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By W. Ningal. Columbus State University. 2018.

Mundy GR (1999) Bisphosphonates as Abi-Said D cheap malegra dxt 130mg fast delivery, Wildrick DM generic 130 mg malegra dxt overnight delivery, Gokaslan J Clin Invest 98:1400–1408 cancer drugs best malegra dxt 130mg. Rosen LS buy malegra dxt 130mg fast delivery, Harland SJ cheap 130 mg malegra dxt amex, Oosterlinck W [Suppl 1]:73–78 skeletal complications of metastatic (2002) Broad clinical activity of zole- 58. J Clin dronic acid in osteolytic to osteoblastic Treatment of spinal epidural metas- Oncol 16:2038–2044 bone lesions in patients with a broad tases: randomized prospective compar- range of solid tumors. This comprehen- sive reference surveys the literature related to the con- trol of spinal cord circuits in human subjects, showing how they can be studied, their role in normal move- ment, and how they malfunction in disease states. Chapters are highly illustrated and consistently organised, reviewing, for each pathway, the experimen- tal background, methodology, organisation and con- trol, role during motor tasks, and changes in patients withCNSlesions. Eachchapterconcludeswithahelpful resume that can be used independently of the main text´ ´ to provide practical guidance for clinical studies. This is therefore the last word on the role of the spinal cord in human motor control. It will be essential reading for research workers and clinicians involved in the study, treatment and rehabilitation of movement disorders. Emmanuel Pierrot-Deseilligny is Professor of Rehabil- itation and Clinical Neurophysiology at the Hopital deˆ la Salpetriere, University of Paris. T IR IT O S IN ItsRole in M otor Control and M ovem ent Disorders Emmanuel Pierrot-Deseilligny Hopital de la Salpetriereˆ ˆ ` and David Burke University of Sydney cambridge university press Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo Cambridge University Press The Edinburgh Building, Cambridge cb2 2ru,UK Published in the United States of America by Cambridge University Press, New York www. Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. First published in print format 2005 isbn-13 978-0-511-12544-7 eBook (EBL) isbn-10 0-511-12544-5 eBook (EBL) isbn-13 978-0-521-82581-8 hardback isbn-10 0-521-82581-4 hardback Cambridge University Press has no responsibility for the persistence or accuracy of urls for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. In the 1910–1920s Paul Hoffmann demonstrated that percutaneous electrical stimulation of the posterior tibial nerve in human subjects produced a synchro- nised response in the soleus muscle with the same central delay as the Achilles tendon jerk. Subse- quently, much of the primary knowledge about the spinal circuitry has come from animal experiments, but human studies have retained a unique role: the abilitytosheddirectlightonhowspinalmechanisms are used in the control of voluntary movement. Modern views about spinal pathways began to emerge when Anders Lundberg and colleagues showed in the 1960s and 1970s that, in the cat, each set of spinal interneurones receives extensive convergence from different primary afferents and descending tracts, and that the integrative function of spinal interneurones allows the motoneurones to receive a final command that has been updated at a premotoneuronal level. Methods have now been developed to enable indirect but nevertheless valid measurements of spinal interneuronal activ- ity in human subjects, and these techniques have demonstrated reliability, particularly when congru- ent results are obtained with independent meth- ods. Their use has allowed elucidation of how the brain modulates the activity of specific spinal xv xvi Preface interneurones to control movement. This, together ied, (ii) how they are used in normal movement, and with the abnormalities of motor control resulting (iii) how they malfunction in disease states. It is a thesis of this conditions), isometric voluntary contractions have book that the final movement is only that part of been the main motor tasks during which changes in thesupraspinallyderivedprogrammethatthespinal transmission in spinal pathways have been investi- cordcircuitrydeemsappropriate. However, recent technological advances now of the spinal cord to generate or sustain even simple allow the investigation of spinal pathways during movements, particularly in human subjects, is lim- naturalmovements,includingreachingandwalking. The motor cortex, it is possible to investigate the corti- recent recording by Eberhard Fetz and colleagues cospinal control of spinal interneurones, but there fromspinalinterneuronesduring,andbefore,volun- are little data for other descending controls from tary movement in the awake monkey well illustrates basal ganglia and the brainstem, other than vestibu- this role of the spinal cord. There techniqueshavebeendevelopedtoallowmoreaccu- has been an explosion of studies on human move- rate probing of spinal pathways in human subjects, ment and of the dysfunction that accompanies dif- providing data that can validate and extend the find- ferent neurological disorders, and the prime ration- ings from H reflex studies. As a result, knowledge of ale for this book is to summarise the literature the role of spinal pathways in normal and pathologi- related to the control of spinal cord circuitry in cal motor control has increased greatly, and this pro- human subjects. Forexample, ronal circuits can be studied reliably in human sub- the use of post-stimulus time histograms has allowed jects, and no one book can provide a complete the investigation of single motoneurones in human overview of the role of spinal circuitry in normal and subjects, the technique of spatial facilitation allows pathological movement: there are no data for the the exploration of the convergence of different vol- many circuits that cannot yet be studied in human leys on spinal interneurones, and transcortical stim- subjects, let alone the cat. This book is intended to ulation of the motor cortex allows the corticospinal provide a comprehensive account of (i) how some control of spinal pathways to be investigated. This