Loading

Extra Super Avana

2019, Drake University, Achmed's review: "Order cheap Extra Super Avana online no RX - Best Extra Super Avana OTC".

Disturbances of conduct are distinguished from an adjustment reaction by a longer duration and by a lack of close relationship in time and content to some stress discount 260mg extra super avana with mastercard erectile dysfunction exercises wiki. They differ from a personality disorder by the absence of deeply ingrained maladaptive patterns of behavior present from adolescence or earlier cheap generic extra super avana canada impotence grounds for divorce states. Where the emotional disorder takes the form of a neurotic disorder described under 300. Overanxious reaction of childhood and adolescence Excludes: abnormal separation anxiety (309. Sibling jealousy Excludes: relationship problems associated with aggression, destruction, or other forms of conduct disturbance (312. The category of mixed disorders should only be used when there is such an admixture that this cannot be done. In early childhood the most striking symptom is disinhibited, poorly organized and poorly regulated extreme overactivity but in adolescence this may be replaced by underactivity. Impulsiveness, marked mood fluctua- tions and aggression are also common symptoms. Delays in the development of specific skills are often present and disturbed, poor relationships are common. If the hyperkinesis is symptomatic of an underlying disorder, code the underlying disorder instead. Developmental disorder of hyperkinesis Use additional code to identify any associated neurological disorder 314. Hyperkinetic conduct disorder Excludes: hyperkinesis with significant delays in specific skills (314. In each case development is related to biological maturation but it is also influenced by nonbiological factors and the coding carries no aetiological implications. Speech or language difficulties, impaired right-left differentiation, perceptuo-motor problems, and coding difficulties are frequently associated. Most commonly there is a delay in the development of normal word-sound production resulting in defects of articulation. When this occurs the coding should be made according to the skill most seriously impaired. The mixed category should be used only where the mixture of delayed skills is such that no one skill is preponderantly affected. The mental disturbance is usually mild and nonspecific and psychic factors [worry, fear, conflict, etc. In the rare instance that an overt psychiatric disorder is thought to have caused a physical condition, use a second additional code to record the psychiatric diagnosis. Where there is a specific cognitive handicap, such as in speech, the four-digit coding should be based on assessments of cognition outside the area of specific handicap. The assessment of intellectual level should be based on whatever information is available, including clinical evidence, adaptive behavior and psychometric findings. Mental retardation often involves psychiatric disturbances and may often develop as a result of some physical disease or injury. In these cases, an additional code or codes should be used to identify any associated condition, psychiatric or physical. The "late effects" include conditions specified as such, or as sequelae, which may occur at any time after the resolution of the causal condition. The category is also for use in multiple coding to identify these types of hemiplegia resulting from any cause. The category is also for use in multiple coding to identify these conditions resulting from any cause. The "late effects" include conditions specified as such, as sequelae, or present one year or more after the onset of the causal condition. Signs and symptoms that point rather definitely to a given diagnosis are assigned to some category in the preceding part of the classification. In general, categories 780-796 include the more ill-defined conditions and symptoms that point with perhaps equal suspicion to two or more diseases or to two or more systems of the body, and without the necessary study of the case to make a final diagnosis. Practically all categories in this group could be designated as "not otherwise specified," or as "unknown etiology," or as "transient. Where a code from this section is applicable, it is intended that it shall be used in addition to a code from one of the main chapters of the International Classification of Diseases, Injuries and Causes of Death, indicating the nature of the condition. Machinery accidents [other than connected with transport] are classifiable to category E919, in which