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This child had experienced enuresis cheap gyne-lotrimin 100mg without a prescription, often more 186 Treating Pediatric Bed-wetting with Acupuncture & Chinese Medicine than one time per night buy discount gyne-lotrimin 100mg on-line, since he was three years old purchase 100 mg gyne-lotrimin overnight delivery. His parents were worried about this and had tried many Western and Chinese medicines with no success. Each time the child was nervous or became fatigued, the frequency of enuresis increased to often more than three times a night. Besides enuresis, this child presented with a fatigued spirit, sweating on exertion, below average school per- formance, a lusterless, bright white facial complexion, poor appetite, sloppy stools, lack of warmth in the hands and feet, a pale tongue with thin, white fur, and a deep, weak pulse. Urine tests were normal, but x-rays showed evidence of occult spina bifida. For this, a variation of Gui Zhi Jia Long Gu Mu Li Tang (Cinnamon Twig, Dragon Bone & Oyster Shell Decoction) was prescribed based on the principles of diffusing and warming yang, supplementing the kidneys, securing, astringing, and stopping urination. This formula consisted of: Gui Zhi (Ramulus Cinnamomi), 10g, Bai Shao (Radix Paeoniae Albae), 10g, calcined Long Gu (Os Draconis), 15g, cal- cined Mu Li (Concha Ostreae), 15g, Bai Ji Tian (Radix Morindae Officinalis), 10g, Bu Gu Zhi (Fructus Psoraleae), 10g, Yi Zhi Ren (Fructus Alpiniae Oxyphyllae), 10g, Sang Piao Xiao (Ootheca Mantidis), 10g, Wu Yao (Radix Linderae), 10g, mix-fried Huang Qi (Radix Astragali), 10g, earth stir-fried Bai Zhu (Rhizoma Atractylodis Macrocephalae), 10g, Fu Xiao Mai (Fructus Levis Tritici), 15g, Da Zao (Fructus Jujubae), 7 pieces, and Sheng Jiang (uncooked Rhizoma Zingiberis), 3 slices. One packet of these medicinals was decocted in water two times and the resulting medicinal liquid was divided into four doses per day. After taking five packets of this formula consecutively, the enuresis was improved to just one time a night instead of 2-3 times per night. Simultaneously, the child could wake by himself to urinate, his cheeks were rosy, and his limbs were slightly warmer. His tongue was now pale with thin, white fur, and his pulse had more force although it was still slow. Another four packets were administered in order to secure the treatment results. Representative Case Histories 187 Case 3:3 This patient was a 10 year-old boy who had had enuresis since infancy, often 2-3 times per night. Other signs and symptoms included being shorter than normal and having slower development, scanty hair, a bright, white facial complexion, aversion to cold, sleeping curled up, often complaining of sore, painful knees which were worse at night but better with heat, a poor appetite, a pale tongue with thin, white fur, and a deep, slow, forceless pulse. The treatment principles were to mainly warm and sup- plement kidney yang but also to fortify the spleen, secure and astringe. Hence, the formula Zhen Wu Tang Jia Wei (True Warrior Decoction with Added Flavors) was prescribed which was com- posed of: Fu Ling (Poria), Bai Shao (Radix Paeoniae Albae), and Bai Zhu (Rhizoma Atractylodis Macrocephalae), 9g each, blast-fried Fu Zi (Radix Lateralis Praeparatus Aconiti Carmichaeli), 6g, Sheng Jiang (uncooked Rhizoma Zingiberis), 3 slices, Dang Shen (Radix Codonopsitis), 12g, and Sang Piao Xiao (Ootheca Mantidis), 4. One packet of these medicinals was administered each day, and initially three packets were given. Case 4:4 The patient was an eight year-old male little boy whose initial visit occurred on June 19, 1997. This boy had had enuresis 1-2 times nightly since infancy and had gone for only short periods of time without enuresis. His signs and symptoms included a fatigued essence spirit, an emaciated body, a bright, white facial complexion, frequent catching cold, sweating on exertion, a poor appetite, bowel movements after eating, a pale tongue with thin, white fur, and a vacuous, weak, forceless pulse. For these purposes, the doctor selected Bu Zhong Yi Qi Tang (Supplement the Center & Boost the Qi Decoction) plus Suo Quan Wan (Reduce the Stream Pills) with additions and subtractions: Huang Qi (Radix Astragali), 10g, Dang Shen (Radix Codonopsitis), 8g, Bai Zhu (Rhizoma Atractylodis Macrocephaleae), 8g, Chen Pi (Pericarpium Citri Reticulatae), 5g, Sheng Ma (Rhizoma Cimicifugae), 1g, Chai Hu (Radix Bupleuri), 3g, Dang Gui (Radix Angelicae Sinensis), 6g, Yi Zhi Ren (Fructus Alpiniae Oxyphyllae), 8g, Fu Pen Zi (Fructus