By O. Julio. Elmhurst College. 2019.
The cephalic phase (reflex phase) of gastric secretion buy cheap kamagra chewable 100mg erectile dysfunction treatment scams, which is relatively brief order kamagra chewable 100 mg mastercard erectile dysfunction pump covered by medicare, takes place before food enters the stomach order kamagra chewable 100mg without a prescription strongest erectile dysfunction pills. For example buy cheap kamagra chewable 100 mg on-line next generation erectile dysfunction drugs, when you bring a piece of sushi to your lips, impulses from receptors in your taste buds or the nose are relayed to your brain, which returns signals that increase gastric secretion to prepare your stomach for digestion. This enhanced secretion is a conditioned reflex, meaning it occurs only if you like or want a particular food. The gastric phase of secretion lasts 3 to 4 hours, and is set in motion by local neural and hormonal mechanisms triggered by the entry of food into the stomach. For example, when your sushi reaches the stomach, it creates distention that activates the 1112 Chapter 23 | The Digestive System stretch receptors. This stimulates parasympathetic neurons to release acetylcholine, which then provokes increased secretion of gastric juice. However, it should be noted that the stomach does have a natural means of avoiding excessive acid secretion and potential heartburn. When partially digested food fills the duodenum, intestinal mucosal cells release a hormone called intestinal (enteric) gastrin, which further excites gastric juice secretion. This stimulatory activity is brief, however, because when the intestine distends with chyme, the enterogastric reflex inhibits secretion. One of the effects of this reflex is to close the pyloric sphincter, which blocks additional chyme from entering the duodenum. The Mucosal Barrier The mucosa of the stomach is exposed to the highly corrosive acidity of gastric juice. Finally, stem cells located where gastric glands join the gastric pits quickly replace damaged epithelial mucosal cells, when the epithelial cells are shed. Ulcers: When the Mucosal Barrier Breaks Down As effective as the mucosal barrier is, it is not a “fail-safe” mechanism. Sometimes, gastric juice eats away at the superficial lining of the stomach mucosa, creating erosions, which mostly heal on their own. A potential complication of ulcers is perforation: Perforated ulcers create a hole in the stomach wall, resulting in peritonitis (inflammation of the peritoneum). Digestive Functions of the Stomach The stomach participates in virtually all the digestive activities with the exception of ingestion and defecation. Although almost all absorption takes place in the small intestine, the stomach does absorb some nonpolar substances, such as alcohol and aspirin. Mechanical Digestion Within a few moments after food after enters your stomach, mixing waves begin to occur at intervals of approximately 20 seconds. A mixing wave is a unique type of peristalsis that mixes and softens the food with gastric juices to create chyme. The initial mixing waves are relatively gentle, but these are followed by more intense waves, starting at the body of the stomach and increasing in force as they reach the pylorus. It is fair to say that long before your sushi exits through the pyloric sphincter, it bears little resemblance to the sushi you ate. The pylorus, which holds around 30 mL (1 fluid ounce) of chyme, acts as a filter, permitting only liquids and small food particles to pass through the mostly, but not fully, closed pyloric sphincter. In a process called gastric emptying, rhythmic mixing waves force about 3 mL of chyme at a time through the pyloric sphincter and into the duodenum. This prevents additional chyme from being released by the stomach before the duodenum is ready to process it. Chemical Digestion The fundus plays an important role, because it stores both undigested food and gases that are released during the process of chemical digestion. While the food is in the fundus, the digestive activities of salivary amylase continue until the food begins mixing with the acidic chyme. Ultimately, mixing waves incorporate this food with the chyme, the acidity of which inactivates salivary amylase and activates lingual lipase. Lingual lipase then begins breaking down triglycerides into free fatty acids, and mono- and diglycerides. Its numerous digestive functions notwithstanding, there is only one stomach function necessary to life: the production of intrinsic factor. The intestinal absorption of vitamin B12, which is necessary for both the production of mature red blood cells and normal neurological functioning, cannot occur without intrinsic factor. People who undergo total gastrectomy (stomach removal)—for life-threatening stomach cancer, for example—can survive with minimal