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By A. Jaffar. University of Guam.

Relapsing fever and typhus can quickly spread in such poor hygienic conditions if someone brings infected lice into the village on their body or clothes purchase ranitidine 150 mg overnight delivery gastritis diet еврофутбол. You have to educate families to wash their clothes purchase 150mg ranitidine with mastercard gastritis diet порево, bedding and bodies frequently to prevent diseases related to poor personal hygiene buy ranitidine 300 mg visa gastritis symptoms uk, particularly relapsing fever and typhus generic 150mg ranitidine mastercard gastritis symptoms mayo. Relapsing fever and typhus have similar clinical manifestations such as fever, headache, joint and muscle pains. It is very difcult to distinguish between them by clinical manifestations alone, without laboratory investigations. Relapsing fever and typhus can occur at any season if poor hygienic conditions and overcrowding encourage lice infestation. Treatment with drugs is not sufcient to control an epidemic of relapsing fever or typhus. Health education about personal hygiene, and delousing clothes and bedding with chemicals such as permethrin, are other necessary control measures. The correct antibiotics can effectively treat relapsing fever and typhus if the patient is referred immediately. Visit his village to see the other sick persons and actively search for other cases, which you should immediately report to the District Health Ofce. There might be an epidemic of one of the febrile illnesses, which needs to be controlled by sustained preventive actions. Advise them to destroy all rubbish heaps and rodent burrows around the house, and ll cracks in walls where sandies like to breed. They should agree to their house being sprayed with insecticide and they should cover exposed skin and sleep under insecticide-treated bed nets to avoid sandy bites. Schistosoma haematobium, which mainly affects the bladder is limited to lowland swampy land and oodplains in the Awash and Wabe Shebele valleys and along the border with the Sudan. They are also more likely than adults to stand in the water to urinate or defaecate. In addition to the pain caused by the disease, infected children are usually stunted in their growth and perform poorly at school. Suturing the wound seals the viruses inside the body and makes it more difcult to ush it with soap and water, detergent, alcohol or iodine. Thoroughly clean the wound and send Mr Kebede to the nearest health facility for post-exposure prophylaxis. Admitting him to the Health Post delays referring him for urgent vaccination and rabies immunoglobulin treatment. It should be destroyed if its behaviour is abnormal; otherwise it should be kept contained for ten days to see if it develops any signs of rabies and killed if it does. They should ensure that Kemal has no further contact with this (or any other) dog, because children are at high risk of being bitten. It is almost inevitable that a person will die if they develop symptoms of rabies, no matter what medical treatment they receive. Taeniasis causes discomfort in people who have a tapeworm in their intestines, but the disease is almost never fatal. Thorough cooking kills the tapeworm larvae embedded in the meat and prevents their transmission to humans who eat the meat. The common symptoms of taeniasis are abdominal pain and the appearance of at white worms in the stools. Open defaecation in grazing lands is a risk factor for taeniasis, because the eggs deposited in human faeces are eaten by cows; the lifecycle of the tapeworm is completed when the larvae become cysticerci in the cows muscles and people eat infected raw or undercooked beef. A newborn with red and swollen conjunctiva could have got the infection from its mother during birth and should be treated with tetracycline eye ointment (1%). Corneal opacity is a permanent type of damage and cannot be improved by treating with tetracycline ointment. Disability resulting from podoconiosis and lymphatic lariasis can be reduced by foot and leg hygiene, exercising the affected part, and raising the legs when sitting or sleeping. Podoconiosis is not a communicable disease it is caused by contact with red clay soils, not an infectious agent. However, trachoma and scabies are communicable diseases found in conditions of poverty, overcrowding and poor access to clean water and sanitation. Tell them that the presence of eye discharge and poor personal hygiene will transmit trachoma bacteria to other people through ies landing on the face, and dirty hands and clothing touching the eyes. In Study Session 3 of this Module, you learned that measles can cause blindness, particularly among malnourished children who are lacking vitamin A. In Study Session 37 you learned that onchocerciasis can affect the eyes and cause so-called river blindness because the insect vector (blackies) needs fast-owing water to breed. Trachoma causes blindness due to corneal damage resulting from bacterial infection of the conjunctiva. You may also have noted that the allergic reaction to body lice bites causes itching and scratching, which enables the infectious agents of relapsing fever and typhus to enter the body through breaks in the skin. Podoconiosis is due to an allergic reaction to red clay soils penetrating the skin of bare feet. You should only collect data which is useful for the control of communicable diseases. Surveillance can also be used to assess the magnitude of health problems, to allocate resources based on disease burdens and to evaluate progress of activities by the health facilities. A combination of active and passive surveillance is one of the indicators of a high quality surveillance system. Regular recording and reporting is one of the essential elements of a surveillance system. Without proper recording and reporting, action against communicable diseases cannot be taken. Active surveillance covers specic diseases (not all diseases), unlike a passive surveillance system. You should verify the existence of similar cases in the community and educate the community on environmental sanitation, such as using a latrine, ensuring a safe water supply for drinking and cooking, and using personal hygiene measures such as hand washing with soap to prevent the transmission of diarrhoeal diseases. Malnutrition is a weekly reportable health problem, not an immediately reportable priority disease. Polio, avian inuenza, rabies and neonatal tetanus are all immediately reportable priority diseases. It also creates an opportunity to integrate data on all important diseases at central level. To identify cases in the community, community workers and Health Extension Practitioners should use simplied community case denitions. Diseases targeted for eradication, such as neonatal tetanus, should be reported immediately. For example, a single case of cholera or of acute accid paralysis may signal an epidemic of cholera or polio. In particular, the death of a person over 5 years old from diarrhoea is an indicator of cholera (think back to Study Session 33). Communicable diseases by their occurrences in time and space sporadic: scattered, dispersed cases of a communicable disease, without any connections in time and space (e. Wild animals living near the house (rodents, mammals) - mouse: salmonella - field mouse: tick-borne encephalitis - birds: ornithosis, chlamydia - hedgehogs: rabies - rats: plague - monkeys: Marburg- disease, yellow fever - rabbits: tularemia 3. Vector Transmission Arthropod vectors carry pathogens from one host to another by 51 both mechanical and biological transmission. Direct spray onto the conjunctives and mucous membranes What kind of diseases may spread this way? Vehicle-borne -Air - aeroplankton: pathogens absorbed on solid and fluidal drops 1.

