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However, because there exists a gradient in the resting membrane potential between the different segments-from -50 mV at the fundus to -80 mV at the pylorus-the frequency of contractions in the antral portion of the stomach is less than that at the corpus. The "slow waves" initiated in the pacer cells (of the greater curvature) do not spread to the more proximal fundus because it has a less negative resting membrane potential among other myoelectric characteristics limiting its excitability. Nitric Oxide), and adrenergic neurons have an inhibitory influence on fundic contractions. Two properties control the propagation of contractions in the rest of the stomach: 1) the gradient in slow wave intrinsic frequencies in different segments (corpus>antrum>pylorus), and 2) the conduction velocity of the action potential of different segments (4 cm/sec in the distal antrum vs. Neurohumoral Mechanisms In the proximal stomach, receptive relaxation is mediated through stimulation of mechanoreceptors. This, then, is the basis for the decrease in gastric accommodation, and gastric compliance (increased luminal pressure) post-vagotomy. Some evidence also suggests a role for vagal fibers in maintaining basal fundic tone. This reflex is diminished by either vagotomy or splanchnicectomy, and abolished if both are severed. Both consistency and composition of a meal are key in determining contraction amplitude: particulate foods induce more powerful antral contractions than homogenized foods, and meals of higher caloric content induce a more prolonged contractile response (fats > proteins > carbohydrates). Neurohumoral factors control the fed state, although the specific mediators are still unknown. A fundo-antral reflex is believed to increase antral contractions in response to fundal distention, and may serve in mixing and peristalsis. The pylorus has many unique features that distinguish it from the distal stomach (antrum). These neurotransmitters suggest an inhibitory neural predominance resulting in pyloric relaxation. The electrical coupling of pacer cells with neighboring cells propagates electrical activity, which is the basis for the generation and propagation of contractility. This may result in neurogenic and/or myogenic disturbances of the stomach leading to gastroparesis. This subgroup of patients may pose a challenging diagnostic dilemma since unless suspected; underlying gastroparesis may easily be overlooked. Many patients may have abdominal pain only as a presenting symptom and therefore other gastrointestinal pathologic conditions such as ulcer disease must be ruled out. Diabetes Mellitus Nearly 6% of adults suffer from diabetes (with another 5% estimated to have a subclinical form of the disease). Delayed gastric emptying, however, has not been associated with a specific type of myoelectric or motor disturbance on manometry, nor has any correlation been observed between it and clinical autonomic neuropathy. Aberrant sympathetic function, and impaired gastric smooth muscle cellular response are also thought to play a part in the etiopathogenesis of gastroparesis. Moreover, it has been observed that hyperglycemia, in the absence of prior neuropathy, can alter normal antral contractions. In fact, delays of both gastric liquid and solid emptying have been reported during hyperglycemic states, which corrected with reinstitution of euglycemia. In addition to its effects on gastric motor function, hyperglycemia has also been implicated in the alteration of gastric sensory function, hence intensifying symptoms such as nausea. Disturbances of fundic and antral contractility have been documented on several occasions. Non-motor factors may also be involved, as symptoms do not always correlate with delays in gastric emptying. Nausea and bloating have also been reported after surgery for gastroesophageal reflux disease, including the newer laparoscopic fundoplication. It remains largely unknown, however, whether the observed gastric motor disturbances reported in this group of patients antedates, or is a result of, the surgery. Other surgeries, such as esophagectomy with gastric pull-through (esophageal cancer), the pylorus preserving Whipple procedure (pancreatic cancer) and chronic pancreatitis surgery are often complicated by gastroparesis. Isolated delayed solid emptying has been noted with atrophic gastritis, whether associated with pernicious anemia or not. Malignancy predisposes to gastroparesis; this has been reported with both non-obstructive pancreatic cancer and small cell lung carcinoma (Figure 7). The latter patients often develop symptoms of gastroparesis and intestinal pseudoobstruction. It is worth noting that gastric stasis from malignancy has a poor response to medical therapy, and often requires surgical drainage. Intolerance to both solids and liquids is common following abdominal irradiation, and may not necessarily be due to delayed gastric emptying. Scleroderma When Scleroderma affects the stomach, it rarely causes intractable nausea and vomiting, but may exacerbate esophageal reflux symptoms. In the most severe cases, however, delayed gastric emptying may result in weight loss and nutritional deficiencies. Neurologic Disease Disorders such as multiple sclerosis, brain stem stroke, amyloid neuropathy, primary dysautonomia and iatrogenic vagal injury may result in gastroparesis. Psychiatric Diseases Depression, classical eating disorders (anorexia, bulimia), and psychotropic medications can be associated with gastric dysrhythmias, making intrinsic motility problems and eating disorders difficult to distinguish. The rumination syndrome, in which undigested food is effortlessly regurgitated, is a behavioral disorder most often observed in mentally disabled patients, although it is also seen among adults of normal mental capacity. Abnormalities of gastric or duodenal motility have not been consistently documented with this syndrome. Patients with gallbladder disorders, post-cholecystectomy patients, and those with cirrhosis and portal hypertension have also been known to experience delayed gastric emptying. Gastric stasis is also associated with ethanol (alcohol), smoking, and marijuana use. Pregnancy and chronic renal failure with or without dialysis have inconsistently been associated with gastric motor slowing. Abdominal pain is of a varied nature, and may be described as burning, cramping, or diffuse. The physical exam may reveal varying degrees of abdominal distention and/or tenderness; guarding, however, is absent. The rest of the exam should be directed to identifying signs of underlying diseases/disorders. There are, however, tests available that aid diagnosis of underlying systemic illnesses. Gastric stasis may be suggested by the finding of retained food residue (in extreme cases bezoars) after an overnight fast and subsequent endoscopy Figure 8. Patient positioning and room setup for endoscopy Radiology An oral barium contrast x-ray is an alternative to endoscopic evaluation. The requirements of the test are as follows: the patient meal should be of solid consistency, and adequate caloric content (at least 200 kcal), to induce powerful gastric contractions the radiotracer should be effectively bound to the substrate (meal), and resistant to a wide pH range (1-7. Later, pressure recordings are monitored after the patient has eaten a solid meal- which facilitates testing on the effects of different prokinetic agents. Other Tests Ultrasonography Ultrasonography, which records gastric volume after liquid meal ingestion, is an increasingly common means of evaluating gastroparesis. Solid meals, however, cannot be evaluated through ultrasonography due to their echogenicity. Breath Tests Breath tests after 13C-octanoate or 13C-acetate ingestion are useful in assessing gastric emptying in patients in whom radioactive tracer administration is contraindicated, such as children or pregnant women. This test, however, is only applicable to those patients with normal absorptive function. Although cutaneous gastric electrical recordings were successfully obtained as far back as 1921, it is only in recent years that this method has begun to attract interest as a means of evaluating gastric motor dysfunction. Furthermore, in a subset of patients (such as diabetics and those with nausea/dyspepsia related to pregnancy), resolution of symptoms was observed when pharmacologic therapy resulted in normalization of gastric rhythm. If that is not possible, treatment should aim to promote gastric emptying and relieve symptoms. Medications that inhibit or delay gastric emptying should immediately be discontinued, if possible.
