Kayode Ayodele Williams, M.B.A., M.B.B.S.

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0020086/kayode-williams

A comparative study of shrimp feed pellets processed through cooking extruder and meat mincer hiv infection rates new zealand buy generic zovirax cream 5 gm online. Effects of diets with different plant proteins on the performance of silver perch (Bidyanus bidyanus Mitchell) and on water quality in earthen ponds hiv stories of infection generic 5 gm zovirax cream with visa. Deomonstration of alternative feeds for the Pacific white shrimp hiv infection cd4 count cheap zovirax cream 5 gm overnight delivery, Litopenaeus vannamei antiviral uk release generic zovirax cream 5 gm line, reared in low salinity waters of west Alabama hiv infection to symptom timeline discount zovirax cream 5 gm overnight delivery. Nutritional evaluation of several protein sources for yellowtail (Seriola quinqueradiata) chronic hiv infection symptoms discount zovirax cream 5 gm without a prescription. Nutritional value of dietary nucleic acids and purine bases to rainbow trout (Oncorhynchus mykiss). Digestive efficiency, growth and qualities of muscle and oocyte in Atlantic salmon (Salmo salar L. The effects of various binders and moisture content on pellet stability of research diets for freshwater crayfish. Digestibility, apparent amino acid availability and waste generation potential of soybean flour: Poultry meat meal blend based diets for tilapia, Oreochromis niloticus (L. Digestibility, apparent amino acid availability and waste generation potential of soybean flour-poultry meat meal blend diets for the sharp-toothed catfish, Clarias gariepinus, fingerlings. Evaluation of stress- and immune-response biomarkers in Atlantic salmon, Salmo salar L. Incorporation of animal by-products in carp diets: Evaluation of poultry litter and goat blood meal as dietary protein sources for rohu (Labeo rohita), fingerlings. Production performance of Labeo calbasu in polyculture with three Indian major carps Catla catla (Hamilton), Labeo rohita (Hamilton) and Cirrhinus mrigala (Hamilton) with provision of fertilizers, feed and periphytic substrate as varied inputs. Dietary phytase supplementation and the utilisation of phosphorus by Atlantic salmon (Salmo salar L. Performance and spermatogenesis of Nile tilapia fingerlings fed with cottonseed meal or cottonseed flour. Effect of adding cottonseed meal or cottonseed flour to rations for Nile tilapia (Oreochromis niloticus) broodstock. Revista Brasileira De Zootecnia ­ Brazilian Journal of Animal Science, 28(6): 1169­1176. Evaluation of the reference diet substitution method for determination of apparent nutrient digestibility coefficients of feed ingredients for South African abalone (Haliotis midae L. Apparent and true availability of amino acids from common feed ingredients for South African abalone (Haliotis midae L. Effect of soybean phospholipids on Canthaxanthin lipoproteins transport, digestibility, and deposition in rainbow trout (Oncorhynchus mykiss) muscle. Effect of synthetic feed additive Stafac-20 on growth characteristics of juveniles of white prawn Penaeus indicus (Crustacea/Penaeidea). Substitution of fish meal by co-extruded soybean poultry by-product meal in practical diets for the Pacific white shrimp, Litopenaeus vannamei. Use of molasses as carbon source in limited discharge nursery and grow-out systems for Litopenaeus vannamei. A methodology for evaluation of dietary feeding stimulants for the Pacific white shrimp, Litopenaeus vannamei. Determination of antitrypsin activity on agar plates: relationship between antitrypsin and biological value of soybean for trout. Modifications of digestive enzymes in trout (Oncorhynchus mykiss) and sea bream (Sparus aurata) in response to dietary fish meal replacement by plant protein sources. Replacement of fish meal with poultry byproduct meal in practical diets for redclaw crayfish (Cherax quadricarinatus). Bioavailability of amino acid-chelated and glass-embedded manganese to rainbow trout, Oncorhynchus mykiss (Walbaum), fingerlings. Changes of phosphorus absorption from several feed ingredients in rainbow trout during growing stages and effect of extrusion of soybean meal. Effects of different oil cakes on the growth and survival of Liza parsia (Hamilton-Buchanan, 1822). Inter-individual variation in total fatty acid compositions of flesh of Atlantic salmon smolts-fed diets containing fish oil or vegetable oil. Digestibility, faeces recovery, and related carbon, nitrogen and phosphorus balances of five feed ingredients evaluated as fishmeal alternatives in Nile tilapia, Oreochromis niloticus L. Enhancement of vibriosis resistance in juvenile Penaeus vannamei by supplementation of diets with different yeast products. Effects of different dietary protein and lipid levels on growth, feed utilization and body composition of red porgy (Pagrus pagrus) fingerlings. Evaluation of pea protein isolate as alternative protein source in diets for juvenile tilapia (Oreochromis niloticus). Evaluation of the ability of partially autolyzed yeast and Grobiotic-A to improve disease resistance in rainbow trout. Influence of Ulva meal on growth, feed utilization, and body composition of juvenile Nile tilapia (Oreochromis niloticus) at two levels of dietary lipid. Coating crystalline methionine with tripalmitin-polyvinyl alcohol slows its absorption in the intestine of Nile tilapia, Oreochromis niloticus. Influence of dietary lipid composition on cardiac pathology in farmed Atlantic salmon, Salmo salar L. Development of intimal thickening of coronary arteries over the lifetime of Atlantic salmon, Salmo salar L. Pro-inflammatory cytokine expression and respiratory burst activity following replacement of fish oil with rapeseed oil in the feed for Atlantic salmon (Salmo salar L. Evaluation of soybean meal-red blood cell coextruded feed ingredient in diets fed to rainbow trout Oncorhynchus mykiss. Effect of different feed formulations on feed efficiency, gonad yield and gonad quality in the purple sea urchin Heliocidaris erythrogramma. Effect of the different oil on growth performance and body composition of rainbow trout (Oncorhynchus mykiss W. Effects of dietary lipids on growth and fatty acid composition in Russian sturgeon (Acipenser gueldenstaedtii) juveniles. Effect of vegetable protein and oil supplementation on growth performance and body composition of russian sturgeon juveniles (Acipenser gueldenstaedtii Brandt, 1833) at low temperatures. Replacement of dietary fish oil with olive oil in young yellowtail Seriola quinqueradiata: effects on growth, muscular fatty acid composition and prevention of dark muscle discoloration during