However buy ranitidine 150 mg low cost gastritis fundus, corticosteroids were administered to 44% of gravidas compared with 66% of nonpregnant women ( 20) purchase ranitidine 150 mg on-line gastritis working out. Unexpectedly order 300 mg ranitidine mastercard chronic gastritis for years, upon discharge discount ranitidine 300mg mastercard gastritis recovery diet, oral corticosteroids were prescribed for 38% of gravidas and 64% of nonpregnant women with asthma ( 20). At the 2-week follow-up by telephone, asthma symptoms were reported by 35% of gravidas compared with 23% of nonpregnant women (20). Thus, pharmacotherapy was inadequate in that oral corticosteroids were less likely to be prescribed with continued asthma symptoms at 2 weeks after emergency department treatment. This combination produces a 19% to 50% increase in minute ventilation by late pregnancy ( 22,23 and 24). The increase in minute ventilation produces a respiratory alkalosis attributable to increases in progesterone. Arterial blood gas concentrations reflect a compensated respiratory alkalosis with pH ranging from 7. The maternal partial pressure of oxygen (Po2) has been reported to be from 91 to 106 mm Hg (25). The near-term alveolar-arterial oxygen gradient is 14 mm Hg in the sitting position compared with 20 mm Hg in the supine position. An explanation for the larger alveolar-arterial oxygen gradient supine is decreased cardiac output because compression of the inferior vena cava by the uterus reduces venous return. Total lung capacity is unchanged or reduced by 4% to 6%, and vital capacity is preserved in the absence of exacerbations of asthma. The gravida breathes at reduced lung volumes because residual volume and functional residual capacity are reduced. As with the development of maternal hyperventilation, the residual volume and functional residual capacity decline before significant uterine enlargement occurs. The diaphragm flattens during gestation, and there is less negative intrathoracic pressure reported in some studies. One could speculate that early airway closure would occur if there were less negative intrathoracic pressure. Because during acute asthma episodes the patient with asthma generates large negative intrathoracic pressures to apply radial bronchodilating traction, any decline in ability to develop more negative inspiratory pressures would predispose gravidas with asthma to more sudden deteriorations because of airway closure. The increase in serum progesterone concentration during gestation did not correlate with improvement in bronchial responsiveness ( 27). This observation suggests that factors other than progesterone contribute to changes in bronchial responsiveness, although progesterone relaxes smooth muscles of the uterus and gastrointestinal tract. Other Physiologic Changes Cardiac output increases 30% to 60% because of an increase in heart rate, yet stroke volume increases little ( 28). The decrease in systemic vascular resistance is accompanied by an increase in the heart rate from 10 to 20 beats/min. Although correcting any dehydration is indicated, injudicious fluid replacement has resulted in acute pulmonary edema with normal cardiac function. During the latter half of gestation, these changes become manifest because the gravida has increased preload (mild volume overload), increased chronotropy, and reduced afterload (28). The maternal hemoglobulin concentration decreases, although during gestation there is a 20% to 40% increase in erythrocyte mass ( 28). Such an increase is offset by the even larger increase of plasma volume, resulting in relative anemia. The fetus survives in a low-oxygen environment with little reserve oxygen stores, should the supply of oxygen-rich uterine blood be compromised. Animal and human studies demonstrate reduced fetal oxygenation if there is reduced uterine blood flow such as occurs with severe maternal hypotension, hypocarbia, or shock ( 25). Maternal hyperventilation can reduce venous return and shift the maternal oxyhemoglobin dissociation curve to the left. Modest declines in maternal oxygenation seem to be tolerated by the fetus, but substantial degrees of maternal hypoxemia can threaten fetal survival. Uterine vessels during gestation are dilated maximally based on experimental data primarily from pregnant sheep and some human studies. Uterine vessels do not vasodilate after b-adrenergic agonist stimulation, but do vasoconstrict from a-adrenergic agonists. Some obstetric anesthesiologists administer intravenous ephedrine 25 to 50 mg for hypotension during epidural anesthesia. The b-adrenergic effects of ephedrine result in increased cardiac output, which raises systolic pressure and maintains uterine perfusion. Subcutaneous epinephrine provides primarily b-adrenergic stimulation, whereas intravenous epinephrine results in both a- and b-adrenergic effects. For the fetus in distress, such changes can be important, but clearly the uteroplacental circulation is a large shunt. For the same incremental increases in arterial P O2, the leftward shift of the fetal hemoglobin oxygen dissociation curve results in larger increases in fetal P O2 than in maternal blood. Studies in the literature report varying degrees of improvement, deterioration, or no change in clinical course ( 31). A prospective study of 198 pregnancies recorded similar results in that 40% of gravidas had no change in antiasthma medications, 42% required more medications, and 18% of gravidas required fewer medications ( 12). Pregnancy in adolescents with asthma has been associated with many emergency department visits and hospitalizations for asthma ( 34). Accurate serial data were not available to compare preconception and gestational asthma events. Some adolescents with severe asthma may not benefit from antiinflammatory medications such as inhaled beclomethasone dipropionate because of their poor compliance with physician advice and medications ( 34). The combination of poverty, inadequate or no prenatal care, and limited education can complicate adolescent pregnancies ( 35). Clearly, gravidas must