Richard A. Humes, MD

• Professor
• Department of Pediatrics
• Wayne State University
• Chief
• Division of Cardiology
• Children? Hospital of Michigan
• Detroit, Michigan

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Whose case when as the carefull Dwarfe had tould, And made ensample of their mournefull sight Vnto his maister, he no lenger would There dwell in perill of like painefull plight, But early rose, and ere that dawning light Discouered had the world to heauen wyde, He by a priuie Posterne tooke his flight, That of no enuious eyes he mote be spyde: For doubtlesse death ensewd, if any him descryde. Scarse could he footing find in that fowle way, For many corses, like a great Lay-stall Of murdred men which therein strowed lay, Without remorse, or decent funerall: Which all through that great Princesse pride did fall And came to shamefull end. And them beside Forth ryding vnderneath the castell wall, A donghill of dead carkases he spide, the dreadfull spectacle of that sad house of Pride. From lawlesse lust by wondrous grace fayre Vna is releast: Whom saluage nation does adore, and learnes her wise beheast. Who after Archimagoes fowle defeat, Led her away into a forrest wilde, And turning wrathfull fire to lustfull heat, With beastly sin thought her to haue defilde, And made the vassall of his pleasures vilde. Yet first he cast by treatie, and by traynes, Her to perswade, that stubborne fort to yilde: For greater conquest of hard loue he gaynes, That workes it to his will, then he that it constraines. With fawning wordes he courted her a while, And looking louely, and oft sighing sore, Her constant hart did tempt with diuerse guile: But wordes, and lookes, and sighes she did abhore, As rocke of Diamond stedfast euermore. And subtile engines bet from batteree, With greedy force he gan the fort assayle, Whereof he weend possessed soone to bee, And win rich spoile of ransackt chastetee. Ah heauens, that do this hideous act behold, And heauenly virgin thus outraged see, How can ye vengeance iust so long withhold, And hurle not flashing flames vpon that Paynim bold? The pitteous maiden carefull comfortlesse, Does throw out thrilling shriekes, & shrieking cryes, the last vaine helpe of womens great distresse, And with loud plaints importuneth the skyes, That molten starres do drop like weeping eyes; And Phoebus flying so most shamefull sight, His blushing face in foggy cloud implyes, And hides for shame. Eternall prouidence exceeding thought, Where none appeares can make her selfe a way: A wondrous way it for this Lady wrought, From Lyons clawes to pluck the griped pray. Her shrill outcryes and shriekes so loud did bray, That all the woodes and forestes did resownd; A troupe of Faunes and Satyres far away Within the wood were dauncing in a rownd, Whiles old Syluanus slept in shady arber sownd. Who when they heard that pitteous strained voice, In hast forsooke their rurall meriment, And ran towards the far rebownded noyce, To weet, what wight so loudly did lament. Vnto the place they come incontinent: Whom when the raging Sarazin espide, A rude, misshapen, monstrous rablement, Whose like he neuer saw, he durst not bide, But got his ready steed, and fast away gan ride. The wyld woodgods arriued in the place, There find the virgin dolefull desolate, With ruffled rayments, and faire blubbred face, As her outrageous foe had left her late, darkwing. And trembling yet through feare of former hate; All stand amazed at so vncouth sight, And gin to pittie her vnhappie state, All stand astonied at her beautie bright, In their rude eyes vnworthie of so wofull plight. Their harts she ghesseth by their humble guise, And yieldes her to extremitie of time; So from the ground she fearelesse doth arise, And walketh forth without suspect of crime: They all as glad, as birdes of ioyous Prime, Thence lead her forth, about her dauncing round, Shouting, and singing all a shepheards ryme, darkwing. And with greene braunches strowing all the ground, Do worship her, as Queene, with oliue girlond cround. And all the way their merry pipes they sound, That all the woods with doubled Eccho ring, And with their horned feet do weare the ground, Leaping like wanton kids in pleasant Spring. So towards old Syluanus they her bring; Who with the noyse awaked, commeth out, To weet the cause, his weake steps gouerning, And aged limbs on Cypresse stadle stout, And with an yuie twyne his wast is girt about. Far off he wonders, what them makes so glad, If Bacchus merry fruit they did inuent, Or Cybeles franticke rites haue made them mad; They drawing nigh, vnto their God present That flowre of faith and beautie excellent. The God himselfe vewing that mirrhour rare, Stood long amazd, and burnt in his intent; His owne faire Dryope now he thinkes not faire, And Pholoe fowle, when her to this he doth compaire. The woodborne people fall before her flat, And worship her as Goddesse of the wood; And old Syluanus selfe bethinkes not, what To thinke of wight so faire, but gazing stood, In doubt to deeme her borne of earthly brood; Sometimes Dame Venus selfe he seemes to see, But Venus neuer had so sober mood; Sometimes Diana he her takes to bee, But misseth bow, and shaftes, and buskins to her knee. The wooddy Nymphes, faire Hamadryades Her to behold do thither runne apace, And all the troupe of light-foot Naiades, Flocke all about to see her louely face: But when they vewed haue her heauenly grace, They enuie her in their malitious mind, And fly away for feare of fowle disgrace: But all the Satyres scorne their woody kind, And henceforth nothing faire, but her on earth they find. Glad of such lucke, the luckelesse lucky maid, Did her content to please their feeble eyes, And long time with that saluage people staid, To gather breath in many miseries. A Satyres sonne yborne in forrest wyld, By straunge aduenture as it did betyde, And there begotten of a Lady myld, Faire Thyamis the daughter of Labryde, That was in sacred bands of wedlocke tyde To Therion, a loose vnruly swayne; Who had more ioy to raunge the forrest wyde, And chase the saluage beast with busie payne, Then serue his Ladies loue, and wast in pleasures vayne. The forlorne mayd did with loues longing burne, And could not lacke her louers company, darkwing. But to the wood she goes, to serue her turne, And seeke her spouse, that from her still does fly, And followes other game and venery: A Satyre chaunst her wandring for to find, And kindling coles of lust in brutish eye, the loyall links of wedlocke did vnbind, And made her person thrall vnto his beastly kind. So long in secret cabin there he held Her captiue to his sensuall desire, Till that with timely fruit her belly sweld, And bore a boy vnto that saluage sire: Then home he suffred her for to retire, For ransome leauing him the late borne childe; Whom till to ryper yeares he gan aspire, He noursled vp in life and manners wilde, Emongst wild beasts and woods, from lawes of men exilde. For all he taught the tender ymp, was but To banish cowardize and bastard feare; His trembling hand he would him force to put Vpon the Lyon and the rugged Beare, And from the she Beares teats her whelps to teare; And eke wyld roring Buls he would him make To tame, and ryde their backes not made to beare; And the Robuckes in flight to ouertake, That euery beast for feare of him did fly and quake. Thereby so fearelesse, and so fell he grew, That his owne sire and maister of his guise Did often tremble at his horrid vew, And oft for dread of hurt would him aduise, the angry beasts not rashly to despise, Nor too much to prouoke; for he would learne the Lyon stoup to him in lowly wise, (A lesson hard) and make the Libbard sterne Leaue roaring, when in rage he for reuenge did earne. And for to make his powre approued more, Wyld beasts in yron yokes he would compell; the spotted Panther, and the tusked Bore, the Pardale swift, and the Tigre cruell; the Antelope, and Wolfe both fierce and fell; darkwing. Such ioy he had, their stubborne harts to quell, And sturdie courage tame with dreadfull aw, That his beheast they feared, as tyrans law, His louing mother came vpon a day Vnto the woods, to see her little sonne; And chaunst vnwares to meet him in the way, After his sportes, and cruell pastime donne, When after him a Lyonesse did runne, That roaring all with rage, did lowd requere Her children deare, whom he away had wonne: the Lyon whelpes she saw how he did beare, And lull in rugged armes, withouten childish feare. The fearefull Dame all quaked at the sight, And turning backe, gan fast to fly away, Vntill with loue reuokt from vaine affright, She hardly yet perswaded was to stay, And then to him these womanish words gan say; Ah Satyrane, my dearling, and my ioy, For loue of me leaue off this dreadfull play; To dally thus with death, is no fit toy, Go find some other play-fellowes, mine own sweet boy. In these and like delights of bloudy game He trayned was, till ryper yeares he raught, And there abode, whilst any beast of name Walkt in that forest, whom he had not taught To feare his force: and then his courage haught Desird of forreine foemen to be knowne, And far abroad for straunge aduentures sought: In which his might was neuer ouerthrowne, But through all Faery lond his famous worth was blown. Yet euermore it was his manner faire, After long labours and aduentures spent, Vnto those natiue woods for to repaire, To see his sire and offspring auncient. And now he thither came for like intent; Where he vnwares the fairest Vna found, Straunge Lady, in so straunge habiliment, Teaching the Satyres, which her sat around, darkwing. He wondred at her wisedome heauenly rare, Whose like in womens wit he neuer knew; And when her curteous deeds he did compare, Gan her admire, and her sad sorrowes rew, Blaming of Fortune, which such troubles threw, And ioyd to make proofe of her crueltie On gentle Dame, so hurtlesse, and so trew: Thenceforth he kept her goodly company, And learnd her discipline of faith and veritie. But she all vowd vnto the Redcrosse knight, His wandring perill closely did lament, Ne in this new acquaintaunce could delight, But her deare heart with anguish did torment, And all her wit in secret counsels spent, How to escape. At last in priuie wise To Satyrane she shewed her intent: Who glad to gain such fauour, gan deuise, How with