By J. Murak. Kent State University.
Descending effects Strong contractions Corticospinal excitation During strong contractions purchase 40mg prednisone, cutaneous and joint Spatial interactions have been found between cor- afferents facilitate the transmission of homony- tically evoked and Ib inhibitions of the soleus H mous Ib inhibition of quadriceps motoneurones (cf buy prednisone 40 mg overnight delivery. The reasons why convergence of femoral inhibitory actions are weak, the interaction is facil- groupIandjointorcutaneousvolleysisrevealedonly itatory, suggesting convergence onto interneurones during strong contractions of the target muscle are mediating Ib inhibition, as demonstrated in the cat discussed below. Increasing the strength of cortical and group I inhibitory actions During weak contractions of the quadriceps, invol- reverses the interaction, suppressing the inhibition. Ib and Ia afferents from quadriceps (Q) in the femoral nerve (FN), joint afferents in the deep peroneal (DPN) and cutaneous (Cut) afferents in the superﬁcial peroneal (SPN) nerves converge onto common Ib interneurones (INs) projecting onto Q motoneurones (MN). Pathways through which separate stimulation of DP and SP nerves evoke facilitation of Q MNs are not represented. Note the lack of suppression in the initial bins of the peak of femoral excitation (i. Motor tasks – physiological implications 267 Ia excitation evoked by femoral nerve stimulation elicited by combined deep and superﬁcial pero- in a voluntarily activated vastus lateralis unit was neal volleys in Fig. If anything, in the absence of the femoral group I volley, combined stimulation of deep and superﬁ- Conclusions: necessity for convergence cial nerves produced some facilitation in the PSTH of multiple inputs (not illustrated). This indicates that convergence of thetwoconditioningvolleyswiththefemoralgroupI The above ﬁndings indicate that group I afferents in volley is required for the inhibition to manifest itself. At rate stimuli (h)reveals a profound suppression that rest, or during weak contractions, this convergence spares the ﬁrst 0. This initial sparing conﬁrms the conver- articular and cutaneous, which excite Ib interneu- genceofthedifferentvolleysontointerneuronesthat rones through ﬁrst-order interneurones (see the areintercalatedinadisynapticinhibitorypathwayto sketch in Fig. The most parsimonious explanation would be gence has been observed when combining afferent that during such contractions there is a descend- volleys in the superﬁcial (or the deep) peroneal and ingfacilitationoftheﬁrst-orderinterneuronesmedi- the lateral articular nerve of the knee joint. Thus, descending voluntary drives would have two effects: (i) depression of transmis- Resting conditions sion in Ib inhibitory pathways, which would prevent At rest, stimulation of either the superﬁcial or the the Ib discharge from the contracting muscle from deep peroneal nerves at appropriate ISIs and inten- hinderingthedischargeofactivemotoneurones;and sities facilitates the quadriceps H reﬂex (Figs. Yet, when the two con- transmission through interneurones mediating this ditioningvolleyswerecombined,thefacilitationpro- Ibinhibition,thusallowingautogeneticinhibitionto duced by either volley alone was reversed to signiﬁ- reappear when necessary to modulate contractions cant suppression (Fig. Thus, suppression of the quadriceps Motor tasks and physiological Hreﬂex, due to convergence of conditioning volleys implications inbothdeepandsuperﬁcialperonealnerveswiththe femoral test volley may be observed at rest. The brief Human tendon organs respond readily in isometric duration of the inhibition of the quadriceps H reﬂex voluntary contractions and usually discharge 268 Ib pathways strongly during shortening contractions, even in rest, but this inhibition is markedly depressed dur- the absence of an external load. The discharge ing a tonic