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By C. Roy. Delta College.

Modulation of the MEP in biceps and triceps brachii by ulnar volleys in a patient with a spinal lesion at the C6–C7 junction generic 17.5mg nicotinell amex quit smoking 6 months pregnant. The lesion (thick horizontal dotted line) is presumed to interrupt axons of PNs and largely to spare the corticospinal projections to MNs and segmental INs order 17.5 mg nicotinell otc quit smoking now for free. Samples of averaged (20 sweeps) rectified control (thick lines) and conditioned (thin lines) MEPs (expressed as a percentage of the background EMG) are illustrated for the biceps at the 4. Control MEPs in triceps (below the lesion) had the same latency (∼13 ms) and similar area on both sides, consistent with the relative sparing of the corticospinal projections to low-cervical MNs and segmental INs. Studies in patients 481 complete disappearance of the ulnar-induced facil- cortico-reticulospinal connections (Benecke, Meyer itation of the triceps MEP. The take-over by one system of enter the spinal cord below the lesion (at C8–T1), it a function lost by another would be more likely is unlikely that the lesion selectively interrupted the if the output from these two systems converged part of the volley directed to triceps motoneurones onto common neurones projecting onto motoneu- (also below the lesion) while sparing an ascend- rones. In this respect, C3–C4 propriospinal neu- ing branch towards biceps motoneurones. The sim- rones receive extensive excitatory input from several plest explanation would therefore be that, on the descendingtractsandprimaryafferents,andarewell affected side, the lesion at the junction between the placed to play a role in the process of recovery from C6 and C7 spinal segments interrupted the descend- hemiplegia. Thus, on the affected side, ulnar facilitation and cutaneous inhibition of Superficial radial-induced suppression of the on- propriospinal neurones was no longer able to mod- going EMG of ECR has been compared on the ify the MEP of triceps motoneurones. Recovery Method It islikelythat,inthispatient,asinthecatafterselec- tive section of propriospinal axons, the command The symmetry of the voluntary contraction was normally relayed through propriospinal neurones achieved by matching the level of integrated recti- was subsumed by spared corticospinal projections fied EMG activity in contractions of ∼6–8% of MVC via segmental interneurones. However, an identical level why,despitetheinterruptionofpropriospinalaxons, of absolute EMG activity corresponds to a differ- control MEPs were reasonably symmetrical in tri- ent percentage of maximal effort on the affected ceps, and the motor impairment was mild in this and unaffected side, and it is therefore relevant that, muscle. The intensity of the Stroke patients conditioning stimulus was graded using the motor response in thenar muscles due to a spread of stim- Theseverehemiparesisthatcanaccompanyastroke ulation to the median nerve. However, in patients with poor recovery, restricted to proxi- The central finding of the study was the asymmetry mal muscles, it has been suggested that the resid- ofthesuppressionelicitedbyatrain. PN Recovery in stroke patients C4 Feedback poor good inhibitory (f ) (g) IN 120 120 100 100 C5 80 80 60 60 C6 40 40 20 20 Bi MNs ECR Superficial Unaff. Asymmetry of the superficial radial suppression of the ongoing EMG of ECR in stroke patients. The same subset of propriospinal neurones (PN) project to extensor carpi radialis (ECR) and biceps (Bi) motoneurones (MNs). There is transiently increased efficacy of descending (possibly reticulospinal) projections to PNs (see pp. The lesion (✚) has interrupted corticospinal projections to PNs and feedback inhibitory interneurones (IN). Each thin line represents one patient and the thick lines (and ●) the mean values. Studies in patients 483 one normal subject (b), but much more profound of the same magnitude as in normal subjects, when on the affected side than on the unaffected side of using a single shock (Fig. These dence against increased corticospinal activation of results are representative of those in the control and inhibitory interneurones (a possibility that would patientgroups;themeanvaluesofEMGsuppression be unlikely, given the corticospinal lesion). In fact, elicited by the train were not different for the right the corticospinal lesion is more likely to have caused and left sides of healthy controls and the unaffected decreasedcorticospinaldriveonfeedbackinhibitory side of the patients. The greater suppression observed on greater EMG suppression on the affected side of the affected side with the train could thus be the patients(Fig. Theasymmetryseenwith net result of two opposing effects: decreased cor- the train in stroke patients contrasts with the sym- ticospinal drive on inhibitory interneurones, and metry of the weak suppression elicited by single agreater component of the descending command volleys (0. MEP during ramp contractions Evidence for disfacilitation Support for a greater component of the descend- In three patients, it was possible to compare the ingcommandrelayedthroughthepropriospinalsys- modulationoftheon-goingEMG,theMEPandtheH tem is provided by the asymmetry found in stroke reflexatthetimeoftheirfirsttest,whentheasymme- patients between the musculo-cutaneous facilita- try of the EMG suppression was prominent. On the tion of the MEP evoked in the FCR by TMS at the unaffected side, the cutaneous volleys produced, as onset of a ramp task involving co-contraction of FCR in normal subjects, a suppression of the EMG and of and biceps: the facilitation was significantly larger the MEP, with little change in the H reflex. There affected side, the on-going EMG and the MEP were is therefore evidence from another laboratory, using suppressed more than the H reflex. The asymmetry adifferenttechnique,forincreasedexcitationofpro- of the two former responses was significantly greater priospinalneuronesduringvoluntarycontractionin than the asymmetry of the H reflex, and this argues stroke patients. Possible mechanisms underlying increased excitation of the propriospinal neurones during voluntary contraction Increased excitation of propriospinal neurones and recovery from hemiplegia Increased excitation could result from unmasking and/or reorganisation of projections from the ipsi- Evidence for a greater component of the lateral undamaged hemisphere. It has been sug- descending command relayed through the gested that the residual motor capacity in patients propriospinal system with poor recovery could involve such projections. Greater suppression of the on-going EMG by cuta- Data obtained with TMS of the ipsilateral undam- neous volleys in patients with poor recovery may agedhemisphereinpatientswithpoorrecoveryfrom result from more of the descending command pass- stroke are consistent with this view. Indeed, MEPs ing through the propriospinal relay or from an are more likely to be elicited by stimulation of the increase in the excitatory corticospinal drive to feed- undamaged hemisphere in the ipsilateral affected back inhibitory interneurones.

