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Asthma Free Forever

Jerry Ericson is a researcher and alternative medical practitioner. Jerry created this asthma treatment book basing on over 20 years of his personal experience in helping asthma sufferers relieve their symptoms within minutes, and get rid of asthma permanently without medications. Inside this guide, users will discover the methods that helped the author cure his asthma without useless and harmful medications. The e-book contains a guided program that walks asthma sufferers through the process step by step, without the need for doctors. The program does not involve medication, drug therapies, or over the counter solutions. Asthma Free Forever is based on finding a natural solution to the problem, therefore it does not have any side effects. The natural treatments that are suggested are suitable for all asthma sufferers regardless of their gender or age. With the help of Asthma Free Forever, you can solve your asthma problem for good in just a few days right in the comfort of your own home. This treatment is based on proven medical research, so you can be sure that it's safe and guaranteed to work. Just apply the info that you will learn from this guide and you can breathe easily without coughing and congestion. You can strengthen your respiratory system and live a healthy and active lifestyle again. Read more here...

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Author: Jerry Ericson
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I started using this book straight away after buying it. This is a guide like no other; it is friendly, direct and full of proven practical tips to develop your skills.

When compared to other ebooks and paper publications I have read, I consider this to be the bible for this topic. Get this and you will never regret the decision.

Material Asthma Status Alters Relation Of Infant Feeding To Asthma Childhood

Key words Asthma, breastfeeding, infant feeding practices, wheezing, childhood, epidemiology Abstract The relation of infant feeding to childhood asthma is controversial. This study tested the hypothesis that maternal asthma alters the relation of breastfeeding to childhood asthma. Questionnaires were completed at age 6, 9 or 11 years by parents of 1043 children enrolled at birth. Active MD asthma was defined as a physician diagnosis of asthma plus asthma symptoms reported on one of the questionnaires. Duration of exclusive breastfeeding, categorized as never, 4 months, was based on prospective physician reports or questionnaires completed at 18 months. The relationship between breastfeeding and asthma differed by maternal asthma status. For children with maternal asthma, the percent developing active MD asthma increased significantly with longer duration of exclusive breastfeeding. Odds of developing asthma among these children were significantly elevated (OR 5.7,CI 2.8-1 1 .5),...

Specific asthma drug treatment

On admission to the ICU there should be a rapid review of earlier asthma treatment to identify elements that can be intensified or deficiencies remedied. Drugs contraindicated in asthma include b blockers, aspirin, non-steroidal anti-inflammatory drugs, and adenosine. Evidence continues to accumulate that early treatment with adequate doses of corticosteroid improves outcome in severe acute asthma. There does not appear to be any benefit from high doses of hydrocortisone exceeding 400 mg day, and no Figure 13.2 (A) Schematic diagram of an asthmatic patient exhibiting significant residual flow at end expiration. (B) The oesophageal pressure (Poes), an estimate of intrapleural pressure, shows the degree of pressure change required to overcome intrinsic pressure (PEEPi) and initiate inspiratory flow. (C) A progressive increase in lung volume (breath stacking) occurs if expiratory time is insufficient to allow complete exhalation of the tidal volume. Figure 13.2 (A) Schematic diagram of...

Bayes Testing Asthma Prevalence

Consider the example of a clinic whose administrator needs to decide whether the proportion of patients it sees with asthma is greater than 5 during the summer months. If the proportion is larger, the clinic administrator will need to invest resources in the clinic so that it may better serve its community. This will involve both an education program for the clinic staff as well as the provision of ample medical supplies to treat asthma. In his quest to determine the proportion of asthma The administrator wishes to take a Bayesian action. Let 9 be the prevalence of asthma. In order to take a Bayesian action in this problem of testing for the location of 9, the administrator must be armed with the following three items He also identifies the distribution of the estimated proportion of patients with asthma from a sample of clinic data. If the number of patients who visit the clinic is n, then the prevalence of asthma patients follows a normal distribution with mean 9 and variance 9(1 -...


Asthma is characterized by a widespread but variable increase in airflow resistance together with hyperinflation of the lungs. It has a circadian rhythm irrespective of the many environmental factors that affect its severity (Fig. 12.1) 2 . Nocturnal asthma may cause frequent arousals from sleep, particularly after the first cycle of NREM and REM sleep, and it may lead to excessive daytime sleepiness. The arousals are partly due to the increased work of breathing, but also to frequent coughing, and they improve once the asthma is controlled. The lowest peak flow rates in asthmatics are recorded at around 4.00 am. There is a normal cir-cadian fluctuation in peak flow rates of less than 10-15 , with the highest values at around 4.00 pm, but this is exaggerated in asthmatics, perhaps with a slight shift in the time of the lowest peak flow rates as well.

