The diagram shows that one of the mechanisms of acupuncture is regulation of the autonomic nervous activity that modulates the body homeostasis cheap kamagra oral jelly online amex erectile dysfunction over 60. The acupuncture signal is first transmitted to the central nervous system via the sensory nervous system (including afferent fibers buy kamagra oral jelly 100mg mastercard impotence meaning, thalamus buy kamagra oral jelly australia erectile dysfunction doctor in houston, cerebral cortex, etc. However, the biological mechanisms underlying acupuncture are yet to be fully understood. Neither the meridian model nor the neurophysiological model could completely elucidate all the findings obtained from the clinical tests and research, and both the theories have their shortcomings and limitations. In this chapter, we will discuss whether (1) the neural signal initiated by stimulation of acupoint could influence in the activation of numerous neural pathways in the central and peripheral nervous 83 Acupuncture Therapy of Neurological Diseases: A Neurobiological View systems; and (2) the activation changes of those neural pathways underlie the therapeutic effect of acupuncture. Even though arguing remains about the biological mechanisms underlying the initiation of acupuncture signal at the acupoint, it has been well documented that certain patterns of acupuncture signals evoked by the stimulation of acupoint are crucial for treating various diseases. A most significant phenomenon regarding the initiation of acupuncture signal is the needling sensation (De-Qi) generated by the stimulation of acupoint. The results obtained from the clinical observation and research experi- ment indicate that the selection of acupoint, modality, frequency, intensity, and timing plays an important role in generating the needling sensation and thus, determining the effectiveness of acupuncture. In the following sections, we will first discuss about the factors that affect the initiation of acupuncture signal, and then, determine whether there is any neural mechanism underlying the needling sensation. The specificity of acupoints is an important issue, as the effectiveness of acupuncture is largely dependent on the acupoint (single or multiple) selected. Numerous evidences from electrophysiological recordings of the unit response of the neurons to the acupoint stimulation, microinjection of compounds (such as agonist or antagonist that specifically bind to a neurotransmitter receptor) into the brain area, or destruction of certain brain nucleus have revealed that manipulation of neuronal activation in certain brain areas could significantly change the functional effect of the acupoint stimulation, indicating an existence of an acupoint-brain activation relationship during acupuncture. Investigations using these methods have demonstrated that different brain-area activities could be evoked by needling, which have been designated as 84 3 Neural Transmission of Acupuncture Signal real acupuncture or sham acupuncture in both human and animal models. Wu et al (2002) compared the real electro-acupuncture with three other acupuncture control groups, namely, mock electro-acupuncture (no stimulation), minimal electro- acupuncture (superficial and light stimulation), and sham electro-acupuncture (same stimulation as real electro-acupuncture but applied at non-meridian points). On comparing the minimal electro-acupuncture with mock electro- acupuncture, the minimal electro-acupuncture was observed to elicit significantly higher activation over the medial occipital cortex. Furthermore, single-subject analysis showed that superior temporal gyrus (encompassing the auditory cortex) and medial occipital cortex (encompassing the visual cortex) frequently respond to minimal electro-acupuncture, sham electro-acupuncture, or real electro-acupuncture. Furthermore, acupuncture- specific neural substrates in the cerebellum were also evident in the declive, nodulus, and uvula of the vermis, quadrangular lobule, cerebellar tonsil, and superior semilunar lobule. This suggests that different brain network (a different set of brain areas) may be involved during manual or electro-acupuncture stimulation. Furthermore, an overlapped acupoint-brain activation pattern was also reported by Napadow et al (2005). On the other hand, both acupuncture stimulations produced more widespread responses than the placebo-like tactile control stimulation. Acupuncture with laser needle is painless and do not any tactile optical stimulation. The advantage of a patient being unaware of the acupunctural stimulation helps the researchers to perform true double-blind studies in acupuncture research (Litscher et al. It has been found that 2 or 100 Hz electro-acupuncture stimulation can induce analgesia via distinct central mechanisms. Low-frequency acupuncture is observed to