By E. Goran. University of Cincinnati. 2018.

Target these organizations: a fundamental law of selling states that it is easier to make a sale from someone who has already bought (and seen the benefits of) a similar product discount nitrofurantoin 50 mg amex antibiotic 1000mg. Ask for buy nitrofurantoin 50mg fast delivery virus 1999 torrent, and read carefully, any literature that they produce, in particular guidelines for those submitting proposals. Try to find out what they have given money to, and if possible get hold of those proposals in order to analyse the structure and style. Grant-giving organizations get no points for giving out money; they do get points for funding work that can be seen to have moved forward our knowledge of science, or (particularly if patient groups are involved) have had a demonstrable clinical effect. Work backwards: what headlines would you hope your research to attract (provided all goes well)? Use these thoughts to inform your message, and make sure that your message is clearly given when you write your application. Was it sent to the wrong organization, in which case how do you find out the right one? Did it fail to inspire the panel, in which case was it because you failed to make clear the amazing implications – or was it a run-of-the-mill idea that will not advance anything very much and therefore will prove difficult to fund? Good for glittering careers, but hardly reader-friendly (see putting on the posh overcoat). Green ink brigade There is a prejudice among many editors that those who write in green ink are mad. Until someone does the definitive study, however, if you write a letter to an editor, hide your ink preference by using a word processor. Although the system is not scientific, it is as good as any other system of selection – perhaps better. Hard copy Text that appears on paper rather than being elec- tronically stored and presented. Headlines There is a useful distinction to make between titles and headlines. Titles (as appearing on the top of scientific papers) are labels that identify what the writing covers, but (with the exception of declarative titles) they do not give away, or try to sell, the message. The job of subeditors on newspapers and magazines is to write these headlines. They often have to do this to tight deadlines, and on copy where the message is not always clear. They also have to write to very tight design specifications – such as (in the first story above) four lines of no more than 10 characters each. These design considerations mean that, when you submit an article, the title you choose is unlikely to make it through to publi- cation. Yet it will be on the headline that your peers will focus their critical powers (see false feedback loop). Heartsink writer Some writers always know better than their editors, never accept no for an answer, keep arguing and generally behave like the worst kind of patient. Homophones When it comes to words, there are many confusing pairs; homophones are those that sound the same, such as: • born and borne: (1) arriving in this world, and (2) carried, • complementary and complimentary: (1) something that adds, and (2) something that is free or giving praise, • discreet and discrete: (1) not likely to gossip, and (2) each separate piece, • principal and principle: (1) main (person), and (2) a rule, • stationary and stationery: (1) at a standstill, and (2) envelopes and writing paper. Which sentence brings us to another question: should we be ending sentences with prepositions? Humiliation Some see this as an essential part of commenting on what another person has written (see balanced feedback; politics of writing). Hyphens These give rise to two main problems: • whether to put them in at all. As a general guide, put them in to help the reader group words correctly, or to avoid ambiguity (last-minute changes or last minute changes? When narrow columns are being used, many of the words become split over two lines, and therefore hyphenated. This can turn the right-hand margin into a succession of small horizontal lines. In the old days, when type was set by hand, typesetters could take time and care to avoid this by subtle manipulation of letters and spaces. Now the computers seem to be in control: there seems to be little we can do to change this. Icarus fallacy In Greek mythology, Icarus was the one who soared nearer and nearer to the sun. Unfortunately, while the notion of building wings was ingenious and the construction of them skilful, the theory was based on a major miscalculation: his wings were made of feathers and wax, and when he flew near to the sun the wax melted and he fell back to earth.