not smoke during gestation for their own well-being and that of their children. Aspirin and nonsteroidal antiinflammatory drugs should be withheld in the aspirin-intolerant gravida. Medications It is preferable to recommend antiasthma medications for which established data from human pregnancies are available. Furthermore, inhaled drugs are favored as the potential drug dosage that would cross the placenta is reduced. Organogenesis in human pregnancies is relatively short (days 12 56) compared with animals. The time for fetal growth and development is much longer in humans, whereas it is shorter in animals. About 25% of major malformations are genetically related, and 3% are due to recognized chromosomal abnormalities. Food and Drug Administration classification system for drug administration during gestation must be considered in the context of drug advertising by manufacturers and is not an absolute prohibition on prescription of a drug during gestation, with the exception of a class X agent. Experience with inhaled beclomethasone dipropionate has not identified fetal abnormalities in pregnancies where therapeutic dosages were used at conception or during the first trimester ( 8,9,11,34). Budesonide also has not been associated with harmful effects during conception and the first trimester ( 16). Published experience from Northwestern University with prednisone, beclomethasone dipropionate, or both totals over 300 pregnancies without an increased risk of teratogenesis. Another antiinflammatory drug, cromolyn, has not been associated with an increased risk of congenital malformations in a series of 296 cases ( 39) as well as during use in the United States since 1973 ( 2). Reports on the use of nedocromil, which blocks early and late allergic-induced bronchial reactions and has antieosinophil activity, in the first trimester are meager.

This issue is of particular concern given that 300mg ranitidine gastritis thin stool, even in circumstances where the nature of a risk is well established cheap 300 mg ranitidine diet makanan gastritis, difficulty is often experienced in communicating that risk to an individual in a way that is meaningful to them order ranitidine 150mg otc atrophic gastritis definition. Donation is permitted both to known and unknown recipients; moreover discount 150 mg ranitidine otc gastritis definicion, children conceived after 1 April 2005 as a result of donated gametes are entitled to ask for identifying information about their 262 donor once they reach the age of 18 years. One implication of the private nature of much infertility practice is that there is no national framework either for recruiting egg and sperm donors, or for allocating donated gametes, and hence approaches vary between clinics. Another is that the transactions involved in undergoing fertility treatments are already on a commercial footing, insofar as fees will be payable to the clinic for its services, even though financial reward for the donor of gametes is forbidden. While we cannot aim to respond to all these issues in this one report, we return to many of the concerns in more detail in later chapters. Similar concerns about undue influence arise in connection with the possibility of coercion within the family, where one family member is being encouraged to donate bodily material to help another. Recompense The rather different rules applied to recompensing losses incurred in donations of different forms of bodily material (see paragraph 2. Given the risks to the donor inherent in living organ donation, how far should regulatory bodies go in actively encouraging living donation? Introduction "We should have a system where supply for daily essentials (blood for instance) is greater than demand. A demand-driven service will always be running hard to try and catch up with its own shadow. However, the momentum of demand is also created by the research 264 See Acknowledgments and Appendix 1 for details of this event involving 43 members of the public. We do, however, realise that speaking in these terms may also carry connotations of impersonal procurement, without consideration of the human nature of their source. Corneas, on the other hand, do not always need to be matched on an immunological basis, but 265 do need to be transplanted into a person of similar age to the donor. As the body ages, it is more likely to need medical treatment and, subsequently, the use of 267 bodily material as part of that treatment. The eye banks match recipients with corneas from similar aged donors and recent increases in the age of donors has resulted in a shortage of quality corneas for younger recipients. It should also be noted, however, that older people may contribute to the supply of bodily material. For example, bone removed during the course of a hip replacement operation may be donated and used in the treatment of others. There may also be a particular need for donors with a 273 certain blood type to donate. Supply is further compromised in that a high proportion of donor organs are currently not suitable for transplant... It is likely, however, that these numbers under-represent the number of individuals who could potentially benefit from a transplant: patients are listed for transplantation when the benefits clearly outweigh the risks and there is a good prospect of long-term graft and patient survival. The alternatives to transplantation vary for the different types of organ failure: for kidneys it is generally dialysis, for the pancreas it is insulin treatment, for the heart there is the possibility of a left ventricular assist device, while for the liver and lungs there is no alternative and patients will die. Transplantation has become standard practice over the last 50 years, and in that time the short and long-term survival of transplanted organs has consistently improved, but re- transplantation will still be required for a significant number of recipients. If this target were achieved, an additional 1,200 transplants could be carried out each year, 700 of which would be kidney transplants. These may include road