Alan Cheng, MD

• Assistant Professor of Medicine
• Doctor, Arrhythmia Device Service
• Johns Hopkins University School of Medicine
• Baltimore, Maryland

Even a few drinks per week may be associated with a slightly increased risk of breast cancer in women allergy shots tingling discount 5mg clarinex. Continious Update Project: Cancer preventability estimates for diet allergy medicine cold symptoms generic 5mg clarinex otc, nutrition jackfruit allergy treatment 5 mg clarinex mastercard, body fatness allergy medicine 7253 generic clarinex 5 mg mastercard, and physical activity allergy shots vs xolair purchase clarinex 5 mg on-line. Healthy living is the best revenge: findings from the European Prospective Investigation Into Cancer and Nutrition-Potsdam study allergy treatment in europe clarinex 5mg low cost. American Cancer Society Guidelines on Nutrition and Physical Activity for cancer prevention: reducing the risk of cancer with healthy food choices and physical activity. Body mass index, prostate cancer-specific mortality, and biochemical recurrence: a systematic review and meta-analysis. A systematic review of the impact of weight loss on cancer incidence and mortality. Prevalence of Overweight, Obesity, and Extreme Obesity Among Adults: United States, 1960-1962 through 2011-2012. The Associations Between Food, Nutrition and Phyisical Activity and the Prevention of Cancer: A Global Perspective. Adherence to cancer prevention guidelines and cancer incidence, cancer mortality, and total mortality: a prospective cohort study. Following cancer prevention guidelines reduces risk of cancer, cardiovascular disease, and allcause mortality. The American Cancer Society Recommendations for Community Action Many Americans encounter substantial barriers to consuming a healthy diet and engaging in regular physical activity. Among those barriers that have collectively contributed to increased obesity are: limited access to affordable, healthy foods; increased portion sizes, especially of restaurant meals; marketing and advertising of foods and beverages high in calories, fat, and added sugar, particularly to kids; schools and worksites that are not conducive to good health; community design that hinders physical activity and promotes sedentary behavior; and economic and time constraints. Acknowledging that reversing obesity trends will require extensive policy and environmental changes, the Society calls for public, private, and community organizations to create social and physical environments that support the adoption and maintenance of healthy eating and physical activity behaviors to help people stay well. Achieving these recommendations requires multiple strategies and bold action, ranging from the implementation of community and workplace health promotion programs to policies that affect community planning, transportation, school-based physical activity, and food services. The tobacco control experience has shown that policy and environmental changes at the national, state, and local levels are critical to achieving changes in individual behavior. Measures such as smoke-free laws and increases in cigarette excise taxes have been highly effective in deterring tobacco use. The causes of health disparities within each of these groups are complex and include interrelated social, economic, cultural, environmental, and health system factors. However, disparities predominantly arise from inequities in work, wealth, education, housing, and overall standard of living, as well as social barriers to high-quality cancer prevention, early detection, and treatment services. Moreover, 12% of blacks and 20% of Hispanics/ Latinos were uninsured, compared to 8% of non-Hispanic whites. Discrimination is another factor that contributes to racial/ethnic disparities in cancer mortality. Racial and ethnic minorities tend to receive lower-quality health care than non-Hispanic whites even when insurance status, age, severity of disease, and health status are comparable. Social inequalities, including communication barriers and provider/patient assumptions, can affect interactions between patients and physicians and contribute to miscommunication and/or delivery of substandard care. In addition to poverty and social discrimination, cancer occurrence in a population may also be influenced by cultural and/or inherited factors that decrease or increase risk. Individuals who maintain a primarily plant-based diet or do not use tobacco because of cultural or religious beliefs have a lower risk of many cancers compared to non-Hispanic whites. For example, Hispanics and Asians have lower rates of lung cancer because they have historically been less likely to smoke (Table 9). Conversely, because these populations include a large number of recent immigrants, they have higher rates of cancers related to infectious agents. However, it is important to note that genetic differences associated with race or ethnicity make only a minor contribution to the disparate cancer burden between populations. Non-Hispanic Black: Non-Hispanic black (henceforth black) men have higher overall cancer incidence (592. For example, cancer mortality rates among both black and non-Hispanic white men with 12 or fewer years of education are almost 3 times higher than those of college graduates for all cancers combined because of limited access to prevention, early detection, and treatment services. This is in part because they are more likely to engage in behaviors that increase cancer risk, such as using tobacco, not being physically active, and having an unhealthy diet, but also due to higher prevalence of cancer-causing infections, workplace exposures, and other environmental exposures. Factors that contribute to a higher prevalence of cancer risk factors in this population include marketing strategies by tobacco companies and fast food chains that target these populations and environmental and/or community factors that provide few opportunities for physical activity and access to fresh fruits and vegetables. Barriers to preventive care, early detection, and optimal treatment include inadequate health insurance; financial, structural, and personal barriers to health care; and low health literacy rates. Racial and Ethnic Minorities Disparities in the cancer burden among racial and ethnic minorities largely reflect obstacles to receiving health care services related to cancer prevention, early detection, and high-quality 50 Cancer Facts & Figures 2016 Table 9. Source: Incidence ­ North American Association of Central Cancer Registries, 2015. Cancer death rates in black men are twice those in Asian and Pacific Islanders (128. Black women have 14% higher cancer death rates than non-Hispanic white women despite 6% lower incidence rates. Hispanic/Latino: Cancer patterns in Hispanics generally reflect those in immigrant countries of origin, but become more similar to non-Hispanic white Americans across generations due to acculturation. For example, compared to non-Hispanic whites, cervical cancer incidence rates are 44% higher, and liver and stomach cancer incidence rates are about twice as high (Table 9, page 51). Differences in the prevalence of smoking, obesity, and hypertension likely contribute to these disparities. For information about American Cancer Society advocacy efforts dedicated to reducing the cancer burden among minority and medically underserved populations, see "Advocacy" on page 62. Lung cancer death rates are more than 3-fold higher in Kentucky (92 and 55 per 100,000 in men and women, respectively) ­ the state with the highest rates ­ than in Utah (26 and 16 per 100,000 in men and women, respectively), which has the lowest rates. These differences reflect the substantial historic variation in smoking prevalence among states, which continues today. For example, smoking prevalence in adults in 2013 ranged from 10% in Utah to 27% in Kentucky and West Virginia. Geographic variations in cancer occurrence also reflect differences in environmental exposures, socioeconomic factors related to population demographics, and screening behaviors. There is little state variation in the occurrence of cancers that are less influenced by behavior and/or early detection tests, such as nonHodgkin lymphoma (Table 4, page 7). The Global Fight against Cancer the ultimate mission of the American Cancer Society is to eliminate cancer as a major health problem. Cancer is an enormous global health burden, touching every region and socioeconomic group. More than 60% of cancer deaths occur in low- and middle-income countries, many of which lack the medical resources and health systems to support the disease burden. Moreover, the global cancer burden