digestive dysfunction if they receive vitamin B12 injections. The contents of the stomach are completely emptied into the duodenum within 2 to 4 hours after you eat a meal. Since enzymes in the small intestine digest fats slowly, food can stay in the stomach for 6 hours or longer when the duodenum is processing fatty chyme. However, note that this is still a fraction of the 24 to 72 hours that full digestion typically takes from start to finish. In addition, called the small and large bowel, or colloquially the “guts,” they constitute the greatest mass and length of the alimentary canal and, with the exception of ingestion, perform all digestive system functions. The Small Intestine Chyme released from the stomach enters the small intestine, which is the primary digestive organ in the body. Since this makes it about five times longer than the large intestine, you might wonder why it is called “small. As we’ll see shortly, in addition to its length, the folds and projections of the lining of the small 2 intestine work to give it an enormous surface area, which is approximately 200 m , more than 100 times the surface area of your skin. This large surface area is necessary for complex processes of digestion and absorption that occur within it. Just past the pyloric sphincter, it bends posteriorly behind the peritoneum, becoming retroperitoneal, and then makes a C-shaped curve around the head of the pancreas before ascending anteriorly again to return to the peritoneal cavity and join the jejunum. The duodenum can therefore be subdivided into four segments: the superior, descending, horizontal, and ascending duodenum. Located in the duodenal wall, the ampulla marks the transition from the anterior portion of the alimentary canal to the mid-region, and is where the bile duct (through which bile passes from the liver) and the main pancreatic duct (through which pancreatic juice passes from the pancreas) join. This ampulla opens into the duodenum at a tiny volcano-shaped structure called the major duodenal papilla. The hepatopancreatic sphincter (sphincter of Oddi) regulates the flow of both bile and pancreatic juice from the ampulla into the duodenum. Jejunum means “empty” in Latin and supposedly was so named by the ancient Greeks who noticed it was always empty at death. No clear demarcation exists between the jejunum and the final segment of the small intestine, the ileum. The ileum joins the cecum, the first portion of the large intestine, at the ileocecal sphincter (or valve). Parasympathetic nerve fibers from the vagus nerve and sympathetic nerve fibers from the thoracic splanchnic nerve provide extrinsic innervation to the small intestine. Nutrient-rich blood from the small intestine is then carried to the liver via the hepatic portal vein. Histology The wall of the small intestine is composed of the same four layers typically present in the alimentary system. These features, which increase the absorptive surface area of the small intestine more than 600-fold, include circular folds, villi, and microvilli (Figure 23. These adaptations are most abundant in the proximal two-thirds of the small intestine, where the majority of absorption occurs. Beginning near the proximal part of the duodenum and ending near the middle of the ileum, these folds facilitate absorption. Their shape causes the chyme to spiral, rather than move in a straight line, through the small intestine. Spiraling slows the movement of chyme and provides the time needed for nutrients to be fully absorbed. There are about 20 to 40 villi per square millimeter, increasing the surface area of the epithelium tremendously.
This important nutrient is also found in green leafy vegetables 100mg kamagra chewable erectile dysfunction za, broccoli quality 100 mg kamagra chewable erectile dysfunction doctor delhi, and intact salmon and canned sardines with their soft bones cheap kamagra chewable 100 mg overnight delivery erectile dysfunction pump ratings. Nuts discount 100mg kamagra chewable with mastercard garlic pills erectile dysfunction, beans, seeds, and shellfish provide 242 Chapter 6 | Bone Tissue and the Skeletal System calcium in smaller quantities. Except for fatty fish like salmon and tuna, or fortified milk or cereal, vitamin D is not found naturally in many foods. Other Nutrients Vitamin K also supports bone mineralization and may have a synergistic role with vitamin D in the regulation of bone growth. While magnesium is only found in trace amounts in the human body, more than 60 percent of it is in the skeleton, suggesting it plays a role in the structure of bone. Inflammation can interfere with the function of osteoblasts, so consuming omega-3 fatty acids, in the diet or in supplements, may also help enhance production of new osseous tissue. These hormones are involved in controlling bone growth, maintaining bone once it