refrigerated storage. Effect of dietary lipid sources on odouractive compounds in muscle of turbot (Psetta maxima). Identification of odour-active compounds in muscle of brown trout (Salmo trutta) as affected by dietary lipid sources. Effects of canola meal on physiological and biochemical parameters in rainbow trout (Oncorhynchus mykiss). Effect of different rice bran on the growth of Thai silver barb (Puntius gonioniotus Bleekri) in seasonal ponds. Evaluation of apparent digestibility coefficient of corn, wheat and feather meal for Labeo rohita. Behavioural responses of the Persian sturgeon (Acipenser persicus) juveniles to free amino acid solutions. Effect of betaine as a feed attractant on growth, survival, and feed utilization in fingerlings of the Indian major carp, Labeo rohita. Replacement of fish meal with poultry by-product meal in diets formulated for the humpback grouper, Cromileptes altivelis. Effects of dietary fish oil replacement with vegetable oils on growth and tissue fatty acid composition of humpback grouper, Cromileptes altivelis (Valenciennes). Comparative investigations on some biological and biochemical aspects in freshwater crayfish (Procambarus clarkii) fed on Echhornia crassipes, Echinochloa stagnina L. American-Eurasian Journal of Agriculture and Environmental Science, 5(4): 579­589. Replacement of soybean meal by shell shrimp meal in the diet for hybrid tilapia fry (Oreochromis niloticus x O. Abstract of the Fisheries Society of Taiwan 2004 Annual Conference, Taipei (Taiwan), 25­26 December 2004, 32(1): 29. Addition of combined defatted soybean meal, malt protein flour, and meat meal to yellowtail diet. Effect of dietary types on nutritive values of fish mealbased diet for yellowtail. Partial and total substitution of fishmeal with plant protein concentrates in formulated diets for the South African abalone, Haliotis midae. International Abalone Symposium, Cape Town, South Africa, February 2000 19(1): 534. The partial and total replacement of fishmeal with selected plant protein sources in diets for the South African abalone, Haliotis midae L. International Symposium on Abalone Biology, Fisheries, and Culture, Cape Town, Western Cape, South Africa, 6­11 February 2000, 20(2): 637­645. Liver oil of pharaoh cuttlefish Sepia pharaonis Ehrenberg, 1831 as a lipid source in the feed of giant freshwater prawn, Macrobrachium rosenbergii (De Man, 1879). Apparent digestibility coefficients of energy and nutrients of fullfat soybean meal with and without phytase for Nile tilapia (Oreochromis niloticus). China rose (Hibiscus rosasinensis) petals: a potent natural carotenoid source for goldfish (Carassius auratus L. Effects of dietary lipid source and concentration on channel catfish (Ictalurus punctatus) egg biochemical composition, egg and fry production, and egg and fry quality. Apparent digestibilities and growth experiments with tilapia (Oreochromis niloticus) fed soybean meal, cottonseed meal and sunflower seed meal. Journal of Applied Ichthyology/Zeitschrift fur angewandte Ichthyologie, 12(2): 125­130. Effect of fish meal replacement by plant protein sources on non-specific defence mechanisms and oxidative stress in gilthead sea bream (Sparus aurata). Digestibility of bacterial protein grown on natural gas in mink, pigs, chicken and Atlantic salmon. Lactic acid fermentation of wheat and barley whole meal flours improves digestibility of nutrients and energy in Atlantic salmon (Salmo salar L. Evaluation of housefly maggot meal as an alternative protein source in the diet of Oreochromis niloticus. Amino acid availability of four practical feed ingredients fed to Striped bass Morone saxatilis. Response of the tropical spiny lobster Panulirus ornatus to protein content of pelleted feed and to a diet of mussel flesh. Growth response of the black tiger shrimp, Penaeus monodon fed diets containing different lupin cultivars. Digestibility of lupin kernel meals in feeds for the black tiger shrimp, Penaeus monodon. Failure of a plant-and-krill-based diet to affect the performance of Yellowstone Cutthroat trout broodfish. Replacement of soybean meal protein by canola meal protein in diets for Nile tilapia (Oreochromis niloticus) in the growing phase. Revista Brasileira de Zootecnia-Brazilian Journal of Animal Science, 30 (4): 1172­1177. Nutritive values of some non-conventional animal protein feedstuffs used as fishmeal supplement in aquaculture in Nigeria. Evaluation of earthworm (Hyperiodrilus euryalos, Clausen, 1914; Oligocheata: Eudrilidae) meal as protein feedstuff in diet for Heterobranchus longifilis Velevciennes, 1840 (Teleostei, Claridae) fingerlings under laboratory condition. Nutritional evaluation of termite (Macrotermes subhyalinus) meal as animal protein supplements in the diets of Heterobranchus longifilis (Valenciennes, 1840) fingerlings. Nutritive potentials and utilization of garden snail (Limicolaria aurora) meat meal in the diet of Clarias gariepinus fingerlings. Productivity potentials and nutritional values of semi-arid zone earthworm (Hyperiodrilus euryaulos; Clausen, 1967) cultured in organic wastes as fish meal supplement. Behavioural responses of glass eels of Anguilla anguilla to non-protein amino acids. Influence of dietary oil content on the growth and chemical composition of Atlantic salmon (Salmo salar). Water hyacinth protein concentrate meal as a partial fish meal replacer in red tilapia diets, pp. Using of tomato and potato by-products as non-conventional ingredients in Nile tilapia, Oreochromis niloticus diets. Alkaline preserved herring by-products in feed for Atlantic salmon (Salmo salar L. Effects of adding various oils to the diet on growth, feed conversion and chemical composition of carp (Cyprinus carpio). The effects of substituting selected oilseed protein concentrates for fish meal in rainbow trout Oncorhynchus mykiss diets. The apparent digestibility of diets containing fish meal, soybean meal or bacterial meal fed to Atlantic salmon (Salmo salar): evaluation of different faecal collection methods. Availability of protein, phosphorus and other elements in fish meal, soy-protein concentrate and phytase-treated soy-protein-concentrate-based diets to Atlantic salmon, Salmo salar. Growth, uptake and retention of nitrogen and phosphorus, and absorption of other minerals in Atlantic salmon Salmo salar fed diets with fish meal and soy-protein concentrate as the main sources of protein. Digestibility of macronutrients, energy and amino acids, absorption of elements and absence of intestinal enteritis in Atlantic salmon, Salmo salar, fed diets with wheat gluten. Bacterial protein grown on natural gas in diets for Atlantic salmon, Salmo salar, in freshwater.