is growing at an alarming pace; in 2030 alone, about 21. The future burden may be further increased by the adoption of behaviors and lifestyles associated with economic development and urbanization. Cancer Facts & Figures 2016 53 Worldwide Tobacco Use Tobacco-related diseases are the most preventable cause of death worldwide, responsible for the deaths of approximately half of all long-term tobacco users. It features specific provisions to control both the global supply of and demand for tobacco, including the regulation of tobacco product contents, packaging, labeling, advertising, promotion, sponsorship, taxation, illicit trade, youth access, exposure to secondhand tobacco smoke, and environmental and agricultural impacts. Parties to the treaty are expected to strengthen national legislation, enact effective domestic tobacco control policies, and cooperate internationally to reduce global tobacco consumption. A number of major tobacco-producing nations, including Argentina, Indonesia, Malawi, and the United States, have not ratified the treaty. The Society works to reduce the global burden of cancer by preventing cancer, saving lives, diminishing suffering, catalyzing local responses, and shaping the global policy agenda. Cervical and breast cancers are the most commonly diagnosed cancers among women in most areas of the world. Focusing on fighting these cancers is a priority for the American Cancer Society, not only because they affect so many women, but also because cost-effective and proven prevention, screening, and treatment options exist. Chan School of Public Health to estimate the cost of achieving comprehensive global cervical cancer prevention over the next decade in low- and middle-income countries. The study found that scaling up comprehensive prevention steadily from 2015 through 2024 would cost $18. Many governments in low- and middle-income countries are ill-prepared to adequately address the increasing burden of cancer. In many cases, civil society actors (nongovernmental organizations, institutions, and individuals) are also not yet fully engaged in cancer control efforts. Untreated moderate to severe pain, which is experienced by about 80% of people with advanced cancer, is a consistent feature of cancer care in resource-limited settings. Improved access to essential pain medicines is arguably the easiest and least expensive need to meet, would do the most to relieve suffering, and may also extend survival, according to recent data. The Society has projects in Nigeria, Ethiopia, Kenya, Uganda, and Swaziland to improve access to essential pain medicines. In Nigeria, the Society collaborated with the government to make morphine available for the first time in several years and set up a local production system in 27 teaching hospitals that lowered the price for patients by 80% to 90%. The Society continues to support the national morphine production facility in Uganda, which has been operating since 2010, and is supporting Kenya to replicate the model in the national hospital in Nairobi. The Society is also training health workers in more than 25 teaching and referral hospitals across the 5 countries through the Pain-Free Hospital Initiative, a 1-year hospital-wide quality improvement initiative designed to change clinical practice by integrating effective, high-quality pain treatment into hospital-based services. The Society continues to work with global collaborators to increase awareness about the growing global cancer and tobacco burdens and their impact on low- and middle-income countries. In addition, recent publications by the Intramural Research department include: · Global Cancer Facts & Figures, 3rd Edition (cancer. Its purpose was to raise awareness about cancer symptoms, treatment, and prevention; to investigate the causes of cancer; and to compile cancer statistics. We combine our relentless passion with the wisdom of over a century of experience to make this vision a reality, and we get results. Our Divisions and local offices are organized to engage communities in the cancer fight, delivering patient programs and services and raising money at the local level. Offices are strategically located around the country in an effort to maximize the impact of our efforts and be as efficient as possible with the money donated to the Society to help finish the fight against cancer. The Society also offers many products to employers and other systems to help their employees stay well and reduce their cancer risk, too. Targeted behaviors include organizational readiness, tobacco control, cancer screening, healthy eating, physical activity, and cancer care. The e-newsletter focuses on exercising, eating better, and maintaining a healthy weight. Following the completion of the survey, the company receives a detailed report that includes information needed to help create new ­ or enhance existing ­ workplace tobacco policies, programs, and benefits. The resource can assist employers in creating a safe, tobacco-free environment that enhances employee well-being. Volunteers the Society relies on the strength of millions of dedicated volunteers. Supported by professional staff, Society volunteers drive every part of our mission. Prevention and Early Detection the American Cancer Society is doing everything in our power to prevent cancer. We are diligent in encouraging cancer screenings for early detection and promote healthy lifestyles by bringing attention to obesity, healthy diets, physical activity, and avoiding tobacco. The Quit For Life Program employs an evidence-based combination of physical, psychological, and behavioral strategies to enable participants to take responsibility for and overcome their addiction to tobacco. A critical mix of medication support, phone-based cognitive behavioral coaching, text messaging, web-based learning, and support tools produces an average 6-month quit rate of 49%. Following the completion of the survey, the company receives a detailed report that includes information needed to help create new-or enhance existing workplace policies, programs and benefits. The Society publishes guidelines on nutrition and physical activity for cancer prevention in order to review the accumulating scientific evidence on diet and cancer; to synthesize this evidence into clear, informative recommendations for the general public; to promote healthy individual behaviors and environments that support healthy eating and physical activity; and, ultimately, to reduce cancer risk. The Society also continues to encourage the early detection of breast cancer through public awareness and other efforts targeting poor and underserved communities. Information, 24 Hours a Day, 7 Days a Week the American Cancer Society is available 24 hours a day, 7 days a week online at cancer. Callers are connected with a cancer information specialist who can help them locate a hospital, understand cancer and treatment options, learn what to expect and how to plan, address insurance concerns, find financial resources, find a local support group, and more. The Society can also help people who speak languages other than English or Spanish find the assistance they need, offering services in more than 200 languages. Information on every aspect of the cancer experience, from prevention to survivorship, is also available through cancer. The site contains in-depth information on every major cancer type, as well as on treatments, side effects, caregiving, and coping. The Society also publishes a wide variety of brochures and books that cover a multitude of topics, from patient education, quality of life, and caregiving issues to healthy living. Early Detection Finding cancer at its earliest, most treatable stage gives patients the greatest chance of survival. To help the public and health care providers make informed decisions about cancer screening, the American Cancer Society publishes a variety of early detection guidelines. Those guidelines are assessed regularly to ensure that recommendations are based on the most current scientific evidence. The Society currently provides screening guidelines for cancers of the breast, cervix, colorectum, endometrium, lung, and prostate, as well as general recommendations for a cancer-related component of a periodic checkup to examine the thyroid, oral cavity, skin, lymph nodes, testicles, and ovaries. Throughout its history, the Society has implemented a number of aggressive awareness campaigns targeting the public and health care professionals. Campaigns to increase usage of Pap testing and mammography have contributed to a 70% decrease in cervical cancer death rates since 1969 and a 36% decline in breast cancer death rates since 1989.

