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Science productivity and quality of care: Robot-aided neuro- 1999; 286:888–890 purchase astelin 10 ml with amex allergy symptoms ear ache. Volpe B cheap 10 ml astelin fast delivery xyzal allergy testing, Krebs H, Hogan N, Edelstein L, Diels C, of a robot arm using simultaneously recorded neurons Aisen M. Devel- nication: self-regulation of slow cortical potentials for opment of robots for rehabilitation therapy: the Palo verbal communication. Electroencephalogr Clin ventional therapy techniques for the rehabilitation of Neurophysiol 1988; 70:512–523. Suffczynski P, Kalitzin S, Pfurtscheller G, Lopes da Phys Med Rehabil 2002; 83:952–959. Wolpaw JR, Birbaumer N, McFarland D, ing arm movement impairment after chronic brain Pfurtscheller G, Vaughan TM. Answering ques- training of paraplegic patients using a robotic ortho- tions with an electroencephalogram-based brain- sis. Hesse S, Werner C, Uhlenbrock D, Frankenberg S, C, Simpson R, Vanderheiden G, eds. An electromechani- Accessible Telecommunications, Information and cal gait trainer for restoration of gait in hemiparetic Healthcare Technologies: IEEE Press, 2002. Biol Cybern 1991; 65:147– environment training improves motor performance in 159. PART II COMMON PRACTICES ACROSS DISORDERS Chapter 5 The Rehabilitation Team THE TEAM APPROACH designations mean something different in The Rehabilitation Milieu every program of inpatient or outpatient care. PHYSICIANS Intensive does not imply a particular intensity Responsibilities of practice. Intensive may mean that a patient Interventions is assigned to 3 hours a day with therapists. In NURSES reality, the patient may actively participate in Responsibilities therapy for considerably less time. Compre- Interventions hensive may mean that most disciplines are PHYSICAL THERAPISTS represented, not that their activities aim to re- Responsibilities store a broad range of functions. To the pa- Interventions for Skilled Action tient, comprehensive care may mean satisfying OCCUPATIONAL THERAPISTS all health-related needs. Responsibilities Inpatient and outpatient therapy are con- Interventions for Personal Independence strained by the costs of care. The duration and SPEECH AND LANGUAGE THERAPISTS intensity of rehabilitation is also constrained by Responsibilities the ability of a therapist or a team to articulate Interventions for Dysarthria and Aphasia the value of continuing to work on an aspect NEUROPSYCHOLOGISTS of disability and to offer an evidence-based SOCIAL WORKERS practice to enhance gains. The length of inpa- RECREATIONAL THERAPISTS tient rehabilitation stays has been declining in OTHER TEAM MEMBERS the United States since 1985. This trend may SUMMARY continue with the institution of a Prospective Payment System under Medicare and Medic- aid (www. The oppor- and personal needs, require a team of profes- tunities to offer patients therapy beyond lim- sionals who partner in inpatient and outpatient ited compensatory skills for basic activities of settings. I will refer to the team of rehabilita- daily living (ADLs) depends upon research that tion specialists, such as nurses, physical thera- demonstrates evidence-based interventions. To- THE TEAM APPROACH gether, they practice the experiential art and science of the possible. In a Rehabilitationists provide what many pro- multidisciplinary model, each member with grams call intensive and comprehensive neu- specialty training treats particular disabilities. For example, training procedures for health care goals still take a back seat in most motor and cognitive learning or behavioral deliberations. Rehabilitationists, in contrast, modification are reinforced by all members, us- seek both short-term and long-term goals that ing agreed upon strategies. Patients come to be understood in the con- the impediments to a return to a usual role in text of their cultures and values, their senses, daily life activities. In the medical model, team as a group and of its member specialists the physician controls the action and nearly all depends more on interpersonal and interpro- communication with a patient. The patient pas- fessional skills than on a specific model of in- sively awaits amelioration or cure.