well-recognised and defined circuits can be stud- book details this newer knowledge for the use of Preface xvii those who have an interest in the subject but who been the subject of phylogenetic adaptations have not had time to read the rapidly accumulating to different motor repertoires. Inevitably, there will be inconsis- lower limb, more elaborate reflex assistance is tencies in conclusions from studies on intact human required for bipedal stance and gait. Greater has been this phylogenetic adaptation argues validity comes from using a number of independent that spinal pathways have a functional role techniques to demonstrate the same finding, as is in human subjects and are not evolutionary emphasised in the following chapters. It requires experiments per- Possible future directions for the research are formed during natural movements, as can be discussed. The differ- tributionofhumanstudiestotheunderstanding ent spinal pathways for which there are reliable and of motor control physiology. Thus, even though non-invasive methods of investigation are consid- many of the conclusions are speculative, this ered with, for each pathway: book gives a large place to the probable func- (i) A brief background from animal experiments. The general human subjects, but the validation of a tech- methodologies that are used for investigating path- niqueforexploringagivenpathwaymayrequire ways are considered in a first chapter with, for each controls only possible in animal experiments method, its advantages and its disadvantages.

Furthermore cheap malegra dxt 130 mg without a prescription, it is unclear what visual perceptions will be evoked by stimulation of cortical neurons discount malegra dxt 130mg. Also malegra dxt 130 mg lowest price, the complex topography of the cor- tical anatomy makes it a di‰cult site for implantation order malegra dxt 130mg visa. Other groups are attempting to develop retinal prostheses that will cause visual perception by electrical stimulation of the healthy inner layers of the retina in patients who su¤er from diseases such as retinitis pigmentosa and age-related mac- ular degeneration buy discount malegra dxt 130mg line. Progress in the field of neural prosthetics has converged with advances in retinal surgery to enable the development of an implantable retinal pros- thesis. Initial experiments with intraocular stimulation were performed by de Juan and Humayun several years ago (Humayun et al. Since that time, several re- search groups have begun the development of retinal prostheses (Zrenner et al. Their approaches can be clas- sified according to where their device will be positioned—on the retinal surface (epi- retinal) or in the subretinal space (subretinal). Epiretinal implantation has the advantage of leaving the retina intact by placing the implant in the vitreous cavity, a naturally existing and fluid-filled space. Studies at John Hopkins University Hospital have demonstrated that this position for an array is biocompatible (Majji et al. Other groups are examining this approach as well (Eckmiller, 1997; Rizzo and Wyatt, 1997). The basic concept that has been described in the past is to mount a miniature video camera (e. The video signal and power of the output would be processed by a data processor, and the information transferred to intraocular electronics by either an 820-nm wavelength laser (Rizzo and Wyatt, 1997) or radio- frequency transmission from an external metal coil to an intraocular coil (Troyk and Schwan, 1992; Heetderks, 1988). The power and data transmitted from the laser or the coil would be converted to electrical current on a stimulating chip that would then control the distribution of current to the epiretinal electrode array. A later section of this chapter discusses a means of naturally imaging light onto an epiretinal prosthesis. Subretinal implantation of a retinal prosthesis is being developed by Zrenner (Zrenner et al. This approach essentially replaces the diseased photoreceptors with a microelectronic stimulator device. However, the sur- gical implantation requires detaching the retina, and the location of the device may be disruptive to the health of the retina (Zrenner et al. The histology of the retina after long-term implantation of a device showed a decline in the densities of inner nuclear and ganglion cell layers (Peyman, et al. These issues are being examined in recently announced phase I clinical trials of a subretinal implantation by Chow and col- leagues in Chicago. A disadvantage of this approach is that it is not applicable to patients with AMD because the retina is no longer transparent. Another approach to a retinal prosthesis was proposed by Yagi at the Kyushu Institute of Technology, Japan (Yagi and Hayashida, 1999; Yagi and Watanabe, 1998). This device would be an integrated circuit and include both electronic and cellular components. The neurons on the device would extend their axons to the central nervous system and thus create a natural device/CNS interface. The epiretinal and subretinal approaches have several advantages over the cortical approach. They both have the ability to use existing physiological optics of the eye, less severe consequences in case of infection, obvious spatial mapping or retinotopic organization, and natural processing of the electrically stimulated images along the proximal visual pathways. However, the retina encodes many properties of the image that are passed on to the higher visual centers (color, intensity, motion, etc. There- fore it may be necessary to integrate some image-processing functions into a retinal prosthesis. Overview of an Intraocular Retinal Prosthetic Device The basic concept of an IRP is straightforward: Visual images can be produced in the brain by electrical stimulation of retinal cells. A layer of retinal cells, such as a gan- glion cell layer, can be stimulated by using an adjacent microelectronic array that inputs electrical impulses to create the perception of an image. The axons of the stimulated ganglion cells then transmit the image through the optic nerve to cells in the visual cortex. This is in place of the normal phototransduction process that occurs in a healthy retina.