is formed, and remodeling it. Hormones That Influence Osteoblasts and/or Maintain the Matrix Several hormones are necessary for controlling bone growth and maintaining the bone matrix. It triggers chondrocyte proliferation in epiphyseal plates, resulting in the increasing length of long bones. Thyroxine, a hormone secreted by the thyroid gland promotes osteoblastic activity and the synthesis of bone matrix. They too promote osteoblastic activity and production of bone matrix, and in addition, are responsible for the growth spurt that often occurs during adolescence. Additionally, calcitriol, the active form of vitamin D, is produced by the kidneys and stimulates the absorption of calcium and phosphate from the digestive tract. In Paget’s disease, new bone is formed in an attempt to keep up with the resorption by the overactive osteoclasts, but that new bone is produced haphazardly. In fact, when a physician is evaluating a patient with thinning bone, he or she will test for osteoporosis and Paget’s disease (as well as other diseases). Osteoporosis does not have the elevated blood levels of alkaline phosphatase found in Paget’s disease. While osteoporosis can involve any bone, it most commonly affects the proximal ends of the femur, vertebrae, and wrist. As a result of the loss of bone density, the osseous tissue may not provide adequate support for everyday functions, and something as simple as a sneeze can cause a vertebral fracture. When an elderly person falls and breaks a hip (really, the femur), it is very likely the femur that broke first, which resulted in the fall. Histologically, osteoporosis is characterized by a reduction in the thickness of compact bone and the number and size of trabeculae in cancellous bone. Not only do their menstrual periods lessen and eventually cease, but their ovaries reduce in size and then cease the production of estrogen, a hormone that promotes osteoblastic activity and production of bone matrix. Anyone with a family history of osteoporosis has a greater risk of developing the disease, so the best treatment is prevention, which should start with a childhood diet that includes adequate intake of calcium and vitamin D and a lifestyle that includes weight-bearing exercise. Promoting proper nutrition and weight-bearing exercise early in life can maximize bone mass before the age of 30, thus reducing the risk of osteoporosis. The fracture itself may not be serious, but the immobility that comes during the healing process can lead to the formation of blood clots that can lodge in the capillaries of the lungs, resulting in respiratory failure; pneumonia due to the lack of poor air exchange that accompanies immobility; pressure sores (bed sores) that allow pathogens to enter the body and cause infections; and urinary tract infections from catheterization. Current treatments for managing osteoporosis include bisphosphonates (the same medications often used in Paget’s disease), calcitonin, and estrogen (for women only). Minimizing the risk of falls, for example, by removing tripping This OpenStax book is available for free at http://cnx. Hormones That Influence Osteoclasts Bone modeling and remodeling require osteoclasts to resorb unneeded, damaged, or old bone, and osteoblasts to lay down new bone. As a result, calcium is released from the bones into the circulation, thus increasing the calcium ion concentration in the blood. Calcitonin inhibits osteoclast activity and stimulates calcium uptake by the bones, thus reducing the concentration of calcium ions in the blood. Hormones That Affect the Skeletal System Hormone Role Growth Increases length of long bones, enhances mineralization, and improves bone density hormone Thyroxine Stimulates bone growth and promotes synthesis of bone matrix Sex Promote osteoblastic activity and production of bone matrix; responsible for adolescent growth hormones spurt; promote conversion of epiphyseal plate to epiphyseal line Calcitriol Stimulates absorption of calcium and phosphate from digestive tract Stimulates osteoclast proliferation and resorption of bone by osteoclasts; promotes Parathyroid reabsorption of calcium by kidney tubules; indirectly increases calcium absorption by small hormone intestine Calcitonin Inhibits osteoclast activity and stimulates calcium uptake by bones Table 6. Calcium ions are needed not only for bone mineralization but for tooth health, regulation of the heart rate and strength of contraction, blood coagulation, contraction of smooth and skeletal muscle cells, and regulation of nerve impulse conduction. Hypocalcemia, a condition characterized by abnormally low levels of calcium, can have an adverse effect on a number of different body systems including circulation, muscles, nerves, and bone. Without adequate calcium, blood has difficulty coagulating, the heart may skip beats or stop beating