traffic mortality rates, the 288 incidence of deaths after brain injury, and the availability of intensive care facilities. Since 2007-2008, the 290 number of living donors has exceeded the number of deceased donors. Gametes and embryos for treatment "There have always been those who seek to disparage or deprioritise gamete (sperm, egg and embryo) donation on the grounds that the absence of pregnancy is not a disease. In both men and women, there may also be concerns about passing on a genetic disease to offspring. In some of these cases, treatment using donor gametes or embryos may be appropriate. The figure of one in seven couples related to couples who are unable to conceive after two years. In women, egg donation may be suggested because of premature menopause; the removal of ovaries, for example where they 293 are cancerous; and ovarian failure following chemotherapy or radiotherapy. In addition, donor eggs may be used for women for non-medical reasons to enable them to bear children later in life, and donor sperm to 295 enable single women or lesbian couples to have children. However, the demand for donor gametes is greater: potential recipients of gametes or embryos for treatment are likely to wait over a year for suitable gametes to be available, and some may 297 abandon the idea of treatment. In a review of fertility clinics 49 of which responded to a specific question about meeting demand for treatment with donor sperm half reported that they were not able to meet the demand for treatment with donor sperm, with nine of these experiencing particular difficulties matching donors and recipients from minority ethnic 298 groups. Of the 39 clinics that responded to a question about the demand for egg donation, 90 299 per cent said that they were unable to meet demand. Half of the clinics responding to the question about donated embryos reported that they were not able to meet the demand for treatment using donated embryos (17 clinics), with the most common reason cited for this being 300 a lack of donated embryos. Thus egg donors must be aged between 18 and 35 years in order to donate, and sperm donors must be between 18 and 45 years. In addition, each potential donor may be selected only after rigorous screening procedures have taken place. This process includes identifying and screening out persons whose donations could present a health risk to others such as the possibility of transmitting infections or health risks to the donors themselves, for example where there may be psychological consequences of donating. In addition, the centre that recruits gamete donors should also consider the personal or family history of heritable 302 disorders. The trigger for this change in the law was a High Court judgment in 2002 where it was held that Article 8 of the European Convention on Human Rights (which guarantees respect for private and family life) was engaged in a situation where a donor- conceived person sought to obtain non-identifying information (such as their hair colour or 304 ethnicity) about the donor. The government response extended beyond the scope of the judgment (which related only to non-identifying information) to specify that identifying information, too, should in future be provided. The number of sperm donors who stated that their donation should be limited to one family only has risen in recent years, with 20 donors stipulating a one 309 family limit in 2007, 48 donors in 2008, and 67 donors in 2009. Gametes and embryos for research "There is no evidence of a demand from women to be allowed to donate eggs for research. Sperm is used primarily in research related to fertility, while eggs and embryos are used more widely: research uses include contributing to basic science research; increasing knowledge about fertility; contributing to knowledge about both heritable and non-heritable diseases; and research using embryonic stem cells. However, the number of eggs donated for research purposes has fallen significantly in recent years. Tissue for medical treatment " if human tissue is to be used, it must be used with due respect " - Miriam Pryke, consultation respondent " there is a need to separate materials related to treatment and research, for otherwise research may drive treatment needs. Although over 2,000 people a year donate corneas after their 315 death, there is currently a shortfall of approximately 500 corneas per year. In addition, some families decide not to donate and, following discussions with health care professionals, decline to proceed. In these circumstances, clinicians can draw on tissue banks in other European countries. Blood and tissue for research "Clearly, uses of tissues for diagnosis and treatment and organs for transplant must take precedence over the needs of researchers. While some researchers experience difficulties in obtaining the bodily materials they need for their research, in many cases these difficulties may arise less as a result of shortages in stocks of the material itself, than from difficulties in accessing available material, for example because of inadequate systems in place for obtaining appropriate consent at the time the material is taken. Breakthrough Breast Cancer recently commented that "the main barrier to progress [is] a shortage of good quality tissue - the raw 318 material for research. The premises where tissue is being removed from deceased donors, or after a post mortem, must be licensed under the Human Tissue Act (see paragraph 2. These problems may be due in 316 A deceased donor can donate 2,000-4,000cm of skin, which takes 100 days to convert into a graft-ready tissue. The average adult patient with severe burns uses 2,000-9,000cm per grafting, but may need 2-3 grafts with a 1-3 day gap between each operation. Participants in first-in-human trials "Every new treatment has to be used for the first time Without first-in- human [trials, there would be] a catastrophic fall in progress in therapeutics. This may be due, in part, to the accompanying publicity which revealed the amount of money 326 the young men were being paid to participate.