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Once the prescription is filled, the patient will be given a Retail Pack containing the Medication guide, Package Insert, Medicine, and the Follow-up Survey. At this time, the pharmacist will once again encourage the patient to enroll in the follow-up survey. Tegaserod-treated patients reported greater relief from symptoms and a greater increase in number of stools than placebo-treated patients, with the largest difference during the first four weeks. Fasting oral bioavailability is approximately 10% and administration with food reduces bioavailability by >40%. Monitoring: Relief of constipation should be demonstrated, with diarrhea the most common side effect. During episodes of diarrhea lasting >2 days, periodically monitor electrolyte levels (sodium, potassium, chloride, bicarbonate). Gastroparesis: Introduction Gastroparesis, or gastric stasis, is a disorder of delayed gastric emptying in the absence of mechanical obstruction. It is manifest clinically through a set of largely non-specific symptoms such as early satiety, bloating, nausea, anorexia, vomiting, abdominal pain, and weight loss. Gastroparesis often presents as a subclinical disorder; hence there is no true estimate of its incidence or prevalence. Location of the stomach in the body Gastric Motor Physiology Normal gastric motility/emptying requires an integrated, coordinated interplay between the sympathetic, parasympathetic, and intrinsic-gut (enteric) nervous systems, and the gastrointestinal smooth muscle cells. Disturbance at any level has the potential to alter gastric function, and ultimately affect gastric emptying. To better understand gastric motility, it is important to be familiar with both the functional zones and the major digestive functions of the stomach -including the difference between an empty and a full stomach. The proximal stomach comprises the cardia, fundus, and body-and is characterized by a thin layer of muscle that produces relatively weak contractions. Upon the ingestion of food, the proximal stomach exhibits receptive relaxation, with very little increase in intragastric pressure. The pattern of contraction in the distal stomach also regulates the rate at which partially digested food is emptied into the duodenum. Mechanical and enzymatic breakdown of larger particles into smaller particles (< 2 mm), known as chyme. Slow delivery of chyme to the duodenum at a rate not to exceed the digestive and absorptive capacity of the small intestine. These appear after 12-24 hours of fasting and may be related to low blood glucose levels. In the proximal stomach (fundus), contraction waves propagate more slowly (< 1 cm/sec) and are quite weak. This allows some mixing of ingested food and gastric secretions, but more importantly, serves to facilitate food storage. This is soon followed by a forceful pyloric closure (as the wave reaches the pyloric sphincter), forcing intragastric contents back into the antrum and corpus. Solids have to be reduced to between 1-2mm in size before they can be successfully delivered to the duodenum. As a consequence, relatively large, indigestible solids remain in the stomach unless they are eliminated by vomition. Spontaneous "slow waves" result from a balanced inward depolarizing Ca flux and a repolarizing K efflux. Whether or not muscle cells respond to these basal depolarizations and contract is largely dictated by neural and hormonal mechanisms. These rhythmic contractions are thought to originate in the non-smooth muscle pacer cells, (possibly, in the interstitial cells of Cajal). For the majority of patients, dietary modifications are an effective means of reducing symptoms while maintaining nutrition. Solid foods should be reduced and replaced by liquids (these empty more readily from the stomach). Medical Therapy Prokinetic Therapy In most patients, medications that promote gastric emptying have become a cornerstone of disease management. The most commonly used medications worldwide are metoclopramide, cisapride, erythromycin, and domperidone. Erythromycin is a potent stimulant of gastric emptying and promotes solid and liquid emptying through induction of forceful antral contractions similar to those initiated through the migrating motor complex. In addition to being useful in improving diabetic gastroparesis, erythromycin has benefited patients after vagotomy, subtotal gastrectomy, and esophagectomy. Unfortunately, erythromycin may adversely interact with a number of medications, and many patients have reportedly become resistant to its effects after several weeks (tachyphylaxis) of use. Improvement of gastric tone has also been reported in patients with prior vagotomy and/or gastrectomy, as well as in patients with anorexia nervosa. The usual adult oral dose is 5-20mg four times a day, taken 30 minutes before meals, and at bedtime. Extrapyramidal movements may develop in chronically treated, and may even be irreversible-especially in the elderly. Other adverse effects include depression, hyperprolactinemia, galactorrhea, amenorrhea, and impotence. Other Agents Bethanechol: Bethanechol, a muscarinic agent that causes uncoordinated gastric contractions, is of historical value, but has no current role in the management of gastroparesis. Its prokinetic effects are those of increased lower esophageal sphincter tone, and improved antral, jejunal, and colonic motility. The routine dose is 10-20mg four times daily (preferably given 30 minutes before meals and at bedtime). Although a rare occurrence, this ventricular arrhythmia may result in hypotension, syncope, or even sudden death. Occasionally, however, a refractory patient is encountered for whom additional therapy is required. Ondansetron is available as a liquid and lingual dissolving tablet, of which both are well tolerated and quickly absorbed. This device helps drain the stomach, thus aiding in the avoidance of nausea and vomiting flares. Novel Therapies Botulinum Toxin Studies suggest that type I diabetics suffer from poor coordination of antro-pyloro-duodenal contraction and relaxation functions. More importantly, when they do experience contractions, they suffer a failure of pyloric relaxation. Botulinum toxin, a product of the bacteria Clostridium botulinum, is a neurotoxin that prevents acetylcholine release from nerve terminals. When locally injected into striated or smooth muscle segments, it prevents muscle contraction. Prolonged pyloric contractions may cause functional resistance to gastric outflow. To date, only a few patients have been treated with pyloric injections of botulinum toxin. Preliminary reports, however, have described good response in decreasing pyloric resistance and improving gastric emptying. Gastric Pacing There has recently been increasing interest in treating gastroparesis by gastric electric stimulation. Novel Potential Agents There is considerable ongoing research aimed at identifying novel therapies for gastroparesis. Putative agents include: Sildenafil (potentiates nitric oxide) improves pyloric relaxation. Clonidine (a 2-receptor agonist), a commonly used anti-hypertensive, decreases antro-duodenal contractions. Although in studies clonidine did not alter gastric emptying in healthy adults, it did improve emptying in diabetics. Inflammatory Bowel Disease Irritable Bowel Syndrome Similarities and Differences and 2 Researchers believe that several factors, such as a family predisposition and a faulty immune system, play a role in their development. Irritable Bowel Syndrome Irritable bowel syndrome is a condition that affects the function and behavior of the intestines. Normally, the muscles lining the intestines intermittently contract and relax to move food along the digestive tract. Symptoms can include cramping, abdominal pain, bloating, gas, mucus in the stool, diarrhea and/or constipation.
