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By T. Daro. Bennington College.

This chapter summarizes the therapeutic practice and mechanistic research on acupuncture treatment for depression purchase viagra plus 400mg amex. Some examples of typical clinical cases will be discussed in the following sections viagra plus 400 mg. Simultaneously buy viagra plus 400mg on-line, we will also list some of the commonly used acupoints for the treatment of depression. In these studies, either the primary or secondary depression has been addressed, although there are some studies without double-blinded control. These clinical data give us some indications that acupuncture can be utilized as a therapy for depression. A total of 440 patients with depressive neurosis, a subtype of depression, were employed in this study, and were divided into three groups: an acupuncture group, a non-acupoint needling group, a Prozac group. On the other hand, needling the points that deviate from the acupoints was prescribed for the non-acupoint group, as a control treatment. These results demonstrate more positive clues that acupuncture is an effective and safe therapy for depressive neurosis. The therapeutic effect of acupuncture on depressive neurosis is observed to be possibly better than or similar to fluoxetine, but with less side effects. Thus, the well- designed clinical trials carried out in multi-centers with strict control provided further evidence on the clinical applications of acupuncture. In 2007, another pilot study was published on the Chinese Journal of Integrated Traditional and Western Medicine (Zhongguo Zhong Xi Yi Jie He Za Zhi) (Li and Liu 2007). A total of 56 depressed patients (from mild to severe) were randomized into two groups: acupuncture group and medication group. Furthermore, the therapeutic effect appeared earlier and lasted longer in the acupuncture group than in the medication group. However, this study did not monitor the side effects of acupuncture and did not set up the sham-acupuncture control and double-blinded assessment systems. Nevertheless, this study further suggests that acupuncture could be a promising therapy for depression. Furthermore, a randomized controlled study focused on the female patients with climacteric depression, a subtype of secondary depression was carried out (Zhou and Wu 2007). A total of 60 cases were examined and randomly assigned to acupuncture group and medication group. As a control therapy, 20 mg/d of fluoxetine was administered to the medication group. Although the results imply that acupuncture can improve the climacteric depression, the clinical implications of acupuncture on this condition must be investigated further. On the other hand, the oral medication of fluoxetine (20 mg/d) was prescribed for the control group. In one study, 68 participants who did not take any mood-altering drugs (11 with anxiety, 8 with depression, and 49 with both anxiety and depression) were recruited to assess the impacts of acupuncture on anxiety and depression symptoms in patients with chronic disease (Tao 1993). The results showed a statistically significant reduction in both anxiety and depression, 1 month after acupuncture treatment. The first study was double-blinded placebo-controlled, in which 29 depressed inpatients were included. In addition, based on the results and research protocol of the previous study, a multi-centered collaborative study was conducted, in which 241 inpatients with depression were included. Particularly, it can be a beneficial choice for depressed patients who could not comply with the classic tricyclic antidepressants owing to their anticholinergic side effects. To further scientifically confirm the efficacy of acupuncture on depression and improve the clinical application, it is very important to carry out well-designed clinical trials of randomized controlled double-blinded protocol. The aim of this pilot study was to determine whether acupuncture holds promise as a treatment for depression during pregnancy. Standardized acupuncture treatments were individually tailored and provided in a double-blind fashion. All the responders to the acute phase of all the treatments had significantly lower depression scores at 10 weeks postpartum, than the non-responders. Thus, this study demonstrated that acupuncture is a promising technique for the treatment of depression during pregnancy. Each 8-week intervention regimen consisted of 12 acupuncture sessions at an acupuncturist’s clinic in the community. This study is the first randomized, controlled, double-blinded study on the efficiency of acupuncture treatment for depression, reported in the western scientific literature. However, 20 patients opted out themselves (they were not excluded by the study group) from the treatment before the completion of the 8-week intervention (13%). Random regression models of the intent-to-treat