement of the local signs of infammation tulae, in wounds with necrotic tissue, in the treatment of was noticed. Negative pressure therapy in wounds with enteric plication of the negative pressure for the management of fstulas. Colocutaneous fs still remains controversial with various reports favoring tula management in a dehisced wound: a case study. Al goiter and searched patients with suspected thyroid though the exact mechanism of the relationship remains diseases. The descriptive study was to examine the frequency of thyroid majority had multinodular goiter (7. The incidence of other tient and tumor characteristics in patients with and with thyroid disorders are shown in Table 1. We did not check all breast cancer patients for thy thyroidec to my in breast cancer patients roid disease, we evaluate only patients with known thy Tyroid disease N % roid disease and patients with suspected thyroid disease Multinodular goiter 177 7. Meanwhile, we suggest oncologists to check for thyroid disease in women with breast cancer. The relationship between prognos tic fac to rs of breast cancer and thyroid disorders in Turkish women. Multiple primary breast In a prospective study, prevalence of au to immune and thyroid cancer. Cancer Epidemiol Biomarkers Prev 2002; breast diseases (19%) and healthy controls (18. Au to immune thyroid di ed risk of thyroid cancer following breast cancer and sease in women with breast carcinoma. Breast cancer in association with suggests a fairly frequent occurrence of thyroid disease thyroid disorders. However, we could not fnd an association between the presence of a thyroid disorder and any tumor characteristic.
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Also anxiety questionnaire pdf buy atarax, laparoscopic or robotic assisted approaches are more invasive than endoscopic correction and their advantages over open surgery are still debated. It can be offered as an alternative to the caregivers in centres where there is established experience [761, 780-788]. The choice of management depends on the presence of renal scars, clinical course, grade of reflux, ipsilateral renal function, bilaterality, bladder function, associated anomalies of the urinary tract, age, compliance, and parental preference. Offer immediate, parenteral antibiotic treatment for febrile breakthrough infections. Strong Offer definitive surgical or endoscopic correction to patients with frequent breakthrough Weak infections. Offer open surgical correction to patients with persistent high-grade reflux and Strong endoscopic correction for lower grades of reflux. Strong Offer surgical repair to children above the age of one presenting with high-grade reflux and Weak abnormal renal parenchyma. Offer close surveillance without antibiotic prophylaxis to children presenting with lower Strong grades of reflux and without symp to ms. Offer surgical correction, if parents prefer definitive therapy to conservative management. Strong Select the most appropriate management option based on: Weak the presence of renal scars; clinical course; the grade of reflux; ipsilateral renal function; bilaterality; bladder function; associated anomalies of the urinary tract; age and gender; compliance; parental preference. In high-risk patients who already have renal impairment, a more aggressive, Strong multidisciplinary approach is needed. Due to its recurrent nature, every effort should be made to discover the underlying metabolic abnormality so that it can be treated appropriately. Obtaining a s to ne-free state with close follow-up are of the utmost importance, although, it may not be possible in some circumstances. Bladder s to nes are still common in underdeveloped areas of the world and are usually ammonium acid urate and uric acid s to nes, strongly implicating dietary fac to rs . Patients with augmented bladder constitute another important group with a risk of up to 15% . Paediatric s to ne disease is endemic in Turkey, Pakistan and in some South Asian, African and South American states. However, recent epidemiological studies have shown that the incidence of paediatric s to ne disease is also increasing in the Western world [791-793], especially in girls, Caucasian ethnicity, African Americans and older children . More than 70% of s to nes in children contain calcium oxalate, while infection s to nes are found more frequently in younger children . Super-saturation of calcium (hypercalciuria) and oxalate (hyperoxaluria) or decreased concentration of inhibi to rs, such as citrate (hypocitraturia) or magnesium (hypomagnesemia) play a major role in the formation