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The study concluded: "increased benefit for extremely depressed patients seems attributable to a decrease in responsiveness to placebo, rather than an increase in responsiveness to medication. Further, "[T]here are few scientists who will rise to its defense, and some prominent psychiatrists publicly acknowledge that the serotonin hypothesis is more metaphor than fact. When examined at two weeks of age, these infants were more excitable than those born to women who did not take antidepressants. Of these, 55 were classified as suicide attempt with about 75% of those being children. Far from proving effectiveness, of the 1,493 patients who participated, 74% discontinued taking antipsychotic drugs before the end of their treatment due to inefficacy, intolerable side effects or other reasons. After 18 months of taking Zyprexa, 64% of the patients stopped taking it-most commonly because it caused sleepiness, weight gain or neurological symptoms like stiffness and tremors. Further, there were 1,328 reports of other side effects, some life-threatening, such as convulsions and low white blood cell count. The results of the study showed that "antipsychotics were associated with an almost 60% increase in the risk of pneumonia. Jeffrey Lieberman of Columbia University and other researchers published a study in the New England Journal of Medicine comparing an older generation of antipsychotics with several newer ones. There is also a "rebound effect" where the individual experiences even worse symptoms than they started with as a result of chemical dependency. Heather Ashton reported cases of babybattering, wife-beating and "grandmother-bashing" could be attributed to people taking benzodiazepines. Abrupt cessation can lead to severe withdrawal symptoms, including convulsions in some patients. Short-term treatment and a long tapering period is now recommended to limit these risks. The drug chemically induces amnesia and often causes decreased blood pressure, drowsiness, visual disturbances, dizziness, confusion, gastrointestinal disturbances, and urinary retention. Symptoms can include throat closing, or nausea and vomiting requiring emergency care. Because airway obstruction can cause death, patients in whom angioedema develops after taking zolpidem should not be "rechallenged with the drug. John Steinberg, medical director of the Chemical Dependency Program at the Greater Baltimore Medical Center and president of the Maryland Society of Addiction Medicine, confirmed that patients taking one Xanax tablet each day for several weeks could become addicted. Further, after a patient stops taking Xanax, it takes the brain six to eighteen months to recover. The responses consisted of physical assaults by two patients, behavior potentially dangerous to others by two more, and verbal outbursts by the remaining four. Teens who abused prescription drugs were 12 times likelier to use heroin, 14 times likelier to use Ecstasy and 21 times likelier to use cocaine, compared to teens that do not abuse such drugs. Cowdrey, "Alprazolam-Induced Dyscontrol in Borderline Personality Disorder," the American Journal of Psychiatry, Vol. If you purchase 20 or more you will receive a 30% discount or if you buy 100 or more you will receive a 40% discount. Progress to the next exercise only when the pain from the previous exercise decreases. If symptoms diminish in the legs, continue as instructed even if accompanied by a temporary increase in low back pain. For example, if heart rate is increased because the patient was jogging just prior to assessment, the increase pulse rate would not add to the score. No part of this written material or illustrations may be reproduced, or stored in any retrieval system, by any means - photocopy, electronic, mechanical, recording or otherwise - for any use other than "fair use" without written consent from the publisher. We control all phases of the production process, from procurement and testing of raw ingredients to the manufacturing and packaging of our formulas. Our Certificates of Analysis (see pages 7 and 8) attest to the extensive testing our products undergo. Each herb is also examined for cleanliness and for the absence of filth or animal parts, bugs or larvae. Only superior grades are selected, and any adulterated, improperly substituted or poor quality herbs are rejected. Our database contains detailed specification describing the physical characteristics and quality markers of more than 300 Chinese herbs. Certain Chinese herbs are treated with sulfur to give them an appearance of freshness and, as a result, many have demonstrated unacceptably high levels of sulfites. At Kan Herb Company, our first concern is safety, and we make every effort to ensure that our herbs are indeed sulfite-free. We choose to use organic herbs when available, such as is the case with our Ginseng, as we have access to a steady supply of organic-grade material. The selection of organic Chinese herbs, while growing, is not yet encompassing of all of the herbs that we use regularly, nor is it always available. We assemble, test and manufacture our herbal formulas at our facility in the United States, following stringent manufacturing standards, to assure that the potency and purity you expect is in every bottle. Every step of the manufacturing process is evaluated according to rigorous qualitative and quantitative standards. Our internal manufacturing controls provide documented proof that correct procedures are consistently followed, at each step of the manufacturing process, every time the product is made. Extensive controls cover the sanitation and hygiene of our facilities, utensils, production materials and containers, as well as frequent, and at least weekly, testing of our manufacturing equipment, utensils and holding tables for total aerobic count, yeast and mold, E. All raw materials, in-process and finished Chinese herbal dietary supplements are inspected by our Quality Control unit; complete inspection records and laboratory tests are maintained. Controls are also in place for handling in-process dietary materials throughout each step of the production process, such as worksheets and traveling tags, assuring consistency from batch to batch, easy monitoring, and averting opportunities for adulteration. All bulk herbal ingredients are stored in temperature-controlled quarantine areas. Finished product is bottled in approved containers that are then capped and sealed with a tamper-proof covering and shrink-wrapped. Our entire manufacturing plant and warehouse are monitored daily for proper temperature and humidity. Any dietary ingredient, in-process, finished dietary supplement, packaging unit or label not meeting specifications is rejected. The rejection is recorded in our rejection log, documenting the reason why it was