By O. Sanuyem. Franklin University.

It is rarely used today and generally is not recommended for use in pregnant women buy rosuvastatin 20mg free shipping good cholesterol foods list, although there is 32 Antimicrobials during pregnancy little or no scientific evidence to suggest that it is teratogenic generic rosuvastatin 20 mg mastercard cholesterol in eggs ldl or hdl. In a review from the Collaborative Perinatal Project of approximately 100 infants exposed to chlorampheni- col in the first trimester, there was no evidence of an increased frequency of congenital malformations (Heinonen et al. It has been associated with the ‘gray baby syn- drome’ (cyanosis, vascular collapse, and death) in the premature neonate given large doses of this drug. Although chloramphenicol does cross the placenta readily (Scott and Warner, 1950), transplacental passage of the drug rarely, if ever, causes gray baby syn- drome in the fetus or newborn (Landers et al. The most significant potential adverse maternal effect is aplastic anemia, which has been reported in approximately one of 100 000 cases. Sulfonamides The sulfonamides inhibit folate synthesis and are analogs of para-aminobenzoic acid, which is necessary for production of folic acid by bacteria (Landers et al. There are no scientific reports of an association between congenital malformations and the use of sulfonamides during pregnancy. Although the sulfonamides are not terato- genic, they do compete for bilirubin binding sites and, if used near delivery, may cause hyperbilirubinemia, especially in the premature infant (Landers et al. Maternal side effects include hypersensitivity, photosensitivity, blood dyscrasias, and gastrointesti- nal intolerance. Trimethoprim Although trimethoprim crosses the placenta, it has not been shown to cause adverse fetal effects. In one report of over 100 women treated with a combination of trimethoprim and sulfamethoxazole, there was no increase in the frequency of fetal anomalies (Williams et al. In another study of 186 pregnant women receiving either a placebo (66 patients) or trimethoprim plus sulfamethoxazole (120 patients), the inci- dence of fetal malformations was actually lower in the group receiving the antibiotics (3. Like sulfonamides, trimethoprim is associated with few adverse maternal effects (skin rash, gastrointestinal intolerance, and possible hematologic abnormalities). Nitrofurantoin Nitrofurantoin macrocrystals, commonly used for urinary tract infections during preg- nancy, have not been reported to be associated with adverse fetal effects. In a random- ized prospective study of 100 women treated with nitrofurantoin versus 100 controls, there were no significant differences in birth weight, head circumference, or body length of the offspring (Lenke et al. Nitrofurantoin has been reported to cause hemolytic anemia in women with glucose-6-phosphate dehydrogenase deficiency (Powell et al. However, in the authors’ experience of approximately 1000 pregnant women receiving this medication for urinary tract infections, hemolytic anemia has not occurred in either the mother or the fetus. Vancomycin Vancomycin is an antibiotic which does not belong to any other class of antimicrobial agents. It is both bactericidal and bacteriostatic, and is effective against a wide variety of Gram-positive organisms, including the Enterococci (Hermans and Wilhelm, 1987). It is the drug of choice for Clostridium-difficile-associated pseudomembranous colitis. It is also used in penicillin-allergic pregnant women for bacterial endocarditis prophylaxis. There is no available scientific information linking this agent with adverse pregnancy outcomes, including congenital malformations. However, vancomycin may be associ- ated with significant maternal side effects, such as nephrotoxicity and ototoxicity. Although there are no such reports, vancomycin could theoretically result in the same toxicity in the fetus, since this drug readily crosses the placenta. Aztreonam Aztreonam belongs to a relatively new class of antibiotics: the monobactams. It is effec- tive against most of the aerobic Gram-negative rods or Enterobacteriaceae, and is used as an alternative to the aminoglycosides. However, according to its manufacturer, aztreonam has not been shown to be teratogenic in several animal models given several times the human dose. Moreover, a particular advantage of this antibiotic over the aminoglycosides is that it is not associated with either nephrotoxicity or ototoxicity in either the mother or the fetus. It is presently combined with cilastatin, which inhibits the renal metabolism of imipenem. Imipenem is effective against a wide variety of 34 Antimicrobials during pregnancy Gram-positive and Gram-negative aerobic and anaerobic organisms. It has the potential to be very effective as single-agent therapy for polymicrobial pelvic infections in women. There are no available human reproductive studies, but the imipenem–cilastatin combi- nation has not been shown to be teratogenic in rats or rabbits, according to its manu- facturer. There are few indications for the use of this very ‘potent’ antibiotic in pregnant women.