of calcium oxalate s to nes. Hypercalciuria: this is defined by a 24-hour urinary calcium excretion of more than 4 mg/kg/day (0. Idiopathic hypercalciuria is diagnosed when clinical, labora to ry, and radiographic investigations fail to delineate an underlying cause leading to hypercalcaemia. In secondary (hypercalcemic) hypercalciuria, a high serum calcium level may be due to increased bone resorption (hyperparathyroidism, hyperthyroidism, immobilisation, acidosis, metastatic disease) or gastrointestinal hyperabsorption (hypervitaminosis D) . Neonates and infants have a higher calcium excretion and lower creatinine excretion than older children [796, 797]. If the follow-up ratios are normal, then no additional testing for hypercalciuria is needed. The 24-hour calcium excretion test is the standard criterion for the diagnosis of hypercalciuria. In addition to calcium, the 24-hour urine analysis should also include phosphorus, sodium, magnesium, uric acid, citrate and oxalate. Dietary sodium restriction is recommended as well as maintenance of calcium intake consistent with the daily needs of the child . A brief trial of a low calcium diet can be carried out to determine if exogenous calcium intake and/or calcium hyperabsorption is contributing to high urinary calcium. Any recommendation to restrict calcium intake below the daily needs of the child should be avoided. Hydrochlorothiazide and other thiazide-type diuretics may be used to treat idiopathic hypercalciuria, especially with calcium renal leak, at a starting dosage of 0. In long-term use of thiazide-type diuretics, a decrease in hypocalciuric effect may be seen after the third month and may cause hypokalemia, hypocitraturia, hyperuricaemia and hypomagnesaemia. Therefore, control of blood and serum values should be performed with regular intervals. Hyperoxaluria may result from increased dietary intake, enteric hyperabsorption (as in short bowel syndrome) or an inborn error of metabolism. In rare primary hyperoxaluria, one of the two liver enzymes that play a role in the metabolism of oxalate may be deficient. With increased deposition of calcium oxalate in the kidneys, renal failure may ensue in resulting deposition of calcium oxalate in other tissues (oxalosis). The diagnosis is made upon labora to ry findings of severe hyperoxaluria and clinical symp to ms. Other forms of hyperoxaluria, as mentioned earlier, may be due to hyperabsorption of oxalate in inflamma to ry bowel syndrome, pancreatitis and short bowel syndrome. The treatment of hyperoxaluria consists of the promotion of high urine flow, restriction of dietary oxalate and regular calcium intake. Pyridoxine may be useful in reducing urine levels, especially in primary hyperoxaluria. Hypocitraturia usually occurs in the absence of any concurrent symp to ms or any known metabolic derangements. The presence of hypocitraturia ranges from 30% to 60% in children with calcium s to ne disease [812, 814]. The res to ration of normal citrate levels is advocated to reduce s to ne formation, although there are few relevant studies in children. The side effects of potassium citrate are very rare and most of the time they include non-specific gastrointestinal complaints. Potassium citrate should be used with caution in hyperkalemic and chronic renal failure conditions. A daily output of uric acid of more than 10 mg/kg/day (0,6 mmol/kg/day) is considered to be hyperuricosuria . In cases who failed with conservative measures with sustaining hyperuricosuria and hyperuricemia, s to ne recurrences or myeloproliferative diseases, allopurinol (10 mg/kg) may be used. This medication may cause several drug reactions (rash, diarrhoea, eosinophilia) and should be cautiously used in chronic renal failure patients. Cystinuria is an incompletely recessive au to somal disorder characterised by failure of renal tubules to reabsorb four basic amino acids: cystine, ornithine, lysine and arginine. Cystine solubility is pH-dependent, with cysteine precipitation beginning at pH levels < 7. Cystine s to nes are faintly radiopaque and may be difficult to visualise on regular radiograph studies. The initial treatment consists of maintaining a high urine flow and the use of alkalinising agents, such as potassium citrate to maintain urine pH at above 7. If this treatment fails, the use of alphamercap to propionyl glycine or D-penicilamin may increase cystine solubility and reduce cystine levels in urine and prevent s to ne formation. Urease converts urea in to ammonia and bicarbonate, alkalinising the urine and further converting bicarbonate in to carbonate. Haematuria, usually visible, occurring with or without pain, is less common in children. However, non visible haematuria may be the sole indica to r and is more common in children. In some cases, urinary infection may be the only finding leading to radiological imaging in which a s to ne is identified [818, 819]. Low dose pro to cols have also been developed with the goal of reducing radiation dose with adequate image quality . Figure 8 provides an algorithm of how to perform metabolic investigations in urinary s to ne disease in children and how to plan medical treatment accordingly.
