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Medical Instructor, Harvard Medical School
You will learn more about the signs and symptoms and care of anaphylaxis in Chapter 16 asthma symptoms cold air buy cheap singulair. Some people know that they are allergic to certain substances or to insect stings asthma symptoms 4dpiui trusted 5mg singulair. They may have learned to avoid these things and may carry medication asthma breathing machine order discount singulair on-line, such as an epinephrine auto-injector asthma symptoms triggers 10mg singulair fast delivery, to reverse the allergic reaction. People who have severe allergic reactions may wear a medical identification tag, bracelet or necklace. Croup Croup is a common upper airway virus marked by a harsh, repetitive cough that most commonly affects children younger than 5 years of age. The airway constricts, limiting the passage of air, which causes the child to produce an unusual-sounding cough that can range from a high-pitched wheeze to a barking cough. Most children with croup can be cared for at home using mist treatment or cool air. However, in some cases, a child with croup can progress quickly from respiratory distress to respiratory arrest. Responding to Emergencies 116 Breathing Emergencies Epiglottitis Epiglottitis, a far less common infection than croup, causes severe swelling of the epiglottis. When it swells, it can block the windpipe and lead to severe breathing problems and even death. Epiglottitis usually is caused by bacterial infection with the Haemophilus influenzae bacteria. The signs and symptoms of epiglottitis may be similar to those of croup, but epiglottitis is a more serious illness and can result in death if the airway becomes blocked completely. In the past, epiglottitis was a common illness in children between 2 and 6 years of age. However, the incidence of epiglottitis in children has decreased dramatically in the United States since the 1980s, when children began routinely receiving the H. A person with epiglottitis may need to sit up and lean forward, perhaps with the chin thrust out, in order to breathe. Other signs and symptoms include drooling, trouble swallowing, voice changes, chills, shaking and fever. Signs and Symptoms of Respiratory Distress A person who is experiencing respiratory distress is, understandably, often very frightened. Because the person is struggling to breathe, speaking in complete sentences may be difficult. You might hear wheezing, gurgling or high-pitched noises as the person tries to breathe. First Aid Care for Respiratory Distress When a person is experiencing a breathing emergency, it is important to act at once. In some breathing emergencies, the oxygen supply to the body is greatly reduced, whereas in others the oxygen supply is cut off entirely. If breathing stops or is restricted long enough, the person will become unresponsive, the heart will stop beating and body systems will quickly fail. Call 9-1-1 or the designated emergency number and give appropriate first aid care until help arrives: If you know the cause of the respiratory distress (for example, an asthma attack or anaphylaxis) and the person carries medication used for the emergency treatment of the condition, offer to help the person take their medication. Providing reassurance can reduce anxiety, which may also help to make breathing easier. A person who is having trouble breathing may breathe more easily in a sitting position. Responding to Emergencies 117 Breathing Emergencies If the person is responsive, gather additional information by interviewing the person and performing a head-to-toe check. Try phrasing your questions as "yes" or "no" questions so the person can nod or shake their head in response instead of making the effort to speak. Asthma Many people have asthma, a chronic illness in which certain substances or conditions, called triggers, cause inflammation and narrowing of the airways, making breathing difficult. Common triggers include exercise, temperature extremes, allergies, air pollution, strong odors (such as perfume, cologne and scented cleaning products), respiratory infections, and stress or anxiety. The trigger causes inflammation and swelling, which causes the opening of the airways to become smaller and makes it harder for air to move in and out of the lungs.
