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Diocles points out that one should look for the essential cause: sweet things may cause certain effects order suhagra 100mg with visa erectile dysfunction grand rapids mi, but not necessarily so and not in so far as they are sweet cheap 100 mg suhagra free shipping erectile dysfunction treatment pune. Nor does Diocles make the distinction between Ëp†gousi t‡v koil©av, o¬ dì ½xe±v kaª drime±v lÅousi tŸn oÎrhsin. On Mnesitheus being a possible target see Smith (1980) 444, and von Staden (1992) 240; a more sceptical attitude is taken by Bertier (1972) 30–1. Denn erstens wird dort nur zu einem geringen Teil eine Erklarung fur die Wirkung bestimmter¨ ¨ Nahrungsmittelgegeben,undzweitensliegtdiesenAusfuhrungenkeinstrenghypothetischesSchema¨ zugrunde(imGegensatzzurFeuer-Wasser-TheoriedeserstenBuches). Besides, there are more general reasons which should make us reluctant to associate Diocles with the author of On Ancient Medicine. The picture of Diocles that emerges not just from this single fragment, but from the more than two hundred that are preserved from him, shows that in matters of physiology and pathology Diocles’ opinions display many speculative characteristics in whose company the author of On Ancient Medicine would have felt himself quite uncomfortable. Diocles’ acceptance of the four primary qualities and of concepts such as innate pneuma and humours is frequently attested, and his use of them in the causal explanation of diseases in his work Affection, Cause, Treatment (P†qov, a«t©a, qerape©a) is well documented. Fragment 176 does not present itself as (nor claims to be) a methodological programme for medical science as a whole: it is concerned with dietetics, with the powers of foodstuffs and with the practical prob- lems the physician has to face. It is far from self-evident that what Diocles says here also applies to anatomy, pathology and general physiology – or even if it would apply, what the implications of this would be. He points out that there are many cases in which causal 37 On Diocles’ physiology see frs. A large number of Diocles’ aetiological views on diseases arereportedinthetreatiseonacuteandchronicdiseasesbytheso-calledAnonymusParisinusFuchsii, edited by Garofalo (1997). Although we should take into account the possibility that in many cases it is the Anonymus who is responsible for the precise wording of the aetiologies, the testimonies nevertheless point to a sophisticated use of causal explanation by Diocles in dealing with diseases. The question of the reliability of the Anonymus (which is too often approached from an a priori negative point of view, for instance by Kudlien (1963) 462) can only be answered on the basis of an unbiased study of the whole text, which has only recently been made available in its entirety by Garofalo (1997); see also van der Eijk (1999b). Diocles of Carystus on the method of dietetics 91 explanation is impossible, and that there are also cases in which it may be possible, but unnecessary for practical purposes – and one could imagine that in this respect the author of On Ancient Medicine would not have been too happy with Diocles’ criticism of claim three, for On Ancient Medicine is one of the first among the Hippocratic treatises to proclaim the urgency of stating the cause in dietetics. As for On Regimen, I believe that Fredrich was right in detecting a very strong, almost indiscriminate application of the search for causes in the chapters on the powers of foodstuffs of this treatise (40–56). The use of words indicating causal links such as ‘because’, ‘since’, ‘as a result of’ (di»ti, Œte, Âti, di†) in these sections is very frequent indeed. But it is especially the nature of these explanations which calls for consideration, for the fact is that many of them suffer from defects that might be interpreted as provoking the kind of criticism Diocles is expressing, such as circularity – no clear distinction being made between the level of qualities and that of powers – shifting the problem, and tautology – explanandum and explanation being stated in the same terms. It warms, because it is vinous, moistens because it is nutritious, and sends to stool because it is sweet and moreover boiled-down’); 2. The most prominent instances where the importance of causal explanation is stated are: 20. Considering these examples, we may be inclined to say that Diocles’ warnings against too automatic an application of causal explanation, as well as his prescription (in section 11 of fr. It rather seems to me that Diocles is arguing against what he believes to be – in the context of dietetics – some undesirable consequences of the search for causes or principles, or to put it in other words, against too strict an application of what in itself – and in Diocles’ opinion too – remains a sound scientific procedure. These consequences seem to have pervaded Greek scientific thought in the fourth century to such an extent that opposition to it was also expressed by Aristotle and Theophrastus (in their case, the opposition is probably directed against certain tendencies in the early Academy). There are a number of passages which reflect a similar awareness in Aristotle and Theophrastus of the limits of causal explanation. Theophrastus, Metaphysics 9 b 1–13: ‘Wherefore this too is problematical or at any rate not easy to say, up to which point and of which entities one should seek the cause, in the objects of sense and in the objects of thought alike: for the infinite regress is foreign to their nature in both cases and destroys our understanding.