the fourth digit allows a broad classification of the type of machinery involved. If a more detailed classification of type of machinery is required, it is suggested that the "Classification of Industrial Accidents according to Agency," prepared by the International Labor Office, be used in addition. Categories for "late effects" of accidents and other external causes are to be found at E929, E959, E969, E977, E989, and E999. Definitions and examples related to transport accidents (a) A transport accident (E800-E848) is any accident involving a device designed primarily for, or being used at the time primarily for, conveying persons or goods from one place to another. Includes: accidents involving: aircraft and spacecraft (E840-E848) watercraft (E830-E838) motor vehicle (E810-E825) railway (E800-E807) other road vehicles (E826-E829) In classifying accidents which involve more than one kind of transport, the above order of precedence of transport accidents should be used. Vehicles which can travel on land or water, such as hovercraft and other amphibious vehicles, are regarded as watercraft when on the water, as motor vehicles when on the highway, and as off-road motor vehicles when on land, but off the highway. Excludes: accidents: in sports which involve the use of transport but where the transport vehicle itself is not involved in the accident involving vehicles which are part of industrial equipment used entirely on industrial premises occurring during transportation but unrelated to the hazards associated with the means of transportation [e. Excludes: accidents: in repair shops in roundhouse or on turntable on railway premises but not involving a train or other railway vehicle (c) A railway train or railway vehicle is any device with or without cars coupled to it, designed for traffic on a railway. It is defined as a motor vehicle traffic accident or as a motor vehicle nontraffic accident according to whether the accident occurs on a public highway or elsewhere. Excludes: injury or damage due to cataclysm injury or damage while a motor vehicle, not under its own power, is being loaded on, or unloaded from, another conveyance (f) A motor vehicle traffic accident is any motor vehicle accident occurring on a public highway [i. A motor vehicle accident is assumed to have occurred on the highway unless another place is specified, except in the case of accidents involving only off-road motor vehicles, which are classified as nontraffic accidents unless the contrary is stated. A roadway is that part of the public highway designed, improved and ordinarily used, for vehicular travel. Includes: approaches (public) to: docks public building station Excludes: driveway (private) roads in: parking lot industrial premises ramp mine roads in: private grounds airfield quarry farm (i) A motor vehicle is any mechanically or electrically powered device, not operated on rails, upon which any person or property may be transported or drawn upon a highway. Any object such as a trailer, coaster, sled, or wagon being towed by a motor vehicle is considered a part of the motor vehicle. Includes: motorized: bicycle scooter tricycle (k) An off-road motor vehicle is a motor vehicle of special design, to enable it to negotiate rough or soft terrain or snow. Examples of special design are high construction, special wheels and tires, drive by tracks, or support on a cushion of air. Includes: army tank hovercraft, on land or swamp snowmobile (l) A driver of a motor vehicle is the occupant of the motor vehicle operating it or intending to operate it. Includes: animal carrying a person or goods animal-drawn vehicle animal harnessed to conveyance bicycle [pedal cycle] street car tricycle (pedal) Excludes: pedestrian conveyance [definition (q)] (n) A streetcar is a device designed and used primarily for transporting persons within a municipality, running on rails, usually subject to normal traffic control signals, and operating principally on a right-of-way that forms part of the traffic way. Includes: interurban electric or streetcar, when specified to be operating on a street or public highway tram (car) trolley (car) (o) A pedal cycle is any road transport vehicle operated solely by pedals. Includes: bicycle pedal cycle tricycle Excludes: motorized bicycle [definition (i)] (p) A pedal cyclist is any person riding on a pedal cycle or in a sidecar attached to such vehicle. Includes: person: changing tire of vehicle in or operating a pedestrian conveyance making adjustment to motor of vehicle on foot (s) A watercraft is any device for transporting passengers or goods on the water.