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Manifestaciones del sindrome climaterico 173 anxiety symptoms constipation atarax 10mg online, 174 farmacos y fac to res hereditarios, sin embargo, es el tiempo transcurrido desde la menopausia Sin to mas climatericos uno de los predic to res mas fuertes de osteoporosis y fracturas175, 176. La deficiencia estrogenica produce muchos sin to mas que reflejan las multiples mujer posmenopausica obesa tambien esta expuesta a osteoporosis y fracturas178, 179, a pesar que acciones de los estrogenos. Tal variedad y cantidad de sin to mas dificulta la evaluacion detallada el mayor peso se asocia con una mayor capacidad de aromatizacion de esteroides sexuales hacia de cada uno de ellos y su impac to relativo en la salud y en la calidad de vida. La Jun to con insomnio y sin to mas por atrofia urogenital, las artralgias persisten por muchos anos des compleja interrelacion de es to s fac to res explica lo multifacetico e individual de las expresiones del pues de la menopausia190. La intervencion clinica en las mujeres en climaterio considera en lo posible to dos es to s aspec to s136. Metabolico y cardiovascular Varios anos antes de la menopausia se pueden reconocer sin to mas climatericos137, 138. Se pueden 191, 192, 193 Coincidiendo con el climaterio, la mujer presenta cambios metabolicos que se expresan en presentar dos tipos de evolucion: relativo hipoestrogenismo, con sin to mas vasomo to res, emocio redistribucion adiposa194 con incremen to del indice de masa corporal195, de la circunferencia abdom nales, artralgias y otros; o bien, relativo hiperestrogenismo con insuficiencia lutea. Este ultimo tiene inal, aumen to del colesterol to tal serico196 y disminucion del colesterol de alta densidad197. Es to s un sustra to bien reconocido, se caracteriza por un aumen to en el numero de foliculos reclutados en cambios significan un aumen to en el riesgo de enfermedades cardiovasculares198 y se relacionan el ciclo ovarico con el consecuente aumen to en la proporcion de estrogenos circulantes, llegando a con la menopausia mas que con la edad199, 200, 201, tan to para accidentes vasculares cerebrales202, 203 superar la cantidad de estrogenos tipica de un ciclo normal. En el sindrome metabolico, los cambios en el peso, la sensibilidad a la insulina, la presion arteri Las mujeres perimenopausicas139, 140, 141 independiente de la regularidad de sus sangrados, y pos al y los niveles de lipidos son to dos interdependientes y pueden llegar a conformar un sindrome menopausicas con sin to mas vasomo to res, presentan significativa mayor prevalencia de ansiedad, metabolico. Requieren un enfoque integral para la proteccion de la salud desde el pun to de vista depresion142, 143 sin to mas somaticos144, 145, 146 insomnio147, sexualidad deprimida148, y molestias atrofi medico, psicologico, fisico y nutricional (Orientaciones Tecnicas para Prevencion de Enfermedades cas urogenitales149, 150, 151, causando significativo deterioro de su calidad de vida152. Neurologico La mejor evidencia sobre la relacion entre deficit hormonal y funciones cerebrales, esencialmente Salud del sistema osteo-articular y musculo-tendinoso 212, 213, 214, 215, 216, 217 cognitivas y memoria ejecutiva, proviene de mujeres ooforec to mizadas grupo que La perdida de la densidad mineral osea puede iniciarse incluso cuatro anos previos al advenimien to puede ser observado aislando los efec to s gonadales de aquellos relacionados con la edad. Se ha de la menopausia, coincidiendo con la declinacion de la funcion ovarica159, 160. La densidad mineral de 218 219, 220 relacionado la ooforec to mia bilateral con mayor riesgo de demencias y de parkinsonismos. Jun to con insomnio y sin to mas por atrofia urogenital, las artralgias persisten por muchos anos des pues de la menopausia190. Metabolico y cardiovascular Coincidiendo con el climaterio, la mujer presenta cambios metabolicos191, 192, 193 que se expresan en redistribucion adiposa194 con incremen to del indice de masa corporal195, de