Jennifer Freedman, PhD

• Assistant Professor in Medicine
• Member of the Duke Cancer Institute

https://medicine.duke.edu/faculty/jennifer-freedman-phd

Ridley M F weight loss quickly order shuddha guggulu 60 caps otc, the natural habitat of Cladosporium carrionii weight loss pills drug store 60 caps shuddha guggulu, a cause of chromoblastomycosis in man weight loss doctors near me buy shuddha guggulu 60caps line. Tratamiento con la asociacion thiabendazole y 5-fluorocitosina weight loss pills 30 day free trial order 60 caps shuddha guggulu with visa, seis anos de seguimiento. A case with a widespread rash, lymph node metastasis and multiple subcutaneous nodules. In vitro testing of susceptibilities of filamentous ascomycetes to voriconazole, intraconazole, and amphotericin B, with consideration of phylogenetic implications. Chromoblastomycosis: A review of 100 cases in the state of Rio Grande do Sul, Brazil. A case of chromoblastomycosis: with special reference to the mycology of the isolated Exophiala jeanselmei. In vitro sensitivity to 5-fluorocytosine of strains isolated from patients under treatment for chromomycosis. Treatment of chromomycosis by cryosurgery with liquid nitrogen: a report of seven cases. Queiroz-Telles F, Purim K S, Fillus J N, Bordignon G F, Lameira R P, van Cutsem J, Cauwenbergh G. Unfortunately, this pneumonia has continued to occur despite the recognition in the 1970s that chemoprophylaxis could greatly reduce the incidence of this disease in the immunocompromised host. However, recent applications of molecular techniques demonstrated that the organism shares many characteristics with fungi, especially Saccharomyces (Edman et al, 1988; Stringer et al, 1989; Cailliez et al, 1996). Based on its morphology, which is similar to that of protozoa, the life cycle of P. It has been suggested that the mode of replication occurs through binary fission and excystment (Hughes et al, 1977). Advances in molecular biology have better delineated the metabolism of this organism. Sites of action and targets of some of the effective antimicrobial agents have been cloned, sequenced, and characterized. Evidence supports that disease may be due to primary infection, reinfection, or reactivation. In addition, highdose corticosteroid use for long time periods poses a great risk for the development of P. Pneumocystis carinii is presumably inhaled, bypasses the defenses of the upper respiratory tract, and is deposited into the alveolar space. Individuals with intact immunity can control this primary infection, but the organism likely remains latent in the lungs. The principal histologic finding is the formation of a foamy vaculoated eosinophilic alveolar exudate. The alveolar-capillary permeability increases leading to impairment of gas exchange, not unlike that seen with adult respiratory distress syndrome. Physiologically, hypoxemia occurs with an increased alveolar-arterial oxygen gradient and respiratory alkalosis, impaired diffusion capacity along with alterations in lung compliance and total lung capacity. As the disease progresses in severity, there may also be hyaline membrane formation along with interstitial fibrosis and edema. Cough may be similar to that seen with a viral infection, and the shortness of breath may be no- ticed only with exertion. Constitutional symptoms and prolonged prodromal illness may be present for months before presentation. Routine laboratory testing is also unremarkable except for nonspecific elevations of serum lactate dehydrogenase. The radiologic findings are dictated by the stage of illness at the time the patient presents for evaluation. The typical chest radiograph is one of diffuse and symmetrical increased interstitial markings. In patients with a normal chest radiograph, a high resolution (thin section) computed tomography scan of the chest will usually demonstrate a characteristic ground glass appearance (Gruden et al, 1997). Chest radiograph showing symmetrical interstitial infiltrates typical of Pneumocystis pneumonia. The development of monoclonal antibodies has resulted in a rapid, sensitive and easy to perform immunofluorescence assay, which often is more efficient for detecting P. Other effective regimens include trimethoprim-dapsone (Leoung et al, 1986; Medina et