These transgenic animals detect two kinds of genetic events in two targets-point mutations in gpt detected by resistance to 6thioguanine and spi deletions that permit growth on P2 lysogens (Okada et al asthma treatment without insurance order singulair 5mg visa. Other transgenic assays are under development and offer the prospect of expanding the versatility of such assays (Lambert et al asthma definition ats generic singulair 4mg without a prescription. Various mutagens asthma symptoms lying down purchase genuine singulair on-line, including alkylating agents asthma related deaths singulair 4 mg on line, nitrosamines, procarbazine, cyclophosphamide, and polycyclic aromatic hydrocarbons have been studied in transgenic mouse assays, and mutant frequencies have been analyzed in such diverse tissues as liver, skin, spleen, kidney, bladder, small intestine, bone marrow, and testis (Lambert et al. Tissue-specific mutant frequencies can be compared to the distribution of adducts among tissues and to the site specificity of carcinogenesis (Mirsalis et al. An important issue that remains to be resolved is the extent to which transgenes resemble endogenous genes. Therefore, transgenic animals offer promising models for the study of chemical mutagenesis, but they must be further characterized before their ultimate place in hazard assessment is clear. Mammalian Cytogenetic Assays Chromosome Aberrations Cytogenetic assays rely on the use of microscopy for the direct observation of the effects of interest. This approach differs sharply from the indirectness of traditional genetic assays in which one observes a phenotype and reaches conclusions about genes. In conventional cytogenetics, metaphase analysis is used to detect chromosomal anomalies, especially unstable chromosome and chromatid aberrations. A key factor in the design of cytogenetic assays is obtaining appropriate cell populations for treatment and analysis (Preston et al. Cells with a stable, well-defined karyotype, short generation time, low chromosome number, and large chromosomes are ideal for cytogenetic analysis. For this reason, Chinese hamster cells have been used widely in cytogenetic testing. Other cells are also suitable, and human cells, especially peripheral lymphocytes, have been used extensively. Cells should be treated during a sensitive period of the cell cycle (typically S), and aberrations should be analyzed at the first mitotic division after treatment so that the sensitivity of the assay is not reduced by unstable aberrations being lost during cell division. Cytogenetic assays require careful attention to growth conditions, controls, doses, treatment conditions, and time intervals between treatment and the sampling of cells for analysis (Kirkland et al. It is essential that sufficient cells be analyzed because a negative result in a small sample is inconclusive. Results should be recorded for specific classes of aberrations, not just an overall index of aberrations per cell. Mutagenicity assays in transgenic animals combine in vivo metabolic activation and pharmacodynamics with simple microbial detection systems, and they permit the analysis of mutations induced in diverse mammalian tissues (Mirsalis et al. The transgenic animals that have figured most heavily in genetic toxicology are rodents that carry lac genes from E. The bacterial genes were introduced into mice or rats by injecting a vector carrying the genes into fertilized oocytes (Mirsalis et al. After mutagenic treatment of the transgenic animals, the lac genes are recovered from the animal, packaged in phage, and transferred to E. Mutant plaques are identified on the basis of phenotype, and mutant frequencies can be calculated for different tissues of the treated animals (Mirsalis et al. Its use offers technical advantages as a small, easily sequenced target in which mutations are detected by positive selection, and it permits interesting comparisons both within and between assays. A metaphase with more than one aberration: a centric ring plus an acentric fragment and a dicentric chromosome plus an acentric fragment. In interpreting results on the induction of chromosome aberrations in cell cultures, one must be alert to the possibility of artifacts associated with extreme assay conditions because aberrations induced under such circumstances may not be a reflection of a chemical-specific genotoxicity (Scott et al. Questionable positive results have been found at highly cytotoxic doses (Galloway, 2000), high osmolality, and pH extremes (Scott et al. The possibility that metabolic activation systems may be genotoxic also warrants scrutiny (Scott et al. Although excessively high doses may lead to artifactual positive responses, the failure to test to a sufficiently high dose also undermines the utility of a test. Therefore, testing should be extended to a dose at which there is some cytotoxicity, such as a reduction in the mitotic index (the proportion of cells in division), or to an arbitrary limit of about 10 mM if the chemical is nontoxic (Kirkland et al.