Diagnosis the detailed history allergy symptoms dizzy discount 5mg clarinex overnight delivery, physical examination allergy shots for poison ivy cheap 5mg clarinex with mastercard, and radiographs confirm the diagnosis allergy medicine voice buy clarinex 5 mg on line. Larynx allergy testing kits for physicians safe clarinex 5 mg, Trachea and bronchus management Medical: Antibiotics allergy treatment vancouver generic clarinex 5 mg with mastercard, steroids and oxygen are administered immediately allergy shots ingredients purchase clarinex 5 mg fast delivery, and continued after the bronchoscopy. Gap and crepitus between fractured fragments of thyroid and cricoid cartilages or hyoid bone. Chapter 51 w management of Impaired airway Respiratory distress: If a child with respiratory distress is becoming quiet, it indicates that the child is about to have respiratory collapse. Pathology Depending on the mode and severity of injury, the following lesions can occur: Bruises: External cervical bruises. Tear and laceration of mucosa: Tears in laryngeal or pharyngeal mucosa results in subcutaneous emphysema. Fractures: Compound (external or internal) or comminuted fractures of the laryngeal framework are common after 40 years of age because of calcification of the laryngeal framework. Hyoid bone Thyroid cartilage (vertical or transverse): Fracture of upper part of thyroid cartilage may cause avulsion of epiglottis and false cords. Fractures of lower part of thyroid cartilage can disrupt true vocal cords Cricoid cartilage Upper tracheal cartilages Hematoma and edema of supraglottic or subglottic region. Direct laryngoscopy is relatively contraindicated as it may precipitate respiratory distress. X-ray soft tissue neck lateral view: It may show subcutaneous emphysema, mucosal swelling, fracture/displacement of epiglottis, thyroid and cricoid cartilages, hyoid bone, or change in the air column. Complications Laryngeal stenosis: Supraglottic, glottic or subglottic Perichondritis Laryngeal abscess Vocal cord paralysis Treatment Watch out for respiratory distress. Management of impaired airway: In cases of laryngeal trauma, tracheostomy is preferred over endotracheal intubation which may be difficult and hazardous. Open reduction: It should be done in 3­5 days after injury, and definitely before 10 days. Wire and titanium miniplate: For fractures of hyoid bone, thyroid or cricoid cartilage. Internal splint of laryngeal structures: A laryngeal stent or silicone tube may have to be left for 2­6 weeks. Congenital stridor with a hoarse cry: Some of the causes are laryngeal web, laryngeal paralysis and congenital laryngeal cyst. Laryngomalacia: It is the commonest cause of "inspiratory stridor" shortly after the birth. Stridor is relieved when child is put in prone position and disappears spontaneously as the child grows. Congenital subglottic stenosis: In case of premature neonate with subglottic stenosis, tip of 3 mm diameter bronchoscope cannot be passed through subglottis. In a full term newborn with subglottic stenosis tip of 4 mm diameter bronchoscope cannot be passed. X-ray chest may show either hyper inflated (emphysema) lung on one side or unilateral atelectasis (collapse) of lung. Laryngeal trauma: the chief danger of laryngeal trauma is respiratory distress stridor. Foreign body inhalation in children: Decisive factors for carrying out bronchoscopy. Comparative study of percutaneous dilatational tracheostomy and conventional tracheostomy in the intensive care unit. Elective open tracheostomy for patients under prolonged mechanical ventilation-a study. Section 7: Neck 52 Points of Focus Neck Cervical Symptoms and Examination One should not trifle with a thing, though it may be very insignificant. Although the congenital/developmental swellings occur in children (< 15 years of age) and young adults (16­40 years of age), they are less common than inflammatory masses in these age groups. In contrast, neoplasia should be considered first in older adults (> 40 years of age). The specific history aspects and physical findings limit the number of diagnostic tests and can avoid unnecessary investigations. The key features of physical examination include: Site of the swelling according to anatomic lymphatic drainage. Palpation of cervical lymph nodes is carried out while standing behind the seated patient. Examiner uses both hands simultaneously, with fingers semiflexed and adducted, and thumbs in partial opposition. Internal jugular chain (upper, middle and lower) groups lie deep to sternocleidomastoid muscle, which needs to be retracted. The nodes are explored systematically: the submental triangle, the submandibular glands and triangles (thumbs over buccinators); the retromandibular depressions (thumbs probing over parotids), the upper attachment of sternocleidomastoid, and the occipital attachment of trapezius. Palpation then continues along the vertical chains of cervical nodes which have superficial (associated with the external jugular and anterior jugular veins, the superficial cervical and anterior cervical groups) and deep nodes (upper, middle and 521 chapter 52 w a. Metastatic nodes are usually hard but metastatic melanoma and lymphoma nodes are soft. Common submandibular swellings: Lymphadenopathy, submandibular salivary gland swelling, deep or plunging ranula, extension of growth from mandible. Common swellings of lower part of posterior triangle: Lymph nodes enlargement, cystic hygroma and cervical rib. Swellings moving with deglutition: Goiter, thyroglossal cyst, laryngeal swellings, subhyoid bursitis, and prelaryngeal and pretracheal tubercular and metastatic lymph nodes attached to larynx and trachea. Branchial cyst: this cystic swelling is partially covered by the anterior margin of upper third of sternocleidomastoid. Sternomastoid tumor: An oval firm swelling in the line of sternomastoid muscle of a newborn baby with torticollis (head is bent to one side whilst the chin points to the other side). Secondary metastatic nodes: Hard, painless, and progressively enlarging swelling at the levels of cervical lymph nodes. Osteomyelitis sinus of mandible: this single sinus lies slightly below the inferior margin of mandible. Actinomycosis: Sulfur-like grains in the pus coming out from multiple sinuses over an indurated mass at the upper part of neck. Branchial fistula: A pin-point opening present since birth at the lower third of anterior border of sternocleidomastoid muscle. In these cases, neck movements (flexion, extension, rotation and lateral flexion) are limited. While testing cervical movements, deaths have been reported from the dislocation of atlantoaxial joint and dens pressing