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Finally order accutane 30mg overnight delivery acne 3 weeks pregnant, Women’s Cosmetics generic accutane 40mg with mastercard skin care professionals, probably the first medieval Latin text of its kind,6 reflects the strictly empirical side of Salernitan medicine. It describes in head-to-toe order how to beau- tify women’s skin, hair, face, lips, teeth, and genitalia. Offering no theories of dermatological conditions or their causes, it simply lists and describes in detail how cosmetic preparations are to be made and applied. Women’s Cosmetics thus reflects not so much a formal, textual Arabic influence as the regular personal interactions between Christians and Muslims living side-by-side in southern Italy and Sicily. To varying degrees, then, the three Trotula texts give us evidence of not simply how the diseases of women were formally theorized by medical writers eager to assimilate the new Arabic texts but also how local Salernitan prac- titioners, with or without formal training, conceptualized and treated the medical conditions of women. The specific characteristics of twelfth-century Salernitan culture thus form a necessary prelude to a detailed analysis of the Trotula texts. Salerno In trying to explain the efflorescence of medicine in eleventh- and twelfth- century Salerno, scholars have often wondered why this explosion in medical thought and writing happened here and not someplace else. For our purposes, it is necessary to understand why Salerno offered fertile ground for exchange between these cultures, and how women’s social status in Salerno may have played a role in the formation of women’s medicine. T C Between  and , a Spanish Jew named Benjamin toured through south- ern Italy, describing the communities in which he found co-religionists. Of Salerno, ‘‘where the Christians have schools of medicine,’’ he said ‘‘It is a city with walls upon the land side, the other side bordering on the sea, and there is a very strong castle on the summit of the hill. A Muslim traveler, al- Idrisi, writing a decade or two before Benjamin, had called Salerno ‘‘an illus- trious city, with flourishing merchants, public conveniences, wheat and other cereals. One part spreads out over the plain, the other the hill, And whatsoever you desire is provided by either the land or the sea. It was essentially refounded by the Lombards, who gradually built up the city from the harbor all the way to the top of the hill (fig. Amarotta, Salerno romana e medievale: Dinamica di un in- sediamento, Società Salernitana di Storia Patria, Collana di Studi Storici Salernitani,  (Salerno: Pietro Laveglia, ), p. Involved in Mediterranean trade, espe- cially with Muslim North Africa, which bought its grain, lumber, and linen cloth, Salerno was one of the wealthiest Italian cities of its day. Although not on the regular trades routes of Jewish or Arab merchants in the eleventh or twelfth century, Salerno is occasionally mentioned as a destination in mer- chants’ accounts coming out of Egypt. The ‘‘very strong castle on the summit of the hill’’ that Benjamin of Tudela had described began its exis- tence as a simple church at the end of the tenth century. A tower was added in the fifth decade of the eleventh century and then, between  and  under the threat of Norman invaders, it was transformed into a real fortress. Salerno’s cathedral, still famous for its mosaics, marbles, and bronze doors,  Introduction was constructed under the supervision of Archbishop Alfanus and dedicated in . The city had at least two dozen churches and nine monasteries, three of which were female houses. One of the earliest documents we have records the gift of a vineyard whose profits are to be used to support the monastery’s infirmary; the intent is that the sick nuns will pray for the donor’s soul. Three aqueducts, originally constructed in Roman times and later restored by the Lombard princes, brought water to the city; these waters were supplemented by spring water coming down from the hills, plus wells and cisterns (to collect rainwater) in private courtyards. The nuns of San Giorgio had such a bathhouse, and while we do not have specifics about its construction, documents from the male house of Santa Sofia suggest what it may have looked like. The latter seems to have been a substantial establish- ment, with at least two levels, furnaces and bronze cauldrons for providing hot water, and a pool. It was so luxurious, in fact, that contracts were drawn up allowing monastics from other houses (male and female) and secular clerics to come bathe there as well. Naples, on the Tyrrhenian coast north of Salerno, and Bari, on the eastern coast of the peninsula, were larger;21 nearby Amalfi was a more important center of international trade. The whole region of southern Italy shared in a relative bounty of grains, fruits, nuts, and other foodstuffs,22 with increasing surpluses of raw materials and textile goods to export to other lands. It was made the capital of the newly created Lombard principality of Salerno in . The city’s fortunes immediately took off, for it became the main supply center for the Amalfitan merchants, whose own hinterland was insuffi- cient to feed them and whose port was inadequate to sustain traffic in the heavy goods theyexported from southern Italy to north Africa.

