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Nurses were able to improve disease control among most of the patients: 68% of patients with high blood pressure order carbamazepine 100mg, 82% of those with diabetes buy 200mg carbamazepine visa,109 and 84% of those with asthma (34). Five greater efficiency from their health systems health-care facilities, each with a multidisciplinary team of by combining disease management for all staff, were involved in the decision-making and planning of chronic conditions. They enable the » reallocation of financial and human resources to facilitate organization of patient information, tracking implementation of these services. Multidisciplinary health-care teams, centred on primary The Secretariat of Health of Mexico health care, are an effective means in all settings of achieving this has launched a “crusade for the goal and of improving health-care outcomes (37 ). It is possible, however, to provide some the implementation of a structured of the core skills from these disciplines in other ways (by training diabetes education programme. It may be possible to provide core trained to adopt a quality improve- aspects of effective health care that in more resourced settings ment methodology. Among the inno- would be provided by health professionals from several different vations in primary health centres disciplines. The while among those receiving usual production of an evidence-based guideline is a resource-intensive care the proportion only increased and time consuming process. Documented foot lines are available for many chronic diseases (see, for example, care education increased to 76% of http://www. For example, simply providing information about the guideline is likely to have little impact, but linking the guideline to workshops or outreach training sessions and providing prompts within medical records are much more likely to change practice (41). Inter- A chronic disease self-management programme was developed in Shanghai from 1999 to 2001. The ventions that aim to improve the ability of patients and their programme was conducted by trained volunteer lay carers to manage conditions can be highly effective and leaders and included exercise, the use of cognitive are an essential component of chronic disease care (46). In some conditions, communities and six districts of Shanghai, and is being notably after myocardial infarction, rehabilitation reduces replicated in other cities (43). Multidisciplinary and intensive rehabilitation programmes, common in high income countries, are typically not feasible in low and middle income countries. This included mobil- » Multidisciplinary rehabilitation services in patients with chronic ity training and training to perform normal low back pain can reduce pain and improve function (48). Quality of life improved for » Cardiac rehabilitation (following myocardial infarction), with a some 95% of participants (44). In many from targeted communities (villages and low and middle income countries, this rehabilitation approach is not slum areas) were taught to identify and feasible owing to shortages of health workers and other resource train people with disabilities. Review of effective interventions In these situations, community-based rehabilitation is a viable alter- native, using and building on the community’s resources as well as those offered at district, provincial and central levels. Community-based rehabilitation is implemented through the combined efforts of people with disabilities, their families, organizations and communities, as well as the relevant governmental and nongovernmental health, education, vocational, social and other services. Such efforts are being made in more than 90 (mostly low and middle income) countries. There have been As an overall approach, some important successes that might be applied nationally. For example, the Pain it has not been rigorously and Palliative Care Society in Kerala has developed a network of 33 palliative care evaluated but site-spe- clinics providing free care to those who need it, with an emphasis on home care. Palliative care ranges from which five countries – Botswana, Ethiopia, Uganda, United personal care and assistance in daily living to Republic of Tanzania and Zimbabwe – and the World counselling and pain management. The current evidence provides little guid- local nongovernmental organizations, particularly Hospice ance on whether one approach is superior to Africa Uganda, the Ministry of Health has included pain another and suggests that further studies would relief and palliative care in the home care package, based be useful (52–54). Services include essential drugs for pain and other symp- tom relief, food and family support. I was also having trou- ble remembering things and had to urinate a lot,” she recalls. After that, Zahida ignored her symptoms for eight long years before seeking medical care again, this time in Islamabad, 70 km from her home town. A second blood test finally established the nature of the problem and she started feeling much better almost immedi- ately after taking her first shot of insulin. One of her legs was amputated below the knee, as a result of an ulcer on her foot going untreated. Zahida holds her local hospital responsible for not having detected raised blood glucose in the first place, but admits that she should have reported the ulcer on her foot to her doctor much sooner. Now 65 years old, she is slowly recovering at home from the physical and emotional effects of surgery with the help of her son and daughter- in-law. Many of the complications of diabetes, such as leg 115 amputation, can be prevented with good health care. Chronic diseases are already the major cause of death in almost all countries, and the threat to people’s lives, their health and the economic development of their countries is growing fast. Yet, as this part of the report has shown, the knowledge exists to deal with this threat and to save millions of lives. Effective and cost-effective interventions, and the knowledge to implement them, have been shown to work in many countries. If existing interventions are used together as part of a comprehensive, integrated approach, the global goal for preventing chronic diseases can be achieved.