rejected. Any deviation or out-of-specification to the manufacturing cycle is investigated, and approved or rejected by Quality Control. We ensure that our products are free of any herb that may contain aristolochic acid. The newest technologies are employed, providing a high level of sensitivity for any desired marker, and a highly accurate representation of activity. Our tests are comprehensive, accurate, and available in reports that are easy to understand. Stability testing is performed at one, two, three and four years after the manufacturing date for all our finished dietary supplements. All batches of finished product must be approved by Quality Control before they can be bottled and released for sale. The Certificate of Analysis includes all pesticide, microbiological and heavy metal levels found in that specific batch for that specific formula. Excellent manufacturing techniques are required to yield the high concentration of active ingredients necessary for effective herbal therapy. Due to the molecular composition of the herbs, some herbs extract well in water, while others, such as Ginseng, require alcohol to extract the active ingredients (such as ginsenocides). With strict control of temperature and timing, the herbs are extracted at low temperatures, with all volatile oils captured in our closed glass system. This process ensures a complete extraction that yields maximum active ingredients from each of the herbs being extracted. The diversity of taste and smell inherent to each herb found in each formula is clearly rendered in the final product. Each product is referenced against up to three prior batches, confirming proper extraction as indicated by consistent color, appearance, odor and taste. The highest level of active constituents are included in our final product, rendering small batches of fresh, full-spectrum herbal extracts with an 8:1 potency.
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Mapping of cancer foci showed the highest density in the anterior proximal fundus (37%) and cardia/proximal fundus (27%). Our results argue for the incorporation of cancer focus distribution into any biopsy protocol, although detection is likely to remain extremely low, and they call into question the validity of endoscopic surveillance. Conflicts of Interest and Source of Funding: the authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Although the majority of cases are sporadic, about 10% of gastric cancers are qualified as familial and related to several syndromes and genes. Nonetheless, given that prophylactic gastrectomy is the only known preventive treatment, strategies to optimize timing of the operation are needed. The preoperative diagnosis of early diffuse-type gastric cancer is difficult because the tumor cells begin infiltrating the mucosa while preserving a normal surface epithelium, and rarely are any visible lesions spotted endoscopically. Each stomach was entirely submitted for histologic examination using 3- to 5-mm-thick sections that were routinely processed, paraffin-embedded, sectioned at 5 mm, and stained with hematoxylin and eosin. Orientation and microscopic-macroscopic correlation was achieved through annotation on gross photographs. On the basis of regional variation, we modeled a topographically weighed biopsy protocol and determined theoretical detection rates. Normal was defined as absence of abnormal neck cells, that is, absence of signet ring cells. Signet cell carcinoma in situ was defined as individual neoplastic cells of signet ring type within the confines of the basement membrane. These appeared as rounded cells with distended cytoplasm with misplaced and crescent-shaped hyperchromatic nuclei. Patient Population Patients were first seen between 2006 and 2009 at the High-risk Gastrointestinal Genetics Clinic of the Massachusetts General Hospital, and established screening guidelines were applied. Here we focus on histopathologic aspects of the cohort; the surgical aspects and clinical management of this cohort are presented elsewhere. The color codes indicate sections in which foci of signet ring cell carcinoma in situ and intramucosal carcinoma were noted. A, Signet cell carcinoma in situ (pTis) is characterized by large atypical neck cells with intracytoplasmic mucin accumulation that displaces the crescentshaped, hyperchromatic nucleus to the periphery, resulting in so-called signet-ring cell appearance. D, Intramucosal carcinoma (pT1a) invading lamina propria around B4 gastric units (outlined by dotted line). Intramucosal carcinoma was diagnosed when infiltrating neoplastic cells were detected outside the confines of a glandular unit, and invasive signet ring cells were present within the lamina propria. Submucosal diffusetype carcinoma was diagnosed when cancer cells extended through the muscularis mucosa into the submucosa. Morphometric Evaluation the mucosal length per block and size of each cancer focus were measured microscopically, and lesions present in adjacent blocks were assumed to be at least 3 mm in diameter. The area of antral-type or fundic-type mucosa was determined and mapped on scanned photographs. The total number of gastric units in the resection specimens was estimated on the basis of the average density of at least 10 randomly chosen gastric gland units in the antral-type and fundic-type mucosa and the assumption that cross-sections of superficial aspects of gastric units (pits) are vaguely circular. The percentage of sampled gastric units was calculated using the average glandular density and total sampled length per block. The subtypes of neoplastic foci were tallied, and the total number of affected glands was used to calculate the percentage of affected gastric units per patient. Review of preoperatively obtained biopsy samples was used to determine the average number of glands sampled per biopsy. The biopsies were obtained using large particle biopsy forceps (so-called "jumbo forceps"). Using the range of affected units, the number of glands per stomach, and the average number of sampled gastric units, we estimated the theoretical number of biopsies necessary to capture at least 1 cancer focus, assuming a clinically suboptimal (50%) and more acceptable detection rate (90%). Identification of site predilection of cancer foci involved the merging of individual density maps into a combined normalized map. The size-proportionate cancer foci were also merged through form fitting into a 2-dimensional coordinate system erected along the minor gastric curvature (x axis) and the maximum sagittal circumference (width) of the opened specimen (y axis). Distribution of cancer foci was also studied in 8 anatomic regions (cardia; anterior and posterior proximal fundus; anterior and posterior distal fundus; lesser curvature; greater curvature and antrum); and the fundus was divided into proximal and distal by halving the lesser curvature (greater and lesser curvatures were defined as 2cm-wide bands, not split into proximal and distal). These microphotographs highlight the residual inner ring of benign cells with preserved E-cadherin immunoreactivity (red arrowheads, A, B), whereas the peripheral crown of neoplastic signet ring cells is not immunoreactive (black arrows, A, B). Clinical and Genetic Characteristics in the Cohort Case 1 2 3 4 5 6 7 8 9 10 Age 38 41 43 42 38 42 50 49 26 27 Sex Female Male Male Male Female Male Female Male Male Female Mutation Name p. Patients 4, 5, and 6 are from one family; patients 7, 8, and 9 are from another family. Median time from genetic testing to surgery was 3 months (range, 1 to 7 mo), and in 9 of the patients, gastrectomy was performed prophylactically, whereas chromoendoscopy and biopsy before surgery demonstrated intramucosal carcinoma in 1 patient (case #3). The histopathologic analysis