Three steps are involved in determining whether linkage exists and hiv symptoms time frame infection zovirax cream 5 gm mastercard, if so antiviral agents discount zovirax cream 5 gm with visa, estimating the distance between the gene and the known marker hiv infection rates heterosexual vs homosexual best zovirax cream 5 gm. Establish linkage phase between the disease-producing allele of the gene and an allele of the marker in the family hiv infection window purchase 5 gm zovirax cream with mastercard. A family in which a mutation causing neurofibromatosis type 1 is transmitted in 3 generations hiv infection rates city order 5 gm zovirax cream amex. Is it also possible to determine which allele of the marker was passed from the grandmother to her daughter? If linkage is present antiviral homeopathic buy generic zovirax cream 5 gm line, the diseaseproducing allele (A) is linked to allele 1 of the marker. Recombination frequencies can be related to physical distance by the centimorgan (cM) the recombination frequency provides a measure of genetic distance between any pair of linked loci. For example, if two loci show a recombination frequency of 2%, they are said to be 2 centimorgans apart. This relationship is only approximate, however, because crossover frequencies are somewhat different throughout the genome. In fact, there is some small chance that the gene and the marker are not actually linked at all and the data were obtained by chance. We could be more confident that our conclusions were correct if we had used a much larger population. The "odds of linkage" is simply the probability that each recombination frequency () is consistent with the family data. If data from multiple families are combined, the numbers can be added by using the log10 of these odds. Therefore, the most likely distance between the gene and the marker is a recombination frequency of 10%, or 10 cM. Gene mapping by linkage analysis serves several important functions: · It can define the approximate location of a disease-causing gene. In practice, markers that are useful for genetic testing must show less than 1% recombination with the gene involved (be < 1 cM distant from the gene). A family with an autosomal dominant disorder is typed for a 2 allele marker, which is closely linked to the disease locus. A man who has alkaptonuria marries a woman who has hereditary sucrose intolerance. Both are autosomal recessive diseases and both map to 3q with a distance of 10 cM separating the two loci. What is the chance they will have a child with alkaptonuria and sucrose intolerance? In a family study following an autosomal dominant trait through 3 generations, two loci are compared for their potential linkage to the disease locus. In this pedigree, the disease allele is consistently transmitted with the 1 allele. There is no case in this small number of individuals where recombination between these two loci has occurred. Linked markers can be "uninformative" (choice E) in some pedigrees if, for example, the same alleles are expressed in all family members. A child will inherit a gene for alkaptonuria from the father and the normal allele of this gene from the mother. Conversely, the child will inherit a gene for hereditary sucrose intolerance from the mother and a normal allele of this gene from the father. The child will therefore be a carrier for each disease but will not be affected with either one. In each case, individuals who receive the A allele also receive the disease allele. The goal of genetic diagnosis is to determine whether an at-risk individual has inherited a disease-causing gene. For example, the most common mutation causing hemochromatosis is the C282Y mutation that results from a G to A substitution in codon 282. Note that this test merely determines genotype, and many considerations must be taken into account before predictions about phenotype could be made. Hemochromatosis has only about 15% penetrance, and in those who do have symptoms, variable expression is seen. This approach has the advantages of ready computerization and miniaturization (hundreds of thousands of oligonucleotides can be embedded on a single 2-cm2 chip). This disease shows anticipation, and family members with a severe form of myotonic dystrophy may have several thousand copies of this repeat. However, it is sometimes necessary if no specific set of mutations is responsible for most cases of a disease. Indirect Diagnosis High-Yield If the mutation causing a disease in a family is not known, indirect genetic analysis can be used to infer whether a parent has transmitted the mutation to his or her offspring. Indirect genetic analysis uses genetic markers that are closely linked (showing <1% recombination) to the disease locus. The affected father in generation I transmitted the disease-causing mutation to his daughter, and he also transmitted allele 3 of the marker. Thus, the risk for each child, instead of being the standard 50% recurrence risk for an autosomal dominant disease, is much more definitive: nearly 100% or nearly 0%. A Three-Generation Family inin Which Marfan Syndrome Is Being Transmitted Transmitted Marfan Syndrome Is Recurrence risks may have to take into account the small chance of recombination between the marker allele and the disease-causing gene. A man and a woman seek genetic counseling because the woman is 8 weeks pregnant, and they had a previous child who died in the perinatal period. The parents wish to know whether the current pregnancy will result in a child with the same rare condition as the previous child who died. In the direct test, the mutation causing the disease is the same as the one that alters the restriction site. There is no distance separating the mutations and no chance for recombination to occur, which might lead to an incorrect conclusion. In the indirect assay, the mutation in the restriction site (a marker) has occurred independently of the mutation causing the disease. Its major limitation is that the disease-producing mutation(s) must be known if one is to test for them. Diagnosis of a genetic disease in a fetus may assist parents in making an informed decision regarding pregnancy termination and in preparing them emotionally and medically for the birth of an affected child. Fetal cells are present in the amniotic fluid and can be used to diagnose single-gene disorders, chromosome abnormalities, and some biochemical disorders. The risk of fetal demise due to amniocentesis is estimated to be approximately 1/200. The villi are of fetal origin and thus provide a large sample of actively dividing fetal cells for diagnosis. This technique has the advantage of providing a diagnosis earlier in the pregnancy. There is a small possibility of diagnostic error because of placental mosaicism. Preimplantation diagnosis Embryos derived from in vitro fertilization can be diagnosed by removing a single cell, typically from the eight-cell stage (this does not harm the embryo). The advantage of this technique is that pregnancy termination need not be considered: only embryos without the mutation are implanted. The pedigree below shows a family in which hemophilia A, an X-linked disorder, is segregating. A 22-year-old woman with Marfan syndrome, a dominant genetic disorder, is referred to a prenatal genetics clinic during her tenth week of pregnancy. Will not develop Marfan syndrome, but