Rubi), 5g, mix-fried Gan Cao (Radix Glycyrrhizae), 3g, Shi Chang Pu (Rhizoma Acori Tatarinowii) and stir-fried Mai Ya (Fructus Germinatus Hordei), 6g each. Therefore, the doctor decided to add Shan Yao (Radix Dioscoreae) to the above formula for 10 more days. The doctor prescribed 20 more packets of the current formula, after which time, the case was cured, and there was no recurrence in the first six months after treatment. Case 5:5 The next case is that of a 12 year-old boy who was first seen on March 15, 1980. Since the winter of 1977, the patient commonly had enuresis in the evening. The child had already taken medici- nals to supplement the kidneys and secure and astringe and also took the formula Bu Shen Gou Rou Tang (Supplement the Kidneys Dog Meat Decoction) but had obtained no results. The latter for- mula contained Gou Qi Zi (Fructus Lycii), Rou Gui (Cortex Cinnamomi), and Shu Di (cooked Radix Rehmanniae) with Gou Rou (dog meat). There was also a bright, lusterless complexion, a pale tongue with thin, white fur, and a deep, fine pulse. For this, Gan Jiang Ling Zhu Tang Jian (Licorice, Ginger, Poria & Representative Case Histories 189 Atractylodes Decoction with Additions and Subtractions) plus Suo Quan Wan (Reduce the Stream Pills) was prescribed with addi- tions and subtractions: Pao Jiang (blast-fried Rhizoma Zingiberis), Bai Zhu (Rhizoma Atractylodis Macrocephalae), Shan Yao (Radix Dioscoreae), and Fu Ling (Poria), 10g each, Yi Zhi Ren (Fructus Alpiniae Oxyphyllae), mix-fried Gan Cao (Radix Glycyrrhizae), and Wu Yao (Radix Linderae), 8g each. The child was asked to restrict the amount of water he drank after midday. Case 6:6 The patient in this case history was a 14 year-old female who was first examined on May 17, 1984.

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He was quick to point out that a stimulus or agent for disease was not limited to what could be visualized under a microscope or put in a test tube best 100 mg gyne-lotrimin. Sounds buy gyne-lotrimin 100 mg mastercard, voices buy gyne-lotrimin 100 mg without prescription, sights, smells, colors, touches, and all the varied sensory stimuli that impinge on humans were legitimate material for scien- tific inquiry. Combine all of those into human communication and language and those complexes were equally legitimate material for scientific study—difficult, but amenable to direct observation and study. I came to fully understand that the mind and the body were one—not separated, not disconnected. Sitting above all the molecules, tissues, organs, and mind of the human body was an integrated person. Tis person was connected to a family and perhaps to a spouse, and the family was connected to some social structure and society at large. All this social structure impinged on the person, and the person impinged on the social structure. Tere was a continuum all the way from so- ciety to the person to the organs and even down to the molecules. George Engel (1977) posited such a continuum and hierarchy of interlocking subsystems in his classic paper Te Need for a New Medical Model: A Challenge for Biomedicine. It may seem strange that I am describing my transition from a belief that the mind and body were separated to one that saw no separation. Even today, some physicians still func- tion as if the body and mind are separate and disconnected entities. Tis erroneous view is part of the explanation for our excessive use of procedures and technology. In addition to having an integrated model of humans and dis- ease, Sapira was also a superb teacher of interviewing techniques. Foremost, he was a first-order bedside clinician and would later capture much of his wisdom in his masterpiece, Te Art and Sci- ence of Bedside Diagnosis (1999). At the beginning of mentoring me in interviewing techniques, Sapira had me see patients with him. He showed me that the longer the wait, the richer the material offered by the patient. My allowing the anxi- ety level to rise in the patient elicited from the patient information that would not have come in response to a direct question. I also learned to notice that the last thing a patient said as I left the room was often the most revealing and important information of the en- tire session. I was learning to go deeper than the superficial level of physical symptoms. I found it possible to be both observer and participant, keeping a third eye and ear on the interchange. I also was beginning to make a slight but definite change in my behavior with patients. Books like that, 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.

