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By: Ziad F. Gellad, MD

• Associate Professor of Medicine
• Core Faculty Member, Duke-Margolis Center for Health Policy
• Member in the Duke Clinical Research Institute

https://medicine.duke.edu/faculty/ziad-f-gellad-md

Since then cholesterol kidney disease generic zetia 10mg line, Saharawi people have been To my eyes the Saharawi people appeared as a camped in Algerian territory cholesterol quantity in food buy 10 mg zetia with mastercard, under prohibitive proud and dignified population cholesterol medication contraindications zetia 10mg, who were firmly Delivering Health Care in Severely Resource–Constrained Settings 93 seeking for a peaceful and legal solution of their presence and the types of consultation I could offer struggle cholesterol levels test range buy zetia master card. Their objective is to cholesterol levels equivalent discount 10 mg zetia with visa be recognized by the as an endocrinologist—diabetes cholesterol level chart in urdu zetia 10mg without prescription, thyroid diseases, international community as an independent popu and infertility. As a matter of fact, these areas cover lation, with the right of self–determination and to the vast majority of endocrine disorders all over the return to their homeland, where they would like world. People that needed to be examined came and to build up a new country inspired by democracy sat down on the floor, either inside or outside the and freedom. The Saharawis’ dramatic vicissitude building, waiting their turn for consultation. I usu has won this population numerous international ally worked all day, in two sessions, morning and acknowledgements, as well as the admiration of all afternoon, separated by lunch time. I was constantly assisted by someone from the to social, educational and health organizations, they Saharawi health organization, who translated from have started experimental cultivations (vegetables) Hassanya (the Arabic dialect spoken by Saharawi and breeding (goats and chicken). On one side, the translation took some time, but Delivering Health Care on the other side, it was impossible to go into very the activity of our medical team was usually car complex problems. As diagnostic tools I used capil ried out as follows: date, objective and components lary blood glucose for diabetic people (and pretty of the medical expedition, which were planned soon my assistant helped me a lot in this measure preliminarily with the Saharawi representative in ment), and thyroid ultrasound was performed by Italy. Then we flew from Rome to Alger, where we a colleague on the team with a portable instrument spent a night. On the following day we embarked carried with us from Italy, for people with thyroid on a domestic flight from Alger to Tindouf, where diseases. All consultations were recorded on sheets some Saharawi people were waiting for us and of papers, in Spanish. The more or less in the same way, each one of them in following day we started our work. Surgery was possible in a the territory inhabited by Saharawi people fairly well–equipped hospital. Gastroscopy was also includes four large “wilayas” or villages and some performed with an instrument carried from Italy. Rahmani Sidi Mustafa, aged these sites can be reached by a 30–60 minute drive, 40 and father of four children, constantly and except one wilaya, Dahla, which requires a four– enthusiastically assisted me in my work until 1996. It is easy to understand that transporta Then, supported by solidarity funds from Cuban tion is one of the major problems in the daily life Government, he went to Cuba, where he stayed of Saharawi people. I saw him again in 2002, in the Saharawi the four wilayas where the population lives (when refugee camps, where he had returned and was now we went to Dahla, we slept there). It was a moving and clinic was prepared for me in the local hospital or joyous meeting. As expected, diabetes of family life, the family future and a warranty of mellitus is relatively frequent even in conditions support for parents and grandparents. Apparently it never goes that the usual demographic issues that tend to dis below 1–2% of the entire population. I was struck by courage families from having many children in a the occasional lack of insulin store, which represents condition of poverty may not apply to developing a life–threatening condition for all people with type countries. Contraception principles would not be 1 diabetes who have an absolute need of insulin easily accepted there. I heard that when such situation occurred, tries should not give lessons on this topic, because patients desperately go and search for insulin in the we cannot just impose our view of the problem nearby Algerian town of Tindouf. Having observed an elevated num ber of people with large goiters (mainly women), one of the expeditions was mainly dedicated to Not Only Work survey the population for the presence of goiter Every now and then during these short visits by thyroid palpation. This gave me the opportunity ever, less than two percent had stage 2 goiter and to become more deeply acquainted with Saharawi all the others had stage 1. In spite of the obvious poverty, the visitor is endemic was not due to iodine deficiency, as might welcomed and surrounded by a friendly and warm be expected since this is the most common cause. I experienced a pleasant the contrary, measurement of urine iodide excretion immersion into Saharawi habits, which include rich in random samples from 72 people from different traditions of music, dance, and feasting. Saharawi wilayas revealed that iodide excretion was moder people are open–minded, moderate Muslims. Therefore, the cause of goiter endemic tents are safe places, where the visitor is welcomed in Saharawi refugee camps is presently unknown. Thus, one discovers the great dignity there is not much that can be done, especially in a of these men and women, their intense longing to place like these camps. Since I went there several return to their homeland, their expectations for the times, I noticed that many couples came back every future, their friendly feelings, the freshness of the year for consultation, even if expectations were not young Saharawi women dressed in their traditional optimistic. They kept hoping that I might bring customs, and the noisy intrusion of children—fasci some good news for them, for instance some new nated by the presence of foreign people and readily therapy. In the tent, among pleasant the same happened for secondary infertility, that chatter, they offer you Saharawi tea, a true ritual, is couples with “only” one to two children, who which is a fundamental aspect of your visit. If you would have liked to have more and failed to obtain do not drink their tea, in three rounds, it would be other conceptions. Tea will taste countries infertility may represent a social problem bitter as life on the first round, sweet as love on the even greater than in western societies. Saharawi people like to drink tea several times in Children (more than two) are considered a very a day. One time tea was served in a very particular important feature of “normality” in Saharawi circumstance. While we were traveling towards the Delivering Health Care in Severely Resource–Constrained Settings 95 remote wilaya of Dahla, our vehicle must have hit He had been admitted to the hospital several something and suddenly a front wheel came off. Some years he presented to multiple providers, mostly minutes later, while we were waiting for some aid, at sector–level health centers, with complaints of the driver calmly drew out all the equipment to rectal discomfort and bleeding. He was never given prepare tea from a drawer of the car, including a a rectal examination, he had never been referred to gas–stove, water, tea–pot, cups, spoon, sugar and a specialist, and had been variably diagnosed with tea, and started preparing Saharawis’ preferred and treated for hemorrhoids or intestinal worms. After few minutes condition only worsened, and he eventually came he was placidly offering hot tea to all passengers. Here he was found to have a large, fragile, bloody mass protruding through his anus. On rectal examination, one could not feel the Conclusion top of mass, suggesting it was rather extensive. He the experience of delivering health care in the was unable to sit because of the pain. The tumor had Saharawi refugee camps has deeply impressed my infiltrated and destroyed his anal sphincters (the understanding of the health care needs of popula muscular valves that