that pensiue Maid he best might thence arise. So on a day when Satyres all were gone, To do their seruice to Syluanus old, the gentle virgin left behind alone He led away with courage stout and bold. Too late it was, to Satyres to be told, Or euer hope recouer her againe: In vaine he seekes that hauing cannot hold. So fast he carried her with carefull paine, That they the woods are past, & come now to the plaine. The better part now of the lingring day, They traueild had, when as they farre espide A wearie wight forwandring by the way, And towards him they gan in hast to ride, To weet of newes, that did abroad betide, Or tydings of her knight of the Redcrosse. But he them spying, gan to turne aside, For feare as seemd, or for some feigned losse; More greedy they of newes, fast towards him do crosse. A silly man, in simple weedes forworne, And soild with dust of the long dried way; His sandales were with toilesome trauell torne, And face all tand with scorching sunny ray, As he had traueild many a sommers day, Through boyling sands of Arabie and Ynde; And in his hand a Iacobs staffe, to stay His wearie limbes vpon: and eke behind, His scrip did hang, in which his needments he did bind. The knight approching nigh, of him inquerd Tydings of warre, and of aduentures new; But warres, nor new aduentures none he herd. Then Vna gan to aske, if ought he knew, Or heard abroad of that her champion trew, That in his armour bare a croslet red. Aye me, Deare dame (quoth he) well may I rew To tell the sad sight, which mine eies haue red: these eyes did see that knight both liuing and eke ded. That cruell word her tender hart so thrild, That suddein cold did runne through euery vaine, And stony horrour all her sences fild With dying fit, that downe she fell for paine. Ah dearest Lord (quoth she) how might that bee, And he the stoutest knight, that euer wonne? Where is (said Satyrane) that Paynims sonne, That him of life, and vs of ioy hath reft? Not far away (quoth he) he hence doth wonne Foreby a fountaine, where I late him left Washing his bloudy wounds, that through the steele were cleft. Therewith the knight thence marched forth in hast, Whiles Vna with huge heauinesse opprest, Could not for sorrow follow him so fast; And soone he came, as he the place had ghest, Whereas that Pagan proud him selfe did rest, In secret shadow by a fountaine side: Euen he it was, that earst would haue supprest Faire Vna: whom when Satyrane espide, With fowle reprochfull words he boldly him defide. And said, Arise thou cursed Miscreaunt, That hast with knightlesse guile and trecherous train Faire knighthood fowly shamed, and doest vaunt That good knight of the Redcrosse to haue slain: Arise, and with like treason now maintain Thy guilty wrong, or else thee guilty yield. The Sarazin this hearing, rose amain, And catching vp in hast his three square shield, And shining helmet, soone him buckled to the field. Therewith they gan, both furious and fell, To thunder blowes, and fiersly to assaile Each other bent his enimy to quell, That with their force they perst both plate and maile, And made wide furrowes in their fleshes fraile, That it would pitty any liuing eie. Large floods of bloud adowne their sides did raile; But floods of bloud could not them satisfie: Both hungred after death: both chose to win, or die. So fiersly, when these knights had breathed once, They gan to fight returne, increasing more Their puissant force, and cruell rage attonce, With heaped strokes more hugely, then before, That with their drerie wounds and bloudy gore They both deformed, scarsely could be known. O foolish faeries sonne, what furie mad Hath thee incenst, to hast thy dolefull fate? But that false Pilgrim, which that leasing told, Being in deed old Archimage, did stay In secret shadow, all this to behold, And much reioyced in their bloudy fray: But when he saw the Damsell passe away He left his stond, and her pursewd apace, In hope to bring her to her last decay. But for to tell her lamentable cace, And eke this battels end, will need another place. The Redcrosse knight is captiue made By Gyaunt proud opprest, Prince Arthur meets with Vna great ly with those newes distrest. Great maistresse of her art was that false Dame, the false Duessa, cloked with Fidessaes name. Who when returning from the drery Night, She fownd not in that perilous house of Pryde, Where she had left, the noble Redcrosse knight, Her hoped pray, she would no lenger bide, But forth she went, to seeke him far and wide. To rest him selfe, foreby a fountaine side, Disarmed all of yron-coted Plate, And by his side his steed the grassy forage ate. He feedes vpon the cooling shade, and bayes His sweatie forehead in the breathing wind, Which through the tre[m]bling leaues full gently playes Wherein the cherefull birds of sundry kind Do chaunt sweet musick, to delight his mind: the Witch approching gan him fairely greet, And with reproch of carelesnesse vnkind Vpbrayd, for leauing her in place vnmeet, With fowle words tempring faire, soure gall with hony sweet. Vnkindnesse past, they gan of solace treat, And bathe in pleasaunce of the ioyous shade, Which shielded them against the boyling heat, And with greene boughes decking a gloomy glade, About the fountaine like a girlond made; Whose bubbling waue did euer freshly well, Ne euer would through feruent sommer fade: the sacred Nymph, which therein wont to dwell, Was out of Dianes fauour, as it then befell. Thenceforth her waters waxed dull and slow, And all that drunke thereof, did faint and feeble grow. Hereof this gentle knight vnweeting was, And lying downe vpon the sandie graile, Drunke of the streame, as cleare as cristall glas; Eftsoones his manly forces gan to faile, And mightie strong was turnd to feeble fraile. His chaunged powres at first them selues not felt, Till crudled cold his corage gan assaile, And chearefull bloud in faintnesse chill did melt, darkwing. Yet goodly court he made still to his Dame, Pourd out in loosnesse on the grassy grownd, Both carelesse of his health, and of his fame: Till at the last he heard a dreadfull sownd, Which through the wood loud bellowing, did rebownd, That all the earth for terrour seemd to shake, And trees did tremble. But ere he could his armour on him dight, Or get his shield, his monstrous enimy With sturdie steps came stalking in his sight, An hideous Geant horrible and hye, That with his talnesse seemd to threat the skye, the ground eke groned vnder him for dreed; His liuing like saw neuer liuing eye, Ne durst behold: his stature did exceed the hight of three the tallest sonnes of mortall seed. Such now he marcheth to this man forlorne, And left to losse: his stalking steps are stayde Vpon a snaggy Oke, which he had torne Out of his mothers bowelles, and it made His mortall mace, wherewith his foemen he dismayde. That when the knight he spide, he gan aduance With huge force and insupportable mayne, And towardes him with dreadfull fury praunce; Who haplesse, and eke hopelesse, all in vaine Did to him pace, sad battaile to darrayne, Disarmd, disgrast, and inwardly dismayde, And eke so faint in euery ioynt and vaine, Through that fraile fountaine, which him feeble made, That scarsely could he weeld his bootlesse single blade. The Geaunt strooke so maynly mercilesse, That could haue ouerthrowne a stony towre, And were not heauenly grace, that him did blesse, He had beene pouldred all, as thin as flowre: But he was wary of that deadly stowre, And lightly lept from vnderneath the blow: Yet so exceeding was the villeins powre, That with the wind it did him ouerthrow, And all his sences stound, that still he lay full low. So daunted when the Geaunt saw the knight, His heauie hand he heaued vp on hye, And him to dust thought to haue battred quight, Vntill Duessa loud to him gan crye; O great Orgoglio, greatest vnder skye, O hold thy mortall hand for Ladies sake, Hold for my sake, and do him not to dye, But vanquisht thine eternall bondslaue make, And me thy worthy meed vnto thy Leman take. He hearkned, and did stay from further harmes, To gayne so goodly guerdon, as she spake: So willingly she came into his armes, darkwing. Then vp he tooke the slombred sencelesse corse, And ere he could out of his swowne awake, Him to his castle brought with hastie forse, And in a Dongeon deepe him threw without remorse. From that day forth Duessa was his deare, And highly honourd in his haughtie eye, He gaue her gold and purple pall to weare, And triple crowne set on her head full hye, And her endowd with royall maiestye: Then for to make her dreaded more of men, And peoples harts with awfull terrour tye, A monstrous beast ybred in filthy fen He chose, which he had kept long time in darksome den. Such one it was, as that renowmed Snake Which great Alcides in Stremona slew, Long fostred in the filth of Lerna lake, Whose many heads out budding euer new, Did breed him endlesse labour to subdew: But this same Monster much more vgly was; For seuen great heads out of his body grew, An yron brest, and backe of scaly bras, And all embrewd in bloud, his eyes did shine as glas. Vpon this dreadfull Beast with seuenfold head He set the false Duessa, for more aw and dread. The wofull Dwarfe, which saw his maisters fall, Whiles he had keeping of his grasing steed, And valiant knight become a caytiue thrall, When all was past, tooke vp his forlorne weed, His mightie armour, missing most at need; His siluer shield, now idle maisterlesse; darkwing. His poynant speare, that many made to bleed, the ruefull moniments of heauinesse, And with them all departes, to tell his great distresse. He had not trauaild long, when on the way He wofull Ladie, wofull Vna met, Fast flying from the Paynims greedy pray, Whilest Satyrane him from pursuit did let: Who when her eyes she on the Dwarf had set, And saw the signes, that deadly tydings spake, She fell to ground for sorrowfull regret, And liuely breath her sad brest did forsake, Yet might her pitteous hart be seene to pant and quake. The messenger of so vnhappie newes Would faine haue dyde: dead was his hart within, Yet outwardly some little comfort shewes: At last recouering hart, he does begin To rub her temples, and to chaufe her chin, And euery tender part does tosse and turne: So hardly he the flitted life does win, Vnto her natiue prison to retourne: Then gins her grieued ghost