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The influence of the agent will be enhanced by a combination with avena sativa cheap rosuvastatin 10mg free shipping cholesterol/hdl ratio in canada, saw palmetto order rosuvastatin 10 mg fast delivery cholesterol lowering diet and lifestyle, or staphysagria, in cases of this character, when Thuja should be given in doses of from two to ten drops, four or five times daily. As an external application Thuja produces at first a sensation of smarting or tingling when applied to open sores or wounds and it is usually best to dilute it with one, two or four parts of water, or to combine the non- alcoholic extract with an ointment base in the above proportion. This constitutes an excellent mildly antiseptic and actively stimulating dressing to indolent, phagedenic or gangrenous ulcers. It is of much service in bed sores and in other open ulcers dependent upon local or general nerve exhaustion. In chronic skin diseases of either a non-specific or specific character, it Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 434 is a useful remedy. Vegetations of all kinds, especially those upon mucous surfaces, will yield to it readily. A small dose internally four or five times daily, with the application of fluid hydrastis in a spray, will quickly retard or remove such abnormal growths. It is also applicable to sloughing wounds, and to phagedena of the venereal organs. It causes gangrenous surfaces to dry without hemorrhage or other discharge, destroys offensive odors and influences granulation. Recent reports have been made concerning the very beneficial action of thuja on papilloma of the larynx and affections of that character in the post nasal region. Moreau Brown has reported a number of cases satisfactorily treated with this remedy. The same writer uses this agent in the treatment of growths in the posterior nares. He treats chronic enlargement of the tonsils with this remedy and has succeeded in reducing many severe cases to the normal size. He has treated some cases of disease of the turbinated bones with the same remedy. He believes that in all cases of normal hypertrophy, where there is no diathesis, underlying the difficulty, in the post nasal region, this remedy is of inestimable value. The use of thuja persistently in these cases is as effectual as it is when used in the same manner for syphilitic ulcerations. Mix thoroughly by drawing a quantity into the syringe, and forcing it back repeatedly for a few times, then draw up about two drams of the dilute mixture in the barrel of the syringe to be ready for use. Introduce a large exploring needle into the sac of the tunica vaginalis testis and allow the fluid to escape. Then in order to cause the liquid to enter every crevice of the sac of the hydrocele, pinch and knead the scrotum with the fingers quite vigorously. The pain induced is quite considerable for at least half an hour, then the patient goes about his business and usually no additional treatment is required. The non-alcoholic preparation is combined with vaseline or other unctuous substance and applied once or twice daily. However severe the case, he had no case especially where there was severe granulation of the lids that was so stubborn but that he could benefit it with a mild solution of thuja. It is applied directly to the growth as often as possible without inducing inflammation. Walker for many years has injected small tumors with thuja full strength, twenty drops for the first injection, increasing the subsequent injection every day or two until in some cases he has used as high as half an ounce. The agent is especially advised in the treatment of urinary disorders of the aged and young. It gives satisfaction in the treatment of nocturnal eneuresis when the difficulty is of functional origin. It is also valuable when there is dribbling of urine, loss of control from paralysis of the sphincter, perhaps, in the aged, where urinary incontinence is present, with severe coughs, lack of control when coughing or sneezing. Sometimes in severe cases of nocturnal eneuresis, it is accompanied with belladonna or rhus aromatica with good results. In old men with chronic prostatitis, with constant dribbling of the urine, this agent is valuable. It tones the muscular structure of the bladder and exercises a desirable influence over the mucous structures of the entire urinary apparatus. It also stimulates secretion within the tubules of the kidneys by its direct influence. Where there is irritability of the bladder from the presence of uric acid, or Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 436 other precipitates in the urine, or where there is chronic rheumatism or gout, the agent is serviceable. The agent is useful in urethral caruncle, and as a remedy for gleet, when granular urethritis is present. The remedy is valuable in the treatment of disorders of the mucous lining of the bronchial tubes.

