By O. Rathgar. Cornell University.
I am indebted to the love and support of my children and their vii viii Symptoms of Unknown Origin families: Mary Kathleen Meador generic levitra 10mg mastercard, Graham K 10 mg levitra otc. Meador, Rebecca Meador, Jon and Ann Meador Shayne, Aubrey and Celine Meador, David and Elizabeth Meador Driskill, and Clifton and Mary Neal Meador. I especially value and appreciate the editing and other assis- tance from the staﬀ of Vanderbilt University Press: director Mi- chael Ames, Dariel Mayer, Sue Havlish, and Bobbe Needham. Many physicians have shaped my thinking and have been per- sonal mentors through the years: Robert F. Loeb, Tinsley Harrison, Grant Liddle, David Rogers, Carl Rogers, Joseph Sapira, Stonewall Stickney, Drayton Doherty, H. Michael Balint, George Engel, Tomas Kuhn, John Grinder, Richard Bandler, Milton Erickson, Jerome Frank, and Berton Roeuche. Finally, I want to thank all the patients who taught me so much about people and illness. Introduction Te overarching thesis of this book is that the prevailing biomo- lecular model of disease is too restricted for clinical use. I was pushed to come to that view through my experiences with patients who did not ﬁt the narrow model. Tese are the stories of those patients and my interaction with them as a physician over a ﬁfty- year period. I have selected patients and their stories that riveted my attention and changed my thinking about the nature of disease, about doctor-patient relationships, and about principles of caring for patients who came to me with symptoms of unknown origin. I have changed the names of the patients and certain other details to preserve their anonymity. When I graduated from medical school in 1955, I adopted the model of disease then prominent, if not exclusive, in U. Each case (as I encountered the person and the facts) began to unravel my rigid views about disease and illness. Eventually, I found the biomolecular model of disease applicable only to a narrow segment of patients who seek medical care. We need to draw clear distinctions between the reductionist research model and the need for an ex- panded clinical model that encompasses the psychological and social aspects of human beings. Human biology and clinical med- icine overlap, but they are also quite diﬀerent and are too often confused. When I did, I was heavily inﬂuenced by his writings and began to understand some of the clinical problems I was encountering. Balint studied general practitioners for several years in the United Kingdom as if they were pharmacologic agents. He was examining the correct dos- age, underdosage, overdosage, and duration of action of physicians themselves as a drug. Balint developed the term apostolic function of a physician to describe the beliefs and teachings of physicians as these aﬀected their relationships with their patients. Of the apostolic function, Balint (1955, 684) writes: We meant that every doctor has a set of fairly ﬁrm beliefs as to which illnesses are acceptable and which are not; how much pain, suﬀering, fears, and deprivations a patient should tolerate, and when he has the right to ask for help and relief: how much nuisance the patient is allowed to make of himself and to whom, etc. Tese beliefs are hardly ever stated explicitly but are nevertheless very strong. Tey compel the doctor to do his best to convert all of his patients to accept his own standards and to be ill or to get well according to them. Te eﬀect of the apostolic function on the ways the doctor can administer himself to his patients is fundamental. Abram and I jointly published a chapter in his book Basic Psychiatry for the Primary Care Physician.
Body oscillations post-synaptic potentials and changes in ﬁring probability inbalancingduetosegmentalstretchreﬂexactivity buy levitra 10 mg overnight delivery. Auto- between pre-activity and stretch reﬂex in human triceps genetic inhibition of motoneurones by impulses in group brachii during landing from forward falls cheap levitra 10mg online. H-reﬂexes of different sizes guished from pre-programmed muscle activations follow- exhibit differential sensitivity to low frequency depression. Evidence for interneuronally mediated Ia excita- gence of monosynaptic excitatory afferents onto many dif- tory effects to human quadriceps motoneurones. JournalofNeurophysiology,14, Journal of Physiology (London), 419, 321–51. Integrative pattern of Ia Hreﬂex by homonymous Ia afferent ﬁbres in man. Pattern of propriospinal-like exci- lysis of muscular activity in the hindlimb of the cat during tation to different species of human upper limb unrestrained locomotion. State-dependent modulation of sensory dence for further recruitment of group I ﬁbres with high feedback. Modulation of transmit- Electroencephalography and Clinical Neurophysiology, 93, ter release from Ia afferents by their preceding activity – a 353–7. Assessing changes in presynaptic inhibition of Ia tribute to the medium latency soleus stretch reﬂex during ﬁbres: a study in man and the cat. Grouped spindle and electromyographic responses depressionoftheH-reﬂexinhumansubjects. Acta Neurobiologiae parison of postactivation depression of synaptic actions Experimentalis, 56, 423–33. Experimental Neurology, 86, tribution of recurrent inhibition in the human upper limb. In Handbook of Physi- Conditioning of H-reﬂex by a preceding subthreshold ten- ology,Section I, The Nervous System,vol. Journal potentiation and facilitation of synaptic potentials evoked of Physiology (London), 437, 269–86. Journal of Neurophysiology, 81, The pattern of monosynaptic Ia-connections to hindlimb 2893–902. Mechanism of facilitation and depression of Proceedings of the Royal Society B, 221, 261–89. Journal of Neurology, Neu- monosynaptic Ia excitation of wrist ﬂexor motoneurones, rosurgery and Psychiatry, 28, 328–34. Canadian connections from large muscle afferents to the motoneu- Journal of Neurological Sciences, 2, 285–93. Neuronpatternscontrollingtransmission quadriceps motoneurones during human gait. Conduction and synaptic transmission of the reﬂex & Pierrot-Deseilligny, E. Journal of Neurophysiol- monosynaptic excitation to early and late recruited units ogy, 6, 317–26. Monosynaptic Ia projections from intrinsic hand micallyactivatedmonosynapticreﬂexpathways.