al, 1990; Safrin et al, 1996), primaquine-clindamycin (Ruf et al, 1991; Toma et al, 1993; Safrin et al, 1996), trimetrexate (Sattler et al, 1994), and atovaquone (Hughes et al, 1993). Trimethoprim-sulfamethoxazole is the agent of choice for initial therapy of acute P. When abdominal imaging studies are performed on patients with pneumocystis pneumonia, lesions in visceral organs can sometimes be recognized. These lesions, which often disappear during therapy, probably represent subclinical cases of disseminated pneumocystosis. However, no systematic evaluation of a series of patients has been done to determine the frequency of visceral hepatic, splenic, or renal lesions. Reported sites of dissemination include lymph nodes, liver, spleen, bone marrow, pleura, ear, choroid of the eye, thyroid, adrenal gland, intestines, and meninges (Raviglione, 1990; Telzak et al, 1990). Clinical manifestations of extrapulmonary disease may occur with or without lung involvement. While extrapulmonary pneumocystosis is not invariably fatal, the mortality rate is difficult to estimate since extrapulmonary sites are rarely looked for unless extrapulmonary manifestions are clinically apparent. Organisms are recognized via colorimetric or immunofluorescent stains since the organism cannot be cultured. With the development of improved diagnostic techniques, diagnoses can now be established by less invasive methods. Virtually all patients can be diagnosed by careful analysis of bronchoalveolar lavage fluid (Meduri et al, 1991; Baughman, 1994). Agent Specific Therapy Trimethoprim/ sulfamethoxazole Pentamidine Trimethoprim plus Dapsone Clindamycin plus Primaquine Atovaquone Trimetrexate with Leucovorin Adjunctive Therapy Prednisone or Solumedrol (if room air PaO2 within 72 hours of initiating therapy) 70 mmHg 40 mg q 12 hours for 5 days then 40 mg q day for 5 days p. The q 8-hour regimen is preferred by many clinicians since toxicity would be expected to be less than with q 6-hour dosing and there is no evidence that efficacy is improved with the higher dose. Total duration of therapy is usually 21 days, but there is no concrete evidence that 21 days of therapy is more effective than 14 days (Catterell et al, 1985). Toxicities include fever, rash, headache, nausea, vomiting, pancytopenia, hepatitis, and aseptic meningitis. Minor laboratory abnormalities should not be an indication to switch to a less effective alternative therapy. The standard dose of pentamidine is 4 mg/kg/day, given intravenously over at least 1 hour for a minimum of 14­21 days. Small studies suggest that a lower dose of 3 mg/kg/day may be less toxic, but equally effective (Conte et al, 1987; Conte et al, 1990). Dapsone, as a single agent, is not as effective as other alternatives in the treatment of P. This regimen can only be given orally and is therefore not suitable for patients with severe disease or gastrointestinal dysfunction. The combination of clindamycin and primaquine is another reasonable alternative for the treatment of P. Investigators report success rates of 75%­80% in open, noncomparative trials with patients who are intolerant to or failed standard treatment (Ruf et al, 1991; Toma et al, 1993). Clindamycinprimaquine has also been used as a salvage regimen in patients with pneumocystosis induced respiratory failure (Noskin et al, 1992), although many authorities are reluctant to use an oral agent. Clindamycin is given either orally (300 mg to 450 mg every 6 to 8 hours) or intravenously (600 mg to 900 mg every 6 to 8 hours). Clindamycin alone is not effective in animal models unless primaquine is given concurrently. Monitoring Therapy Respiratory rate, arterial oxygenation, ventilation, temperature, and chest radiograph should be assessed to determine initial clinical status and then assessed serially to determine response to therapy. Laboratory tests should be done to recognize bone marrow, liver, pancreatic, or renal toxicity. This decline has been attributed to dying organisms, which elicit an intense inflammatory response. The initial regimen should probably be continued for at least 5­10 days before lack of response or poor response dictate a change in therapy. Concomitant congestive heart failure due to processes unrelated to pneumocystosis may also occur.