Solubility of Polymorphic Substances

Several indirect methods have been proposed to determine the solubility of metastable polymorphs. Milosovish (1964) deduced the relative solubilities of metastable and stable polymorphs based on the measurement of intrinsic dissolution rates. Ghosh and Grant (1995) proposed an extrapolation technique to determine the solubility of a crystalline solid that undergoes a phase change upon contact with a solvent medium. Brittain (1996) used the time evolution of light scattering from aqueous suspensions of anhydrous theophylline as a means to evaluated its solubility, and also to study its phase transformation into its monohydrate solvatomorph.

Intratracheal Thyroid

In a review of 23 cases, the patients ranged in age from newborn to 56 years, with a mean of 28.3 years, but most were young adults.9 Females outnumbered males in a ratio of 3.8 1. Clinical presentation varied from asymptomatic cases found on autopsy, to symptoms such as cough, wheezing, stridor, and dyspnea. Symptoms worsened in 3 patients during pregnancy, 1 of them also with menses.9,10 Another patient had increasing wheezing during labor and died postpartum because she had been treated for asthma and was not suspected to have an intratracheal mass.10 Increased dyspnea was noted in a girl with menarche. These have led some to suggest hormonal stimulation as a basis for ectopic tissue enlargement during phases of altered female sex hormone production. Several theories have been proposed to explain aberrant location of thyroid tissue including malformation and ingrowth theories.11

Primary Prevention Of Allergy

It is well established that exposure to tobacco smoke in infancy and early childhood is associated with an increased risk for respiratory infections and wheezing, as well as for sensitisation to inhalant allergens50. Other measures, like efforts to reduce the levels ofindoor allergens like house dust mites and pets have largely been disappointing51 Recent studies even suggest that the contrary may be true, i.e. that exposure to allergens during infancy may reduce the prevalence of allergic asthma in school children 52.

Type I Simple Drainage

The type I drainage (Fig. 8.2a) is established by eth-moidectomy including the cell septa in the region of the frontal recess 14 . The inferior part of Killian's in-fundibulum and its mucosa remain untouched. This approach is indicated when there is only minor abnormality in the frontal sinus and the patient does not suffer from prognostic risk factors like aspirin hy-persensitivity and asthma, which are associated with poor quality of mucosa and possible problems in outcome. In the majority of cases the frontal sinus heals because of the improved drainage via the ethmoid cavity.

Preoperative Evaluation

Preoperative evaluation of the sinus patient begins with a complete otolaryngologic history and physical examination 20 . The typical complaints that a patient with hyperplastic rhinosinusitis presents with polyposis are nasal obstruction and anosmia 24 . A significant number of patients will have a history of repeated sinus infections, headache, and may have a medical history significant for asthma and aspirin sensitivity 11 . Environmental allergy may also be prevalent 1 . Since the major complaint associated with hyperplastic rhinosinusitis and nasal polypo-sis is subjective in nature, many institutions advocate the use a preoperative sinonasal questionnaire. Many different questionnaires exist in the literature and all are focused on defining the baseline symptomatology of the disease as well as the level of exacerbation of the disease process 13 . Recurrent acute sinusitis Obstructive nasal polyposis Asthma exacerbations in patients with Samter's triad

PH Bile Salts and Proteins for Biorelevance pH Adjustment

Yamashita and coworkers studied the effect of medium pH on the transport rate of several passively and actively transported drugs in Caco-2 cells (including antipyrine, theophylline, hydrochlorothiazide, atenolol, terbutaline, nadolol, salicylic acid, furosemide and cephalexin). Transport was studied in the absence (apical and basolateral medium buffered at pH 7.4) or presence (apical medium buffered at pH 6.0, basolateral medium buffered at pH 7.4) of a pH-gradient. The observed differences in apparent permeability were attributed to both difference in drug partitioning and modification of carrier-mediated transport (Yamashita et al., 1997). A similar study was run in the PAMPA model (Sugano et al., 2001). The permeation of 30 model compounds, expected to be passively tran-scellularly transported, was assessed as a function of pH. For both models, it was concluded that a better prediction of the fraction absorbed in humans would be obtained under pH-gradient conditions. Although...

Other Positive Inotropic Drugs

There is no doubt that the aforementioned glycosides are the most satisfactory inotropic compounds. However, digitalis drugs can be counter productive in some patients for a number of reasons. Theophylline has been intensively studied as an inotropic agent however, it turned out to be unfit for long-term use.

