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Several drugs are carcinogens kamagra polo 100 mg overnight delivery, including are described in relevant chapters buy kamagra polo 100 mg fast delivery. For patient who are seriously ill on first contact, enlist ity apparently results from drug-induced alterations in help for more rapid assessment and treatment. Teratogenicity is the ability of a substance to cause ingestion leads to better patient outcomes. Standard cardiopulmonary Toxic Effects of Drugs resuscitation (CPR) measures may be needed to maintain breathing and circulation. An intravenous (IV) line is Drug toxicity (also called poisoning, overdose, or intoxica- usually needed to administer fluids and drugs, and inva- tion) results from excessive amounts of a drug and may sive treatment or monitoring devices may be inserted. It Endotracheal intubation and mechanical ventilation is a common problem in both adult and pediatric popula- are often required to maintain breathing (in uncon- tions. It may result from a single large dose or prolonged scious patients), correct hypoxemia, and protect the ingestion of smaller doses. Hypoxemia must be corrected quickly to avoid scription, over-the-counter, or illicit drugs. Poisoned pa- brain injury, myocardial ischemia, and cardiac dys- tients may be seen in essentially any setting (e. In some cases, the patient or someone accompanying the Serious cardiovascular manifestations often require patient may know the toxic agent (eg, accidental overdose of pharmacologic treatment. Hypotension and hypoperfu- a therapeutic drug, use of an illicit drug, a suicide attempt). Dysrhythmias are treated according to Advanced causative drug or drugs are unknown, and the circumstances Cardiac Life Support (ACLS) protocols. For unconscious patients, as soon as an IV line is es- and may indicate other disease processes. Because of the vari- tablished, some authorities recommend a dose of able presentation of drug intoxication, health care providers naloxone (2 mg IV) for possible narcotic overdose CHAPTER 2 BASIC CONCEPTS AND PROCESSES 25 TABLE 2–2 Antidotes for Overdoses of Selected Therapeutic Drugs Overdosed Drug (Poison) Antidote Route and Dosage Ranges Comments Acetaminophen (see Chap. Give IV slowly, over Infrequently used because of its (atropine; see Chap. If cardiac arrest seems immi- nent, may give the dose as a bolus injection. If amount seizures and correction of of INH unknown, give 5 g; may be acidosis repeated. Lead Succimer Children: PO 10 mg/kg q8h for 5 days Opioid analgesics (Chap. Maximum dose, 30 g/24h (continued) 26 SECTION 1 INTRODUCTION TO DRUG THERAPY TABLE 2–2 Antidotes for Overdoses of Selected Therapeutic Drugs (continued) Overdosed Drug (Poison) Antidote Route and Dosage Ranges Comments Tricyclic antidepressants Sodium bicarbonate IV 1–2 mEq/kg initially, then contin- To treat cardiac dysrhythmias, (see Chap. This group issued treatment guide- fingerstick blood glucose test should be done and, if lines that have also been endorsed by other toxicology hypoglycemia is indicated, 50% dextrose (50 ml IV) organizations. Once the patient is out of immediate danger, a thorough used routinely and that adequate data to support or ex- physical examination and efforts to determine the clude their use are often lacking. Opinions expressed drug(s), the amounts, and the time lapse since exposure by the consensus group and others are described are needed. If the patient is unable to supply needed in- below: formation, interview anyone else who may be able to do Ipecac. Ask about the use of prescription, over-the-counter, may delay administration or reduce effectiveness alcohol, and illicit substances. There are no standard laboratory tests for poisoned pa- bowel irrigation. Ipecac may be used to treat mild poi- although baseline tests of liver and kidney function are sonings in the home, especially in children. Specimens of blood, urine, or gastric should call a poison control center or a health care fluids may be obtained for laboratory analysis. If used, it is most Screening tests for toxic substances are not very beneficial if administered within an hour after in- helpful because test results may be delayed, many sub- gestion of a toxic drug dose. It is contraindicated in less than alert pa- layed to obtain results of a toxicology screen. Identifi- tients unless the patient has an endotracheal tube in cation of an unknown drug or poison is often based on place (to prevent aspiration). If the in- Serum drug levels are needed when acetaminophen, gested agent delays gastric emptying (eg, tricyclic alcohol, digoxin, lithium, aspirin, or theophylline is antidepressants and other drugs with anticholinergic known to be an ingested drug, to assist with treatment. For orally ingested drugs, gastrointestinal (GI) de- after ingestion of pills or capsules, the tube lumen contamination has become a controversial topic.