will be a carrier of the disease allele 400 Chapter 6 Genetic Diagnosis 3. A 66-year-old man (I-2) has recently been diagnosed with Huntington disease, a late-onset, autosomal dominant condition. She cannot be homozygous for the disease-producing allele (choice B) because her father is unaffected. Homozygosity for the normal allele (choice C) is inconsistent with the results shown on the gel. Note that her father is not affected, and the bottom band in his pattern is in linkage phase with the normal allele of the gene. Choice E is incorrect because Marfan is a dominant disease with no "carrier" status. The restriction site is 10 million bp upstream from the phenylalanine hydroxylase gene so there is a minimum chance of recombination of 10%. Heteroplasmy (choice B) is associated with mitochondrial pedigrees, and the phenylalanine hydroxylase gene is a nuclear one. All the males shown are hemizygous (choice B) for the dystrophin gene because they have only one copy. In an X-linked pattern, this would be characteristic of a female with two copies of the disease-producing allele and is very rarely seen. There is no information about which one is in linkage phase with his diseaseproducing huntingtin allele. Before her testing, he had a 50% chance of having the disease-producing huntingtin allele. See Vitamin E Alport disease, 64 Alternate segregation reciprocal translocations, 356, 357 Robertsonian translocations, 359, 360 Amino acids activation, 44, 54, 68 amino group removal, 265­267 branch-chain amino acids, 189 codon specification, 49, 50 essential, 123 glucogenic, 211, 212, 213 hydrophobic vs. See Cytochrome b/c1 Antineoplastic drugs, 273, 292, 293 Antioxidant vitamins, 234 Apoproteins hypolipidemias, 236­237 lipoprotein classes and, 229, 230­233 lipoprotein metabolism, 230 lipoprotein structure, 228 Arginine, 123, 125, 275 Aromatic amino acid side chains, 120 Arsenate and glycolysis, 179 Ascorbate (vitamin C), 151 as antioxidant, 234 iron absorption, 279 scurvy, 66, 68, 151 vitamin K vs. See Vitamin A Carriers in inheritance autosomal recessive inheritance, 306, 307 genetic testing, 87, 106, 398. See also Genetic analysis banding, 348­349 crossover in meiosis, 52, 382 cytogenetics, 347. See Metabolism Energy of reaction (G), 124 electron transport chain, 195 rate of reaction versus, 124 Enhancers of gene expression, 76, 77 genomic vs. See also Pedigrees polymerase chain reaction, 108­114 polymorphic markers, 379­381 recurrence risk, 304­305 restriction fragment length polymorphisms, 106­107. See Genetic analysis Genetics allelic heterogeneity, 271, 297 of common diseases, 371­376 cytogenetics, 347. See also Cytogenetics definitions, 303­305 genetic code as amino acid sequence, 3, 49, 50 heteroplasmy, 313 incomplete penetrance, 315­316 inheritance, 305­313 multifactorial inheritance, 371­376 penetrance, 311, 315­316 pleiotropy, 316 population variations, 337­340. See Western blots Imprinting, 320­322 In vitro fertilization and genetic diagnosis, 398 In vivo gene therapy, 94, 96, 97 Incomplete penetrance, 315­316 familial cancer, 316 hemochromatosis, 315­316 variable expression versus, 315, 316 Indirect genetic diagnosis, 391, 394­397 direct versus, 396, 397 Infants. See also Autosomal recessive inheritance heritability and liability for disease, 376 incomplete penetrance, 315­316 mitochondrial, 200, 312, 313 multifactorial, 371­376 penetrance, 311, 315­316 X-linked dominant, 311­312, 319 X-linked recessive, 307­310, 336­337, 397 Y chromosome, 311 Insertion mutation, 304 Insulin adipose tissue response, 169, 170, 243 -oxidation and, 245 blood potassium levels and, 252 cholesterol and, 237, 238 fatty acid synthesis, 169, 224­225, 226, 244, 245 vs. See Myophosphorylase deficiency Mutations, 51­52, 304­305 allelic heterogeneity, 271, 297, 314 balanced vs. See Vitamin B6 Pyrimethamine and tetrahydrofolate, 292 Pyrimidines catabolism, 293 mutations, 51 nomenclature, 7 structure, 5­6, 8, 9 synthesis, 290­293 synthesis deficiencies, 269, 291 thymine dimer repair, 25­26 Pyruvate carboxylase, 212, 213 acetyl-CoA regulation of, 214, 245, 251 citrate shuttle, 225 Pyruvate dehydrogenase, 187­189 acetyl-CoA regulation of, 187­188, 214 fatty acid synthesis, 224 Pyruvate kinase deficiency, 178, 183 gluconeogenesis, 212 glycolysis, 178, 180, 181 Q Quaternary protein structure, 59 Quinolones, 22, 23 R Ragged-red muscle fiber disease, 200, 313 Rate of reaction (v) energy of reaction versus, 124 Lineweaver-Burk equation, 126 Michaelis-Menten equation, 124­125 Rate-limiters allosteric inhibitors and activators, 165 cholesterol synthesis, 238 fatty acid synthesis, 225 glucagon vs. C deficiency, 159 Vitamin D (cholecalciferol), 152­154 cholesterol required, 237 deficiency, 152, 154 toxicity, 154 Vitamin E (-tocopherol), 152, 160 atherosclerosis and, 234 deficiency, 152, 160 Vitamin K, 152, 157­160 anticoagulant therapy, 160, 161 deficiency, 158­159 vitamin K vs. Carnivores may obtain up to 90% of energy requirements from amino acid metabolism Vegetarians may obtain only a small fraction of their energy needs from amino acids. Microorganisms can also use amino acids for an energy source if they are present in their environment. Plants using photosynthesis for energy rarely, if ever, use amino acids for energy. In animals, amino acids undergo oxidative degradation during 3 different metabolic circumstances. If a person has a diet rich in protein and has excess amino acids, they can not be stored and will be degraded. For example, people on the Atkins diet eat abundant amounts of protein and very little carbohydrates. During starvation or in patients with diabetes when carbohydrates are not available for energy, then protein must be used for an energy source. In the process ammonia is also generated and is available for the biosynthesis of amino acids, nucleotides and other biological amines. In addition, the carbon skeleton can eventually be converted to glucose through the citric acid cycle to provide energy. Digestion Bolus Formation Lubrication Dissolves Food Aids in Taste Protection Soft Tissue Repair Moistens Mouth & Throat Aids in Speech 2. Pepsinogen secretion from the Chief cells is also stimulated by Gastrin and it is converted from this inactive, "zymogen" form to active Pepsin Gastric juice. Proteins are cleaved on the aminoterminal side of aromatic amino residues Tyrosine, Phenylalanine and Tryptophan by Pepsin. As the contents pass into the small intestine, the pancreas secretes bicarbonate to neutralize the acid and allow other protein degrading enzymes to function. Secretin: produced in the upper portion of the small intestine (duodenum) and inhibits gastric acid secretion & stomach motility stimulates the pancreas to release bicarbonate ions and stimulates the gall bladder to secrete bile. The zymogen Trypsinogen is converted to the active protease called Trypsin by an enzyme called enteropeptidase. Trypsin then cleaves proteins at sites of Lysine and Arginine on the carboxyterminal side. The Chymotrypsin then cleaves on the carboxyterminal side of Tyrosine, Phenylalanine and Tryptophan. Elastase is formed from Proelastase by the action of Trypsin and then cleaves proteins at bonds in which the carboxyl group is contributed by small side chain amino acids (alanine, glycine & serine). Carboxypeptidases are "broad spectrum" enzymes and make multiple hits on remaining small peptides.