Types of Beta Blockers

Now, many varieties of beta-blockers are available, some with longer durations of action permitting once or twice a day dosing, and some that are selective for the beta-1-receptor with less potential for aggravating the breathing of people with asthma or emphysema. Severe thyrotoxicosis, sometimes called thyroid storm, used to be a dangerous condition with a significant risk of death. Aggressive use of beta-blockers, as well as other supportive measures, such as better intensive care, the use of steroids, stable iodide, and attention to other illnesses complicating the condition, has made thyroid storm less likely to develop, and less likely to be fatal. The following is a table of some common beta-blockers and their pertinent features. Some of them come in long-acting forms that are not listed here. All of them have the suffix -olol.

Pathophysiologic Changes Induced by Cytotoxic Therapy

Pulmonary disease after chemotherapy or radiation therapy may also have obstructive or restrictive components. Obstructive diseases result from airway narrowing. This may be due to bronchospasm,mucus or luminal narrowing as a result of edema and inflammation or scarring 88 . Airway narrowing due to disease can be detected as a decrease in expiratory airflow. Pulmonary function tests demonstrate a decrease in the ratio of the volume exhaled in 1 second (FEVj) to the total exhaled forced vital capacity (FVC). Pneumonitis and pulmonary fibrosis are the two most important consequences of irradiation of the lung. Pulmonary fibrosis occurs in almost 100 of patients receiving high doses of radiation, but it may not be of clinical significance if the volume is small. The clinically significant presentation of pulmonary toxicity is usually pneumonitis, due to its prevalence and potential morbid outcome. The presentation varies with the type of lung injury present. Often there are complaints of...

Interpretation of the model

In the model (4.1), the predictor variables can be continuous or discrete. If there is just one binary predictor variable X, then the interpretation is closely related to the log-rank test described in Swinscow.1 In this case, if the coefficient associated with X is b, then exp(b) is the relative hazard (often called the relative risk ) for individuals for whom X 1 compared with X 0. When there is more than one covariate, then the interpretations are very similar to those described in Chapter 3 for binary outcomes. In particular, since the linear predictor is related to the outcome by an exponential transform, what is additive in the linear predictor becomes multiplicative in the outcome, as in logistic regression section 3.4. In the asthma example the risk of asthma of 1.22 for children exposed to other milk products before four months assumes all other covariates are held constant. The model assumes multiplicative risks so that if the risk of developing asthma early is double in...

What are confidence intervals

Specifically, there are numerical attributes or parameters of the population which we would like to estimate. Examples of such population parameters might be the percentage five-year survival of patients with newly diagnosed oesophageal cancer , the prevalence of Down's syndrome in babies born to mothers over 35 years of age , the risk of colonic cancer in patients who have had ulcerative colitis for more than 10 years , or the reduction in general practice consultation rates following introduction of a new policy for managing patients with asthma in the community . Corresponding to each such population parameter is a sample statistic for example, the percentage five-year survival in a sample of patients with newly diagnosed oesophageal cancer, the prevalence of Down's syndrome in a sample of babies born to mothers over 35 years of age, etc.

Chemokine Receptors in Allergic Lung Disease

This chapter is an attempt to integrate recent studies concerning the role of chemokine receptors in the initiation, development, and maintenance of allergic lung diseases collectively referred to as asthma. The pathogenesis of asthma involves the coordinated trafficking of inflammatory cells to the lungs and draining lymph nodes, as well as the activation of these inflammatory cells. Chemokine receptors and their ligands play a prominent role in directing the inflammation associated with allergic lung disease. T lymphocyte-mediated immune responses can be broadly categorized as being type 1 or type 2, based on the cell types present and the associated cytokines produced. Allergic lung disease is a predominately type 2-mediated disease. The chemokine receptors CCR4, CCR6, and CCR8 serve to promote the recruitment of type 2 T (T helper 2 Th2) cells, whereas CXCR3 antagonizes type 2 and promotes type 1 T (T helper 1 Th1) cells. The pathophysiologic manifestations of asthma, including...

ICH E9 1998 Note for Guidance on Statistical Principles for Clinical Trials

Equivalence trials are, of course, routinely used in the evaluation of bioequiv-alence and the methodology there is well established, both European and FDA guidelines exist. More recently we have seen the need to establish therapeutic equivalence and Ebbutt and Frith (1998) provide a detailed case study in the development of an alternative propellant for the asthma inhaler. More usually,

Confidence intervals for equivalence

We will start by looking at equivalence and then move on to consider non-inferiority. The first step in establishing equivalence is to define equivalence. Following Ebbutt and Frith (1998), suppose we are looking to establish the equivalence of a new asthma inhaler device with an existing inhaler device in a trial setting and further suppose that our clinical definition of equivalence is 15l min. In other words, if the difference in the mean increase in PEF following four weeks of treatment is less than 15 l min then we will conclude that the two devices provide a clinically equivalent benefit. We may want to argue over whether 15 l min is the appropriate value, but whatever we do we must choose a value. The 15l min values are termed the equivalence margins and the interval -15 l min to +15 l min is also called the equivalence region (see Figure 12.1).