sample revealed that although patients receiving acupuncture improved better than those awaiting intervention, no evidence of differential efficacy of the depression-specific over the nonspecific intervention was found. Furthermore, the response rates in the acupuncture-treated patients were relatively low after 8 weeks (22% and 39% for specific and nonspecific intervention groups, respectively), with the response rate after the entire 16-week trial reaching 50%. It is possible that the factors that are unique with respect to the implementation of acupuncture in this research study may have limited the efficacy of the interventions, when compared with those provided in the naturalistic settings. Apart from the abovementioned researches, a few studies on acupuncture as a treatment for depression or depression-like syndromes had been published in Eastern Europe, Germany, and the former Soviet Union (Cherkezova and Toteva 1991; Dudaeva et al. However, collectively, these studies suggest that acupuncture can be an effective treatment for depression and depressive symptoms, and that in some cases, it may be as effective as the antidepressant medications. These findings encouraged us to carry out a well-controlled double- blinded large multi-centered study to examine the efficacy of acupuncture on depression. The most frequently used dominant acupoints for the treatment of depression are listed in Table 17. However, acupuncture combined with medicine may be the best choice for the treatment of severe depression, according to the clinical experiences of the Chinese Traditional Medical Society. Nevertheless, further critical clinical trial is required to examine the clinical efficacy and safety of acupuncture on depression. In an earlier study, a total of 61 cases with mental depression were randomly divided into a treatment group of 30 cases and a control group of 31 cases (He et al. However, no remarkable difference was observed between the two groups in terms of adverse reactions. Another clinical study carried out in China examined 42 patients with depression (Zhang et al. However, the significant improvement rate evaluated at the end of the 6-week treatment was remarkably higher in the observation group than that in the control group (72. To assess the clinical therapeutic effect and safety of acupuncture combined with fluoxetine on depression, Lin et al (2005) divided 53 patients with depression into an observation group (n 30) treated with acupuncture combined with fluoxetine, and a control group treated with fluoxetine alone. Furthermore, the adverse effect in the observation group was less and milder than that in the control group.

Susceptibility—Susceptibility to infection is universal; paralysis occurs in only about 1% of infections buy viagra plus 400mg low price. The rate of paralysis among infected nonimmune adults is higher than that among nonimmunized infants and young children generic 400 mg viagra plus amex. Type-specific immunity viagra plus 400mg cheap, apparently of lifelong duration, follows both clinically recognizable and inapparent infections. Second attacks are rare and result from infection with a poliovirus of a different type. Intramuscular injections, trauma or surgery during the incubation period or prodromal illness may provoke paralysis in the affected extrem- ity. The significance of these cases with regard to the possibility of eventually stopping poliomyelitis immunization is under review and studies are in place to look for instances in developing countries. No secondary cases were associated with long-term excretors of vaccine-derived polioviruses. More troublesome have been epidemics of poliomyelitis caused by vaccine-derived polio viruses, which are often recombinants with other neurovirulent enteric viruses capa- ble of spreading through populations. These viruses become manifest in non-vaccinated or incompletely vaccinated indi- viduals. These campaigns should be conducted during the cool, dry season to achieve maximum effect. On the attainment of a high level of control in a country, targeted house-to-house mop-up immunization campaigns in high-risk areas are recommended to interrupt the final chains of transmission. With progress towards the international goal of eradica- tion, the risk profile of paralytic poliomyelitis is changing, particularly in industrialized and high/middle income coun- tries. Results of virus culture of stools, demo- graphic information, immunization history, clinical examina- tion and examination for residual paralysis after 60 days will be covered in supplemental reports. Nonparalytic cases are also reported to the local health authority, Class 2 (see Reporting). In communities with modern and adequate sewage disposal systems, feces and urine can be discharged directly into sewers without preliminary disinfection. Epidemic measures: In any country, a single case of