purchase 260 mg extra super avana fast delivery

effective 260mg extra super avana

An exception to the idea that “pathogenesis always starts with oropharyngeal colonization” is the case of infection by Pseudomonas spp discount 260mg extra super avana visa erectile dysfunction treatment doctors in bangalore. Thus 260mg extra super avana mastercard erectile dysfunction treatment following radical prostatectomy, the findings of several studies have indicated that tracheal colonization by these pathogens may occur without previous oropharyngeal colonization (42–44). One prospective observational study evaluated 158,519 patients admitted to a single center over a four-year period (46). An existing high incidence of resistance to antibiotics in the hospital area or unit 4. Stay in a nursing home or an extended care facility Nosocomial Pneumonia in Critical Care 181 c. The detection of an increased load of oropharyngeal commensals (viridans group strepto- cocci, coagulase-negative staphylococci, and Corynebacterium spp. The authors of this study highlighted that the anaerobes recovered mirrored the bacteriology of the oropharynx and that only in four patients were they the only microorganisms isolated. No anaerobic bacterium was found in the blood or associated with necrotizing disease. Early-onset and late-onset disease can be distinguished using quantitative culture methods of diagnosis. When pneumonia develops within four or five days of admission (or intubation), microorganisms associated with community-acquired pneumonia are isolated with some frequency. In contrast, when disease develops after five days, few pathogens associated with community-acquired pneumonia are recovered, and gram-negative bacilli and S. Although indicators of late-onset disease, these bacteria can also cause early-onset pneumonia, especially in patients with severe comorbidities under recent antimicrobial treatment, making it more difficult to distinguish between early-onset and late-onset disease. Fungal or viral pathogens are rarely the causative agents in immunocompetent patients. Influenza, parainfluenza, adenovirus, and respiratory syncitial virus account for 70% of all nosocomial viral pneumonias. The diagnosis of these viral infections is often made by rapid antigen testing and viral cultures or serological assays. Within the categories described, the causes of nosocomial pneumonia also vary considerably according to geographic, temporal, and intra-hospital factors. In these subjects, respiratory tract function is impaired, lung volume is diminished, and airway clearance may be reduced. Trauma, surgery, medications, and respiratory therapy devices may additionally impair the capacity of the lungs to ward off infection. Notwithstanding, the most significant risk factor for nosocomial pneumonia is mechan- ical ventilation. In effect, the terms “nosocomial pneumonia” and “ventilator-associated pneumonia” are often used interchangeably. It has been described that when an endotracheal tube is introduced, many lines of host defense are bypassed, such that microorganisms gain direct access to the lower respiratory tract (26,83,87,89). Further, as the tube is inserted, possible damage to the tracheal mucosa will allow pathogens to achieve a foothold. Key components are (i) ensuring staff education and infection surveillance, (ii)preventing the transmission of microorganisms, and (iii) modifying host risk factors for infection. Effective infection-control measures, hand hygiene, and patient isolation to reduce cross- infections are routine mandatory practices (2,33,96,112,122). Senior management is accountable for ensuring that an adequate number of trained personnel are assigned to the infection prevention and control program 3. Senior management is accountable for ensuring that healthcare personnel, including licensed and nonlicensed personnel, are competent to perform their job responsibilities. Direct healthcare providers (physicians, nurses, aides and therapists) and ancillary personnel (house-keeping and equipment-processing personnel) are responsible for ensuring that appropriate infection prevention and control practices are used at all times 5. Hospital and unit leaders are responsible for holding their personnel accountable for their actions 6. Avoidance of H2 antagonist or proton pump inhibitors for patients without a high risk of gastrointestinal bleeding 2. Selective digestive tract decontamination for all patients undergoing ventilation 3. When the pH of the stomach contents is raised, its infective organism load may increase. Moreover, the preferential use of sucralfate or H2-blocking agents remains an unresolved issue (2). Accordingly, a semirecumbent position (95,98–101,144–146) and the use of an inflated esophageal balloon (in patients with a nasogastric tube and enteral feeding tube) during mechanical ventilation (147) can reduce gastroesophageal reflux and, thus, lower the risk of bronchial aspiration of gastric contents. The circuit should be replaced only when visibly soiled or not working properly (2). Endotracheal tube cuff pressure should be at least 20 cm H2O to prevent leakage of bacterial pathogens around the cuff into the lower respiratory tract (156,157). Contaminated condensates should be carefully emptied from ventilator circuits, and their entry into the endotracheal tube or in-line medication nebulizer should be avoided (157,161,162). Silver-coated endotracheal tubes have been reported to reduce the incidence of Pseudomonas pneumonia in intubated dogs and to delay airway colonization in intubated patients, although patient subsets likely to benefit from this practice still need to be identified before the system can be applied on a large scale (163–165)]. A selective transfusion policy should be adopted for the transfusion of red blood cells or other allogeneic blood products (24). Preventive measures are ineffective if not put into practice by all medical staff. Individually, these measures improve care, but when applied together, they give rise to a substantial improvement. The scientific basis for each bundle component has been sufficiently established to be considered the care standard. Elevate the bed headrest (308 to 458) so that the patient adopts a semirecumbent position 2. Wide spectrum antimicrobial therapy should be started if there is reasonable suspicion, and this can then be adjusted once the results of microbiological tests become available (26,179,180). The presence of infection is determined on the basis of two or more of the following data: fever greater than 388C or hypothermia, leukocytosis or leukopenia, purulent secretions, and reduced oxygenation (181). In the absence of demonstrable pulmonary infiltrates, a diagnosis of infective tracheobronchitis is pursued (182). Radiological infiltrates are difficult to define and difficult to distinguish from other frequent conditions in this patient population. This also occurs when we compare any gold standards such as the postmortem examination (181,185) and bronchoscopic examination (185,188–190). Ground glass infiltrates appeared to have a higher specificity, but were found in only 45% of patients. Added to these limitations, we find interobserver variability in interpreting radiological observations (192).