Internet journal title with geographic qualifier added to place of publication for clarity The Journal of Venomous Animals and Toxins Including Tropical Diseases [Internet] order ranitidine 300 mg overnight delivery gastritis diet тнт. Botucatu (Brazil): Universidade Estadual Paulista buy ranitidine 150 mg fast delivery gastritis stress, Centro de Estudos de Venenos e Animais Peconhentos cheap 150mg ranitidine with mastercard gastritis duodenitis diet. Internet journal title with unknown place of publication Thoracic Surgical Science [Internet] ranitidine 300 mg without prescription gastritis quimica. Geneva: World Health Organization, Essential Drugs and Medicines Policy Department. Internet journal title with government agency as publisher Amber Waves: the Economics of Food, Farming, Natural Resources, and Rural America [Internet]. Internet journal title with publisher name translated Pernatyie Khishchniki = Raptors Conservation [Internet]. Internet journal title with unknown publisher The International Journal of Forensic Psychology [Internet]. Internet journal title with unknown place of publication and publisher Haptics-e: the Electronic Journal of Haptics [Internet]. Internet journal title with standard volume and issue number Journal of Pediatric Neurosciences [Internet]. Internet journal title with volume having another name Alasbimn Journal: Revista de Medicina Nuclear [Internet]. Digest of Neurology and Psychiatry: Abstracts and Reviews of Selected Literature in Psychiatry, Neurology, and their Allied Fields [Internet]. Internet journal title with volumes viewable for online version different from print version American Journal of Kidney Diseases: the Official Journal of the National Kidney Foundation [Internet]. Internet journal title with volume number and year the same Neurology and Clinical Neurophysiology [Internet]. Internet journal title with volume number but no issue Enformatika: Transactions on Engineering, Computing and Technology [Internet]. Internet journal title with issue number, but no volume Veterinary Sciences Tomorrow [Internet]. Internet journal title with multiple issue numbers European Journal of Biochemistry [Internet]. Internet journal with article numbering in place of volume and issue The Online Journal of Current Clinical Trials [Internet]. Internet journal title with date only, no volume, issue, or article numbers Molecular Systems Biology [Internet]. Internet journal title with season in date The Journal of Genetic Genealogy [Internet]. Internet journal title previously published under another name The Journal of Venomous Animals and Toxins Including Tropical Diseases [Internet]. Internet journal title continuing to be published under another name Neurology and Clinical Neurophysiology [Internet]. Internet journal title with frequency of publication note The Virtual Mentor: American Medical Association Journal of Ethics [Internet]. Internet journal title with note on the print version Problems in General Surgery [Internet]. Internet journal title with system requirements The World Wide Web Journal of Biology [Internet]. Entire Databases/Retrieval Systems on the Internet Sample Citation and Introduction Citation Rules with Examples Examples B. Parts of Databases on the Internet Sample Citation and Introduction Citation Rules with Examples Examples C. Sample Citation and Introduction to Citing Entire Databases/Retrieval Systems on the Internet The general format for a reference to a database/retrieval system on the Internet, including punctuation: - for a serial database that is open: Databases/Retrieval Systems on the Internet 1243 - for a serial database that is closed: 1244 Citing Medicine - for a single database: Databases/Retrieval Systems on the Internet 1245 - for a retrieval system: Examples of Citations to Entire Databases/Retrieval Systems on the Internet A database is a collection of individual records that are most often standardized in both format and content. There are two broad categories of databases found on the Internet: serial and single. These are collections of records published only once, usually with no intent to update or add records, although minor corrections/changes may be made. System providers may allow users to select an individual database for access or to select all or subsets of all of the databases to be searched in one operation. Updates and revisions to Internet retrieval systems may be labeled as new versions, releases, or editions. This is particularly true of commercial systems which carry copyright dates, but may not be true for government-sponsored or other noncommercial systems. Citations to databases and retrieval systems have been combined in this chapter because they are cited the same way. This may include all capital letters or all lower case 1246 Citing Medicine letters, capital letters within words, run-together words, and symbols. Continue to Citation Rules with Examples for Entire Databases/Retrieval Systems on the Internet. Continue to Examples of Citations to Entire Databases/Retrieval Systems on the Internet. Citation Rules with Examples for Entire Databases/Retrieval Systems on the Internet Components/elements are listed in the order they should appear in a reference. Author/Editor (R) | Author Affiliation (O) | Title (R) | Content Type (O) | Type of Medium (R) | Edition (R) | Editor and other Secondary Authors (O) | Place of Publication (R) | Publisher (R) | Date of Publication (R) | Date of Update/Revision (R) | Date of Citation (R) | Availability (R) | Language (R) | Notes (O) Author/Editor for Databases/Retrieval Systems on the Internet (required) General Rules for Author/Editor If there are no authors or editors, as is often the case, see No author can be found below List names in the order they appear on the title page or opening screens Enter surname (family or last name) first for each author/editor Capitalize surnames and enter spaces within surnames as they appear on the assumption that the author approved the form used. Place the organization in the publisher position when the organization appears to be serving as both author and publisher. Database/retrieval system on the Internet with editors where there is no author 9. Databases/Retrieval Systems on the Internet 1255 Ignore diacritics, accents, and special characters in names. Box 15 Names for cities and countries not in English Use the English form for