la circunferencia abdom inal, aumen to del colesterol to tal serico196 y disminucion del colesterol de alta densidad197. En el sindrome metabolico, los cambios en el peso, la sensibilidad a la insulina, la presion arteri al y los niveles de lipidos son to dos interdependientes y pueden llegar a conformar un sindrome metabolico. Requieren un enfoque integral para la proteccion de la salud desde el pun to de vista medico, psicologico, fisico y nutricional (Orientaciones Tecnicas para Prevencion de Enfermedades Cronicas del Adul to ). Neurologico La mejor evidencia sobre la relacion entre deficit hormonal y funciones cerebrales, esencialmente cognitivas y memoria ejecutiva, proviene de mujeres ooforec to mizadas212, 213, 214, 215, 216, 217 grupo que puede ser observado aislando los efec to s gonadales de aquellos relacionados con la edad. Se ha relacionado la ooforec to mia bilateral con mayor riesgo de demencias218 y de parkinsonismos219, 220. Algunos estudios asocian la percepcion de tras to rnos de memoria tambien con la menopausia es pontanea221, 222, 137, 223, 224. La contribucion de multiples fac to res225, 226, 227 se van agregando a mayor edad, lo que hace dificil establecer relaciones causales, no obstante, hay evidencia que la exposicion a estradiol (no a es trogenos conjugados equinos228, 229, 230, 231) contribuye a mantener la memoria en mujeres232, 233, 234, 50 51 235, 236, 237 incluso en las de mucha edad238, 239, 240, 241, mientras que el hipogonadismo inducido la dis Los cambios hormonales estan muy asociados con los tras to rnos emocionales285, 286, 287, 288, 289 e in minuye242, 243. Fac to res psicosociales de riesgo de depresion durante el climaterio Efec to s del hipoestrogenismo en la piel Fac to res de riesgo modificable Fac to res de riesgo no modificables La piel es el organo de contac to con el ambiente y su eficiencia depende de su trofismo, lo que se 249, Abuso de sustancias expresa en resistencia, elasticidad, humedad y capacidad de regeneracion o curacion de heridas Sexo Falta de apoyo social 250. Estudios microscopicos demuestran adelgazamien to y disminucion de la piel por efec to de la Capacidad reproductiva Baja au to estima 251, 252, 253, 254, Edad privacion hormonal posmenopausica y su reversibilidad mediante la reposicion hormonal Conflic to s con la pareja His to ria personal o familiar de depresion 255, 256, 257. Existe un paralelismo con el deterioro que se observa en la calidad de la fibra colagena en Sensacion de perdida de la femineidad. Violencia de genero La semiologia elemental permite apreciar facilmente es to s elemen to s, incluyendo la distribucion y Fuente: Dp to. Los tras to rnos climatericos de la piel influyen mucho sobre la calidad de vida por provocar sin to mas como pruri to por anhidrosis o fragilidad cutanea y por afectar la capacidad de establecer relaciones interpersonales, objetivo relevante desde el pun to 2. Al planificar intervenciones La importancia de es to s fac to res queda demostrada al analizar el importante gas to en que incurren se requiere seleccionar aquellos problemas que mas afectan la calidad de vida relacionada con el las mujeres para subsanar los efec to s de las atrofias mediante produc to s cosmeticos, los cuales de 259 climaterio, de acuerdo a la evaluacion que hace cada mujer del impac to sobre su vida diaria. Existen berian considerarse en el cos to global del tratamien to de la posmenopausia. Tambien se deberia diversos instrumen to s au to administrables con la capacidad de evaluar la relevancia de los efec to s298. Esos sin to mas no alcanzan a constituir un tras to rno depresivo mayor en la mayoria de las mujeres, aunque el riesgo de de La mujer califica la relevancia de sus sin to mas en una escala de 0 (ausencia de sin to mas) a 4 (sin to presion mayor aumenta cuatro veces a partir de la perimenopausia266, 267, 268; es mas frecuente la mas severos); el puntaje se calcula por dominio y tambien como suma to tal. La mujer que tiene antecedentes de depresion y problemas emocio para conocer la situacion actual de la consultante y mas tarde, es util para evaluar el efec to de cual nales presenta mayor vulnerabilidad en la peri y posmenopausia269, 270. Fac to res psicosociales de riesgo de depresion durante el climaterio Fac to res de riesgo modificable Fac to res de riesgo no modificables Abuso de sustancias Sexo Falta de apoyo social Capacidad reproductiva Baja au to estima Edad Conflic to s con la pareja His to ria personal o familiar de depresion Sensacion de perdida de la femineidad. Evaluacion de sin to mas en mujeres en edad del climaterio La mujer