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Nevertheless discount 100mg kamagra polo visa, one has to be familiar with the Western medical theory to understand the problems aris- ing out of our normal treatment methods 100mg kamagra polo otc. Our small patients normally already have an odyssey of unsuccessful Western treatment behind them before they come for treatment with Chinese medicine. For a Chinese medical therapist, it is of utmost importance to know how to deal with the side effects of Western medicine. In conclusion, this book is a positive enrichment to the Chinese medical literature and helps to shed light on this difficult, complex topic that puts such a large burden on small patients. Neunkirchen-Seelscheid, Germany This book is an excellent resource for practitioners of Chinese medicine interested in including pediatrics in their practice. Helmer has compiled an impressive amount of clinical information on treating enuresis. By understanding the TCM approach to this very common pediatric condi- tion, practitioners can offer a valuable treatment option to parents and gain valuable insight into the general field of TCM pediatrics. How to put all this knowledge into practice is demonstrated in quite a few well structured case histories. This book takes the integration of Western and Chinese medical approaches one step further. Mödling, Austria Instead of writing a book explaining the theoretical basis and standard pattern discrimination of nocturnal enuresis, Helmer presents a vast and varied amount of real-life clinical literature from China. For the first time in the treatment of this common pediatric complaint, Western practitioners can base their treatments on the same amount of material which builds the base of clinical practice of expert Chinese doctors. The author is very thorough in Western and Chinese diagnosis and treatment of enuresis and he has also done a convincing job that his modality of diagnosis and treatment really works. I could also tell that the author has treated many children with this problem. I highly recommend this book to any physician and acupuncturist who treat this difficult, recalcitrant problem. Conclusion ………………………………………………… 207 Appendix 1: Nocturnal Enuresis In-take Form …………… 209 Appendix 2: Tips for Dryer Nights ………………………… 213 Appendix 3: Guided Imagery Exercise ……………………… 219 Appendix 4: How to Measure a Childs Bladder Capacity …… 221 Appendix 5: Hints On Prescribing & Administering ……… 223 Appendix 6: Hints On Administering Acupuncture ……… 225 English Language Bibliography …………………………… 227 Index …………………………………………………………… 231 Preface This book is a clinical manual on the treatment of pediatric enure- sis or bed-wetting. It is based on my research and translation of the Chinese medical literature, my studies with numerous Chinese medical pediatricians in China over a number of years, and my own clinical practice of Chinese medical pediatrics in Canada. For 2,000 years, Chinese medical practitioners have treat- ed pediatric enuresis using a variety of modalities, and, over the last 25 years, clinical trials have proven that these treatments are effective for the cure of this condition. Modern Western medi- cine, on the other hand, does not have an effective treatment for this disease, and, in terms of biomedical pathophysiology, there is no known cause in 97-99% of cases of pediatric bed-wetting. In fact, within the Chinese medical literature, there is far more research on these traditional Chinese medical treatments for this condition than there is in English on the modern Western medical pharmaceuticals used to treat this disease. Unfortunately for prac- titioners of Chinese medicine and their patients, prior to this book, this information was only available in the Chinese language. I have also chosen to write about pediatric enuresis because it is easy to determine how effective the treatment has been. Therefore, the information in this book can be used for further research on the traditional Chinese medical (TCM) treatment of this disorder in the non-Chinese setting. I trust this book will help Chinese medicine grow and flourish in years to come and help establish TCM as an effective treatment for enuresis outside of China. The book begins with discussions of the modern Western medical nosology, etiology, pathophysiology, diagnosis, and treatment of this common condition. This is followed by discussions of its modern Chinese medical disease causes and mechanisms, pat- tern discrimination, and standard, textbook treatment via acupunc- ture, tuina, and internally administered herbal medicine. However, the bulk of the book is a presentation of summaries of numerous recently published Chinese clinical trials on the treatment of pedi- atric enuresis with a host of treatment modalities and protocols. This is because the bibliographic information for each clinical trial is given in the body of the text. There is an English language bibliography as well as several, hopefully useful appendices. Where these sources are cited in the text, the reader will find a corresponding number in paren- theses in order to identify the source. Robert Helmer June 2005 1 Introduction Enuresis is a term of Greek origin that literally means to expel urine. This is described as the involuntary voiding of urine during sleep beyond the age of anticipated urinary control.