I also was beginning to make a slight but definite change in my behavior with patients discount 52.5 mg nicotinell visa quit smoking encouraging words. Books like that buy nicotinell 17.5mg low cost quit smoking yahoo, at least for me, always come at a special time, when there is a readiness to absorb what the author is saying. Carl Rogers left a deep and lasting impression on me through both his writings and his person. He laid out in some detail what listening was about and described the process of true listening. Some people call the process active listening: Te listener reflects back what has been heard until there is mutual agreement between listener and speaker. Rogers had also formulated a school of psychotherapy called client-centered therapy. Te notion, in very brief and too abbreviated terms, held that people have the internal resources to heal their own psy- chological problems. Rogers believed that at the center of each per- son there is a core of goodness. Te psychotherapist had only to fa- cilitate that core into action by very careful listening to the person. It is far beyond the scope of this book to go into more detail about what Rogers had to say. David Rogers, who had been chair of medi- cine at Vanderbilt when I was a senior resident on his service in 1959–60. David Rogers went on to an illustrious medical career until his early death in the 1990s. After his time as chief of medicine at Van- derbilt, where he was an active investigator of infectious diseases, he became dean of the School of Medicine at Johns Hopkins. After Hopkins, he served as the first president of the Robert Wood John- son Foundation. Tere, he set the direction for the foundation and established many of its national programs. One of these, Human Mind and Body 53 Dimensions in Medicine, was championed by his father, Carl Rog- ers. I participated in the course and experiences of Human Dimen- sions in Medicine and got to know Carl himself. A widespread pub- lic belief then held that medicine had become cold and detached. As I ended my time as dean in Birmingham, I asked for and obtained a sabbatical to regroup and further retrain my clinical skills. All I knew then was that I no longer wanted to be dean, and that I wanted to return to clinical medicine. I joined Carl Rogers at his Center for the Study of the Person in La Jolla in 1973. Te offices of the center sat high above the seemingly endless Pacific Ocean. On a clear day, I could sometimes see pods of whales surface in the dis- tance, rising from some unfathomable depth. When I spent time with Carl, I was quite sure that he had nothing on his mind except trying to understand what I was say- ing and thinking. He seemed to draw the words out of my mouth and somehow helped me to express myself more fully and more ac- curately. He would continue to gently rephrase what I had said until I agreed with his rephrasing. He had a remarkable listening talent, which he describes in detail in On Becoming a Person. Te seminars and contacts with the fellows at the Center for the Study of the Person led me to a much deeper understanding of both human communication and myself. Many of the seminars were conducted as experiential learning sessions, with the focus limited to the interactions between the people in the room.