release endorphins (enkephalin and ȕ-endorphin), while high-frequency acupuncture is found to release dynorphin. Positive correlations were observed in the 2 Hz group in the contralateral primary motor area, supplementary motor area, and ipsilateral superior temporal gyrus, while negative correlations were found in the bilateral hippocampus. In the 100 Hz group, positive correlations were observed in the contralateral inferior parietal lobule, 86 3 Neural Transmission of Acupuncture Signal ipsilateral anterior cingulate cortex, nucleus accumbens, and pons, while negative correlations were detected in the contralateral amygdala. For example, only low-frequency electro-acupuncture was observed to produce signal increases in the pontine raphe area. The results indicate that distinct brain activation patterns elicited by either low or high frequency, though overlapped, are displayed, suggesting that the functional activities of certain brain areas, correlated with the effect of electro-acupuncture, are frequency-dependent. In traditional acupuncture practice, the intensity of acupuncture could be enhanced by different methods including the rotation of acupuncture stimulation. The rotating of the needle was observed to strengthen the effects of the acupuncture only at the real acupoints, by activating the secondary somatosensory cortical areas, frontal areas, the right side of the thalamus, and the left side of the cerebellum. No such effects of the needling technique were seen while stimulating the sham point. The duration of acupuncture stimulation is also important for the disease treatment, and there is no restriction with respect to the time of the stimulation. In general, at least 10 min is required for the production of the therapeutic effects of acupuncture, with the maximal effect caused from 30 min to a few hours of acupuncture. The therapeutic windows are numerous, broadly ranging from hours to days based on the patient’s condition and the acupuncture methodology selected. A prolonged therapeutic effect of acupuncture is thought to be caused by the increased release of endogenous opioid in the endocrine system. Traditional practitioners suggest that initial treatments should be 1 2 times per week, until the patient’s body begins to maintain the desired balance. Subsequently, the treatment can be continued weekly, every other week, or monthly. However, there is still a lack in the follow-up study with the functional imaging method in the patients treated with different paradigms of acupuncture. According to the clinical practice, some patients eventually have just a seasonal “tune-up”. With a still unknown mechanism, acupuncture will cause a reduced effect in curing diseases by tolerance of the patients to the acupuncture treatment. Than, what is the mechanism by which acupuncture signal is initiated by needling of the acupoint(s)? In the recent years, many studies have been carried out to demonstrate the transmission of acupuncture signal in the afferent nerves. Attention has been paid particularly to explore the biological mechanism of a special needling sensation (De-Qi), the experience of the needling sensation is considered commonly as an indicator of the effectiveness of the acupuncture procedure. The needling sensation experienced by the patient during acupuncture includes numbness, heaviness, and radiating paraesthesia along the pathways of the meridians. Zhou et al (1979) demonstrated an anatomical association of meridians, especially where the acupoints are located, with the distribution of peripheral nerves. These data provided indirect anatomical evidences of the structural relationship of the meridian with the peripheral nerves in terms of the acupoint distribution, and support the idea that the acupuncture signal may be initiated at the nerve fibers surrounding the acupoints. To study the biological basis of the needling sensation during acupoint stimulation, the needling sensations of 168 affected points were evaluated and compared with that of 131 normal points in 76 patients with various neurological diseases (Department of Physiology and Acupuncture Research Group, Shanghai First Medical College 1973; Chen et al. The needling sensation was absent at all points in the affected regions in patients with complete brachial plexus and spinal transactional lesions. Patients with spinal motor neuron disease, myopathy, and deep sensory deficits such as Tabes dorsalis involving the posterior column were able to feel the needling sensations at all the affected points. The after-effects of the needling sensations in patients with Tabes dorsalis disappeared quickly. Thus, these results indicate that the impulses of needling sensations are ascended mainly through the ventrolateral funiculi, in which pain and temperature sensations are Figure 3. The needling sensations and acupuncture effects are observed to be closely related to the structural and functional integrity of the pathway conducting pain and temperature sensations.