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Thus cheap accutane 30mg without a prescription acne 7 year old boy, the “limiting amino acid” will determine the nutritional value of the total nitrogen or protein in the diet cheap 10mg accutane with amex skin care face. This has been illustrated in experiments comparing the relative ability of different protein sources to maintain nitrogen balance. For example, studies have shown, depending on its source and preparation, that more soy protein might be needed to maintain nitrogen balance when compared to egg- white protein, and that the difference may be eliminated by the addition of methionine to the soy diet. This indicates that sulfur amino acids can be limiting in soy (Zezulka and Calloway, 1976a, 1976b). The concept of the limiting amino acid has led to the practice of amino acid (or chemical) scoring, whereby the indispensable amino acid composition of the specific protein source is compared with that of a refer- ence amino acid composition profile. Table 10-23 shows the com- position of various food protein sources expressed as mg of amino acid per g of protein (nitrogen × 6. The composition of amino acids of egg and milk proteins is similar with the exception of the sulfur amino acids methionine and cysteine. However, wheat and beans have lower propor- tions of indispensable amino acids, especially of lysine and sulfur amino acids, respectively. Amino Acid Scoring and Protein Quality In recent years, the amino acid requirement values for humans have been used to develop reference amino acid patterns for purposes of evalu- ating the quality of food proteins or their capacity to efficiently meet both the nitrogen and indispensable amino acid requirements of the individual. Based on the estimated average requirements for the individual indispens- able amino acids presented earlier (Tables 10-20 and 10-21) and for total protein (nitrogen × 6. These are given in Table 10-24 together with the amino acid requirement pattern used for breast-fed infants. It should be noted that this latter pattern is that for human milk and so it is derived quite differently compared to that for the other age groups. There are three important points that need to be highlighted about the proposed amino acid scoring patterns. First, there are relatively small differences between the amino acid requirement and thus scoring patterns for children and adults, therefore use amino acid requirement pattern for 1 to 3 years of age is recommended as the reference pattern for purposes of assessment and planning of the protein component of diets. Second, the requirement pattern proposed here for adults is funda- mentally different from a number of previously recommended require- ment patterns (Table 10-25). The other requirement patterns shown in Table 10-25 for adults were pub- lished in two recent reviews (Millward, 1999; Young and Borgonha, 2000). Thus, the reference amino acid scoring patterns shown in Table 10-24 are designed for use in the evaluation of dietary protein quality. However, two important statistical considerations need to be raised here: first, the extent to which there is a correlation between nitrogen (protein) and the requirement for a specific indispensable amino acid; second, the impact of the variance for both protein and amino acid requirements on the derived amino acid reference pattern. The extent to which the requirements for specific indis- pensable amino acids and total protein are correlated is not known. In this report it is assumed that the variance in requirement for each indispens- able amino acid is the same as that for the adult protein requirement. This analysis illustrates one of the uncertainties faced in establishing a reference or scoring pattern and judging the nutritional value of a protein source for an individual. However, on the basis of different experimental studies in groups of subjects, experience shows that a reasonable approxi- mation of the mean value for the relative quality of a protein source or mixture of proteins can be obtained by use of the amino acid scoring pattern proposed in Table 10-26 and a standard amino acid scoring approach, examples of which are given in the following section. Comments on Protein Quality for Adults While the importance of considering protein quality in relation to the protein nutrition of the young has been firmly established and accepted over the years, the significance of protein quality (other than digestibility) of protein sources in adults has been controversial or less clear. The amino acid scoring pattern given in Table 10-24 for adults is not markedly differ- ent from that for the preschool age group, implying that protein quality should also be an important consideration in adult protein nutrition. It is important to realize however, that this aggregate analysis does not suggest that dietary protein quality is of no importance in adult protein nutrition. The examined and aggregated studies included an analysis of those that were designed to compare good quality soy protein (Istfan et al. The results of these studies showed clearly that the quality of well-processed soy proteins was equivalent to animal protein in the adults evaluated (which would be predicted from the amino acid reference pattern in Table 10-26), while wheat proteins were used with significantly lower efficiency than the animal protein (beef) (again this would be predicted from the procedure above). Thus, the aggregate analyses of all available studies analyzed by Rand and coworkers (2003) obscured these results and illustrate the conservative nature of their meta-analysis of the primary nitrogen balance. Moreover, this discussion and presentation of data in Table 10-27 underscores the fact that while lysine is likely to be the most limiting of the indispensable amino acids in diets based predominantly on cereal proteins, the risk of a lysine inadequacy is essentially removed by inclusion of relatively modest amounts of animal or other vegetable proteins, such as those from legumes and oilseeds, or through lysine fortification of cereal flour. Food Sources Protein from animal sources such as meat, poultry, fish, eggs, milk, cheese, and yogurt provide all nine indispensable amino acids, and for this reason are referred to as “complete proteins.