Random vs fixed effects

Suppose we wish to include a variable in a model that covers differing groups of individuals. It could be a generic description, such as smokers or non-smokers or it could be quite specific, such as patients treated by Doctor A or Doctor B. The conventional method of allowing for categorical variables is to fit dummy variables as described in Chapter 2. This is known as a fixed-effect model, because the effect of being in a particular group is assumed fixed, and represented by a fixed population parameter. Thus smoking will decrease lung function by a certain amount on average. Being cared for by Doctor A may also affect your lung function, particularly if you are asthmatic. However, Doctor A's effect is of no interest to the world at large, in fact is only so much extra noise in the study. However, the effect of smoking is of interest generally. The main difference between a fixed and a random effect model depends on the intention of the analysis. If the study were repeated, would...

Nonventilatory Considerations

Steroids are useful in speeding the resolution of airway inflammation but are implicated in the myopathy associated with critical illness47 and our practice is to taper the dose rapidly. The value of nebulised steroids has not been established in this situation. Adequate nutritional support is essential but should not be excessive. There is no convincing evidence that manipulation of the metabolic costs of feeding by energy substitution with fats speeds weaning. The risk of nosocomial pneumonia increases with longer ventilatory support. Nursing in the head up position may reduce the incidence,48 while the risk benefits of ulcer prophylaxis49 and gut sterilisation50 continue to be debated. Adequate hydration is clearly important in mobilising tenacious secretions. Inhaled or nebulised b2 stimulants are more effective than saline in aiding sputum clearance, and mucolytics such as N-acetyl cysteine or DNase may occasionally be helpful. High inspired oxygen ( 50 ) inactivates N-acetyl...

Random effects models in action

Doull et al.11 looked at the growth rate of 50 children with asthma before and after taking inhaled steroids. They showed that, compared to before treatment, the difference in growth rate between weeks 0 to 6 after treatment was 0.067 mm week (95 CI 0.12 to 0.015), whereas at weeks 19 to 24, compared to before treatment it was 0.002 (95 CI 0.054 to 0.051). This showed that the growth suppressive action of inhaled corticosteroids is relatively short lived. The random effect model enabled a random child effect to be included in the model. It allowed differing numbers of measurements per child to be accounted for. The model gives increased confidence that the results can be generalised beyond these particular children.

Clinical physiological and laboratory assessment

The immediate assessment of patients with asthma should include the degree of respiratory distress (ability to speak, respiratory rate, use of accessory muscles, air entry), degree of hypoxia (cyanosis, pulse oximetry, level of consciousness), and cardiovascular stability (arrhythmias, blood pressure). Accessory muscle use, wheeze, paradox, and tachypnoea may diminish as the patient tires.16 Figure 13.1 Mucus cast of bronchial tree coughed up by an asthmatic patient during an exacerbation. Reproduced with permission of E Klatt, Utah. Figure 13.1 Mucus cast of bronchial tree coughed up by an asthmatic patient during an exacerbation. Reproduced with permission of E Klatt, Utah.

Drug therapy for intubation and mechanical ventilation

Etomidate and thiopentone are short acting imidazole and barbiturate drugs, respectively, that are commonly used for intubation although rarely bronchospasm and anaphylactoid reactions have been reported. Longer term sedation may be obtained by infusion of midazolam (2-10 mg h) metabolites may accumulate in renal and hepatic impairment. Propofol is a useful drug for intubation and intermediate term sedation, mainly because of its rapid onset and offset of action. It is easily titratable for intubation, providing deep sedation rapidly, although it has no analgesic properties. However, vasodilatation and hypotension occur, especially in dehydrated patients. Relatively little literature regarding its specific use in asthma is available. The doses of all the above agents need to be adjusted for patient size and pre-existing level of consciousness. Ketamine is a general anaesthetic agent that has been used before, during, and after intubation in patients with acute severe asthma.61-63 It...

Mechanical ventilation

Mechanical ventilation provides respiratory support while drug therapy reverses bronchospasm and airway inflammation.28 Abolishing hypoxia is the most important aim. Outcome is improved in mechanically ventilated asthmatics by limiting airway pressure using a low respiratory rate and tidal volume while permitting a moderate degree of hypercar-bia and respiratory acidosis.67 Hypercarbia has not been found to be detrimental except in patients with raised intracranial pressure or severe myocardial depression. Moderate degrees of hypercarbia with an associated acidosis (pH 7.2-7.15) are generally well tolerated. Reducing the respiratory rate to 8 or 10 breaths min prolongs expiratory time so that I E ratios of greater than 1 2 can be achieved. An attempt to increase minute ventilation (to reduce Paco2) by increasing the ventilator respiratory rate invariably reduces the expiratory time and I E ratio, increases air trapping, and may paradoxically cause an increased PaCO2. This has resulted...

