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It is recommended that children using this system should have bi- weekly follow-up visits to sustain motivation buy viagra professional 50mg cheap, problem solve any difficulties cheap viagra professional 50 mg mastercard, and monitor the success of the treatment 50 mg viagra professional with mastercard. In short generic 50 mg viagra professional free shipping, alarm therapy has been proven to be more effective than pharma- cological therapy in Western medicine since it has no side effects purchase viagra professional 50mg otc, has a better long-term conditioning cure, has a decreased chance of relapse, and is more cost-effective. Alarm clock An alternate method for a child who is unable to awaken him- or herself at night is to teach them to use an alarm clock or clock radio to wake them. Instead of the alarm, alternatively the parent may wake the child after 3-4 hours. Similar to the above method, the alarm clock method is used to elicit a conditioned response of waking when the bladder is full. To improve the results, the child is encouraged to practice responding to the alarm during the day while lying on the bed with their eyes closed. The child should be made to take respon- sibility to set the alarm each night. The individual should be praised for getting up at night, even if he or she is not dry in the morning. Hypnotherapy & guided imagery Hypnotherapy has been effective in some cases of enuresis. The child is put into a hypnotic state and then given suggestions about modifying their behavior. It is then hoped that the child sub- sequently although unconsciously acts upon these suggestions. Parents who are interested in using this therapy in their children will need a referral from their physician or should seek out a trained and licensed therapist in the Yellow Pages under Psychotherapists. Guided imagery can be used in the same way you can explain enuresis to a child. In Appendix Two is an example that I came across in my research that I use in my clinic and one example of guided imagery I give to parents to use with their child. It can also be useful to combine these explanations with pictures to further explain if at all possible. Star charts & reward systems Star charts and reward systems prove very beneficial for some patients and are used either alone or in conjunction with other ther- apies. Everyone knows that it is easier to wake up in the morning when the next day holds promise and excitement. Star charts use this concept to their advantage by offering a child a star on the cal- endar for each dry night. When the child collects or obtains a cer- tain number of stars (usually 3-7), they are given a small reward. When the child is dry for a longer duration, such as 21 nights, he or she receives a larger, more appreciated and anticipated prize. The explanation for the effectiveness of this treatment is that, by rewarding the child, you put the reticular activating system of the brain in a more heightened state of readiness and it is better able to wake up when the bladder signals that it is full. For some, this method alone is sufficient to make them responsive to a full blad- der. However, according to some authorities, if this treatment does not improve the enuresis within two weeks, its use should not be continued without being combined with another therapy. Dr Richard Butler, a psychologist, suggests using a point system The Western Medical Treatment of Enuresis 33 instead of the star charts. This does not have to be an expensive gift or reward but instead may be time set aside for a particular activity that the child enjoys doing with their parent. For example, the child may have to earn 30 points to enjoy an afternoon at the zoo, playing baseball, or having a camp-out. You agree that a certain amount of points will be rewarded to them for positive behavior outcomes that have previously been identified and agreed upon and then help the child achieve these over a period of time. Children will soon become competitive if supported by the adults that are around them and will strive to attain this goal. Butler argues that this method is preferable to the star system of only rewarding the child when they do not wet the bed. He feels the child will be totally demoralized and stop trying if he or she accu- mulates too many consecutive nights of wetting the bed. Pharmacological therapy This section is an introduction to the pharmacological treatments currently available in modern Western medicine to treat enuresis. The intent of this section is to educate the practitioner on possible treatments their patients may have received prior to coming to your office and to supply the practitioner with information to bet- ter educate their patients and their families on an effective treat- ment plan.