the medulla. Thyroglossal cyst and fistula: this cervical midline cyst is present between hyoid and thyroid gland, and moves with deglutition. Cyst may get secondarily infected, and form abscess which may be either incised surgically or burst spontaneously, and results in thyroglossal fistula. Cold abscess neck pointing at two sites: posterior triangle and suprasternal region Thyroglossal cyst: this midline neck mass is recognized by its movement with swallowing. Carotid triangle swellings: the most common causes of swellings in this region are paragangliomas, schwannomas, meningiomas and nodal metastases. DiagNoStic teStS In suspected cases of inflammatory adenopathy, a trial of antibiotic therapy and observation (not > 15 days) is well accepted as a clinical test. Radionuclide scanning: this scan shows whether the mass has functioning or nonfunctioning tissue. It is helpful in thyroid disorders, and in localizing the mass inside or outside of the salivary gland. Fine needle aspiration cytology and open biopsy: A 25-gauge needle biopsy is gold standard in diagnosis of a neck mass. If needle biopsy is inconclusive or negative and suspicion is high, open biopsy should be performed. Papillary carcinoma is common in young girls whereas follicular carcinoma occurs in middleaged women. Simple goiters grow very slowly, and may remain of the same size for years at a stretch. The papillary and follicular carcinomas also grow slowly for years before metastasizing. Primary thyrotoxicosis: these patients may or may not have goiter, and the brunt of attack falls on nervous system. The symptoms include loss of weight, staring or protruding eyes, preference for cold, excessive sweating, excitability, irritability, insomnia, tremors and muscle weakness. Secondary thyrotoxicosis: In this condition, longstanding thyroid nodule and simple or multinodular goiter develop toxic features. In this disease, the brunt of attack falls on cardiovascular systems, and patients do not have protruding eyes and tremors. The cardiovascular symptoms include palpitation, ectopic beats, chest pain and dyspnea on exertion. Other features are cardiac arrhythmias, congestive cardiac failure and swelling of ankles. Myxedema (hypothyroidism): the symptoms include weight gain, intolerance to cold weather, dry skin, puffiness of face, dull expression, loss of hair and two-third of eye brows, muscle fatigue, lethargy and mild hoarseness of voice. Pressure effects: Enquire about dyspnea (pressure on trachea), dysphagia (pressure on esophagus) and hoarseness of voice (pressure on recurrent laryngeal nerve). Hypothyroidism causes weight gain, bradycardia, dry and rough skin and depression. The thyroid swellings are palpated both from the front and behind (Figs 11 and 12). Mobility: Movements with deglutition are greatly limited in cases of chronic thyroiditis inflammation and malignancy. Note the obliteration of suprasternal space that raises suspicion of retrosternal extension Section 7. Fingers palpate lobes of the gland, and thumbs are placed on occipital region to keep the neck flexed w Neck. Patient is first requested to swallow her saliva and then surgeon pushes his fingers in suprasternal region to feel the lower extent of thyroid mass. One hand pushes the gland to make the lobe prominent, and the other hand palpates the prominent lobe Retrosternal extension (Figs 13 and 14): It puts pressure on the great veins at the thoracic inlet and results in dilatation of subcutaneous veins over the upper part of chest. In these cases, it is not possible to get the lower limit of goiter on deglutition. Raising of both arms and touching both the ears result into facial congestion, cyanosis and distress. Clinically, it is difficult to know whether the nodule is solid or cystic because the cystic fluid may be under great tension. Ultrasonography neck examination easily differentiates between solid and cystic swellings. Surrounding structures Trachea: It can be displaced and compressed from both the sides (scabbard trachea). Recurrent laryngeal nerve: Its involvement leads to vocal cord palsy and hoarseness of voice, and suggests malignancy. Malignant goiter can engulf the carotid sheath and then carotid pulsations are not detected. Measurement of neck circumference: Measurement of neck circumference at the most prominent part of goiter helps in determining the progress and results of treatment. Metastasis: In addition to the draining neck lymph nodes, surgeon should look for distant metastases in skull and pathological fractures of long bones. The small amount biologically active hormones remain unbound and free, and have metabolic activity. T3 is toxic Manifestations the cardinal signs of primary toxic goiter include exophthalmos, enlargement of thyroid gland, tachycardia and tremors. In the secondary toxic goiter (toxicity occurring in preexisting longstanding adenoma or nodular goiter), exophthalmos and tremors are usually absent. The free T3 and T4 are preferred, and the assay of total T3 and T4 are now becoming obsolete. Thyroid autoantibodies: the levels of antibodies against thyroid peroxidase (thyroid microsomal antigen) and thyroglobulin are significantly high in many cases of autoimmune thyroiditis. In the follow-up cases of thyroid carcinomas, surgeon should not forget that anti-thyroglobulin antibody affects the levels of thyroglobulin levels. X-ray chest and thoracic inlet: It shows the retrosternal extension of goiter, tracheal deviation and compression and pulmonary metastasis. Their indications include malignancy, retrosternal extension and recurrent thyroid swellings. Isotope scanning: It is indicated only in thyrotoxicosis to localize the area of overactivity in thyroid gland (single nodule or multinodular goiter) that has important implications for therapy. Whole-body scanning is indicated in operated patients of thyroid carcinoma to demonstrate metastases. Serum calcitonin and carcinoembryonic antigen: They are screening tests for medullary carcinoma. Isolated cysticercosis cellulosae of sternocleidomastoid muscle: a case report with review of literature. No power can avert them; when once you have put them in motion, you will have to bear them. In children and young adults, congenital/developmental swellings are more common than inflammatory masses. The specific history aspects and physical findings limit the number of diagnostic tests, and can avoid unnecessary investigations. Thorough physical examination gives an idea about the derivation of mass-inflammatory, congenital or neoplastic; vascular, salivary, thyroid or nodal. See the table of common neck masses in Chapter "Cervical Symptoms and Examination.