For spleen-kidney dual vacuity purchase levitra 10mg overnight delivery, a combination of the above two formulas was added order 10mg levitra with amex. One packet of these medicinals was decocted in water and administered in three divided doses per day. External treatment consisted of 10 grams of powdered Wu Bei Zi (Galla Rhois) mixed with an appropriate amount of rice vinegar and applied to the umbilicus. This paste was applied one time per night for five consecutive days (one course of treatment), and then the treatment was stopped for two days. Study outcomes: Fifteen cases (60%) were cured, eight cases (32%) improved, and two cases (8%) had no improvement. From The Treatment of 105 Cases of Pediatric Enuresis with Acupuncture by Gao Jie-yin, Hu Bei Zhong Yi Za Zhi (Hubei Journal of Chinese Medicine), 1992, #5, p. The patients were between 5-10 years old in 56 cases, between 10-14 years old in 43 cases, and more than 14 years old in six cases. These cases of enuresis were often accompanied by poor appetite, a lusterless facial complexion, and decreased essence- spirit. Compared to other children their age, these children had a lower body weight. Treatment method: The main points consisted of: Chinese Research on the Treatment of Pediatric Enuresis 121 Guan Yuan (CV 4) Qi Hai (CV 6) San Yin Jiao (Sp 6) Auxiliary points included: Shen Shu (Bl 23) Zhong Ji (CV 3) Zu San Li (St 36) Two to four points were chosen each time and these points were alternated. Hand stimulation was applied to the points, and the needles were retained for 20 minutes. The patient received two treatments each week, and 2-4 treatments equaled one course. Study outcomes: After 1-2 courses of treatment, 76 cases were cured, 29 cases improved, and two cases did not improve. From The Treatment of 53 Cases of Pediatric Enuresis Using Bai Hui (GV 20) & Pattern Discrimination by Dong Wen- yi & Wu Chao, Liao Ning Zhong Yi Za Zhi (Liaoning Journal of Chinese Medicine), 1995, #9, p. Eighteen cases were less than five years old, 27 cases were between 6-10 years old, and eight cases were between 11-14 years old. The Chinese medical pattern discrimina- tion was heart-kidney yang vacuity in 38 cases and spleen-lung qi vacuity in 15 cases. Treatment method: Bai Hui (GV 20) was the main point used in this protocol. If there was heart-kidney yang vacuity, the following points were added bilaterally: Shen Shu (Bl 23), Tai Xi (Ki 3), Shen Men (Ht 7), and 122 Treating Pediatric Bed-wetting with Acupuncture & Chinese Medicine Guan Yuan (CV 4). If there was spleen-lung qi vacuity, then San Yin Jiao (Sp 6), Zu San Li (St 36), Nei Guan (Per 6), and Qi Hai (CV 6) were added. The even supplementing-even draining method of stimulation was used on all these points except for Bai Hui which was supplemented. Needles were retained for 15 minutes and stimulated three times during this period. One treatment was given per day, and 10 treat- ments equaled one course. The least number of courses a patient was treated was one, and the most was four courses of treatment. Study outcomes: The following table shows the comparative outcome between those manifesting different patterns.