allow us to control our bowel tions living in resource–constrained settings. I am movements), leading to his continual incontinence now more conscious of the tremendous worldwide of stool. He had devised makeshift diapers from disparities in human rights, adequate access to scrounged plastic (hard to find in Rwanda) and cloth acceptable health services, and expectations for the strips. He was emaciated, his gaunt face and sunken future are a global and ethical concern. I learned temples reminiscent of photos of concentration important lessons from Saharawi people, and I camp prisoners. In the weeks prior to my arrival the feel that I received from them much more than I tumor had been biopsied, the specimen reviewed by gave them. Is there any chance Poverty, Surgery, and Systems I can offer Jean de Dieu the best care possible? Robert Riviello Even in the best of circumstances, attempts at complete surgical removal of a locally advanced tumor in a nutritionally compromised individual Meet Jean de Dieu* is challenging at best. In a comparatively weak surgical delivery system, operative extirpation of aggressive disease is less likely to be curative, more first met Jean de Dieu during ward rounds at likely to have devastating complications, and there Butaro District Hospital in northern Rwanda. It makes me wonder if ward—not because he had a transmissible disease, the surgical risk versus benefit ratio is in his favor. Further complicating decision–making is my own status at this hospital—I am only going to be around for a week now and then back for a *Name changed to preserve confidentiality couple weeks in a few months. Fall 2012 as I graduated high school, I envisioned my life’s help Jean de Dieu now. I raise concerns about his work as a long–term missionary surgeon, provid nutritional status, citing his evident tumor–wasting ing continual surgical care at a hospital like Butaro. Thotho, my colleague, a Rwandan– Now, making rounds with Rwandan colleagues, I Congolese general practitioner with advanced am acutely aware of the change in career path. As I this kind of contextual expertise and linguistic and interact with Jean de Dieu, I recognize that I can cultural competence. His rectal tumor is quite large; I can As a surgeon, most people see the greatest util feel it at the pelvic peritoneal reflection—the deep ity in my skill set tied to the ability to take sick and est part of the abdomen, perhaps 10 centimeters injured patients into the operating theater with the from the anus—confirming the findings of the poor goal of fixing their surgical problems. We a surgeon, providing direct clinical care by operating then perform a diverting colostomy to provide him on patients who need surgery is my highest yield relief from the incontinence and the related exco activity in terms of positive feedback. This procedure detours the stool investment is usually visible and immediate; at the away from his anus, and his cancer, by bringing an end of the day, you know you made a difference for end of his colon out through his abdominal wall, to someone. As a result I find internal dissonance in my be collected in a plastic bag—allowing him to regain current style of hybrid, academic engagement—I control of his personal hygiene again. Post–operatively, he begins cation, and comparatively little time delivering the nutritional supplementation—essentially adding as surgical care and training that provides immediate much peanut butter as possible to his diet. Already he looks ater and a surgical system that works to provide that healthier and happier. But honestly, most days I still (that is, pre–operative) combined chemotherapy long to pack my things, my family, and our efforts and radiation therapy has been demonstrated to and move to Africa for a life of direct service. Radiation therapy Shaking myself out of this reverie, it is clear that is another story—that can only be delivered in we need to make some decisions about how to best neighboring Uganda and is quite expensive. The Delivering Health Care in Severely Resource–Constrained Settings 97 Right–to–Health–Care funds that usually provide Is Jean de Dieu Better Off? I muse that John de Dieu’s case highlights an Am I his primary doctor, as my surgical train ever–present tension—we seek, from a rights–based ing has inculcated in me that I ought to be? They have had guidance from the Because that is the window of time until a surgeon, multi–institutional cancer team based in Boston. Again, I am forced to wonder if resident in general surgery worked along with we are doing the best by him. A senior (very few) other surgeons in the country, and I know Harvard medical student working on a quality that they are swamped. Ultimately, Jean de Dieu’s improvement project at Butaro Hospital has acted treatment course has to pivot around the scarcer as the coordinator for the surgical team, as there resources—in this case, a trained surgeon. A big operation, Butaro, constantly training Rwandan anesthesia usually done with two surgeons—one working providers, and strengthening the critical care capac from above in the abdomen, the other working ity. Working in concert, this team has been Jean de from below in the perineum—to remove the Dieu’s primary doctor. The left ureter is inad they’ve created a system of health delivery to benefit vertently divided, and so has to be re–implanted the many. There shrunken by the chemotherapy is still rather is joy in seeing Jean de Dieu receive and benefit large and locally advanced. Given the limited There is joy in seeing him be able to sit erect, now lighting, equipment, and reconstructive options, I that the tumor is removed. There is joy in seeing decide that the safest course of action is to shave a surgical delivery system grow and transform. A the tumor off the gland delicately—rather than a year ago, Butaro Hospital was essentially able to radical resection, which would require a complex only offer emergency caesarian sections—a critical reconstruction of his bladder and urinary system, service, but hardly a full complement of surgical which we lack the capability to perform or to care care. Ninety–eight percent of his tumor is removed, is providing more complex orthopedic, plastic, and but the last two percent still remains in his body, general surgery services, as in Jean de Dieu’s case. We didn’t multi–institutional cancer team—he will require get it all right for Jean de Dieu. He had surgical further chemo, but it is unclear if this will offer complications. He Sadath Sayeed recognizes he may eventually die of cancer pro gression or recurrence, but he is still grateful. But Jean de Dieu’s story has —Arundhati Roy from the God of Small Things reinforced for me that delivering quality surgical care for destitute, sick, and injured patients will require developing and strengthening collabora Father and Son tive, interdisciplinary systems of care. The system Twenty minutes before I was to be taxied to the strengthening that happened around his care airport in Port–au–Prince, the baby boy handed to continues to improve health for countless others. Born a few hours earlier at home—probably serve Jean de Dieu and others like him from this in one of the hundreds of make–shift tent cities. I academic, hybrid post—helping to deliver care, did ask if the baby cried after he came out of mom. Climbed onto a moped with his ment of Surgery and the President of Brigham and baby wrapped in a blanket. While under one arm and rode between piles of rubble to performing a thoracic surgery operation for empy the closest health care facility. They pushed air into his mouth like It’s not that any one thing is going wrong, it’s just you are doing. After a few minutes, they said that that all of it is harder than it is in Boston. They patients are weaker, our therapeutics are more took the time to hand him a note before they sent limited, and there are a lot fewer funds with which him on his way. When the work is hard, I am reminded that seeking justice and loving mercy are guiding principles for all of us in this work of Strained Resources solidarity. And when the dissonance of the hybrid L’Université d’État d’Haïti has been the main teach life hits too high a pitch, I reflect that, “who knows ing hospital for all of the country for decades. Many, but if perhaps we are in this position for just such if not most, formally trained Haitian health care a time as this? Delivering Health Care in Severely Resource–Constrained Settings 99 Dad must have been directed to the pediatric missions, they think of as jobs.