names of cities and countries when possible. Moskva becomes Moscow Wien becomes Vienna Italia becomes Italy Espana becomes Spain Examples for Author Affiliation 10. Rome: Ministero della Salute, Direzione General del Sistema Informativo e Statistico. Box 19 Titles ending in punctuation other than a period Most titles end in a period. Database of -Amino Acids may become Database of Beta-Amino Acids If a title contains superscripts or subscripts that cannot be reproduced with the type fonts available, place the superscript or subscript in parentheses TiO2 Nanoparticles may become TiO(2) Nanoparticles Box 21 No title can be found Under rare circumstances a database does not appear to have any title; the database simply begins with the records in it. In this unusual circumstance: Construct a title based on the content of the records Use enough words to make the constructed title meaningful Place the constructed title in square brackets Examples for Title 11. Database/retrieval system on the Internet title with upper/lowercase letters and symbols Databases/Retrieval Systems on the Internet 1259 14. Database/retrieval system on the Internet with title ending in other than a period 15. Database/retrieval system on the Internet published with equal text in two languages Content Type for Databases/Retrieval Systems on the Internet (optional) General Rules for Content Type A content type alerts the user that the reference is not to a standard book but to a database or retrieval system Begin type information with a left square bracket Enter the words "database on" or "retrieval system on" End the content type with a space Specific Rules for Content Type Titles ending in punctuation other than a period Titles not in English Box 22 Titles ending in punctuation other than a period Most titles end in a period. Database/retrieval system on the Internet with title ending in other than a period Edition for Databases/Retrieval Systems on the Internet (required) General Rules for Edition Indicate the edition/version being cited after the Type of Medium when a database/retrieval system is published in more than one edition or version Abbreviate common words (see Abbreviation rules for editions below) Capitalize only the first word of the edition statement, proper nouns, and proper adjectives Express words and numbers representing editions in arabic ordinals. Databases/Retrieval Systems on the Internet 1265 Language Word for Edition Abbreviation publicacion publ. Box 29 Both an edition and a version If a database/retrieval system on the Internet provides information for both an edition and a version: Give both, in the order presented Separate the two statements with a semicolon and a space End edition/version information with a period Examples: 2nd ed.

M1 and M3 receptors promote bronchoconstriction and mucus secretion cheap ranitidine 300 mg without a prescription gastritis relief, whereas M2 receptors promote bronchodilatation ( 123) purchase 150mg ranitidine mastercard gastritis quimica. All of the currently available anticholinergics nonselectively inhibit all muscarinic receptor subtypes ( 124) 150mg ranitidine sale gastritis diet food list. The blockade of M2 receptors may potentiate bronchoconstriction ranitidine 150 mg otc gastritis symptoms foods avoid, which antagonizes the bronchodilatory effect of M1 and M3 receptor blockade ( 125,126). This has led to a search for selective drugs that do not antagonize the bronchodilatory effects of M2 receptors, but none is currently available. Because muscarinic receptors are found primarily in the central airways, anticholinergic bronchodilatation occurs mostly in the larger airways (127,128). The anticholinergics provide virtually complete protection against bronchoconstriction induced by cholinergic agonists such as methacholine ( 126,127). Pharmacology Atropine is well absorbed from mucosal surfaces and reaches peak serum levels within an hour. Atropine relaxes smooth muscle in the airways, gastrointestinal tract, iris, and peripheral vasculature. Atropine crosses the blood brain barrier and can cause central nervous system side effects. Scopolamine has similar pharmacologic properties, but is even more likely to cause central nervous system side effects at low doses (130). The quaternary ammonium structure allows for poor absorption across respiratory and other mucous membranes (131). This results in a lack of significant anticholinergic side effects and allows ipratropium to remain in the airways longer than atropine. Ipratropium does not cross the blood brain barrier or inhibit mucociliary clearance ( 131,132). Efficacy Anticholinergics are less effective bronchodilators than b-adrenergic agonists. Peak bronchodilatation occurs 30 to 90 minutes after inhalation of ipratropium, compared with 5 to 15 minutes after inhalation of albuterol ( 133). Some patients may respond better to ipratropium than to albuterol, but there are no reliable predictors for which patients respond well to ipratropium (134,135). Anticholinergic agents are superior to b-adrenergic agonists in preventing bronchospasm induced by b blockers or psychogenic bronchospasm (135,136,137 and 138). Ipratropium bromide appears to improve outcomes when added to albuterol in emergency treatment of acute exacerbations of asthma, but the additional effect is not always large ( 139). Ipratropium bromide nasal spray relieves rhinorrhea associated with allergic ( 140) or nonallergic rhinitis ( 141) and viral upper respiratory infections ( 142). Safety and Drug Interactions Atropine may cause significant side effects, even at therapeutic doses. Warmth and flushing of the skin, impairment of mucociliary clearance, gastroesophageal reflux, and urinary retention are common. Central nervous system effects ranging from irritability to hallucinations and coma may occur. Tahyarrhythmias may occur at low doses, and atrioventricular dissociation may occur at high doses. Because of the frequency of side effects, potential for severe toxicity, and availability of drugs with superior safety and efficacy, there is no role for atropine in the management of asthma; it is mainly used to treat symptomatic bradycardia and reverse organophosphate poisoning. Ipratropium bromide has no severe adverse effects or drug interactions and is very well tolerated. Rare cases of acute angle-closure glaucoma and blurred vision and dilatation of the pupil