There are no hard and fast rules discount suhagra 100mg overnight delivery impotence emotional causes, and every procedure in every child must be assessed individually and the different elements considered in collaboration with the parent and purchase suhagra 100mg otc erectile dysfunction treatment miami, where appropriate, with the child. For example, the younger the child the greater the likelihood of a need for general anaesthesia. At the other end of the age range it is unlikely that a 15-year old will need general anaesthesia for simple orthodontic extractions, although this might be required for moderately complex surgery, such as exposing and bonding an impacted canine. The degree of trauma involved is also another factor; a single extraction is most likely to be carried out under local anaesthesia, removal of the four first permanent molars is most likely to be carried out under general anaesthesia. Anxiety perceived as excessive, especially after an attempt at treatment under local anaesthesia and sedation, would lead to simple treatment such as conservative dentistry being carried out under a general anaesthetic usually involving endotracheal intubation. Serious medical problems, for example, cystic fibrosis with the associated respiratory problems would justify using sedation instead of general anaesthesia even for more traumatic surgery, such as removal of impacted canines, but it would be appropriate to carry out this sedation in a hospital environment. The degree of intellectual and/or physical impairment in handicapped children would also be a factor to be considered. General anaesthesia carries with it a finite risk of serious morbidity such as psychological trauma and even death (3 to 4 per million). No child should be submitted to a general anaesthetic without consideration of this potentially devastating outcome. Intermediate between the minimally intrusive techniques of local anaesthesia and the major intrusion of general anaesthesia are the techniques of conscious sedation (Fig. Key Points • Each child should be assessed on their merits and an appropriate method of pain control used. The drugs and techniques used to provide conscious sedation for dental treatment should carry a margin of safety wide enough to render unintended loss of consciousness unlikely. The level of sedation must be such that the patient remains conscious, retains protective reflexes, and is able to understand and respond to verbal commands. The routes of administration of sedative drugs used in clinical paediatric dentistry are oral, inhalational, intravenous, and transmucosal (e. However, the transmucosal routes are little used in the United Kingdom and currently, intravenous sedation is considered unsuitable for the operator/sedationist when working on children. Key Point • The goal of conscious sedation is to use a pharmacological agent to augment behavioural management to decrease anxiety levels while maintaining a responsive patient. Although the techniques are designed to reduce this risk to a minimum it should always be borne in mind that every time a sedative is given to a patient there is a risk of an idiosyncratic reaction to the drug, which may result in hypoxia or unexpected loss of consciousness. The clinician must arrange the clinical session so that sedation, irrespective of complications, can proceed smoothly and safely. This includes the need for all patients who are having sedation to be accompanied. This can be any adult, who understands the implications and potential problems of caring for a child during the later stages of recovery. In addition, the clinical facilities need to include suitable resuscitation equipment coupled with the knowledge and skills to use them. Key Points • The main complications related to paediatric conscious sedation are: -hypoxia, -nausea, -vomiting, -inadvertent loss of consciousness (general anaesthesia/over sedation). For this reason emergency equipment and drugs should be within arms reach of the operator and ready for immediate use.