cheap extra super avana 260mg amex

And the Lord said unto Moses discount 260mg extra super avana otc icd 9 code erectile dysfunction due diabetes, Make thee a fiery serpent cheap extra super avana 260mg fast delivery erectile dysfunction what doctor, and set it upon a pole: and it shall come to pass, that every one that is bitten, when he looketh upon it, shall live. And Moses made a serpent of brass, and put it upon a pole, and it came to pass, that if a serpent had bitten any man, when he beheld the serpent of brass, he lived. When they cried to Moses in repen- tance and he in turn prayed to God on their behalf, God instructed him to make a fiery serpent of brass and set it upon a pole so all whoever was bitten by the serpents had to do was look upon the brazen ser- pent and live. Thus God telling Moses to make a brazen serpent indicated that the serpent had been judged for the sins of the children of Israel. And all they needed to do was accept this substitution by The Mystery of The Cross looking at the serpent; then they would live and not die. This brazen serpent was indeed a type of Christ, foreshadowing His death on the Cross. Thus when Jesus said to Nicodemus in John 3:14-15, “And as Moses lifted up the serpent in the wilderness, even so must the Son of man be lifted up: That whosoever believeth in him should not perish, but have eternal life” He meant He was to be judged for us. Our sins were to be placed on Him, so just like the children of Israel, we would not perish but obtain the life of God and live. And Aaron shall come into the tabernacle of the con- gregation, and shall put off the linen garments, which he put on when he went into the holy place, and shall leave them there:” Once every year, specifically on the tenth of the seventh month, God instructed the high priest to make atonement for the sins of the children of Israel (Leviticus 16:29-31). He was to select two goats; one to be the sin offering and the second the scapegoat. After killing the sin offering and offering its blood within the veil, He was to take the scapegoat and con- fess on its head all the iniquities of the children of Israel, and for the rest of the year till the following year, their sins would be covered, and they wouldn’t be judged for them. Next, the scapegoat would be led by the hand of a fit man into the wilderness, into a land not in- The Mystery of The Cross habited; bearing upon its head the sins of the people. This Scapegoat was actually a type of Christ, who offered Himself as a sacrifice for us. But in His case, He did not die for the children of Israel but for all people everywhere. When you consider the betrayal, arrest and condemnation of Jesus to death you will understand better why both Jews and Gentiles can hold claim to Him as their sacrifice for sins. In Matthew 20:18,19 Jesus said to His disciples on their way to Jerusalem, “Behold, we go up to Jerusalem; and the Son of man shall be betrayed unto the chief priests and unto the scribes, and they shall condemn him to death, And shall deliver him to the Gentiles to mock, and to scourge, and to crucify him: and the third day he shall rise again. John 11:49-52, “And one of them, named Caiaphas, being the high priest that same year, said unto them, Ye know nothing at all, Nor consider that it is expedient for us, that one man should die for the people, and that the whole nation perish not. Later He was taken to the hall of judgment in Pontius Pilate’s house, who eventually scourged Him and de- livered Him up to the Jews to be crucified (John 19: 1-16), signifying that He was to be crucified for the Gentiles also. Then He was led by the Roman soldiers to Calvary where He was crucified on the Cross, bear- ing the sins of the whole world. They didn’t fully realize that Jesus, by the hands of the high priest and Pontius Pilate had become the Scapegoat for us and carried our sins away forever. You know, in God’s plan, if it was possible to take away the sins of the world, then the effects of sin could be removed forever. Sickness, as we have seen, came as a result of sin, and Jesus by dying for sins also died that the ef- fects could be removed forever. The Mystery