Despite almost 50 years of clinical experience weight loss websites shuddha guggulu 60 caps with visa, little is known about the metabolism of amphotericin B weight loss naturally buy cheap shuddha guggulu 60caps on-line. Serum concentrations weight loss pills new purchase shuddha guggulu 60caps without a prescription, as such weight loss chocolate buy shuddha guggulu 60caps lowest price, are not changed and accumulation of amphotericin B does not occur in patients with hepatic or renal failure. Several pharmacokinetic parameters of amphotericin B are different in children as compared to adults (Starke et al, 1987; Benson and Nahata, 1989). For instance, children have a smaller volume of distribution and a larger clearance compared to adults. When equivalent weight-based doses of amphotericin B are administered, peak serum concentrations in children are approximately one-half of those obtained in adults. The increased clearance of amphotericin B in children may, in part, explain the clinical finding that higher doses are better tolerated in children as compared to adults. Despite the lower serum concentrations seen in children, cerebrospinal fluid concentrations of amphotericin B treated neonates are higher than those noted in adults. Pharmacodynamics Pharmacodynamics involves the integration of several pharmacologic measurements made in vitro. These parameters have proven useful in classifying antibiotics as either concentrationdependent or time-dependent in their bactericidal activity. These parameters have also been instrumental in selecting the optimal anti-infective treatment regimens for bacterial infections. Amphotericin B has traditionally been portrayed as a concentration-dependent antifungal agent. The lack of standardized antifungal susceptibility testing has also hindered studies exploring amphotericin B pharmacodynamics. Additional studies are required to evaluate the predictive value and clinical usefulness of these pharmacodynamic parameters in optimizing therapy of human infections. Initial studies evaluating amphotericin B pharmacodynamic models in vitro and in vivo have been contradictory. In a study of neutropenic mice infected with Candida, the antimycotic effects of amphotericin B were observed for 23­30 hours (Andes, 1999). In contrast, several in vitro studies have shown a shorter duration of antimycotic effect (0­10. Data on these important parameters affecting antimycotic pharmacodynamics and clinical outcome have not been adequately defined. Despite the limitations discussed above, some studies have begun to define clinically relevant pharmacodynamic parameters of antifungals that affect clinical outcome. This latter pharmacodynamic property is characteristic of a nonconcentrationdependent. A reasonable hypothesis in reconciling these results involves the enhanced tissue binding of amphotericin B. Specifically, the enhanced tissue storage and long elimination rates of amphotericin B confound traditional dynamic estimates and the release of free drug from tissue sites is difficult to discriminate from the residual effects of inhibitory antifungal concentrations. Adverse Effects the utility of amphotericin B is hindered by significant toxicity. The resulting, nonselective disruption of mammalian cells is believed to be the underlying cause of most of the adverse effects associated with this drug (Andreoli, 1973; Hsuchen and Feingold, 1973). Reversible renal impairment occurs within 2 weeks of therapy in more than 80% of amphotericin B treated patients (Butler et al, 1964). Infusion-related fever and chills are observed in over half of the patients receiving amphotericin B. The clinical consequences can be significant in certain patient populations such as the elderly and critically ill. Other adverse effects include thrombophlebitis, nausea, vomiting, headaches, myalgias, and arthralgias. It is clinically useful to classify these reactions as infusion-related, dose-related, or idiosyncratic reactions. Infusion-related reactions include a symptom complex of fever, chills, nausea, vomiting, headache, and hypotension. Cardiac arrhythmias may occur when high concentrations are rapidly infused, especially in patients with heart disease, patients with renal failure and those receiving an accidental drug overdosage (Cleary et al, 1993). Caution is also recommended for patients receiving the drug by a central venous catheter. Doserelated reactions occur with longer courses of treatment and are related to total dose. Examples include renal dysfunction with secondary electrolyte imbalances and anemia. Idiosyncratic reactions are unpredictable and include anaphylaxis, liver failure, hypertension, and respiratory failure. Infusion-related fever and chills are observed in over half the patients receiving amphotericin B. Our clinical experience is that patients having severe infusion reactions often have undiagnosed adrenal insufficiency (especially those with disseminated histoplasmosis); consequently, adrenal function should be evaluated in these individuals. These infusion-related effects are believed to be due to the production of proinflammatory mediators by monocytes and macrophages in response to amphotericin B (Gigliotti et al, 1987; Chia and Pollack, 1989; Cleary et al, 1992). The