A consistent finding was that order kamagra polo 100mg online, as in inant descending effect is facilitation of feed- Fig discount kamagra polo 100 mg free shipping. Agood focus the command on the few motoneurones candidate would be increased excitability of the pro- involved in such contractions. Medium-latency propriospinally mediated inhibi- tion of antagonistic motoneurones contributes sig- Patients with spinal cord lesions nificantly to the relaxation of the antagonists dur- ing flexion-extension movements (see Chapter 11, Peroneal facilitation of the quadriceps H reflex pp. Facilitation of the quadriceps H reflex by com- mon peroneal nerve stimulation is also increased Stance phase of walking in patients with spinal cord lesions (Remy-Neris´ ´ et al. The increase was sometimes limited (i) The group I discharge from the pretibial flex- to the early group I peak (Fig. Propriospinally mediated group I inhibition late group II-mediated excitation is considered in from intrinsic plantar muscles could be one of the Chapter 7 (pp. It Studies in patients and clinical was assumed to be mediated by the same neurones implications asthepropriospinallymediatedexcitationdescribed above,butthisisdoubtful,givenitsmuchlongercen- Spasticity tral delay (11–15 ms). Changes in the CPN facilitation of quadriceps motoneurones in spastic patients. Corticospinal projections revealed by TMS are interrupted by the lesion (horizontal dashed arrow) in spastic patients. The net result of the corticospinal lesion would be disfacilitation of feedback inhibitory interneurones (IN) inhibiting propriospinal neurones (PN). Resume´ ´ 505 motoneurones with a strong input from peripheral Conclusions afferents (in particular group II afferents) and from vestibulospinal and reticulospinal tracts. Organisation of the lumbar propriospinal system Striking differences exist between the organisation Methodology of the lumbar and cervical propriospinal systems. The more caudal the motoneu- no evidence for cutaneous inhibition of the relevant rone pool in the spinal cord, the longer central delay, interneurones. Corticospinal excitation of feedback again suggesting mediation through premotoneu- inhibitory interneurones seems to be stronger than rones located rostral to motoneurones. Over its first 3 ms, this Voluntary contractions facilitationispurelygroupIinorigin. Withallowance for the difference in the lengths of the afferent path- The main descending input during weak vol- ways,theamountofgroupIfacilitationcanbemeas- untary contractions seems to be to feedback ured at the 10-ms ISI to assess the excitability of the inhibitory interneurones, presumably to focus the lumbar propriospinal neurones. The suppression of command on the few motoneurones involved in the theHreflexproducedbytheconvergenceofperoneal contraction. Facilitation of increased in spastic patients, probably because of the on-going quadriceps EMG by common peroneal the disruption of the strong corticospinal control on nerve stimulation is a simple method, which can be feedback inhibitory interneurones. Resume´ ´ Organisation and pattern of connections Background from animal experiments Peripheral excitation of lumbar Two systems of short-axoned lumbar propriospinal propriospinal neurones neurones have been described: (i) dorsolateral, located in L3–L5, projecting to distal motoneurones, Thisperipheralexcitationdiffersfromthattocervical the input of which is mainly (if not exclusively) from propriospinal neurones in several respects. However, both the potency of the group rones inhibiting propriospinal neurones, probably Iexcitation and the above convergence could be to focus the command to the few motoneurones specific to the common peroneal nerve-quadriceps involved in such contractions. During gait, the pero- combination, the only one so far investigated in neal group I discharge is needed to depolarise pro- detail. As a result the facilitation can increase with the stimulus intensity far above The excitability of propriospinal neurones is 1 × MT, at least in the common peroneal nerve– increased in spastic patients, whether the cor- quadriceps combination. This bition between the effects elicited by two different increased group I-induced excitability could be due nerves is often found. The greater increase in excitation in patients with spinal cord Inhibition of motoneurones injury is considered in Chapter 7. There is no change in propriospinal group I excitation in parkinsonian Inhibition of motoneurones has been regularly patients. This inhibition is superim- dependent effects evoked by foot muscle afferents on leg posed on the disynaptic reciprocal Ia inhibition, muscle activity in humans. Electroencephalography and occurs only during active dorsiflexion and, although Clinical Neurophysiology, 101, 339–48. The C3–C4 propriospinal TMS produces activation of both propriospinal neu- system: target-reaching and food-taking.