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Parenteral and released in response to certain stimuli (eg gyne-lotrimin 100mg free shipping, allergic reac- ranitidine reaches peak blood levels in about 15 minutes; CHAPTER 60 DRUGS USED FOR PEPTIC ULCER AND ACID REFLUX DISORDERS 873 65% to 80% is excreted unchanged in the urine generic gyne-lotrimin 100 mg with visa. Famotidine Omeprazole discount gyne-lotrimin 100 mg on-line, esomeprazole, lansoprazole, pantoprazole, and nizatidine are similar to cimetidine and ranitidine. Omeprazole was the first Compared with cimetidine, the other drugs cause similar and is still widely used. It is well absorbed after oral adminis- effects except they are less likely to cause mental confusion tration, highly bound to plasma proteins (about 95%), metab- and gynecomastia (antiandrogenic effects). In addition, they olized in the liver, and excreted in the urine (about 75%) and do not affect the cytochrome P450 drug-metabolizing system bile or feces. Acid-inhibiting effects occur within 2 hours and in the liver and therefore do not interfere with the metabolism last 72 hours or longer. Omeprazole (Prilosec) Proton Pump Inhibitors is expected to be approved for over-the-counter sales for treat- ing heartburn. If heartburn is not improved within 14 days of PPIs are strong inhibitors of gastric acid secretion. These treatment, clients should be evaluated by their health care drugs bind irreversibly to the gastric proton pump (ie, the en- provider. Prescription omeprazole has been very expensive; zyme H+, K+-ATPase) to prevent the pumping or release of with nonprescription use, the cost should be much less. Inhibition of the proton pump suppresses gastric acid secretion in re- Prostaglandin sponse to all primary stimuli, histamine, gastrin, and acetyl- choline. Thus, the drugs inhibit both daytime (including Naturally occurring prostaglandin E, which is produced in mu- meal-stimulated) and nocturnal (unstimulated) acid secretion. It also inhibits are usually the drugs of choice for treatment of duodenal and the mucosal damage produced by gastric acid, aspirin, and gastric ulcers, GERD with erosive esophagitis, and Zollinger- NSAIDs. Compared with H2RAs, PPIs suppress sion and ulceration of gastric mucosa may occur. This effect mechanism by which aspirin and other NSAIDs are thought to provides faster symptom relief and faster healing in acid- cause gastric and duodenal ulcers (see Chap. For example, healing of duodenal and gas- Misoprostol is a synthetic form of prostaglandin E approved tric ulcers after 2 weeks is similar to the healing after 4 weeks for concurrent use with NSAIDs to protect gastric mucosa of H2RA therapy. The PPIs and H2RAs are similarly effective from NSAID-induced erosion and ulceration. It is indicated in maintenance therapy of peptic ulcer disorders, with similar for clients at high risk of GI ulceration and bleeding, such as rates of ulcer recurrence. In clients with GERD, PPIs usually those taking high doses of NSAIDs for arthritis and older abolish symptoms within 1 to 2 weeks and heal esophagitis adults. The drugs are also effective in maintenance tial, unless effective contraceptive methods are being used, therapy to prevent recurrence of esophagitis. Nausea, diarrhea, and headache are the most frequently reported adverse effects. However, long-term consequences of profound gastric acid Sucralfate suppression are unknown. Sucralfate is a preparation of sulfated sucrose and aluminum hydroxide that binds to normal and ulcerated mucosa. It is effective Nursing Notes: Apply Your Knowledge even though it does not inhibit secretion of gastric acid or pepsin and it has little neutralizing effect on gastric acid. Its Ellen Jones, a 54-year-old homemaker with a seizure disorder mechanism of action is unclear, but it is thought to act locally that has been well controlled on carbamazepine (Tegretol), on the gastric and duodenal mucosa. Possible mechanisms in- comes to the clinic complaining of ataxia, slurred speech, and clude binding to the ulcer and forming a protective barrier be- lethargy. You obtain a history and the only significant change for tween the mucosa and gastric acid, pepsin, and bile salts; Ellen over the last few weeks is an episode of severe heartburn. She has lansoprazole (Prevacid) ordered • Drug therapy with aspirin and other NSAIDs, cortico- for gastroesophageal reflux disease (GERD). You are planning to open the capsule and mix it with applesauce and her blenderized- steroids, and antineoplastics.