patient to patient variability of amphotericin B infusion-related toxicity may correlate with quantitative differences in cytokine production in vivo (Gelfand et al, 1988). The clinical manifestations of amphotericin Binduced nephrotoxicity include decreased glomerular filtration, decreased renal blood flow, and renal tubular acidosis. Additionally, normochromic, normocytic anemia is frequently observed, likely in response to decreased erythropoietin production (Lin et al, 1990). Calcium deposits have been found in the renal tubule lumen, tubule cells, and interstitium upon histopathologic examination of renal tissue specimens obtained from patients treated with amphotericin B (Sabra and Branch, 1990; Carlson and Condon, 1994). Onset of nephrotoxicity often occurs before laboratory or clinical signs and symptoms are evident. Many clinicians accept an endpoint at which some intervention is required as a rise in serum creatinine of greater than 0. The action taken is variable and ranges from amphotericin B discontinuation or dosage reduction, stopping concurrent nephrotoxic drugs, changing to an alternate day infusion schedule and pretreating patients with normal saline. Animal studies have demonstrated the vasoconstrictive properties of amphotericin B, particularly with regard to the afferent arteriole (Sawaya et al, 1991). Conversely, damage to the medullary thick ascending limb by amphotericin B was ameliorated by ouabain in a rat kidney model, suggesting an alternative role for this pump in amphotericin B-induced nephrotoxicity. Others have suggested a role for amphotericin B-induced release of prostaglandins and leukotrienes as well as oxidative injury in this process (Carlson and Condon, 1994). The tubuloglomerular feedback mechanism normally involved in renal homeostasis also plays a prominent role in the pathogenesis of amphotericin B-induced nephrotoxicity (Branch et al, 1987). This feedback process is believed to be activated by transport of sodium chloride across the macula densa cells into the distal nephron, resulting in constriction of the afferent arteriole, possibly mediated by adenosine, and subsequent impairment of glomerular filtration (Sabra and Branch, 1990). Dehydration and sodium depletion accentuate this response and exacerbate amphotericininduced renal failure. Sodium loading with intravenous administration of 500 mL to 1000 mL of normal saline prior to initiation of amphotericin B, when tolerated by the patient, is recommended in order to decrease the likelihood of renal toxicity (Branch, 1988). Amphotericin B 39 Drug Interactions Drugs that interact with amphotericin B are best categorized by the effect they have on a clinical outcome of amphotericin treatment. It is useful to classify these agents as (1) those that alter therapeutic outcome, (2) those that alter toxicity, and (3) those that have miscellaneous outcomes. Controversy exists concerning the risk:benefit ratio of corticosteroids for prevention of infusionrelated reactions. Clinical experience overwhelmingly supports the therapeutic benefit of administering hydrocortisone to patients suffering infusion-related reactions. However, circumstantial evidence suggests that administration of this immunosuppressant could be detrimental to the therapeutic success of amphotericin B (North 1971; Snyder and Unanue, 1982; Tatro, 1998). Although further investigation of this therapeutic issue is required, it seems prudent to limit the dose and duration of corticosteroids by a therapeutic taper once infusion-related reactions are ameliorated. Intravenous meperidine has proven useful in abrogating infusionrelated rigors (Burks et al, 1980). Diligent monitoring of renal function is warranted in patients treated concurrently with these nephrotoxic agents. A variety of other therapeutic agents may result in amphotericin B-associated adverse events that require diligent monitoring. Pulmonary leukostasis and respiratory failure associated with concomitant leukocyte transfusions or indium-labeled leukocyte scanning can be life-threatening (Wright et al, 1981; Dutcher et al, 1989).

Zohary does comment that the dwarf chicory weight loss for teens purchase shuddha guggulu 60 caps on-line, like several of the nine Mediterranean species of Cichorium weight loss acupuncture discount shuddha guggulu 60 caps on-line, is eaten by cattle and humans alike weight loss xenadrine buy shuddha guggulu 60 caps. A weedy progenitor is more likely to have been eaten by biblical peasants than the cultivated chicory or endive weight loss 5 day juice cleanse generic shuddha guggulu 60caps on-line, which Zohary excludes from his account. However, neither Zohary or I now can guarantee that any or all species were or were not eaten in the biblical setting. Zohary notes that chicory (and Reichardia) are only possible representatives of a large group of so-called edible bitter herbs in the Middle East, almost like our spring tonic greens down South. Not necessarily chicory, nor dandelion, nor endive, nor fenugreek were necessarily the most important of the biblical merorim (Arabic mureir), a general term to embrace many different species of bitter edible herbs. To blanch, tie the outer leaves in a cone, or place a big flower pot over each plant to curb the light. Exodus 