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Methods used in clinical neu- but so far not demonstrated cheap nitrofurantoin 50 mg on line antibiotic 5898 v, that analyses of the rophysiology help determine the extent to which pathophysiological mechanisms underlying spas- spinalpathwaysmalfunctionafteralesionofthecen- ticity provided by clinical neurophysiological stud- tral nervous system buy nitrofurantoin 50mg on line bacteria 5 types. If this were so, accu- involvement of spinal pathways in the pathophysi- rate evaluation of the mechanisms underlying spas- ology of other motor disorders, such as dystonia, has ticity in individual patients would become increas- been discussed in previous chapters. These thera- pies include: botulinum toxin injection, blockade Spasticity of peripheral nerves by alcohol or phenol, intrathe- cal and oral medication, and physical/occupational Spasticity is one of the components of the upper therapy (for review, see Satkunam, 2003). Moreover, motor neurone syndrome, and occurs in a variety clinical neurophysiological techniques may provide 556 Spasticity 557 the objective and quantitative data necessary for to have a low correlation with the briskness of the clinical trials and longitudinal studies and to follow tendon jerks (Fellows, Ross & Thilmann, 1993), and the progress of individual patients. Either the description was too simplistic, paper by Landau (1980) who pointed out the care- and therefore unhelpful, or the participants could less use of the word spasticity, emphasising that it not agree on the detailed quantitative features of the is only a facet of the upper motor neurone syn- exaggeratedstretchreflexinspastichypertonia. Con- drome, not necessarily the one that causes the great- flicting views were presented concerning the domi- estdisability. How- ever, attractive as it may be, it must be recognised Definition that this proposition has not echoed as much, and the term upper motor neurone syndrome continues Spasticity and stretch reflex exaggeration to be used in the literature. The tonic stretch reflex has been shown pathways involved by the lesion are different after 558 Pathophysiology of movement disorders cerebral and spinal lesions, it is not surprising that contracting muscle, and is only demonstrable clin- the pathophysiology of spasticity is different after ically for the quadriceps muscles, where the range stroke and spinal cord injury (pp. There are other decreaseintheresistancetostretchthatoccurswhen features of spasticity, such as clonus and the clasp- a dynamic reflex response subsides as movement knife phenomenon, but these are not invariably slowsorceases. Thus, the relaxation of a vigorous reflex con- In neurological practice, the crucial question about traction stretches muscle spindle endings and can spasticity is the extent to which it contributes to produce a volley that, given the hyperactivity of the the motor impairment and limitation of activity in reflex arc, is sufficient to trigger another reflex con- patients with a corticofugal syndrome. The presence of clonus is directly related assumed that a voluntary movement that stretches to the tendon jerk hyperreflexia, and whether it can a spastic muscle might be expected to produce be elicited depends on the skill of the examiner who reflex activity that would oppose the movement. As clonus subsides, the spin- depends both on the exaggeration of the stretch dle discharge produced by relaxation of the twitch reflex and changes in the transmission in spinal contractiongraduallybecomesdispersed. Spasticity 559 Spastic restraint–adebated proposition reflex threshold (Powers, Marder-Meyer & Rymer, 1988), increased stretch reflex gain (Thilmann, The contribution of spasticity to motor impair- Fellows & Garms, 1991), but no evidence for abnor- ment has been the subject of vigorous discussion, mal stretch reflex (Dietz et al. However, the prevailing view concluded that the increased resistance to stretch is that the exaggeration of stretch reflexes in some of spastic muscles mainly results from changes in of these patients may give rise to crucial restraint non-neuralfactors(see pp. Accordingly, ferent results may be obtained in patients with dif- the usefulness of reducing spasticity is now gener- ferent lesions of the central nervous system, and/or ally accepted (using, e. Patients with spinal cord lesions Stroke patients In patients with spinal cord lesions, in particular In stroke patients, there is evidence that the in spinal cord compression, chronic myelopathies increased resistance to stretch in the triceps surae or hereditary spastic paraparesis, there is evi- is due to mechanical rather than reflex causes (Perry dence that exaggerated stretch reflexes can disrupt et al. Thatreductionofspasticitywillimprove in favour of