have occurred with nebulized ipratropium, presumably due to direct contact with the eye ( 143,144 and 145). Dry mouth is a common side effect, and some patients complain of a bad taste or worsening bronchospasm with ipratropium ( 126). Preparations and Dosing Ipratropium bromide is available in a metered-dose inhaler, alone or in combination with albuterol, and is administered as two inhalations four times a day. Atropine and scopolamine in low doses are incorporated in combination tablets with antihistamines and decongestants to treat rhinitis symptoms. However, the emphasis on treatment of inflammation in asthma, as well as the introduction of newer drugs with similar or superior efficacy and improved safety and tolerability, has led to decreased use of theophylline. Pharmacology Theophylline is a member of the methylxanthine family of drugs, which includes the naturally occurring alkaloid compounds caffeine and theobromine. The solubility of the methylxanthines is low unless they form salts or complexes with other compounds such as ethylenediamine (as in aminophylline). Theophylline is rapidly absorbed after oral, rectal, or parenteral administration, and maximum serum levels occur 2 hours after ingestion on an empty stomach. Most theophylline preparations in current use are sustained release and administered once or twice a day. High-protein, low-carbohydrate diets and diets high in charcoal-grilled foods, as well as smoking tobacco and marijuana, may increase theophylline clearance and therefore decrease serum levels. The clinical effects of theophylline are primarily relaxation of smooth muscle in pulmonary arteries and airways ( 150), increased respiratory drive during hypoxia ( 157), and decreased fatigue of diaphragmatic muscles (152). Theophylline also increases mucociliary clearance and decreases microvascular leakage of plasma into airways ( 153). In recent years, modest antiinflammatory effects of theophylline have been reported. Theophylline inhibits eosinophil infiltration into the airways of asthmatics (154,155). Withdrawal of theophylline in patients treated with both theophylline and inhaled corticosteroids has been reported to result in increased numbers of total + and activated eosinophils in the airways ( 156). Challenge Studies In several studies it is reported that theophylline inhibits bronchial hyperresponsiveness to methacholine ( 159,160 and 161). In other studies, theophylline inhibits the early-phase but not the late phase response to inhaled allergen ( 162,163 and 164). Efficacy Studies have demonstrated that theophylline is similar in efficacy but less well tolerated than cromolyn ( 165,166). A recent comparison study with the leukotriene antagonist zileuton found that it was as effective as theophylline and had fewer unpleasant side effects ( 167). Theophylline is more effective as maintenance therapy than long-acting oral albuterol or inhaled albuterol four times daily ( 168,169). Inhaled beclomethasone dipropionate and inhaled fluticasone have superior efficacy to theophylline for moderate to severe bronchial asthma, and the inhaled corticosteroids have fewer adverse effects ( 170,171). The addition of theophylline to low-dose budesonide was as effective as doubling the dose of budesonide in one study of moderate asthma (172). Low-dose budesonide was superior to theophylline in the treatment of nocturnal asthma, and adding theophylline to budesonide provided no additional benefit ( 173). However, salmeterol has similar efficacy and fewer side effects (174,175,176 and 177). In most comparison studies, more patients withdrew from theophylline treatment groups because of inability to tolerate the drug. In the past, intravenous theophylline has been considered to be a standard therapy for status asthmaticus. However, recent studies in adults and children have reported that theophylline offers little additional benefit to corticosteroids and beta 2 agonists in hospitalized asthmatics ( 178,179 and 180). Safety and Drug Interactions Theophylline is a drug with a narrow therapeutic index. In a 10-year prospective study of theophylline overdoses referred to the Massachusetts Poison Control Center, there were 356 cases in which the theophylline level was greater than 30 g/mL. In addition to potentially life-threatening side effects, theophylline has unpleasant side effects that patients may find intolerable.

The biologically active molecules responsible have been identified buy generic ranitidine 300mg gastritis diet mango, and a thorough biochemical and structural elucidation of diverse lipid mediators has been accomplished cheap ranitidine 150 mg with amex gastritis diet 60. The activity of mediator-generating cells and their diverse products has been assigned a central role in both immunoglobulin E (IgE)-mediated acute and prolonged inflammatory events buy ranitidine 300mg with visa gastritis diet in hindi. This chapter places in perspective the mediator-generating cells purchase ranitidine 300 mg without a prescription gastritis child, the mediators themselves, and these newer concepts of their roles in pathobiologic and homeostatic events. Mast cells are heterogeneous, and both connective tissue and mucosal types have been recognized ( 3) (Table 4. The latter predominate in the lamina propria of the gastrointestinal tract and in the peripheral airways and alveolar septa. Both occur in the upper airway and nose, and the connective tissue subtype dominates in the skin ( 4). They are especially prominent in bone, dense connective tissue adjacent to blood vessels (particularly small arterioles and venules), and peripheral nerves. Mast cells are large (10 to 15 mm in diameter) and possess a ruffled membrane, numerous membrane-bound granules (0. Ultrastructurally, human mast cell granules display whorl and scroll patterns ( 13). Basophils, most closely related to eosinophils, are circulating leukocytes whose presence in tissue is unusual except in disease states ( 14). Basophils possess a polylobed nucleus and differ from mast cells in their tinctorial properties, their relatively smooth cell surface, and their granule morphologic makeup, which is larger and less structured than that of the mast cell. The number of such receptors is upregulated by exposure of the mast cell or basophil to increased amounts of IgE ( 15). The bridging of two or more such Fc receptors by antigen cross-linking