Phases 5-6 (Widespread Human Infection or Pandemic) recommendations focus on the local use of antiviral drugs in three situations: 1) when pandemic influenza is sporadically reported in the United States (without evidence of spread in the United States) asthma symptoms 5 year old quality singulair 5 mg, 2) when there is limited transmission of pandemic influenza in the United States asthma symptoms and treatment buy singulair 4mg with visa, and 3) when there is widespread transmission in the United States asthmatic bronchitis attack order singulair on line amex. Throughout Phases 5-6 (Widespread Human Infection or Pandemic) is asthmatic bronchitis fatal generic 5 mg singulair fast delivery, education of health care providers will continue. Recommendations for antiviral use in Phases 1-3 (Limited Human Spread) and Phase 4 (Sustained Human to Human Spread) Use of antivirals in management of seasonal strains of influenza Influenza epidemics occur every winter in Arizona. Antiviral medicines are a useful adjunct to influenza vaccine for controlling, treating, and preventing influenza Current human influenza illness in the United States can be treated and prevented with antivirals. The M2 ion channel inhibitors (also known as amantadanes) are amantadine (Symmetrel) and rimantadine (Flumadine). The neuraminadase inhibitors oseltamivir (Tamiflu) or zanamivir (Relenza) are effective for both influenza A and B. Although many influenza A strains are sensitive to amantadine or rimantadine, the avian influenza A (H5N1) isolates are resistant. At the present time, avian influenza A (H5N1) is usually sensitive to both oseltamivir and zanamivir. As long as pandemic influenza is not being reported abroad or in the United States, and there is no epidemiologic link to cases of avian influenza, seasonal influenza is unlikely to be caused by a novel influenza virus. Epidemiologic links that should suggest the risk of a novel influenza virus would include: · · · · A history of travel to areas where there are avian/animal influenza outbreaks A history of contact with a person with an unexplained respiratory disease in an area with avian or animal influenza outbreaks Contact with patients ill with a known or suspected novel virus Contact with sick poultry or animals See Clinical Guidelines (Supplement 5) for more detailed information about epidemiologic criteria for suspecting a novel influenza virus. Physicians can use antiviral medicines to treat and give prophylaxis against seasonal influenza. Treatment is most effective in reducing the length of illness when given within the first 48 hours of symptoms. Physicians should choose which antiviral medicine to use based on a variety of factors: · · · · · What strain is currently circulating in the community (influenza A or B or both) the known sensitivities to antivirals of these circulating strains Rapid influenza testing results the age of the patient Whether the antiviral medicine will be used for treatment or prophylaxis (See Appendix 7. This will allow health care providers to be better prepared to use antivirals during pandemic influenza. Use of antivirals in management of cases of novel influenza In this document the term "novel strains of influenza" is used to refer to avian or animal influenza strains that can infect humans (like avian influenza A [H5N1]) and new or re-emergent human influenza viruses that cause cases or clusters of human disease. Criteria for early detection and identification of novel strains of influenza are discussed in Supplement 1. Sentinel laboratories throughout Arizona send influenza isolates to the Arizona Public Health Laboratory. Use of antivirals for treatment of suspected avian influenza A (H5N1) or another novel strain of influenza. A patient with a suspected case of avian influenza A (H5N1) or another novel strain of influenza should be isolated as described in Supplement 4 and treated in accordance with the clinical algorithm for Phases 1-3 (Limited Human Spread) and Phase 4 (Sustained Human-to-Human Spread) provided in Supplement 5. As of July 2010, a patient with a suspected case of avian influenza A (H5N1) or another novel strain of influenza should be treated with oseltamivir or zanamivir. The antiviral should be administered as early as possible and ideally within 48 hours after onset of symptoms. Neuraminidase inhibitors are preferred because the majority of avian influenza A (H5N1) viruses currently affecting humans are resistant to amantadine and rimantadine. Cross-resistance between zanamivir- and oseltamivir-resistant viruses is variable. Use of antivirals for prophylaxis of contacts suspected avian influenza A (H5N1) or another novel strain of influenza. Close contacts may include family, schoolmates, workmates, health care providers, and fellow passengers if the patient has been traveling. If deemed necessary by public health authorities, these persons may receive post-exposure prophylaxis with oseltamivir, as zanamivir is not currently indicated for prophylaxis. This measure would be implemented in small, well-defined settings such as the initial introduction of a virus with pandemic potential into a small community or a military base, however, once a pandemic is underway, such a strategy would not represent an efficient use of limited antiviral supplies. Because targeted antiviral prophylaxis would require rapid delivery and administration of substantial stocks of antiviral drugs, the feasibility to use antivirals to contain disease clusters caused by a novel strain of influenza will be evaluated at the time based on available antiviral supply and interim updated recommendations on antiviral drug use. Targeted antiviral prophylaxis would also require intensive case finding in the affected area as well as effective communication with the affected community. Preparedness planning for use of antivirals during a pandemic National recommendations on use of antivirals during a pandemic During an influenza pandemic, demand is likely to far outstrip supplies available in stockpiles or through usual channels of distribution. This requires coordination and collaboration with health care providers who will administer antivirals during a pandemic.