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The pathological processes include production of pus under tension and hyperemic decalcification and osteoclastic resorption of bony walls allergy symptoms medication safe 5 mg clarinex. Production of pus under tension: the inflammatory process to mucoperiosteal lining increases the amount of pus food allergy symptoms quiz 5 mg clarinex with visa. Swollen mucosa of the antrum and attic impede the drainage and result in further accumulation of pus allergy shots moving buy generic clarinex 5mg. Hyperemic decalcification and osteoclastic resorption: Hyperemia causes dissolution of calcium from the mastoid air cells (hyperemic decalcification) allergy symptoms getting worse order 5 mg clarinex fast delivery. The destruction and coalescence of mastoid air cells convert mastoid into a single large cavity allergy treatment honey discount clarinex 5mg line, which is filled with pus and also called "empyema mastoid allergy shots zyrtec generic clarinex 5 mg with mastercard. The discharge may cease (due to obstruction in its drainage) with progressive worsening of clinical features. Mastoid tenderness: Tenderness may be present over the middle of mastoid process, mastoid tip, posterior border or the root of zygoma. Sagging of posterosuperior meatal wall: It indicates periostitis of bony wall that lies between the antrum and deep bony canal. Swelling over the mastoid region: Edema of periosteum imparts a smooth "ironed out" feeling over the mastoid. Culture and sensitivity of ear discharge: To know the organism and the antibiotics to which they are sensitive. Hospitalization and antibiotics: these patients need intravenous antibiotics in high doses. Positive reservoir sign: external auditory canal fills with pus immediately after it has been cleaned. No improvement or worsening of condition in spite of adequate medical treatment for 48 hours. Zygomatic abscess (Figs 3A and B): Infection of zygomatic air cells, which are situated at the posterior root of zygomatic arch, results in zygomatic abscess. Etiology: Inadequate dose, frequency and duration of antibiotic therapy are the most incriminating factors. Pathology: Mastoidectomy in latent mastoiditis shows extensive destruction of the air cells with granulation tissue and dark gelatinous material filling the mastoid. Erosion of the tegmen tympani and sinus plate can result in an extradural and perisinus abscess respectively. Treatment: Treatment consists of cortical mastoidectomy with full doses of antibiotics. Parapharyngeal and retropharyngeal abscesses: Infection of the peritubal cells in cases of acute coalescent mastoiditis can result into these abscesses. The abscess may follow any of the following courses: Lie deep to sternocleidomastoid muscle and pushing it laterally. Lie in the digastric triangle: Follow the posterior belly of digastric and present between the tip of mastoid and angle of jaw. Clinical features: Sudden onset of pain, fever, a tender swelling in the neck and torticollis in cases of purulent otorrhea. Intravenous antibiotics are given as per the report of culture and sensitivity of the pus taken at the time of surgery. Cortical mastoidectomy with exploration of mastoid tip for a fistulous opening into the soft tissues of the neck. Incision and drainage of the neck abscess is done through a separate incision and putting a drain. Posterosuperior tract: From the attic and antrum the tract passes around semicircular canals to petrous apex. Through the mastoid tip abscess extends either deeper to sternocleidomastoid muscle or into the submandibular triangle Persistent ear discharge in cases of cortical or modified radical mastoidectomy may be due to petrositis. Most patients respond well to antibacterial therapy alone, which is given in high doses and continued for 4­5 days after the disappearance of symptoms. Radical or modified radical mastoidectomy: the fistulous tract is curetted and enlarged to provide free drainage. The affected dura gets covered with granulations and appears unhealthy and discolored. An extradural abscess may lie in Middle cranial fossa Posterior cranial fossa Perisinus abscess: Outside the dura of lateral venous sinus in posterior cranial fossa chapter 20 w Clinical features: In cases of dehiscent fallopian bony canal, facial nerve lies just under the middle ear mucosa. Inflammation of middle ear easily spreads to epineurium and perineurium and results in facial paralysis, which usually manifests within 10 days. Treatment: Facial nerve function usually recovers with systemic antibiotics and wide-field myringotomy or tympanostomy tube. Persistent headache, which disappears with free flow of pus from the ear (spontaneous abscess drainage) occurs on the side of otitis media. High-resolution computed tomography of temporal bone: It is essential in the evaluation of facial nerve palsy. Facial canal should be examined from the geniculate ganglion (processus cochleariformis) to the stylomastoid foramen. In cases of granulation tissue and cholesteatoma, bony facial canal is uncapped in the area of involvement. Granulation tissue surrounding the nerve is removed without damaging the nerve sheath. The nerve grafting is usually preferred in the second stage when infection is controlled and fibrosis has matured. Mastoidectomy (cortical, radical or modified radical): the overlying bone is removed until the healthy dura appears. In cases of strong suspicion overlying intact tegmen tympani or sinus plate is deliberately removed to evacuate any collection of pus. Follow-up Patient should be closely observed for further intracranial complications, such as sinus thrombosis, meningitis or brain abscess. The subdural space is divided into several large compartments, which are anatomically confined, by foramen magnum, tentorium cerebelli, base of the brain and falx cerebri. An extradural abscess pathology Infection can spread either by erosion of bone and dura or by thrombophlebitic process (intervening bone remains intact). Thrombophlebitis of cortical veins of cerebrum: Aphasia, contralateral hemiplegia and hemianopia. Preformed pathways Patent petrosquamosal suture Perineural spaces to the internal auditory canal (uncommon via endolymphatic ducts) via labyrinth through round and oval windows Retrograde venous thrombophlebitis Direct erosion of bone (mastoiditis and petrositis) and dura microbiology Major pathogens are Hemophilus influenzae and Streptococcus pneumoniae. The raised intracranial tension and meningeal and cerebral irritations vary with the extent of disease. Earliest symptoms include­ Fever (102­104° F) often with chills and rigors Headache Vomiting (sometimes projectile) Photophobia Irritability and restlessness Seizures: Infants may have seizures. Lumbar puncture is contraindicated as it can result in herniation of cerebellar tonsil. If there is no satisfactory response to medical treatment, early surgery is required. Antibiotics: Crystalline penicillin, ampicillin, chloromycetin or third generation cephalosporin (drugs of choice) intravenously for 7­10 days. Stage of invasion (Initial encephalitis) of 1­3 days: the mild symptoms include headache, low grade fever, malaise and drowsiness. Stage of localization (Latent abscess) of 4­10 days: In this asymptomatic stage, which may last for several weeks, pus is getting localized by the formation of a capsule. Stage of enlargement or early capsule formation (manifest abscess) of 10­13 days: the enlarging abscess surrounded by a zone of edema aggravates the severity of clinical manifestations, which are due to raised intracranial tension and the focal involvement of brain. Stage of termination or late capsule formation (rupture of abscess) of 14 days: the enlarging abscess ruptures into either the ventricle or subarachnoid space. It is surrounded by an area of inflammation (encephalitis) · Fifty percent cases of brain abscesses in adults and 25% in children are otogenic. As the brain abscess is often associated with extradural abscess, perisinus abscess, meningitis, sinus thrombosis and labyrinthitis, the clinical picture may be overlapping. Clinical features are mainly due to raised intracranial tension and the area of brain affected. Raised intracranial tension Headache is severe and generalized, worse in the morning. Nausea and vomiting (usually projectile): It is more common in cerebellar abscess. Bimodal Age Distribution: Peak incidences are in pediatric age and 4th decade of life. Retrograde thrombophlebitis of dural vessels, which terminate in white matter, is usually caused by the osteitis and granulation tissue. Cerebral abscess: Cerebral abscess is often associated with extradural abscess that occurs due to erosion of the tegmen. It is often associated with extradural abscess, perisinus abscess, sigmoid sinus thrombophlebitis or labyrinthitis. Aerobic: Gram-positive: Pyogenic staphylococci, Streptococcus pneumoniae and Streptococcus haemolyticus Gram-negative: Proteus mirabilis, Escherichia coli, Klebsiella and Pseudomonas aeruginosa Anaerobic: Peptostreptococcus and Bacteroides fragilis. Localizing features of temporal lobe abscess Nominal aphasia: It occurs if the lesion is of dominant cerebral hemisphere, which is left side in right handed persons. Contralateral homonymous hemianopia: It indicates pressure on the optic radiations. Contralateral motor paralysis: They are: ­ Upward spread: Facial palsy is followed by palsy of arm and leg. Localizing features of cerebellar abscess Suboccipital headache associated with neck rigidity. Dysdiadokokinesia: Rapid pronation and supination movements become slow and irregular on the affected side. Raised intracranial tension: Dexamethasone, 4 mg intravenous 6 hourly or mannitol 20% in doses of 0. Neurosurgical: Life saving neurosurgical intervention takes precedence over the otologic management. Neurosurgeon may consider any of the following procedures: Burr hole: Repeated aspiration of pus Excision of abscess Open incision of the abscess and evacuation of pus C. Otologic: Only neurologically stabilized patients are taken for tympanomastoid surgery. Ear surgery is planned only after the abscess has been managed by antibiotics and neurosurgery. Cholesteatoma needs radical mastoidectomy, which removes the irreversible disease and exteriorizes the infected area. With the advent of new range of antibiotics, the incidence of this complication has declined yet mortality remains high. It detects not only the subtle changes in brain parenchyma but also spread of abscess into the subarachnoid space or into the ventricle. Endophlebitis and mural thrombus: Inflammation of the inner wall of the venous sinus results in thrombus formation (deposition of fibrin, platelets and blood cells) within the lumen of sinus. Obliteration of sinus and intrasinus abscess: Expanding mural thrombus occludes the sinus lumen. Organisms invade the thrombus and form intrasinus abscess that releases infected emboli into the blood stream (septicemia). It may spread to confluence of sinuses, superior sagittal sinus, cavernous sinus, mastoid emissary vein, jugular bulb or internal jugular vein. Medical: the different medical treatments are: Antibiotics: Parenteral chloromycetin, penicillin or its derivatives. Aminoglycoside, such as gentamicin, covers bacteriology Acute otitis media: Hemolytic streptococcus, Pneumococci. Cholesteatoma: Bacillus proteus, Pseudomonas pyocynea, Escherichia coli and Staphylococci. Fever: Hectic type of fever with chills and rigors coincides with the release of septic emboli into blood stream. Profuse sweating follows during the fall of temperature and patient becomes alert with a sense of well-being. Headache becomes severe when venous obstruction increases the intracranial pressure. Cavernous sinus thrombosis: Chemosis, proptosis, fixation of eyeball and papilledema. Otitic hydrocephalus: Thrombus extends to superior sagittal sinus through the transverse and confluence of sinuses. Papilledema: It is seen when clot extends to superior sagittal sinus, which is in the continuation of right sigmoid and transverse sinus. Crowe-Beck test: Pressure on opposite side internal jugular vein produces engorgement of retinal veins and supraorbital veins and subside on release of pressure. Blood sample is taken when patients have chills and rigor because at that time organisms enter the blood stream. It is an empty triangular area having rim enhancement and central low density area that is seen at the level of sigmoid sinus. Sinus bony plate must be removed to expose the dura and drain the perisinus abscess. Destruction of sinus dura, unhealthy and discolored dura with granulations on its surface indicate infected clot or intrasinus abscess, which must be drained. After packing the sinus above and below with a pack that lies between the bone and dura of sinus to control bleeding, dura of the sinus is incised and the infected clot and abscess is drained. Ligation of internal jugular vein: Though rarely required, it is needed when antibiotic and surgical treatment fails to control embolic phenomenon and rigors and tenderness and swelling of internal jugular vein is spreading into the heart. Some prefer the term "benign raised intracranial tension" because there is no associated ventricular dilation.