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Homeopathy is a form of complementary medicine in which clinicians treat clients with diluted preparations called remedies 10 mg rosuvastatin mastercard cholesterol emboli syndrome definition. You would need to see a homeopath for this individualized therapy order rosuvastatin 5 mg line cholesterol blood test guidelines, which might be worthwhile and confers little risk. For two cycles, fourteen women sat in front of a bright light (10,000 1x cool-white fluorescent light), compared with dim red light, for two weeks before their period. John’s wort is superior to placebo for depression, based on a review of twenty- three randomized trials 54 of 1,757 patients. But consult with your doctor if you already are taking an antidepressant or antipsychotic medication. However, bioidentical hormone replacement can be useful for irregular menstrual cycles once you’ve been thoroughly evaluated by your local physician, and it improves sleep in perimenopause. Progesterone in Balance When you’ve got your progesterone at its proper level—not too little and not too much—you feel like Goldilocks in the just-right bed: sleepy at the right times, triumphant, and content. I blamed estrogen for many of my new physical quirks: painful periods that interrupted my childhood at age ten; breasts and hips that grew too fast and caused stretch marks; and breakouts that perplexed even my dermatologist. Hormones in general, and estrogen in particular, felt inscrutable, volatile, and beyond my comprehension. I mentioned this in the last chapter, but it’s worth repeating: estrogen is the hormone that most defines you as a woman. In fact, estrogen is the primary female sex hormone, made by all animals with a spine (“Mom, duh! In humans, the female brain becomes exquisitely sensitive to estrogen at puberty, and this continues until about your mid-forties, when the brain becomes less sensitive again —that is, the ovary is increasingly numb to the admonitions of the ovaries, and vice versa. At puberty, release of estrogen increases the feel- good chemicals of oxytocin, the arbiter of love and affiliation, and dopamine, the neurotransmitter of pleasure, satisfaction, and reward- based learning. With its biochemical girlfriends, oxytocin and dopamine, estrogen kick-starts your period at around age ten to fifteen. Estrogen: Archetype of Femininity Here’s the short version of what estrogen does: • Externally, estrogen gives you hips and breasts. Estrogen is nature’s Prozac, adjusting the level of available serotonin—another important neurotransmitter—so that it’s in more ready supply. Serotonin regulates your mood, sleep, and appetite, and acts as a general gatekeeper of other neurotransmitters in your brain. If conception does not occur, the lining is released about every twenty- eight days as your period. If conception does occur, estrogen, combined with progesterone, thickens and deepens that lining for the fertilized egg to settle into and grow. Ideally, you have a rhythm between these two hormones, which should function like well-matched dance partners. Estrogen is the flirtatious, curvy member of the team; progesterone plays a less dramatic, supportive role. Balance is crucial because estrogen and progesterone have opposing yet interdependent effects, similar to the Chinese concept of yin and yang. Estrogen stimulates the lining of the uterus to grow; progesterone stops the growth, stabilizes it, and then releases it in a coordinated fashion called menstruation. Estrogen stimulates breast cells to grow; progesterone prevents cysts from developing in painful breasts. Estrogen creates progesterone receptors, the locks on a cell’s nucleus into which a hormone inserts like a key; progesterone makes estrogen receptors jam and shut down. When they work in tandem, maintaining the body’s delicate equilibrium, you dance to a passionate rhythm. When your estrogen and progesterone are synchronized, your bones are strong, dense, and pliable. Your cardiovascular system stays clear of meddlesome debris, like clots and plaque. You know that you have reached this balanced state when you measure your levels of estradiol (the main estrogen of the reproductive years) and progesterone in saliva on Day 21 of the menstrual cycle, and the ratio of progesterone to estrogen is 100 to 500, and optimally 300. Estrogen as Dominatrix: Background on Estrogen Dominance Just like couples on a dance floor, problems can arise when one partner dominates. Excess estrogen can lead to a host of annoying ailments: water retention and its first cousin, breast tenderness; painful periods, perhaps endometriosis; mood swings, or your garden- variety free-floating irritability —take this a step further, and you have full-fledged anxiety or depression. Maybe you’ve noticed that you have more headaches, or that your face is redder than you want it to be. When estrogen levels are high in relation to progesterone, women often experience a wild ride of emotions before their periods. Beyond mood swings, symptoms can include hair loss, headaches, breast tenderness, bloating, difficulty losing weight, depression, fatigue, insomnia, decreased libido, foggy brain, and/or memory loss. Studies on rats show that high estrogen can interfere with the ability to learn and pay attention.