thus to lament and mourne. Ye dreary instruments of dolefull sight, That doe this deadly spectacle behold, Why do ye lenger feed on loathed light, Or liking find to gaze on earthly mould, Sith cruell fates the carefull threeds vnfould, the which my life and loue together tyde? Now let the stony dart of senselesse cold Perce to my hart, and pas through euery side, And let eternall night so sad [sight] fro me hide. O lightsome day, the lampe of highest Ioue, First made by him, mens wandring wayes to guyde, When darknesse he in deepest dongeon droue, Henceforth thy hated face for euer hyde, And shut vp heauens windowes shyning wyde: For earthly sight can nought but sorow breed, And late repentance, which shall long abyde. If death it be, it is not the first wound, That launched hath my brest with bleeding smart. Begin, and end the bitter balefull stound; If lesse, then that I feare, more fauour I haue found. She heard with patience all vnto the end, And stroue to maister sorrowfull assay, Which greater grew, the more she did contend, And almost rent her tender hart in tway; And loue fresh coles vnto her fire did lay: For greater loue, the greater is the losse. Was neuer Ladie loued dearer day, Then she did loue the knight of the Redcrosse; For whose deare sake so many troubles her did tosse. At last when feruent sorrow slaked was, She vp arose, resoluing him to find A liue or dead: and forward forth doth pas, All as the Dwarfe the way to her assynd: And euermore in constant carefull mind She fed her wound with fresh renewed bale; Long tost with stormes, and bet with bitter wind, High ouer hils, and low adowne the dale, She wandred many a wood, and measurd many a vale. At last she chaunced by good hap to meet A goodly knight, faire marching by the way Together with his Squire, arayed meet: His glitterand armour shined farre away, Like glauncing light of Phoebus brightest ray; From top to toe no place appeared bare, That deadly dint of steele endanger may: Athwart his brest a bauldrick braue he ware, That shynd, like twinkling stars, with stons most pretious rare. Vpon the top of all his loftie crest, A bunch of haires discolourd diuersly, With sprincled pearle, and gold full richly drest, darkwing. The same to wight he neuer wont disclose, But when as monsters huge he would dismay, Or daunt vnequall armies of his foes, Or when the flying heauens he would affray; For so exceeding shone his glistring ray, That Phoebus golden face it did attaint, As when a cloud his beames doth ouer-lay; And siluer Cynthia wexed pale and faint, As when her face is staynd with magicke arts constraint. No magicke arts hereof had any might, Nor bloudie wordes of bold Enchaunters call, But all that was not such, as seemd in sight, Before that shield did fade, and suddeine fall: And when him list the raskall routes appall, Men into stones therewith he could transmew, And stones to dust, and dust to nought at all; And when him list the prouder lookes subdew, He would them gazing blind, or turne to other hew. Ne let it seeme, that credence this exceedes, For he that made the same, was knowne right well To haue done much more admirable deedes.

Laboratory investigation usually requires a high vaginal swab in transport medium zyrtec causes erectile dysfunction cheap levitra professional 20mg free shipping. Candida is commonly present in the vagina and small numbers may not be clinically important erectile dysfunction trials purchase levitra professional once a day. Low vaginal swabs are to be avoided as they may be contaminated with perineal flora erectile dysfunction doctor in pune levitra professional 20mg with mastercard. Investigation of patients with risk factors for sexually transmitted infection or with mucopurulent cervicitis should preferably be carried out in the Sexual Health clinic erectile dysfunction drugs not working buy generic levitra professional line. Sexual Health Clinic Women with risk factors for sexually transmitted infections should be considered for referral to a Sexual Health Clinic erectile dysfunction treatment portland oregon generic 20mg levitra professional otc, especially if they have recurrent symptoms erectile dysfunction non prescription drugs purchase levitra professional from india. Treatment Treatment should be in line with the local approved antimicrobial guidelines. Recurrent proven candida clotrimazole 500mg for 3-6 months patients experiencing cyclical or pessary relapse that requires once suppressive therapy. Management of common Infections Guidance for Primary Care for Consultation and Local Adaptation. Professor, Department of Microbiology Moti Lal Nehru Medical College, Allahabad, U. Abstract Objective: the aim of our study was to identify the distribution of Candida species among clinical isolates and their sensitivity pattern for common antifungal drugs. Methods: this descriptive study was carried out in a tertiary care hospital in Allahabad. Identification and speciation of the isolates were carried out by Germ-tube test, Chlamydoconidia production test, colony characterization in chromogenic agar medium, carbohydrate assimilation test and growth at 45 C. Four antifungal drugs such as Fluconazole (25 mcg), Clotrimazole (10 mcg), Nystatin (100 U) and Amphotericin-B (100 U) were tested by disk diffusion method. Descriptive statistics was used which involves the use of simple percentage and bar chart to analyze the data. Resistance rates for commonly use antifungal drugs among the isolates are as followed Fluconazole 76 (73%), Amphotericin B 40 (38. For Candida albicans and Candida dubliniensis most active antifungal drug was Nystatin (93%; 100% respectively). Discussion: Species level identification of Candida and their antifungal sensitivity testing should be performed routinely in all microbiology laboratories to prevent the spread of antifungal resistance. Keywords: Antifungal susceptibility; Non-albicans Candida; In India, there is insufcient data regarding the Candida species and Candida dubliniensis their susceptibility pattern [4] hence, the present study was undertaken to identify diferent Candida species and their sensitivity pattern with Introduction the available antifungal agents. Candida is major human fungal pathogens that cause both mucosal Material and methods and deep tissue infections. In recent years, the incidence of Candida infection has increased largely because of the rising rate of immune this prospective study was conducted during the period from suppressive therapy [1] and also enhances the infection with multi November 2016 to April 2017 from patients of the tertiary care drug resistant bacteria which leads to overuse of higher classes of hospitals in Allahabad afer obtaining permission from the antibiotic and as a result there is a destruction of commensal bacteria, institutional ethical committee. One hundred and four strains of owing to this there is an increased opportunity of Candida to cause Candida species with signifcant growth were isolated from the infection in those patients. The treatment of such Candidal infections specimen such as clean catch midstream urine, blood and sputum is a major concern since they are showing a high rate of anti-fungal using standard sterile procedures from the study population. Germ tube was considered as a slender tube four antifungal drugs disk Fluconazole (25 mcg), Clotrimazole (10 with straight walls, without septum and without constriction at the mcg), Nystatin (100 U) and Amphotericin-B (100 U). Antifungal susceptibility testing was performed by disk difusion method using Mueller-Hinton Agar + 2% Glucose and 0. Chlamydoconidia production test was performed using corn meal document M44-A2, 2009. The two slides, incubated in the wet chamber at 30 C for 72 h and antifungal susceptibility of the isolates was interpreted as sensitive (S), visualized in an optical microscope (10X and 40X magnifcation). Candida dubliniensis, Candida tropicalis, Candida glabrata and Demographic data of patients: Of the 104 patients, 62 (54%) were Candida krusei on the basis of colour and colony morphology. The most which defne light green colonies as Candida albicans, purple fuzzy common predisposing factor was diabetics [37(35. The carbohydrate assimilation test determines the ability of a yeast We also found that a maximum number of blood isolates were from isolate to use a particular carbohydrate substrate as its sole carbon in a non-Candida albicans species [7(7%)], and Candida albicans were medium. Candida dubliniensis (N=20) 0 15(25%) 5(14%) The suspension was placed in 15 cm Petri dishes and afer solidifcation of the medium, discs with the 2% carbohydrates Candida tropicalis (n=10) 3(37. Glucose was used as a positive control since all the Candida glabrata (n=3) 1(12. The carbohydrate assimilation was observed with a presence of a halo of growth around Table 1: Distribution of Candida species in diferent clinical isolates. Resistance rates for commonly use antifungal drugs among the Growth at 45?C isolates are as followed Fluconazole 76 (73%), Amphotericin B 40 (38. Growth at 45 C has been considered a useful test for the Prevalence of drug resistance among the Candida albicans, Candida diferentiation of Candida dubliniensis (no growth) from Candida dubliniensis and non-Candida albicans and non-Candida dubliniensis albicans (growth). Discussion species instead of Candida glabrata or Candida parapsilosis in all age groups. For many years Candida albicans were the most dominant species to The antifungal susceptibility testing revealed that amphotericin B cause invasive infection in most clinical settings, a considerable exhibited a higher sensitivity against Candida albicans, Candida percentage of patients are now infected with non-albicans Candida dubliniensis respectively, which points out that this drug can serve as a species. Infections with these Candida species also have a direct impact good candidate for empirical therapy of Candida albicans and Candida on the choice of empiric antifungal therapy and clinical outcome as dubliniensis infections. This fnding is similar to the studies done by they show resistance to multiple antifungal drugs. In the present study, we have found that among the study However, non-albicans and non-dubliniensis Candida were showing population maximum numbers of the isolates were from urine, which