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By H. Copper. New World School of the Arts.

And art improved their few things take you out of yourself or cheer you up faster than an unexpected delight: mood buy 300mg gabapentin overnight delivery medicine ads. generic gabapentin 300mg with mastercard symptoms stomach ulcer. buy generic gabapentin 600mg on-line medicine ball chair. Jukic calls it normalizing buy 800 mg gabapentin amex medicine online, a process art can create that helps people feel more in control, less fearful. True, the sick remain the Clinic s central concern and patients are measurably benefting from the presence of art and musicians a 2012 Clinic survey found 91 percent of patients responding reported that visual art improved their mood during hospital stays of two to three days. That program, which focuses on visual art, manages Cleveland Clinic s existing art collection, This is something and adds to that collection by commissioning and acquiring new pieces. Many of the programs and works of art have been subsidized by donations from grateful patients and visitors to Cleveland Clinic. Committees of experts including curators select the pieces to be bought and/or displayed. The quality of the art selected must be high, says Cohen, because it needs to stand the test of time. Those who choose the art aim for eclectic media and subject matter, because Cleveland Clinic has a global reach, and staff and patients from all over the world. It wants to refect those many different viewpoints, which is also far more interesting and engaging to a diverse population across Cleveland and other geographic areas, she adds. Yet the something-for-everyone approach does contain one other qualifcation: Cleveland Clinic art needs to have something positive to say about the human condition and spirit. Art that s collaborative and/ or environmentally conscious, art that calms, comforts, amuses or uplifts these are the kinds of images and objects that contribute to healing. Water, landscapes, sunlight such subjects tend to mellow people s moods and brighten their outlooks. Cohen says that one of Cleveland Clinic s most successful pieces is a video by Jennifer Steinkamp of a tree that went through seasonal changes. Others danced in front of it, and the wall had to be repainted frequently because so many viewers tried to touch and hug it. They can also help decrease the amount of staff turnover by making the workplace less stressful. So there are economic benefts to having an arts program but the value of the Arts and Medicine Institute is much greater than that, Fattorini says. Photo by Cleveland Clinic Photography Below: Docents lead tours of the Cleveland Clinic art collection several times per week. Patients suffering from memory loss and their caregivers enjoy a special tour program monthly. Photo by Jim Lang Community Partnership for Arts and Culture 14 Creative Minds in Medicine the intersection of arts and health What is the Arts and Health Intersection? From writing poetry or playing music with friends to taking photos or experiencing theater, arts and culture serve as outlets for individual learning, expression and creativity. Participation in arts and culture has been shown to yield positive cognitive, social and behavioral outcomes for human development and for overall quality of life throughout the human lifespan. Because of its ability to span both personal and public spheres in varying degrees, arts and culture participation can yield far-reaching results. At another level, the paintings can be developed into public murals that call attention to areas or issues in need of improvement. Even further, the paintings can become an exhibition that rallies the broader community, encouraging it to take actions that address neighborhood challenges. In this way, a multifaceted view of impact is critical to develop a full understanding of the ways in which arts and culture infuence the human condition on a personal and global scale. In a similar way, an inquiry into the nature of the arts and culture / health and human services intersection (referred to hereafter as the arts and health intersection, for simplicity) requires4 a multifaceted approach. In this general sense, the terms arts and health can be ambiguous because their defnitions are dependent on the manner through which they intersect. Defnitions are ultimately determined by who is participating in the arts and health intersection, where the intersection takes place and what the intersection s goals are. Clinical outcomes in physical and mental health, improved health and human services delivery and personal enjoyment of arts and culture all exist on the continuum of this creative intersection. Artistic practice commonly challenges convention, organically develops new methods and accepts subjective outcomes, while protocols for health