contraction involving only the triceps increases during concentric contractions as EMG surae (Fournier, Katz & Pierrot-Deseilligny, 1983; builds up (Burke, Hagbarth & Lofstedt,¨ 1978). The stronger the force of the tonic Changes in transmission in oligosynaptic pathways contraction, the greater the suppression of the fed by Ib afferents during various motor tasks in Ib inhibition (Pierrot-Deseilligny & Fournier, 1986; humans have provided insight into the control of Fig. The controls so disclosed suggest that these pathways might serve several functions. Heteronymous Ib inhibition from quadriceps However, functional interpretations drawn from to soleus such experiments must be made with care because it cannot be taken for granted that the response During selective tonic contractions of triceps surae, of interneurones fed by Ib afferents to a natural Ib inhibition of the soleus H reﬂex produced by desynchronised input would be the same as to the stimulation of the femoral nerve is also suppressed, phasic synchronised input produced by artiﬁcial and this reveals the heteronymous monosynaptic Ia electrical volleys explored in the experiments below. This suppression probably reﬂects the con- vergence of group I afferents from quadriceps and Suppression of Ib inhibition to voluntarily triceps surae onto common Ib interneurones pro- activated motoneurones jecting onto soleus motoneurones (cf. ChangesintransmissionofIbinhibitiontovoluntar- Possible mechanisms underlying changes ily active motoneurones have been investigated for in transmission in Ib pathways the pathways from and to triceps surae during selec- tive voluntary contractions of this muscle (Fournier, Three questions arise about the mechanism(s) Katz & Pierrot-Deseilligny, 1983; Pierrot-Deseilligny responsible for the suppression of the group I inhi- &Fournier,1986;Stephens&Yang,1996). Theeffects bition of the soleus H reﬂex during triceps surae vol- ofconditioningcutaneousandarticularvolleysonIb untary contractions: (i) Does a decrease in Ia excita- interneurones have been investigated on the path- tion contribute to it? The changes elicited by the conditioning infer- Evidence for suppression of the inhibition to ior soleus volley are the net result of two effects voluntarily activated motoneurones (monosynaptic Ia excitation and Ib inhibition), and the suppression of the inhibition during contraction Homonymous Ib inhibition of soleus could therefore result from a decrease in presynap- motoneurones is suppressed during tonic tic inhibition of Ia terminals as well as a decrease contractions of gastrocnemius-soleus in Ib inhibition.
Within their formula purchase prednisone 20mg mastercard, Sang Piao Xiao and Yi Zhi Ren sup- plement the kidneys generic prednisone 20 mg visa, assist yang, and reduce urination. Shan Yao supplements the spleen and stomach and boosts the liver and kidneys. Therefore, when all these medicinals are used together, the lungs and spleen become exuberant, the kidneys become full and replete, water fluids are contained, and the goal of stopping enuresis is achieved. Since the kidneys govern the bones, spina bifida is believed to be a mani- festation of kidney vacuity in Chinese medicine. Likewise, many Chinese believe that enuresis is mainly due to kidney vacuity. In any case, it should be noted that all five cases of pediatric enure- sis in this study who had spina bifida were cured by using Suo Niao San (Reduce Urination Powder). From The Use of Self-Devised Zhi Yi Fang (Stop Enuresis Formula) for the Treatment of 42 Cases of Pediatric Enuresis by Chen Jian-zhong & Chen Hai-sheng, Gui Yang Zhong Yi Xue Yuan Xue Bao (Guiyang College of Chinese Medicine Academic Journal), 1998, #1, p. The course of disease was as short as three months and as long as seven years. All cases had an x-ray or a CT scan examina- tion, and 10 cases had spina bifida in the lumbrosacral