Diagnosis is facilitated by observation of psoriatic plaques elsewhere on the body or typical nail disease cheap 100 mg kamagra oral jelly amex xalatan erectile dysfunction. The therapeutic measures used for dandruff and seborrheic dermatitis are also the ﬁrst line therapy for scalp psoriasis order kamagra oral jelly 100mg visa erectile dysfunction nutrition. Irritant dermatitis of the scalp presents with thin cheap 100mg kamagra oral jelly visa erectile dysfunction biking, dry, crackling scale plus symptoms of stinging, burning, or itching. It is most often produced by barrier disruption from strong sur- factants in shampoos or chemical treatments for hair styling. Patients with atopic dermatitis are particularly susceptible to such barrier damage. Tinea capitis, particularly Trichophyton tonsurans infection, may mimic dandruff or seb- orrheic dermatitis. Microscopic examination of scale and plucked hairs plus culture should be performed when tinea capitis is a possibility. Suggestive signs include “dandruff” in pre-puber- tal children, hair breakage or loss in affected areas, and cervical or postauricular adenopathy. This presents with large masses of scale adherent ﬁrmly to the hair shafts, especially at the vertex of the scalp. The initial focus of treatment is softening and removal of the matted scale by keratolytic agents. Other uncommon conditions may also be associated with scalp scaling such as ichthyo- sis, pityriasis rubra pilaris, zinc deﬁciency, Langerhans cell histiocytosis, and Wiskott–Aldrich syndrome (18). The tenets of this hypothesis are that the evolutionary forebears of Homo sapiens were adapted to a warm aquatic environment and that some of those adaptations persist today. Examples include our thick subcutaneous fat layer, lack of fur, stretched hind limbs, voluntary respiration, diving reﬂexes, and infant swimming. Even the ﬁnding that omega 3 fatty acids (“ﬁsh oils”) promote healthy human and ape brain development accords with this hypothesis (19–21). For dermatologic ﬁndings, this theory notes hair and sebaceous gland distribution as pro- moting streamlining for forward swimming in water. Thus, male vertex balding, the growth pattern of nose, ear and chest hair, and sebaceous gland concentration at the scalp, forehead, nose, and shoulders all appear adaptive for swimming. Even dandruff ﬁts this hypothesis, as individual scales at the base of hairs are angled to assist in “slicking down” the hairs for decreased water resistance. The Greeks Galen and Celsus argued whether the nature of the squames was dry or exudative. In the late nineteenth century, Rivolta, Malassez (24) and Sabouraud described a bottle-shaped fungus (later called Pityrosporum ovale) on scalps with dandruff and considered it the cause of the condition. However, the ﬁnding of the same organism on normal scalps placed that explanation in doubt (25). By the mid-twentieth century, the theory that dandruff was a hyperproliferative state unrelated to the presence of yeasts was proposed (26,27). Renewed interest in the role of scalp yeasts arose with the ﬁnding that oral ketoconazole was effective in decreasing seborrheic dermatitis (13,28,29). This advent of more effective antifungal agents and the development of more precise microbiologic tech- niques have lead to the current appreciation of the role of yeasts in dandruff and seborrheic dermatitis. Malassezia Malassezia yeasts (previously called Pityrosporum) are a normal part of the skin ﬂora. Because they require lipids for growth, they are found on lipid-rich areas of the body, especially the chest, back, face, and scalp. Colonization of the scalp occurs in infancy and is correlated with the age of appearance of “cradle cap” seborrheic ﬂaking (30,31). The difﬁculty culturing these lipid-dependent (33–35) organisms makes culture unproductive for routine use. Malassezia are present in both normal and dandruff scalps, and constitute the most abun- dant population in both. The other common microorganisms recovered from sampling the scalp are aerobic cocci and Propionibacterium acnes (36). The role of bacteria in the genesis of dandruff is presumably minor since selective antifun- gal agents are the most effective therapeutic agents (37). However, those few patients who fail to respond to antifungal shampoos often show especially heavy colonization with bacteria. In especially severe seborrheic dermatitis, secondary infection with Staphyococcus may complicate the scalp inﬂam- mation (36). In general, scalps with dandruff have more yeast than non-dandruff scalps (38), but the quantity and distribution of the yeasts are less important than the host response to their pres- ence. In early childhood, before the sebum production needed for these