However cholesterol medication does not work best 10mg zetia, patients >65 were more likely to is there bad cholesterol in shrimp 10mg zetia with mastercard have clinically/surgically relevant findings cholesterol foods pdf buy zetia 10mg otc. However cholesterol glucose ratio buy 10mg zetia with visa, older patients in our series were more likely to cholesterol in omega 3 eggs buy zetia with paypal present with clinically/surgically relevant findings cholesterol test ireland purchase zetia 10mg without a prescription, and a lower threshold for ordering imaging examinations in this patient population should be considered. This finding, when present, was utilized as a predictor of nonviability of the torsed ovary. Each torsed ovary was categorized as either a) viable or b) nonviable based on presence/absence of a perifollicular T2-hypointense rim. Sensitivity and specificity values for individual and combined imaging signs were calculated using surgical diagnosis as the reference standard for acute cholecystitis. Combining stones, distention, pericholecystic fluid and gallbladder fossa restricted diffusion yielded sensitivity of 35% and specificity of 92. The combination of stones, distention and gallbladder fossa hyper enhancement was 43. Most signs can be detected by diffusion and single shot T2 weighted sequences only. Gallbladder fossa restricted diffusion is a novel imaging sign, and when combined with the presence of gallstones, pericholecystic fluid and distention yields a specificity of 92. This leads to common misinterpretations which would further results in wrong management with potentially negative outcome. In this course, we will review important typical features of common pancreatic pathologies and mimics of these pathologies that may require different treatment and improved prognosis. The availability of senstive urine pregnancy tests means that we are seeing patients at a time when It may be very difficult to see any sonographic findings of pregnancy. We will also review the appearance of heterotopic pregnancy and non-tubal ectopics including Cesarean scar implantation, interstitial and cervical implantation, and abdominal and ovarian ectopic with demonstration of the role of color Doppler, 3D ultrasound and other imaging modalities. Modern management of ectopic pregnacy has become much less aggressive, in part because the diagnosis is made so much earlier. The indications for the various treatment options will be outlined with illustrative case of local injection as well as intraoperative photos during laparoscopy. In the second setting, the currently accepted criteria for definite miscarriage and for probable miscarriage will be presented. The lecture will also address findings that indicate a high likelihood of impending pregnancy failure when an embryo with heartbeat is seen on ultrasound. While many anomalies cannot be detected until later in pregnancy, the discussion will focus on those anomalies that can be detected in the first trimester. Specific topics covered will be central nervous system anomalies, including anencephaly, encephalocele and holoprosencephaly, ventral wall defects including omphalocele and gastroschisis, bladder outlet obstruction, and skeletal anomalies including skeletal dysplasias. Detection of anomalies early in gestation, before the second trimester, permits time to assess the fetus for other anomalies, syndromes, and aneuploidy. Renal vascular complications from transplantation were diagnosed in 23 patients, which included 14 with arterial stenosis, three with arterial kinking, two with arteriovenous fistulas, two with venous stenosis, one with pseudoaneurysms, and one with fibromuscular dysplasia. Three patients had two renal transplants and nine patients had nine accessory renal arteries. It may be used for evaluation of patients with renal transplant, and in particular for those with renal insufficiency. The degree of stenosis was assessed by using a 4-point scale (grade 1, normal appearing vessel; grade 2, vessel narrowing < 50%; grade 3, stenosis 50%-99%; grade 4, vessel occlusion) for 15 predefined anatomical segments. The segmental vascular enhancement and the image noise were rated on five-point scales (1-poor/non-diagnostic, 5-excellent) by two readers. Such a non contrast technique may have potential advantage in patients with severe renal disease or with other risk factors that prohibit the use of iodinated or gadolinium-based contrast material. The technique appropriately detected the presence of perforators in 40/41 patients and ruled out perforators in 1/2 patients, yielding a sensitivity, specificity and accuracy of 97. Preoperative localization of the vessels significantly impacts surgical planning and may prevent unnecessary surgical explorations in a percentage of patients. Anatomical variations determined by pre and intra-operative findings, costs, and time for preoperative images were recorded. Image quality for the depiction of hepatic vessels, bile ducts and graft volume were ranked on a 4-point scale and compared between both groups. In patients with arteriosclerosis, reflected flow appears within the lower abdominal aorta during early diastolic phase. The purpose of our study was to test if 4D Flow can depict reflected flow in the lower abdominal aorta, to quantitate the retrograde flow volume, and to verify their association with atherosclerosis, in the non-dilated lower abdominal aorta. The prominent retrograde flow represents reflected flow from the iliac arteries, which may be due to the lack of compliance of the atherosclerotic aorta and peripheral arteries. Both patients with aortic ulcera and patients with aortic aneurysms showed lower mean values for peak velocity (p < 0. Reduced wall shear stress is associated with aneurysma growth and might therefore help to identify patients at risk. Acceleration Techniques and Their Effect on Arterial Input Function Sampling: Non-accelerated versus View-sharing and Compressed Sensing Sequences Tuesday, Dec. Each acquisition with administration of 10 ml contrast agent (Dotarem, Guerbet) via a power injector (2ml/s flow rate) was repeated three times. Essential sequence parameters were standardized: flip angle 15°; spatial resolution 2. The two most common abnormalities included atherosclerotic narrowing (12 patients) and anatomical variations (4 patients). Addition of venous phase of imaging led to clinically occult venous pathologies in 4 patients, including deep venous thrombosis (2), varicose veins (1) and arteriovenous malformation/fistula (1). Two radiologists independently compared the diagnostic quality of the different angiographic sequences, in terms of visualization of aortic wall and lumen and main arterial branches. The vascular calipers at different aortic levels were calculated, compared and statistically analyzed among the different sequences. They also demonstrated high sensitivity and specificity in the evaluation of vascular plaques, thrombus and adjacent structures. Due to their reliance on single-direction velocity encoding and regional flow analysis (2D planes) both methods can underestimate peak velocities, especially in cases of complex flow jets as commonly seen in patients with abnormal aortic valves. Bland-Altman analysis of peak velocity assessment showed excellent inter-observer variability (mean difference = -0. However, it seems to be challenging to obtain precise and reproducible findings, due to the limited angulations that are available. The results were compared to the measurements from echocardiography and intraoperative measurements served as reference. With the exception of apical septal defects the size of the defects seems not to correlate with a specific location. As the gauge of the fenestrated is smaller than of the conventional nonfenestrated catheter, optimal enhancement can be achieved by controlling the injection pressure. We compared the injection rate, aortic enhancement, and injection pressure when intravenous contrast material was injected with fenestrated and conventional non-fenestrated catheters. In group A we delivered the contrast medium via a 22-gauge conventional non-fenestrated catheter and in group B we used a 24-gauge fenestrated catheter. There was no significant difference in the injection rate and aortic enhancement (p = 0. The maximum injection pressure was significantly lower in group B than group A (0. After manual segmentation of each lobe mean and coefficient of variation (CoV) were calculated. Each pulmonary nodule was manually segmented and its computerized texture features were extracted by using an in-house software program. Multivariate logistic regression analysis was performed to investigate the differentiating factors of metastatic nodules from non-metastatic lesions. A subgroup analysis was performed to identify significant differentiating parameters in non-calcified pulmonary nodules. Pulmonary metastases and non-metastatic lesions exhibited significant differences in various histograms and volumetric parameters (P<. The subgroup analysis with non-calcified pulmonary nodules (13 metastases and 18 non-metastases) revealed significant differences