area. Treatment method: The prescription Zhi Yi Fang (Stop Enuresis Formula) was com- posed of: Yi Zhi Ren (Fructus Alpiniae Oxyphyllae), 9g Fu Pen Zi (Fructus Rubi), 9g Chinese Research on the Treatment of Pediatric Enuresis 81 Sang Piao Xiao (Ootheca Mantidis), 12g Wu Yao (Radix Linderae), 9g Dang Shen (Radix Codonopsitis), 9g Fu Ling (Poria), 15g Shi Chang Pu (Rhizoma Acori Tatarinowii), 6g Yuan Zhi (Radix Polygalae), 6g uncooked Long Gu (Os Draconis), 15g One packet of these medicinals was decocted in water two times, the decoction was then divided into two doses, and these two doses were administered once in the morning and once at night. If there was qi and blood vacuity weakness with profuse sweat- ing, a bright white or sallow yellow facial complexion, and the essence spirit was less than normal, 12 grams of Huang Qi (Radix Astragali) and nine grams of Dang Gui (Radix Angelicae Sinensis) were added. If there was poor appetite, six grams each of Shen Qu (Massa Medica Fermentata), Mai Ya (Fructus Germinata Hordei), and Ji Nei Jin (Endothelium Corneum Gigeriae Galli) were added. Ten days equaled one course of treatment, and, in general, the medicinals were given for three courses of treatment. Of the 10 cases with spina bifida, four cases markedly improved, three cases got some improvement, and three cases got no improvement. Therefore, winthin the above formula, Yi Zhi Ren, Fu Pen Zi, and 82 Treating Pediatric Bed-wetting with Acupuncture & Chinese Medicine Sang Piao Xiao supplement the kidneys and reduce urination. Dang Shen and Fu Ling boost the heart qi, while Shi Chang Pu and Yuan Zhi open the heart orifices and promote the interaction of the heart and kidneys. When all these medicinals are used together, they supplement the kidneys, boost the heart, promote the interaction of the heart and kidneys, reduce urination, and stop enuresis. Similar to the above protocol, this protocol also was able to achieve success in those with spina bifida. From The Treatment of 33 Cases of Pediatric Enuresis with Yi Zhi Ren Zhu Pao Tang (Alpina & Pork Bladder Decoction) by Pei Wei-hua, Guang Xi Zhong Yi Yao (Guangxi Chinese Medicine & Medicinals), 1999, #4, p. Twenty-two of these were 3-9 years old, nine were 10-16 years old, and two were 17-19 years old. Twenty-eight cases had enuresis every night, and five cases had enuresis 3-5 times per week. The patients presented clinically with dizziness, fatigued spirit, lack of strength, low back and knee soreness and limpness, a cold body and chilled limbs, a white, lusterless facial complexion, torpid intake, a pale tongue with white fur, and a deep, fine, weak pulse. Treatment method: Based on the principles of fortifying the spleen and boosting the lungs, supplementing the kidneys, invigorating yang, and securing and containing the lower origin, Yi Zhi Ren Zhu Pao Tang (Alpinia & Pork Bladder Decoction) was composed of: Zhu Pao (pork bladder), 30-50g Yi Zhi Ren (Fructus Alpiniae Oxyphyllae), 3-10g Sang Piao Xiao (Ootheca Mantidis), 3-10g Bu Gu Zhi (Fructus Psoraleae), 5-10g Chinese Research on the Treatment of Pediatric Enuresis 83 Jin Ying Zi (Fructus Rosae Laevigatae), 5-10g Tu Si Zi (Semen Cuscutae), 3-10g Dang Shen (Radix Codonopsitis), 10-15g Da Zao (Fructus Jujubae), 10-15g Shan Yao (Radix Dioscoreae), 10-20g Wu Wei Zi (Fructus Schisandrae), 3-5g Nuo Mi (Semen Oryzae Glutinosae), 30-50g If there was torpid intake, 5-10 grams of Shen Qu (Massa Medica Fermentata) were added. If there were sloppy stools, 5-10 grams of stir-fried Bai Zhu (Rhizoma Atractylodis Macrocephalae) were added. The dosage was 60 milliliters of the decocted liquid two times per day for 3-10 year-olds, and 100 milliliters two times per day for 11- 19 year-olds. All ages ate the cooked pork bladder and rice after drinking the decoction. One packet of the above medicinals was decocted per day, and five days equaled one course of treatment.