of the entire gastric mucosa required up to 490 sections per case (embedded in 120 to 252 blocks per case). The prosection of the gastrectomies yielded a grand total of 1817 slides that were examined (an average of 182 slides per case). When related to the lesser curvature (on average 15 cm long), the antrum corresponded to the distal 1. Mapping of cancer foci in outlines of all 10 gastrectomy specimens [(A): case #1 to (J): case #10]. Despite the high variability of involvement, the proximal fundus shows the highest density of cancer foci. Using the total length of reviewed mucosa, we determined the total number of examined gastric units as B1. This individual presented with 4 invasive foci (such as the one shown in the lower inset) that were in close association with intramucosal foci (such as the one shown in the upper inset). The foci of intramucosal carcinoma typically spanned the width of 1 or 2 gastric units (Table 3). In total, 1820 gastric units were affected by cancer (range, 8 to 1205 affected units per patient), and when this was related to the total number of examined gastric units, the average involvement was B0. Review of surveillance biopsies available for 6 of the patients showed an average of 28. On the basis of the number of glands sampled per biopsy (n = 25), the number of gastric units per stomach (B3 million), and the average involvement as determined in the cohort (range, 0. For a detection rate of 90%, the theoretical number of biopsies to observe 1 neoplastic focus ranges from 90 to 11998 (average, 3469) (Table 4). Mapping of all cancer foci on gastrectomy outlines of each specimen showed absence in the antral-type mucosa and marked variability in fundic-type mucosa. Individual and combined density mapping showed the highest density in the proximal fundus. Transformation into a coordinate system erected over the lesser gastric curvature allowed optical summation of all cancer foci into a common gastric outline. Analysis of merged cancer foci demonstrated the following order of cancer prevalence: anterior proximal fundus (37%) > cardia (27%) > anterior distal fundus (12%) >posterior proximal fundus (10%) > lesser curvature (8%) > greater curvature (4%) > posterior distal fundus (2%) > antrum (0%). Each gastrectomy specimen contained at least 5 separate cancer foci, and we identified a total of 302 cancer foci (range, 5 to 136 foci). Eighty-nine foci of signet cell carcinoma in situ were present, and only 1 patient showed superficial submucosal invasion in 4 separate regions (submucosal diffuse-type carcinoma). Here, we demonstrate that the estimated total number of biopsies necessary to achieve suboptimal (50%) or substantial (90%) diagnostic yield, on the basis of our cohort of 10 patients, is exorbitant and clinically unsustainable; however, in light of serial sampling during ongoing surveillance, these numbers approach realistic levels. Importantly, despite interindividual variability, our mapping demonstrated the highest cancer predilection in the proximal fundic-type mucosa. Biopsies High Range 5832 11998 Average 1768 3469 Low Range 50 90 Average 1745 3141 Low Range 45 82 High Range 5782 10408 r 2012 Lippincott Williams & Wilkins
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Providing Safe Solutions for Pediatric Care Gentle Warriors includes 16 herbal formulas - 11 general formulas and 5 Peacemakers formulas. All are mild tasting, low-alcohol, liquid extracts that are easy for children to swallow. The Gentle Warriors formulas support and protect the welfare of children, addressing many of the most common childhood disharmonies. According to Chinese tradition, the Middle Burner governs the activities of the Stomach and Spleen, dominating physiological and psychological processes during infancy and early childhood. Children are active metabolically, yet limited by their immature respiratory, digestive, nervous and immune systems. Infants and young children are at the height of their adaptive capacities, yet they are vulnerable because the Middle Burner is challenged by the need to keep up with rapid growth. Children can easily and quickly succumb to disharmonies that make them feel badly, and just as quickly regain their equilibrium so that they feel well. Because of their voracious appetites and easily overburdened eliminative functions, children can develop accumulations of food, fluids and Qi, which in turn may evolve into patterns of Qi Stasis, Food Stagnation, Dampness, Phlegm, Damp Heat, Heat and Internal Wind. Common manifestations of this disequilibrium of Qi might include occasional upsets in the stomach, surplus mucus in the nose, ears, throat and sinuses, occasional irregular bowels, rashes or excessive sweating, temperature changes, occasional sleep disturbances, restlessness and irritability. These can predispose a child to weakened defenses as well as a loss of mental focus and emotional equanimity. Vulnerable and responsive to fluctuating internal and external influences, children can have dramatic responses. So it is important to pay attention to the timing and dosage of immunizations, antibiotics, decongestants and antihistamines as well as to their exposure to new foods and environments. Food intolerance can disrupt the fragile ecology of the gut, as can antibiotics or immunizations, spawning tribulations of different sorts. Following are a few simple and supportive measures that can be employed to help prevent physical vulnerabilities and developmental problems from occurring: 1. Do not hurry to substitute cow, goat, sheep or soy for breast milk, as these can induce allergic reactions and immunological changes in the small and large intestine, and have profound nutritional consequences unless supplemented with other foods. Experiment with naturally fermented products such as yogurt, but be alert to any signs of intolerance such as mucus congestion, skin irritation, indigestion, diarrhea, irritability or sleep disturbance. Contrary to conventional wisdom, it is not essential for children to continue drinking milk after the cessation of breastfeeding in order to maintain adequate calcium levels for proper growth. Sufficient calcium is available in other foods, including leafy green vegetables such as kale and collard greens, sprouted barley and quinoa, black and pinto beans, almonds and hazelnuts, sunflower and sesame seeds, sardines or other small fish in which the bones can be consumed with the meat. One indicator of the right moment may be the emergence of the two upper and lower teeth. Emphasize simple, easy to digest, non-allergenic foods: soupy porridge made from non-glutinous white rice, cooked and pureed carrots, yams, spinach, apples, pears or bananas; diluted, unsweetened fruit juices; vegetable or meat broth. Finally, it is good to avoid the early or excessive feeding of sugar, honey, fruit juice, grains, starchy foods (bread, crackers, pasta), raw fruits and vegetables. Avoid giving infants or toddlers iced or refrigerated liquids or foods - the cold causes Stomach Qi to stagnate, inhibiting the capacity to digest, assimilate and eliminate. Liquids and soft cooked foods served warm or at room temperature are the most desirable and beneficial, especially when children are sick. Since it is better for children to develop senses of taste and smell at their own pace, avoid adding flavorings or condiments to food, including salt, soy sauce, pepper, garlic, ginger, sugar, oil or vinegar unless it is for specific reasons. Chinese traditional thinking warns against overly enthusiastic or frenetic activities that cause excessive physical, mental and emotional stimulation. Overexcitement of the mind and senses can agitate infants and toddlers, creating a dissonance between psyche and soma (Shen-Jing) that may lead to physical, psychological and