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Sodium phenylacetate/sodium benzoate should be used concomitantly with arginine hydrochloride hiv infection control trusted zovirax cream 5 gm. Hyperchloremic metabolic acidosis has been reported in 2 pediatric patients receiving excessive arginine hiv infection prophylaxis cheap 5 gm zovirax cream free shipping. In addition natural antiviral supplements discount 5 gm zovirax cream amex, certain defects in the urea cycle prevent the formation of citrulline which decreases the synthesis of arginine hiv transmission statistics heterosexual zovirax cream 5 gm lowest price. Monitoring Plasma ammonia levels every hour during dialysis until levels stabilize to less than 200 to 300 micromoles/L anti viral pink eye purchase zovirax cream 5 gm otc. Special Considerations/Preparation Arginine hydrochloride is supplied as a 10% solution antiviral wipes discount zovirax cream 5 gm fast delivery. Urea Cycle Disorders Conference group: Consensus statement from a conference for the management of patients with urea cycle disorders. For loading and maintenance doses, dilute arginine and sodium phenylacetate/sodium benzoate in 25 to 35 mL/kg of D10W prior to administration [4]. Hemodialysis is the primary treatment of acute hyperammonemia during the early management period [2] [5] [3] [4] [6]. Excessive arginine accumulation can result in nitric oxide overproduction with potential for vasodilation and hypotension [5] [3] [4] [7]. Pharmacology the use of arginine provides an alternative pathway for waste nitrogen excretion in patients with urea cycle disorders, attenuating the risk for ammonia- and glutamineinduced neurotoxicity. Arginine increases the synthesis of citrulline which contains a nitrogen from ammonia and is efficiently excreted in the urine. This results in arginine becoming an essential amino acid in patients with urea cycle disorders [5] [3] [6]. Monitor electrolytes and acid-base status closely during the acute phase (eg, every 4 hours). Monitor amino acids daily to assess the effectiveness of citrulline/arginine replacement and glutamine removal [3] [4]. Special Considerations/Preparation 86 Micormedex NeoFax Essentials 2014 Arginine hydrochloride is supplied as a 10% solution. Higher doses (6 to 10 mg/kg/day) have been used in neonates undergoing heart surgery [1] [6] [7] [8]. Uses 87 Micormedex NeoFax Essentials 2014 Antiplatelet agent for the prophylaxis and treatment of thrombotic events. Aspirin is recommended as thromboprophylaxis after Fontan surgery, in patients with systemicto-pulmonary shunts, in patients after ventricular assist device placement, and in patients with mechanical heart valves who have had thrombotic events while receiving therapeutic antithrombotic therapy or patients in whom there is a contraindication to full-dose vitamin K antagonists [1] [3] [4] [5] [9]. Use caution in patients with bleeding disorders, peptic ulcer disease, renal impairment, or severe hepatic impairment. Severe allergic reactions, including asthma, hives, and facial swelling, may occur [15]. This enzyme inhibition blocks the formation of thromboxane A2 from arachidonic acid which would reduce platelet shape change, aggregation, and the release reaction [20] [21] [22] [23]. Rapidly absorbed following oral administration with peak concentration achieved in 2 hours. Rapidly hydrolyzed by esterases in the liver, intestine, and blood to salicylic acid. Eliminated through hepatic metabolism and renal excretion with elimination pathways dependent on dose. At higher doses, when saturation of metabolic pathways occurs, renal excretion dominates with greater than 50% of unchanged salicylic acid eliminated in the urine. Elimination half-life is approximately 2 to 3 hours at low dose and 12 hours at anti-inflammatory doses [18]. Headache and tinnitus have also been reported 88 Micormedex NeoFax Essentials 2014 frequently in children. Mild salicylism is characterized by headache, dizziness, tinnitus, hearing and vision impairment, sweating, nausea, vomiting, nasal congestion, and slight hyperpyrexia. Monagle P, Cochrane A, Roberts R et al: A multicenter, randomized trial comparing heparin/warfarin and acetylsalicylic acid as primary thromboprophylaxis for 2 years after the Fontan procedure in children. A prospective clinical trial with three different preparations of acetylsalicylic acid. In a prospective, multicenter, randomized study (n=111) of warfarin vs aspirin for primary thromboprophylaxis in children after Fontan surgery, the thrombosis event rate at 2 years was 19% with no significant difference between warfarin and aspirin therapy (24% vs 14%; p=0. Association has been shown to be mainly dose dependent, occurring with anti-inflammatory doses (greater than 40 mg/kg/day), rather than lower doses used for antiplatelet effects [11] [12] [5] [13] [14]. Pharmacology the main mechanism of action of aspirin is through inhibition of prostaglandin biosynthesis. Aspirin is a more potent inhibitor of both prostaglandin synthesis and platelet aggregation than its other salicylic derivatives due to the acetyl group on the aspirin molecule, which inactivates cyclooxygenase via acetylation [19]. The antithrombotic effect of aspirin occurs by an irreversible inhibition of platelet cyclooxygenase. Platelet inhibition 91 Micormedex NeoFax Essentials 2014 occurs at lower doses (1 to 5 mg/kg/day). At therapeutic doses, most elimination occurs through hepatic metabolism to 3 major metabolites (all inactive); less than 10% is excreted unchanged in the urine. Symptoms of severe salicylate toxicity include hyperventilation, mental confusion, restlessness, irritability, hyperthermia, and alterations in acid-base balance, primarily respiratory alkalosis [10]. Monitoring Mild salicylism is characterized by headache, dizziness, tinnitus, hearing and vision impairment, sweating, nausea, vomiting, nasal congestion, and slight hyperpyrexia. Litalien C: Risks and benefits of nonsteroidal anti-inflammatory drugs in children: a comparison with paracetamol. Szczeklik A, Kizanowski M, Gora P et al: Antiplatelet drugs and generation of thrombin in clotting blood. Bye A: Effect of a single oral dose of aspirin on the platelet aggregation response to arachidonic acid. Prevention of bradycardia during endotracheal or nasotracheal intubation [1] [2] [3] [4] [5]. Terminal Injection Site Compatibility Amiodarone, cimetidine, dobutamine, famotidine, fentanyl, furosemide, glycopyrrolate, heparin, hydrocortisone succinate, meropenem, methadone, metoclopramide, midazolam, milrinone, morphine, nafcillin, netilmicin, pentobarbital, potassium chloride, propofol, ranitidine, and sodium bicarbonate. Dose can be repeated every 10 to 15 minutes to achieve desired effect, with a maximum total dose of 0. Uses Reversal of severe sinus bradycardia, particularly when parasympathetic influences on the heart (digoxin, beta-blocker drugs, hyperactive carotid sinus reflex) predominate. Also used to reduce the muscarinic effects of neostigmine when reversing neuromuscular blockade. Increases