Angell M (1997) Anti-polymer antibodies generic 40 mg accutane fast delivery acne 404 nuke, silicone breast implants accutane 5 mg without a prescription acne body wash, and I would like to acknowledge the support of P. This is an open-access article distributed under the Mangalore, Karnataka, India terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author B. Manipal Academy of Higher Education Funding: The authors received no specific funding for this article. Manipal, Karnataka, India References Competing Interests: The authors have declared that no competing interests exist. T e rotu la A edieval Com pendium of W om en’s edicine Edited and Translated by M onica. The city of Salerno as depicted in an eighteenth- century engraving  Figures  and . A case of uterine suffocation from a late thirteenth-century English manuscript – Figures  and . Fumigation pots and pessaries from a fifteenth-century Dutch translation of the Trotula – Figure . A private bath for a woman; from a late twelfth-century copy of the Salernitan Antidotarium magnum  Figure . Opening page of the standardized Trotula ensemble  This page intentionally left blank Preface I    as in histories of medicine, readers often find a passing reference to a mysterious person called Trotula of Salerno. She is also alleged to have been the first female professor of medicine, teaching in the southern Italian town of Salerno, which was at that time the most important center of medical learning in Europe. Other sources, however, assert that ‘‘Trotula’’ did not exist and that the work attributed to her was written by a man. Any figure who could generate such diametrically opposed opinions about her work and her very existence must surely be a mystery. Yet the mys- tery of ‘‘Trotula’’ is inevitably bound up with the text ‘‘she’’ is alleged to have written. The Trotula (for the word was originally a title, not an author’s name) was indeed the most popular assembly of materials on women’s medicine from the late twelfth through the fifteenth centuries. Written in Latin and so able to circulate throughout western Europe where Latin served as the lingua franca of the educated elites, the Trotula had also by the fifteenth century been trans- lated into most of the western European vernacular languages, in which form it reached an even wider audience. The Latin Trotula was edited for publication only once, in the sixteenth century, under the title The Unique Book of Trotula on the Treatment of the Diseases of Women Before, Dur- ing, and After Birth,2 and the only modern translations available are based on this same Renaissance edition. The Renaissance editor, undoubtedly with the best of intentions, added what was to be the last of many layers of editorial ‘‘improvements. True, they were all probably of twelfth-century Salernitan origin, but they reflected the work of at least three authors with distinct perspectives on women’s diseases and cosmetic concerns. The first and third of these texts, On the Conditions of Women and On Women’s Cosmetics, were anonymous. The sec- ond, On Treatments for Women, was attributed even in the earliest manuscripts to a Salernitan woman healer named Trota (or Trocta). Each of the texts went through several stages of revision and each circulated independently through- out Europe through the end of the fifteenth century, when manuscript culture began to give way to the printed book. By the end of the twelfth century, an anonymous compiler had brought the three texts together into a single ensemble, slightly revising the wording, adding new material, and rearranging a few chapters. This ensemble was called the Summa que dicitur ‘‘Trotula’’ (The CompendiumWhich Is Called the ‘‘Tro- tula’’), forming the title Trotula (literally ‘‘little Trota’’ or perhaps ‘‘the abbre- viated Trota’’) out of the name associated with the middle text, On Treatments for Women. The appellation was perhaps intended to distinguish the ensemble from a general, much longer medical compilation, Practical Medicine, com- posed by the historical woman Trota. The Trotula ensemble soon became the leading work on women’s medicine, and it continued to be the object of ma- nipulation by subsequent medieval editors and scribes, most of whom under- stood ‘‘Trotula’’ not as a title but as an author’s name. He rewrote certain passages, suppressed some material and, in his most thorough editorial act, reorganized all the chapters so as to eliminate the text’s many redundancies and inconsis- tencies (due, we know now, to the fact that several authors were addressing the same topics differently). There is no way that a reader of this emended printed text could, without reference to the manuscripts, discern the presence of the three discrete component parts.