Box 9011 cheap gyne-lotrimin 100 mg visa, sion of the cord are localized in front 6500GM Nijmegen generic 100mg gyne-lotrimin with visa, The Netherlands of the cord cheap gyne-lotrimin 100mg on-line, it is obvious that an an- Tel. The different surgical the offending pathology allows atraumatic and extensive Introduction decompression. In cervical spondylotic myelopathy (CSM) there is dysfunc- tion of the spinal cord because of degenerative changes in Surgical strategy the spine. Essentially there are two major The goal of surgical treatment is to achieve a maximum of mechanisms which cause myelopathy: direct compression decompression without compromising the spinal stability of the cord and ischemic changes because of alterations in and respecting the sagittal profile of the spine. Since studies on the affected area the decompression may be executed have demonstrated that the pathology of CSM is located through a simple discectomy, with or without fusion, or predominantly anteriorly, it seems logical to approach through extensive vertebrectomy with grafting and inter- the spine where the lesion is and choose an anterior ap- nal fixation. Removal of extruding intervertebral disc, spurs, a discectomy without fusion [60, 90], but the majority of osteophytes and calcified posterior longitudinal ligament patients included in those studies had disc herniation and relieves the compression of the anterior cord and improves not CSM. The nonfusion discectomy eliminates the radic- to some extent the blood supply to the cord. The surgical ular symptoms in most of the cases but results for a long approach as described by Smith and Robinson covers time in axial neck pain and compromises the lordotic cur- the area between the vertebral bodies of C2 and T1. This is the reason why discectomy is tients with long slender necks the vertebral body of T3 may predominantly combined with interbody fusion today. The Smith and Robinson In a systematic review covering the literature until approach allows atraumatic dissection of the anterior as- 1996 we were not able to identify the anterior interbody pect of the cervical spine. There is a low potential risk for fusion as a gold standard for the treatment of degenerative injuries of the esophagus, trachea, the recurrent laryngeal disc disease Nevertheless, the anterior discectomy and nerve, and the carotid artery. The direct visualization of interbody fusion is the time-honored procedure in treat- 107 line. The width of the trough is up to 18 mm and may in- clude the medial part of the uncovertebral joints. Some authors do not advocate entire removal of the mid- section of the posterior wall of the vertebral body. Grafts, bone substitutes, devices, internal fixation Structural autografts harvested from the anterior iliac crest or from the fibula are used in anterior fusion of the cervical spine. The grafts must enhance stability and sub- stitute for the regenerative capacity of bone. Fresh autolo- gous grafts posess some osteogenic potential and have os- teoinductive and osteoconductive properties. Note the restoration of lordosis tural corticocancellous grafts from the anterior iliac crest are commonly used, and their mechanical strength is greater than that of the posterior crest. They are considered the biological and biomechan- stenotic changes at single or multiple levels. Restoration ical standard for mono- and bisegmental reconstruction of of the intervertebral height and the lordotic curvature is the anterior cervical spine [3, 11, 17, 73, 75, 86, 98, 102, possible when approaching each level separately (Fig. In longer fusions after corpectomies a struc- On the other hand, this may result in increased risk for tural fibula graft is appropriate. There are different tech- symptomatic pseudarthrosis because of the large number niques for stabilizing the strut graft within the decom- areas to fuse [39, 54, 83]. Vascularized fibula in CSM cover a large area of the subaxial spine, corpec- grafts may accelerate the process of fusion in the case of tomy and grafting may be advocated [9, 10, 58]. Additional internal terms have been adopted to describe the partial vertebral fixation may provide immediate intrinsic stability in long body resection, including complete or partial vertebrec- strut graft constructs [15, 16, 46, 67, 92]. Basi- vantages when using autologous grafts such as potential cally all the terms refer to a partial resection of the verte- donor site morbidity, increased operative time, and hospi- bral body without removal of the transverse processes, tal stay. Re- To avoid these disadvantages allografts may be consid- section of the lateral part of the uncovertebral joints must ered. There are also disadvantages concerning the use of also be avoided to prevent injury of the vertebral artery. The use of allografts nal fixation [21, 31, 36, 38, 44, 51, 63, 66, 94, 95]. This nonunion rate is significantly higher than that with autologous grafts, which is estimated at Surgical technique 27%. Allografts may be preserved as fresh-frozen or freeze-dried [27, 52, 87].

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