heart rate by decreasing the effects of the parasympathetic system while increasing the effects of the sympathetic system. Relaxes bronchial smooth muscle, thus reducing airway resistance and increasing dead space by 30%. Special Considerations/Preparation 96 Micormedex NeoFax Essentials 2014 Supplied in multiple concentrations (0. Pharmacology Azithromycin is classified as an azalide, a subclass of macrolide antibiotics. In vitro activity has been demonstrated against Bordetella pertussis, as well as Streptococci (Groups C, F, G and Viridans), Ureaplasma urealyticum, and Peptostreptococcus species. Primarily excreted unchanged in the bile, with some hepatic metabolism to inactive metabolites. There is one new case report of pyloric stenosis in 2 of 3 triplets treated with azithromycin for pertussis. Reconstitute 300 mg bottle with 9 mL of water to provide a final concentration of 100 mg per 5 mL (20 mg/mL). Azithromycin for intravenous injection is supplied in single use vials containing 500 mg lyophilized powder. The concentration of the reconstituted 98 Micormedex NeoFax Essentials 2014 solution is 100 mg/mL. Terminal Injection Site Incompatibility Amikacin, aztreonam, cefotaxime, ceftazidime, ceftriaxone, cefuroxime, clindamycin, famotidine, fentanyl, furosemide, gentamicin, imipenem-cilastatin, morphine, piperacillin-tazobactam, potassium chloride, ticarcillin-clavulanate, and tobramycin. Title Azithromycin Dose Treatment and Prophylaxis of Pertussis Infections: 10 mg/kg/dose orally once daily for 5 days. Prophylaxis of Ophthalmia Neonatorum (erythromycin ointment shortage only): 1 to 2 drops of the 1% ophthalmic solution instilled in each conjunctival sac. Uses Treatment and postexposure prophylaxis against Bordetella pertussis as a substitute for penicillin in situations of significant allergic intolerance. In the event of an erythromycin ointment shortage, azithromycin ophthalmic solution is an alternative for prophylaxis of ophthalmia neonatorum. The prolonged terminal half-life (approximately 80 hours) is thought to be due to extensive uptake and subsequent release of drug from tissues. Special Considerations/Preparation Oral suspension is available in 300, 600, 900, and 1,200 mg bottles. Dilute prior to administration using a compatible solution to a final concentration of 1 to 2 mg/mL. Diluted solution stable for 24 hours at room temperature or 7 days in refrigerator. Recommended antimicrobial agents for the treatment and postexposure prophylaxis of pertussis. Surveillance for transmission and antibiotic adverse events among neonates and adults exposed to a healthcare worker with pertussis. Pharmacokinetics of intravenously administered azithromycin in pediatric patients. Azithromycin is as effective and better tolerated than erythromycin estolate for the treatment of pertussis. Product Information: Zithromax azithromycin tablets and oral suspension, Pfizer, 2011. Generally used in combination with ampicillin (empirical treatment of sepsis) or an aminoglycoside (for synergism against Pseudomonas and Enterobacteriaceae). Good tissue and fluid penetration has been demonstrated in adults, along with protein-binding of 50 to 65%. Side effects are rare but include eosinophilia, elevation of serum transaminases, and phlebitis at the injection site. Terminal Injection Site Incompatibility Acyclovir, amphotericin B, azithromycin, ganciclovir, lorazepam, metronidazole, and nafcillin. Cuzzolin L, Fanos V, Zambreri D, et al: Pharmacokinetics and renal tolerance of aztreonam in premature infants. Although bactericidal against aerobic gram-negative bacteria, it has virtually no activity against aerobic gram-positive and anaerobic bacteria, thereby producing little alteration of bowel flora. Special Considerations/Preparation 104 Micormedex NeoFax Essentials 2014 Available as powder for injection in 500-mg, 1-g, and 2-g vials. Reconstituted solution stable for 48 hours at room temperature, 7 days refrigerated. Amikacin, aminophylline, ampicillin, bumetanide, calcium gluconate, caspofungin, cefazolin, cefepime, cefotaxime, cefoxitin, ceftazidime, ceftriaxone, cimetidine, clindamycin, dexamethasone, dobutamine, dopamine, enalaprilat, famotidine, fluconazole, furosemide, gentamicin, heparin, hydrocortisone succinate, imipenem, insulin, linezolid, magnesium sulfate, metoclopramide, mezlocillin, morphine, netilmicin, nicardipine, piperacillin, piperacillin/tazobactam, potassium chloride, propofol, quinupristin/dalfopristin, ranitidine, remifentanil, sodium bicarbonate, ticarcillin/clavulanate, tobramycin, vancomycin, and zidovudine. Slowly withdraw entire contents of vial into a plastic syringe through a large (greater than 20 gauge) needle [1]. Administer four quarter-doses with the infant in different positions to enhance distribution. Contraindications/Precautions Transient episodes of bradycardia and decreased oxygen saturation may occur during administration. Other adverse events include hypotension, endotracheal tube reflux or blockage, hypertension, hypercarbia, and apnea. Monitoring Monitor systemic oxygen and carbon dioxide levels with arterial or transcutaneous measurements frequently during therapy [1]. Prophylaxis: First dose is given as soon as possible after birth, with up to three additional doses in the first 48 hours of life, if indicated [1]. Administration Before administration, allow to stand at room temperature for 20 minutes, or warm in the hand for at least 8 minutes. Discard excess Survanta through catheter so only total dose to be given remains in syringe [1]. Alternatively, Survanta can be instilled through the catheter by briefly disconnecting the endotracheal tube from the ventilator. Increased risk of post-treatment nosocomial sepsis was noted in Survanta-treated infants in controlled clinical studies [1]. Animal metabolism studies show that most of a dose becomes lung-associated within hours of administration, and lipids enter endogenous surfactant pathways of reuse and recycling [1]. Monitoring 108 Micormedex NeoFax Essentials 2014 Monitor systemic oxygen and carbon dioxide levels with arterial or transcutaneous measurements frequently during therapy [1]. Infants with congestive heart failure or abnormal renal function will need a higher dose. There were no 109 Micormedex NeoFax Essentials 2014 pharmacodynamic advantages (urine output and electrolyte excretion rate) to doses greater than 0. Urine sodium losses are lower with bumetanide than furosemide, but urine calcium losses are higher. Adverse Effects Water and electrolyte imbalances occur frequently, especially hyponatremia, hypokalemia, and hypochloremic alkalosis. May displace bilirubin from albumin binding sites when given in high doses or for prolonged periods. Monitoring 110 Micormedex NeoFax Essentials 2014 Serum electrolytes and urine output. The intravenous formulation, diluted in sterile water and given orally, has been used successfully in infants with congenital heart disease [4]. Aztreonam, cefepime, furosemide, lorazepam, milrinone, morphine, piperacillin/tazobactam, and propofol.