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After taking only two packets of these medici- nals 50 mg viagra professional, the young woman did not have enuresis for four nights buy 100mg viagra professional. After continuing to take the medicine for another five packets discount viagra professional 100mg with mastercard, the enuresis did not return even on follow-up after one year 50 mg viagra professional amex. Case 7:7 This case is of an eight year-old boy who was initially seen on January 7 generic viagra professional 100 mg on line, 1984. For more than three years, the child had had enuresis 1-2 times every night. The child had already taken medic- inals to fortify the spleen and boost the kidneys, secure, astringe, and reduce urination as well as acupuncture and moxibustion all with no success. The tongue fur was thin and white, and his pulse was moderate (or slightly slow). The doctor used Ge 190 Treating Pediatric Bed-wetting with Acupuncture & Chinese Medicine Gen Tang (Puerariae Decoction). The formula prescribed consisted of: Ge Gen (Radix Puerariae), 10g, Ma Huang (Herba Ephedrae), 4g, Gui Zhi (Ramulus Cinnamomi), mix-fried Gan Cao (Radix Glycyrrhizae), and Bai Shao (Radix Paeoniae Albae), 6g each, Sheng Jiang (uncooked Rhizoma Zingiberis), 2g, and Da Zao (Fructus Jujubae), 7 pieces. After nine packets of these medici- nals, the enuresis was completely cured and did not return. Case 8:8 The patient in this case was a 12 year-old female whose initial examination took place on October 5, 1984. In the summer, the child had enuresis 1-3 times per night, but, in the winter, this increased to 3-6 times per night. The child had used modern Western medicine, Chinese herbal medicine, and acupuncture prior to her initial assessment without success. The child had a less than normal essence-spirit, a bright, white facial complexion, lack of strength, cold limbs, cold stomach, long, clear urination, a pale tongue, and a deep, slow, forceless pulse. Based on these signs and symptoms, her pattern was determined to be spleen-kidney yang vacuity, and she was prescribed Ma Huang Tang Jia Wei (Ephedra Decoction with Added Flavors) composed of: Ma Huang (Herba Ephedrae), Fu Zi (Radix Lateralis Praeparatus Aconiti Carmichaeli), and Xing Ren (Semen Armeniacae), 10g each, Gui Zhi (Ramulus Cinnamomi), 12g, Wu Yao (Radix Linderae), uncooked Shan Yao (Radix Dioscoreae), and Sang Piao Xiao (Ootheca Mantidis), 30g each, Yi Zhi Ren (Fructus Alpiniae Oxyphyllae), Rou Gui (Cortex Cinnamomi), and Gan Cao (Radix Glycyrrhizae), 6g each. After tak- ing only one packet of these medicinals, the frequency of enure- sis decreased, and, after three packets, it had stopped. The patient continued to take six more packets to secure the treat- ment results. Case 9:9 This boy was 10 years old, and he was first seen on July 22, 1987. He was nervous, sometimes severely so, and he was disqui- eted at night. His appetite and bowels were normal, his facial complexion was yellow, and Representative Case Histories 191 his body was emaciated. Based on these signs and symptoms, the treatment principles advanced were to fortify the spleen and quiet the spirit, secure and contain and stop enuresis. Therefore, the following version of Gui Pi Tang Jia Wei (Restore the Spleen Decoction with Added Flavors) was prescribed: Dang Shen (Radix Codonopsitis), Huang Qi (Radix Astragali), Fu Ling (Poria), Yuan Zhi (Radix Polygalae), Long Yan Rou (Arillus Longanae), Wu Wei Zi (Fructus Schisandrae), and stir-fried Bai Zhu (Rhizoma Atractylodis Macrocephalae), 10g each, uncooked Long Gu (Os Draconis) and Mu Li (Concha Ostreae), 20g each, Suan Zao Ren (Semen Zizyphi Spinosae) and Sang Piao Xiao (Ootheca Mantidis), 15g each, Sheng Jiang (uncooked Rhizoma Zingiberis), 2 slices, and Da Zao (Fructus Jujubae), 5 pieces. After continuing to take five more packets, the enuresis decreased to 1-2 times per week. The doctor then prescribed five more packets, after which the enuresis was cured. Initially the child had tried using Liu Wei Di Huang Wan (Six Flavors Rehmannia Pills), Long Dan Xie Gan Wan (Gentiana Drain the Liver Pills), and another empirical formula but obtained no results. When examined, the following signs and symptoms were found: night-time enuresis, negative urine culture, thirst with a desire for chilled drinks, red, swollen gums, average development, a red tongue with yellow fur, and a slippery, rapid pulse. The doctor, therefore, chose to use Qing Wei San (Clear the Stomach Powder). This formula consists of: Huang Lian (Rhizoma Coptidis), Sheng Ma (Rhizoma Cimicifugae), Dan Pi (Cortex Moutan), Sheng Di (uncooked Radix Rehmanniae), and Dang Gui (Radix Angelicae Sinensis). Unfortunately, the Chinese author did not include doses of these ingredients. The patient decocted these medicinals and took this formula one time each during the day and night for five days. At the second visit, the thirst with a desire for chilled drinks and the red, swollen gums were improved. Already there was no enuresis 192 Treating Pediatric Bed-wetting with Acupuncture & Chinese Medicine at night.