In the preg- with pregnancy purchase 40 mg prednisone free shipping, chronic disorders that require continued nant woman purchase prednisone 10mg, physiologic changes alter drug pharmacokinet- treatment during pregnancy or lactation, and habitual use of ics (Table 67–1), and drug effects are less predictable than in nontherapeutic drugs (eg, alcohol, tobacco, others). Most of the drugs in this chapter are purpose of this chapter is to describe potential drug effects on described elsewhere; they are discussed here in relation to 965 966 SECTION 11 DRUGS USED IN SPECIAL CONDITIONS TABLE 67–1 Pregnancy: Physiologic and Pharmacokinetic Changes Physiologic Change Pharmacokinetic Change Increased plasma volume and body water, approxi- Once absorbed into the bloodstream, a drug (especially if water soluble) is distrib- mately 50% in a normal pregnancy uted and diluted more than in the nonpregnant state. However, this effect may be offset by other pharmacokinetic changes of pregnancy. Increased weight (average 25 lb) and body fat Drugs (especially fat-soluble ones) are distributed more widely. Drugs that are distrib- uted to fatty tissues tend to linger in the body because they are slowly released from storage sites into the bloodstream. The rate of albumin pro- The decreased capacity for drug binding leaves more free or unbound drug available duction is increased. However, serum levels fall for therapeutic or adverse effects on the mother and for placental transfer to the because of plasma volume expansion. Thus, a given dose of a drug is likely to produce greater effects than it would plasma protein-binding sites are occupied by hor- in the nonpregnant state. Some commonly used drugs with higher unbound mones and other endogenous substances that amounts during pregnancy include dexamethasone (Decadron), diazepam (Valium), increase during pregnancy. Increased renal blood ﬂow and glomerular ﬁltration Increased excretion of drugs by the kidneys, especially those excreted primarily un- rate secondary to increased cardiac output changed in the urine. In late pregnancy, the increased size and weight of the uterus may decrease renal blood ﬂow when the woman assumes a supine position. This may result in decreased excretion and prolonged effects of renally excreted drugs. Drugs enter the brain easily because the blood–brain bar- ﬂuence some aspect of pregnancy. Approximately half of in greater detail and include those used to induce abortion the drug-containing blood is then transported through the um- (abortifacients), drugs used to stop preterm labor (tocolytics), bilical arteries to the placenta, where it reenters the maternal and drugs used during labor and delivery. Thus, the mother can metabolize and excrete some drug molecules for the fetus. MATERNAL–PLACENTAL– FETAL CIRCULATION DRUG EFFECTS ON THE FETUS Drugs ingested by the pregnant woman reach the fetus through The fetus, which is exposed to any drugs circulating in mater- the maternal–placental–fetal circulation, which is completed nal blood, is very sensitive to drug effects because it is small, about the third week after conception. On the maternal side, has few plasma proteins that can bind drug molecules, and has arterial blood pressure carries blood and drugs to the pla- a weak capacity for metabolizing and excreting drugs. In the placenta, maternal and fetal blood are separated drug molecules reach the fetus, they may cause teratogenicity by a few thin layers of tissue over a large surface area. However, since 1984, cental transfer begins approximately the ﬁfth week after con- the Food and Drug Administration (FDA) has required that ception. When drugs are given on a regular schedule, serum new drugs be assigned a risk category (Box 67–1). For drugs taken during the second and amounts are pharmacologically active because the fetus has third trimesters, adverse effects are usually manifested in low levels of serum albumin and thus low levels of drug bind- the neonate (birth to 1 month) or infant (1 month to 1 year) ing. Most are as growth retardation, respiratory problems, infection, or transported to the liver, where they are metabolized. Overall, effects are determined mainly by the type olism occurs slowly because the fetal liver is immature in and amount of drugs, the duration of exposure, and the level quantity and quality of drug-metabolizing enzymes. In addition, Fetal effects of commonly used therapeutic drugs are listed the fetus swallows some amniotic ﬂuid, and some drug mol- in Box 67-2. Effects of nontherapeutic drugs are described in ecules are recirculated. Other drug molecules are transported directly to the heart, Alcohol is contraindicated during pregnancy; no amount which then distributes them to the brain and coronary arter- is considered safe. Heavy intake may cause fetal alcohol CHAPTER 67 DRUG USE DURING PREGNANCY AND LACTATION 967 BOX 67–1 U.
A normal uroflow study shows a single bell-shaped curve with a normal peak and average flow rate for age and size prednisone 5 mg on line. Patients with urethral obstruction and neurogenic bladder have prolonged curves or an interrupted series of curves and low peak and average urine flow rates generic 5 mg prednisone with visa. 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.