Desloratadine in combination with montelukast suppresses the dermographometer challenge test papule asthma treatment experiments purchase singulair 4 mg visa, and is effective in the treatment of delayed pressure urticaria: a randomized asthma kids cheap singulair 10 mg without a prescription, doubleblind asthma symptoms 10 month old purchase singulair uk, placebo-controlled study asthma cough treatment buy genuine singulair on-line. Efficacy and safety of desloratadine in adults with chronic idiopathic urticaria: a randomized, double-blind, placebo-controlled, multicenter trial. Randomized placebo-controlled trial comparing desloratadine and montelukast in monotherapy and desloratadine plus montelukast in combined therapy for chronic idiopathic urticaria. Treatment of chronic urticaria with cetirizine dihydrochloride a nonsedating antihistamine. Therapeutic effects of cetirizine in delayed pressure urticaria: clinicopathologic findings. Comparison of the effects of fluticasone propionate aqueous nasal spray and loratadine on daytime alertness and performance in children with seasonal allergic rhinitis. Once-Daily Cetirizine Is Safe and Effective for Children with Allergic Rhinitis with and without Intermittent Asthma. Antihistamines Page 41 of 72 Final Report Update 2 Drug Effectiveness Review Project 97. Cetirizine treatment of rhinitis in children with pollen allergy: evidence of its antiallergic activity. A placebo-controlled trial of cetirizine in seasonal allergic rhino-conjunctivitis in children aged 6 to 12 years. Once-daily cetirizine effective in the treatment of seasonal allergic rhinitis in children aged 6 to 11 years: a randomized, double-blind, placebo-controlled study. Fexofenadine is efficacious and safe in children (aged 6-11 years) with seasonal allergic rhinitis. Treatment of seasonal allergic rhinitis in children with cetirizine or chlorpheniramine: A multicenter study. Efficacy and safety of loratadine suspension in the treatment of children with allergic rhinitis. Intranasal fluticasone propionate versus loratadine in the treatment of adolescent patients with seasonal allergic rhinitis. Long-term cetirizine treatment reduces allergic symptoms and drug prescriptions in children with mite allergy. Cetirizine reduces cytokines and inflammatory cells in children with perennial allergic rhinitis. A comparison of cetirizine and montelukast for treating childhood perennial allergic rhinitis. Assessment of the efficacy and safety of three dose levels of cetirizine given once daily in children with perennial allergic rhinitis. The comparison of the efficacy and safety of cetirizine, oxatomide, ketotifen, and a placebo for the treatment of childhood perennial allergic rhinitis. Double-blind comparison of cetirizine and loratadine in children ages 2 to 6 years with perennial allergic rhinitis. A double-blind, placebo-controlled, and randomized study of loratadine (Clarityne) syrup for the treatment of allergic rhinitis in children aged 3 to 12 years. Antihistamines Page 42 of 72 Final Report Update 2 Drug Effectiveness Review Project 112. Randomized placebocontrolled trial comparing montelukast and cetirizine for treating perennial allergic rhinitis in children aged 2-6 yr. Efficacy and safety of ebastine 20 mg compared to loratadine 10 mg once daily in the treatment of seasonal allergic rhinitis: a randomized, double-blind, placebo-controlled study. The comparison of cetirizine, levocetirizine and placebo for the treatment of childhood perennial allergic rhinitis. A randomized double-blind placebo controlled study of azelastine nasal spray in children with perennial rhinitis. Double-blind multicenter study on the efficacy and tolerability of cetirizine compared with oxatomide in chronic idiopathic urticaria in preschool children.