altogether, muscles may have difficulty contracting, nerves may have 246 Chapter 6 | Bone Tissue and the Skeletal System difficulty functioning, and bones may become brittle. Conversely, in hypercalcemia, a condition characterized by abnormally high levels of calcium, the nervous system is underactive, which results in lethargy, sluggish reflexes, constipation and loss of appetite, confusion, and in severe cases, coma. The bones act as a storage site for calcium: The body deposits calcium in the bones when blood levels get too high, and it releases calcium when blood levels drop too low. When all these processes return blood calcium levels to normal, there is enough calcium to bind with the receptors on the surface of the cells of the parathyroid glands, and this cycle of events is turned off (Figure 6. When blood levels of calcium get too high, the thyroid gland is stimulated to release calcitonin (Figure 6. The epiphyses, which are wider sections at each end of a long bone, are filled with spongy bone and red marrow. The epiphyseal plate, a layer of hyaline cartilage, is replaced by osseous tissue as the organ grows in length. The outer surface of bone, except in regions covered with articular cartilage, is covered with a fibrous membrane called the periosteum. Projections stick out from the surface of the bone and provide attachment points for tendons and ligaments. Bone matrix consists of collagen fibers and organic ground substance, primarily hydroxyapatite formed from calcium salts. Compact bone is dense and composed of osteons, while spongy bone is less dense and made up of trabeculae. Osteogenesis imperfecta is a genetic disease in which collagen production is altered, resulting in fragile, brittle bones. Common types of fractures are transverse, oblique, spiral, comminuted, impacted, greenstick, open (or compound), and closed (or simple). Healing of fractures begins with the formation of a hematoma, followed by internal and external calli. Osteoclasts resorb dead bone, while osteoblasts create new bone that replaces the cartilage in the calli. Calcium, the predominant mineral in bone, cannot be absorbed from the small intestine if vitamin D is lacking. Growth hormone increases the length of long bones, enhances mineralization, and improves bone density. The sex hormones (estrogen in women; testosterone in men) promote osteoblastic activity and the production of bone matrix, are responsible for the adolescent growth spurt, and promote closure of the epiphyseal plates. Hypocalcemia can result in problems with blood coagulation, muscle contraction, nerve functioning, and bone strength. Hypercalcemia can result in lethargy, sluggish reflexes, constipation and loss of appetite, confusion, and coma. With respect to their direct effects on osseous tissue, the other which pair of hormones has actions that oppose each other? In what type of fracture would closed and discuss what features of the skeletal system allow it to reduction most likely occur? If you were a dietician who had a young female patient with a family history of osteoporosis, what foods would 43. During the early years of space exploration our astronauts, who had been floating in space, would return 44. In what ways is the structural makeup of compact and to earth showing significant bone loss dependent on how spongy bone well suited to their respective functions?
If the answer is no order kamagra chewable 100mg fast delivery erectile dysfunction treatment in vadodara, ask the caregiver to hold the child ﬁrmly and make sure the child is calm cheap 100mg kamagra chewable erectile dysfunction drugs egypt. Cut the nipple of the capsule at the middle (not at the tip or bottom) with scissors and immediately squeeze the drops of liquid into the child’s mouth (see Figure 7 order kamagra chewable 100 mg free shipping erectile dysfunction doctor delhi. Do not give a vitamin A capsule to any woman of reproductive age during an Enhanced Outreach Strategy Programme cheap 100mg kamagra chewable with visa erectile dysfunction medications drugs. A large dose of vitamin A supplements can damage the fetus if the woman is pregnant. Do not put the vitamin A capsule into the child’s mouth or allow the child to swallow the capsule. If obstruction persists, turn the infant over and give ﬁve chest thrusts with two ﬁngers, one ﬁngerbreadth below nipple level in midline (see Figure 7. If the obstruction persists, go behind the child and pass your arms around the child’s body; form a ﬁst with one hand immediately below the child’s breast bone (sternum); place the other hand over the ﬁst and pull upwards into the abdomen; repeat this Heimlich manoeuvre ﬁve times (see Figure 7. If the obstruction persists, check the child’s mouth for any obstruction, which can be removed. It also describes how you can prevent these from happening and what actions