12:8 the children of Israel may have learned to eat bitter herbs from the Egyptians. Ancient Egyptians used to place healthy green herbs on the table, mixed with mustard, and then dunk their healthy whole-grain bread in the mixture, like my dad and I used to dunk cornbread in turnip green broth. Moldenke and Moldenke believed that Cichorium endivia, Cichorium intybus, Lactuca sativa, Nasturtium officinale, Rumex acetosella, and Taraxacum officinale were among the green herbs of the Bible. Zohary figures instead that chicory and the poppy-leaved Reichardia (which looks like dandelion) as more promising candidates. Commission E reports contraindications of hypersensitivity to chicory and other Asteraceae and adverse effects of rare allergic skin reactions. The patient also reported reactions after ingestion of botanically related endive (Cichorium endivia) and lettuce (Lactuca sativa). Lactucin and lactucopicrin proved to be antimalarial compounds in chicory, folklorically regarded for malaria in Afghanistan (X15507374). Italians are producing circa 250,000 tons of red chicories a year, 100-g servings of which can provide as much as 130 mg anthocyanins and 650 mg total phenolics, scavenging highly reactive oxidants in the stomach, benefitting age-associated oxidative stress, and improving neuronal and cognitive brain function (X16218660). Although the spice trade tends to lump cassia and cinnamon in the same spice jar, Israeli botanist Michael Zohary and the Bible itself treat them as separate items. Although both are mentioned many times in the Bible, nowhere are they both mentioned in the same verse; but it is very close in the case quoted above, where cinnamon was mentioned in verse 23 and cassia in verse 24. All parts of the plant possess an essence, cinnamic aldehyde, which may be distilled for export. Commission E reports contraindications for bark; hypersensitivity to cinnamon or Peruvian balsam; pregnancy, and adverse effects often allergic reactions of skin and mucosae. Come, let us take our fill of love until the morning: let us solace ourselves with loves. Come, let us take our fill of love till morning; let us delight ourselves with love. Do come, let us drink our fill of love until the morning; do let us enjoy each other with love expressions. For my husband is not in his house; he has gone traveling on a way of some distance. And they are consistent in translating them as myrrh, aloes (in this case Aquilaria), and cinnamon, the latter more appealing to my olfactories. Zohary confirms that the long-discussed identification of the biblical kinnamon as Cinnamomum has been confirmed by various scholars. Alien to the Holy Land, and native to Sri Lanka and coastal India, it must have followed the old trade routes for drugs, incenses, perfumes, and spices. I would not hesitate to use one or the other for the indication of one or the other. Many of the reported studies were, in fact, performed on purchased materials that may have been one or the other or a mixture of the two. Commission E reports bark contraindications: hypersensitivity to cinnamon or Peruvian balsam and adverse effects: often allergic reactions of skin and mucosae. Newall, Anderson, and Phillipson (1996) caution that the cinnamaldehyde in the volatile oil is allergenic and an irritant. Regrettably, I was unable to read the article on allergic contact dermatitis from cinnamon used as an odor-neutralizing agent in shoe insoles (X15186386). High doses caused vomiting in experiments with dogs, corresponding with reported side effects in humans. Extracts and cinnamaldehyde reported mutagenic in some studies, nonmutagenic in others. Oral eugenol is rapidly absorbed, reaching blood plasma levels of 5 M, significantly antioxidant levels, 2 hours after 150 mg of the eugenol, but almost completely excreted in the urine by 24 hours (X15941312). Pakistani scientists (X14633804) found that cinnamon improves glucose and lipids of type-2 diabetics. Cinnamate supplementation resulted in higher catalase and glutathione peroxidase activities. Because ladanum used to be combed from the fur of sheep, or the beards of goats that had been grazing the Rock Rose, it often represented a mixture of species. While I suspect goats and sheep are discriminating grazers, I doubt that they were restricted to grazing one of the many species in so many Mediterranean areas. It is doubtful that all ladanum has been scientifically or taxonomically verified, so the accumulated literature may apply to various species. The absolute is reportedly used in levels up to 4000 ppm, the essential oil up to 8000 ppm but only in perfumery. Barely food farmacy; fruits pickled after boiling in several changes of water to remove bitter elements. Hungry Bedouins may even eat the seed after soaking in water, able to survive nearly 2 weeks on the seed (although probably with diarrhea). The following fungi affect colocynth: Colletotrichum bryoniae, Erysiphe cichoracearum, E. Alpha-spinasterol significantly (circa 1000 X simvastin, a coenzyme-A inhibitor) modulates development and/or progression of diabetic nephropathy. It reduced significantly attendant increases of serum triglycerides, renal weight, and urinary protein excretion in diabetic mice (X15326549). How we remember the