of The Cross Jesus Died Two Deaths Isaiah 53:9, “And he made his grave with the wicked, and with the rich in his death; because he had done no violence, neither was any deceit in his mouth. He would never have died physically, no matter what the Roman soldiers did, if He did not die spiritually first. But this is really pitiful, be- cause they’re ignorant of what Jesus did for us on the cross. He Was Made Sin For Us 2 Corinthians 5:21, “For he hath made him to be sin for us, who knew no sin; that we might be made the righteousness of God in him. And God had declared that without the shed- ding of blood, there is no remission of sins (Leviticus 17:11). In answer to man’s need, God gave His Son (Romans 4:25), who tasted death for everyone, so we no longer would be under the bondage of the fear of death (Hebrews 2:9,14). Because of this the Father turned His back on Him, and He cried out, “My God, my God why hast thou forsaken me” (Mark 15:34). All the transgressions that had been committed from the beginning of the world, right through the time of the Old Testament up till that time were laid on Him (Isaiah 53:5,7; Romans 3:25). Isaiah 53:2-3, “For he shall grow up before him as a tender plant, and as a root out of a dry ground: he hath no form nor comeliness; and when we shall see him, there is no beauty that we should desire him. He is despised and rejected of men; a man of sorrows, and acquainted with grief: and we hid as it were our faces from him; he was despised, and we esteemed him The Mystery of The Cross not. Isaiah 53:4 says, “Surely he hath borne our griefs, and carried our sorrows: yet we did esteem him stricken, smitten of God, and afflicted. Habakkuk 1:13, “Thou art of purer eyes than to behold evil, and canst not look on iniquity: where- fore lookest thou upon them that deal treacherously, and holdest thy tongue when the wicked devoureth the man that is more righteous than he? And while He was in hell, He grappled with prin- cipalities and powers and overthrew them. They wrestled with Him, trying to knock Him down, but because the demand of justice had been satisfied, He threw them all off. That’s why we say we’re happy He died for us, because, when the claims of justice had been fulfilled and He was raised up from the dead, we were justified, declared not guilty. Romans 4:25, “Who was delivered for our of- fences, and was raised again for our justification. Hebrews 9:26 says, “For then must he often have suffered since the foundation of the world: but now once in the end of the world hath he appeared to put away sin by the sacrifice of himself. We became qualified to receive the divine life, and He poured out His life into our spirit. That same sacrifice that was effective in the washing away of our sins was equally effective in de- stroying the power of sickness over our lives. Isaiah 53:5, “But he was wounded for our trans- gressions, he was bruised for our iniquities: the chas- tisement of our peace was upon him; and with his The Mystery of The Cross stripes we are healed. Of course, the devil may want to afflict your body, but when you stand on your rights he will flee from you. With the knowledge of who you are will come bold I ness to be that person whom God has made you to be. When you understand who you are, then you will realize why it is possible for you to live in health always and say ‘No! The New Testament books: Matthew, Mark, Luke and John, are not the history of Jesus, but the revelation of the man Jesus. They cannot be a histori- cal account or a biography, because when you read the last pages of these gospels, you’ll conclude that Jesus Christ is still alive. At the end of your study, you’ll come to the knowledge of Jesus Christ as the Son of God. You cannot come out of that study without making a discovery of the revelation of Jesus. Coming over to the epistles, we also have the revelation of another man, this time the new creation. While Paul was writing, the Holy Ghost took hold of his hand and brought forth the revela- tion of a man - the new creation in Christ. You are that new creation, and the earlier you come to an un- derstanding of who you are, the better your life would be.