a neural origin of spastic hyperto- gait remains to be firmly established (Landau, 2003; nia than of changes in the muscle itself. More Cramer, 2004) and, on the contrary, its reduction recently, unwanted stretch reflex activity in the mightbecounterproductiveasspasticityoftenhelps antagonisttriggeredbythedynamicconcentriccon- support the body during locomotion (see Dietz, traction of the agonist has been shown to limit the 2003). Conflicting results have been obtained con- amplitude and/or to slow down the movement of cerning the resistance opposed by the biceps brachii knee muscles (Knutsson, Martensson & Gransberg,˚ to voluntary elbow extension: decreased stretch 1997). However, the exaggeration of the brate rigidity immediately follows the causal lesion, tonic stretch reflex has only a low correlation with while spasticity takes days, often weeks to develop. Moreover, the This gives time for rearrangements to occur at spinal increased resistance to stretch is also, and perhaps level (see pp. The contribution of exaggerated stretch reflexes to motor disability of Possible spinal mechanisms underlying patients with corticofugal lesions has been overes- the pathophysiology of spasticity at rest timated, and varies with the underlying cause, being more important in patients with spinal cord lesions As indicated in Fig. Reduction of spasticity accompanies selective (ii) Why do spinal pathways malfunction? In fact, the excitability of the the main feature of both is the increased reactivity stretch reflex depends on an intact reflex arc and to a stretch stimulus which is (i) more pronounced on several excitatory and inhibitory mechanisms. It was there- itation of an inhibitory one will reduce the stretch fore presumed that the same spinal mechanisms reflex, even though its exaggeration (spasticity) is might be responsible for the stretch reflex exagger- caused by other mechanisms. In decere- brate rigidity of the cat, the mechanisms include Hyperexcitability of motoneurones hyperexcitability, over-activity, suppression of Ib inhibition, closure of pathways mediating FRA Here,anormal stretch-induced reflex volley would inhibition to extensor motoneurones, and possibly produceanexaggeratedresponsebecausemotoneu- opening of pathways mediating oligosynaptic Ia and rones are closer to their discharge threshold. Hyperexcitability of motoneurones may result Spasticity 561 Descending tracts PAD INs NA Feedback PN inhib. Sketch of some spinal pathways that underlie the stretch reflex exaggeration in spasticity. Excitatory synapses are represented by Y-shaped bars and inhibitory synapses by small filled circles, excitatory interneurones by open circles and inhibitory interneurones by large filled circles. Ia afferents with their presynaptic inhibition (PAD INs) sketched in continuous red. Group II afferents with their presynaptic inhibition (PAD INs) sketched in dotted blue.

Balance functions of the interpositus nucleus and spin- deficits vary with the location of the lesion buy generic nitrofurantoin 50 mg on line antimicrobial kerlix. Postural control is managed Damage to the anterior vermis affects antero- by the fastigial nucleus with its vestibular and posterior sway cheap nitrofurantoin 50 mg free shipping virus 68 in michigan. The olivocerebellar system lonodular lobe damage causes sway in all di- functions as an oscillatory circuit that can gen- rections and poor tandem walking. Neurons of the fasti- spinal and brain stem motor regions, inform the gial and interpositus nuclei burst primarily cerebellar cortex of the place and rate of move- during the flexor phase of stepping. These fibers put the motor bellum receives inputs from alpha and gamma intention generated by the cerebral cortex into motor neurons and Ia interneurons, as well as the context of the status of the body at the time from segmental dorsal root afferents. An fMRI study, for example, rons project to the cerebellar cortex from the demonstrated independent activation of sepa- contralateral lateral funiculus and burst during rate cerebellar regions during a task of visual locomotion, reflecting activity in spinal central attention and during motor performance. Spinoreticulocerebellar pathways also the hot spot for attention, but a sustained mo- carry bilateral information predominantly from tor task did not. The neocere- tems as it acquires new information and builds bellum monitors the outcome of every move- internal models based on previous experience ment and optimizes movements using pro- for the analysis and smooth control of actions. Given the great compu- A careful neuropsychologic evaluation often re- tational interest the cerebellum has in the de- veals aspects of frontal lobe-like dysfunction in tails of afferent information from joints and patients who have lesions within