One implica- ous topics in the modern dental curriculum shows tion to be drawn from this situation is that in pure- wide variances generic suhagra 100 mg without prescription erectile dysfunction diabetes qof. Thus purchase suhagra 100 mg with amex erectile dysfunction drugs and heart disease, retaining a certain amount of diversity fessional organizations and universities has been in curricular content is healthy and positive. Observers of dental education are surprised by the In addition, a growing number of state dental speed with which new clinical information and tech- licensing bodies have implemented mandatory con- nology is integrated into dental curriculum. There are signs that in some states initial means to expose clinical faculty to the external prac- steps are being taken to address the facilities issue. Recent expansion in the availability of participation courses can be The dental profession maintains a fundamental linked to the more rapid deployment of advanced, commitment to life-long learning through continu- new dental treatment technologies. Subject to a sound, market-based dental care econ- The quality, comprehensiveness and ethics of den- omy, there will be a continuing flow of well-qualified tal education bear directly on the vitality and stan- applicants to dental education. This assumption incor- dards of the dental profession, which in turn impact porates the reality that there will be acceptable sinu- the oral health and the quality of dental care avail- soidal swings in the dental applicant pool. The new public (governmental) financial support for dental method and the new access locations for taking the education will continue to decline, resulting in multi- online dental aptitude tests may have had a temporary ple and serious compromises to the quality of dental attenuating effect on the numbers of test takers. Continued erosion in The environment for dental practice is extremely state and federal financial support to dental education favorable, and especially so for new practitioners. Such from dental admissions directors that the modest a trend appears currently underway, and if it contin- decline in the size of the applicant pool has not been ues will cause the gap between medical and dental accompanied by a parallel decline in the grade point schools to widen rather that to narrow, as was recom- average of entering students. Moreover, it would be helpful to know the accept- Attainment of dental student diversity will require able base-rate of dental faculty vacancies. Such efforts should be tion that over 300 faculty vacancies are fully funded at rewarded by increases in under-represented minori- the present time needs to be substantiated. Women students will continue to study must also make clear that the university expec- constitute about 40 percent of dental school tations of future dental faculty will be higher than has enrollees, although market place changes could been the case over the past few decades, which can cause this percentage to increase slowly. Part-time dental faculty cannot provide, long-term, from lower-income families and under-represented the standards or productivity in academic scholarship minorities may shy away from dental careers. The future availability of quality dental faculty will be strongly x The direct and indirect negative effects may influenced by: result in reduced access to oral health care for fam- ilies of lower socioeconomic status. An economy will have a positive impact, while a strong important factor that could reduce the size and dental care economy will have a negative impact). Mentoring for women and under-represented private, and private/state dental and medical minority faculty will require increased effort. Dental education will generate both techno- A thorough and intensive follow-up study on the logical and quality change in dentistry, and similar- extent and future magnitude of a dental faculty ly will efficiently absorb into the curriculum exter- shortage is urgently needed to allow better policy nally generated technological advancements. Such a study must also place major emphasis information technology will be the most influential on recommending solutions to avoid dental faculty force shaping the dental curriculum and changing even shortages. Emphasis should be placed on identify- more profoundly its delivery to the dental student. This devel- and cooperation among institutions in ways not opment will occur as one possible way to counter the considered previously. The age of the Internet has higher cost of operating university campus-based furthered electronic communications in ways not clinical facilities. The longer-term economic viability dreamed of only a few years ago, and already aca- of such arrangements still needs to be tested. The current dental cur- never been simpler and more effective, the challenge riculum, and the current specialization structure of the of the electronic curriculum of the future is an dental profession, has barely begun to think seriously immense undertaking that will require significant about the implications of this change. New basic science and clinical science discoveries Early and fragmented experiences suggest that the will diffuse into the dental curricula. For the next development of new electronic curriculum products 10-15 years, there simultaneously exists the major may require the recruitment into dental schools of challenge of altering the delivery of the dental specialized computer and Internet expertise that tra- curriculum. The ongoing approach to absorbing ditionally has not resided in schools of dentistry.

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