Allergic-like reactions following premedication may still occur hiv infection by needle stick order zovirax cream 5 gm visa, although the frequency of such reactions is unknown [10] hiv infection symptoms after 2 weeks cheap 5 gm zovirax cream with amex. It should be noted that there has been no prospective hiv infection through urethra order zovirax cream 5 gm amex, controlled investigation performed to assess the efficacy of premedication for the prevention of allergic-like reactions to iodinated contrast media in children hiv infection real stories buy discount zovirax cream 5 gm on-line. Treatment of Allergic-Like Reactions General guidelines for the treatment of allergic-like reactions in children are similar to those used for adult patients antiviral drugs youtube purchase zovirax cream 5 gm line. Pediatric medication dosages kleenex anti viral ingredients purchase 5 gm zovirax cream amex, however, may be significantly different from adult dosages used in the management of such reactions (Table 2 and Table 3). It can be helpful to have a pediatric medication chart with weight-based dosages placed on the emergency cart or posted in the rooms where intravascular contrast media is to be injected into children. Dedicated pediatric emergency resuscitation equipment (including various sizes of supplemental oxygen facemasks) also should be available in all such locations (Table 4). A separate box of pediatric airway equipment attached to the emergency cart may be useful in areas where both children and adults receive contrast media. Contrast-Induced Nephrotoxicity in Children There has been no large prospective investigation dealing with the possible nephrotoxic effects of intravascular low-osmolality iodinated contrast agents in children. Consequently, the effects of contrast media on the kidneys are generally assumed to be similar between children and adults. Serum creatinine concentration reflects the balance between creatinine production and excretion. Creatinine is a breakdown product of skeletal muscle, and its rate of production is proportional to muscle mass. Muscle mass depends on a variety of factors, including patient age, gender, and level of physical activity. Normal serum creatinine concentrations, thus, are quite variable in pediatric patients, even in the presence of preserved renal function. It is important to recognize that normal adult creatinine concentrations cannot be applied to the pediatric population. Normal pediatric serum creatinine concentrations increase with age, with the upper limits of normal always less than adult values. Age-based normal serum creatinine concentrations also may vary slightly from laboratory to laboratory. First, a normal serum creatinine value does not mean that renal function is preserved. Serum creatinine concentration may not become abnormal until glomerular filtration has decreased substantially. Second, it may take several days in the setting of acute renal failure for serum creatinine concentration to rise. A patient, therefore, may have impaired renal function and a normal serum creatinine concentration. In addition, the assay used to measure serum creatinine concentration must be known. These agents are most commonly used off-label in children as several of these agents are not approved for use in all age groups. A few pediatric-specific issues regarding these contrast agents are discussed below. For example, the osmolality of gadoteridol (ProHance) is 630 mosm/kg H O, and the osmolality of gadobenate dimeglumine (MultiHance) is 1,970 mosm/kg H O. These physical properties, however, potentially are less important when using gadolinium-based contrast agents in children compared to iodinated contrast agents. The much smaller volumes of gadolinium-based contrast agents typically administered to pediatric patients likely result in only minimal fluid shifts. The slower injection flow rates generally used for gadolinium- based contrast agents result in lower injection-related pressures and decreased risk for vessel injury and extravasation. A more recent study by Davenport et al that included 15,706 administrations of gadolinium-based contrast media in children (under the age of 18 years) documented only eight allergic-like reactions, for a reaction rate of 0. Although mild reactions are most common, more signifi reactions that require urgent medical management may occur [15]. Pediatric allergic-like reactions to gadolinium-based contrast media are treated similarly to those reactions to iodinated contrast agents (Table2). While no investigation has studied the efficacy of corticosteroid and antihistamine premedication regimens for the prevention of allergic-like reactions to gadolinium-based contrast agents in children or adults, regimens, such as those presented in Table A at the end of the chapter, are thought to provide some protective benefit. A variety of physiologic side effects may also occur following administration of gadolinium-based contrast media, including coldness at the injection site, nausea, headache, and dizziness (see package inserts). There is no evidence for pediatric renal toxicity from gadolinium-based contrast media at approved doses. Extravasation of gadolinium-based contrast media is usually of minimal clinical significance because of the small volumes injected. Seventeen of these children had documented exposure to gadolinium-based contrast material. Thirteen of 13 children with available clinical data pertaining to renal disease had substantial renal dysfunction (acute kidney injury and/or chronic kidney disease), and 10 were on hemodialysis or peritoneal dialysis (or both). Though not based on specific evidence, some have suggested the avoidance of high-risk gadolinium agents in very young children. Gastrointestinal Contrast Media the most commonly used gastrointestinal contrast agents in children are barium-based. These agents can be administered by mouth, rectum, ostomy, or catheter residing in the gastrointestinal tract. These contrast agents are generally contraindicated in patients with suspected or known gastrointestinal tract perforation. Iodinated contrast agents are usually preferred in the setting of suspected gastrointestinal tract perforation. As with intravascular iodinated contrast agents, osmolality should be considered when deciding which iodinated contrast agent to administer orally due to significant variability. Hyperosmolality iodinated contrast agents within the gastrointestinal tract may cause fluid shifts between bowel wall and lumen and, once absorbed, between extravascular soft tissues and blood vessels [27-31]. Neonates, infants of very low birthweight, and older children with cardiac and renal impairment may be most susceptible to such fluid shifts. In such patients, low-osmolality or iso-osmolality contrast agents should be considered for imaging of the upper gastrointestinal tract. Regarding rectal use, higher osmolality contrast agents can usually be diluted to a lower osmolality and still have sufficient iodine concentration to allow diagnostic imaging. High-osmolality iodinated contrast agents should be avoided in children who are at risk for aspiration. Aspirated hyperosmolality contrast medium may cause fluid shifts at the alveolar level and chemical pneumonitis with resultant pulmonary