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The effect of corti- cause hypotension and other symptoms also occur with costeroids on risks for development of other oppor- many illnesses malegra dxt 130 mg low price. The normal response to critical illness tunistic infections or neoplasms is unknown cheap 130mg malegra dxt with mastercard. If this does not occur generic 130 mg malegra dxt free shipping, or if too little cortisol is produced order malegra dxt 130 mg mastercard, a state of adrenal insufficiency ex- Home Care ists cheap 130mg malegra dxt mastercard. One way to evaluate a client for adrenal insuffi- ciency is a test in which a baseline serum cortisol level Corticosteroids are extensively used in the home setting, by all is measured, after which corticotropin is given IV to age groups, for a wide variety of disorders, and by most routes stimulate cortisol production, and the serum cortisol of administration. Because of potentially serious adverse ef- level is measured again in approximately 30 to 60 min- fects, especially with oral drugs, it is extremely important that utes. Test results are hard to interpret in seriously ill these drugs be used as prescribed. A major responsibility of the clients, though, because serum cortisol concentrations home care nurse is to teach, demonstrate, supervise, monitor, that would be normal in normal subjects may be low in or do whatever is needed to facilitate correct use. In addition, a lower-than-expected rise the home care nurse needs to teach clients and caregivers in- in serum cortisol levels may indicate a normal HPA axis terventions to minimize adverse effects of these drugs. Read the drug label carefully to be certain of having the cor- Many corticosteroid drugs are available in several different prepa- rect preparation for the intended route of administration. For example, hydrocortisone is available in formulations for intravenous (IV) or intramuscular (IM) administration, for intra-articular injection, and for topical application in creams and ointments of several different strengths. These preparations can- not be used interchangeably without causing potentially serious adverse reactions and decreasing therapeutic effects. For example, several preparations are for topical use only; beclomethasone is prepared only for oral and nasal inhalation. With oral corticosteroids, (1) Give single daily doses or alternate day doses between Early morning administration causes less suppression of 6 and 9 AM hypothalamic–pituitary–adrenal (HPA) function. To decrease gastrointestinal (GI) upset (5) With oral budesonide (Entocort EC), ask the client to This drug is formulated to dissolve in the intestine and have local swallow the drug whole, without biting or chewing. For IV or IM administration: (1) Shake the medication vial well before withdrawing Most of the injectable formulations are suspensions, which need medication. For oral or nasal inhalation of a corticosteroid, check the in- These drugs are given by metered dose inhalers or nasal sprays, struction leaflet that accompanies the inhaler. Observe for therapeutic effects The primary objective of corticosteroid therapy is to relieve signs and symptoms, because the drugs are not curative. With adrenocortical insufficiency, observe for absence or These signs and symptoms of impaired metabolism do not occur decrease of weakness, weight loss, anorexia, nausea, vomiting, with adequate replacement of corticosteroids. With rheumatoid arthritis, observe for decreased pain and edema in joints, greater capacity for movement, and increased ability to perform usual activities of daily living. With asthma and chronic obstructive pulmonary disease, ob- serve for decrease in respiratory distress and increased tolerance of activity. When the drug is given to suppress the immune response to organ transplants, therapeutic effect is the absence of signs and symptoms indicating rejection of the transplanted tissue. Observe for adverse effects These are uncommon with replacement therapy but common with long-term administration of the pharmacologic doses used for many disease processes. Adrenocortical insufficiency—fainting, weakness, anorexia, This reaction is likely to occur in clients receiving daily cortico- nausea, vomiting, hypotension, shock, and if untreated, death steroid drugs who encounter stressful situations. It is caused by drug-induced suppression of the HPA axis, which makes the client unable to respond to stress by increasing adrenocortical hormone secretion. However, the al- terations in self-image can lead to psychological problems. These changes cannot be prevented, but they may be partially reversed if corticosteroid therapy is discontinued or reduced in dosage. Fractures of vertebrae, long bones, and ribs are relatively growth in children common, especially in postmenopausal women and immobilized clients. De- creased growth in children results from impaired bone formation and protein metabolism. They are more likely to occur hypernatremia, hypokalemia, metabolic alkalosis with older corticosteroids, such as hydrocortisone and prednisone. Drugs that increase effects of corticosteroids: (1) Estrogens, oral contraceptives, ketoconazole, macrolide These drugs apparently inhibit the enzymes that normally metab- antibiotics (eg, erythromycin) olize corticosteroids in the liver. Drugs that decrease effects of corticosteroids: (1) Antacids, cholestyramine Decrease absorption (2) Carbamazepine, phenytoin, rifampin These drugs induce microsomal enzymes in the liver and increase the rate at which corticosteroids are metabolized or deactivated.