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For instance generic rosuvastatin 5 mg otc best cholesterol foods, it is known that neurotensin regulates the release of norepinephrine 10mg rosuvastatin with amex cholesterol medication makes me sick, its cotransmitter. Now that the fallacy of the “one neuron— one transmitter” dogma has been revealed, it is logical to assume that multiple trans- mitters (neurotransmitter plus a cotransmitter) may regulate each other’s release and metabolism in a given synapse and that there may be considerable overlap among presynaptic auto- and heteroreceptor functions. To be defined as a classical neuro- transmitter, a molecule must be synthesized and stored in a neuron, released from that neuron in a Ca2+ dependent process, diffuse to an adjacent neuron, specifically dock with a receptor on that adjacent neuron, and have its binding to this receptor blocked by a competitive antagonist. A neuromodulator, on the other hand, is a molecule which is present in the synaptic cleft and which modifies either the frequency or the efficiency of the neurotransmitter molecule, thereby either amplifying or attenuating the neuro- transmitter action. The traditional neurotransmitters have been recognized for a number of decades and include acetylcholine, norepinephrine, and glutamate. At this point it is well to consider that the classical definitions and concepts in this field have been undergoing considerable change, and that the distinctions between neurotransmitters, cotransmitters, neuromodulators, and neurohormones often become blurred. Many peptide hormones of the hypothalamus and hypophysis, for instance, have been recognized as having neurotransmitter activity at other sites, and neurohormones and the discipline of neuroendocrinology have become increasingly important in the biosciences. In recent decades, an explosive development in the discovery of cotransmitters has greatly expanded our understanding of neurotransmission, and of the homeostatic equi- librium that is regulated by aminergic and peptidergic cotransmitters even in systems as simple as that of Hydra. Postsynaptically, cotransmitters can influence the same recep- tor on the target, bind to two different receptors on the same target, or bind to two dif- ferent receptors on two different targets. This multipotential reactivity may explain the fact that some drugs and endogenous substances are partial agonists only: they may miss the help of a cotransmitter that the full agonist receives. Cross-reactivity of cotransmitter combinations may also explain the many side effects and shortcomings of neuroactive drugs that have been designed without the benefit of knowing the complete story of in vivo processes at the target. It should be kept in mind that a single synapse may operate with as many as four transmitters simultaneously, in any combination of amine and peptide, or even peptide and peptide, within the groupings shown. Amine neurotransmitters are synthesized in the synapse and are stored in small or large vesicles. Different populations of the same type of neurons may differ in their content of cotransmitters. The brain is really a collection of highly specialized components of enormous anatomical complexity. The brains of different mammals are very different, and the evo- lutionary changes in the brain are seen primarily as an increase in relative size and in the complexity of cortical folding, thus increasing the area devoted to association (i. The brain is divided into three gross parts: the brain- stem, the cerebrum, and the cerebellum. Structurally, the brain may be likened to a bou- quet of flowers with the cerebrum (as two cerebral hemispheres) “blossoming” outwards above the brainstem; the cerebellum is attached at the back of the brainstem. The brain consists of the brain stem (medulla oblongata, cerebellum, pons, mesencephalon, diencephalon) and the cerebrum (cerebral hemispheres, subcortical white matter, basal ganglia). Twelve pairs of nerves, collectively referred to as the cranial nerves, originate in the brainstem and sub- serve sensory and motor function in the head and neck. One of these nerves, the vagus nerve (so called because it wanders throughout the thorax and abdomen), is important to the autonomic nervous system (section 4. Within the medulla are a number of neurons actively involved in the biosynthesis of epinephrine (section 4. Lying partly in the pons and partly in the mesencephalon is the locus ceruleus (or nucleus pigmentosus), which is rich in norepinephrine-containing neurons and thus plays a role in the adrenergic neurotransmitter systems (see section 4. The dorsal (back) portion of the pons and mesencephalon is referred to as the tegmentum and contains a variety of nerve fibre tracts. The mesencephalon contains the substantia nigra, a region of the brain that is intimately involved with the dopamine neurotransmitter and is thus involved in the medicinal chemistry of Parkinson’s disease (section 4. The dien- cephalon is divided into the following regions: thalamus, hypothalamus, subthalamus, and epithalamus. The thalamus acts as a relay station that transmits, correlates, and integrates all ascending sensory information from the body on its way to the cerebrum. The hypothalamus has a regulatory influence over the autonomic nervous system and is the point at which the nervous system (using neurotransmitters as messengers) and the endocrine system (using hormones as messengers) interface. The pituitary gland is attached to the hypothalamus and is crucial to the synthesis of many neurohormonal messenger molecules (chapter 5). The pineal gland is part of the epithalamus and is important to the timing of the onset of puberty. The pineal gland contains melatonin, biosynthetically derived from serotonin (section 4. Running up the centre of the brainstem is a region called the reticular activating system. The raphe nuclei are in the middle of the brainstem (in the midline of the medulla, pons, and mesencephalon); they are associ- ated with the reticular formation and are actively involved with the biosynthesis of sero- tonin (section 4.