Inhalational anaesthetic agents

Halothane, isoflurane, and sevoflurane are potent bronchodi-lators in asthmatic patients receiving mechanical ventilation who have failed to respond to conventional b adrenergic agents.84 Experimental evidence indicates a direct effect on bronchial smooth muscle mediated via calcium dependent channels as well as by modulating vagal, histamine, allergen, and hypoxia induced bronchoconstrictor mechanisms.85 86 Furthermore, these agents reduce pulmonary vascular tone resulting in lower pulmonary artery pressures in acute asthma.87 Bronchodilator responses are seen in the form of reduced peak airway pressures within minutes, associated with improved ventilation distribution (lower Paco2) and reduced air trapping.88 Although bronchodilator effects are seen at sub-anaesthetic concentrations, these agents also offer a relatively expensive method of sedation. A few ICU ventilators, such as the Seimens Servo 900 series, can be fitted with a vaporiser allowing anaesthetic gases to be...

Clinical Presentation

Symptoms at the time of the aspiration episode. Paroxysmal coughing is the primary sign, noted by parents or caregivers, in the pediatric population. With time, however, these characteristic features may abate. With delayed presentation, distal airway foreign bodies may present without symptoms or with nonspecific symptoms such as a nonproductive cough, the new onset of inspiratory and or expiratory wheezing (often assumed to be newly diagnosed asthma), and complaints of mild shortness of breath. Unlike aspirated foreign material in the laryngotracheal location, dyspnea is less frequently reported as a symptom of foreign bodies in the distal airway compared with those centrally located in the airway.

Awakenings from sleep

At night, often with a description of starting again with a gasp and jerking movements. The subject may wake feeling startled and that he or she has woken suddenly for no obvious reason. If the arousal occurs slightly earlier, there may be an awareness of the noise generated by the OSA, and if arousal occurs even earlier there is a sensation of choking since the airway is still closed. These episodes of choking should be distinguished from vocal cord adduction, which is often due to gastro-oesophageal reflux, nocturnal asthma and left ventricular failure.

B ROS and Phagocytosis

In order to sort out which one(s) of the above-mentioned possible mechanisms for hsp induction was most important, we took a number of approaches. We first addressed the issue as to whether other lung pathologies associated with eosinophilic infiltrates were characterized by an increased hsp expression. It was found that both AMs and epithelial cells form patients with asthma expressed increased levels of hsp 70 and that there was a close correlation between the levels of hsp 70 and the severity of asthma as established by AAS score (10), whereas eosinophilia also correlates with the severity of asthma (11). These data suggested that hsp could be a marker of eosinophilic inflammation in asthma. We next investigated whether this was also the case in another pathology associated with eosinophils, that is, chronic eosinophilic pneumonia (Carrington's disease), a disease in which phagocytosis of eosinophils by the AMs is a characteristic feature (12). As shown in Figure 4, using...

External validity of reviews

A key aspect of a review is the rationale for including or excluding studies. As with primary studies, the applicability of a review will be limited by the characteristics of the study participants included in it and the settings in which the studies were conducted. Ideally a guideline group wants evidence from studies within which the study participants are typical of those to whom the guideline will be applied. Therefore the minimum requirement is that a review lists the important characteristics of the participants within each study. However, this will not provide information on other aspects such as recruitment rates in studies. The setting in which a study is conducted will also influence its external validity, particularly if it relates to elements of service delivery. Studies of patients with exacerbations of asthma draw patients from emergency room settings however, the nature of patients and the severity of their asthma may differ between countries where there is a...

Neuroendocrine Tumours

There are no real premalignant neuroendocrine lesions. DIPNECH (diffuse idiopathic pulmonary neuroendocrine hyperplasia) has been placed in the preinvasive section of the new WHO classification. The author has seen very rare cases, associated with tumourlets and typical carcinoids. However, DIPNECH is a nonspecific reaction to airway inflammation and or fibrosis. There is neuroendocrine (NE) cell hyperplasia in association with peripheral car-cinoid tumours. However, adjacent to central typical car-cinoids there is a decrease in NE cells. No in situ lesion has been found in association with small cell carcinoma, although dysplastic squamous epithelium may lie over the tumour.