between metastases and non-metastases in various parameters. Group 2 (n=34) had empiric embolization of gastroduodenal artery (n=23) or left gastric artery (n=11). After adjusting for age and Rockall score, following clinical outcomes were measured: 30-day mortality, hospital stay, repeat procedures and transfusion requirements. Radiation exposure (fluoroscopy time and reference point air kerma) in both groups and cost of embolization in group 2 were collected. Patients who had at least one repeat procedure (angiogram or endoscopy) after the initial angiogram was similar (50% vs. Among the available transfusion records (group 1=15; group 2=14), there was no difference in the units of packed red blood cells transfused after the initial angiogram (4. A total of 183 coils and 34 coil pushers were used during 32 angiograms in group 2. However, with one of the largest series, our review fails to support the same which is associated with higher fluoroscopy time and costs. Endovascular procedures were classified as technical success if bleeding origin was identified and treated, technical failure if identified bleeding was incompletely treated; and radiologic abstention if no abnormality was depicted and no treatment performed. Factors associated with postprocedural rebleeding were analyzed, together with second line treatments. Technical success, technical failure, or radiologic abstention were observed in 48 (70%), 9 (13%), and 12 patients (17%), respectively. Rebleeding rates were 29%, 58%, and 100% in case of success, abstention or failure at the first endovascular procedure, respectively (p < 0. Treatment efficacy was the only factor associated with rebleeding (success vs failure p < 0. Rebleeding was treated by endovascular treatment, surgery, or both, in 12 (40%), 11 (37%) and 7 (23%) patients, respectively. Overall, 72% of the patients were successfully treated by endovascular procedures alone. Whatever the anatomy, however, the general principle is that occlusion is performed at the site of the abnormal arteriovenous shunts and not in the vessel proximal to this point. The embolization of arterial feeding vessels, which was performed for many years with metallic coils or particulate matter such as polyvinyl alcohol, is akin to proximal surgical ligation and must be avoided. It has little effect upon symptoms in most individuals and renders subsequent treatment more difficult because the arterial inflow vessels have been occluded. This presentation will concentrate on the radiological management of these high-flow lesions. Associated symptoms including dyspareunia, vulvar pain or lower limb venous insufficiency as well as complications were also assessed. The most common incompetent veins were the left ovarian (82%), internal pudendal (right 49%; left 39%), inferior gluteal (right 32%; left 31%) and uterine (right 19%; left 23%) veins. Patient demographics, technical details, angiographic findings, complications, rate of recurrence, and need for repeat intervention were reviewed. Person-years were calculated to evaluate the incidence of recurrence by endovascular treatment method. One procedure for recurrent hemorrhage was impeded by previously placed embolization coils. Data from patient files was collected regarding method of embolization (Amplatzer plugs, coils or both) and regarding all complications. The radial artery has also proven to be a feasible approach to performing this procedure with implications for a safer access site. It is responsible for numerous comorbidities including diabetes mellitus and its complications, cardiovascular disease, sleep apnea, and premature osteoarthritis. This is the first use of left gastric artery embolization in the Western Hemisphere to treat morbid obesity. This is also the first radial artery access experience with implications for the morbidly obese where groin access may be more challenging. This talk outlines the background behind the procedure as well as the latest human experience. Twenty-five breast disease patients who underwent surgery from January 2014 and April 2014 were retrospectively analyzed. Two independent sample t test was employed and receiver operating characteristic curves were plotted for data analysis. K was significantly higher in the malignant lesions than in the benign lesions (0. Between January and October 2013, 73 patients with 81 calcifications (40 biopsy proven malignant calcifications, 24 biopsy-proven benign calcifications, 17 typical benign calcifications) were consecutively enrolled. Eight radiologists specialized in breast imaging were divided equally into two groups and each group reviewed images of 100 breasts retrospectively. However, the reconstructed s2D images frequently have a different appearance varying by breast density and lesion type, particularly "calcification-only" lesions. The percentage of screened patients recalled for calcifications, masses, asymmetries, architectural distortion and technical reasons was 1. Findings (calcifications, asymmetries, masses, architectural distortions) on C-view+Tomo were prospectively assessed as better, equally, or less well seen compared to 2D+Tomo. Multivariate logistic regression analysis determined effect of breast density or age on visualization of C-view+Tomo findings. This was most evident for architectural distortions and calcifications (architectural distortions 100%,12/12); calcifications 96. Logistic regression models showed neither density nor age had a significant effect on visibility of findings (p 0. Cancer detection rate was the same as both cancers were identified on both modalities. The sample included 120 consecutive patients with 73 biopsy-proven cancer (confirmed histologically) and 64 biopsy-proven benign lesions. Two dedicated breast radiologists, blinded to the clinical information and histological diagnosis, retrospectively reviewed all the studies.

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Oxycodone has a high oral done has a much lower propensity for euphoric effects bioavailability of 60–80% cholesterol levels with diabetes quality zetia 10mg. It is metabolized in multiple and is therefore used in maintenance programs for steps to cholesterol medication that starts with c buy 10mg zetia different metabolites cholesterol vs fat buy 10 mg zetia otc, of which oxymorphone drug addicts cholesterol chart ratio cheap zetia online amex. In addition cholesterol levels smoking effects discount 10mg zetia with amex, there is incomplete cross is the most active and 8 times more potent than mor tolerance to cholesterol medication that is not a statin order zetia on line other opioids. Oxycodone has a similar therapeutic profile to has the potential to initiate Torsades de Pointes, a po morphine; however, it is only available as an oral ex tentially fatal arrhythmia caused by a lengthening of tended-release formulation (10–80 mg tablets). After oral applica of its metabolites (M1) binds to the μ-opioid receptor, tion (single dose 4 mg), the onset of analgesia occurs af which elicits additional analgesia. Hydromorphone is extensively me genetic variations may differentiate poor from exten tabolized in the liver, with metabolism of approximately sive metabolizers, and hence the respective differences 60% of the oral dose. Tramadol exists as an oral (50– 3-glucuronide can cause neurotoxic effects (excitation 100–150–200 mg tablets) and parenteral formulation syndrome: hyperalgesia, myoclonus, epilepsy), similar to (50–100 mg). Because of Methadone potential interactions, tramadol should not be given together with monoamine oxidase inhibitors, since the Methadone is a μ-opioid receptor agonist with 0. In addition sion, hyperpyrexia, central nervous system excitation, to its opioid receptor activity, it is also an antagonist delirium, and seizures. It ex tency of morphine and significant anticholinergic and ists as an oral (5–40 mg tablets) and parenteral for local anesthetic properties. Methadone is used postoperatively, since in addition to its analgesic metabolized with no active metabolites by multiple effects, it has anti-shivering properties. Meperidine ex different enzymes of the liver in a highly variable ists as an oral (50 mg/mL solution) and parenteral for manner, which explains its broad variation of half-life mulation (50–100 mg/2 mL). It is metabolized in the (up to 150 h) and makes regular dosing quite difficult liver to normeperidine with a half-life of 15–30 hours, for patients. In general, pain relief is better obtained and has significant neurotoxic properties. Meperidine 44 Michael Schäfer should not be given to patients being treated with (s. Its metabolites are inactive and are combination may produce severe respiratory depres mainly excreted via the biliary duct. Oral bioavailabil sion, hyperpyrexia, central nervous system excitation, ity is 20–30% and sublingual bioavailability is 30–60%. Because of its very stable and long duration of action, buprenorphine is Fentanyl used for substitution therapy for drug addicts (4–32 Fentanyl, a strong μ-opioid agonist, belongs to step 3 of mg/daily). Fentanyl mainly exists as a paren pressant effects are reversed only by