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The release of cy- blood levels of IGF-1 and its uptake into the tokines near the time of an acute injury buy 100mg viagra professional free shipping, for Biologic Adaptations and Neural Repair 107 example purchase viagra professional 50mg fast delivery, may make the environment unsafe for rons buy viagra professional 100mg. When the stem cells were transplanted new cell survival order viagra professional 100 mg without a prescription, proliferation or migration order 100 mg viagra professional otc, as into the striatum, cortex, hippocampus, and ol- well as set off a series of cellular cues that lead factory bulb of adult mice, the cells migrated to delayed cell death or inhibition of axonal re- and differentiated extensively only in the generation. In contrast, embry- erebral grafts have partially restored a variety onic neuronal precursors and adult precursors of sensorimotor and cognitive skills in animal that were grown in vitro before transplantation models of injury, but methodologies must take have been more efficient at migration and dif- into account many factors (Table 2–8). Neural pro- be able to take on the cell type characteristics genitor cells from embryonic human forebrain of their neighbors. Given that they can prolif- tissue have remarkable potential for adaptabil- erate and migrate, they may also serve as trans- ity in a new environment. When implanted into port vehicles for a variety of genetically engi- the hippocampus and subventricular zone of neered proteins (Table 2–9). Many immunosuppression and neuropro- stores and bone marrow offer an intriguing tection strategies are being tried. Embryonic stem cells, a cocktail of the growth factor GDNF was com- so far, seem more flexible than stem cells found bined with a caspace inhibitor of apoptosis to in adult tissues, but the gap appears to be clos- enhance the survival of dopamine neurons ing. The way the donor material is prepared from fetal ventromesencephalic tissue. These techniques are improving, tion that has been rapidly expanded to supply but the results of transplantation are rather un- as many cells as needed. For example, neural stem cells hand, neural precursor cells, such as human from the subventricular zone preferentially mi- mesencephalic precursors that make dopamine, grate to the olfactory bulb and form interneu- may require a cocktail of growth factors, cy- Table 2–9. Neural Stem or Precursor Cells as Delivery Vehicles POTENTIAL CAPABILITIES Cell replacement in a circuit Provide extracellular matrix products Contact with intact cells, altering their activity Provide anti-inhibitory molecules for axonal growth Myelination cone extension Provide diffusable molecules (e. Clinicians can also help put replication into the neurons of choice in large the potential of stem cell research for mollify- numbers. Genes can also be delivered directly ing neurologic disease into the context of the into neurons by infecting them with a virus that disabilities caused by these diseases in millions carries the message for cells to produce a neu- of people. The remark- been genetically engineered to transport spe- able effects of exercise have implications cific genes or cells into the nervous system. It is structs may provide the substances missing in difficult enough to show an exercise-dose to genetic diseases that affect the CNS. Also, tent cells are potentially useful for repairs, re- reducing stress-induced glucorcorticoids and placements, and to transport genes for trophic adding growth factors may lead to greater pro- factors, proteins, and neurotransmitters. Basic researchers must still pursue genes that produce specific neurotrophins or how the myriad genetic, molecular, and envi- other molecules that can diffuse toward cells ronmental factors that continue to be identi- in need of nurture and toward axons that may fied come to regulate proliferation, migration, be coaxed to regenerate. Sophisticated tech- differentiation, and incorporation of newly niques for gene therapy allow both direct and minted neurons. At the moment, the state-of- cell-mediated transfer of therapeutic genes the-art cannot quite define the identity of in into the CNS. Greater knowledge of the endogenous boundary, they migrate better than Schwann regulators of natural neurogenesis may even- cells,146 elicit axonal regeneration in rat spinal tually lead to proactive self-repair strategies cord,147 and form a thin layer of myelin over manipulated by clinicians. Clinicians can These include adrenal medulla autotransplan- do a great service for stem cell research by tation, dopaminergic neurons from human fe- making sure that lay people understand just tuses, a human teratocarcinoma cell line, com- what comprises a blastocyst from which ES mitted dopaminergic neurons from embryonic Biologic Adaptations and Neural Repair 109 midbrain expanded in vitro, immortalized pro- than 10% of human fetal substantia nigral cells genitor cells given a gene or other factor for survive grafting; approximately 25% are dam- dopaminergic differentiation, and other clever aged by manipulation, and another 25% are manipulations. Reports suggested that graft dead before implantation, even when the sur- survival in animal models of induced Parkin- geon immediately deploys the cells. Some grafts in ro- gather large numbers of cells came from the dents have been placed in the substantia nigra apparent success of implanting fetal pig cells where a small percentage of neurons have sent into rodents and then into humans. No clinical cultured mesencephalic tissue cells from 4 em- gains were described 18 months later. Fiber outgrowth tal precursor cells, striatal cells, and human from the transplant, demonstrated by PET donor cells from the lateral ventricle of fetuses scanning, occurred in most of these cases. At into rats and primate models of HD has led to postmortem examination of two subjects, the human trials. Hopes have been high, in part dopamine neurons generated dendrites from 2 because the dominant region of pathology in to 3 mm from the cell body. Unfortunately, this neurodegenerative disease, which is 15% of these subjects developed dystonia and caused by increased cytosine, adenine, guani- dyskinesias.