of receptor-bound surface IgE molecules leads to cell activation and rapid release of preformed granular constituents and to the generation of unstored mediators. Other important secretagogues include a family of histamine-releasing factors ( 19) and complement fragments C3a and C5a. The secretagogue-induced activation of mediator release is noncytolytic, a process termed stimulus-secretion coupling. In vitro, extremely complex intertwined and potentially interacting systems have been identified, some of which may play roles in cell activation ( 20). An additional complexity is added as stored granule-associated mediators are regulated independently from unstored newly generated mediators. Finally, the cell gains control over mediator release, the process stops, and the cell regranulates ( 21). Although initiated at the time of IgE and antigen activation, the generation of cytokines is expressed over a time frame of hours to days. Both mast cells and basophils are important sources of a variety of inflammatory cytokines, as described later. The presence of these additional modulatory pathways suggests that mast cell and basophil mediators participate in inflammatory conditions in hich IgE may not be present. Some mediators are preformed and are stored in the granules of the cell; others are generated only after cell activation and originate in the cytosol or membrane. Mast cell mediators affecting cell migration Spasmogenic Mediators Histamine, generated by decarboxylation of histidine, was the first mast cell mediator to be identified, and it is the sole preformed mediator in this functional class. It is 6 bound to the proteoglycans of mast cell and basophil granules (5 and 1 mg/10 cells, respectively) (24,25). Histamine circulates at concentrations of about 300 pg/mL with a circadian maximum in the early morning hours (26). Histamine excretion exceeds 10 mg/24 hours; a small fraction is excreted as the native molecule, and the remainder as imidazole acetic acid or methyl histamine. H1 receptors predominate in the skin and smooth muscle; H2 receptors are most prevalent in the skin, lungs, and stomach and on a variety of leukocytes; and H 3 receptors predominate in the brain. The biologic response to histamine reflects the ratio of these receptors in a given tissue. Both H 1 and H2 actions are required for the full expression of pruritus, cutaneous vasodilation, and cardiac irritability ( 27). Increased levels of histamine have been reported in the blood or urine of patients with physical urticaria, anaphylaxis, systemic mastocytosis, and antigen-induced rhinitis and asthma (31). Oxidative Products of Arachidonic Acid Arachidonic acid is a C20:4 fatty acid component of mast cell membrane phospholipids, from which it may be liberated by the action of phospholipase A 2 or by the concerted action of phospholipase C and diacylglycerol lipase. At least 20 potential end products may be generated from arachidonic acid by the two major enzymes, 5-lipoxygenase and cyclooxygenase, which regulate its fate. They induce wheal-and-flare responses that are long lived and are accompanied histologically by endothelial activation and dermal edema. In the airway, they enhance mucus production and cause bronchoconstriction, especially by affecting peripheral units. Adenosine is a potent vasodilator, inhibits platelet aggregation, and causes bronchospasm on inhalation by asthmatics. Adenosine, acting through a cell surface receptor, probably the A2b and A3 subtypes ( 46,47) enhances mast cell mediator release in vitro and potentiates antigen-induced local wheal-and-flare responses in vivo. Chemotactic Mediators Several chemotactic molecules have been characterized by activities generated during IgE-dependent allergic responses. A new family of cytokines has been described; these cytokines, called chemokines, have chemoattractant activity for leukocytes and fibroblasts ( Table 4. In the C-X-C or a chemokines, the cysteines are separated by one amino acid, whereas the cysteines are adjacent in the C-C or b chemokines. Most a chemokines attract neutrophils, whereas b chemokines attract T cells and monocytes (some also attract basophils and eosinophils). Its release in asthmatic patients is antigen dose dependent, inhibited by cromolyn, and accompanied by transient leukocytosis. The latter ones have been found in the blood of humans after induction of physical urticaria or allergic asthma. Mediators with Enzymatic Properties Two important proteases are found in human mast cells and not basophils. Tryptase ( 51), a tryptic protease of 140,000 daltons, is present in all human mast cells. It constitutes nearly 25% of mast cell granular protein and is released during IgE-dependent reactions. It is capable of cleaving kininogen to yield bradykinin, diminish clotting activity, and generate and degrade complement components such as C3a and a variety of other peptides. Tryptase is not inhibited by plasma antiproteases, and thus its activity may be persistent. It is present in plasma in patients experiencing anaphylaxis and in those with systemic mastocytosis. The amount and ratio of a and b subtypes have proved useful markers in these disorders ( 52). Its true biologic role is unclear, but it enhances smooth muscle reactivity and is a mitogen for fibroblasts, increasing their production of collagen ( 53,54). A chymotryptic protease termed chymase is present in a subclass of human mast cells, particularly those in the skin and on serosal surfaces, and has thus been used as a marker to identify connective tissue mast cells. Structural Proteoglycans The structural proteoglycans include heparin and various chondroitin sulfates. Heparin 6 Heparin is a highly sulfated proteoglycan that is contained in amounts of 5 pg/10 cells in human mast cell granules (55) and is released on immunologic activation. Human heparin is an anticoagulant proteoglycan and a complement inhibitor, and it modulates tryptase activity. Human heparin also may be important in angiogenesis by binding angiogenic growth factors and preventing their degradation, and it is essential for the proper packaging of proteases and histamine within the mast cell granule. Chondroitin Sulfates Human basophils contain about 3 to 4 pg of chondroitin 4 and 6 sulfates, which lack anticoagulant activity and bind less histamine than heparin.

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