Brief History From CFCs to HFAs

The first metered dose inhaler, Medihaler EpiTM was introduced in 1956 by Riker Laboratories (3M Pharmaceuticals) for the management of asthma and COPD. The delivery device has been well accepted since that time, as evidenced by the annual production of over a half-billion units (McDonald and Martin, 2000). Since the introduction of the MDI, p-adrenergic agonists, anticholinergics, corticosteroids, and cromolyn compounds have been the staple of management for the commonly occurring lung diseases, asthma and COPD. Due to the environmental ramifications of CFC use, the Montreal Protocol was devised, and then ratified in 1989, initiating the phase-out of CFC pro-pellants, including those used in MDIs (Figures 1a-c). As of 2002, the Montreal Protocol has been ratified by 183 countries (UN Environmental Program, 1996). However, because pharmaceutical inhalers are considered life saving for many asthmatic and COPD patients, they were exempted from the protocol pending availability of...

Who Is Most Likely to Suffer from Dry Eyes

Dry eyes are often a woman's problem since so many autoimmune diseases, which plague women in particular, are associated with dry eyes. Aside from Graves' disease, women can also be plagued with Sjogren's syndrome, which impairs lacrimal gland function and the formation of watery tears (90 percent of Sjogren's syndrome sufferers are women). Hormonal changes during pregnancy and menopause can also cause dry eyes, while in the general population asthma, glaucoma, blepharitis (chronic inflammation of the eyelids), cornea surgery, and corrective surgery for nearsighted-ness are other causes.

Alveolar Type Ii Cell Tumors

A greater understanding of the developmental pathway and the location and regulation of stem cells in the adult lung is important for several reasons. Heroic modern medical treatment enables improved survival of premature humans but also incurs a risk of chronic lung injury. Improved knowledge of stem cells is prerequisite for future interventions to speed lung maturation or to support regeneration of lung tissue damaged due to premature birth. Similarly, phenotypic changes in the epithelium, such as mucous cell hyperplasia, are hallmarks of common lung diseases including asthma, chronic bronchitis, and cystic fibrosis. A better understanding of cell lineages and the regulation of cell pheno-type may lead to potentially beneficial therapies. Lung cancer is the world's most prevalent lethal cancer. Stem cells probably are at greatest risk of malignant transformation. Thus, identification of lung stem cells and their modification during multistage carcinogenesis may form the basis for...

Years old one year after my second childs birth

I've relapsed - a secondary in my lung. I need major surgery and I am very sick. I might die. Bethany was one year old last month. And now my biggest fear She may not even remember me. Nobody told me this could happen. My cancer was 17 years ago and I thought I was cured. But now it all makes sense and I can see what has happened. The doctor showed me a chest x-ray taken five years ago, when Adam was two years old. There it was - an embryonic secondary, just a tiny grain of salt but I could see it nonetheless. That's when my chest began to get bad -1 just thought it was asthma. Then I had the two miscarriages and afterwards my breathing got so much worse. Then I became pregnant with Bethany and since then it's been one chest infection after another and now I know why. The secondary was there all the time growing alongside my babies, developing into a fully fledged killer and now the enemy has been unleashed and I have to fight it again, not just for me but for my...

Palpitations and Racing Heart Tachycardia

In people like me (Sara), who are on a TSH suppression dose of thyroid hormone, mild tachycardia or palpitations can persist, along with adrenaline surges that can cause or worsen panic attacks (see Chapter 24). For people in this situation, beta-blockers are usually given lifelong to prevent these complications. If you're thyrotoxic and suffering from these symptoms, but are also asthmatic or have chronic obstructive lung disease from smoking, other medications can be used to slow the heart, since beta-blockers may worsen your breathing in such conditions.

Table 123 NSCLC resections City of Hope Cancer Center 19871996

Once staging studies have demonstrated that the patient is a candidate for surgical resection, the next important consideration is whether the patient has physiological reserves sufficient to sustain the requisite loss of pulmonary function. A major problem in treating LC lies in the fact that cigarette smoking causes multiple other diseases that may complicate the surgical treatment of the lung neoplasm. Chronic obstructive lung disease (COPD) is almost always present and may be severe enough to preclude lobectomy or pneumonectomy. Cigarette smoking is also a major risk factor for carotid and coronary artery disease. Basic workup consists of a careful history and physical examination with particular attention to exercise capacity, sputum production, and history of asthma and COPD. Pulmonary function studies (PFTs) and arterial blood gas determination are critical. Chronic hypercarbia or hypoxemia severe enough to require oxygen supplementation are contraindications to major pulmonary...

Ingestion of Sharp Objects

Young children should not have access to small objects such as toys with small detachable parts, coins, pins, and the like. Children younger than 3 years should not be given food in forms that could be aspirated nuts, popcorn, vegetable chunks, and so on should be avoided. Care should be taken to avoid aspiration when feeding older adults who have stroke or other serious debilitating disease. If metered dose inhalers are carried in bags or pockets without their safety caps on, foreign bodies may enter their mechanism and be expelled forcefully into the bronchial tree. The ensuing symptoms are often difficult to distinguish from those of an acute attack of asthma.