The concentration of zinc in the plasma is not a sensitive indicator of zinc status and does not reflect the doseresponse relationship between zinc levels in the body and effects at various target sites asthma knowledge questionnaire buy singulair with visa. Zinc ions are involved as inter- and intracellular messengers and the homeostasis of zinc has to be tightly controlled asthma symptoms high blood pressure discount 4mg singulair with visa. Zinc is an effective inducer of metallothionein synthesis and asthma definition and implications for treatment cheap 10 mg singulair free shipping, when metallothionein is saturated in intestinal cells asthma x ray signs generic singulair 4mg free shipping, zinc absorption is decreased. Liver metallothionein concentration is influenced by hormonal factors, including adrenocorticotropic hormone and parathyroid hormone, and various stimuli that impact zinc metabolism. The high concentration of zinc in the prostate is probably related to the rich content of zinc-containing enzyme acid phosphatase. Essentiality and Deficiency More than 300 catalytically active zinc metalloenzymes and 2000 zinc-dependent transcription factors exist (Ziegler and Filer, 1996; Cai et al. Zinc participates in a wide variety of metabolic processes, supports a healthy immune system, and is essential for normal growth and development during pregnancy, childhood, and adolescence. Zinc deficiency is related to poor dietary zinc intake, dietary phytate intake, chronic illness, or over-supplementation with iron or copper (Prasad, 2004). Symptoms of zinc deficiency include growth retardation, appetite loss, alopecia, diarrhea, impaired immune function, cognitive impairments, dermatitis, delayed healing of wounds, taste abnormalities, and impaired sexual function (Prasad, 2004; Cai et al. Acrodermatitis enteropathica is a rare genetically based, heredity disorder involving zinc deficiency due to poor intestinal absorption (Perafan-Riveros et al. Zinc supplementation, alone or with other micronutrients, is recommended for zincdeficient children, especially in developing countries. Therapeutic uses of zinc include the treatment of acute diarrhea in infants with severe zinc deficiency, the treatment of common cold by its antiviral and immunomodulatory effects, therapy for Wilson disease to help reduce copper burden and to induce metallothionein, and in the prevention of blindness in age-related macular degeneration (Prasad, 2004). Toxicity Acute zinc toxicity from excessive ingestion is uncommon, but gastrointestinal distress and diarrhea have been reported following ingestion of beverages standing in galvanized cans. Following inhalation of zinc oxide, and to a lesser extent other zinc compounds, the most common effect is "metal-fume fever" characterized by fever, chest pain, chills, cough, dyspnea, nausea, muscle soreness, fatigue, and leukocytosis. Acute inhalation of high levels of zinc chloride as in the military use of "smoke bombs" results in more pronounced damage to the mucous membrane including interstitial edema, fibrosis, pneumonitis, bronchial mucosal edema, and ulceration. Following long-term exposure to lower doses of zinc, symptoms generally result from a decreased dietary copper absorption, leading to early symptoms of copper deficiency, such as decreased erythrocyte number or decreased hematocrit. Zinc can also act as a neurotransmitter for normal brain functions (Frederickson et al. Zinc modulates the solubility of -amyloid in the brain and protects against -amyloid toxicity, but excess zinc may trigger neuronal death that is independent or synergistic with the toxic effect of -amyloid (Valko et al. In addition, excess zinc released by oxidants can act as a potent neurotoxin (Frederickson et al. Pancreatic Toxicity Because large amounts of zinc accumulate in secretory granules of pancreatic islet beta-cells, zinc released under certain conditions can affect the function or survival of islet cells and cause beta-cell death. A single, high-dose injection of zinc increases plasma -amylase activity and can produce fibrosis and necrosis of pancreatic exocrine cells, but does not affect the islets of Langerhans cells (Cai et al. In addition, zinc deficiency may be associated with increased risk of cancer in humans (Prasad and Kucuk, 2002). Zinc supplementation could decrease oxidative stress and improve immune function, which may be a possible mechanism for its cancer preventive activity (Prasad and Kucuk, 2002). In experimental animals, zinc prevents cadmiuminduced testicular cancer, but facilitates cadmium-induced prostate tumors (Waalkes, 2003). Chemical compounds of aluminum occur typically in the trivalent valence state (Al3+). As a hard trivalent ion, aluminum binds strongly to oxygen-donor ligands such as citrate and phosphate. The chemistry of aluminum compounds is complicated by a tendency to hydrolyze and form polynuclear species, many of which are sparingly soluble (Harris et al. Aluminum has many uses, mainly in the form of alloys, and finds use in packing, construction, transportation, electrical applications, and beverage cans. Human exposure to aluminum comes primarily from food and secondarily from drinking water. The amount of aluminum in the food supply is small compared to pharmaceutical use of aluminum in antacids and buffered analgesics (Soni et al. Occupational exposures to aluminum occur during mining and processing, as well as in aluminum welding.
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