We have found bins of 1 min to be a good compromise between plotting too much detail and losing real-time contact with the network discount 10mg levitra overnight delivery. Minute means from all channels with standard deviations allow a minute-to-minute evaluation of network activity and channel variability and an immediate comparison with past network activity discount levitra 10mg without prescription. The values for CVnetwork are obtained by averaging the binned values (60 s) across all channels, followed by calculations of a new average across time for a particular experimental episode. These for CVtime are obtained from activity variables per minute that are averaged for each channel across time (i. Hence, if a population is synchronized but the activity varies with time, a low CVnetwork and high CVtime are obtained. Conversely, a nonsynchronized network with several simultaneous regular (periodic) patterns yields a high CVnetwork with a 194 Guenter W. Gross and colleagues ANALOG MULTICHANNEL RECORDING Digital Processing Analog Processing Plexon Inc. MNAP whole channel 14-channel RC integration tape recorder spike discrimination Chart Recorder Oscilloscopes Time Stamps Waveforms Channel Activity Variables: NEX Software burst rate (bpm) spike rate (spm) mean burst duration per min spike train burst train mean burst period per min statistics statistics mean burst intervals per min Network Activity Variables Cross-channel means per min Episode means and coefficients of variation Global means and coefficients of variation Figure 9. The 64-channel (maximum) analog data are pro- cessed digitally via the Plexon Inc. MNAP/NEX software, which allows a multitude of conventional data manipulations. Spike proﬁles on single channels are usually discriminated, but can also be lumped as whole-channel responses for displays of total spike production and major burst patterns. Parallel analog processing involved display on an 8- or 12-channel chart recorder after RC integration (integration con- stant approximately 700 ms). In the latter case, each channel could be periodic, but with di¤erent periods and patterns on each channel or subsets of channels. Although the calculation of CVs is an e¤ective tool for quantifying the states of oscillatory networks and burst coordination, which are always seen as steady states during disinhibition (i. In fact, the recognition and quan- tiﬁcation of transient spatiotemporal patterns that are continually generated by networks in vitro present a formidable challenge. Here, extensive application of non- linear dynamics and sophisticated schemes of pattern recognition will be necessary before substantial progress can be made in dealing with subtle pattern changes in nonlinear and nonstationary systems. However, changes induced by toxins and other neuroactive compounds are generally robust and relatively large in magnitude and therefore quantiﬁable. Thus, pharmacological investigations and applications are realistic with present techniques and methods. Note the coordinated burst patterns on most of the channels and variable phase delays for burst onsets. CVN N N Σ CVch/N CVtime Σ bv1/N 1 minute means and CVs for all channels1 n cv1........ All calculations are based on 1-min bins where a speciﬁc burst variable (bv) is either logged as a number for burst rate or averaged for burst duration and interburst interval. These values are used to obtain episode means with CVs for experimental episodes (left/right), or minute means for each minute of the experimen- tal episode (top to bottom). The episode CVs for each channel represent a measure of temporal pattern ﬂuctuation for that channel. Averaged across the network, these CVs reﬂect pattern regularity even if sev- eral patterns exist and even if they are not synchronized. Averaged across the experimental episode, they reﬂect the degree of synchronization even if the pattern ﬂuctuates in time. For simplicity, they have been designated CVtime and CVnetwork, respectively (from Keefer et al.
But in this context the posters are usually dull and 97 THE A–Z OF MEDICAL WRITING badly presented 10mg levitra visa, apparently favouring cut-down versions of the scientific paper (see IMRAD) cheap levitra 20 mg otc, rather than using the medium to its full potential. This makes it particularly important for those who wish to present a poster to work out in advance why they are doing it, and how they will judge their success (see brief setting). You may want to influence your supervisor, who will be at the conference, in which case you should look at his or her posters and follow that style. You may be wanting to impress the prestigious research unit up the road, in which case follow their style. On the other hand, you may wish to make an impact, in which case you should consider doing something fairly dramatic, such as limiting your poster to a photograph, one main sentence in bold type, and a few numbers. Once you have decided what you want to achieve, you can start thinking about the mechanics. Print out individual sheets of text and glue them onto large sheets of card. Print out your text onto sheets of A4, enlarge them onto a clean photocopier to A3 and then get them encapsulated. This makes them tough and transportable – even in a normal- sized briefcase. When you have finished, send the file to a specialist printer who will print it out on a large sheet of paper. In many institutions there are specialist departments who will construct these for you. They will normally have considerable expe- rience of producing posters, and are worth listening to. However, you will be responsible for your poster, so keep the following principles in mind. Many people feel that being creative with a poster involves overloading it with text and different typographical devices. Trim your message to the bare essentials; this is not an examination but the communication of a message to someone whose feet are beginning to hurt. If you use illustrations make sure they are good, and that they are there for a purpose (e. Both you and the institution will benefit from the continuity that a house style affords. During the communist era the newspaper of this name became a byword for biased stories favouring the controlling elite (see propaganda). Premature expostulation Some people start writing as soon as they have an idea – and before they have done any thinking about that idea. Prepositions These little linking words can cause huge amounts of aggravation. To some extent this is slop- piness, but there is also a question of usage. The latest Fowler (see grammar booklist) states clearly that this is a nonsense, and sometimes would be wrong. Yet I have seen some dreadful presenta- tions from senior doctors – too much information, badly presented with long lists of tiny type, or columns of endless figures written in purple ink and flashed up on the screen for about six seconds.