When you have used it down to the undissolved granules rosuvastatin 20 mg without prescription cholesterol test in bangalore, add more water and shake again order rosuvastatin 20mg with visa cholesterol lowering foods kerala. It does not contain cobalt (the blue or green gran- ules) which causes heart disease and draws cancer parasites to the skin. It is the main ingredient of non- chlorine bleach and has excellent cleaning power without fading colors. For bleaching (only do this occasionally) use original chlorine bleach (not “new improved” or “with special brighteners”, and so forth). Any dish soap that you use should be safe enough to eat because nothing rinses off clean. Start each day by steril- izing your sponge (it harbors Salmonella) or with a new one while the used one dries for three full days. It does not lather but goes right to work removing sweat and soil without stripping your color or natural oils. Hair gets squeaky clean so quickly (just a few squirts does it) that you might think nothing has happened! Only citric acid is strong enough to get the borax out, lemon juice and vinegar are not. All hair shampoo penetrates the eye lids and gets into the eyes although you do not feel it. Remarkably a little lemon juice (not from a bottle) has some holding power and no odor! Pour 3 cups of very cold water (refrigerate water overnight first) into the 2-quart saucepan. Slowly and carefully add the lye, a little bit at a time, stir- ring it with a wooden or plastic utensil. In olden days, a sassafras branch was used to stir, imparting a fra- grance and insect deterrent for mosquitoes, lice, fleas, ticks. Meanwhile, the unwrapped lard should be warming up to room temperature in the plastic dishpan. Pour 95% grain alcohol (190 proof) to this mark (for 50% grain alcohol or vodka make your mark one fifth of the way up). Use this for general sanitizing purposes: bathroom fixtures, knobs, handles, canes, walkers, and for personal cleanliness (but use chlorine bleach for the toilet bowl once a week). This is still not clean enough; use a final damp paper towel with skin sanitizer added. Do not use this recipe, nor keep any bottles of alcohol in the house of a recovering alcoholic. You can never completely rid yourself of these bacteria, although they may temporarily be gone after zapping. Baking soda has been deleted as a deodorant because ben- zene was found in some boxes. She or he may wish to make it up for you too, but do not let them add anything else to it. These homemade deodorants are not as powerful as the commercial varieties–this is to your advantage. If this leaves you uncomfortable, brush the extra times with plain water and a second “water-only” toothbrush. Make sure that nothing solid, like powder, is on your toothbrush; it will scour the enamel and give you sensitive teeth, especially as you get older and the enamel softens. Salt water plus grain alcohol or food-grade hydrogen peroxide makes a good denture-soak. Mouthwash A few drops of food grade hydrogen peroxide added to a little water in a glass should be enough to make your mouth foam and cleanse. For persons with metal tooth fillings, use chemically pure baking soda or just plain hot water. Contact Lens Solution A scant cup of cold tap water brought to a boil in glass saucepan. After cooling, pour it into a small bottle to carry in your purse or pocket (refrigerate the remain- der). You can make a better lip soother by adding some lysine from a crushed tablet, vitamin C powder, and a vitamin E capsule to the alginate mix. Foot Powder Use a mixture of cornstarch and zinc oxide poured into a salt shaker with a lid. Then add the sodium alginate base to the desired thickness (about equal amounts) and shake. Vitamin E oil from Now Foods was not polluted at the time of this writing, but for the future it would be safer to rely on capsules. This is a very light oil, useful as an after shave lotion and general skin treatment. Grind the tablet first by putting it in a plastic bag and rolling over it with a glass jar. Applicator: use a plastic coffee stirrer or straw; cut a slit in the end to catch some cotton wool salvaged from a vitamin bottle and twist (cotton swabs, cotton balls and wooden toothpicks are sterilized with mercury which in turn is polluted with thallium).