practice and clinical outcome measurement demand greater rigidity. In these ways, arts and culture have the10 ability to span multiple disciplines and be applied through a wide range of methods. This ability makes arts and culture interventions useful in responding to the unique needs and concerns of individuals that arise in multiple healthcare situations. Arts and Health in Cleveland Cleveland is fortunate to be home to world-class sets of healthcare and cultural institutions. Meanwhile, Cleveland s arts and culture institutions have multiplied in number and discipline, expanded in size and reputation, and become renowned attractions for both local and international audiences. The Framework of this White Paper While Cleveland is known for the strength of its arts and culture and health and human services sectors, the intersections of those sectors are still being explored and developed. This white paper examines the concept of such intersections with a brief historical perspective on the development of the feld. The organization of subsequent chapters is based on a number of examples of real-life programs and practices illustrating the many ways in which arts and culture contribute to healthcare practice and human services delivery:11 Arts integration in healthcare environments. Community Partnership for Arts and Culture 16 Creative Minds in Medicine Arts and health integration with community development, public health and human services. In the following chapters, these categories will be defned more fully and will highlight key examples of arts and health collaborations that are happening in Cleveland. The fnal sections of this paper will introduce best practices and policy recommendations to further strengthen Cleveland s arts and health intersections in the future. The Historical Development of the Arts and Health Field I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon s knife or the chemist s drug. They have worked to apply scientifc methods in light of and sometimes in spite of the cultural conditions of the period and location in which they work. The patient-centric approach with its stronger15 connection to the social sciences has emerged more recently, following a period of stricter emphasis on disease-based, standardized treatment in the vein of natural sciences methodology. Expressive arts therapies have been recognized since ancient times for their utility as treatments for a host of ailments and both Aristotle and Plato wrote of the healing infuence of music on behavior and health. During the moral therapy or humane-treatment movement of the late 19th and early 20th centuries, art and music were incorporated into the treatment of mental illness. Such practices18 continued as the formal integration of arts and health progressed during the period of the frst and second World Wars. During this time, the value of the visual arts in raising public awareness about infectious diseases gained greater prominence through the design of posters. Thayer Gaston professionalized the music therapy feld with his research demonstrating the impact of music on health and supporting the development of educational programs. In 1950, the National Association for Music Therapy was founded21 and became one of the frst expressive arts therapy organizations to codify its operations, set educational standards, and conduct and disseminate research. During the Works Progress Administration s Federal Art Project, art teachers were hired to work with psychiatric patients. These led in the 1970s to the art therapy feld dividing into two24 approaches: The frst views the process of art-making in and of itself as a therapeutic practice; the other, art psychotherapy, regards art-making as a way for patients to express their emotions symbolically and for therapists to interpret their patients mental conditions. Hospital Audiences was a key contributor to the development of one of the frst arts programs in a hospital, a performance series at Duke University Medical Center. It is an alliance of professional creative arts therapies associations who are working together to further the use of the arts as therapeutic modalities while collaborating on education, research, and advocacy. Percent- for-art programs, which devote a set percent of a project s cost to support the incorporation of arts and culture, also helped jumpstart some early hospital art programs. Whatever the type of facility, design considerations are typically focused on creating environments that welcome patients and their families, ease navigation Key Benefts to destinations and facilitate positive general wellness and therapeutic outcomes. Florence Nightingale,36 the founder of modern nursing, was one of the earliest practitioners of medicine that tied a patient s In patients, research has demonstrated arts and environment to his or her health results.