poliomy- elitis must now be considered a public health emergency, requiring an extensive supplementary immunization response over a large geographic area. Disaster implications: Overcrowding of nonimmune groups and collapse of the sanitary infrastructure pose an epidemic threat. Planning a large-scale immunization response must begin immediately and, if epidemiologically appropriate, in coordi- nation with bordering countries. Primary isolation of the virus is often best accomplished in a laboratory designated to be part of the Global Polio Eradication Laboratory Network. Once a wild poliovirus is isolated, molecular epidemiology can often help trace the source. An independent international commission has certified that no locally acquired cases of polio have occurred in the Americas since August 1991. Identification—Acute generalized chlamydial disease with variable clinical presentations; fever, headache, rash, myalgia, chills and upper or lower respiratory tract disease are common. Respiratory symptoms are often mild when compared with the extensive pneumonia demonstrable by X-ray examination. Cough is initially absent or nonproductive; when present, sputum is mucopurulent and scant. Pleuritic chest pain and splenomegaly occur infrequently; pulse may be slow in relation to temperature. Encephalitis, myocarditis and thrombophlebitis are occa- sional complications; relapses may occur. Although usually mild or moderate, human disease can be severe, especially in untreated elderly persons. The diagnosis may be suspected in patients with appropriate symptoms, a history of exposure to birds and elevated or increasing antibody titres to chlamydial antigens in sera collected 2–3 weeks apart. Isolation of the infectious agent from sputum, blood or postmortem tissues in mice, eggs or cell culture, under safe laboratory conditions only, confirms the diagnosis. Recovery of the agent may be difficult, especially if the patient has received broad-spectrum antibiotics. Outbreaks occasionally occur in households, pet shops, aviaries, avian exhibits and pigeon lofts. Apparently healthy birds can be carriers and shed the infectious agent, particularly when subjected to stress through crowding and shipping. Mode of transmission—By inhaling the agent from desiccated droppings, secretions and dust from feathers of infected birds. Imported psittacine birds are the most frequent source of exposure, followed by turkey and duck farms; processing and rendering plants have also been sources of occupational disease. Rarely, person-to-person transmission may occur during acute illness with parox- ysmal coughing; these cases may have been caused by the recently described C. Susceptibility—Susceptibility is general, post-infection immunity incomplete and transitory. Preventive measures: 1) Educate the public to the danger of exposure to infected pet birds. Medical personnel responsible for occupational health in processing plants should be aware that febrile respiratory illness with headache or myalgia among the employees may be psittacosis. Prevent or eliminate avian infections through quarantine and appropriate antibiotics. Tetracyclines can be effective in control- ling disease in psittacines and other companion birds if properly administered to ensure adequate intake for at least 30 and preferably 45 days. Infected birds must be treated or destroyed and the area where they were housed thoroughly cleaned and disinfected with a phenolic compound. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Obligatory case report in many countries, Class 2 (see Reporting). If they cannot be killed, ship swab-cultures of their cloacae or droppings to the laboratory in appropriate transport media and shipping containers, in compliance with postal regulations; after the cultures are taken, the birds should be treated with a tetracycline drug. Place in plastic bags, close securely and ship frozen (on dry ice) to nearest laboratory capable of isolating Chlamydia. Erythromycin is an alternative when tetracycline is contrain- dicated (pregnancy, children under 9). Epidemic measures: Cases are usually sporadic or confined to family outbreaks, but epidemics related to infected aviaries or bird suppliers may be extensive. In poultry flocks, large doses of tetracycline can suppress, but not elimi- nate, infection and thus may complicate investigations. International measures: Compliance with national regula- tions to control importation of psittacine birds. Identification—An acute febrile rickettsial disease; onset may be sudden with chills, retrobulbar headache, weakness, malaise and severe sweats. There is considerable variation in severity and duration; infections may be inapparent or present as a nonspecific fever of unknown origin. A pneumonitis may be found on X-ray examination, but cough, expectora- tion, chest pain and physical findings in the lungs are not prominent.