Additionally nicotinell 17.5 mg sale quit smoking vapor sticks, I raise and explore answers Introduction xiii to a set of questions about patients who carry diagnoses of diseases they do not have: 1 cheap nicotinell 17.5 mg line quit smoking keep coughing. If the patient does not have the disease diagnosed, then what does he or she have? What harm can come from having a diagnosis of a disease that is not present? Why has this error been almost completely ignored in the medical literature? In the later chapters, I present patient stories, findings, and out- comes that came from my adoption of a broader model of disease and illness. Many patients were referred to me by physicians who knew of my interest in problem patients and particularly in patients who carried diagnoses of diseases they did not have. In the last chapters of the book, I present applications of a broader paradigm of disease that was proposed by George Engel, which may be a step in this new direc- tion. Abram and I formulated the following hypothetical statement to define this broader biopsychosocial model: I do not believe in a single causation for most diseases. I be- lieve the symptoms of disease arise in a highly complex mix of genetic weakness, psychosocial events and stresses, physico- chemical abnormalities, and a host of other factors. I see pa- tients as people with problems who may or may not also have a demonstrable physicochemical defect. If the defect is defin- able, I prescribe medication aimed at correcting the physio- xiv Symptoms of Unknown Origin logic abnormality or I recommend a surgical procedure. I also listen to the patient in a manner that will permit him to bring up whatever is bothering him. I am impressed with the fre- quency with which my patients can tell me what happened in their lives just before getting sick. I recount my time with Carl Rogers at the Center for the Study of the Person in La Jolla, California, and with Joseph Sapira, a mas- ter clinician at the University of Alabama in Birmingham, and with Stonewall Stickney, one of my mentors in psychiatry at the Univer- sity of South Alabama School of Medicine in Mobile. I am suggesting the term symptoms of unknown origin, or SUO, for all patients who do not have a ready or immediate medi- cal explanation for their physical symptoms. Tis approach also avoids the use of more pejorative terms like crock, shad, or turkey. We really do not know what the origin of any symptom is when we first meet a patient. My plea is to stay in that mode until the level of certainty of the diagnosis is compelling. Most important, this term enlists the patient in inspecting his or her life to find the variables that may be triggering or even causing the symptoms. Several colleagues have suggested that the clinical methods de- scribed here need a unifying name. Tey tell me this will help others use, explore, and test the interventions. Te mainstay of PDR as a method is enlisting and directing patients to uncover the causes of their symptoms. Te physician remains a coach on the sidelines and, through the use of unspecified language and other techniques, calls on the mind of the patient to re-collect lost or unknown associations that lie behind the symptoms. Te details of the PDR methods are presented in the case reports and in Chapter 20. A nurse and physician rolled a patient in a wheelchair into the bottom of the amphitheater. A white-haired fiftyish-appearing woman in a bath- robe and nightgown sat slumped to one side of the wheelchair. She struggled to raise her head from its dangling position but could not. Te rows of seats of the amphitheater slanted upward in an acute angle for nearly two stories. Students sitting in the top rows looked almost directly down into the pit below.

Children are instructed to void into a special toilet with a pressure-sensitive rotating disc at the base discount nicotinell 17.5mg overnight delivery quit smoking 5th day. A normal uroflow study shows a single bell-shaped curve with a normal peak and average flow rate for age and size cheap 35mg nicotinell fast delivery quit smoking ear treatment. Patients with urethral obstruction and neurogenic bladder have prolonged curves or an interrupted series of curves and low peak and average urine flow rates. Electrocardiogram If heart block is suspected, an electrocardiogram is performed. Each has its strong and weak points and each is indicated for cer- tain types of enuresis. Patient & family counseling The first treatment provided by the Western medical practitioner should be patient and family counseling. This should begin during the first visit and is provided to reassure and provide emotional support to those affected by this disease. Parents should also be asked what they think is causing the enuresis so any irrational fears may be discussed if present. In addition to explaining what does and does not cause enuresis, the practitioner should explain to those involved that enuresis can be a self-resolving condition but that treatment will help the child overcome this condition even quicker. It is especially important to explain to the child and their family that the child has no control over this condition and it is not their fault. Further counseling tips for children and their fam- ilies are given below and may be incorporated into clinical practice either verbally, via a handout, or both. These tips include a num- ber of different methods of treatments, such as behavioral modifi- cation, motivational therapy, and dietary therapy, that may be used to both treat and possibly prevent enuresis. Motivational therapy Motivational therapy includes any method that involves reassuring 28 Treating Pediatric Bed-wetting with Acupuncture & Chinese Medicine the parents and the child, removing the guilt associated with bed- wetting, and providing emotional support to the child. These methods include instructing the child to take responsibility for his or her bed-wetting. In other words, youngsters who have enuresis should be helped to understand their condition and to realize that, while they did not cause the problem, they do have a role in the treatment plan. Positive reinforcement for a desired behavior may be used and some examples are listed in the Tips for Dryer Nightsin Appendix 2. The total resolution rate for those that receive motivational therapy alone is 25%. While this is not high, it is higher than the 15% rate of spontaneous resolution. In addi- tion, up to 70% of children who receive motivational therapy have shown an obvious improvement in their condition. Forms of behavior modification included below are positive rein- forcement, periodic waking, and restricted fluid intake. Some sources say behavior modification alone can often improve night- time dryness in one month. One study on dietary therapy showed that foods suspected of contributing to enuresis included some of the above mentioned foods as well as dairy products, cit- rus fruits, and juices. These exercises are accomplished by having the child hold their urine while on the The Western Medical Treatment of Enuresis 29 toilet. Useful ways of accomplishing this training include having the child either sing or count to ten while sitting on the toilet before voiding. In general, children are asked to hold their urine for longer periods of time during the day. These holding-on exer- cises are practiced during the day, and some believe these exer- cises can help the muscles of the bladder to hold more urine before they have to urinate. Some studies demonstrate that the functional bladder capacity may be less in children with enuresis, which then leads to the bladder prematurely emptying during the night. In yet another study (29), 66% of children reported some improvement after using this method for six months, and 19% had a complete resolution of symptoms after the same length of treatment. The bladder capacity did increase significantly in those patients who responded to this therapy. Unfortunately, these findings are based on only one study and must be combined with similar supportive data to confirm the effectiveness of this treatment. In my own personal opinion, this treatment may help and is rather benign if not done excessively, i.