During this period the cells adapt to the culture conditions and the length of this phase will depend upon the growth phase of the cell line at the time of subculture and also the seeding density allergy medicine orange juice buy discount clarinex 5 mg. Logarithmic (Log) Growth Phase ­ cells actively proliferate and an exponential increase in cell density arises allergy shots vancouver bc 5 mg clarinex amex. The cell population is considered to be the most viable at this phase allergy shots vs xolair discount 5 mg clarinex mastercard, therefore it is recommended to assess cellular function at this stage allergy forecast rapid city sd generic clarinex 5 mg otc. Each cell line will show different cell proliferation kinetics during the log phase and it is therefore the optimal phase for determining the population doubling time allergy treatment parasite generic clarinex 5 mg fast delivery. Plateau (or Stationary) Phase ­ cellular proliferation slows down due to the cell population becoming confluent allergy rash generic 5 mg clarinex mastercard. It is at this stage the number of cells in the active cell cycle drops to 0-10% and the cells are most susceptible to injury. Decline Phase ­ cell death predominates in this phase and there is a reduction in the number of viable cells. Cell death is not due to the reduction in nutrient supplements but the natural path of the cellular cycle. Note: Different cell lines have different timescales for each phase, this graph is provided as a general example of a typical growth curve. The in vitro age of a cell culture is particularly useful to know for cell lines with a finite lifespan or unstable characteristics that change over time in continuous culture. In addition, the culture environment should be stable in terms of pH and temperature. Over the last 30 years various defined basal media types have been developed and are now available commercially. These have since been modified and enriched with amino acids, vitamins, fatty acids and lipids. Consequently media suitable for supporting the growth of a wide range of cell types are now available. The precise media formulations have often been derived by optimising the concentrations of every constituent. Examples of the different media and their uses are given in Table 2 (see next page). Primarily they help to retain the osmotic balance of the cells and help regulate membrane potential by provision of sodium, potassium and calcium ions. All of these are required in the cell matrix for cell attachment and as enzyme cofactors. Most commercial culture media include phenol red as a pH indicator so that the pH status of the medium is constantly indicated by the colour. Usually the culture medium should be changed/replenished if the colour turns yellow (acid) or purple (alkali). The major sugars used are glucose and galactose, however, some media contain maltose or fructose. Media containing the higher concentration of sugars are able to support the growth of a wider range of cell types. Pyruvate is included in the formulation of some media, as an alternative energy source. The concentration of amino acids in the culture medium will determine the maximum cell density that can be achieved - once depleted the cells will no longer be able to proliferate. Optimal cell performance usually requires supplementation of the media with glutamine prior to use. Some media formulations include L-alanyl glutamine which is a more stable form of glutamine, and do not require supplementation. Adding supplements of non-essential amino acids to media both stimulates growth and prolongs the viability of the cells in culture. However, many media are also enriched with vitamins making them consistently more suitable for a wider range of cell lines. Many vitamins, especially B group vitamins, are necessary for cell growth and proliferation and for some lines the presence of B12 is essential. Therefore aliquot your medium before use and only warm and use volumes you need that day. The most common proteins and peptides include albumin, transferrin, fibronectin and fetuin and are used to replace those normally present through the addition of serum to the medium. For convenience, many commonly used media are available as ready mixed powders or as 10x and 1x liquid media. If powder or 10x media are purchased it is essential that the water used to reconstitute the powder or dilute the concentrated liquid is free from mineral, organic and microbial contaminants. In most cases water prepared by reverse osmosis and resin cartridge purification with a final resistance of 16-18M is suitable. Once prepared the pH of the medium should be adjusted appropriately, and then the media filter sterilised before use. The quality, type and concentration of serum can all affect the growth of cells and it is therefore important to screen batches of serum for their ability to support the growth of cells. In addition, there are other tests that may be used to aid the selection of a batch of serum including cloning efficiency, plating efficiency and the preservation of cell characteristics. Serum is also able to increase the buffering capacity of cultures that can be important for slow growing cells or where the seeding density is low. It also helps to protect against mechanical damage which may occur in stirred cultures or whilst using a cell scraper. A further advantage of serum is the wide range of cell types with which it can be used despite the varying requirements of different cultures in terms of growth factors. However, serum is subject to batch-to-batch variation that makes standardisation of production protocols difficult. These risks can be minimised by obtaining serum from a reputable source since suppliers of large quantities of serum perform a battery of quality control tests and supply a certificate of analysis with the serum. Heat inactivation of serum (incubation at 56°C for 30 minutes) can help to reduce the risk of contamination, since some viruses are inactivated by this process, however this process also denatures some proteins and destroys nutrients in the serum with modern production methods for serum, the routine use of heat inactivated serum is not an absolute requirement for cell culture. The use of serum also has a cost implication not only in terms of medium formulation but also in downstream processing. Similarly the focus is on geographical origin, the age of the animals, the breeding and slaughtering conditions, the tissue to be used and the conditions of its processing. Regulatory requirements in Europe stress the importance of justifying the use of material of bovine, caprine or ovine origin in the production of pharmaceutical products. Serum from a reputable supplier should have undergone various quality control tests which will be listed in the product information sheet. Most serum products are cell culture tested including growth promotion, cloning efficiency and plating efficiency tests. Standard tests performed on serum commonly include tests to determine the presence and/or level of the following: Sterility Virus Contamination Mycoplasma Contamination Endotoxin Haemoglobin Total Protein Immunoglobulin Hormone Testing pH (at room temperature) Osmolality 20 The basic principle of successful cryopreservation and resuscitation is a slow freeze and quick thaw. Although the precise requirement may vary with different cell lines as a general guide cells should be cooled at a rate of ­1°C to ­3°C per minute and thawed quickly by incubation in a 37°C water bath for 3-5 minutes. If this and the additional points given below are followed then most cell lines should be cryopreserved successfully. Cultures should be healthy with a viability of >90% and no signs of microbial contamination. Cultures should be in log phase of growth (this can be achieved by using pre-confluent cultures i. Such ultra-low temperatures can only be attained by specialised electric freezers or more usually by immersion in liquid or vapour phase nitrogen. Method Electric (-135oC) Freezer Liquid Phase Nitrogen Advantages · Ease of Maintenance · Steady temperature · Low running costs · Steady ultra-low (-196oC) temperature · Simplicity and mechanical reliability · No risk of crosscontamination from liquid nitrogen · Low temperatures achieved · Simplicity and reliability Disadvantages · Requires liquid nitrogen back-up · Mechanically complex · Storage temperatures high relative to liquid nitrogen · Requires regular supply of liquid nitrogen · High running costs · Risk of cross-contamination via the liquid nitrogen · Requires regular supply of liquid nitrogen · High running costs · Temperature fluctuations between -135oC and -190oC Vapour Phase Nitrogen Storage in liquid phase nitrogen allows the lowest possible storage temperature to be maintained with absolute consistency, but requires the use of large volumes (depth) of liquid nitrogen which is a potential hazard. There have also been documented cases of cross contamination by virus pathogens via the liquid nitrogen medium. For these reasons ultra-low temperature storage is most commonly in vapour phase nitrogen. For vapour phase nitrogen storage, the ampoules are positioned above a shallow reservoir of liquid nitrogen, the depth of which must be carefully maintained. A vertical temperature gradient will exist through the vapour phase, the extremes of which will depend on the liquid levels maintained, the design of the vessel, and the frequency with which it is opened. Temperature variations in the upper regions of a vapour phase storage vessel can be extreme if regular maintenance is not carried out. Modern designs of liquid nitrogen storage vessels are increasingly offering improved vapour phase storage technology. Loss of entire cell stocks through inadequate storage maintenance is distressingly common. All liquid nitrogen storage vessels should minimally include alarms that warn of low liquid nitrogen levels and should also be constantly temperature monitored and alarmed. The bulk liquid nitrogen storage vessel should not be allowed to become less than half full before it is re-supplied. This will ensure that at least one liquid nitrogen delivery can be missed without catastrophic consequences. It is highly recommended that valuable