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All material used in the parts buy viagra plus 400mg visa, one part is surgically inserted into the manufacture of the implant are fully tested for ear buy 400mg viagra plus otc, and the other part known as a speech biological compatibility and durability quality viagra plus 400 mg. The implant electronic components of the receiver are held helps the patient in hearing environmental in a sealed housing which is implanted under sounds and allows speech discrimination the skin behind the ear (Fig. The active electrode connected to the recei- Implant researchers throughout the world ver is inserted into the cochlea through a have found that people who became deaf late cochleostomy into the basal turn. The contacts and had fully developed speech before they (platinum-iridium alloy) are enclosed in became deaf (postlingually deafened) usually silicone and the electrode cable is made in such gain more benefit from a cochlear implant a way that it can be inserted about 25 mm into than those who were born deaf or lost their the cochlea. The However, many prelingually deafened adults speech processor can be body worn or behind and children still gain much benefit from a the ear. The signal from the microphone is sent of 10 months attain normal speech and are along the cable to the speech processor. The speech processor acts on the signal younger the child, the greater the potential for according to coding strategies develop to language development and speech percep- enable optimal hearing with the cochlear tion. In response the auditory nerve carries out its natural function and conducts nerve impulses to the brain. The brain receives the nerve impulses and interprets them as sound, which the implant user hears. The whole process takes place within a few milliseconds, corresponding to the processing time in the normally functioning ear. There is an improved level of auditory sensa- tion and the ability to detect the presence of different sounds. Environmental Sounds: There is immediate detection of normal everyday sounds in the environment such as knock on the door or a door bell, horns of cars and motors, tele- phone ringing, dogs barking, background music and pleasurable sounds such as cooing of babies and rustling of leaves. Understanding of Speech: Implanted patients have limited speech discrimination (understanding). The transmitter transfers the signal toge- implant he can improve his speech ther with the energy required by the production because voice and articulation implanted electronic through the intact can be better controlled. The implanted receiver and stimulator is improvement with lip reading as the decodes the signal and sends a pattern of sound signal from the implant and visual small electrical impulses to the electrodes information work together. The small pulses conducted by the take part in everyday conversation more electrode contacts stimulate the spinal easily and can avoid to write things down. Hearing Aids and Cochlear Implant 129 Most implant users can tell the difference parents. After six months of use, a majo- between a man and a woman’s voice and rity of children respond to their names in they describe speech as sounding natural, quiet environment and spontaneously mechanical, clangy or muffled (like a radio recognise common sounds in the class- not tuned accurately to a station). Children implanted before the age patients enjoy the sound of music and of 3 years develop vocabulary within 3 some interpret music as noise. If there telephone but, in general are not able to are no contraindications, the patient is invited understand words, and for this reason they to take part in further assessments. They are able to the medical assessment so as to ensure that determine if there is a dial tone a busy there are no middle or inner ear problems signal, a ringing tone or whether someone that can interfere with the implantation. Tinnitus (Noises in the ear): These usually standard hearing tests, hearing aid fitting diminish or decrease after implantation. The hearing loss should be implant cannot fully restore nomal profound and an aided audiogram should hearing, adult clinical trials indicate 80 per not show any significant hearing. Child Benefits: Children also show comparison with average cochlear implant significant gains in sound awareness and performance. In small children it is speech uderstanding as reported by their particularly important to evaluate if the 130 Textbook of Ear, Nose and Throat Diseases child can be helped with a conventional receiver/stimulator. The electrode array is hearing aid before considering a cochlear inserted through an opening into the cochlea. Counselling: This is carried out to ensure construction of the electrode array helps it to proper motivation