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Such cyborg-like modules of silicon vices have been created for quadriplegic sub- neurons could partially patch a disconnection jects order 100mg kamagra polo otc. Patterns of cerebral electrical activity ex- in a cortical or spinal circuit buy cheap kamagra polo 100mg line. Brain-derived signals implanted sensors and stimulators, in online may soon command neuroprostheses. The functional and chemical imaging, in targeted cochlear implant restores hearing for people drug delivery, in tissue engineering, and in 193 194 Neuroscientific Foundations for Rehabilitation Table 4–1. The motor point is the most now, painstaking research and development common site for direct electrical stimulation. Bionics, however, is on the are recruited as current spreads from an elec- threshold of creating devices that find and de- trode. Functional neuromuscular stimulation cipher the neural signals that express cognitive requires an intact motor unit. If anterior horn control over important movements from within cells have been destroyed, roots torn or avulsed, their residual pathways. The nerves and motor points af- fected by complete brachial plexopathies, cen- PERIPHERAL NERVOUS tral cord injuries, and conus/cauda equina SYSTEM DEVICES trauma cannot be activated. The amount of current delivered to a given Functional Neuromuscular region determines the success of muscle con- Stimulation traction. The current produced by a stimulator at a surface or implanted electrode is adjusted The term functional neuromuscular stimula- by its pulse waveform, usually a square wave, tion (FNS) will be used to describe devices and especially by its amplitude and duration. Functional ond aim for a tetanic contraction, which occurs electrical stimulation (FES) is a term often at 15 Hz–30 Hz. I will apply it, however, are used, coil shape and placement, the mag- to describe electrical stimulation devices that netic gradient, and pulse duration manipulate were designed primarily to increase muscle the current. High rates of stimulation and a volume and strength or to decrease hyper- larger duty cycle, which is the ratio of time that tonicity, but not to directly affect self-care the stimulator is on compared to off, produce skills. Func- cations to stimulation include pacemakers, tional neuromuscular stimulation devices high susceptibility to cardiac arrhythmias, and have faced a difficult road in reaching con- autonomic instability, along with severe bone sumers. Implanted electrodes and agencies over safety and efficacy, as well as stimulators that are placed under the skin be- with liability issues, cost-benefit analyses, and come a contraindication for imaging studies by production costs for items that may have a MRI and can lead to complications such as bac- very limited market. Neurostimulators and Neuroprostheses 195 Portable FNS systems powered by batteries SYSTEMS FOR THE UPPER EXTREMITY allow consumers to learn how to time the on- set and offset of the desired muscle contrac- The first commercial neuroprosthesis for hand tion and movement. The trainer sets the stim- grasping with implanted electrodes is the ulus parameters through trial and error and $35,000 FreeHand system (NeuroControl practice with the subject. A hand-held button, and extend the wrist, but cannot use their heel switch, or joint position sensor may, for hands. An external shoulder position trans- example, trigger movements during walking. A ducer activates an external programmable con- shoulder movement, wrist angular transducer, trol unit. The unit is wired to a subcutaneously and voice activation switch have worked for implanted receiver/stimulator with eight chan- stimulation of the upper extremity. The outlets are wired to epimysial elec- connects to the stimulator with its programmed trodes sutured onto the adductor pollicus, ex- microprocessors. The microprocessors control tensor pollicus longus, abductor digitorum the firing parameters of each channel and ac- brevis, extensor digitorm communis, and flexor tivate an electrode wired to a muscle. From 4 digitorum superficialis muscles and, some- to 16 muscles of an extremity are modulated, times, other groups such as flexor digitorum firing in various combinations of timed con- profundus and flexor pollicus longus for a tractions. Sensory feedback to create a closed stronger palmar or lateral prehension grasp. Propor- parameters will increase the functionality of tional control of grasp arises from the external FNS systems. The subject chooses either a lateral Short-term or intermittent stimulation ses- pinch to hold small objects or a palmar grip for sions employ surface electrodes with low im- larger items. Long-term stim- that position and another quick jerk unlocks ulation for daily use is most practical using and releases the grip.

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