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Drugs are distributed rapidly to organs receiving a large Metabolism blood supply 10 ml astelin amex allergy johnson city tn, such as the heart generic 10 ml astelin with amex allergy treatment child, liver, and kidneys. Distribution to other internal organs, muscle, fat, and skin is usually slower. Metabolism is the method by which drugs are inactivated or An important factor in drug distribution is protein bind- biotransformed by the body. Most drugs form a complex with plasma changed into one or more inactive metabolites, which are Cell membrane Lipid-soluble drugs dissolve in the lipid layer of the cell membrane and diffuse into or out of the cell. Drug molecules cross cell Carrier proteins attach to membranes to move into and out of body cells by directly pene- drug molecules and move them across cell membranes. CHAPTER 2 BASIC CONCEPTS AND PROCESSES 13 BOX 2–2 DRUG TRANSPORT PATHWAYS AND MECHANISMS Pathways The third pathway involves carrier proteins that transport mol- There are three main pathways of drug movement across cell mem- ecules from one side of the cell membrane to the other. Most systemic drugs are formulated transport systems are an important means of moving drug mole- to be lipid soluble so they can move through cell membranes, even cules through the body. They are used, for example, to carry oral oral tablets and capsules that must be sufficiently water soluble to drugs from the intestine to the bloodstream, to carry hormones to dissolve in the aqueous fluids of the stomach and small intestine. Only a few drugs Mechanisms are able to use this pathway because most drug molecules are too large to pass through the small channels. Small ions (eg, sodium Once absorbed into the body, drugs are transported to and from and potassium) use this pathway, but their movement is regulated target cells by such mechanisms as passive diffusion, facilitated by specific channels with a gating mechanism. For example, after oral administration, the gates are located on the outside of the cell membrane; when the initial concentration of a drug is higher in the gastrointestinal tract gates open, sodium ions (Na+) move from extracellular fluid into than in the blood. When the drug is circulated, the concentration is of the cell membrane; when the gates open, potassium ions (K+) higher in the blood than in body cells, so that the drug moves (from move from the cell into extracellular fluid. Passive diffusion continues until a state of equilibrium gating or chemical (also called ligand) gating. With voltage gating, is reached between the amount of drug in the tissues and the amount the electrical potential across the cell membrane determines whether in the blood. With chemical gating, a chemical sub- Facilitated diffusion is a similar process, except that drug mol- stance (a ligand) binds with the protein forming the channel and ecules combine with a carrier substance, such as an enzyme or changes the shape of the protein to open or close the gate. This process and from nerve cells to muscle cells to cause muscle contraction. Some active drugs yield metabolites that are Most drugs are lipid soluble, a characteristic that aids their also active and that continue to exert their effects on body movement across cell membranes. However, the kidneys, cells until they are metabolized further or excreted. Other which are the primary excretory organs, can excrete only drugs (called prodrugs) are initially inactive and exert no water-soluble substances. Therefore, one function of metabo- pharmacologic effects until they are metabolized. Hepatic drug metabolism or clearance is a major mechanism for terminating drug action and eliminating drug Bloodstream molecules from the body. Most drugs are metabolized by enzymes in the liver (called the cytochrome P450 [CYP] or the microsomal en- zyme system); red blood cells, plasma, kidneys, lungs, and A D A D GI mucosa also contain drug-metabolizing enzymes. The cy- tochrome P450 system consists of 12 groups or families, nine of which metabolize endogenous substances and three of A D which metabolize drugs. Of the many drugs metabolized by the liver, the CYP3 group of enzymes is D D A thought to metabolize about 50%, the CYP2 group about 45%, and the CYP1 group about 5%. Individual members of the groups, each of which metabolizes specific drugs, are fur- D ther categorized. For example, many drugs are metabolized D D by CYP2D6, CYP2C9, or CYP3A4 enzymes. Tissue fluid around cells These enzymes, located within hepatocytes, are complex Figure 2–4 Plasma proteins, mainly albumin (A), act as carriers for proteins with binding sites for drug molecules (and endogenous drug molecules (D). Bound drug (A–D) stays in bloodstream and is pharmacologically inactive. They catalyze the chemical reactions of oxidation, and act on body cells.