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Ketamine is a powerful You inhale the vapour tranquilliser and from the bottle through anaesthetic used on your nose buy accutane 20 mg cheap acne breakout. It is an anaesthetic especially dangerous drug that can very quickly for people with heart or make you unconscious discount accutane 10 mg online acne studios. The Milestones provide a framework for the assessment of the development of the resident physician in key dimensions of the elements of physician competency in a specialty or subspecialty. They neither represent the entirety of the dimensions of the six domains of physician competency, nor are they designed to be relevant in any other context. The internal medicine milestones are arranged in columns of progressive stages of competence that do not correspond with post-graduate year of education. For each reporting period, programs will need to review the milestones and identify those milestones that best describe a resident’s current performance and ultimately select a box that best represents the summary performance for that sub-competency (See the figure on page v. Selecting a response box in the middle of a column implies that the resident has substantially demonstrated those milestones, as well as those in previous columns. Selecting a response box on a line in between columns indicates that milestones in the lower columns have been substantially demonstrated, as well as some milestones in the higher column. A general interpretation of each column for internal medicine is as follows: Critical Deficiencies: These learner behaviors are not within the spectrum of developing competence. Column 3: Describes behaviors of a resident who is advancing and demonstrating improvement in performance related to milestones. Ready for Unsupervised Practice: Describes behaviors of a resident who substantially demonstrates the milestones identified for a physician who is ready for unsupervised practice. This column is designed as the graduation target, but the resident may display these milestones at any point during residency. Aspirational: Describes behaviors of a resident who has advanced beyond those milestones that describe unsupervised practice. These milestones reflect the competence of an expert or role model and can be used by programs to facilitate further professional growth. It is expected that only a few exceptional residents will demonstrate these milestones behaviors. Answers to Frequently Asked Questions about Milestones are available on the Milestones web page: http://www. For each reporting period, a resident’s performance on the milestones for each sub-competency will be indicated by:  selecting the column of milestones that best describes that resident’s performance or  selecting the “Critical Deficiencies” response box Selecting a response box in the middle of a Selecting a response box on the line in between column implies milestones in that column as columns indicates that milestones in lower levels have well as those in previous columns have been been substantially demonstrated as well as some substantially demonstrated. Gathers and synthesizes essential and accurate information to define each patient’s clinical problem(s). The copyright owners grant third parties the right to use the Internal Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Internal Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Internal Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Internal Medicine Milestones on a non-exclusive basis for educational purposes. He/she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe, effective, patient-centered, timely, efficient and equitable care. The copyright owners grant third parties the right to use the Internal Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Internal Medicine Milestones on a non-exclusive basis for educational purposes. He/she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe, effective, patient-centered, timely, efficient and equitable care. The copyright owners grant third parties the right to use the Internal Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Internal Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Internal Medicine Milestones on a non-exclusive basis for educational purposes. Identifies forces that impact the cost of health care, and advocates for, and practices cost-effective care. Minimizes unnecessary emergency department visits, effective care providers, suppliers, diagnostic and therapeutic hospital readmissions) Actively participates in financers, purchasers) have tests initiatives and care delivery on the cost of care Incorporates cost-awareness models designed to overcome Possesses an incomplete principles into standard clinical or mitigate barriers to cost- Does not consider limited understanding of cost- judgments and decision-making, effective high quality care health care resources when awareness principles for a including screening tests ordering diagnostic or population of patients (e. The copyright owners grant third parties the right to use the Internal Medicine Milestones on a non-exclusive basis for educational purposes.