fish that we used to eat in Egypt for nothing, the cucumbers and the water melons, and the leeks and the onions, and the garlic; But now our soul is dried away. And it really is a life-sustaining treasure in the desert when you have lost your canteen. Noting that watermelon has been known from Egypt since the Bronze Age, Zohary speculates that watermelon was domesticated in Africa during the Neolithic Period. All developed elevated plasma citrulline (386­1069 mol/l) and moderately elevated plasma arginine (128­251 mol/l). Citrullinaemia, new to me, is indicated by elevated plasma citrulline and arginine, in the absence of orotic or arginosuccinic aciduria or hyperammonaemia (X15902549). I will agree with Moldenke and Zohary, and include the citron among my biblical species and try to find a hardy one for the garden. Until then, I will let my Poncirus substitute for the ethrog when giving my biblical tours of the garden. Supposedly the first Citrus "liberated" from Asia, probably India, citron relics are found in Babylonian excavations of the Sumerian epoch, 4000 b. Diamante citron was the first citrus known to European civilization, and is still cultivated in Calabria, Corsica, Crete, and Israel. The variety "Etrog" is the official citron in the Jewish Feast of the Tabernacle ritual, the entire fruit being eaten. The main products are candies and liqueurs, the oil used in flavoring beverages and sweets. Could poor children in our inner cities, where asthma is increasing dramatically, reduce asthma attacks and/or symptoms (especially around ozone pollution, as on school buses in inner cities) by squeezing citrus peels (apparently all contain limonene) and inhaling the pleasant aroma periodically. Volatile, unsaturated monoterpenes, like limonene, could saturate the pulmonary membranes, equipping airways with local chemical protection against ozone. I doubt I can convince our government to compare citrus inhalation in clinical trials as a third arm against placebo and some expensive pharmaceuticals. But if I had a hundred asthmatic grandchildren, you could bet some of them would be trying citrus peel and others would not, followed by a vice versa crossover, recording the frequency and severity of their attacks for old grandpa. Without praying to improve my odds, I will still bet the citrus peel would score well along side the pharmaceuticals.

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Item # Product Name Testing 5mL Scratch Bulk Extract Glycerin Plant Foods Continued F181 F190 F191 F198 F200 F204 F208 F209 F211 F212 F216 F225 F228 F232 F235 Pineapple Ananas comosus (For Diagnostic Use Only) Potato, Sweet Ipomoea batatas Potato, White Solanum tuberosum Raspberry Rubus idaeus var. Item # Product Name Testing 5mL Scratch Bulk Extract Glycerin Fish and Shellfish F4 F8 F10 F11 F11 F12 F16 F20 F21 F23 F24 F30 F32 F34 F40 F41 Bass, Black Centropristis striata Catfish Ictalurus spp. Lobster Homarus americanus Mackerel Scomberomorus cavalla Oyster Ostrea/Crassostrea Perch Serranus scriba Salmon Salmo salar Scallop Placopecten magellanicus Shrimp, White/Brown/Pink Litopaenaeus setiferus/Farfantepenaeus aztecus/Farfantepenaeus dourarum Trout, Lake Oncorhynchus mykiss Tuna Thunnus sp. Premium Allergens Specific products have been designated as premium allergens due to low utilization, decreased availability of raw materials, increased costs associated with the collection/extraction process, and/or market conditions. The second number after the vial size is the outer diameter of the top of the vial in millimeters. Item # Fill/mL Vial Size Vial Seal Color Qty/Pack Normal Saline Also called Phenolated Saline. Effect of preservatives and conditions of storage on the potency of allergy extracts. Sturdy material designed to help protect vials from breakage during transportation. Stock labels include space for vial labeling information recommended by allergy immunotherapy practice parameter. Item # Description Skin Reaction Guides Skin reaction guides help clinicians accurately measure the wheal and erythema response following percutaneous skin testing. Upon request, customized, laminated color labels are available for all trays at no additional cost. This team is comprised of: ­ an Allergy Sales Consultant, an expert in assessing your allergy immunotherapy needs and helping you find the right solutions; ­ the Medical & Scientific Affairs Department, an assembly of specialized individuals including physicians, nurse practitioners, medical sciences liaisons, and research scientists who assist your clinic with technical information and answer any medically-related questions; and ­ Customer Care Specialists, knowledgeable, friendly, responsive professionals who are dedicated to your overall satisfaction. Systemic reactions include: generalized skin erythema, urticaria, pruritus, angioedema, rhinitis, wheezing, laryngeal edema, and hypotension. Emergency measures and personnel trained in their use must be available immediately in the event of a life-threatening reaction. Immunotherapy may not be suitable for patients with medical conditions that reduce their ability to survive a systemic reaction. Standardized Grass Pollen Allergenic Extracts include Bermuda (Cynodon dactylon), Kentucky Blue (June), (Poa pratensis), Meadow