the high degree of resistance against Amphotericin B. The most active indicates that other than bacteria in our population Candida which antifungal drugs for all the Candida species were Nystatin. Where they have found around 67% of their non-albicans our study isolates in compare to other studies where they had found a isolates were sensitive to clotrimazole. However, in the present study, high prevalence of invasive isolates in their study population [9,10]. Conclusion [4] We are not the frst to report that diabetics were one of the most In conclusion, microbiology laboratories must be able to detect the common predisposing factors for candidiasis other investigator also diferent species of Candida and their resistance pattern in a timely reported the same [11]. Tese fndings indicate that due to the poor manner, Microbiological excellence is needed more than ever, and the immune response by elderly patients and predisposing factor such as resistance should be detected accurately. In addition, there should be diabetes mellitus may act as an important risk factor for candidiasis. Sandhu R, Dahiya S, Sayal P, Budhani D (2017) Increased the role of Factors associated with candidemia caused by non-albicans nonalbicans Candida, potential risk factors, and attributable mortality in Candida species versus Candida albicans in the intensive care unit. Casqueiro J, Casqueiro J, Alves C (2012) Infections in patients with 1997 to 2007: A 10. Pahwa N, Kumar R, Nirkhiwale S, Bandi A (2014) Species distribution infection: An emerging threat. Bajwa S, Kulshrestha A (2013) Fungal infections in intensive care unit: centre at Indore. Eur J Clin Microbiol albicans Candida species and antifungal resistance in intensive care unit Infect Dis 17: 367-368. Reddy A, Mustafa M(2014) Phenotypic identifcation of Candida species albicans, Candida krusei and Candida tropicalis with the chromogenic and their susceptibility profle in patients with genitourinary candidiasis. Clinical and Laboratory Standards Institute (2009) Clinical and Laboratory Standards Institute Method for Antifungal Disk Difusion Susceptibility Testing of Yeasts; Edition 2. With most active samples, the inhibition of the formation of germ tubes and budding, the in vitro pharmacodynamics, using time-kill assays, and the interaction with itraconazole and amphotericin B following the chequerboard technique were evaluated. Conclusions: the results of this study suggest that Colombian medicinal and aromatic plants represent an untapped source of compounds with anti-C. Key words: Essential oils, extracts, Candida albicans, antifungal activity, cytotoxicity, synergism Resumen Objetivo. Determinar la actividad anti-Candida albicans, la citotoxicidad y la interaccion con antifungicos de aceites y extractos de plantas recolec tadas en Colombia. Con las muestras mas activas se evaluo la inhibicion de la formacion de tubo germinal y la gemacion, la farmacodinamia mediante curvas de tiempo muerte y la interaccion con itraconazol y anfotericina B. La mayor actividad se obtuvo con los aceites de Piper bredemeyeri Jacq y Lippia origanoides Kunth (B) y el extracto de Morinda royoc L. Los resultados de este estudio sugieren que las plantas de Colombia son una fuente no explorada de compuestos con actividad anti-C. Palabras clave: aceites esenciales, extractos, Candida albicans, actividad antifungica, citotoxicidad, sinergismo. Screening by using in vitro evaluation is a useful tool for the disco Many researchers, particularly the ones from very of new potential antifungal agents from na countries with a rich biodiversity, have contri tural products such as essential oils and extracts buted to the detection of new antifungal com derived from plants (1). Colombia is the second ri 1 Grupo de Investigacion Dermatologica, Facultad de Medicina, Recibido: 08/10/2010; Aceptado: 03/08/2011 Universidad de Antioquia, Medellin, Colombia Correspondencia: Ana Cecilia Mesa-Arango: Carrera 51D N? Although Colombia possesses Plant material a rich tradition in the use of medicinal plants, the Stems and leaves of 74 plants were collected antifungal activity of medicinal plants derivates in different regions of Colombia, from 2005 to has not been deeply studied. Systemic yeast at the Herbario Nacional de Colombia, Instituto infections are a common consequence of immu de Ciencias Naturales, Facultad de Ciencias, Uni nosuppression, long-term indwelling catheters, versidad Nacional de Colombia at Bogota, whe and endocrinopathies. Additionally, it has the the selected plants belong to the following gene ability to adhere to host surfaces or to prosthesis ra: Lippia (Verbenaceae) (26); Salvia (Lamiaceae) leading to the formation of bioflms which fur (7); Lepechinia (Lamiaceae) (3); Piper (Piperaceae) ther facilitate adhesion, infection and resistance (3); Baccharis (Asteraceae) (2); Hedyosmum (Chlo to the antifungals (3). Extracts and essential oils extraction Furthermore, the combined effects of itracona zole and amphotericin B with the most actives Essential oils (59) and extracts (15) were evalua samples, and their pharmacodynamics were ted. The essential oils were extracted from dried evaluated in vitro by the chequerboard method stems and leaves (300 g) by microwave-assisted and the time-kill curves, respectively. Each sample was Antifungal susceptibility testing tested in duplicate using two different assays. The Tukey a group of clinical isolates of the Candida spe multiple comparison test was used to compare cies collected in our laboratory were used at 5 strains with and without treatment. At fferent assays against each Candida strain and 0, 4, 8, 12, and 24 hours, volumes of 10 ?l were the clinical isolate. The effect on germ tube formation and budding Time-kill curves with itraconazole and amphote was evaluated according to Ishida, et al. In addition, the treatment of the strains (dimethylthiazol-2-yl]-2,5-diphenyl tetrazolium and the clinical isolate with P. The minimal extract, inhibited the process of budding, at 250 dilution of the essential oils that induced 50% ?g/ml. The positive lues for each compound were obtained by linear control inhibited the budding, and in the negative regression analysis of the dose-response curves control there was a normal rate of budding. According to these criteria, we found According to the American National Cancer Ins strong anti-C. Previous studies have shown the antifungal ac tivity in extracts and oils of plants belonging to Discussion Piper, Morinda, and Lippia genus (17-19). The yeast to hyphal transition begins with the formation of Candida albicans has isotropic growth by budding a germ tube and it is the initial stage of hyphal and several antifungal drugs and plant extracts can formation (21). Previous studies have suggested integrity or reorganization of the cytoskeleton (22, that the deleterious effect of the essential oil on the 23). This characteristic could make a new antifun cell wall of the fungus could be the main reason for gal more selective towards the infecting germ the decrease in the rate of yeast budding, because than towards the host cells. In this study, a synergistic effect Chemical analyses of most active essential oils was obtained when itraconazole and the oil from against C. The antimi the toxicity in vivo demonstrated by Gonzalez, et crobial activities of those terpenes have also been (35) al. To the best of our knowledge, this is the frst the discovery of a novel natural product for time that antifungal activity of M. Morinda genus contains substan Taxol, an anticancer agent developed from the tial amounts of anthraquinones, especially in the plant Taxus brevifolia, was discovered after a roots. The antifungal activity of those quinones random screening of 35,000 plant samples that has been demonstrated (32), so it is possible that (36, 37) took more than 25 years. In conclusion, the results of this study suggest that Colombian medicinal and aromatic plants repre In our laboratory, the antifungal activity of L. Screening of some plants used in the Brazilian folk medicine ciamiento para la Ciencia, la Tecnologia y la In for the treatment of infectious diseases. Interspecies variation in Candida bio transition in the pathogenic yeast Candida albicans. Fungal bloods gistatic antifungal agents on the morphogenetic transformation of tream infections in tertiary care hospitals in Colombia. Comparison of different ex vities against yeasts and molds: Lessons learned from bacterici traction methods for the analysis of volatile secondary metabolites dal testing and the need for standardization. Infuence of tannins from Stryphnodendron adstringens Melaleuca alternifolia (tea tree oil). Antifungal effects of herbal essential oils alone and conditions on antifungal time-kill curve results: Proposal for stan in combination with ketoconazole against Trichophyton spp. Ensayo de toxicidad a dosis repetidas del extracto acuoso de of the Euphorbia genus. Earlier, ate Institute of Medical Education & Research, it was pathogenic dimorphic fungi, which were known to cause systemic infections. However, starting from Chandigarh, India the 1960s, opportunistic fungi started causing more number of infections, especially in the immunocompromised host. More recently, newer and less common fungal agents are being increasingly associated with infection in immunosuppressed hosts. Systemic infection due to species under Candida, Aspergillus and zygomycetes is widely prevalent in nosocomial setting, and outbreaks due to unusual fungi are reported occasionally from tertiary care centers. This global change in systemic fungal infections has emphasized the need to develop good diagnostic mycology laboratories in this country and to recognize this increasingly large group of potential fungal pathogens. In 1835, Bassi re the data on burden of systemic fungal infections in India are vealed a mold, Beauvaria bassiana, that caused devastating silk not clear though the climatic diversity in this country is suited worm disease. It was quickly followed by the first discoveries for a wide variety of fungal infections. The systemic fungal infections re Schoenlein in 1837 and 1842, respectively, candidiasis by Gruby ported in India are included in Table 1. However, of the estimated several hundred thou rise was observed in the first half of the 1990s.