relatively large teral formulation (0. A transdermal applica tion system is widely used in industrial countries, but Naloxone/naltrexone because of its costs and the delayed delivery system with additional risks (delayed respiratory depression), it Both substances are classical opioid receptor antago may only be of use in rare cases. However, incorrect use may lead to large preoperatively to treat opioid overdosing and needs to fluctuations in plasma concentration and increase the be titrated and administered repeatedly under constant risk of psychological dependence and addiction. Naltrexone exists only as an oral formula tantly, repeated administration of fentanyl may lead to tion (50 mg/tablet) with a delayed onset (within 60 min) drug accumulation due to redistribution from fat and and a long duration (12–24 h) of action. Naltrexone is muscle tissue into the circulation with increased risk of mainly used for maintenance treatment for alcohol and respiratory depression. Both substances can precipitate acute life-threatening withdrawal symptoms when improperly used. Because of its very high potency, suf 200 years, opioids still remain the mainstay of entanil is mainly used intraoperatively. While opioids are effective to fentanyl, it is much less prone to drug accumula in most postoperative and cancer patients, and tion, because of its low tissue distribution, low pro in some patients with neuropathic pain, most tein binding, and high hepatic metabolization rate to other noncancer pain is hardly responsive to inactive metabolites. It medication for short and long-term treatment usually has a slow onset (45–90 min), a delayed maxi can be accomplished safely. Tere is no evidence mal effect (3 hours), and a long duration of action about a differential indication of the opioids (8–10 hours). Consequently, availability, costs, and Opioids in Pain Medicine 45 personal experience should be the guiding prin References ciples when choosing an opioid. Guide to Pain Management in Low-Resource Settings Chapter 8 Principles of Palliative Care Lukas Radbruch and Julia Downing What is palliative care? Palliative care is an approach that improves the quality of life of patients and their families facing the problems Palliative care is a philosophy of care that is applicable associated with life-threatening illness, through the pre from diagnosis (or beforehand as appropriate) until vention and relief of suffering by means of early identifi death and then into bereavement care for the family. It is the provi explains and reinforces the holistic approach, which not sion of comprehensive holistic care with the patient at only covers the physical symptoms, but extends to other the center of that care, and is dependent on attitudes, dimensions and aims of care for patients as they suffers expertise, and understanding. It is a philosophy that can now with their disease, with their own personal story, be applied anywhere—across a range of skills, settings, and in their actual setting and social context. It begins when illness is diagnosed, and symptoms; continues regardless of whether or not a child receives. Affirms life and regards dying as a normal process; treatment directed at the disease. Intends neither to hasten nor postpone death; evaluate and alleviate a child’s physical, psychological, and. Effective children’s palliative care requires of patient care; a broad multidisciplinary approach that includes the fam-. Offers a support system to help patients live as ily and makes use of available community resources; it can actively as possible until death; be successfully implemented even if resources are limited. This material may be used for educational 47 and training purposes with proper citation of the source. Will enhance quality of life, and may also posi port will enable them to continue in their work for the tively influence the course of illness; benefit of the patients. Her husband died from gations needed to better understand and manage an “unknown cause” 4 years ago, and she has been distressing clinical complications. One year ago she noticed that she was getting pain on micturition and that her peri How is palliative care provided? She did not seek medical help initially as settings and models, including home-based care, facili she thought that this was just part of getting older, and ty-based care, inpatient and day care. Care can be pro culturally it was not appropriate to discuss such prob vided in specialist as well as general settings and should, lems with anyone. Six months later, having been to visit where possible, be integrated into existing health struc a traditional healer first, and not responding to their tures. The concept of palliative care should be adapted treatment, she eventually visited her local health center to reflect local traditions, beliefs, and cultures—all of as the pain was getting very bad; she was experiencing which vary from community to community and from bleeding and found that she was unable to keep herself country to country. On examination at the lo Palliative care is holistic and comprehensive, cal health center she was referred to the district hospi and thus ideally it should be delivered by a multidisci tal, from where she was referred to the national cancer plinary team of care givers, working closely together center, where she was diagnosed as having a fungating and defining treatment goals and care plans together cervical tumor. In many re vical carcinoma, which had spread to her lymph nodes, source-poor countries the multidisciplinary care team her pelvis, and her liver. Treatment with surgery was no will include community workers and traditional healers longer an option, and chemotherapy was not available, as well as nurses, doctors, and other health care profes so five fractions of palliative radiotherapy was given to sionals. Nurses have a key role in the provision of pal try and reduce the pain and the bleeding. She had lost liative care due to their availability within resource-poor weight over the past 6 months and was suffering from settings, and they are often the coordinators of the mul fatigue. The health care professional may be she was seen by the local palliative care team because of working alone with little support from others, particu severe pain in the pelvis and lower back. Community health workers and ment included low-fraction radiotherapy and she was volunteers can provide support to the health workers commenced on 5 mg oral morphine every 4 hours. This and have been trained with good effect to support them dose was increased gradually to 35 mg of oral morphine with basic medical care. In many resource-limited set every 4 hours with a prescribed rescue dose as required. She was also prescribed an antiemetic Tere are however, specific situations where for nausea and a laxative to prevent her from becom professional support from peers or from a team is re ing constipated from the morphine, and to soften her quired. Ethical decision-making in complex situations, stool to reduce discomfort from the fungating wound on disagreeable patients or families, or family systems with defecation. With the radiotherapy along with a cleans complex conflicts may trigger a need for such support. Principles of Palliative Care 49 The national cancer unit was based in the capi only for a drug regimen, but also for a palliative care tal city over 250 km away from her village, and once her plan tailored to individual needs and the patient’s situa pain was controlled and the radiotherapy was finished, tion and context. As well as being nearer to cause of any pain or symptoms that the individual might her children, she could not afford the expense of being in be experiencing, and if the cause is treatable. Tese problems were addressed scription of the care setting should include where the with repeated talks with Grace about issues surrounding patient lives, who provides care, how many people the health of her children, both of whom seemed to be in there are at home, and an overview of financial and good health. Grace was referred to a local home-based emotional resources and the needs of the patient and care team in her village and was advised as to how she family. A sociogram can offer a rapid overview of fam could continue to access oral morphine for pain control, ily relations, and important events in the family history and she was discharged 10 days after having been admit including any history of illness. She was supported by the home care team, the com munity, and spiritual leaders at home until she died 5 weeks later with her symptoms under control and having made arrangements for her children’s care. It is about management of pain and oth er symptoms, but it is also about psychological, social and spiritual problems. It is about the coordination and continuity of care in different settings and across the disease trajectory. It is about interdisciplinary and cross-sectional team work involving staff from different health care professions as well as volunteer services, in cluding caregivers in their role as partners in the team Fig. Sociogram of a family setting of a woman with malignant as