lipid-dependent organisms has begun at puberty, dandruff is rare (40). In older literature, Pityroporum were classiﬁed morphologically as ovale and orbiculare. Now, however, the use of molecular markers has allowed identiﬁcation of at least ten species of this genus (41): M. When applied to samples from non-dandruff and dandruff scalp scales, both groups had similar species present. Only the scalps with the highest dandruff scores showed a very low prevalence of other species: M. This is in accordance with visual observation of Nile Blue-stained scalp scales where the predominant yeasts are the bottle-shaped yeast formerly called P. Some investigators have reported an increase in IgG levels, but 78 Hickman this has been refuted by others (2,49–51). Activation of complement in serum by the alternative pathway has been demonstrated for clinical isolates of Malassezia (Pityrosporum ovale) and pro- posed as a mechanism of non-speciﬁc immune response (52–57). The array of cytokines induced varies with the species of Malassezia tested (60), with M. Lipase activity is a likely mechanism linking the Malassezia yeast to the ﬂaking and inﬂammation of dandruff and seborrheic dermatitis (3). Malassezia globosa yeasts incubated with artiﬁcial sebum change the lipid composition with triglyceride degradation and increased free fatty acids (62). Human sebum from dandruff scalps shows high levels of free unsaturated fatty acids; levels revert to normal after antimicrobial shampoo treatment. Dandruff-like ﬂak- ing can be induced on guinea pig skin by the application of the yeast plus a sebum-like lipid source. This has been demonstrated to be from the production of oleic acid by lipase activity. Non-dandruff subjects did not have the same response to oleic acid, thus emphasizing the role of both the lipid and the individual suscepti- bility (64).
Only half of women with gonorrhea gonorrhea and been treated are still subject to rein- have positive Gram stain results 100mg kamagra oral jelly for sale erectile dysfunction yoga. This test calls for fection at another time if they have sexual contact placing a smear of discharge from the penis or the with someone who has gonorrhea order cheap kamagra oral jelly erectile dysfunction treatment drugs. A lab technician studies the slide under a micro- Symptoms scope to ﬁnd the bacteria order kamagra oral jelly 100mg online erectile dysfunction protocol diet. Sometimes a doctor can Symptoms typically appear about two to 10 days give test results to the patient during an ofﬁce visit. In on a culture plate and incubated for up to two rare cases, people may not show symptoms for days to allow the bacteria to multiply, but the several months, but whether or not infected indi- test’s sensitivity depends on the site where it was viduals are exhibiting signs or symptoms, they can harvested. About 90 percent of the time, cervical spread the infection to sex partners unless they samples detect infection if one exists. A throat culture can be used to determine Most commonly, symptoms are a yellowish whether a patient has pharyngeal gonorrhea. If white or yellow-green discharge from the vagina gonorrhea is present in the male or female genital or penis and/or painful or difﬁcult urination. Men tract, its presence can also be diagnosed with a sometimes have swollen testicles that are painful. Rectal infec- Complications tion results in anal itching, discharge, and painful Although the cervix is usually the site of infection, bowel movements. Women suffer the endocervix, with secondary infection of the rec- most serious complications; these can include tum or urethra. Early symptoms of gonorrhea can ectopic pregnancy, infertility, and pelvic inﬂamma- be mild, and many infected women have none tory disease. Sometimes, a woman’s early symp- female reproductive organs that affects about 1 mil- toms of gonorrhea are mistaken for a bladder or lion American women every year—is the most seri- vaginal infection. Increased levels of ﬂu- infection, blindness, or a serious blood infection in oroquinolone-resistant gonorrhea were being the infant. Immediately after a baby is born to a mother could have acquired the disease in Hawaii, other who has gonorrhea, the doctor can prevent eye Paciﬁc islands, or Asia, where this same resistance is infection (ophthalmia neonatorum) by putting silver common. That would point to treatment for these nitrate or another medication into the baby’s eyes. In men, a complication of gonorrhea is the Also, gonorrhea is beginning to show resistance to painful condition of the testicles called epididymitis. Gonorrhea and treated if infected, even if no symptoms occur, can also affect the prostate and cause urethral scar- and these individuals should be screened for other ring that makes urination difﬁcult. That gonorrhea are: limiting the number of sex part- means that new