There is lower abdom- Investigations inal tenderness and guarding in the lower abdomen purchase gabapentin 400 mg with mastercard medications are administered to. Microscopy Management There is ischaemic loss of mucosa effective 300mg gabapentin medicine 503, ulceration and later Surgical revascularisation depends on the results of an- healing with oedema and inammatory inltrate generic 600 mg gabapentin visa treatment jellyfish sting. Denition Complete necrosis and gangrene of the midgut resulting Aetiology from cessation of blood ow in the superior mesenteric r Squamous carcinoma accounts for more than 90% of artery buy generic gabapentin 300mg line medications nursing. These usually occur in the middle third of the oesophagus although the lower third may also be af- Clinical features fected. Aetiological factors include high alcohol con- There may be a preceding history of non-specic symp- sumption, smoking and chewing betel nuts. Signs of acute intestinal failure include ab- affects the lower third of the oesophagus particularly dominal tenderness, guarding, loss of bowel sounds and the gastrooesophageal junction possibly following ep- rigidity, due to perforation. Calcication within the abdominal aorta may be evident r Familial forms have been noted. Gas lled, thickened, dilated bowel loops and free gas within the peritoneal cavity due to Pathophysiology perforation may also be seen. Following adequate resuscitation laparotomy and resec- tion(whichmaybemassive)arerequired. Patients may present with progressive dysphagia, but of- Asecond look laparotomy can be performed 24 hours tenpresent late with weight loss, anaemia and malaise. If Barium swallow demonstrates an apple core defect or the patient survives they have considerable malabsorp- stricture without proximal dilatation. In the absence of metastases endoscopic ultrasound is useful to assess operability. Management r Wherever possible surgical resection is the primary Age treatment with those occurring in the lower third Rare below the age of 40 years. Neoadjuvant Denition chemotherapy with cisplatin and 5-uorouracil (5- Malignant tumour of the stomach. Sex Prognosis 2M > 1F Surgical resection carries an operative mortality of up to 20%. Benign gastric tumours Aetiology Denition Pre-malignant conditions include chronic atrophic gas- Benign tumours and polyps of the stomach. These can tritiswithintestinalmetaplasiaandadenomatouspolyps be divided into epithelial and mesenchymal derived tu- of the stomach. Hyperplastic polyps are common overgrowths of gas- r Dietary carcinogens possibly including nitrates and tric mucosa often resulting from the healing of an alcohol. Pathophysiology They have a signicant risk of malignant change most Gastric adenocarcinomas are derived from mucus se- likely in large polyps. Tumours may be of three types: Mesenchymal derived benign tumours: r Ulcerating (most common) with appearance similar r Leiomyomas appear as mucosal or intramural nod- to benign ulcers but with raised edges and no normal ules. Most benign tumours are asymptomatic and found on r Inltrating when brous tissue causes a rm non- endoscopy or barium meal. Rarely bleeding or obstruc- distendable or linitis plastica (leather bottle) stomach. Spread may be direct invasion to the liver and pancreas, Management transcoelomic spread resulting in a malignant ascites Allsuspiciouspolypsrequireexaminationbyendoscopic and ovarian Krukenberg tumour, lymphatic spread to excision biopsy, multiple polyps may require gastric re- regional and distant lymph nodes (Virkow s node) and section. There may be dyspepsia or Tumours arising in the mucosa associated lymphoid tis- haematemesis. Dermatomyositis and acanthosis nigricans may be manifestations of an underlying gastric malig- Clinical features nancy. Patients present similarly to gastric adenocarcinoma with non-specic weight loss, anaemia and malaise and Microscopy associated epigastric tenderness. Symptoms may be mild Histologically gastric adenocarcinomas may have an in- despite a large tumour mass. Investigations Diagnostic testing usually involves an endoscopy and Investigations biopsy,whichmaybeprecededbyabariummeal. Anaemia is a non-specic Management nding and liver metastases may cause a rise in liver Lymphoma often responds to H. Patients who do not respond to, or who relapse fol- Treatment of choice is surgical resection wherever pos- lowing eradication therapy are treated with single agent sible. Combination chemotherapy Prognosis may be used in disease not amenable to surgery. Overall Small intestine lymphoma 5-year survival in the United Kingdom is around 10% Denition due to late presentation. Anon-Hodgkin lymphoma which occurs within the small bowel particularly in the ileum. Coeliac disease predis- System Symptom Frequency (%) poses toaTcelllymphoma,treatmentwithglutenfree Skin Flushing 85 diets may reduce the risk. Octreotide (somato- Carcinoid tumours of the intestine statin analogue) relieves diarrhoea and ushing and Denition may reduce tumour growth. Large bowel neoplastic polyps Denition Aetiology/pathophysiology Apolyp is dened as a tumour attached by a stalk to the