well as in their role as family members who require melanoma. Along with information about the context of care, the baseline assessment should not be restricted How important is the assessment to physical symptoms, but should include several di of the patient? Many symptoms such as pain, palliative care interventions as well as regular follow-up dyspnea (difficulty breathing), nausea, or fatigue depend evaluations are paramount to ensuring adequate relief on subjective feelings rather than on objective measur of symptoms and distress, and to adapting treatment able parameters, and so self-assessment by the patient to the individual patient. An African version has been developed Follow-up assessments can be brief, but should include that has been used with good effect in resource-poor short symptom checklists to monitor whether new settings. Treatment for new symptoms eases and with declining cognitive and physical function and problems should be initiated. Assessment by caregivers or staff is usually going therapies should also be re-evaluated regularly, to a close substitute for the patient’s self-assessment and see whether they still are indicated or whether careful should be implemented for such patients. Assessment of psychological, spiritual, and so However, it should be noted that often drugs for the re cial issues can be more complex, with limited tools be lief of pain, dyspnea, and other symptoms must be con ing available to aid the health care professional. Following the death of the patient, an evaluation Performance status is an important parameter of the overall efficacy of the palliative care delivered is because it predicts needs. The easiest way well suited for evaluation and monitoring of services, as is to ask caregivers and family members for an overall it describes the patient population cared for. Symptom relief 1 = Restricted in physically strenuous activity but ambulatory and able to carry out light work. With progression of the un 3 = Capable of only limited self-care, confined to a bed or chair derlying disease, most patients suffer from physical and more than 50% of waking hours. Totally chronic infections such as tuberculosis may result in a confined to a bed or chair. Most patients with advanced disease and What follow-up assessments are limited life expectancy suffer from weakness and tired ness (fatigue), caused either by the disease or its treat needed for re-evaluation? Coping with the diagnosis and prognosis may Assessment is an ongoing process, and so after the initi lead to spiritual and psychological distress, anxiety, and ation of treatment, regular re-evaluation is very impor depression. The efficacy of any treatment given for symptom the alleviation of the symptom load, quality of life will relief has to be monitored, and the treatment, includ be restored. After the initial phase, with stable symptom relief, on the management of the most important and most Principles of Palliative Care 51 frequent symptoms (Table 1). More detailed informa Respiratory depression is a side effect of opi tion on assessment and treatment of symptoms and on oids, but it does not contradict the use of opioids for other areas of palliative care can be found in the clinical dyspnea. Opioids diminish the regulatory drive caused by agement of Adult Illnesses Palliative Care module and elevated carbon dioxide levels, and in consequence pa related materials. Opioids also reduce pain and anxiety, thus al rules of cancer pain management, with analgesic medi leviating stress-induced dyspnea. Mechanical release with pleural puncture management in palliative care in low-resource settings will produce rapid relief. Dyspnea can also be related because they are relatively inexpensive and because ef to severe anemia, leading to reduced oxygen transport fective palliative care is not possible without the avail capacity in the blood, and blood transfusions will alle ability of a potent opioid. Detailed information is avail viate dyspnea in severely anemic patients, though most able in Chapter 6. Oxygen will be helpful for control of dyspnea Is treatment of other symptoms similar only in a minority of patients; however, other nonphar to pain management? For example, reverse what is opening a window or providing a small ventilator or fan, reversible and treat the underlying cause without in will be very effective in the treatment of dyspnea. Medication such as metoclopramide or low-dose neuroleptics such for symptom management should also be given by the as haloperidol. Corticosteroids can be most effective if clock according to the different dosages available and gastrointestinal symptoms are caused by mechanical where possible by mouth, thus making it easier for peo obstruction from inflammation or cancer. Nondrug in ple to continue with their medications at home, where terventions include nutritional counseling. In opioid-naive patients, oral morphine (5–10 mg) or Constipation may be caused by intestinal manifestations subcutaneous morphine (2. Other opioids tidepressants, but also by inactivity, a low-fiber diet, or can be used for this indication as well, with equipo low fluid intake. Patients already receiving opioids for pain should be prescribed for every patient receiving chronic should have a dose increase to alleviate dyspnea. In contrast to other adverse events such tinuous dyspnea should be treated with a continuous as sedation, which most patients report only for the first opioid medication, following similar dose-finding rules few days after initiation of opioid therapy or a dose in as for pain management, although mostly with lower crease, patients do not develop tolerance to constipa starting dosages.

Along the way settling tanks could be built; these allowed the water to cholesterol test san diego effective zetia 10mg be cleaned of sand and other impurities cholesterol test diy purchase zetia. Some of the water could be used outside of the town it was intended for; the rest would be stored in a 53 castellum cholesterol levels dogs order zetia cheap online, a large water tank cholesterol test order zetia australia, from which it would be further distributed cholesterol levels with age order 10mg zetia mastercard. Owens in the initial part of his article “The Kremna Aqueduct and Water Supply in Roman Cities” cholesterol range chart pdf order zetia with visa, Greece and Rome, vol. Hodge stated that the aqueducts were 55 constructed mainly to supply water to the baths. In terms of what the aqueduct water was mainly used for, this is clearly the case. Early baths (Greek and early Roman baths) consisted of a number of bathtubs, in which hot water was poured over the 56 bathers by the attendants. Separate bathtubs were not only a result of moral restrictions but, perhaps more importantly, of insufficient water supply, inadequate for creating large pools, which require incessant flow of water to maintain at least a degree of cleanliness. Without an aqueduct (or a nearby river and a system of pipes), the water for baths had to be taken from wells or carried in barrels or buckets; such an arrangement did not allow for maintaining large pools, even if there was much effort put into constructing and maintaining pumps and treadmills to power them, as the 57 evidence from the Stabian baths in Pompeii shows. After the political and military th th disturbances of the 4 and 5 centuries in the West significantly disrupted the workings of some of the aqueducts, baths in many cities were either rearranged (for example, large pools disappeared completely and separate bathtubs were again introduced) or even closed down altogether. The maintenance of aqueducts was a major issue, and laws reflecting this were quite numerous. They regulated both 58 matters of cleaning and maintaining of the structures themselves, and specified the purposes for which the water could be used (for example, private recipients could 59 obtain individual water supply as a privilege), and in what quantities. Generally, the burden of maintaining the aqueducts in working condition fell on the owners of the land through which the system was passing (they were exempt from other taxation), and on the city officials. Without sufficiently strong central power to enforce these laws, the infrastructure would eventually become neglected, and the amount of 54 N. Author uses term noria to describe the device (later another one was built alongside the first), but the description suggests that it was a “Persian water wheel”, a type of pump, consisting of a chain with a series of containers, like amphorae or pots, attached to it and which could be powered by treadmills or windlasses; a noria, on the other hand, is a type of water wheel used for obtaining mechanical power; the pumps in Stabian baths were clearly powered by a treadmill. Without the continuous flow of water, the bath-house pools would quickly become unusable, and the alternative system of bathing, that of a series of individual bathtubs, would reappear, somewhat similar to 60 ancient Greek public baths; this occurred when – either because of lack of funding or enemy attacks – the supply of fresh water was insufficient