the cerebel- muscles, rehabilitation therapies for walking lar network. The from the internal and external world as well as sorts of motor functions that the cerebellar in- all processed sensorimotor information from puts and outputs attend to, such as timing and the spinal cord, cerebellum, basal ganglia, and error correction for accuracy as the hand ap- substantia nigra. The thalamic nuclei are not proaches an object, are especially important for passive relays. They almost certainly perform patients to practice when a lesion undermines distributed, parallel processing of sensory in- motor control. All thalamic Cognitive Functions relay nuclei respond to excitatory inputs with The cerebellum is also a node in the distrib- either tonic or burst firing. The burst pattern uted neural circuits that subserve aspects of may play a role in attending to a stimulus. The cerebel- Separate channels are maintained within the lum influences at least a few prefrontal regions somatic sensory and motor thalamus for cuta- via thalamic projections and through the den- neous sensation, for slowly adapting and rap- tate nucleus. Thus, individual channels of the thal- planning, initiation, and execution of move- amocortical projections control separate func- ments, and the verification of willed actions tional units of motor cortex which, in turn, and thoughts. The rostral cingulate, septal nu- independently influence the basal ganglia, clei, hippocampus, and amygdala provide lim- cerebellum, and other subcortical motor nu- bic connections to the cerebellum. This divergence of projections pro- duces convergence of a variety of thalamic in- HAND FUNCTIONS puts to targets. Why would so many thalamic cells with similar receptive fields converge onto Rudimentary synergistic movements such as the same assemblies of cortical neurons? One opening and closing the hand persist after a thought is that information about a cutaneous pyramidectomy, probably through the activity stimulus requires cells only in a single recep- of the descending rubrospinal, vestibulospinal, tive field to respond, but a moving stimulus and reticulospinal systems. When learning a motor ments, especially movements related to feed- skill, coding across a population leads to tem- ing. This thalamic mediated more individuated a movement, the greater the activity-dependent plasticity induces rapid cor- amount of corticomotoneuronal activity needed tical reorganization (see Experimental Case to superimpose control on subcortical centers Studies 1–4). Substitution of a brain stem pathway for a cortical one by retraining after a Brain Stem Pathways brain injury may reorganize subcortical con- trollers and increase motor recovery. The pontine nuclei receive projections from the prefrontal and limbic areas noted in the dis- LOCOMOTOR FUNCTIONS cussion of the cerebellum, as well as from other association cortices such as the posterior pari- The brain stem, particularly the reticular for- etal, superior temporal, occipitotemporal, and mation, includes important structures for au- parahippocampal cortices. Each cortical area tomatic and volitional control of posture and projects to a specific lateral basis pontis region. Interacting with the cortex, deep As a general organizing principle, intercon- cerebellar nuclei, substantia nigra, and globus nected cortical areas like these share common pallidus, the brain stem has convergent areas subcortical projections. Reticu- Vestibulospinal and rubrospinal neurons are lospinal and propriospinal projections from the rhythmically modulated by cerebellar inputs, mesencephalic locomotor region (MLR) and primarily for extensor and flexor movements, pedunculopontine region synapse with lumbar respectively. In addition, chains of polysynap- spinal neurons and carry the descending mes- tically interacting propriospinal neurons have sage for the initiation of locomotion. Reticulospinal and propriospinal stimulation of the cerebellar fastigial nucleus fibers intermingle on the periphery of the ven- and the subthalamic nucleus that project to tral and lateral spinal tracts, where reticu- reticulospinal neurons, produce hindlimb lo- lospinal paths may come to be replaced by pro- comotor activity. These regions modulate spinal pattern generators for fibers connect motor neurons to axial, girdle, stepping in animal models and, presumably, in and thigh muscles. In a sense, A hemisection of the upper lumbar spinal the axial and proximal leg motor pools are cord is followed by considerable recovery of lo- wired to interact together. The observer adjusts rats, the initiation of hindlimb locomotion is direction so as to cancel the error between the not compromised after a thoracic spinal cord heading perceived from optic flow and the injury (SCI) until almost all of the ventral white goal.