you need to take to overcome these problems if they occur. As a Health Extension Practitioner, you are expected to encourage family members to grow and consume vitamin A rich foods at all times. You can initiate and coordinate the establishment of horticultural demonstration gardens in health post and schools, as well as agricultural extension demonstration plots in farming areas. These horticultural gardens can also serve as examples for dissemination of information on the use of fruits and vegetables, and the distribution of seedlings that could be grown around rural homes. Health Extension Practitioners can therefore play a signiﬁcantroleinpromotingthe introduction of vitamin A rich foods and improving consumption and storage of such foods. The best food sources are animal foods such as egg yolks, organ meats such as liver, whole milk and milk products, small ﬁsh with the liver intact, ﬁsh, cod liver oil, butter, and ghee. The mother’s secretion of vitamin A into breastmilk is related to her own vitamin Astatus. The best plant sources of vitamin A are dark orange or dark yellow fruits and vegetables such as papayas, mangos, pumpkins, carrots, and yellow or orange sweet potatoes, and dark green vegetables such as spinach and kale. Food fortiﬁcation This involves adding one or more vitamins and minerals to commonly consumed foods, especially those for children, with the purpose of preventing or correcting a demonstrated deﬁciency. It is difﬁcult to fortify foods in Ethiopia because no staple food has been identiﬁed as widely consumed in the entire country. However, efforts are underway to fortify oils that are being produced in some of the larger factories. You read how to conduct testing of the salt that families consume in Study Session 4. Supplementation of iodine capsules to populations in areas where iodine deﬁciency in very common As a short-term strategy in highly endemic areas, iodised oil capsules should Iodine capsule dosages are: be distributed on a one-time basis to individuals. This will cover the recipients One capsule for pregnant women for one to two years until salt iodisation processes are in place. The strategy for the reduction of iron deﬁciency anaemia should be holistic and sustainable. For this to happen there is a need to involve relevant stakeholders from agriculture, education, information and other relevant 89 sectors in planning and implementation of priority programs. The main strategies are the following: Supplementation of iron and folic acid for pregnant and lactating women Pregnant women require a much higher amount of iron than is met by most diets and therefore it is important that they routinely receive iron supplements. In places where anaemia is high, supplementation should continue into the postpartum period to enable them to acquire adequate stores of iron. Six months during pregnancy where anaemia prevalence is less than 40% Folic acid: 400 mcg/day. Six months during pregnancy and three months postpartum where anaemia prevalence is equal to or more than 40%. If it is not possible for women to take iron and folic acid for six months in pregnancy, supplementation should continue into the postpartum period or the dose should be increased to 102 mg/day Supplementation for children and adolescents Many children from six to 24 months of age need more iron than is available in breastmilk and common complementary foods. Infants with low birth weight have fewer iron stores, and are thus at a higher risk for deﬁciency after two months of age. In areas where iron fortiﬁed complementary foods are not available for regular consumption, children should routinely receive supplements in the ﬁrst year of life. In areas where anaemia prevalence in young children is 40% or more, delivery of iron supplements should continue through the second year of life, and also be given to adolescent girls. For example early on, during postnatal care and the well baby visits, you can talk to the mother about this. Other opportunities include school health programmes that you might advise on, or when you are providing family planning services and doing home visits. Treatment of severe anaemia If anaemia is diagnosed by clinical examination (extreme pallor of the palms Children with severe acute of the hands) or by laboratory tests at health centre, treatment is as set out in malnutrition should be assumed to be severely anaemic. Populations should be encouraged to produce and consume iron-rich foods throughout the country at all times. Health Extension Practitioners can play a signiﬁcant role in promoting the introduction of iron-rich foods and improving consumption and storage of such foods. As you can read, the way food is processed and cooked has an impact on how well iron is absorbed. Animal sources of iron Plant sources of iron Animal products (meat, organs and The best