Instead it falls on the integral development of the Noble Eightfold Path as the means to uproot the craving that nurtures the process of re birth itself erectile dysfunction causes anxiety order levitra professional. For practical purposes the eight factors of the path are arranged into three major groups which reveal more clearly the developmental structure of the training: moral discipline (including right speech erectile dysfunction treatment options uk order levitra professional with american express, right action and right livelihood) erectile dysfunction pills otc buy discount levitra professional on line, concentration (including right effort diabetes and erectile dysfunction relationship order levitra professional online pills, right mindfulness and right concentration) impotence because of diabetes levitra professional 20 mg on line, and wisdom (including right understanding and right thought) impotence at 30 cheap 20 mg levitra professional free shipping. By the training in morality, the coarsest forms of the mental defilements, those erupting as un wholesome deeds and words, are checked and kept under control. By the training in concentration the 15 mind is made calm, pure and unified, purged of the currents of distractive thoughts. By the training in wisdom the concentrated beam of attention is focused upon the constituent factors of mind and body to in vestigate and contemplate their salient characteristics. This wisdom, gradually ripened, climaxes in the un derstanding that brings complete purification and de liverance of mind. In principle, the practice of the path in all three stages is feasible for people in any walk of life. The Buddha taught it to laypeople as well as to monks, and many of his lay followers reached high stages of at tainment. However, application to the development of the path becomes most fruitful for those who have re linquished all other concerns in order to devote them selves wholeheartedly to spiritual training, to living the ?holy life (brahmacariya). For conduct to be completely purified, for sustained contemplation and penetrating wisdom to unfold without impediments, adoption of a different style of life becomes impera tive, one which minimizes distractions and stimulants to craving and orders all activities around the aim of liberation. Thus the Buddha established the Sangha, the order of monks and nuns, as the special field for those ready to dedicate their lives to the practice of his path, and in the Dhammapada the call to the monastic life resounds throughout. The thoughtful, who have seen the transience and hidden misery of worldly life, break the ties of family and social bonds, abandon their homes and mundane pleasures, and enter upon the state of homelessness (83, 87-89, 91). Withdrawn to silent and secluded places, they seek out the company of wise instructors, and guided by the rules of the mo nastic training, devote their energies to a life of medi 16 tation. Content with the simplest material requisites, moderate in eating, restrained in their senses, they stir up their energy, abide in constant mindfulness and still the restless waves of thoughts (185, 375). With the mind made clear and steady, they learn to contemplate the arising and falling away of all formations, and ex perience thereby ?a delight that transcends all human delights, a joy and happiness that anticipates the bliss of the Deathless (373-374). The life of meditative con templation reaches its peak in the development of in sight (vipassana), and the Dhammapada enunciates the principles to be discerned by insight-wisdom: that all conditioned things are impermanent, that they are all unsatisfactory, that there is no self or truly existent ego entity to be found in anything whatsoever (277-279). When these truths are penetrated by direct experience, the craving, ignorance and related mental fetters main taining bondage break asunder, and the disciple rises through successive stages of realization to the full at tainment of Nibbana. In the Pali Canon the stages of definite attainment along the way to Nibbana are enumerated as four. At the first, called ?Stream entry (sotapatti), the disciple gains his first glimpse of ?the Deathless and enters irreversibly upon the path to liberation, bound to reach the goal in seven lives at most. This achievement alone, the Dhamma pada declares, is greater than lordship over all the worlds (178). Following Stream-entry come two fur ther stages which weaken and eradicate still more de filements and bring the goal increasingly closer to view. One is called the stage of Once-returner (saka dagami), when the disciple will return to the human 17 world at most only one more time; the other the stage of Non-returner (anagami), when he will never come back to human existence but will take rebirth in a ce lestial plane, bound to win final deliverance there. The fourth and final stage is that of the Arahat, the Per fected One, the fully accomplished sage who has com pleted the development of the path, eradicated all de filements and freed himself from bondage to the cycle of rebirths. This is the ideal figure of early Buddhism and the supreme hero of the Dhammapada. Extolled in Chapter 7 under his own name and in Chapter 26 (385-388, 396-423) under the name brahmana, ?holy man, the Arahat serves as a living demonstration of the truth of the Dhamma. Bearing his last body, per fectly at peace, he is the inspiring model who shows in his own person that it is possible to free oneself from the stains of greed, hatred and delusion, to rise above suffering, to win Nibbana in this very life. The Arahat ideal reaches its optimal exemplifi cation in the Buddha, the promulgator and master of the entire teaching. His aris ing in the world provides the precious opportunity to hear and practice the excellent Dhamma (182, 194). He is the giver and shower of refuge (190-192), the Supreme Teacher who depends on nothing but his own self-evolved wisdom (353). Born a man, the Buddha always remains essentially human, yet his attainment of Perfect Enlightenment elevates him to a level far surpassing that of common humanity. All our familiar concepts and modes of knowing fail to circumscribe his nature: he is trackless, of limitless range, free from all worldliness, the conqueror of all, the knower of all, untainted by the world (179, 180, 353). Inter laced with the verses specific to these four main lev els, there runs throughout the work a large number of verses not tied to any single level but applicable to all alike. The most arresting fea ture of this view is its stress on process rather than persistence as the defining mark of actuality. The uni verse is in flux, a boundless river of incessant becom ing sweeping everything along; dust motes and moun tains, gods and men and animals, world system after world system without number all are engulfed by the irrepressible current. There is no creator of this proc ess, no providential deity behind the scenes steering all things to some great and glorious end. The cosmos is beginningless, and in its movement from phase to phase it is governed only by the impersonal, implaca ble law of arising, change, and passing away. However, the focus of the Dhammapada is not on the outer cosmos, but on the human world, upon man with his yearning and his suffering. The starting point is the human condition as given, and fundamental to the picture that emerges is the inescapable duality of human life, the dichoto mies which taunt and challenge man at every turn. Seeking happiness, afraid of pain, loss and death, man walks the delicate balance between good and evil, pu rity and defilement, progress and decline. His actions 19 are strung out between these moral antipodes, and be cause he cannot evade the necessity to choose, he must bear the full responsibility for his decisions. If he chooses wrongly he can sink to the lowest depths of degradation, if he chooses rightly he can make himself worthy even of the hom age of the gods. The paths to all destinations branch out from the present, from the ineluctable immediate occasion of conscious choice and action. The recognition of duality extends beyond the limits of conditioned existence to include the antitheti cal poles of the conditioned and the unconditioned, samsara and Nibbana, the ?near shore and the ?far shore. But all he can do is indicate the path; the work of treading it lies in the hands of the disciple. The Dhammapada again and again sounds this chal lenge to human freedom: man is the maker and master of himself, the protector or destroyer of himself, the savior of himself (160, 165, 380). In the end he must choose between the way that leads back into the world, to the round of becoming, and the way that leads out of the world, to Nibbana. The pivotal role in achieving progress in all spheres, the Dhammapada declares, is played by the 20 mind. The entire disci pline of the Buddha, from basic morality to the highest levels of meditation, hinges upon training the mind. A wrongly directed mind brings greater harm than any enemy, a rightly directed mind brings greater good than any other relative or friend (42, 43). The mind is unruly, fickle, difficult to subdue, but by effort, mind fulness and unflagging self-discipline, one can master its vagrant tendencies, escape the torrents of the pas sions and find ?an island which no flood can over whelm (25). The one who conquers himself, the vic tor over his own mind, achieves a conquest which can never be undone, a victory greater than that of the mightiest warriors (103-105). What is needed most urgently to train and sub due the mind is a quality called heedfulness (ap pamada). Heedfulness combines critical self aware ness and unremitting energy in a process of keeping the mind under constant observation to detect and ex pel the defiling impulses whenever they seek an op portunity to surface. In a world where man has no sav ior but himself, and where the means to his deliver ance lies in mental