esta expuesta a multiples sin to mas en la edad del climaterio. Al planificar intervenciones se requiere seleccionar aquellos problemas que mas afectan la calidad de vida relacionada con el climaterio, de acuerdo a la evaluacion que hace cada mujer del impac to sobre su vida diaria. Existen diversos instrumen to s au to administrables con la capacidad de evaluar la relevancia de los efec to s298. Debido a la multiplicidad de sin to mas propios del climaterio, se requiere simplificacion para lograr utilidad clinica. La mujer califica la relevancia de sus sin to mas en una escala de 0 (ausencia de sin to mas) a 4 (sin to mas severos); el puntaje se calcula por dominio y tambien como suma to tal. La escala es adecuada para conocer la situacion actual de la consultante y mas tarde, es util para evaluar el efec to de cual quier intervencion. El dominio psicologico agrupa manifestaciones emocionales comunmente ligadas con la ansiedad, angustia, sin to mas depresivos y alteraciones de memoria. No pretende abarcar to dos los sin to mas Examen fisico general emocionales ni es excluyente. El dominio urogenital agrupa molestias de las areas sexual y genital independiente de los mecanis Examen ginecologico mos subyacentes. Toma de muestra para ci to logia debe ser aplicado sin influencia de entrevistadores. En dicha escala se han analizado diversos pun to s cervical (Papanicolau), segun Guia Clinica Cancer Cervico-uterino. La indicacion final dependera de la ausencia de contraindicaciones y el deseo de la mujer. Sistema de Admision Eco to mografia ginecologica segun pro to colo (preferentemente transvaginal). Se indica o rea Agendar una hora con profesional de la salud, a to da mujer entre 45 y 64 anos para ingresar a control liza cuando hay utero, especialmente si el examen ginecologico es anormal. Examen ginecologico Inspeccion de vulva y vagina (enfasis en trofismo, lubricacion, presencia de prolapso, evalua cion de incontinencia de orina con test de esfuerzo), especuloscopia, visualizacion del cuello uterino. Toma de muestra para ci to logia cervical (Papanicolau), segun Guia Clinica Cancer Cervico-uterino. Se indica o rea liza cuando hay utero, especialmente si el examen ginecologico es anormal. Educacion y consejeria Educacion sobre sin to ma to logia relacionada con el climaterio. Tratamien to s no hormonales Indica tratamien to s farmacologicos no hormonales que sean necesarios: calcio, vitamina D, lubri Ejercicios pelvianos. Indaga violencia intrafamiliar y facilita formularios en casos sospechosos (anexos 9 y 10). Acciones educativas y consejerias Especialidades del nivel secundario (ginecologia, endocrinologia, otros). Registros Consejeria sobre el au to cuidado y mejoramien to del estilo de vida: Ficha. Interconsultas Solicita Interconsultas cuando corresponda a: Servicio Social (presencia de riesgo psicosocial).
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Entrenched traditional beliefs and stigma issues inherent in most Pacific cultures anxiety symptoms feeling hot buy atarax australia, with regards to relating to people with disabilities, act as a major barrier to full acceptance and participation in society and to accessing disability services in particular. Clinicians and other rather than expecting them to initiate workers may need to identify attitudes contact and ask for it. Socioeconomic and beliefs that the individual and circumstances should be considered. Any understanding the messages requires decision-making regarding assessment, to o high a proficiency in written treatment and coordination should be English. Increasing Pacific workforce numbers and enhancing cultural competency is likely to From the start, this research should be increase access rates for Pacific families framed to translate in to policy, inform and will contribute to providing culturally best-practice guidelines and provide appropriate services, more effective information to funders for resource treatment and ultimately better outcomes allocation. New Zealand Autism Auckland: Autistic Association of New Spectrum Disorder Guideline Zealand, 2005. Focus on Supplementary Paper on Three Autism & Other Developmental Disabilities Pharmacological Interventions. Focus on Autism & Other w-zealand-autism-spectrum-disorder Developmental Disabilities 2000; 15:232-5. Adults with autism Supplementary Paper on Supported speak out: perceptions of their life Employment Services. Orchestrating voices: autism, w-zealand-autism-spectrum-disorder identity and the power of discourse. The Spectrum Disorder Guideline Psychiatric Clinics of North America 1998; Supplementary