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Ulcerative colitis therapy includes sulfasalazine (Azulfidine) generic rosuvastatin 20 mg with visa cholesterol test can i drink coffee, glucocorticoids 5mg rosuvastatin free shipping cholesterol ratio heart attack, azathioprine, and mercaptopurine. Sulfasalazine is comprised of sulfapyridine and aminosalicylic acid, and usually used for mild or moderate disease (Hanauer, 1996). Sulfapyridine, a sul- fanamide, crosses the placenta (Azad and Truelove, 1979) and theoretically could cause hyperbilirubinemia or kernicterus, but there are no publications of these complications. Azathioprine, an immunosuppressant, may be necessary in the small number of patients who do not respond to the usual regimen. Cyclosporine has also been used to treat patients refractory to intravenous steroids (Hanauer, 1996). Aminosalicylate, metronidazole, corticosteroids, azathioprine, and cyclosporine may also be used to treat pregnant patients with Crohn’s disease. Delivery outcome after the use of acid-suppressing drugs in early pregnancy with special reference to omeprazole. Use of cimetidine, omeprazole, and ranitidine in pregnant women and pregnancy outcomes. However, pruritic urticarial papules and plaques of pregnancy, her- pes gestation, and papular dermatitis of pregnancy do occur and are unique to pregnancy. Two of the most potent human teratogens known, etretinate and isotretinoin, are dermatologic drugs. Six major categories of dermatologic preparations are reviewed: (1) vitamin A deriv- atives, (2) antibiotics, (3) antifungals, (4) antiseborrheics, (5) adrenocorticosteroids, and (6) keratolytics, astringents, and defatting agents. Dermatologic conditions unique to pregnancy and common dermatologic conditions that may occur during pregnancy are discussed under Special Considerations. Isotretinoin (Accutane) and etretinate (Tegison) are oral preparations, and tretinoin (Retin-A) is a topical agent. Isotretinoin Except for thalidomide, isotretinoin is the drug with greatest teratogenic potential of all the medications to which pregnant woman may be exposed in the first trimester. The ‘retinoic acid embryopathy’ is a distinct pattern of anomalies that has been described in several reports encompassing over 80 offspring of women exposed to this agent during Vitamin A derivatives 241 Box 13. Among 94 infants who were born to women who used isotretinoin in early pregnancy, 28 percent had major congenital anomalies (Chen et al. In this series, 18 percent of the pregnancies resulted in sponta- neous abortions. Clinicians are concerned about the risks associated with pregnancy among patients who recently discontinued taking isotretinoin. This agent has a short half-life of 10–12 h, and the risk of congenital anomalies is not increased in the offspring of women who discontinued this medication within days of conception (Dai et al. Major and minor anomalies were found in animal teratology studies with isotretinoin, similar to the pattern of malformations seen in human retinoic acid embryopathy (Agnish et al. A significant complication of use of this medication in women of reproductive age is that it may be detected in serum at ther- apeutic levels for at least 2 years after cessation of therapy (DiGiovanna et al. The manufacturer reports that etretinate is detected at near-therapeutic levels for 3–7 years following cessation of therapy (Hoffman-LaRoche, personal communication). No epidemiological studies have been published of etretinate use by pregnant women. Of 43 pregnancies exposed to etretinate, there were 14 pregnancy terminations and five had malformations similar to retinoid embryopathy. Twenty-nine live-born infants were reported, of whom six had major congenital anomalies (Geiger et al. Case reports are published of neural tube, other central nervous system, and limb reduction defects in the offspring of mothers exposed to this drug during embryogenesis (Happle et al. In one published case report, a fetus with a hypoplastic leg was born to a mother who conceived several months after discontinuing etretinate (Grote et al. Conceptions after etretinate exposure may pose serious risks of birth defects because the drug has an indeterminate half-life. The manufacturer has offered pro bono testing for etretinate in women of