purification, heedfulness becomes the crucial factor for ensuring that the aspirant keeps to the straight path of training without deviating due to the seductive allurements of sense pleasures or the stagnating influences of laziness and complacency. Heedfulness, the Buddha declares, is the path to the Deathless; heedlessness, the path to death. The wise who understand this distinction abide in heedfulness and experience Nibbana, ?the incomparable freedom from bondage (21-23). It yields its riches only through repeated study, sustained reflection, and most importantly, through the applica tion of its principles to daily life. Thence it might be suggested to the reader in search of spiritual guidance that the Dhammapada be used as a manual for con templation. After his initial reading, he would do well to read several verses or even a whole chapter every day, slowly and carefully, relishing the words. He should reflect on the meaning of each verse deeply and thoroughly, investigate its relevance to his life, and apply it as a guide to conduct. If this is done repeat edly, with patience and perseverance, it is certain that the Dhammapada will confer upon his life a new meaning and sense of purpose. Infusing him with hope and inspiration, gradually it will lead him to discover a freedom and happiness far greater than anything the world can offer. If with an im pure mind a person speaks or acts suffering fol lows him like the wheel that follows the foot of the ox. If with a pure mind a person speaks or acts happiness follows him like his never-departing shadow 3. Just as a storm throws down a weak tree, so does Mara overpower the man who lives for the pursuit 23 of pleasures, who is uncontrolled in his senses, im 1 moderate in eating, indolent, and dissipated. Just as a storm cannot prevail against a rocky mountain, so Mara can never overpower the man who lives meditating on the impurities, who is controlled in his senses, moderate in eating, and 2 filled with faith and earnest effort. But whoever is purged of depravity, well established in virtues and filled with self-control and truthfulness, he indeed is worthy of the yel low robe. Those who mistake the unessential to be essential and the essential to be unessential, dwelling in wrong thoughts, never arrive at the essential. Those who know the essential to be essential and the unessential to be unessential, dwelling in right thoughts, do arrive at the essential. Just as rain breaks through an ill-thatched house, so passion penetrates an undeveloped mind. The commentaries explain Mara as the lord of evil forces, as mental defilements and as death. Just as rain does not break through a well thatched house, so passion never penetrates a well-developed mind. The thought, ?Evil have I done, torments him, and he suffers even more when gone to realms of woe. The thought, ?Good have I done, delights him, and he delights even more when gone to realms of bliss. Much though he recites the sacred texts, but acts not accordingly, that heedless man is like a cow herd who only counts the cows of others he does not partake of the blessings of the holy life. Little though he recites the sacred texts, but puts the Teaching into practice, forsaking lust, hatred, and delusion, with true wisdom and emancipated mind, clinging to nothing of this or any other world he indeed partakes of the blessings of a holy life. Clearly understanding this excellence of heedful ness, the wise exult therein and enjoy the resort 4 of the Noble Ones. The wise ones, ever meditative and steadfastly persevering, alone experience Nibbana, the in comparable freedom from bondage. Ever grows the glory of him who is energetic, mindful and pure in conduct, discerning and self controlled, righteous and heedful. By effort and heedfulness, discipline and self mastery, let the wise one make for himself an is land which no flood can overwhelm. The foolish and ignorant indulge in heedlessness, but the wise one keeps his heedfulness as his best treasure. Just as one upon the summit of a mountain be holds the groundlings, even so when the wise man casts away heedlessness by heedfulness and ascends the high tower of wisdom, this sor rowless sage beholds the sorrowing and foolish multitude. Heedful among the heedless, wide-awake among the sleepy, the wise man advances like a swift horse leaving behind a weak jade. The monk who delights in heedfulness and looks with fear at heedlessness advances like fire, burn ing all fetters, small and large. The monk who delights in heedfulness and looks with fear at heedlessness will not fall. Just as a fletcher straightens an arrow shaft, even so the discerning man straightens his mind so fickle and unsteady, so difficult to guard. As a fish when pulled out of water and cast on land throbs and quivers, even so is this mind agi tated. Wonderful, indeed, it is to subdue the mind, so difficult to subdue, ever swift, and seizing what ever it desires. Let the discerning man guard the mind, so difficult to detect and extremely subtle, seizing whatever it desires. Dwelling in the cave (of the heart), the mind, without form, wanders far and alone. Wisdom never becomes perfect in one whose mind is not steadfast, who knows not the Good Teaching and whose faith wavers. There is no fear for an awakened one, whose mind is not sodden (by lust) nor afflicted (by 28 hate), and who has gone beyond both merit and 6 demerit. Realizing that this body is as fragile as a clay pot, and fortifying this mind like a well-fortified city, fight out Mara with the sword of wisdom. Whatever harm an enemy may do to an enemy, or a hater to a hater, an ill-directed mind inflicts on oneself a greater harm. Who shall overcome this earth, this realm of Yama and this sphere of men and gods? Who shall bring to perfection the well-taught path of wisdom as an expert garland-maker would his floral design? A striver-on-the path shall overcome this earth, this realm of Yama and this sphere of men and gods. The striver-on-the-path shall bring to per fection the well-taught path of wisdom, as an ex 7 pert garland-maker would his floral design. As a mighty flood sweeps away the sleeping vil lage, so death carries away the person of dis tracted mind who only plucks the flowers (of pleasure).

The result is more favorable in tuberculous growths in children and syphilitic tumors in adults erectile dysfunction treatment rochester ny purchase levitra professional 20 mg without prescription. In both kinds erectile dysfunction young purchase generic levitra professional on line, syphilitic and tuberculous impotence therapy order levitra professional in india, a nutritious diet and general tonic treatment impotence because of diabetes purchase levitra professional 20mg visa, such as cod-liver oil impotence forums buy levitra professional master card, iron erectile dysfunction treatment over the counter cheap levitra professional 20 mg, arsenic, and quinine should be given. Syphilis may produce a circumscribed tumor, a disease of the arteries or a general hardened infiltration of the brain. They originate in the "Dura Mater" (covering) and spread to the brain structure proper. The disease of the arteries causes a thickening of these vessels, a narrowing of the blood channel in them, thus producing a clot. This is one of the diseases where the victim reaps a big harvest on account of the sexual sin, and in order to escape the bad results for himself, etc. For this there must be radical and careful treatment with mercury and iodide of potash; with tonics and general building up treatment, and then even if the patient lives he may be a nuisance to himself and others. One author says: "General paresis is a chronic, progressive, diffuse, encephalitis (inflammation of the brain), resulting in structural changes in the cerebral (brain) tissue, with involvement of the cortical, and meningeal, (covering) blood and lymph vessels, presenting characteristic symptoms, with progressive course and fatal termination usually within three years. First stage in a typical case:-There are tremblings and slight trouble in speech and expression of the face. He uses bad language, neglects his family, goes with drunkards and bad women, makes indecent proposals to respectable women of his acquaintance without realizing that it is improper. Persistent insomnia comes on early and frequently recurring, one-sided headache often goes with it. After severe attacks there may be one-sided paralysis (hemiplegia) which usually disappears in a few hours or days. Convulsions like epilepsy may appear early, but usually occur in the later stages. The pupils are mostly dilated, rarely contracted, and they are often unequal and react slowly to light. The walk is very spasmodic, but in advanced stages it becomes slouching or dragging. When the feeble-mindedness is fully developed the mind does not perceive anything accurately. He sees imaginary things, and things that he does see do not appear to him as they are. It may, however, become so active, prominent, and important a symptom as to constitute a condition which merits individual management and treatment. Toxic causes due to poison circulating in the blood which by irritation of the brain and cord (axis) and especially of the brain, cause such diseases as nephritis (chronic), jaundice, typhoid fever and consumption. The brain congestion is typified by the nerve-tire of the student; over-study and anxiety bring too much blood to the brain and necessarily too much activity and then insomnia. The brain cells are not properly nourished and hence irritated, and sleeplessness follows. In a very short time you will fall asleep, without any of the painful anxieties attending insomnia. It stimulates this organ and produces a greater circulation, thereby drawing the blood from the head. In the toxic kind drugs must be given to correct other diseases and also tonics given. For brain congestion and anemia kind other means must be used first, and the drugs as the last resort. Hot or