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Moxibustion was then applied to the following acupoints: Dan Tian (CV 4-6) Shen Shu (Bl 23) Bai Hui (GV 20) These patients were treated one time per day cheap 100 mg viagra professional fast delivery, and five days equaled one course of treatment cheap viagra professional 50 mg overnight delivery. In general buy 100mg viagra professional fast delivery, patients received 1-2 courses of treatment generic 100mg viagra professional with amex, although stubborn cases received three courses viagra professional 100mg visa. Chinese Research on the Treatment of Pediatric Enuresis 161 Study outcomes: Ten cases (67%) were cured, four cases were markedly improved, and one case improved. Tuina combined with internal medicine From The Treatment of 60 Cases of Pediatric Enuresis Combining Chinese Medicinals & Spinal Pinch Pull Technique by Wu Xiao-ju, Huai Hai Zhong Yao (Huaihai Chinese Medicine), 2002, #4, p. Forty-eight of these patients (80%) were between 5-8 years old and 12 cases (20%) between 9-15 years old. All the children were more than three years old, and their course of disease was less than one year. Treatment method: External treatment consisted of the spinal pinch-pull technique. In other words, the practitioner pushed and pinch-rolled up the spine five times and then rubbed with their palm in a circular manner from the top to the bottom of the spine two times. Ten days equaled one course of treatment, and, after a three day interval, the patient continued with the next course of treatment. Internal treatment consisted of the oral administration of Bu Shen Suo Niao Tang (Supplement the Kidneys & Reduce Urination Decoction) which was composed of: Huang Qi (Radix Astragali), 30g Dang Shen (Radix Codonopsitis), 10g Shan Yao (Radix Dioscoreae), 10g Tu Si Zi (Semen Cuscutae), 10g Yi Zhi Ren (Fructus Alpiniae Oxyphyllae), 10g Sang Piao Xiao (Ootheca Mantidis), 10g Wu Wei Zi (Fructus Schisandrae), 6g Jin Ying Zi (Fructus Rosae Laevigatae), 10g 162 Treating Pediatric Bed-wetting with Acupuncture & Chinese Medicine Fu Pen Zi (Fructus Rubi), 10g Ma Huang (Herba Ephedrae), 6g One packet of these medicinals was decocted per day in water until 300 milliliters of medicinal liquid remained. Ten days equaled one course of treatment, and the treatment was continued for three successive courses of treatment. From The Treatment of 32 Cases of Pediatric Enuresis with Spinal Pinch Pull, Moxibustion & Cupping by Li Qiang-hua, An Mo Yu Dao Yin (Massage & Dao Yin), 2000, #4, p. The course of disease was less than three years in 19 cases and more than three years in 13 cases. The enuresis occurred one or more times per night in 16 cases, 1-3 times per week in nine cases, and 1-2 times per month in seven cases. Also in seven cases, the enuresis was increased in amount on cold, rainy days. Treatment method: First, spinal pinch-pull was performed five times from Chang Qiang (GV 1) to Da Zhui (GV 14). During the fifth time, the area was pinched three times (instead of one time) and pulled. One treat- ment was given every day, and 10 days equaled one course of treatment. This treatment was done every other day, and five treatments equaled one course of treatment. In addition, Chinese Research on the Treatment of Pediatric Enuresis 163 moxibustion for approximately 10 minutes was done at Guan Yuan (CV 4) and San Yin Jiao (Sp 6) until the skin was slightly red. One treatment was given every day, and 10 days equaled one course of treatment. Among the patients that were cured, eight cases required one course of treatment, 15 cases required two courses of treatment, and four cases required three courses of treatment. Discussion: This study is an example of combining various treatment methods to achieve better clinical results. These methods are all noninva- sive and inexpensive and can be taught to the parents of the child so they can continue to treat the child at home. From The Treatment of 100 Cases of Enuresis Using Acupuncture & Chinese Medicinals Simultaneously by Zhang Li-juan, Ji Lin Zhong Yi Yao (Jilin Chinese Medicine & Medicinals), 1992, #4, p. Treatment method: This protocol consisted of a combination of Chinese medicinals applied to the umbilicus and acupuncture. The following Chinese medicinals were applied to the navel: powdered Rou Gui (Cortex Cinnamomi), 15g Liu Huang (Sulphur), 15g Cong Bai (Bulbus Allii Fistulosi), 5-7 pieces This mixture was applied to Shen Que (CV 8) one time per day 164 Treating Pediatric Bed-wetting with Acupuncture & Chinese Medicine before sleep. In addition, acupuncture was performed at Guan Yuan (CV 4) one time each day. The patient was also allowed to use 5-7 cones of moxa or indirect ginger moxa per day as well.

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