Carcinoid tumours most commonly occur in the ap- surface from which they arise. Clinical features Age Most lesions are asymptomatic although appendix car- Sporadic cases increase with age. Carcinoid syndrome occurs in 5% with liver metastases, the fea- Aetiology/pathophysiology tures of which (see Table 4. Most colorectal cancers arise from adenomatous polyps r Tubular polyps account for 90% and consist of glan- with a median transition of 20 years. Ulcerative colitis is dular tubules with a brovascular core covered by a associated with an increased incidence. Clinical features Pathophysiology Most are asymptomatic but they may cause bleeding and Colonic cancer occurs in the sigmoid colon and rec- diarrhoea. The tumour All neoplastic polyps are pre-malignant, low lesions may spreads by direct inltration into the bowel wall and cir- prolapse through the anus. Subsequent invasion of the blood and lymphatics results in distant metastasis most fre- Management quently to the liver. Tubular polyps are resected endoscopically, villous le- sions require transmural excision or formal resection. Clinical features Presentation is dependant on the site of the lesion, but in Prognosis general a combination of altered bowel habit and bleed- There is a 30 50% risk of recurrence therefore surveil- ing with or without pain is reported. Up to a third of lance with 3 5 yearly colonoscopy in patients under 75 patients present with obstruction, or perforation. Examination may reveal a mass (on abdominal palpation or rectal examination), ascites Large bowel carcinoma and hepatomegaly. Macroscopy/microscopy Raised red lesions with a rolled edge and central ulcera- Incidence tion. Investigations Age r Endoscopic examination of the large bowel with Average 60 65 years. Geography r Pre-symptomatic disease may be identied by surveil- Rare in Africa and Asia (thought to be environmental). B Extending through the 70 muscularis propria but no node involvement Incidence C Any nodal involvement 30 Much less common than rectal carcinoma. D Distant metastases 5 Sex r In arecent study the use of faecal occult blood testing M > F as screening has a positive predictive value was 11% for cancer and 35% for adenoma. Patients present with a localised ulcer or a wart like growth, there is often associated bleeding and discharge. Management Inguinal lymph nodes may be stony hard if spread has Primaryresectionisthetreatmentofchoiceintpatients occurred. Management In all the procedures the associated mesentery and re- Treatment is by combined local radiotherapy and gional lymph nodes are removed en bloc.

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Part of a weekly series of stories about the sociology and psychology behind news events gabapentin 300mg on line medicine 600 mg. Newspaper article with other type of note Examples of Citations to Newspaper Articles 1 order gabapentin 800 mg visa symptoms rotator cuff injury. Standard newspaper article with optional volume and issue numbers Taking steps back to normal after novel rabies therapy purchase gabapentin 100mg with visa symptoms of ebola. Newspaper article in a language other than English Se retractan cientificos sudcoreanos; admiten mentiras sobre la clonacion 800 mg gabapentin sale treatment diffusion. Newspaper article in a language other than English with optional translated title Se retractan cientificos sudcoreanos; admiten mentiras sobre la clonacion [South Korean scientists retract themselves; they admit lies on cloning]. Tchernobyl, 20 ans apres: le vrai impact en France [Chernobly, 20 years after: the real impact on France]. Newspaper title with both a city added and an edition UnitedHealth-PacifiCare deal hailed, deplored. La "gripe del pollo" vuela can las aves silvestres [The "bird flu" flies with the wild birds]. Newspaper article with optional inclusion of letter with page number (omitting section) Krasner J. Newspaper article in a microform A year later, efforts are on to avoid another botched transplant. Newspaper article with a dateline Taking steps back to normal after novel rabies therapy. Maps 489 Citation Rules with Examples for Maps Components/elements are listed in the order they should appear in a reference. Author (cartographer) (R) | Author Affiliation (O) | Title (R) | Map Type (R) | Type of Medium (R) | Edition (R) | Editor and other Secondary Authors (O) | Place of Publication (R) | Publisher (R) | Date of Publication (R) | Pagination (O) | Physical Description (O) | Series (O) | Language (R) | Notes (O) Author (cartographer) for Maps (required) General Rules for Author List names in the order they appear in the text Enter surname (family or last name) first for each author Capitalize surnames and enter spaces within surnames as they appear in the document cited on the assumption that the author approved the form used. Airborne radioactivity survey of the Tabernacle Buttes area, Sublette and Fremont Counties, Wyoming [remote-sensing map]. Rossiiskoe Respiratornoe Obshchestvo [Russian Respiratory Society] Translate names of organizations in character-based languages such as Chinese and Japanese. Map with no author (cartographer) provided