reproductive age who used this drug. Animal teratology studies have produced teratogenic effects with etretinate similar to those observed in the retinoic acid embryopathy, such as limb, genitourinary, neural tube, and cloacal defects (Mesrobian et al. It has an elimination half-life of approxi- mately 60 h, as opposed to 100–120 days for etretinate. Eight cases of acitretin expo- sure during pregnancy have been published, and there was one infant with multiple con- genital anomalies that were consistent with the retinoic acid embryopathy, and one case of congenital hearing deficit (Geiger et al. One case report of an infant born with features of the retinoic acid embryopathy was published. At 18 months’ follow-up, the infants had microcephaly and significant neurodevelopmental delay (Barbero et al. Notably, the dose of acitretin that the mother took from conception to the 10th week of pregnancy was low (10 mg/day) compared to other reports (e. Among 52 pregnancies where exposure to acitretin occurred after 6 weeks post- conception, no congenital anomalies were observed (Geiger et al. Animal mod- els of acitretin teratogenicity have produced anomalies consistent with the retinoic acid embryopathy (Lofberg et al.

Others 10mg rosuvastatin with visa cholesterol nuts, although deprived of medical content buy rosuvastatin 10 mg cholesterol in cell membrane, are nevertheless an integral part of medical discourse. An Folklore 46Folklore 46Folklore 46Folklore 46Folklore 46 113 Larisa Fialkova example is, “When you hear hoofbeats, think horses, not zebras”. Yet as shown by Alan Dundes and colleagues, it is used in a number of variations by doctors in their papers published in professional medical journals. Hoofbeats in this context are deciphered as symptoms of a disorder presaging common diseases (horses) or rare and/or exotic ones (zebras). Here we have a clear example of an in-group proverb which, taken out of professional discourse, loses its medical character entirely. So to my mind the notion “diagnostic”, applied to this proverb by Dundes and colleagues is inaccurate (Dundes et al. This term should be reserved for proverbs with obvious medical diag- nostic content such as “If he has blue veins on the nose, he’ll never wear his wedding clothes” (Elmquist 1934: 79–80), Nebo zhelteet k dozhdiu, chelovek – k bolezni (‘The sky turns yellow before rain, a person – before illness’), Gde kashel’ – tam i khvor’ (‘The cough comes with the illness’) (Fialkov & Fialkova 2009: 74, 86). But the proverb about the horses and zebras suits another para- digm, namely, informal medical discourse (Stoianova 2007). Proverbs are often used as a clinical test for schizophrenia, as well as apha- sia and Alzheimer’s disease. The rationale rests on patients’ impaired abstract mental abilities, that is, their capacity or failure to distinguish a proverb’s metaphoric form from its literal meaning. The test uses both the multiple- choice and the free-answer techniques, the former consisting of 40 items, each with four possible answers; the latter comprises 12 items, scaled in order of difficulty. The free-answer test is more reliable, especially with the high intel- ligence group (Gorham 1956). Other authors have attempted to improve the test’s reliability by including the factor of familiarity/non-familiarity with the proverbs (Ulatowska et al. Wolfgang Mieder pointed out that the items in the proverbs test are extracted from their context, which is of crucial importance for their understanding (Mieder 2004: 142). I would like to add that to my knowledge the papers on the application of the proverbs test in psychiatry published in medical journals carry no references whatsoever to research of proverbs in folklore. This indicates that the tests are designed by people whose under- standing of the proverbs is that of the lay public, not of professionals. A context-related approach to proverbs can be found in the writings of psy- chiatric and/or geriatric social workers, whose daily contact with patients re- quires mobilization of informal resources. Proverbs are important for gaining information about the patients’ mental state when open discussion is suppressed by cultural norms, as in the case of Israeli Bedouins, and/or for facilitating of contact among the patients themselves or between