and realistic expecta- be placed into the cochlea and conform to its tions. The ground electrode is placed participate in regular programming and on the bone under the muscle. When the speech processor adjustment visits during incision is closed and the skin heals, the the first couple of years after implantation. Some specific risks intensive rehabilitation with the cochlear include possible strong interaction of strong implant. Psychological assessment: This is carried out Switch on Speech Therapy and to ensure that the patient is well-motivated Rehabilitation for this kind of treatment and has realistic Four to six weeks after surgey the patient expectations. He/she must also show returns to the hospital for the initial switch willingness to take part in auditory and on of the speech processor. In small children the person might be a candidate, then the initial switch on may require several days. Assessments of partici- rank these signals from very soft to comfort- pation of patient’s relatives in the cochlear ably loud. At the end of the programming implant programme is also done prior to session the information will be stored in the surgery. The begins in which the patient learns to associate surgeon forms a small depression in the speech with the patterns of sound which come mastiod bone behind the ear to hold the from the implant. Hearing Aids and Cochlear Implant 131 The programme involves both the patient facial expressions, gestures and hand and the family. Auditory training: Through an auditory as improvement in communication ability and trainer the deaf person is exposed to speech production. The success of this therapy various listening situations with different depends in large measure on the co-operation degrees of difficulty and are taught selec- of the patient who should also be prepared to tively to concentrate on speech sounds. Speech conservation: It is useful in persons can be increased by logopedic training or having sudden severe hearing loss who speech therapy at regular intervals usually a can’t monitor his own speech produc- couple of hours a week. Here tactile and proprioceptive that is needed can vary widely from case to feedback is used to monitor the speech case. Many postlingually Other Facilities for Severely deafened adults with period of deafness of less Deaf Patients can be than 5 years find speech therapy necessary i. Alerting devices to hear a telephone or therapy is required for deaf born children, door bell or baby cry. These devices who had no spoken language before receiv- produce extra loud signals. Telecommunication devices, where a tally deaf child is at the time of implantation, telephone amplifier is attached to a the more therapy will be necessary in trying telephone to increase the sound or a to make up for the time that was lost regarding telecommunication device for deaf speech and language acquisition. For example, one for sound signals back into type written noise, another for quiet and a third for music. Closed caption television decoders can Training of Deaf-mutes be attached to television sets to provide i. Speech reading or lipreading: Here patient cues for news, dramas and other is trained to study the movements of lips programmes.

When sodium hypochlorite is used viagra plus 400mg on line, it must be counterbalanced by a strong acid like sodium bisulfate or muriatic acid to keep the pH within the ideal range viagra plus 400 mg low cost. Sodium hypochlorite differs from chlorine gas in two respects: method of feed and hydrolization properties purchase viagra plus 400mg with amex. In large concentrations it may artificially elevate pH, leading to precipitation of calcium carbonate. Many of the other problems associated with chlorine remain present with sodium hypochlorite. Waterborne Diseases ©6/1/2018 483 (866) 557-1746 When was Sodium Hypochlorite Discovered? Around 1785 the Frenchman Berthollet developed liquid bleaching agents based on sodium hypochlorite. Characteristics of Sodium hypochlorite Sodium hypochlorite is a clear, slightly yellowish solution with a characteristic odor. As a bleaching agent for domestic use it usually contains 5% sodium hypochlorite (with a pH of around 11, it is irritating). If it is more concentrated, it contains a concentration 10-15% sodium hypochlorite (with a pH of around 13, it burns and is corrosive). Chlorine evaporates at a rate of 0,75 gram active chlorine per day from the solution. This also happens when sodium hypochlorite comes in contact with acids, sunlight, certain metals and poisonous and corrosive gasses, including chlorine gas. Sodium hypochlorite is a strong oxidator and reacts with flammable compounds and reductors. These characteristics must be kept in mind during transport, storage and use of sodium hypochlorite. When sodium hypochlorite dissolves