Paper on Cognitive 21(4):927-40. Academy of Child and Adolescent Diagnostic and Statistical Manual of Psychiatry 1998; 37(1):113-14. How diagnosis can change an spectrum in a population cohort of children outlook on employment for Asperger in South Thames: the Special Needs and syndrome people: a personal account. Predic to rs of outcome among high functioning children with autism and Asperger syndrome. California Department of Developmental Spectrum Disorders: A comprehensive Services. California: and young people with autistic spectrum Department of Developmental Services, disorder and their families within the West 2003. Journal of Child Spectrum Disorders: A guide to services Psychology and Psychiatry and Allied for adults with autism spectrum disorders Disciplines 1999; 40(719-32). Diagnosis and Development & Psychopathology 1995; epidemiology of autism spectrum disorders. Canadienne de Psychiatrie 2003; Patterns of adaptive behavior in very young 48(8):517-25. Pro to col for the Development of Practice for Screening, Diagnosis and a Model Regional Service for Persons with Assessment. Direc to r-General of Health Under s47 of Practice parameters for the assessment and the Health and Disability Services Act 1993 treatment of children, adolescents, and on Casey Albury. Journal of the Vineland Adaptive Behavior Scales: Autism and Developmental Disorders supplementary norms for individuals with 1999; 29(6):439-84. Adaptive Diagnostic Interview: a standardized behaviour in autism and pervasive investiga to r-based instrument. Asperger syndrome and high caregivers of individuals with possible functioning autism. Generic: a standard measure of social and communication deficits associated with the 62. Assessment instruments for psychiatric outpatients: a preliminary Asperger syndrome. Developmental, Diagnostic and 3rd ed: Cambridge University Press, Dimensional Interview (3di): a novel 2000:136-84. Journal of the Diagnostic and Statistical Manual of American Academy of Child and Mental Diseases, Fourth Edition, Text Adolescent Psychiatry 2004; 43(5):548-58. Annotation: Communication Disorders: background, the similarities and differences between inter-rater reliability and clinical use. Australian and New of Child Psychology and Psychiatry 2002; Zealand Journal of Psychiatry 2002; 43(3):327-42. Ten years on: a longitudinal study adults with autism with and without early of families of children with autism. Journal language delays: implications for the of Intellectual and Developmental differentiation between autism and Disability 2002; 27(3):215-22. The disclosure of a Social Sciences and Medicine 2003; diagnosis of an autistic spectrum disorder. Journal of Autism & Autism: Rights in reality: how people with Developmental Disorders 2003; autism spectrum disorders and their 33(4):395-402. Journal of Mothers supporting children with autistic Child Psychology and Psychiatry and spectrum disorders: social support, mental Allied Disciplines 2004; 45(8):1338-49. Guidelines: Children with autism spectrum Journal of Telemedicine and Telecare disorders. Families in a state of flux: the experience of Parent-mediated early intervention for grandparents in autism spectrum disorder. Ma nga kaumata hei education services for learners from tau to ko the tipurangi ake o nga mokopuna. Auckland: Grandparents Raising Journal of the Association for Persons with Grandchildren Trust, 2003. Living with a Brother autistic spectrum disorder or asperger or Sister with Special Needs: A book for syndrome. Living when a child has autism: marital stress and and Loving with Asperger Syndrome. Most Effective Models of Practice in Early Social and emotional adjustment of siblings Intervention for Children with Autism of children with autism. Australia: Australian Psychology & Psychiatry 2004; Government Department of Health and 45(4):855-65. Journal of A survey of sleep problems in autism, Early Intervention 1990; 14:133-46. Closing the Gap: A national blueprint to improve the health of persons with mental 155. Issues in families prepare for and cope with Mental Health Nursing 2002; 23:605-15. Interventions to Thimerosal-containing vaccines and autistic facilitate audi to ry, visual and mo to r spectrum disorder: a critical review of integration in autism: a review of the published original data. People with intellectual disability and their health problems: a review of comparative Autism 2003; 7(3):245fi53.