Author Affiliation for Maps (optional) General Rules for Author Affiliation Enter the affiliation of all authors or only the first author Begin with the department and name of the institution, followed by city and state/Canadian province/country Use commas to separate parts of the address Place the affiliation in parentheses. Box 11 Organizational names for affiliations not in English Give the affiliation of all cartographers or only the first cartographer. Box 12 Names for cities and countries not in English Use the English form for names of cities and countries whenever possible. Madrid: Comunidad de Madrid, Consejeria de Sanidad, Direccion General Planificacion Sanitaria; 2000. Beijing Shi ji ben yi liao bao xian ding dian yi liao ji gou ding dian ling shou yao dian zhi nan tu [map]. Beijing Shi ji ben yi liao bao xian ding dian yi liao ji gou ding dian ling shou yao dian zhi nan tu [Local medical facilities and retail pharmacies in Beijing covered by basic medical insurance] [map]. Box 16 Titles in more than one language If a map title is written in several languages, give the title in the first language found on the map and indicate all languages of publication after the pagination. Carte de Montreal: communaute urbaine de Montreal = Montreal city plan: urban community [map]. Box 18 No title can be found If a map has no formal title, construct a title using the name of the area covered by the map as the title Place the area name in square brackets Example: [World] [demographic map]. Map in a microform Edition for Maps (required) General Rules for Edition Indicate the edition/version being cited when a map is published in more than one edition or version Abbreviate common words if desired (see Abbreviation rules for editions) Maps 501 Capitalize only the first word of the edition statement, proper nouns, and proper adjectives Express numbers representing editions in arabic ordinals. Example: or becomes c Do not convert numbers or words for numbers to arabic ordinals as is the practice for English language publications. Box 22 First editions If a map does not carry any statement of edition, assume it is the first or only edition Use 1st ed. Map with an edition Editor and other Secondary Authors for Maps (optional) General Rules for Editor and other Secondary Authors A secondary author modifies the work of the author. Box 25 Non-English names for secondary authors Translate the word found for editor, translator, or other secondary author into English if possible to assist the reader. Use the city of the first organization found on the map as the place of publication. Arkansas population distribution, with shaded relief features of the physical landscape [map]. Map with unknown place of publication Maps 509 Publisher for Maps (required) General Rules for Publisher Record the name of the publisher as it appears in the map, using whatever capitalization and punctuation is found there Abbreviate well-known publisher names with caution to avoid confusion. For example: Louisiana State University, Department of Geography and Anthropology. Aarhus (Denmark): Aarhus-Universitetsforlag [Aarhus University Press]; If the name of a division of other part of an organization is included in the publisher information, give the names in hierarchical order from highest to lowest Valencia (Spain): Universidade de Valencia, Instituto de Ciencia y Documentacion Lopez Pinero; As an option, translate all publisher names not in English. Designate the agency that issued the map as the publisher and include distributor information as a note, preceded by "Available from:". Box 35 Multiple publishers If more than one publisher is found on a map, use the first one given or the one set in the largest type or bold type An alternative is to use the publisher likely to be most familiar to the audience of the reference list. For those maps with joint or co-publishers, use the name given first as the publisher and include the name of the second as a note if desired. Box 36 No publisher can be found If no publisher can be found, use [publisher unknown]. Recent unexplained mass mortality of marine fauna: a look at ocean nuclear waste dumps as possible sources of stress [Northeast Atlantic Ocean] [map]. Map with unknown publisher Date of Publication for Maps (required) General Rules for Date of Publication Always give the year of publication Convert roman numerals to arabic numbers. Maps 513 1999 Oct-2000 Mar 2002 Dec-2003 Jan Separate multiple months of publication by a hyphen 2005 Jan-Feb 1999 Dec-2000 Jan Separate multiple seasons by a hyphen; for example, Fall-Winter. Box 38 Non-English names for months Translate names of months into English Abbreviate them using the first three letters Capitalize them Examples: mayo = May luty = Feb brezen = Mar Box 39 Date of publication and date of copyright Some maps have both a date of publication and a date of copyright. Box 40 No date of publication, but a date of copyright A copyright date is identified by the symbol, the letter "c", or the word copyright preceding the date. Map with unknown date of publication Pagination for Maps (optional) General Rules for Pagination