plant sources of iron include blood) provide the best food sources of dark green leafy vegetables and legumes. If these are available, Legumes are also excellent sources of children six to 24 months of age and folic acid. Consumption of foods which pregnant women should have priority to are rich in vitamin A will also prevent include small amounts in their diet. Food processing techniques Animal products provide iron that is such as cooking, germinating, absorbed easily. Animal products are fermenting and soaking of grains should also the only source of vitamin B12, an be encouraged as they reduce factors important micronutrient for preventing that inhibit iron absorption. Control of malaria and worms To control non-iron deﬁciency anaemia it is also critical to coordinate action with the malaria control and worms control programmes. Pregnant and lactating women and children should sleep under insecticide-treated bed nets. Drugs Dose for each age group Comments 0-1year 1-2 2-5 years years Albendazole No ½ tablet 1 tablet These two are particularly treatment attractive because they are single dose and there is no need to weigh Mebendazole No 1 tablet 1 tablet the children 500 mg treatment tablet. Minor side effects like nausea and abdominal discomfort are rare usually well tolerated by the children. Children under one year old are not treated, as they are not exposed to infection. Accidental repeated treatment with several doses of de-worming drugs is not dangerous. Training someone on how to administer the drugs and the beneﬁts of de-worming can be done in a few hours. Help to mobilise and support communities to produce fruit and vegetable gardens to improve access to vitamin A rich foods. Help to strengthen the national iodine deﬁciency control and prevention programme by monitoring use of iodised salt in your community twice a year (Study Session 5). Implementing advocacy and creating demand for universal consumption of iodised salt.
Evidence for the outcome of congestion at 2 weeks is therefore insufficient to support the use of 90 one treatment over the other buy 100mg kamagra chewable amex erectile dysfunction operations. One poor quality trial with high risk of bias reported an imprecise treatment effect cheap kamagra chewable 100mg without prescription erectile dysfunction pills cost. All six showed statistically 91 order 100 mg kamagra chewable with amex erectile dysfunction treatment bodybuilding, 95 significant improvements in congestion with intranasal corticosteroid cheap 100 mg kamagra chewable visa erectile dysfunction medications for sale. Two were good 95 quality trials of 558 patients total (35 percent of patients reporting this outcome). One reported results using a 0-3 point scale but did not report the magnitude of the treatment effect. Four 92, 93, 96, 99 92, 93, 96 trials were rated poor quality due to noncomparable groups at baseline and 93, 96 inappropriate analysis of results (unadjusted for baseline group differences and not intention 99 92, 99 to treat ). Because trials used different symptom rating scales (0-3 and 0-100), the standardized mean difference was calculated. The magnitude of the pooled effect estimate could not be compared with estimates from individual trials not included in the meta-analysis because the latter were not reported. Sixty-five percent of patients were in poor quality trials, and 35 percent were in good quality trials. All six 91-93, 95, 96, 99 trials were consistent in finding statistically significant treatment effects favoring intranasal corticosteroid, and this finding was confirmed in a meta-analysis of three of these 91, 92, 99 trials. The evidence was therefore insufficient to form a conclusion about the comparative effectiveness of oral selective antihistamine and intranasal corticosteroid for this outcome. This trial 92, 93, 95, 96, 99 was rated poor quality, and the result was not statistically significant. One poor quality trial reported neither the magnitude nor the direction of the treatment effect. This trial was excluded from analysis of this outcome, reducing the total number of patients assessed from 1284 to 979. The remaining four trials all favored 50 95 intranasal corticosteroid over oral selective antihistamine. One trial was a good quality trial of 242 patients (25 percent of patients reporting this outcome) that demonstrated a statistically significant improvement in rhinorrhea with intranasal corticosteroid. The remaining three trials were rated poor quality due to noncomparable groups at baseline and inappropriate analysis of results, as described above. The third poor 92 quality trial reported a statistically nonsignificant treatment effect of 0. Evidence for the outcome of rhinorrhea at 2 weeks was insufficient to support the use of one 90 treatment over the other. One poor quality trial with high risk of bias