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So anxiety nos purchase 25 mg atarax fast delivery, again, that which is praised by our enemies [or by the worthless] for when even those who have a grievance think a thing good, it is at once felt that every one must agree with them; our enemies can admit the fact only because it is evident, just as those must be worth less whom their friends censure and their enemies do not. And, generally speaking, all things are good which men deliberately choose to do; this will include the things already mentioned, and also whatever may be bad for their enemies or good for their friends, and at the same time prac ticable. Again, a thing is good if it is as men wish; and they wish to have either no evil at an or at least a balance of good over evil. So are things which befit the possessors, such as whatever is appropriate to their birth or capacity, and whatever they feel they ought to have but lack-such things may indeed be trifiing, but none the less men deliberately make them the goal of their action. Good also are the things by which we shall gratify our friends or annoy our enemies; and the things chosen by those whom we admire: and the things for which we are fitted by na ture or experience, since we think we shall succeed more easily in these: and those in which no worthless man can succeed, for such things bring greater praise: and those which we do in fact desire, for what we desire is taken to be not only pleasant but also better. Further, a man of a given disposition makes chiefiy for the corresponding things: lovers of vic to ry make for vic to ry, lovers of honour for honour, money-loving men for money, and so with the rest. These, then, are the sources from which we must derive our means of persuasion about Good and Utility. A thing which surpasses another may be regarded as being that other thing plus something more, and that other thing which is surpassed as being what is contained in the first thing. Moreover, that for the sake of which things are done is the end (an end being that for the sake of which all else is done), and for each individual that thing is a good which fulfils these condi tions in regard to himself. It follows, then, that a greater number of goods is a greater good than one or than a smaller number, if that one or that smaller number is included in the count; for then the larger number surpasses the smaller, and the smaller quantity is surpassed as being contained in the larger. Again, if the largest member of one class surpasses the lar gest member of another, then the one class surpasses the other; and if one class surpasses another, then the largest member of the one surpasses the largest member of the other. Thus, if the tallest man is taller than the tallest woman, then men in general are taller than women. Conversely, if men in general are taller than wo men, then the tallest man is taller than the tallest woman. For the superiority of class over class is proportionate to the superiority possessed by their largest specimens. A thing may be accompanied by another in three ways, either simultaneously, subsequently, or po tentially. Life accompanies health simultaneously (but not health life), knowledge accompanies the act of learning subsequently, cheating accompanies sacrilege potentially, since a man who has committed sacrilege is always capable of cheating. Again, when two things each surpass a third, that which does so by the greater amount is the greater of the two; for it must surpass the greater as well as the less of the other two. A thing productive of a greater good than another is productive of is itself a greater good than that other. Likewise, that which is produced by a greater good is itself a greater good; thus, if what is wholesome is more desirable and a greater good than what gives pleasure, health to o must be a greater good than pleasure. Again, a thing which is desirable in itself is a greater good than a thing which is not desirable in itself, as for example bodily strength than what is wholesome, since the latter is not pursued for its own sake, whe reas the former is; and this was our definition of the good. Again, if one of two things is an end, and the other is not, the former is the greater good, as being chosen for its own sake and not for the sake of something else; as, for example, exercise is chosen for the sake of physical well-being. And of two things that which stands less in need of the other, or of other things, is the greater good, since it is more self-suficing. That which does not need something else is more self-suficing than that which does, and presents itself as a greater good for that reason. Again, that which is a beginning of other things is a greater good than that which is not, and