cognitive disturbances such as failure to thrive or behavioral problems. Resist exposing young children to prolonged or over-excited conversation, intense visual and auditory experiences like television, movies, loud music, fireworks and other events that may be too intellectually demanding or overwhelming to their sensitive nervous systems. This is particularly true for eating while watching television, which has been linked to long-term obesity and Attention Deficit Disorder. To optimize conditions for immunizations, it is best to avoid the administration of multiple vaccinations simultaneously at one visit. Just as it is rare that one be exposed to multiple diseases simultaneously, receiving multiple immunizations puts an undue burden on an already delicately balanced organism. It is also important to postpone immunizations with a live vaccine (such as measles, mumps, rubella or chicken pox) for one month following an acute febrile illness such as a cold, flu or gastroenteritis, in order to give the immune system time to recover. Some children with weak digestion, poor appetite and slow growth can also benefit from digestive enzymes (vegetable or animal source) that include protease (for proteins), amylase (for starches), lipase (for fats), and lactase (for the milk sugar lactose). The herbs should be given each time the child would ordinarily nurse, drink or eat. For children between five and twelve years old, regularity and timing are also critical factors: the herbs should be taken shortly after awakening, before or after regular meals and at bedtime. In general, it is easiest to administer the formulas to children as part of their morning, mealtime or evening ritual. For small children and for those averse to strange tastes, the extracts may be squirted into the back of the throat where there are fewer taste buds and the swallowing reflex is easily triggered. The herbs need not be refrigerated, as they have a long shelf life when kept tightly capped and out of direct light. No liquid extract should be given chilled from the refrigerator, but rather warmed or at room temperature. The extracts may also be mixed with room temperature fruit juice, milk, cereal and mashed fruits or vegetables to facilitate ingestion and further mask their taste. However, when the herbs become diluted by more than small quantities of foods or liquids, the overall dosage or frequency may need to increase in order to obtain the expected effects, unless a very slow and moderate action is desired. Because of the natural reactivity of infants and small children, rebellion is often the motif of their afflictions: the damp, warm Qi of the Stomach, Intestines and Gallbladder easily revolts upward, obstructing the descent of Heart and Lung Qi (Zong Qi) from the head and chest. Windbreaker deftly address these dramatic, but superficial and usually transient imbalances. This formula can also be used preventively, offering protection from exposure to invasions or the weather, and a bulwark against lowered resistance following excessive mental or emotional stimulation. Within the group of Wind-expelling herbs, Fragrant angelica root, Notopterygium root and rhizome, Siler root, Chinese cinnamon twig and Kudzu root release the exterior, promoting circulation of Blood and Qi and supporting healthy Upper Orifices. Chrysanthemum flower, Chinese mint herb, White mulberry leaf, Burdock fruit and Cimicifuga rhizome dispel Wind, Heat and Invasions in eyes, mouth and throat. The combination of Schizonepeta herb, Cimicifuga rhizome, Kudzu root, Burdock fruit and Chinese mint herb facilitates the expression and resolution of Heat and Invasions in the Blood that are trapped in the Wei and Qi layers. Chinese cinnamon twig, Chinese mint herb, Fragrant angelica root and Magnolia flower support normal secretions and circulation in the nose and sinuses while clearing Heat and dispelling Wind. Forsythia fruit, Honeysuckle flower, Phragmites rhizome and Imperata rhizome purge Heat and Invasions from the exterior and from the Blood, enhancing the abilities of Burdock fruit, Cimicifuga rhizome, Schizonepeta herb and Chrysanthemum flower. The remaining herbs in the formula assist by clearing Heat and Invasions, loosening Phlegm, countering Dryness and rectifying the Qi of the Lung and Stomach. Tangerine dried rind of mature fruit, licorice cured Pinellia rhizome, Chinese licorice root and rhizome and Platycodon root transform Phlegm and help the Qi of the Lung and Stomach to properly descend. When External Invasion of Wind, Heat, Cold or Dampness accumulates in the chest, this disrupts the descending and dispersing functions of the Lung and it is important to restore the proper downward movement of the Qi. Prolonged stagnation of Lung Qi can result in the depletion of Moisture, leading to Dryness. Reinforcing the Qi and Moisture of the Lung supports a healthy respiratory system, provides for adequate lubricating secretions and robust Defensive (Wei) Qi (or immunity). Trichosanthes seed, Bamboo secretion, Scrophularia root and Chinese skullcap root dispel Phlegm Heat, soothe the throat and chest. Bamboo secretion, Scrophularia root and Polygala root calm the Po and Shen that become agitated when Phlegm and Heat pervade the Upper Burner. Licorice cured Pinellia rhizome, Tangerine dried rind of mature fruit, Magnolia bark, Perilla fruit, dry fried Bitter orange immature fruit and Platycodon root help to dispel Phlegm as well as redirect the rebellious Qi downward, which settles the Stomach. While the Stomach and Spleen are the source of Phlegm, the Lung is its receptacle. Poria and Chinese licorice root and rhizome enhance the protective and harmonizing action of the herbs upon both the digestive and respiratory systems. To help the body expel invasions, White mulberry leaf and Schisandra fruit purge External Wind and consolidate the Lung and Defensive Qi (Wei). Many of the herbs in the formula are cooling, so the addition of Ginger rhizome prevents overcooling, especially of the Spleen and Lung as well as help to transform Phlegm and disperse stagnant Qi and Moisture.
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Coping with the diagnosis and prognosis may lead to spiritual and psychological distress, anxiety, and depression. Assessment is an ongoing process, and so after the initiation of treatment, regular re-evaluation is very important. After the initial phase, with stable symptom relief, Principles of Palliative Care frequent symptoms (Table 1). Opioids such as oral morphine are the mainstay of pain management in palliative care in low-resource settings because they are relatively inexpensive and because effective palliative care is not possible without the availability of a potent opioid. Opioids diminish the regulatory drive caused by elevated carbon dioxide levels, and in consequence patients will feel less hunger for air, even if breathing is not improved. Oxygen will be helpful for control of dyspnea only in a minority of patients; however, other nonpharmacological interventions may help, such as repositioning of patients. Continuous dyspnea should be treated with a continuous opioid medication, following similar dose-finding rules as for pain management, although mostly with lower starting dosages. However, many patients will suffer not from major depression, but from feeling depressed, which is not the same. Treatment with antidepressants for these patients may impede coping and add burdensome side effects such as dry mouth or constipation. As the concept of fatigue is often not clearly understood by patients or by all health care professionals, it is recommended to consider the symptoms tiredness and weakness instead of fatigue. Physical activity is possible even for patients with advanced disease, although it has to be adapted