Tracheomalacia and Bronchomalacia

Tracheomalacia And Bronchomalacia

Tracheal and bronchial malacia, most often associated with COPD, seems to occur infrequently. It varies in severity and may well be underdiagnosed, since COPD may seem to be sufficient cause for respiratory distress. It is also difficult to distinguish symptomatically from chronic asthmatic bronchitis. Patients complain of dyspnea, particularly in the expiratory phase, and this is especially manifest on effort. Respiratory crises that border on asphyxia may follow bouts of severe coughing. Seizures may occur, which in the past were termed laryngeal epilepsy. Expiratory stridor is heard cough may be intractable. The harder the patient works to breathe, the more difficult it becomes. Secretions are raised with difficulty, often a leading complaint, because the cough is weak. The cough is characterized by a seal bark quality. Recurrent respiratory infections ensue.

Some Special Characteristics of Synaptic Transmission

Effect of Drugs on Synaptic Transmission. Many drugs are known to increase the excitability of neurons, and others are known to decrease excitability. For instance, caffeine, theophylline, and theobromine, which are found in coffee, tea, and cocoa, respectively, all increase

How Relevant Are Heterodimers as Disease Targets

An intriguing report by McGraw et al. demonstrates that even quite unrelated receptors can form heterodimers (33). The authors reasoned that the successful response of asthmatics to p2-adrenergic receptor agonists might involve GPCR interactions. They followed up on this idea by looking at the signaling of the prostanoid EP1 receptor, because its endogenous agonist PGE2 is abundant in the airway, but its functional implications are poorly defined. Although activation of EP1 failed to elicit airway smooth muscle contraction by itself, it did significantly reduce the bronchodilatory function of a p2-adrenergic receptor agonist. Using bioluminescence resonance energy transfer (BRET), the authors demonstrated that EP1 and p2-adrenergic receptor formed heterodimers that were responsive to an EP1 agonist.

Mask continuous positive airway pressure CPAP and noninvasive ventilation NIV

In spontaneously breathing patients the application of low levels of mask CPAP (3-8 cm H2O) may improve respiratory rate, dyspnoea, and work of breathing in asthma, particularly if there is evidence of smoking related lung disease.20 54 55 There is a danger that CPAP may worsen lung hyperinflation. If patients are intolerant of the mask or do not derive benefit, CPAP should be withdrawn. In hypercapnic patients CPAP alone may not improve ventilation. Few studies have looked specifically at NIV in asthma. Low levels of CPAP and pressure support of 10-19 cm H2O in acute severe asthma improved gas exchange and prevented endotracheal intubation in all but two of 17 hypercapnic patients.56 However, the rate of intubation in patients with acute asthma, even in the presence of hypercapnia, is low at 3-8 .28 57 It is reasonable to give asthmatic patients a trial of NIV over 1-2 hours in an HDU or ICU if there are no contraindications (box 13.1).56 Deciding when to initiate NIV, when a trial...

Allergy And Hypersensitivity

Diffuse from the circulating blood in large numbers into the skin to respond to the poison ivy toxin. And, at the same time, these T cells elicit a cell-mediated type of immune reaction. Remembering that this type of immunity can cause release of many toxic substances from the activated T cells as well as extensive invasion of the tissues by macrophages along with their subsequent effects, one can well understand that the eventual result of some delayed-reaction allergies can be serious tissue damage. The damage normally occurs in the tissue area where the instigating antigen is present, such as in the skin in the case of poison ivy, or in the lungs to cause lung edema or asthmatic attacks in the case of some airborne antigens. Also released from the activated basophils and mast cells is a mixture of leukotrienes called slow-reacting substance of anaphylaxis. These leukotrienes can cause spasm of the smooth muscle of the bronchioles, eliciting an asthma-like attack, sometimes causing...

Two independent variables

Consider the data given on the pulmonary anatomical deadspace and height in 15 children given in Swinscow.1 Suppose that of the 15 children, 8 had asthma and 4 bronchitis. The data are given in Table 2.1 Asthma In Swinscow,1 the problem posed was whether there is a relationship between deadspace and height. Here we might ask, is there a different relationship between deadspace and height for asthmatics than for non-asthmatics Here we have two independent variables, height and asthma status. There are a number of possible models o Non-asthmatics + Asthmatics o Non-asthmatics + Asthmatics Figure 2.1 Deadspace versus height ignoring asthma status. Figure 2.1 Deadspace versus height ignoring asthma status. Deadspace p0+pHeightXHeight+pAsthmaXAsthma (2.3) This is illustrated in Figure 2.2. It can be seen from model (2.3) that the interpretation of the coefficient pAsthma is the difference in the intercepts of the two parallel lines which have slope pHeighr It is the difference in deadspace...