cell stocks should be backed up by storage at a second site. This should be supported by accurate record keeping and inventory control incorporating the following: Did You Know? The glass transition temperature of water is -135oC, below this molecular movement ceases and all biological activity is suspended. As with all laboratory procedures personal protective equipment should be worn at all times whilst handling nitrogen, including a full-face visor and thermally insulated gloves in addition to a laboratory coat and preferably a splash-proof plastic apron. Proper training and the use of protective equipment will minimise the risk of frostbite, burns and other adverse incidents. Risk of asphyxiation the single most important safety consideration is the potential risk of asphyxiation when escaped nitrogen vapourises and displaces atmospheric oxygen. This is critical since oxygen depletion can very rapidly cause loss of consciousness, without warning. Consequently liquid nitrogen refrigerators should be placed in well-ventilated areas in order to minimise this risk and be subject to planned preventative maintenance. Precautions for Dedicated Liquid Nitrogen Storage Areas · · · · · Use oxygen alarms set to 18% oxygen (v/v) Staff training ­ staff should be trained to evacuate the area immediately on hearing the alarm and not return until the oxygen is back to normal levels (~ 20% v/v) Staff should work in pairs when handling liquid nitrogen Prohibit the use of nitrogen outside of normal working hours Mechanical ventilation systems should be installed if at all possible sigma-aldrich. This type of system is known as a tiered banking system or Master Cell Banking system (refer to Figure 3). On initial arrival into the laboratory a new cell culture should be regarded as a potential source of contamination. Following initial expansion 3-5 ampoules should be frozen as a Token Stock before a Master Cell Bank is prepared. One of the Token Stock ampoules should then be thawed and expanded to produce a Master Cell Bank of 10-20 ampoules depending upon the anticipated level of use. Ampoules of this Master Cell Bank (2-3) should be allocated for quality control comprising confirmation that the cell count and viability of the bank is acceptable and that the bank is free of bacteria, fungi and mycoplasma. Additional tests (such as viral screening and authenticity testing) may also be required. Once these tests have been completed satisfactorily an ampoule from the Master Cell Bank should be thawed and cultured to produce a Working Cell Bank. Quality control tests (cell count and viability and the absence of microbial contaminants) are again required prior to using the cultures for routine experimentation or production. Implementation of this banking system ensures: · · · · Material is of a consistent quality Experiments are performed using cultures in the same range of passage numbers Cells are only in culture when required the original cell line characteristics are retained 24 Schematic Representation of a Tiered Cell Banking System: New Cell Line (Handled under Quarantine Conditions) Did You Know? The number of ampoules prepared for Master and Working Cell Banks depends upon the forecast demand for their use. The number of ampoules sampled for quality control is dependent upon the size of bank. Ampoules from the Working Cell Bank should be used sequentially keeping cells in culture for not more than a predetermined number of cell doublings. The Working Cell Bank should be replenished from an ampoule of the Master Cell Bank. This should be done in sufficient time to allow the quality control to be completed. A new Master Cell Bank should be prepared before the number of original Master stock drops below five ampoules. The quality of materials used (cell lines, media and other reagents) will affect the quality of the cultures and the subsequent scientific data and products derived from them. The main areas of quality control that are of concern for tissue culture are: · · · the quality of the reagents and materials the provenance and integrity of the cell lines the avoidance of microbial contamination 9. Good quality reagents and materials are available from numerous manufacturers of tissue culture media and supplements. These state the product and lot numbers and form a vital part of record keeping and tracking of reagents used in the production of cell stocks. Manufacturers of sterile plastic ware (flasks, centrifuge tubes, pipettes) designed for tissue culture use also supply Certificates of Analysis for each batch produced, which should be kept for future reference. Thus the use of cells and reagents of known origin and quality alone is not sufficient to guarantee quality of product (cell stock or culture products); it is necessary to demonstrate quality throughout the production process and also in the final product. Routine screening aids the early detection of contamination since all manipulations are a potential source of contamination. The three main types of microbial contaminants in tissue culture are: · · · Bacteria and Fungi Mycoplasma Viruses Bacterial and Fungal Contamination Bacterial contamination is generally visible to the naked eye and detected by a sudden increase in turbidity and colour change of the culture medium as the result of a change in pH. Daily microscopic observation of cultures will ensure early detection of contamination and enable appropriate action to be taken as soon as the first signs of contamination become apparent. In addition, specific tests for the detection of bacteria and fungi should be used as part of a routine and regular quality control screening procedure (see Protocol 8 on page 55). Mycoplasma Contamination Mycoplasmas are the smallest free-living self-replicating prokaryotes.

Extracts are used as flavor components in various food products allergy medicine lower immune system cheap clarinex 5 mg visa, including alcoholic allergy forecast phoenix az cheap 5 mg clarinex mastercard. The roasted root and its extract are used as coffee substitutes or in instant coffee substitute preparations allergy treatment 5mm generic 5mg clarinex. Young leaves allergy treatment for 6 year old buy clarinex 5 mg free shipping, particularly those of cultivated forms allergy treatment shots buy 5mg clarinex, are used as salad or vegetables allergy treatment benadryl clarinex 5 mg cheap. The root is reportedly used as a laxative, tonic, and diuretic and to treat various liver and spleen ailments. Root and leaves are also used for heartburn and bruises and in treating chronic rheumatism, gout, and stiff joints as well as eczema, other skin problems, and cancers. Due to its high content of inulin, juice of root can serve as source of a special high fructose syrup; a very light-colored syrup containing 71% total sugars of which 77% was fructose has been produced from dandelion root by hydrolysis and other treatment. Extracts are quite extensively used in tonics (especially those for female ailments). Also used in diuretic, laxative, and antismoking preparations as well as in cosmetic and toiletry formulations, presumably for their tonic properties. The herb is used for appetite and dyspeptic disorders, such as abdominal fullness and flatulence. Dandelion root (with herb) and dandelion leaves are subjects of positive German therapeutic monographs, allowed as a diuretic, for loss of appetite, dyspeptic problems, and disturbances in bile flow. Strengths (see glossary) of extracts are expressed in weight-to-weight ratios or flavor intensities. Part used is the dried leaf which has a characteristic coumarin-like (new-mown hay) fragrance. It is postulated that during drying (curing) cis-O-hydroxycinnamic acid glucoside is converted to coumarin by hydrolysis followed by cyclization. The charcoaldecolorized extract (deertongue incolore) has been reported to be nonirritating, nonsensitizing, nonphototoxic, and nonphotoallergenic when applied to the skin of animals and/or humans. Extracts are used as fixatives or fragrance components in perfumes and other cosmetic products. Coumarin and related compounds have been reported to be effective in reducing highprotein edemas, especially lymphedema. Anti-inflammatory activity evaluated in the carrageenan edema assay in rats showed no significant activity (6% inhibition) compared with indomethacin (63% inhibition) in oral administration of an aqueous extract of the roots; positive results were reported, however, in acute inflammatory reactions with intravenous administration. The same tuber extract at a dose corresponding to 400 mg of the dried secondary root/kg proved more efficient than indomethacin at 10 mg/kg. It has been suggested that simultaneous action of various principles other than iridoid glycosides is responsible for positive experimental anti-inflammatory activity. Conflicting results in various studies have been attributed to nonefficacy of oral versus i. Analgesic activity, with a reduction of high uric acid and cholesterol levels, has also been observed. The displayed anticonvulsant effect was similar to that of phenobarbitone and diazepam. The petroleum ether extract of the root displayed selective in vitro antiplasmodial activity against two strains of Plasmodium falciparum (chloroquine-resistant and -sensitive). Bioassay-guided fractionation resulted in the isolation of two diterpenes to which the activity was attributed. Extracts have exhibited an arterial blood pressure reduction in rats, a decrease in heart rate in rabbits, and a protective effect against arrythmias. Used in Africa and since the early 20th century in Europe for indigestion (bitter tonic), blood diseases, headache, allergies, rheumatism, arthritis, lumbago, neuralgia; also as febrifuge, purgative; externally for sores, ulcer, boils, and skin lesions; folk cancer remedy. Root the subject of an official monograph in Germany, indicated for loss of appetite, dyspeptic discomfort, and others. Parts used are the dried ripe fruit (commonly called "seed") and the whole aboveground herb (dill herb) harvested immediately before the fruits mature or, for best quality, before flowering. Dill seed oil is obtained by steam distillation of the crushed dried fruits, and dillweed oil (dill oil or dill