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Interviewees will often ask to see a copy of what you have written before it is published cheap malegra dxt 130 mg fast delivery. The danger with this is that they will try to get rid of their bright buy 130mg malegra dxt, clear quotes and try to put back their posh overcoat (see putting on the posh overcoat) discount 130 mg malegra dxt mastercard. On the other hand purchase malegra dxt 130 mg on-line, passing your copy to them will probably pick up one or two errors of fact order malegra dxt 130mg fast delivery. Use your discretion: a sensible compromise is to read what you have written over the phone. In that way they can pick up errors but will have no time to fiddle with the style. Wherever possible go through the information as soon as the interview is over. When you come to write, you should be in a position to take out of it, from memory, what you need. Avoid where possible writing up transcripts: this takes up huge amounts of time. The test of a good interviewer is not what the interviewee thinks, but the quality of the information elicited, or the liveliness of the quotes. Introductions Many people believe that the role of the first part of a piece of writing is to introduce the reader to what you are going to say so that the reader can decide whether or not to become involved. This probably stems from school essays and has a slightly old-fashioned feel to it. Intro This is the term used by journalists to describe the first sentence of a news story. It is based on the assumption that your best chance of being read is to put your finest information into the first sentence. Once you have done that, you can put in all the qualifying information, in order of importance. The occasional (or perhaps more than occasional, depending on the papers you buy) lapses into extremity should not distract from the fact that this is a sensible approach, and we should adopt it for many types of writing up to about 400 words – particularly letters, e- mails and executive summaries (see marketing). Much of what we call jargon today is actually a technical language that has a precise meaning for fellow professionals, but is mean- ingless to outsiders. All have meanings within their group and are useful because they can describe complex notions and ideas in a simple way. The difficulty comes when these terms are used inappropriately to the wrong audiences. Jargon (as opposed to gobbledegook) has proliferated because of the increasing tendency to write one document for a number of different audiences (see effective writing), or even for the wrong audience (see false feedback loop). The answer is not to get rid of all 67 THE A–Z OF MEDICAL WRITING these uncommon words completely, but to make sure that we use the right language for our audience. Jokes It is difficult to make these work in the unforgiving black and white of the printed word. Journalese Doctors often use this word as a general term of abuse for vulgar and sensational writing. Journalism At its worst the hounder of innocent princesses and enemy of sensible government. At its best the exposer of unprin- cipled villains and deposers of evil regimes. Whether you love it or loathe it, the practice of journalism provides some useful lessons for those wishing to learn how to communicate effectively (see tabloids). It also provides major opportunities for putting out important public health messages (see press releases). BOOKLIST: journalism • The fight for public health, by Simon Chapman and Deborah Lupton, London: BMJ Books, 1994. Written by two experienced campaigners it shows how the mass media, if understood and used properly, can put across immensely powerful public health messages. This book tries to explain how doctors can learn to write for magazines and newsletters rather than journals. Professional exposition of how to write feature articles for newspapers and magazines. Journals All over the world thousands of journals are published each year, most run by commercial organizations, but some in partnership with professional associations. They contain a blend of material, such as editorials, review articles, letters, obitu- aries and news, but what distinguishes them from magazines is that they include scientific papers sent out for peer review.

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