warm general body-baths are very advantageous to stimulate the circulation and restore its balance alike in congestion and anemic cases. After such baths the patient must go to bed at once and not get chilled in cold rooms or by drafts. Cold spongings, cold shower baths, or cold plunge baths are given when the hot or warm bath does not produce the correct result. If he feels rested and quieted, the reaction is proper; if depressed, the treatment is too vigorous and not suitable. The patient should stand ankle deep in a tub of hot water and a "drip sheet," from water at 75 to 80 degrees temperature, thrown over him. Flannel is wrung out in water, 75 to 80 degrees temperature and laid in several thicknesses upon the abdomen; place a dry towel over this, cover all with oiled silk, overlapping widely in order to protect the bed. A fast walk, horseback ride or ride on bicycle for a half hour before bedtime, followed by a rub-down will frequently give a good sleep. The patient must render all the aid he can give, and the physician should gain his confidence. If he does he will not need to give much medicine to put the patient to sleep, and if he does give it he can frequently use a Placebo with the same effect. It is very extreme in some cases, and the next morning they do not know anything about it. Fatigue, worry, poor sleep, restlessness, nervousness, a hearty late dinner are aggravating causes. Such persons had better drop parties, late hours or anything that tends to cause worry, fatigue or nervousness. They teach the patients how to speak slowly, distinctly and to keep their minds off of themselves. It is seen in gastritis, peritonitis, hernia, appendicitis, and in severe forms of typhoid fever. Swallowing hot substances, local disease of the gullet near the diaphragm, and in many cases of stomach trouble and bowel disorder, especially when associated with gas (flatus). He may soon return to entire consciousness, but still suffer from some headache, feel wearied, and tired, and not feel like exerting himself. Occasionally the results are more serious even after a long time has passed, and an abscess of the brain should be watched for, sometimes epilepsy or insanity follows. If the patient grows worse instead of recovering, either deep seeming sleep sets in or symptoms of inflammation of the covering (meninges) or the brain itself follows. Such injuries must be carefully watched, for you can not tell at first how severe they may prove to be. Hot water or ice water, when awake, as is most agreeable to the patient, may be given. Aromatic spirit of ammonia, during the shock is better for the patient to take than alcohol, for alcohol excites the brain; dose, one-half to two drams; the former can be given every ten minutes in a little water for about three doses. Loss of consciousness, complete paralysis, small pulse, collapse, and within a few hours death may follow. Brain symptoms, such as headache, dizziness and fainting, may be present or absent. There may be sudden complete paralysis of the upper and lower extremities depending on how severely the cord is injured, and how high up the injury is. In some cases the symptoms are slight in the beginning, but increase in a few days, or they may suddenly increase a few months afterwards. In other cases, bad symptoms at first may gradually abate which is due to the blood clot having been absorbed. Recovery depends upon the extent of the injury and the constitution of the patient. Absolute rest is a necessity, and must be had for weeks according to the severity of the case. The symptoms develop on coming suddenly to the surface when the atmospheric pressure is greatly lessened. The exciting causes are prolonged exposure to severe colds, too great mental and physical exertion, sexual excess, blows, bleeding into the cord, alcoholic excess, acute infectious diseases, syphilis, etc. The onset may be sudden or gradual-when it is sudden, there may be a chill followed by a fever of 101 to 103 degrees-general feeling of illness, loss of appetite, with coated tongue and constipation. Pain may radiate from the back into the limbs, with numbing and tingling of the limbs. Paralysis may follow in the lower extremities and higher up, sometimes, depending upon how high up in the cord the inflammation exists. This paralysis may cause no motion of the limbs or produce an exaggerated contracting of the affected muscles, the knees being drawn up on the abdomen and the heels touching the buttocks. The medical treatment must be carefully given and a physician of experience should be obtained. The chief predisposing cause is syphilis which precedes it in from seventy to eighty-five of the cases according to various authorities. Exposure to cold and wet, sexual and alcoholic excesses, mineral poisoning, and great physical exertion also exciting causes. These symptoms may constitute the only evidence of locomotor ataxia and last for years; but sooner or later there are added absence of knee cap bone reflex (knee jerk), and immobility of the pupil. The pupil fails to respond to light while it still accommodates for distance, called Argyll Roberston pupil. There may be imperfect control of the bladder with slow, dripping or hasty urination. These symptoms may last for several months and years, and then the second stage symptoms appear. The pains are mostly in the legs, but also occur in the arms, head, loins, back, and trunk. This stage may last for years and remain at a "standstill;" but it is usually progressive, and advances to the third stage. The stage of paralysis is marked by a gradual change to the worse, and the patient must remain in bed, because he cannot get out. The lower and sometimes the upper extremities have lost a great deal of their power of sensation: the joints, mostly the knee and hip joints show on both sides of the body a painless swelling, owing to the great quantities of watery liquid there. Death occurs from exhaustion; bedsores, inflammation of the bladder, or pneumonia coming on as a complication. Treatment;-The only thing to do when the patient has this disease is to make him comfortable and arrest the progress of it, if possible. It is incurable, but treatment sometimes arrests the progress and at least lessens the suffering and prolongs life as long as it is worth living to them. I have given a longer description than was necessary, for I wanted men who live such fast lives to understand what it brings them for most cases are caused by syphilis. The description could have been made longer and other symptoms and complications put in. I think enough has been given and perhaps this description may deter some one from going the same road. The Diagnosis is made at first by the fatigue, peculiar pains, loss of the knee jerk, the peculiar pupil and history of syphilis. Heredity is frequently a cause and it is traced to syphilis, epilepsy, alcoholism, and insanity in the ancestors. The movements of the hands are peculiar, the hands move like in chorea, the speech is slow and drawling. High fever or chills, general feeling of illness, pain all over the body, decided brain symptoms, like delirium or convulsions and intermittent contractions of the muscles may usher in the disease. These forerunning symptoms may last a short time or for several weeks, after which the paralysis is noticed, being extensive as a rule, and affecting one, two, or all of the extremities and sometimes the muscles of the trunk. This general paralysis soon disappears being left permanently in only one extremity, chiefly in one leg. If the paralysis does not show a decided change within the first few months, full recovery is doubtful. There is quite a good deal of this paralysis, and the case should receive careful attention from the start. The circumvallate are from seven to twelve in number and lie near the root of the tongue, arranged in the form of a V, with its open angle turned forward. Each one is an elevation of the mucous membrane, covered by epithelium and surrounded by a trench. On the sides of the papillae, embedded in the epithelium, are small oval bodies called taste-buds. These taste-buds consist of a sheath of flattened, fusiform cells, enclosing a number of spindle like cells whose tapering ends are prolonged into a hair-like process. As the filaments of the gustatory nerves terminate between these rod-like cells, it is probable that they are the true sensory cells of taste. It is also possible that single taste-cells are scattered over the tongue, as the sense of taste exists where no taste-buds can be found. This is easily proved by compressing the nostrils and attempting to distinguish by taste different articles of food. The taste sensation is greatest when the exciting substance is at the temperature of the body. There is no perceptible sweetness to sugar when the tongue has been dipped for a half-minute in water either at the freezing temperature or warmed to 50 degrees C. Neither is there any sense of taste until the substance is dissolved by the natural fluids of the mouth, as will be seen by wiping the tongue dry and placing sugar upon it. Sweet and sour tastes are chiefly recognized at the front and bitter and alkaline tastes at the back of the tongue. The same substance will often excite a different sensation, according as it is placed at the front or back of the tongue. Again, certain tastes may disguise others without destroying them, as when an acid is covered with a sweet. The inhabitants of the Roman Empire were afflicted with mental unsoundness and Nero was considered crazy. Hippocrates, who lived four hundred years before Christ, was the first physician who seemed to have any true conception of the real nature of insanity. For many centuries later the masses believed that madness was simply a visitation of the devil. The insane, in the time of Christ, were permitted to wander at large among the woods and caves of Palestine. The monks built the first hospital or asylum for the insane six centuries after Christ.