to maintain the traditional way of bathing. For centuries the type of baths present in an area was a clear indicator its wealth and security, and of Romanisation in general: the sophistication of the installation could be used as both an indicator of the wealth of the founder as well as of the degree in which the typically Roman models were being used. During Late Antiquity, however, the cities and areas which could previously boast the technologically advanced and well-decorated bath-houses often had to downgrade their infrastructure, for the already mentioned reasons. The forms that were replacing them evolved and, in the long run, took the mediaeval, ‘Byzantine’ form and became the predecessors to the Turkish hamams. As with any gradual process, it would be difficult to pinpoint a particular development that would justify a sudden shift in terminology (such as from ‘Roman’ to ‘Byzantine’), and it is no different with bath-houses. However, of the two technical arrangements which I would deem the most important in, and the most characteristic for a Roman bath house, that is the constantly flowing water and the hypocaust system, the heating was the one that survived quite well into the Byzantine period. It could therefore be justified to view bath-houses with flowing water as the most ‘Roman’, and lack thereof as something that distinguished the later ‘Byzantine’ bathing establishments. Nonetheless, making such distinctions seems to me to be rather artificial and non productive; it would perhaps be better to argue that the characteristics of a ‘Roman’ bath-house changed over time, primarily due to economic factors (discussed in the introduction); unable to utilise all of the comforts and solutions available to their predecessors in earlier times, the late antique Romans had to make do with what was available. The baths’ water tanks, where they existed, were usually placed on the roof, and the water from aqueducts, where available, was delivered directly into those, usually from large water tanks in the city. In some cases a bath would use a mixed system of water delivery; in Herculaneum, the aqueduct supplied water to the 60 J. Water from an aqueduct meant that there was a constant flow of clean water, which was necessary for maintaining at least some hygiene in larger pools, but at the same time it meant that the drainage system had to be highly effective. The drains could either run under the floor, or the water could first wash the floor and then go into the drain (the solution usually found in caldaria). During Late Antiquity, there was a significant decline in the extent of private euergetism: the cities had to rely more and more on imperial benefactions. Zajac noted that providing various public buildings (among which the baths were most prominent) for the people served as a way of expressing the personal legitimation of 62 the emperor’s rule. The baths were also, as was already noted many years ago, a 63 way of expressing power over the natural environment (primarily water). Even this imperial munificence, however, had its limits: in a memorable passage, Ammianus writes that during the emperor’s stay in Rome, Constantius was awed by the city’s architecture; among the notable buildings the emperor admired bath-houses, built in 64 provincial styles, “lavacra in modum provinciarum exstructa”. Catherine Edwards clarifies that Ammianus was referring to the size of the baths, which brought to mind 65 the size of whole provinces, rather than the style they were built in. Judging from the context, this reading is quite plausible, as Ammianus’ description of Rome’s buildings is primarily focused on their size (Constantius was overwhelmed by the scale of the works that were undertaken by previous emperors and abandoned thoughts of surpassing them). This could, perhaps, be treated as an indication of the limited resources of the Empire – or the diminishing importance of Rome, no longer the Empire’s centre of power. Indeed, there is very little evidence of any new th construction works in Rome from 4 century onwards – although many of the existing th th structures did undergo renovations between 4 and 6 centuries (including the baths 61 J. Burton, writing in the 1820s, was appalled by the amount of funds drowned by the emperors in the construction of the thermae and interpreted this passage as Ammianus’ complaint about the excessive spending on the relatively unimportant – in the American historian’s opinion – structures (E. The thermae Constantinianae, built by Constantine sometime prior to 315, had to wait for thirty years for renovation after their destruction by the Goths in 66 410. A particular way of demonstrating imperial power was recorded by Socrates th Scholasticus, a 5 century Church historian, who made a note of a building initiative of Valens (the one who completed Constantinople’s aqueduct), notable for its unusual character: after Procopius (the historian’s earlier namesake) attempted to seize the throne (365-366), the emperor demolished the city walls of Chalcedon, as a punishment for supporting the usurper, and used the thus obtained material for 67 building a public bath in Constantinople. Socrates quotes a prophecy that was supposedly found on one of the stones from Chalcedon that predicted their removal and reuse in construction of a bath-house, as well as future barbarian raids on Roman territory that were to begin after Constantinople was supplied with abundance of water. For this, Socrates provides two possible interpretations: construction of the aqueduct of Valens, and building of the baths that used water from the said aqueduct, by the prefect Clearchus, and called “Plentiful water” – δαψιλής ὕδωρ – dapsiles hydor. Reusing of an old building was not, in itself, rare: in Ephesus, for example, the old civic centre was left beyond the new fortifications, and the materials from the prytaneion and other structures from the area were used to rebuild and adorn the new centre, including the Baths of Scholasticia (renamed after the lady who sponsored the 68 rebuilding). This is a good example of the breakdown of the old civic organization of the city – and of how at least some of the previously valued comforts remained in many cases the same as before. Theophanes the Confessor, an eighth and ninth-century monk and chronicler, who compiled for his purposes many of the earlier authors during 810-815, similarly to Socrates mentions that the “impious Valens” (as the author characterised him) built 66 G. This information is most likely repeated after Ammianus Marcellinus, Roman history (further referred to as Res Gestae), transl. This is also another good example of the tendency to seek fame and lasting memory, preserved in the names of public utility buildings. Assuming that Valens did indeed consider naming the aqueduct as means of preserving his memory, one might add that at least in this case the method proved quite successful. What is perhaps most important about this account is the fact that the ancient historians and chroniclers recognized the importance of such major undertakings. Such construction efforts not only provided direct benefits to the local communities (their most important feature as far as the subject of this thesis is concerned), but in addition provided a clear example of Roman superiority over surrounding nations, and the master of Romans over nature. It is worth noting that the purposes for which major public works were undertaken were occasionally conflicting; at least this seems to be the case in a particular passage from Procopius. He included a much less flattering account of Justinian’s passion for building than the one found in the panegyrical Buildings in the 70 Secret history, also known as Anecdota, a source best characterised as invective (psogos). The ancient author reports that Constantinople’s aqueduct (that of Valens) was already in a very poor state during Justinian’s reign and delivered only a fraction of the water it should; despite that, Justinian did not allow money to be spent on repairing it, but instead, became engaged in construction of many other buildings, by the sea and in the suburbs, that did not (in Procopius’ opinion) serve any useful function; because of this, there was a shortage of drinking water, and the baths were 71 all closed down. This information becomes all the more interesting when put together with a passage from Theophanes, who mentions the drought that plagued Constantinople in 562: he writes that the dominant northern winds caused the drought in November, when the scarcity of water led to fights at the fountains; the following August, Theophanes reports, there was another water shortage, and this time he 69 the Chronicle of Theophanes Confessor. It would however be unwise to make any definite conclusions from this lack of information. It is impossible to determine whether the description of drought is simply repeated, or if the first account of it should be treated separately from the second; if that was the case, it could, after all, mean that at least some of the bath-houses remained operational even when the supply of water from the aqueduct (which also