Provide the total number of sheets on which the map appears Follow the sheet total with a space and the word sheet or sheets End pagination information with a colon and a space, unless no Physical Description is provided, then use a period Maps 515 Specific Rules for Pagination More than one map on a sheet or more than one sheet per map Box 42 More than one map on a sheet or more than one sheet per map If more than one map appears on a sheet, include this information with the pagination. Map pagination and physical description Physical Description for Maps (optional) General Rules for Physical Description Begin with the scale of the map, followed by a semicolon and a space. For example: 1:250,000; Enter the size of the map in centimeters, followed by a semicolon and a space. Specific Rules for Physical Description Language for describing map characteristics Language for describing microform characteristics Box 43 Language for describing map characteristics Describe map characteristics using the features listed below Give each feature as it is found on the map Abbreviate measures used if desired centimeters = cm. If more than one map is found on a sheet and they differ in size, include all sizes: 2 maps on 1 sheet: 52 x 76 cm. Typical words used include: color Maps 517 black & white positive negative 4 x 6 in. Map in a microform Series for Maps (optional) General Rules for Series Begin with the name of the series Capitalize only the first word and proper nouns Follow the name with any numbers provided. Map in a series Language for Maps (required) General Rules for Language Give the language of publication if other than English Capitalize the language name Follow the language name with a period Specific Rules for Language Maps appearing in more than one language 518 Citing Medicine Box 45 Maps appearing in more than one language If the text of a map is written in several languages, give the title in the first language found on the map and indicate all languages of publication after the pagination. Indicate the particular languages, separated by a comma, after the pagination and description. Map in multiple languages Notes for Maps (optional) General Rules for Notes Notes is a collective term for any type of useful information given after the citation itself Complete sentences are not required Be brief Specific Rules for Notes Map accompanied by written or other material Other types of material to include in notes Box 46 Map accompanied by written or other material If a booklet or other supplemental material accompanies a map, begin by citing the map Add the phrase "Accompanied by:" followed by a space and the number and type of material Examples: Accompanied by: 1 booklet. Maps 519 Box 47 Other types of material to include in notes If a map contains material of particular interest to the audience that may not be apparent from the title, describe it Veterans Health Services and Research Administration [United States] [map].

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There is approximately 33% amino acid homology between the human and birch profilin molecules ( 77) order 600mg gabapentin otc symptoms 8 weeks pregnant. Bet v 3 and Bet v 4 have both been cloned and further described as calcium binding molecules ( 91 proven gabapentin 800mg treatment pink eye,92) order 100mg gabapentin with mastercard symptoms ruptured spleen. Recombinant Bet v 5 appears to have sequence homology with isoflavone reductase gabapentin 600mg line medicine on airplanes, but the biochemical function remains unknown ( 93). It reacts with IgE from 20% of birch allergic patients and has been identified as a cyclophilin ( 94). A major allergen has been isolated from the Japanese cedar, which contributes the most important group of pollens causing allergy in Japan. This allergen, designated Cry j 1, was initially separated by a combination of chromatographic techniques. Four subfractions were found to be antigenically and allergenically identical (95). There is some amino acid homology between Cry j 1 and Amb a 1 and 2, but the significance of this is unclear. Allergens from mountain cedar (Juniperus ashei) are important in the United States. The major allergen, Jun a 1, has a 96% homology with Cry j 1 and with Japanese cypress (Chamaecyparis obtusa) (97). In 1726, Sir John Floyer noted asthma in patients who had just visited a wine cellar; in 1873, Blackley suggested that Chaetomium and Penicillium were associated with asthma attacks; and in 1924, van Leeuwen noted the relationship of climate to asthma and found a correlation between the appearance of fungal spores in the atmosphere and attacks of asthma ( 99). Over the next 10 years, case reports appeared attributing the source of fungal allergies to the home or to occupational settings. In the 1930s, Prince and associates ( 100) and Feinberg (101) reported that outdoor air was a significant source of fungal spores and demonstrated that many of their patients had positive skin test reactivity to fungal extracts. More alarming is the association noted between elevated Alternaria airborne spore concentrations and risk of respiratory arrests in Alternaria-sensitive