antibiotics and drug combinations ners, not alternating partners, and practicing absti- must be used to treat resistant strains. When the possibility of infection occurs, see In fact, it is now common for doctors to encounter a doctor and avoid sexual contact until you have gonorrhea strains that are resistant to penicillin, been treated and have responded to treatment. Be so this common antibiotic is no longer used for aware that gonorrhea can even occur in the throat gonorrhea treatment. A person who experiences antibiotics, one of the most effective of which is burning during urination or has a discharge or ceftriaxone, injectable by the doctor in one dose. The sexually orally as a single dose are cefixime, ciprofloxacin, active person who is reluctant to inform partners and ofloxacin. One caveat, however: patients 18 that he or she has gonorrhea should remember gum disease 69 that this disease has very serious complications venting gonorrhea. In ordinary circumstances, a fam- National Committee for Quality Assurance, is a set ily member of the patient acts as health care of measures that are used to evaluate the quality proxy/advocate automatically. Each year, care, which differs from the traditional fee-for- the United States spends about $1. Not surprisingly, civil rights 56 percent reduction was seen in the incidence of groups were soon up in arms about this. Both pelvic inflammatory disease in the year after human rights and public health authorities were intervention. Congress then directed place to place, depending on where an individual Health and Human Services to produce a new list lives. Also, hemophilia A hereditary blood defect (in one’s choice of health resources often depends on males) that slows the clotting of blood and some- ability to pay and on the patient’s use of public times makes stopping bleeding very difficult. The charity facilities or others that are covered by her hemophiliac lacks a protein necessary for blood or his individual health insurance, Medicare, or clotting; for this reason, the individual bleeds Medicaid. The speciﬁc goal in respect to sexual behavior is to increase the number of adolescents who abstain hepatitis A Hepatitis A is a virus that is infectious from sexual intercourse or use condoms if they are and contagious and produces inﬂammation of the sexually active. Hepatitis A, B, and C can cause acute infec- adults, the goal is to increase the use of condoms tions, but B and C can become chronic. Besides these aims, Healthy People 2010 has 28 Cause total focus areas with numerous objectives. The Typically, hepatitis A infection is person-to-person agenda can be viewed on the Web: http://www. Helms Amendment Enacted in 1987, this law One gets hepatitis A by ingestion of infected sought to prohibit people from entering the United fecal matter. Many people get hepa- Doctors often encourage their patients to take titis A by eating food that was prepared by some- advantage of the immunization for hepatitis A, one who did not wash his or her hands thoroughly especially for international travel. Many health after a bowel movement and thus had feces experts believe that children who live in high-dis- remaining on the skin. This virus is easily trans- ease-incidence areas should be immunized, along mitted via food contaminated during preparation. The virus gets into the mouth infected person, which accounts for 12 to 26 per- or on food during preparation. Other associations are 11 to 16 per- have been outbreaks of hepatitis A among gay men cent in day care centers; 4 to 6 percent in that some believe may have been caused by this international travel; 2 to 3 percent via food or kind of transmission. Native American number of sexual partners a man has, the more reservations and Alaskan Native villages have a likely he is to contract hepatitis A. Also, a woman high rate of hepatitis A: about 30 to 40 percent of who engages in the sexual practices of oral–anal or the children are infected by age ﬁve, and almost all digital–anal contact is at increased risk of contract- in the community are infected by the time they ing hepatitis A. Young children rarely have atitis A vaccinations for homosexual men at age symptoms, but adults usually do. If someone does have antibodies, these confer pro- Treatment tection against getting the infection again. A per- If someone does contract hepatitis A, a physician son who has a negative result on a blood test but usually recommends rest, fluids, and medication has good reason to suspect infection should repeat to counter nausea. In people with liver problems, hepati- interest is the fact that some individuals whose tis A can be very serious. In some cases, a person blood shows evidence of having had this disease in with hepatitis A does not recover strength com- the past were never aware that they contracted or pletely for several months.