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The Committee envisions that a New Taxonomy incorporating molecular data could become self-sustaining by accelerating delivery of better health through more accurate diagnosis and more effective and cost-efficient treatments buy accutane 40mg without prescription skin care home remedies. However cheap accutane 40mg visa skin care untuk kulit berminyak, to cover initial costs associated with collecting and integrating data for the Information Commons, incentives should be developed that encourage public private partnerships involving government, drug developers, regulators, advocacy groups and payers. A major beneficiary of the proposed Knowledge Network of Disease and New Taxonomy would be what has been termed “precision medicine. These data are also critical for the development of the Information Commons, the Knowledge Network of Disease, and the development and validation of the New Taxonomy. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease 1 Introduction The Current Opportunity Biomedical research and the practice of medicine, separately and together, are reaching an inflection point: the capacity for description and for collecting data, is expanding dramatically, but the efficiency of compiling, organizing, manipulating these data—and extracting true understanding of fundamental biological processes, and insights into human health and disease, from them—has not kept pace. There are isolated examples of progress: research in certain diseases using genomics, proteomics, metabolomics, systems analyses, and other modern tools has begun to yield tangible medical advances, while some insightful clinical observations have spurred new hypotheses and laboratory efforts. In general, however, there is a growing shortfall: without better integration of information both within and between research and medicine, an increasing wealth of information is left unused. Twenty five years ago, the patient’s mother had breast cancer, when therapeutic options were few: hormonal suppression or broad-spectrum chemotherapy with significant side effects. Today, Patient 1’s physician can suggest a precise regimen of therapeutic options tailored to the molecular characteristics of her cancer, drawn from among multiple therapies that together focus on her particular tumor markers. Moreover, the patient’s relatives can undergo testing to assess their individual breast cancer predisposition. The diagnosis gives little insight into the specific molecular pathophysiology of the disease and its complications; similarly there is little basis for tailoring treatment to a patient’s pathophysiology. No concrete molecular information is available to customize Patient 2’s therapy to reduce his risk for kidney failure, blindness or other diabetes-related complications. Patient 2 and his family are not yet benefitting from today’s explosion of information on the pathophysiology of disease (A. Medical Encyclopedia 2011, Gordon 2011, Kellett 2011) 1 These scenarios are illustrative examples describing typical patients. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease 8 What elements of our research and medical enterprise contribute to making the Patient 1 scenario exceptional, and Patient 2 typical? Could it be that something as fundamental as our current system for classifying diseases is actually inhibiting progress? Today’s classification system is based largely on measurable “signs and symptoms,” such as a breast mass or elevated blood sugar, together with descriptions of tissues or cells, and often fail to specify molecular 2 pathways that drive disease or represent targets of treatment. Consider a world where a diagnosis itself routinely provides insight into a specific pathogenic pathway. Consider a world where clinical information, including molecular features, becomes part of a vast “Knowledge Network of Disease” that would support precise diagnosis and individualized treatment. What if the potential of molecular features shared by seemingly disparate diseases to suggest radically new treatment regimens were fully realized? In such a world, a new, more accurate and precise “taxonomy of disease” could enable each patient to benefit from and contribute to what is known. The Charge to the Committee In consideration of such possibilities, and at the request of the Director of the National Institutes of Health, an ad hoc Committee of the National Research Council was convened to explore the feasibility and need, and to develop a potential framework, for creating “a New Taxonomy of human diseases based on molecular biology” (Box 1-1: Statement of Task). The Committee hosted a two day workshop (see Appendix C) that convened diverse experts in both basic biology and clinical medicine to address the feasibility, need, scope, impact, and consequences of creating a “New Taxonomy of human diseases based on molecular biology”. The information and opinions conveyed at the workshop informed and influenced an intensive series of Committee deliberations (in person and by teleconference) over a 6 month period. The Committee emphasized that molecular biology was one important base of information for the “New Taxonomy”, but not a limitation or constraint. Moreover, the Committee did not view its charge as prescribing a specific new disease nomenclature. Rather, the Committee saw its challenge as crafting a framework for integrating the rapidly expanding range and detail of biological, behavioral and experiential information to facilitate basic discovery, and to drive the development of a more accurate and precise classification of disease (i. Preventative or therapeutic interventions can then be concentrated on those who will benefit, sparing expense and side effects for those who will not. Those who favor the latter term do so in part because it is less likely to be misinterpreted as meaning that each patient will be treated differently from every other patient. As part of its deliberations, the Committee will host a large two-day workshop that convenes diverse experts in both basic and clinical disease biology to address the feasibility, need, scope, impact, and consequences of defining this New Taxonomy.