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The treat- ment principles were to warm and supplement the kidney qi and secure and astringe the lower origin generic nitrofurantoin 50mg antibiotic resistance timeline. First Shen Jing (Kidney Channel) was massaged with supplementation method generic nitrofurantoin 50 mg antibiotics for dogs at petsmart. Then Dan Representative Case Histories 201 Tian (CV 4-6) and Gui Wei (GV 1) were kneaded 100 times each. One treatment was given per day, and seven times equaled one course of therapy. After massaging the child, moxa was used with the warming method on the acupoints Guan Yuan (CV 4) and San Yin Jiao (Sp 6). Each day, this treatment was given one time, and seven times also equaled one course of treatment. After applying this treatment one time, the child slept more peacefully and had no enuresis. After continuing to use this method one time a day for one week, the enuresis was eliminated and all other symptoms improved. Case 27:27 The patient in this case was an eight year-old female whose initial visit took place on June 12, 1995. This child had suffered from enuresis for many years, and, typically, her urination was frequent but scanty. The enuresis was accompanied by a white facial complexion, an emaciated body, fatigued spirit, lack of strength, scanty appetite, and sloppy stools. Her tongue was pale with thin, white fur, and her pulse was moderate (or slightly slow) and fine. Therefore, the treatment principles were to supple- ment and warm the lungs and spleen and secure and astringe the lower origin. Before doing anything else, Pi Jing (Spleen Channel) and Fei Jing (Lung Channel) were massaged with supplementation method. This treatment was given once per day, and seven times equaled one course of treatment. After massaging the fore- going points, moxa was used with warming method on the acu- points Guan Yuan (CV 4) and Zu San Li (St 36). Each point was stim- ulated for five minutes, and each day the treatment was given one time. After one course of this tuina and moxibustion, the frequency of the enuresis was reduced. Case 28:28 The patient in this case was a 14 year-old female whose initial examination occurred in July 1993. Her main symptoms included night-time urination, frequent, scanty urina- tion, shortness of breath, a timorous voice, devitalized spirit, lack of strength, profuse sweating on exertion, devitalized appetite, thin, sloppy stools, a lusterless facial complexion, a pale tongue, and a moderate (or slightly slow), weak pulse. The treatment prin- ciples in this case were to fortify the spleen and boost the lungs in order to secure and contain. Treatment consisted of acupunc- ture with supplementation method and moxibustion at San Yin Jiao (Sp 6), Guan Yuan (CV 4), and Pi Shu (Bl 20). In addition, the patient was administered the following Chinese medicinals: Dan Shen (Radix Salviae Miltiorrhizae), Dang Gui (Radix Angelicae Sinensis), Bai Zhu (Rhizoma Atractylodis Macrocephalae), Gan Cao (Radix Glycyrrhizae), and Sheng Ma (Rhizoma Cimicifugae), 10g each, and Chen Pi (Pericarpium Citri Reticulatae), Huang Qi (Radix Astragali), and Chai Hu (Radix Bupleuri), 15g each. One packet of these medicinals were decocted in water and administered per day. The patient took six packets along with Wu Zi Yan Zong Wan (Five Seeds Increase Progeny Pills). After taking these medicinals for two weeks, there was no enuresis and all the other symptoms were improved. The treatment was then switched over from decocted medicine to using Bu Zhong Yi Qi Wan (Supplement the Center & Boost the Qi Pills) and Ren Shen Jian Pi Wan (Ginseng Fortify the Spleen Pills). The doctor also insisted that the patient continue taking the medicinals for two months in order to deal with the after effects of the disease by supplementing and boosting the middle qi, fortifying the spleen, and harmonizing the stomach. Case 29:29 This patient was a 12 year-old female whose initial visit occurred in May 1989. Her main complaint was that she urinated in her bed as many as three times per night, and the urine had a peculiar smell. In addition, there were short voidings of yellow urine, rashness, impatience and irascibility, a red facial complexion and lips, sometimes fear and fright of unreal matters, red tongue margins and tip with yel- low fur, and a bowstring, slippery pulse.

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