herb oil) is obtained by steam distillation of the freshly harvested herb. Dill seed oil is produced mainly in Europe, while dillweed oil is produced primarily in the United States. Part used is the dried ripe fruit (commonly called "seed"); Indian dill seed oil (Indian dill oil or East Indian dill seed oil) is obtained by steam distillation of the crushed fruit. Dill seed oil contains mainly carvone (35­60%), d-limonene, and a-phellandrene, which together can account for 90% of the oil. Of these compounds, nine were reported for the first time and included a monoterpene, six monoterpene glycosides, an aromatic, and an alkyl glucoside. Two minor aromatic compounds (a propiophenone and a biphenyl derivative) were isolated from 3 kg of dried Indian dell seeds. Ethanolic extracts of dill seeds as well as the volatile oil have been shown to produce diuresis in dogs, while significantly increasing Na ю and ClА excretion. Oral administration of the essential oil had a comparable effect on triacylglycerides but had no effect on cholesterol level. The reduction of gastric lesions was attributed not only to the antacid effect of the extracts but also to a possible cytoprotective effect of their terpene and flavonoid constituents. Both in domestic Western and Chinese medicine, dill seed and dill seed oil are used as aromatic carminative and stimulant in the treatment of flatulence, especially in children. Reported to have carminative, antispasmodic, sedative, lactagogue, and diuretic properties. Used in India, Africa, and elsewhere for hemorrhoids, bronchial asthma, neuralgias, renal colic, dysuria, genital ulcers, dysmenorrhea, and others. Dill weed oil is used as a fragrance component in cosmetics, including soaps, detergents, creams, lotions, and perfumes. Dill and Indian dill are reportedly used in baked goods, meat and meat products, condiments and relishes, fats and oils, and others; highest average maximum use level is about 2. Dill seed is the subject of a positive German therapeutic monograph, indicated as a spasmolytic and bacteriostatic for dyspeptic disorders, with a mean daily dosage of 3 g (or 0. Common/vernacular names: Quack grass, couch grass, witchgrass, quick grass, quitch grass, triticum, and agropyron. Parts used are the dried rhizomes and roots collected in the fall or early spring. Used in European phytomedicine for irrigation therapy in the treatment of inflammatory diseases of the urinary tract and the prevention of kidney stones. Extracts are used as flavor components in nonalcoholic beverages, frozen dairy desserts, candy, baked goods, and gelatins and puddings. Used as a diuretic and expectorant, to reduce blood cholesterol, and in treating nephrolithiasis (kidney stones), diabetes, chronic skin diseases, and liven ailments, among others. The lectin binds to N-acetylgalactosamine and agglutinates erythrocytes of blood group A. Root subject of a positive German therapeutic monograph for inflammatory diseases of the kidney tract. Jamaican dogwood bark is different from the bark of flowering dogwood (also known as common dogwood, boxwood, and simply, dogwood). An extract of Jamaican dogwood has been reported to exhibit a sedative effect in cats and guinea pigs as well as marked antitussive and antipyretic activities; it also has anti-inflammatory properties and antispasmodic action on smooth muscles. It is used as analgesic, narcotic, and antispasmodic; in promoting sleep; and in treating whooping cough, toothache, asthma, and other ailments. Bauer and coworkers at Munich and Dsseldorf now makes distinction of source u species in commercial supplies possible. Other constituents include a resin (yielding oleic, linoleic, cerotic, and palmitic acids on hydrolysis), rnyristic and linolenic acids, n-triacontanol, b-sitosterol, stigmasterol, sitosterol-3-b-O-glucoside (leaves and stems), behenic acid ethyl ester (roots), and three glycoproteins. In stored roots (commercial dried root), these components are oxidized by atmospheric oxygen to the hydroxylated derivatives 8-hydroxytetradeca-9E-en-11,13diyn-2-one;8-hydroxypentadeca-9E,13Z-dien11 -yn-2-one; and 8-hydroxypentadeca-9E-en11,13-diyn-2-one. Alkylamides include isomeric dodeca-(2E,4E,8Z,10E/Z)-tetraenoic acid isobutylamides, dodeca-2Z,4E-diene8,10-diynoic acid isobutylamide (also in E. The authors attributed the observed effect to the antihyaluronidase activity of echinacoside. Yeasts, such as Saccharomyces cerevisiae and different species of Candida, are susceptible to the light-mediated activity of E. Immunostimulant activity involves an overall increase in phagocytosis by macrophages and granulocytes. Active components of lipophilic (chloroform) extracts may include polyacetylenes, alkylamides, and essential oils. In the granulocyte smear test, all ethanolic root extracts of the three species increased in vitro phagocytosis by 20­30% (E. In lipophilic fractions, alkylamides and the polar caffeic acid derivative cichoric acid contribute to activity of alcoholic extracts. At a dose of 2­4 mL/day, patients with diminished immune response (expressed by a low T4:T8 cell ratio) were found to benefit significantly from preventative treatment with the Echinacea preparation. These studies investigated the efficacy of echinacea in immunostimulation,31­33 upper respiratory tract infections, common cold, and flu. Numerous in vivo and in vitro studies have been reported about new activities of echinacea. The fact that the same extracts stimulated cytokine production in uninfected cells further substantiated the reputed immunostimulant effects of Echinacea. Also, detailed monographs have been published that describe in detail the botany, chemistry, and pharmacology of the different species of Echinacea. Echinacea preparations, especially oral (liquid extract), topical (ointment), and parenteral products of the fresh aboveground preparations of E. As immunostimulants; internally a prophylactic at the onset of cold and flu symptoms and for treatment of Candida albicans infections, chronic respiratory infections, prostatitis, polyarthritis (rheumatoid arthritis), and so on. Numerous oral dosage products, vicariously positioned as cold and flu preventatives. Echinacea seems to have been used as a remedy for more ailments than any other plant. For example, more than 50 cases of allergy were detected in Australia and were linked to the use of echinacea preparations. Class 1 dietary supplement (can be safely consumed when used appropriately); formerly E. Flowers are used as diuretic, laxative, and diaphoretic, as well as a gentle astringent for the skin and in treating rheumatism, usually in the form of a tea, infusion, poultice, or water distillate. Bark of American elder and bark, leaf, flower, root, and fruit of European elder have been reported to be used in cancers. Elder flowers are generally considered to have diuretic, diaphoretic, and laxative properties. European elder flower water (water phase from steam distillate) has been used as a vehicle for eye and skin lotions. Flowers are reported to be used as flavor components in numerous food products, including alcoholic (bitters and vermouths) and nonalcoholic beverages, frozen dairy desserts, candy, baked goods, and gelatins and puddings. Strengths (see glossary) of extracts are expressed in weight-to-weight ratios or in flavor intensities. Parts used are the dried roots and rhizomes collected in late fall or early winter. Among 105 plant lactones studied, alantolactone and isoalantolactone are among the few that have been reported to exhibit the highest bactericidal and fungicidal properties in vitro. Reportedly used as a flavor ingredient in major food products, including alcoholic (aromatic bitters, vermouths, etc. Reportedly used in treating asthma, bronchitis, whooping cough, nausea, diarrhea, and other ailments. Also used as a diuretic, stomachic, and anthelmintic both in Western domestic medicine and in Chinese medicine, usually in the form of a decoction or tea. Alantolactone is used as an anthelmintic, primarily in the United Kingdom and Europe. Root subject of a German therapeutic monograph; not recommended due to lack of evidence of efficacy and risk for allergic reactions. Proksch, Economic and Medicinal Plant Research, Academic Press, New York, 1985, p. Part used is their resinous pathological exudation from which an essential oil (elemi oil) is obtained by steam distillation. Elemi resinoid and elemi oil are used as fixatives and fragrance components in soaps, detergents, creams, lotions, and perfumes. Elemi gum (oleoresin) contains 65­75% triterpenoid resinous compounds, which include 262 Eleuthero Food. Elemi oil is reported to be used as a flavor component in major categories of food products, including alcoholic and nonalcoholic beverages, frozen dairy desserts, candy, baked goods, gelatins and puddings, meat and meat products, and condiments and relishes. Common/vernacular names: Siberian ginseng, eleutheroco, eleuthero ginseng, and Ussurian thorny pepperbush. In traditional Chinese medicine, the bark of the Russian workers initially isolated seven compounds from a methanol extract of roots, deemed eleutherosides A­G (in a ratio of 8:30:10:12:4:2:1), ranging from 0. Eleutheroside B4 ((А)sesamin), eleutheroside D ((А)-syringaresinol-di-O-b-D-glucoside), and eleutheroside E (acanthoside D) are lignans. A new lignan, termed eleutheroside E2, together with isomaltol glucoside and thymidine were later isolated by Li et al. Additional phenylpropanoids include caffeic acid, caffeic acid ethyl ester, dicaffeoylquinic acids, coniferyl aldehyde, and sinapyl alcohol; other components include b-sitosterol, galactose, a- and b-glucose, a- and b-maltose, sucrose, vitamin E, b-carotene,2,4 polysaccharides (eleutherans A­G),5 and two glucose-, galactose-, and arabinose-containing polysaccharides. Some observed end points included quality of life in geriatrics, steroidal hormone indices and lymphocyte subset numbers, endurance, cellular stress, and physical fitness. The collective results of these trials indicate an inconsistent pattern of effectiveness for Siberian ginseng.

Additional information:

• Olmesartan
• Mebeverine
• Nalidixic acid

References

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