This chapter (¶) is drawn from the alternate source cheap carbamazepine 100mg online, the Hippocratic Book on Womanly Matters best 100 mg carbamazepine. In the ‘‘rough draft’’ of Con- ditions of Women,theTreatise on the Diseases of Women, it was stated very clearly that movement of the womb to the upper body was possible: ‘‘Sometimes the womb [moves] from its place, so that it ascends up to the horns of the lungs, that is, the pennas [feathers], and [sometimes] it descends so that it goes out  Introduction of [the body] and then it produces pain in the left side. And it ascends to the stomach and swells up so much that nothing can be swallowed. The sign of this is that she feels pain in the left side, and she has distention of the limbs, difficulty swallowing, cramping, and rumbling of the belly. What this change in phrasing from the first draft does is dis- tinguish three nosological conditions: movement up to the respiratory organs (discussed in ¶¶–), prolapse downward, sometimes with complete extru- sion (¶¶–), and this third intermediate condition where it goes neither up nor all the way down. Conditions of Women’s allusions suggest that the ‘‘wandering womb’’ was indeed part of the general belief structure in southern Italyat this time. The ten- sion between, on the one hand, the Galenic/Arabic view of uterine suffocation as caused by either a sympathetic link between uterus and respiratory organs or the actual physical transmission of a noxious vapor and, on the other hand, the traditional Hippocratic idea of the ‘‘wandering womb’’ finds a graphic ex- pression in the work of Johannes Platearius, another Salernitan writer working at perhaps the same time that Conditions of Women was composed. Johannes Platearius had interpreted Ibn al-Jazzār’s reference to ‘‘fumes’’ as meaning that the fumes filled the uterus and caused it to move upward to the respiratory organs. Interestingly, he asserts that it is women who say they ‘‘have their womb in their stomach’’ or in their throat or at their heart. It was a gen- eral medical assumption throughout most of the medieval period that women needed regular sexual activity in order to remain healthy. Indeed, Soranus’s distinctive views on sexu- ality were suppressed when Muscio’s Gynecology was twice readapted to new uses in or before the eleventh century. Johannes Platearius went farther than Conditions of Women in reincorporating the traditional Hippocratic recommendation of sex and marriage as suitable, even preferable cures: ‘‘If [the disease] occurs because of corrupt semen, let her know her husband. This is, nevertheless, one of the first acknowledgments by a medical writer of a category of Christian women who were chaste not by force of circumstance but by individual choice. Although not produced at the same time as the Trotula text found within this manuscript, these images do offer vivid evidence of how medical theory and practice may have been played out. First, on the top of the recto side of folio , we see the woman falling in a seizure; the dog with her signifies that she is of noble status, though it perhaps also indicates that she has only her pet to keep her company. In the upper half of the verso page, we see her as if dead, already laid out on a bier while her servants, apparently, mourn her death. The bowl on her chest points to an amplification that Platearius made on the Viaticum’s text when he suggested that the woman’s condition could be determined by either a flock of wool placed to the nose or a glass bowl placed on the chest. Just as the wool would move slightly with her breath, so the water in the bowl would, by its slight vibrations, show that she was still alive. Illustrations of a case of uterine suffocation from a late thirteenth- century English manuscript. The final frame depicts the kinds of women most susceptible to uterine suffocation: widows (note the prayer- book falling from the hand of the veiled woman) and virgins who have just reached the age of marriage. Here we also get an additional mode of treat- ment: the female attendant is holding a bone to the nose of the older woman. Although burnt bones were mentioned in neither Conditions of Women nor Platearius, various kinds of burnt substances—because of their stench—were usually recommended for application to the nose. Odoriferous therapy was still the basis of treatment for uterine suffoca- tion, and the associative links it had with the notion of uterine movement seem to have been strong. As we saw earlier, Soranus had vehemently rejected odor- iferous therapy as nonsensical and harmful, and his views, even if somewhat attenuated, were carried into Latin in the late antique Latin translations. Yet use of odoriferous therapy persisted in almost all other gynecological texts in the early Middle Ages, so much so that it is not really surprising to find that the compiler who abbreviated Muscio’s Gynaecia in the eleventh century or so put odoriferous therapy back into the text. The inclusion of odor- iferous therapy for prolapse is particularly notable, since it was not found in the Viaticum. Indeed, the author of Conditions of Women thought it so impor- tant that, uncharacteristically, he situated it before the therapies offered by Ibn al-Jazzār. The notion of ‘‘revulsion’’ dictated that blood was to be drawn off from a vein quite distant from the affected part. The objective was to force the flow of blood in a direction in which it was not accustomed to flowing. In all three Introduction  cases, blood is drawn from the saphenous vein under the arch of the foot in order to reorient the body’s bloodflowdown toward the uterus,which is where it normally should flow. The employment of cupping glasses—used for exces- sive menstruation (¶) and suffocation (¶)—has a similar rationale as that of phlebotomy. In both cases, the suction created on the surface of the skin by the cupping glass pulls blood toward that area. In the first instance, however, cupping glasses are applied near the breasts in order to encourage bloodflow away from the uterus, since it is clearly in excessive abundance there. In the sec- ond case, cupping glasses are applied to the groin to encourage menstrual flow downward. Finally, scarification (the superficial incision of the skin) works on the same principle, though, like cupping glasses, it produces a less intensive effect than phlebotomy. It is mentioned only once in Conditions of Women,as an alternate therapy for menstrual retention (¶). These were not simply used to di- rect odors to thevagina and womb, but were also a means of introducing medi- cations for menstrual retention (¶), a retained afterbirth (¶), and uterine pain (¶).