extra super avana 260mg overnight delivery

purchase cheap extra super avana on-line

Acupuncture Research 15(2): 157 158 (in Chinese with English abstract) 80 3 Neural Transmission of Acupuncture Signal 1 1 2 Jinmin Zhu generic extra super avana 260mg on-line erectile dysfunction doctors naples fl, David N cheap extra super avana 260 mg on line erectile dysfunction caused by stroke. However, the true mechanisms underlying the effectiveness of acupuncture are still under debating. In this model, acupuncture is believed to treat the diseased organ of the patient by balancing the Yin and Yang conditions that are regulated by an energy substance (Qi) flowing constantly through the whole meridian, a network connecting all the organs of the body. Therefore, in the acupuncture treatment, it is crucial to select special acupoint(s) along the meridian that links the diseased organs, as well as to modulate the Qi flowing in the meridian through the induction of the needling sensation (De-Qi). On the other hand, a neurobiological model established in the recent decades, has supported the notion that an important mechanism of acupuncture in curing diseases is mediated by the nervous system. Stimulation by needles at acupoints is considered to initiate acupuncture signals through the nerve fibers (e. The acupuncture signal is transmitted through the central nervous system, which activates and integrates with the neurons located in broad areas, such as those in the cortex, limbic system, brainstem, spinal cord, which in turn, regulate other systems. The nerve-mediated model provides us a better explanation regarding the biological mechanisms of acupuncture signal transmission in the body which has been broadly documented by both in vivo and in vitro studies under controlled conditions. In this chapter, we will review in particular, the research concerning the influence of acupuncture-elicited signals in the nervous system and how the neural pathways mediate the therapeutic effects of acupuncture. Keywords acupuncture signal, afferent nerves, autonomic nervous system, central nervous system, transmission Acupuncture Therapy of Neurological Diseases: A Neurobiological View 3. Modern clinical research has confirmed the impressive therapeutic effect of acupuncture on numerous human ailments, such as controlling pain, nausea, and vomiting. According to this model, acupuncture is believed to treat the diseased organs by modulating two conditions known as Yin and Yang, which represent all the opposite principles that people find in the universe, both inside and outside the human body. Yin and Yang complement each other, and are subjected to changes between each other. The balance of Yin and Yang is thought to be maintained by Qi, an energy substance flowing constantly through the meridian, a network connecting all the organs of the body. The illness, according to this theory, is the temporary dominance of one principle over the other, owing to the blockade of the Qi from flowing through the meridian under certain circumstance. Thus, the goal of acupuncture treatment is to restore the balance of Yin and Yang conditions in the diseased organ(s). This theory has been considered to be useful to guide this ancient therapy, such as carrying out diagnosis, deciding on the principle, and selecting the acupoints. However, neither Qi nor meridian can be detected under a controlled condition in the animal model or in humans, using current scientific technology. In the past 50 years, extensive efforts have been taken to explore the biological mechanisms and its significance in acupuncture, using modern technologies. The successful results of the tests, ranging from animal experiments to clinical analysis, clearly support the neurobiological hypothesis of acupuncture in regulating multiple systems including the hormonal and immune system. Hypothetically, the acupuncture signal is initiated at the acupoints surrounding the nerve terminals, and is transmitted to the intro- and super-spinal regions, following the afferent nerve fibers. In the central nervous system, the acupuncture signal is believed to regulate the activity of the neurons in certain brain areas (i. Indeed, through controlled experiments, a chain of events triggered by the mechanical stimulation at the acupoints with needling or its electrical equivalent (electro-acupuncture) can be traced. For instance, in the human or animal model, the acupuncture-induced unit discharges of neurons could be recorded using electrophysiological methods, the level of synthesized and/or the release of a neurotransmitter or its receptor can be measured by biochemical assays, and the activity of a brain area owing to acupuncture can be monitored by noninvasive functional imaging methods, thus, investigating the association of acupoint-brain activity. The fact that acupuncture 82 3 Neural Transmission of Acupuncture Signal could activate or inhibit specific brain areas associated with functions of nociceptive, cardiovascular, and vision, suggests that a number of neural circuits and substrates are specifically involved in the therapeutic effect of acupuncture. Among them, the limbic system which mediates both the neural-endocrine system and the brainstem-descending control-spinal cord in the acupuncture analgesia has been perhaps the most extensivelystudied. The diagram shows that one of the mechanisms of acupuncture is regulation of the autonomic nervous activity that modulates the body homeostasis. The acupuncture signal is first transmitted to the central nervous system via the sensory nervous system (including afferent fibers, thalamus, 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.

Universidad Tecnológica de Chihuahua
Avenida Montes Americanos, No. 9501, Sector 35, C.P. 31216
Tel. +52(614) 4 32 20 00 Ext. 1159, contacto@utch.edu.mx
Chihuahua, Chih., México