in water, two substances form, which play a role in oxidation and disinfection. Sulfuric acid is a strong acid that strongly reacts with bases and is very corrosive. Sodium hypochlorite can be produced in two ways: - By dissolving salt in softened water, which results in a concentrated brine solution. In households, hypochlorite is used frequently for the purification and disinfection of the house. Salt Electrolysis System The advantage of the salt electrolysis system is that no transport or storage of sodium hypochlorite is required. Another advantage of the onsite process is that chlorine lowers the pH and no other acid is required to lower pH. The hydrogen gas that is produced is explosive and as a result ventilation is required for explosion prevention. The maintenance and purchase of the electrolysis system is much more expensive than sodium hypochlorite. Because sodium hypochlorite is used both to oxidize pollutants (urine, sweat, cosmetics) and to remove pathogenic microorganisms, the required concentration of sodium hypochlorite depends on the concentrations of these pollutions. Especially the amount of organic pollutants helps determine the required concentration. If the water is filtered before sodium hypochlorite is applied, less sodium hypochlorite is needed. Waterborne Diseases ©6/1/2018 485 (866) 557-1746 Theory Disinfection with chlorine is very popular in water and wastewater treatment because of its low cost, ability to form a residual, and its effectiveness at low concentrations. Although it is used as a disinfectant, it is a dangerous and potentially fatal chemical if used improperly. Despite the fact the disinfection process may seem simple, it is actually a quite complicated process. When free chlorine is added to the wastewater, it takes on various forms depending on the pH of the wastewater. It is important to understand the forms of chlorine which are present because each has a different disinfecting capability. The graph below depicts the chlorine fractions at different pH values (Drawing by Erik Johnston). Ammonia present in the effluent can also cause problems as chloramines are formed, which have very little disinfecting power. Some methods to overcome the types of chlorine formed are to adjust the pH of the wastewater prior to chlorination or to simply add a larger amount of chlorine. An adjustment in the pH would allow the operators to form the most desired form of chlorine, hypochlorus acid, which has the greatest disinfecting power. Adding larger amounts of chlorine would be an excellent method to combat the chloramines because the ammonia present would bond to the chlorine but further addition of chlorine would stay in the hypochlorus acid or hypochlorite ion state. Waterborne Diseases ©6/1/2018 486 (866) 557-1746 Recommendations for Preparing/Handling/Feeding Sodium Hypochlorite Solutions As a result of the pressures brought to bear by Health and Safety requirements, some users of gas have chosen to seek alternative forms of disinfectants for their water and wastewater treatment plants. Product Stability The oxidizing nature of this substance means that it should be handled with extreme care. Waterborne Diseases ©6/1/2018 487 (866) 557-1746 Waterborne Diseases ©6/1/2018 488 (866) 557-1746 Exposure There is no threshold value for to sodium hypochlorite exposure. After swallowing sodium hypochlorite the effects are stomach ache, a burning sensation, coughing, diarrhea, a sore throat and vomiting. Routes of Exposure Inhalation Hypochlorite solutions can liberate toxic gases such as chlorine. Chlorine is heavier than air and may cause asphyxiation in poorly ventilated, enclosed, or low-lying areas. Children exposed to the same levels of gases as adults may receive a larger dose because they have greater lung surface area/body weight ratios and higher minute volumes/weight ratios. Children may be more vulnerable to corrosive agents than adults because of the smaller diameter of their airways. In addition, they may be exposed to higher levels than adults in the same location because of their short stature and the higher levels of chlorine found nearer to the ground. Skin/Eye Contact Direct contact with hypochlorite solutions, powder, or concentrated vapor causes severe chemical burns, leading to cell death and ulceration. Because of their relatively larger surface area/weight ratio, children are more vulnerable to toxicants affecting the skin. Ingestion Ingestion of hypochlorite solutions causes vomiting and corrosive injury to the gastrointestinal tract. Household bleaches (3 to 6% sodium hypochlorite) usually cause esophageal irritation, but rarely cause strictures or serious injury such as perforation. Commercial bleaches may contain higher concentrations of sodium hypochlorite and are more likely to cause serious injury.