them and the staff. Some of them have evident medical content: “An apple a day keeps a doctor away”, “An ounce of prevention is worth a pound of cure” (Jackson 1995: 8), “After much patience and frustration the situation will lead to the grave” (Al-Krenawi: 2000: 99). The last item can be likened to a Moldavian proverb Esli tebia odolevaet gore i pechal, beris’ za lopatu (‘If you are overburdened with sorrow and grief, take a shovel’) (Fialkov & Fialkova 2009: 127). As an example I can quote a prov- erb: “The second wife is very sour even if it is a handle of the pot” (Al-Krenawi 2000: 98); used by a wife in a polygamous family, this conveys a cause of psy- chological distress. This context-oriented approach to proverbs in medical set- tings may be based on some knowledge of folklore studies (Al-Krenawi 2000) or be completely devoid of it (Jackson 1995). However, they vary in the plethora of their understandings of “medical” and in their principles of classification. Medical proverbs are quite often com- bined with aphorisms spoken by figures from various times and peoples (Gar- rison 1928; Dudnikov 1969; Kadymov 1971; Zakharov & Zhungietu 1975; Sysoev 2007), while other collections contain only folk material (Dunaevskii 1969; Elmquist 1934; Fialkov & Fialkova 2009; Vysotskii 1903). Present almost al- ways are rubrics which correspond to the narrow understanding of “medical”, namely “Health”, “Illness”, “Treatment”, “Bad Habits” (or alternatively “Alco- hol”, “Smoking”), and “Sleep”. A broad understanding can embrace such ru- brics as “Love, family”, “Sport”, “Appearance of a person”, and “Man and na- ture” (Zakharov & Zhungietu 1975), “The role of labor”, “Family, children, up- bringing” (Kadymov 1971); “The wise way of life” (Sysoev 2007) and more. Non-medi- cal proverbs found include Na vkus i tsvet tovarishcha net (‘There is no friend in color and taste’), Vkus pel’menei v miase (‘The taste of meat dumplings is in meat’) (Zakharov & Zhungietu 1975: 120), Delaia zlo, na dobro ne nadeisia (‘If you do bad things, don’t hope to get something good’) (Sysoev 2007: 12), “The fox never found a better messenger than himself” (Garrison 1928: 983), etc. The items are generally set under the rubrics in alphabetical order, as is usual in any general collection of proverbs. In a book of proverbs from various Folklore 46Folklore 46Folklore 46Folklore 46Folklore 46 115 Larisa Fialkova peoples, they are usually assembled according to the thematic heading. How- ever, in Sysoev’s book only Russian proverbs come under specific rubrics; prov- erbs of other peoples are placed after the Russian ones under the name of the nation, two to six for each, irrespectively of their sub-thematic content (Sysoev 2007: 79–94). In our own collection (Fialkov & Fialkova 2009) we decided to evade alphabetical order, so we put the proverbs together in blocks based on the same, a synonymous or a contrasting image, for example: Vrach sam sebia ne lechit (‘A doctor can’t cure himself’ – Tamil), Vrach khorosho lechit chuzhie bolezni (‘A doctor cures well the illnesses of others’ – Jewish), Vrach, uvrachui snachala svoi nedug (‘Doctor, cure yourself first’ – Rus- sian), Lekar’ ne mozhet lechit’ sebia sam (‘Doctor can’t cure himself’ – Zulu), Sam ne mozhet izbavit’sia ot bolezni, a drugikh lechit (‘He can’t cure himself and yet he treats others’ – Moldavian), Koli ty khirurg, vprav’ snachala sobstvennye kishki (‘If you are a sur- geon, set your own guts first’ – Persian), Liudei ot nasmorka lechit, a sam nasmorkom izoshiel (‘He treats people for a sniffle, while he is sniffling himself’ – Russian), Mozhet li lekar’ vylechit’ drugikh, esli bolen sam? Today, having completely abandoned that idea, I still consider this classification appropriate for applied folklore. Clusters of proverbs based on a certain idea, with corresponding images and belonging to various cultures, furnish some kind of inner discourse and simultaneously accentuate the items’ universality and cultural specifics alike. In fact, this classification is the oppo- site of the scientific structural approach based on the form, not the image (Dundes 1994: 45–46). It adds nothing to our understanding of proverbs as a genre, but can be utilized in concrete activities with the audience.

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