provided water to the fountains) was running low. The question of the prefect’s identity is a fairly important one in determining the degree of possible bias in Procopius’ account; this, in turn, is significant in establishing the usefulness of one of the few surviving passages from this period that directly and in some detail refer to the functioning of urban infrastructure. The context for the prefect’s dismissal in the Chronographia strongly suggests it was due to his inability to cope with the lack of water. If Procopius was indeed forbidden to spend money on repairs and restore the aqueduct’s capacity, the unjust nature of the loss of his function would be evident and could, perhaps, even explain the reason (or one of the reasons) behind the writing of the invective. According to her, John of Nikiu’s identification of the prefect Procopius (known from Theophanes) of 562 with the historian is most likely erroneous. She further argues that if both Buildings and Secret history had been written around 560s, then that would have been in stark contrast to the way the Wars were written: from a longer perspective, and without 75 being connected much to the current events. The Secret history claims to be a 76 commentary to Wars (and therefore it would make sense for it to have been written around the same time), and scathing criticism of Belisarius and Theodora written 77 many years after their deaths does not seem likely, either. Thus, linking Procopius the author and Procopius the prefect would require assuming either considerable chronological discrepancies in the primary sources (which is not entirely impossible), or a considerable delay with writing Anecdota by Procopius after he completed Wars (or, perhaps, a very long time of its writing). Regardless of who the prefect Procopius might have been, and despite the fact that the information contained in both of the discussed here sources should be treated with significant caution, the texts do assert the reliance of the public bath-houses on the continuous supply of water. Gates, who linked the disappearance of bathing culture in the West with the faltering 78 water infrastructure. This process was but one aspect of the general economic decline, which itself was quite complex and proceeded at an uneven pace. There are examples of slow degeneration even from the third century, but it did not affect everyone equally, and there are examples of, at least small scale, construction works (a bath-house, in this case) even in areas (like southern Etruria) that were generally becoming impoverished; still, T. Potter also mentions that at the beginning of the fifth century a large bath-house, that was in use until that point, was demolished, and replaced by what was most likely a villa; there is no mention of any conspicuous traces that would indicate the continued use of part of the old facility, or creation of a 79 smaller bathing establishment. The gradual impoverishment of agrarian 80 communities and cities was visible in all aspects of communal life, and necessarily 75 A. The archaeology of urban life in the Ancient Near East and Egypt, Greece and Rome. Potter, “Towns and territories in southern Etruria”, in: City and country in the ancient world, ed. Ward-Perkins, “Specialized production and exchange”, in: Late Antiquity: Empire and Successors, A. In both of the cited works, Ward-Perkins stresses the role of the specialisation of various regions in the 33 affected costly-to-run establishments, such as bath-houses. Nevertheless, there is some evidence from fifth-century Gaul showing that, while there are definite examples of crisis, at least some of the landowners were able to retain relatively 81 luxurious lifestyles. Letters of Sidonius Apollinaris provide much insight into this matter, and I am going to discuss some of them below. As for the East, the literary sources provide less information on the decline of the water infrastructure in this period – the anecdotal evidence from Procopius, while intriguing, is not representative, and the generally better economic situation of the Eastern part of the Empire in this period combined with few signs of material decay suggest that the water infrastructure continued to supply the cities without significant problems. It was only in the seventh century, as Liebeschuetz – discussing the case of Anatolia – notes, that while gymnasia went out of use, and even some of the aqueducts were abandoned, the bath-houses survived, and in some cases were newly built as well. It is also in this time that the civic structures become neglected, as the need for defences consumed available resources; the old public buildings in some cases became the 82 source of material for walls. Bouras, in an article published in 2002, noted that Byzantine aqueducts have not been studied systematically; the situation has been at least partially improved by the more recent studies, such as the already mentioned project examining the water 83 supply system of Constantinople, or the recent volume on Constantinople itself published in Poland (which deals to a certain extent with the subject of the city’s 84 water supply). While in certain areas of the former Empire only a few of the aqueducts built in Late Antiquity survived the Dark Ages, and the old water supply was mostly replaced by tanks, cisterns and wells, in others the infrastructure was preserved and maintained with care. The city of Rome itself benefited from major public works undertaken by some of the popes. While they city’s civil administration th still performed maintenance until the 8 centuries, papal involvement was not economic decline – as trade was becoming disrupted by the invasions and faltering commercial infrastructure, centres of production had no way of exchanging goods and making profit, which led to their downfall – the economic situations in many regions became even worse than before Roman period (B. From a letter of Gregory I, we know that over the course of sixth century, many of the aqueducts that were destroyed 86 by Vitigis in 527 were restored (although they did require further repairs). Provision of water for the city was necessary for baptisteria, mills and baths for pilgrims, making its supply a crucial matter. The public works expenses on part of some of the popes indicate their role as leading figures of the city. The number of establishments, both public and private, provided with water steadily increased throughout antiquity – 87 and the trend did not change during Late Antiquity. To these, Church amenities were added as well, including baptisteria and bath-houses. Coates-Stephens points to the cutting of the aqueducts during the Gothic Wars as a possible reason for the end of the operation of the great bath-houses in Rome during the sixth century (he also considers the possibility that the baths went out of use prior to that). It is also possible that due to the drop in Rome’s population and presumed reduction of the water consumption in bath-houses, the actual water supply per capita was, after partial restoration work on the aqueducts after 527, at a 89 record high. Finally, the evidence of restoration work during Late Antiquity and the early Mediaeval period indicates that the specialised technological knowledge 90 necessary for complex engineering was still being preserved. Coates-Stephens does not consider in the cited article the possibility that a skilled workforce may have been drawn from outside of Rome. One good example of the water infrastructure surviving throughout the Late Antiquity can be seen in Thessalonica, which retained its aqueducts and water tanks; few cities were as fortunate. Coates-Stephens, “The Water-Supply of Rome from Late Antiquity to the Early Middle Ages”, Acta ad archaeologiam et artium historiam pertinentia, vol. Coates-Stephens notes here that the evidence from Liber pontificalis provides hardly any information of technical nature. Some were leased to those who were running them; others were owned by monasteries (and likewise rented out by them). Old Roman baths in Thessalonica, after some modifications, were again in use during middle Byzantine times; we have no 91 information about their water supply, however. While mostly examining a period later than that on which my study is primarily focused, A. Epstein’s work provides further support for some of the observations being made here. They note that during seventh century, cities underwent a major transition from the ancient to mediaeval way of life th 92 – though with a reservation that the 7 century is only a “crude demarcation”. They further note that luxurious, communal bathing disappeared completely in the 8th century, and remains a privilege of some of the emperors. Some revival of bathing took place only during the 12th century – but looking into it would be far beyond the scope of this work. The authors do note that while the communal aspect of bathing was gone, bathing itself remained a part of medical treatment, and was still practised for hygiene, though for example monks bathed rarely, the most common rule dictating 93 to do so once a month.

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