to reduced performance status and cognitive function. Rescue or breakthrough medication should be prescribed for patients with advanced disease, where exacerbations of pain or other symptoms are possible, and rapid treatment of these exacerbations is required. Rescue medications can include different drugs, but for most patients they should include at least an opioid with fast onset for treatment of pain, dyspnea, and anxiety as well as a benzodiazepine such as lorazepam for the treatment of dyspnea, anxiety, and agitation (Table 2). Oral application may be much easier if no professional help is available, but in some patients oral intake is not possible. In these emergencies, the onset of symptom relief should not be delayed unduly by prolonged assessment or differential diagnosis. Emergencies that have to be treated rapidly and adequately are exacerbations of preexisting symptoms, new symptoms with sudden and intense onset, or rare complications such as massive hemorrhage. Prescription (or even better, provision) of rescue medication for emergencies is especially important when health care professionals are not available out of office What should be done in the case of massive hemorrhage? For more severe bleeding, benzodiazepines or morphine via subcutaneous bolus administration may be indicated, but often they will not take effect fast enough. Spiritual support from caregivers as well as from specialized staff, for example religious leaders, may be helpful. Rarely, patients with extreme distress from pain, dyspnea, agitation, or other symptoms that are resistant to palliative treatment, or do not respond fast enough to adequate interventions, should be offered palliative sedation. However, for other patients mild sedation may be enough, so that patients can be roused and can interact with families and staff to some degree. Before the initiation of this treatment, other treatment options have to be considered, and the priorities of the patient should be clarified. Health care professionals should be able to collaborate with other staff and volunteers who care for the patient, and agree on treatment regimens and common goals for the patient. Check the capacity of the patient, impairment from medication or from disease, or from interaction with family members, use verbal and nonverbal cues for perception. Ask the patient about his level of information, what does he know about his disease and about the topic of the talk, and ask the patient how much he wants to know. In many cases, and nearly always in dying patients, nutritional supplements, parenteral nutrition, and fluid replacement are not indicated and should be withdrawn or withheld. A wealth of diverse ritual serves to guide people in societies through the grief process, and it is important for the health professional to be aware of such rituals. Grief not only affects relatives, but also patients themselves, who may experience anticipatory grief prior to their death as they grieve the various losses that they are experiencing such as the loss of their future and the loss of seeing their children grow up. Many different factors can affect the bereavement process for family members, including their relationship with the person who died, the way that they died, whether they were experiencing symptoms and were seen to be suffering, stigma, a lack of disclosure about their illness, local cultural practices and beliefs, personality traits, other stresses that they may also be experiencing, and bereavement overload if they have lost several friends and relatives in a short space of time. However, there are a few patients receiving palliative care who ask for assisted suicide or for active euthanasia or for other forms of hastened death. In most countries, withholding or withdrawing life-sustaining treatment is legally and ethically acceptable, and so treatment reduction may offer an option. Ethical decision making Whereas guidelines and recommendations are available for most areas of symptom control, there are some issues in palliative care that are loaded with ethical implications. Patients and more often other caregivers and health care professionals insist on enteral or parenteral nutrition or at least fluid substitution if patients are no longer able to eat or drink. If the therapist does not comply with this wish, it is often considered as inhumane, as the patient then will starve or die of thirst. Nutrition often has an overwhelming symbolic significance, and as long as the patient is nourished, caregivers will perceive a chance for the patient to get well. Each year about nine million cancer patients worldwide experience moderate to severe pain most of the time. Pain in terminal stages of disease has its own characteristics and special issues. Internationally, 7% to more than 60% of cancer patients use complementary therapies, depending on definitions used in numerous surveys. These therapies often work when used alone, but they are also used with pharmaceuticals, often reducing the dosages required, and thus decreasing side effects and cost. When complementary therapies work synergistically with a pharmaceutical pain regimen, effectiveness may be improved and costs reduced. Often, he claims that mainstream medicine is part of a larger conspiracy that includes industry and government. The most important discovery of modern medicine is not vaccines or antibiotics- it is the randomized trial, which shows what works and what does not. A new "Law of Nature," invoked to explain some extraordinary result, must not conflict with what is already known. If new laws are proposed to account for an observation, the observation is almost certainly wrong. First it is determined that something works, and then its mechanism (how it works) is explored. Every culture throughout time and in every corner of the world has developed herbal remedies. When subjected to study, some of these remedies are shown to be worthwhile, but others often prove ineffective. In addition, the public internationally is confronted with magical or superstitious remedies. Park, University of Maryland, writes about quackery in several publications, including his book Voodoo Science: the Road from Foolishness to Fraud. The integrity of science rests on the willingness of scientists to expose new ideas and findings to the scrutiny of other scientists. A Complementary Therapies for Pain Management 7) Risk/benefit ratio is an important aspect to consider. Sports massage, Shiatsu, and deep tissue massage are modalities that involve deeper pressure, whereas Reiki (very light touch therapy) involves the gentle brushing of hands over the body. Reflexology (massage of the feet, hands, or scalp) is especially useful for people who are frail or are recovering from surgery. Herbal medicines must be considered in terms of any prescription medication the patient is using. Acupuncture, an important component of Traditional Chinese Medicine, originated more than 2,000 years ago. It involves the stimulation of predetermined points on the body with sterile, filiform, disposable needles, sometimes using heat (moxibustion), pressure (acupressure), or electricity to enhance therapeutic effect. The idea of "life energy" or "vital energy" has never been substantiated by scientific understanding. Instead, physiological and imaging studies indicate that acupuncture induces analgesia and activates the central nervous system. It also may reduce the affective dimension, perhaps as the subject reinterprets meanings associated with the painful sensation.