reported an imprecise treatment effect. Evidence was therefore insufficient to support the use of one treatment over the other for this outcome. This trial 92, 93, 95, 96, 99 was rated poor quality, and the result was not statistically significant. All five showed statistically significant improvements in 95 sneezing with intranasal corticosteroid. One of these was a good quality trial of 242 patients (19 percent of patients reporting this outcome) that did not report the magnitude of the treatment 92, 93, 96, 99 effect. The remaining four trials were rated poor quality for noncomparable groups at 92, 99 baseline and inappropriate analysis of results, as described above. Evidence for the outcome of sneezing at 2 weeks was insufficient to support the use of one 90 treatment over the other. One poor quality trial with high risk of bias reported an imprecise treatment effect. All five trials were consistent in finding statistically significant treatment differences favoring intranasal corticosteroid. The evidence was therefore insufficient to support the use of one treatment over the other for this outcome. All four reported statistically significant improvement with intranasal corticosteroid compared with oral selective 95 antihistamine. One of these was a good quality trial of 242 patients (20 percent of patients 92, 93, 99 reporting this outcome). The remaining three trials 92, 93 were rated poor quality for noncomparable groups at baseline and inappropriate analysis of 93 99 results (unadjusted for baseline group differences and not intention to treat ). One poor quality trial with high risk of bias reported no difference between treatments. All four trials were consistent in finding statistically significant treatment effects favoring intranasal corticosteroid. The evidence was insufficient to support the use of one treatment over the other for this outcome. Three of these showed statistically significant improvements with intranasal corticosteroid compared with oral selective 89 antihistamine. One poor quality 99 trial reported neither the magnitude nor the direction of the treatment effect at 4 weeks. This trial was excluded from analysis of this outcome, reducing the total number of patients assessed 92-94, 100 from 1306 to 1008. All four trials were rated poor 92-94 quality due to noncomparable groups at baseline and inappropriate analysis of results 93 100 (unadjusted for baseline group differences and not intention to treat ). Forty-five percent of patients reporting this outcome were in poor quality trials, and 55 percent were in fair quality trials. Treatment effects consistently favored intranasal corticosteroid, although effects were imprecise. The evidence was therefore insufficient to support the use of one treatment over the other for this outcome. Treatment effects consistently favored intranasal corticosteroid but were imprecise. The evidence was therefore insufficient to support the use of one treatment over the other for this outcome. Eye Symptoms Eye symptoms were reported using a variety of measurement scales and varied definitions. Most treatment effects favored intranasal corticosteroid over oral selective antihistamine. One reported a statistically significant treatment effect of 52 93 unknown magnitude for the single symptom of tearing. The other reported a statistically nonsignificant treatment effect of unknown magnitude for undefined symptoms. Forty-four percent of 89, 90, 93 patients were in poor quality trials, and 56 percent were in fair quality trials. The evidence was therefore insufficient to support the use of one treatment over the other for eye symptoms at 2 weeks. One reported a statistically 99 significant treatment effect of unknown magnitude for undefined eye symptoms, and the other reported a statistically nonsignificant treatment effect of 0. A meta-analysis of three of these trials was conducted (N=938 [74% of patients reporting this outcome]; Figure 6). Because trials used different symptom rating scales (0-9 and 0-300), the standardized mean difference was calculated. Treatment effects in two of the pooled trials favored intranasal corticosteroid, 92 93 and in the third, showed no treatment difference. The meta-analysis excluded one trial that showed a statistically significant treatment effect of unknown magnitude favoring intranasal corticosteroid. Treatment effects at 4 weeks were not consistent 91, 93, 99 across individual trials, with three of four trials reporting effects in favor of intranasal 92 corticosteroid and the fourth (28 percent of patients reporting this outcome) showing no treatment difference. The evidence was therefore insufficient to form a conclusion about the comparative effectiveness of oral selective antihistamine and intranasal corticosteroid for this outcome.
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