Fescue (Festuca elatior), Orchard (Dactylis glomerata), Perennial Rye (Lolium perenne), Redtop (Agrostis alba), Sweet Vernal (Anthoxanthum odoratum), and Timothy (Phleum pratense). Glycerinated concentrates contain the soluble extractants of the source material with 0. Source materials for each extract are the specific pollens collected from the respective plants. The presence of IgE antibodies on mast cells and basophils sensitizes these cells and upon interaction with the appropriate allergen-histamine and other mediators are released. IgE antibody has been shown to correlate with atopic diseases such as allergic rhinitis and allergic asthma. A summary of effectiveness by the Panel on Review of Allergenic Extracts, an advisory committee to the U. This is the maximum available strength of standardized Bermuda grass pollen extract. Physicians must exercise care in switching patients from nonstandardized to standardized extracts. Dose selection can be confirmed by side-by-side testing of nonstandardized and standardized extracts at estimated equal doses. The diagnosis of IgE-mediated allergy may be established by the allergy history, clinical evaluation, and skin test reactivity. Immunotherapy with Standardized Grass Pollen Extracts is indicated when testing and patient history have identified the offending allergens and when it is not possible or practical to avoid these allergens. The use of Standardized Grass Pollen Extracts for the above purposes should be made only by physicians with special familiarity and knowledge of allergy. Immunotherapy with specific antigens is contraindicated in those individuals who do not exhibit skin test and clinical sensitivity to the particular antigens. Patients should be informed of these risks prior to skin testing and immunotherapy. Allergenic extracts should be temporarily withheld from patients or the dose adjusted downward if any of the following conditions exist: 1. The amount of new extract given should not exceed 25% of the last dose given from the old vial, assuming both extracts contain comparable amounts of allergen. The risks of anaphylaxis in these patients should be carefully weighed against the benefits of immunotherapy. Because of the danger of serious reactions, caution is needed in testing exquisitely sensitive patients or patients with labile or steroid-dependent asthma. The physician must be prepared to treat anaphylaxis should it occur and have the necessary drugs and equipment on hand to do so. Patients receiving allergenic extracts should be kept under observation a minimum of twenty20 minutes so that any adverse reaction can be observed and properly handled. A separate, sterile syringe and needle or sterile disposable unit must be used for each patient to prevent the transmission of hepatitis or other infectious agents from person to person. The patient should remain under observation for this period of time or longer if instructed by the physician. Large local reactions may be indicative of subsequent systemic reactions as dosages increase. In particular, this includes unusual swelling and/or tenderness at the injection site or reactions such as rhinorrhea, sneezing, coughing, wheezing, shortness of breath, nausea, dizziness, or faintness. No long-term studies in animals have been performed to evaluate carcinogenic potential. It is also not known whether Standardized Grass Pollen Extracts can cause fetal harm when administered to a pregnant woman or whether they can affect reproduction capacity. Standardized Grass Pollen Extracts should be given to a pregnant woman only if clearly needed. Caution should be exercised in testing or treating pregnant females because a systemic reaction may cause an abortion as a result of uterine muscle contractions. Because many drugs are excreted in human milk, caution should be exercised when extracts are administered to a nursing woman. Children less than five years of age on extract immunotherapy may have an increased risk of a severe reaction, but respond well to skin test diagnosis. These reactions consist primarily of allergic symptoms such as generalized skin erythema, urticaria, pruritus, angioedema, rhinitis, wheezing, laryngeal edema, and hypotension. Less commonly, nausea, emesis, abdominal cramps, diarrhea and uterine contractions may occur. Systemic reactions occur with varying frequency in different clinics and are usually less than 1%. To some extent, the reaction rate is related to the type and dose of administered extract and to the degree of sensitivity of the patient. If the injection site is an arm, a tourniquet should be immediately applied above the site. Epinephrine 1:1000 should be injected immediately in the opposite arm in amounts of 0. For children below the age of 6 years, adjust the initial dose of epinephrine to 0. Adverse reactions not responding to epinephrine therapy may require other measures such as the use of inhaled, parenteral bronchodilators, vasopressors, oxygen, or volume replacement therapy. These reactions may appear within a few minutes to hours and persist for several days. Reporting of Adverse Events Reporting of serious or unexpected adverse events occurring after extract administration is encouraged.

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