edema [32-35]. Aspiration of large volumes of both barium-based and iodinated oral contrast agents rarely may be fatal [36]. The Osmotic Effects of Methylglucamine Diatrizoate (Renografin 60) in Intravenous Urography in Infants. Tissue fluid shifts during renal arteriography with conventional and low osmolality agents. Safety of power injector use in children as measured by incidence of extravasation. Frequency and severity of acute allergic-like reactions to gadoliniumcontaining i. A pediatric case of nephrogenic fibrosing dermopathy: improvement after combination therapy. Nephrogenic fibrosing dermopathy in a patient with systemic lupus erythematosus and acute lupus nephriti. How to avoid nephrogenic systemic fibrosis: current guidelines in Europe and the United States. Osmotic effect and solubility of amipaque (metrizamide) in the gastrointestinal tract. Choosing contrast media for the evaluation of the gastrointestinal tract of neonates and infants. Comparison of barium sulfate and oral 40 per cent diatrizoate injected into the trachea of dogs. Production of pulmonary edema by aspiration of water-soluble nonabsorbable contrast media. Rectal contrast media is given for conventional fluoroscopic colon studies and colon cleansing. This chapter discusses indications, contraindications, and adverse reactions resulting from the administration of contrast agents used to assess the gastrointestinal system. Ancillary drugs utilized in gastrointestinal tract imaging and additives to gastrointestinal contrast media will also be reviewed along with their contraindications and adverse/allergic potential. Conventional fluoroscopic examinations Barium sulfate contrast media continue to be the preferred agents for opacification of the gastrointestinal tract for conventional fluoroscopic examinations [1,2]. They provide greater delineation of mucosal detail and are more resistant to dilution than iodinated agents [1,3]. In adult patients, it is also generally agreed upon that in most non- acute clinical situations, barium is the preferred oral contrast medium for the diagnosis of most etiologies of obstruction (with the exception of suspected proximal small bowel obstruction). This is because dilution of water-soluble contrast media in dilated fluid-filled distal small bowel loops may render the contrast media nonvisible. The current use of iodinated water-soluble contrast media is primarily limited to select situations. These include patients in who there is suspected bowel perforation or leak (including bowel fistula, sinus tract, or abscess) or to confirm percutaneous feeding tube position. Less commonly, water-soluble oral contrast media may be preferred over barium contrast media in patients who are to be studied just before endoscopic procedures of the bowel or in patients with likely small bowel obstruction in whom timely surgery is anticipated. Very rarely, iodinated contrast media may be chosen for patients who report prior allergic-like reactions to barium agents. Therapeuticuses of water-soluble enteric contrast media Barium sulfate is a micropulverized white powder that is supplied in various forms, including in bulk for mixing with distilled or tap water. Barium may be obtained in prepackaged aliquot mixtures ready for individual use in patients requiring oral or rectal examinations. High density barium (85% to 100% w/v suspension) has been recommended for optimal imaging in the colon for double contrast examinations. The formulae provided from vendors are altered in different areas of the gastrointestinal tract by local conditions, such as luminal acidity which affects flocculation out of suspension and coating. Also, local differences in tap water composition obtained from municipal sources alter the qualities of barium, so that there is not one formula that works equally well everywhere [3]. Magnesium citrate resulted in greater residual stool in this study, but the results in other studies have been more variable. Additionally, some favor the routine use of magnesium citrate instead of sodium phosphate in the elderly and patients with renal insufficiency or hypertension, especially those being treated with angiotensinconverting enzyme inhibitors, to reduce the risk of acute phosphate nephropathy (a form of acute kidney injury) [12,13]. At the present time, however, no firm recommendation can be made for a preferred or superior cleansing method. Inactive ingredients includes edetate disodium, flavor, polysorbate 80, purified water, saccharin sodium, simethicone, and sodium citrate. Gastrografin and Gastroview are hypertonic and may lead to hypovolemia and hypotension due to fluid loss from the intestine. However, in some children and elderly adults, the loss of plasma fluid may be sufficient to cause a shock- like state. Iodinated contrast media supplied for intravenous use also can be administered safely by mouth or per rectum. The potential complications of a barium leak depend on the site from which the spill occurs. Escape of barium from the colon, where the bacterial count is highest, carries high mortality (with the mortality likely primarily related to leakage of stool). Water-soluble contrast media are absorbed rapidly from the interstitial spaces and peritoneal cavity, a feature that makes them uniquely useful in examining patients with a suspected perforation of a hollow viscus. No permanent deleterious effects from the presence of water-soluble contrast media in the mediastinum, pleural cavity, or peritoneal cavity have been shown to occur [14]. Many investigators, therefore, recommend that iodinated water-soluble oral contrast media be utilized initially in any study in which a bowel perforation is suspected or known to exist. If an initial study with iodinated contrast agent fails to demonstrate a suspected perforation, barium sulfate can then be administered. Such follow-up studies may be important as some small leaks that are undetected with water-soluble media may be seen only when barium sulfate media are administered [15,16]. Although barium sulfate is inert, it can occasionally produce symptoms if aspirated, particularly in patients who have underlying lung disease. While barium is usually mobilized proximally by ciliary action of normal bronchial epithelium, damaged epithelium from bronchial disease delays the normal elimination of barium [9]. If not completely expectorated, retained barium in the lungs can remain indefinitely and may cause inflammation [14]. High volume aspiration can lead to acute respiratory distress or pneumonia, as might be true for aspiration of any nonsterile liquid. Therefore, if water-soluble contrast media are to be used in patients at risk for aspiration, low-osmolality or iso-osmolality contrast media are preferred, as these contrast agents, if aspirated, are associated with only minimal morbidity and mortality [17]. These "reactions" are likely not allergic-like, but are part of a physiologic response resulting from distention of a viscus. Vasovagal reactions can also be encountered, after the colon is distended during a double contrast barium enema. The frequency of allergiclike adverse reactions have been reported to be 1 in 750,000 examinations, with most of the manifestations being mild [19].

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