Treatment method: The main acupoints commonly used based on pattern discrimina- tion were: Guan Yuan (CV 4) Zhong Ji (CV 3) Qi Hai (CV 6) Shen Shu (Bl 23) Pang Guang Shu (Bl 28) San Yin Jiao (Sp 6) Tai Yuan (Lu 9) Tai Xi (Ki 3) The doctor used 28 gauge 10 ml astelin with visa allergy symptoms tired, 1 order 10 ml astelin allergy shots and birth control. After the qi was obtained, they were stimulated via a G6805 electro-acupuncture machine. The frequency was set to 200 cycles per minute, and the needles were retained for 20-30 minutes. Treatment was given one time per day, and six days equaled one course of treatment. Study outcomes: Sixty-one cases were cured, 26 cases improved, and five cases got no effect. From The Treatment of 22 Cases of Pediatric Enuresis with Electro-acupuncture & Ear Press Magnets by Fan Jin, He Bei Zhong Yi (Hebei Chinese Medicine), 2002, #8, p. According to TCM pattern discrimination, 16 cases presented with kidney vacu- ity not securing and six cases presented with liver channel depressive heat. All these patients experienced enuresis during sleep which was either mild (one time per night) or severe (multi- ple times per night). Those with kidney vacuity not securing pre- sented with lassitude of the spirit, lack of strength, low back ache, cold limbs, a somber white facial complexion, and clear, long urination. Those with liver channel depressive heat presented with profuse dreams, grinding of teeth, agitation, vexation, easy anger, red lips and tongue, and scanty urine that had a fishy or animal smell. Treatment method: Electro-acupuncture was administered at the following main acu- points: Guan Yuan (CV 4) Zhong Ji (CV 3) San Yin Jiao (Sp 6) If there was kidney vacuity not securing, Tai Xi (Ki 3) and Shen Shu (Bl 23) were added. If there was liver channel depressive heat, Tai Chong (Liv 3) and Li Gou (Liv 5) were added. Electrical stimulation was added to the handles of the needle which were retained for 30 minutes. Supplementation method was used for the pattern of kidney vacuity not securing, and draining technique was used for the pattern of liver channel depressive heat. Treatment was given every other day for mild cases and was given daily for serious cases. The main ear points treated with magnets consisted of: Shen Men (Spirit Gate) Kidney Bladder Liver Subcortex Brain Point Chinese Research on the Treatment of Pediatric Enuresis 181 The magnets were two millimeters in diameter and were applied to the ear using a 0. These magnets were stimulated or pressed 20 times by the patient four times per day until there was distention or pain in the ear. If the enuresis returned, then the treatment was continued to obtain results. The longest course of treatment was three months, and the shortest was two weeks. Study outcomes: Four cases were cured, 17 cases improved, and one case did not improve, for a total amelioration rate of 95. From Clinical Observations of Using Electro-acupuncture to Treat 102 Cases of Enuresis by Xie Wan-dong, Xin Zhong Yi (New Chinese Medicine), 1989, #10, p. Twenty-four of these cases were between 4-7 years old, 55 cases were between 8-14 years old, and 23 cases were more than 15 years old. The course of disease was less than two years in 30 cases, 2-10 years in 52 cases, and more than 10 years in 20 cases. Treatment method: The main acupoints used in this study were: Guan Yuan (CV 4) Zhong Ji (CV 3) Qu Gu (CV 2) San Yin Jiao (Sp 6) was an auxiliary point. Treatment was given once per day, and five times equaled one course of treatment. Three days interval was given between each successive course of treatment. The needles were retained for 15-20 minutes and stim- ulated using a G6805 electro-acupuncture machine. If the patients body was smaller than normal and their tongue was pale with white fur, this indicated yang vacuity and the doctor would then add moxibustion. Miscellaneous From The Treatment of 42 Cases of Pediatric Enuresis with Spinal Pinch Pull Technique Combined With Cupping the Umbilicus by Yan Xiang-hong & Huang Ji-yan, An Mo Yu Dao Yin (Massage & Dao Yin), 2001, #1, p. There was enuresis once per night in 26 cases and 2-3 times per week in 16 cases.

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