The skin over the nodules often becomes ulcerated erectile dysfunction treatment surgery purchase levitra professional 20 mg on line, and young birds may be killed by heavy infestations erectile dysfunction unani medicine buy levitra professional 20 mg with visa. Life cycle and epidemiology: On fertilization erectile dysfunction pills from india cheap generic levitra professional canada, the female fleas burrow into the skin of the fowl erectile dysfunction statistics 2014 purchase levitra professional american express, mainly on the comb erectile dysfunction drugs grapefruit order levitra professional 20mg amex, wattles and around the eyes of the birds xenadrine erectile dysfunction levitra professional 20mg online, resulting in the formation of nodules in which eggs are laid. The female lays up to 20 eggs at a time and about 400-500 total during her lifetime. Larvae drop to the ground to develop in soil around chicken cages, pupating in two weeks. Diagnosis: this is based on history, clinical signs, and identification of fleas or flea feces on birds. Both the host bird and the environment must be treated at the same time to be effective. Control the fleas by treating the birds, removing them from the infested area for three weeks, and treating the area (removing fecal droppings and litter, and spraying a suitable insecticide) and birds (again) before returning them. A range of insecticides can be used, namely; organophosphates, carbamates, pyrethrins, and pyrethroids for flea control on the birds. Most of these insects are found in poultry houses, where some feed on birds and other animals (including humans) especially at night. Clinical signs, pathology and economic importance: the majority of these flies irritate the host by biting and sucking blood. Their greatest importance lies in their role as intermediate hosts or as mechanical vectors of disease. Black flies and biting midges are intermediate hosts of the protozoa Leucocytozoon spp. Biting midges are vectors for fowl pox, avian infectious synovitis, and Haemoproteus spp. Flies in the family Muscidae may transfer Newcastle disease virus, Heterakis gallinarum, Pasteurella multocida, and Mycobacterium avium to non-infected birds. Diagnosis: Clinical signs and identification of feeding flies, especially at night. Traps can be used to collect and identify flying insects in the vicinity of poultry. Argas persicus (fowl tick) commonly affects chickens, turkeys, pigeons, ducks and geese in tropical and sub-tropical countries. They are found on the skin (especially nymphs and larval stages), but most of the time the ticks hide in cracks in chicken or human houses, market stalls and sheds, or under the tree bark, away from the host. Etiological Characteristics: the unfed adult tick is pale yellow, turning reddish brown when fed. The margin of the body appears to be composed of irregular quadrangular plates or cells, and the hypostome is notched at the tip. Clinical signs and pathology: Argas persicus causes severe blood loss leading to progressive lowered production. Ornithodoros species (the eyeless tampan) affects poultry and other domestic and wild animals. They are found on the skin, but most of the time, the ticks hide in cracks or under the tree bark, away from the host. Etiological Characteristics: the integument has wrinkled patterns that run continuously over the dorsal and ventral surfaces. These parasites are known to transmit Borrelia anserina and Aegyptinella pullorum. Life cycle and epidemiology of these tick species: Females lay eggs in the cracks and crevices they occupy, usually in batches of 30 to 100 or more; they lay several batches of eggs and produce an average of 700 to 800 eggs during their lifetime. Adults are extremely resistant to starvation, and can live more than a year without a blood meal. Diagnosis: this is based on history, clinical signs, collection and identification of ticks from the skin. They are nocturnal feeders and examination of birds at night is necessary for diagnosis, especially in cases of low infestations. Treatment: Treat birds and poultry shed(s) with insecticide, making sure that all cracks are penetrated. The common free-living ectoparasitic mites of poultry belong to the family Dermanyssidae, and include the chicken mite, northern fowl mite, and tropical fowl mite. These mites possess relatively well-sclerotized free dorsal and ventral plates, claws and caruncles on the tarsi, one lateroventral stigma near each third coxa, and small chelicerae on long-sheathed bases. Of lesser importance are members of many other mite families that bore into the skin or infect various internal passages and organs. Etiological characteristics: Dermanyssus gallinae (chicken mites) are quite small, but they can be seen with the naked eye. They can be identified by the shape of the dorsal plate and by the long whip-like chelicerae that look like stylets. Dermanyssus gallinae is cosmopolitan in distribution and has been reported in Tanzania, Nigeria, Zambia and Kenya. Ornithonyssus (Liponyssus) sylvarium, the northern fowl mite, is recognized as a serious pest in temperate countries and is also extremely common in almost all types of production facilities. It is easily distinguished from Dermanyssus gallinae by possession of easily visible chelicerae, and the shape of the dorsal and anal plates. Ornithonyssus bursa (tropical fowl mite) is distributed throughout the warmer regions of the world and possibly replaces O. It closely resembles the Northern fowl mite, but can be distinguished by the shape of the dorsal plate and the pattern of the setae. Ornithornyssus bursa occurs in the tropics and subtropics and has been reported in Zambia and Nigeria, while O. Cnemidocoptes gallinae (feather mites or depluming mites) are the common mites observed in chickens,but also found in pheasants, pigeons, and geese. Stalked pulvilli are present on all legs of larvae and males, but are absent in the nymphal stages and females. Cnemidocoptes mutans is characterized by short stubby legs, the terminal anus, and the dorsal surface covered by faint striation. Mid dorsally, the pattern of dorsal striations is broken in a plate or scale-like pattern. Cytodites nudus (airsac mites) are found in air passages and lungs of wild birds and poultry. The chelicerae are absent, and the palps are fused to form a soft, sucking organ, through which fluids are imbibed. Life cycle and epidemiology: Mites do not spend their entire life cycle on the host bird, except for Cnemidocoptes mutans and Ornithonyssus spp. Adult mites spend most of their lives on the host, but will wander from the birds into crevices and cracks. Adult female mites complete egg-laying in 2 days; the number of eggs laid averages 2 to 5 per female. Dermanyssus gallinae (chicken mites) are gregarious and can be found in large numbers around poultry. The life cycle is fairly complicated, with a series of feeding and non feeding immature stages. Eggs hatch in about 3 days, and the life cycle can be completed in 7 to 10 days under favorable conditions. Adults are resistant to starvation, and can live off the host for more than a month. Ornithonyssus sylvarium breeds continuously on the host bird and is a particular problem for caged birds. After laying eggs, normally on feathers on the cooler regions of the bird, the mites migrate to the neck area. The eggs then hatch within a day, with both larval and nymphal stages completed in four days, and the entire life cycle within a week. Its biology and habits are similar to those of Ornithonyssus sylvarium, although a greater proportion of its eggs are laid in the nests. Clinical signs and pathology: Dermanyssus gallinae are bloodsuckers and are irritating to poultry. Anemia occurs in heavily parasitized birds, reducing feed efficiency, egg production, and the ability to withstand and overcome diseases. Birds infected with some mites will have a change of behavior due to itching effect of the mites. On birds heavily infested with Ornithonyssus sylvarium, inspection can reveal heavy deposits of mite eggs and feces in the vent area. The northern fowl mite is sometimes confused with the red mite, although unlike the red mite, it can be found easily on birds in the day as well as night. Heavy infestations result in blackened feathers and scabby and cracked skin, particularly around the vent, and infested male birds can be discouraged from breeding. Cnemidocoptes gallinae are also associated with severe emaciation, droopiness, and reddened scabby skin in chickens. Cnemidocoptes mutans cause inflammation with exudates and subsequent keratinization of the legs. Pathological findings include small yellowish-grey or reddish-brown, wart-like skin proliferations that seem to begin on the soft parts of the planter side of the tarsus and spread along the digits and up the shanks to the hock. Small infestations with Cytodites nudus (air sac mites) may cause coughing and accumulation of mucus in trachea and bronchi. Diagnosis: this is made on basis of clinical features and finding mites on skin scrapings, acetate-tape strips and coated brushing. Treatment: Mites can live for several months without food, so destocking a shed for a short time will not eliminate the problem. Spray birds and sheds with insecticide, making sure that all cracks are penetrated. Scaly leg of chickens can be treated by smearing Vaseline jelly with insecticide or dipping the leg in paraffin (kerosene) and then gently brushing the leg. Some insecticides suitable for treating sheds and yards are not suitable for treating the birds themselves, and birds should not even be in the shed when they are being applied. Even if insecticides do not seem to affect the birds, they may be absorbed and appear in the eggs or meat, making these products unsuitable for human consumption. This can happen from treatment of the birds themselves or from exposure to a treated shed or yard. The withholding period for a particular insecticide is stated on the label and must be observed. Clinical signs and lesions: There are no reliable signs other than the effects on egg production and egg quality. Once established, the condition results in a failure to achieve egg production targets. Cause, transmission, and epidemiology: Egg drop syndrome is caused by an adenovirus. It is believed that the syndrome was first introduced into chickens from contaminated vaccines. Diagnosis can also be made serologically using a hemagglutination inhibition test. Clinical signs and lesions: Clinical symptoms are mild and characterized by emaciation, weakness, droopiness and anemia. The worm lives underneath the horny lining of the gizzard where it produces soft nodules in the musculature and this weakens the organ. It is associated with glandular degeneration, epithelial necrosis, and inflammatory cell infiltration. Cause, transmission, and epidemiology: this worm has been reported in Africa (Nigeria, Ethiopia, Tanzania, Kenya, Uganda, and Zimbabwe), the Americas, Europe, and Asia. They have long cuticular cordons, which are irregular and wavy, running 2/3 of the way down the body. The adult worms are found embedded in nodules or abscesses under the keratinized layer of the gizzard. This species utilizes the grasshoppers, beetles, sandhoppers and weevils as intermediate hosts. Diagnosis: Presence of embryonated eggs in feces is indicative, but these needs to be differentiated from other spirurid eggs. Prevention: the feasible control method is rearing the birds on wire (off the ground). A wire or cement flooring must be introduced to remove or reduce risk to new flocks. Endoparasites: Amoabotaenia sphenoides (cestode) this worm occurs in the small intestine (duodenum) of the chicken. Endoparasites: Ascaridia galli (nematode) Clinical signs and lesions: Light to medium infestations may be tolerated without clinical signs; however, heavy infestations may cause diarrhea, intestinal occlusion, intussusceptions, emaciation, anemia and death. Differential diagnosis: Hartertia gallinarum, which has been reported from southern and western Africa, and Asia. Cause, transmission, and epidemiology: Ascaridia galli is a nematode parasite that causes ascariasis in chickens, guinea fowl, turkeys, geese and other wild birds worldwide. Adult worms are semi-transparent; males measure 50-76 mm, while female worms are 72 16 mm long. Diagnosis: Diagnosis is through finding eggs in feeces or worms during post mortem. So, after a flock has been infested, new birds cannot be raised on the ground without the risk of infestation.

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