that which is a cause is a greater good than that which is not; the reason being the Again, where there are two sets of consequences arising from two different beginnings or causes, the consequences of the more important beginning or cause are themselves the more important; and conversely, that be ginning or cause is itself the more important which has the more important consequences. Now it is plain, from all that has been said, that one thing may be shown to be more important than ano ther from two opposite points of view: it may appear the more important (1) because it is a beginning and the other thing is not, and also (2) because it is not a beginning and the other thing is-on the ground that the end is more important and is not a beginning. So Leodamas, when accusing Callistratus, said that the man who prompted the deed was more guilty than the doer, since it would not have been done if he had not planned it. On the other hand, when accusing Chabrias he said that the doer was worse than the prompter, since there would have been no deed without some one to do it; men, said he, plot a thing only in order to carry it out. Thus, gold is a better thing than iron, though less useful: it is harder to get, and therefore better worth getting. Reversely, it may be argued that the plentiful is a better thing than the rare, because we can make more use of it. For what is often useful surpasses what is seldom useful, whence the saying: the best of things is water. More generally: the hard thing is better than the easy, because it is rarer: and reversely, the easy thing is better than the hard, for it is as we wish it to be. That is the greater good whose contrary is the greater evil, and whose loss affects us more. Positive goodness and badness are more important than the mere absence of good ness and badness: for positive goodness and badness are ends, which the mere absence of them cannot be. Further, in propor tion as the functions of things are noble or base, the things them selves are good or bad: conversely, in proportion as the things themselves are good or bad, their functions also are good or bad; Moreover, those things are greater goods, superiority in which is more desirable or more ho nourable. Thus, keenness of sight is more desirable than keenness of smell, sight generally being more desirable than smell gene rally; and similarly, unusually great love of friends being more honourable than unusually great love of money, ordinary love of friends is more honourable than ordinary love of money. Con versely, if one of two normal things is better or nobler than the other, an unusual degree of that thing is better or nobler than an unusual degree of the other. Again, one thing is more honourable or better than another if it is more honourable or better to desire it; the importance of the object of a given instinct corresponds to the importance of the instinct itself; and for the same reason, if one thing is more honourable or better than another, it is more honourable and better to desire it. Again, if one science is more honourable and valuable than another, the activity with which it deals is also more honourable and valuable; as is the science, so is the reality that is its object, each science being authoritative in its own sphere. So, also, the more valuable and honourable the object of a science, the more valuable and honourable the science itself is-in consequence. Again, that which would be judged, or which has been judged, a good thing, or a better thing than something else, by all or most people of understanding, or by the majority of men, or by the ablest, must be so; either without qualification, or in so far as they use their understanding to form their judgement. This is indeed a general principle, applicable to all other judge ments also; not only the goodness of things, but their essence, magnitude, and general nature are in fact just what knowledge and understanding will declare them to be. And that is a greater good which would be chosen by a better man, either absolutely, or in virtue of his being better: for instance, to suf fer wrong rather than to do wrong, for that would be the choice of the juster man. One pleasure is greater than another if it is more unmi xed with pain, or more lasting. Again, the nobler thing is better than the less noble, since the noble is either what is pleasant or what is desirable in itself. And those things also are greater goods which men desire more earnestly to bring about for themselves or for their friends, whereas those things which they least desire to bring about are greater evils.