individuals ( 102). Initially, fungal sensitivity was equated to skin test reactivity, but more direct evidence for the role of fungal sensitivity in asthma has been presented by inhalation challenge studies by Licorish and co-workers ( 103). In addition to IgE-mediated reactions, sensitization to certain fungi, especially Aspergillus, can lead to hypersensitivity pneumonitis ( 104). Although fungal spores are thought to be the causative agents in atopic disorders, other particles that become airborne (including mycelial fragments) also may harbor allergenic activity. Alternaria is an important allergenic fungus and has been associated with significant episodes of respiratory distress. Among the Alternaria species, A alternata has been the subject of the most research. The Alt a 1 allergen is rich in carbohydrates, and glycosylation of proteins may be necessary for allergenic activity (107). Alt a 1 can induce positive intradermal test results at extremely low concentrations (6 pg/mL) in Alternaria-sensitive subjects. Interestingly, the fungus Stemphyllium shares at least 10 antigens with Alternaria and an allergen immunochemically identical to Alt a 1 (110). Commercial Alternaria extracts contain widely varying amounts of Alt a 1, underscoring the need for improved methods of standardization (111). There is also evidence of further cross-reactivity with Saccharomyces and Candida (114). Cladosporium species are among the most abundant airborne spores in the world ( 17). Two species, Cladosporium cladosporoides and Cladosporium herbarum, have been the focus of intense investigation. Two major, 10 intermediate, and at least 25 minor allergens have been identified ( 115). Allergen content of 10 isolates of Cladosporium varied from 0% to 100% relative to a reference extract. Two major allergens have been isolated from Cladosporium herbarum: Cla h 1 and Cla h 2 (116). Cla h 1 (Ag-32) was isolated by chromatographic and isoelectric focusing techniques. Cla h 2 (Ag-54) is a glycoprotein that is reactive in a smaller percentage of patients than Cla h 1. Neither allergen is cross-reactive, as determined by passive transfer skin testing. In contrast to Cladosporium and Alternaria extracts, which are traditionally prepared by extracting mycelia and spores, Aspergillus fumigatus extracts generally are prepared from culture filtrate material. This disorder is characterized by the presence of both IgE and IgG antibodies to the offending fungal antigens. When the strains used in the extract were investigated individually, they varied in their quantities of the four most important allergens. Other studies demonstrated that disrupted spore antigens did not cross-react with either mycelial or culture filtrate allergens ( 121). Common allergens occur within the fumigatus and niger groups, which are allergenically distinct from the versicolor, nidulans, and glaucus groups (99). Asp f 1 has been cloned and identified as a cytotoxin, mitogillin, which is excreted from the fungus only during growth ( 122,123). A combination of Asp f 1, Asp f 3, and Asp f 5 has a sensitivity of 97% for diagnosing Aspergillus sensitivity (125). Pen c 1 is a 33-kDa alkaline serine protease with 93% IgE reactivity among patients sensitive to Penicillium species (128,129). Pen c 3 has 83% sequence homology with Asp f 3 peroxisomal membrane protein allergen (131). Sensitivity to spores of the Basidiomycetes is a significant precipitant of allergic disease. Asthma epidemics have been reported in association with elevated Basidiomycetes spore counts (133). Several species have been shown to be allergenic, and extracts from these species show multiple antigens and allergens ( 134). Up to 20% of asthmatic individuals demonstrate positive skin test results to Basidiomycetes species ( 135). Cop c 1 from Coprinus comatus has been cloned, but only 25% of basidiomycete-allergic patients respond ( 136). Psi c 2 from Psilocybe cubensis mycelia was also cloned and shows some homology with Schizosaccharomyces pombe cyclophilin (137). Candida albicans is the most frequently isolated fungal pathogen in humans; however, its role in allergic disease is relatively minimal. The other major allergen appears to be enolase, which cross-reacts as noted before. Candida also secretes an acid protease, which produces IgE antibodies in 37% of Candida-allergic patients (141). Candida sensitivity is also associated with eczema related to infection with the human immunodeficiency virus ( 142). Atmospheric fungal spore counts frequently are 1,000-fold greater than pollen counts ( 99), and exposure to indoor spores can occur throughout the year ( 143). This is in contrast to pollens, which have distinct seasons, and to animal dander, for which a definitive history of exposure usually can be obtained. Some species do show distinctive seasons; nevertheless, during any season, and especially during winter, the number and types of spores a patient inhales on a given day are purely conjectural. In the natural environment, people are exposed to more than 100 species of airborne or dust-bound microfungi.

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