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While enthusiastic toward new experiences and learning, children have a limited tolerance for the stressors of daily life. Like the digestive and respiratory systems, the mind and nervous system of a young child are rapidly changing. Many youngsters have not yet learned how to adjust smoothly to the flux that surrounds them and the enormous changes that are occurring internally. Though healthy, robust children appear outwardly tough and resilient, their immaturity and inexperience make them vulnerable to overstimulation and information overload. Often, but not always, tantrums, crying spells, nightmares, agitation, irritability and anxiety are harbingers of the normal and expected evidence of growth: teething, hormonal surges, sudden hungers and food cravings, meeting new people, adapting to playgroups and babysitters, urges toward independence, and fears surrounding separation, peer group pressure, school rules and achievement all conspire to upset the apple cart of daily life for the infant, toddler as well as the older child. The additional expectation for young, school-age children to sit quietly at their desks, self-consciously focus their attention and not be distracted by nearby activities adds another challenge to their capacity to cope with stress. Together they soothe nerves, relax the Liver, tame the Mind/Hun and quiet the Heart, enfolding the Mind/Spirit while subduing the uprising of Liver Yang (also known as the stirring of Internal Wind). Dry fried Sour jujube seed, Polygala root, Polygonum multiflorum stem, Lotus seed, Silk tree bark and flower, Amber resin and Poria with wood root soothe the Mind/Spirit (Shen), stabilize the Mind/Hun and clarify the senses (clear Heat and Phlegm from the Upper Orifices). Gambir stem branch and twig, Gastrodia rhizome, Silkworm and Gardenia fruit subdue Liver Yang and Internal Wind, clear Heat and allay occasional irritability, tension and restlessness. Lily bulb, Anemarrhena rhizome and Schisandra fruit clear deficiency Heat by replenishing and consolidating Moisture and restoring stability of Qi and Shen. Red tangerine peel and Chinese licorice root and rhizome aid digestion and harmonization of the herbal ingredients while toning Stomach Qi, preventing stagnation due to the excessive accumulation of Moisture (retention of Dampness). Chinese cosmology sees nature as being governed by five primal forces, each of them sharing the character of a climate, a season, a stage in the cycle of life. These five primal forces are known as the Five Phases: Wood, Fire, Earth, Metal and Water. We all have an intrinsic organizing pattern, a true nature (Li), known as our type. A single phase functions as our governing center, the source of our deepest impulses, organizing how experience is received, incorporated and expressed. Every child can be identified as one of these types: a Wood Child, Fire Child, Earth Child, Metal Child or Water Child. Recognizing a Fire: Heart Wood: Liver Water: Kidney Earth: Spleen Metal: Lung Each Peacemakers formula corresponds to one of the five patterns that organize the relationships within us and with the world. Our initial goal was to discover whether our Five Types Model would be useful in assessing the healthy development of a small cohort of babies before they acquired language. We also wanted to explore the prognostic validity of the model in anticipating problems that challenge each of the types in unique ways. The clinical value of our model was demonstrated over more than a decade in their practice that served over 10,000 children. Five Patterns of Dynamic Relationships Five phases interact according to complementary relationships of generation (Sheng) and restraint (Ke), maturation and adaptation that maintain equilibrium between the five Organ Networks. While the Sheng relationships sustain us, affording continuity, what animate us are polar tensions within the adaptive Ke relationships. Sheng sustenance makes us comfortable and content, whereas Ke tension moves us forward, out of our comfort zone. Patterns Equal Type: Manifestations Provide Clues When faced with a physical or cognitive problem to solve, or simply the challenge of growing our selves, the complementary and reconciling Ke relationships can become intensified and antagonistic as we adapt to stress. Heat and a restless mind indicate hyperactive Heart Qi and disturbed Shen, corresponding to the Heart (Fire). Frequent urination, an inability to hold urine, indicates a deficiency of Kidney Qi. Thus the contending triangular relationships typical of the Fire Child are between Fire-Heart and Lung-Metal, and Fire-Heart and Kidney-Water. When strife develops between contending Ke relationships, peace-making resolves the conflict. Peacemakers formulas modulate these critical disharmonies so that change, adaptation and growth can proceed without chaos. And the triangular Ke relationship between three Organ Networks is fundamental to the stability and resilience of the human body. There are three realms (Heaven, Human, Earth), three treasures (Shen, Qi, Jing) and three burners (Upper, Middle, Lower). The five triangles describe the underlying pattern, the context out of which disharmonies and conflict materialize. Each Peacemakers formula harmonizes key interactions between three Organ Networks that constitute a triangle of relationships, corresponding to each pattern and type. By matching observable qualities across ten parameters, the phase most characteristic of that child is uncovered. Please complete the questionnaire by checking the appropriate boxes to describe your child. Occasional vague somatic complaints such as occasional low back pain, joint pain 19. Each formula is comprised of more than a dozen herbal ingredients that have a moderating influence because no single herb or group of herbs has a dominant position. This helps them achieve their goal: to harmonize and optimize interactions between three Organ Network triangles. The production of the Peacemakers requires only a minimal amount of alcohol that can be easily evaporated by diluting the herbs in boiling water. None of the herbs are harsh in their taste or action, and of course all are non-toxic. Vegetable glycerin, added as a preservative, enhances the flavor, making them quite palatable for children. Peacemakers can safely be combined with other Gentle Warriors formulas when indicated. Use a specific Gentle Warriors formula first, and follow-up with a Peacemakers formula to strengthen the child. Combine a Peacemakers formula with a specific Gentle Warriors formula to reinforce its action. For general psychological and physiological support, begin with a Peacemakers formula. When needed, combine the appropriate Peacemakers with another Gentle Warriors formula. For example, quiet Calm and/or Firefighter to reduce excess Heat or soothe disturbed Shen. Or add Grow and Thrive to any Peacemakers formula to help support a healthy appetite. Use Gentle Warriors Peacemakers as a health-promoting developmental boost, as you would a daily multivitamin or nutritional supplement to reinforce wellness. Over time, Peacemakers strengthen health and resistance to external influences, helping to avert problems before they arise. That means harmonizing the interaction between both Wood and Earth (Liver and Spleen), and Metal and Wood (Lung and Liver). The Spleen is a central facet of all five Peacemakers, but its role is highlighted in Wood Builder, which is the key formula for the Wood Child. The Liver and Spleen organize digestion, transformation, assimilation, distribution and storage of Qi, Moisture and Blood. The Spleen generates Qi and Moisture, the nutritive portion of Blood (Ying) and Acquired Essence (Hou Tian Jing) that is ultimately stored by the Kidney. The Liver nourishes the Blood (blends the Essences from the Kidney with the 56 Ying from the Spleen), as well as storing and regulating its volume and distribution. The Liver and Lung harmonize the upward and downward movements of Blood, Qi, Yin and Yang.