In Vitro Sporulation

High sporulation levels of certain Clostridium species such as C. perfringens, are notoriously difficult to achieve, which has resulted in numerous modifications of defined and complex media. Several reagents such as caffeine, theophylline, isobutylmethylxanthine, and papaverine in the methylxanthine family have been reported to enhance sporulation in the Clostridia although their effects are somewhat strain-specific and concentration-dependent.10-13 The effect of sporulation enhancement by these compounds is characterized by reduced growth due to their ability to inhibit macromolecular synthesis.14 Because the compounds in the methylxanthine family are purine analogs, Setlow and Sacks15 concluded that their mechanisms of action are similar to that of purine deprivation in B. subtilis, namely, a drop in the GTP pool. Therefore, it is not surprising

Type III Endonasal Median Drainage

Howarth Lynch Operation

The endonasal median drainage (type III) is indicated after one or several previous sinus operations have not resolved the frontal sinus problem, including an external frontoethmoidectomy. It is also justified as a primary procedure in patients with severe polyposis and other prognostic risk factors affecting outcome, such as aspirin intolerance, asthma, Samter's triad (aspirin hypersensitivity, asthma and allergy), Kartagener's syndrome, mucoviscidosis and ciliary dyskinesia syndrome. Its use in patients with severe polyposis without these risk factors is undetermined and needs to be evaluated. It seems that patients with generalized polyposis but who still show in the periphery of the sinuses along the skull base air on a coronal CT scan ( halo sign ) have a comparatively better prognosis than those without, and can be managed by a more conservative technique. It is useful also for removal of benign tumors in the frontal sinus

Action or Non Rest Tremors TabieMB

Drugs and toxins Beta agonists, dopamine agonists, amphetamines, lithium, tricyclic antidepressants, neuroleptics, theophylline, caffeine, valproic acid, alcohol withdrawal, mercury ( Hatter's shakes ), lead, arsenic, others with handwriting, drawing, holding a spoon, using a drinking cup, and manipulating tools. 74I The vocal cords may be affected, resulting in a wavering voice. Although ET usually occurs in isolation, it can be associated with various other neurological conditions including dystonia, parkinsonism, and certain inherited peripheral neuropathies (e.g., Charcot-Marie-Tooth disease). The differential diagnosis includes normal physiological tremor and the tremors associated with anxiety, thyrotoxicosis, and alcohol withdrawal as well as drug-induced tremors resulting from bronchodilator use, corticosteroids, various CNS stimulants, lithium, and sodium valproate. ET diminishes with rest, ethanol, beta-noradrenergic blockers (usual dose, propranolol 80 to 240 mg day),...

Materials And Methods Chemicals

All the amino acids and sulfur-containing compounds used in the study were obtained from local commercial sources TAU, hypotaurine (HYTAU), isethionic acid (ISA), N-acetylcysteine (NACY S), L-cysteic acid (CA) and aminomethanesulfonic acid (AMSA) were from Sigma Chemical Co., St. Louis, MO ethanesulfonic acid sodium salt (ESA) and 1,2-ethanedisulfonic acid (EDSA) were from Aldrich Chemical Co., Milwaukee, WI B-alanine (BALA) and N-(2-acetamido)-2-aminoethanesulfonic acid (ACES) were from TCI America, Portland, OR, N-methyltaurine (MTAU) was from Pfaltz & Bauer, Waterbury, CT 2-mercaptoethanesulfonic acid (MESA) was from ICN Biomedicals, Aurora, OH a-sulfo-P-alanine (ASBA) was from USB, Cleveland, OH and homotaurine (HMTAU) was from Acros Organics, Pittsburgh, PA. The samples of glucose, disodium phosphate, monosodium phosphate, GSH, cromolyn sodium (CROM), H2O2 (30 ), 2-thiobarbituric acid (TBA), 5,5 '-dithiobis-(2-nitrobenzoic acid) (DTNB), methemoglobin (metHb), sodium azide and...

Interpreting a computer output matched casecontrol study

These data are taken from Eason et al.9 and described in Altman et al.6 Thirty-five patients who died in hospital from asthma were individually matched for sex and age with 35 control subjects who had been discharged from the same hospital in the preceding year. The adequacy of monitoring of the patients was independently assessed and the results given in Table 3.7. Table 3.7 Adequacy of monitoring in hospital of 35 deaths and matched survivors with asthma.9 simple McNemar test is that other covariates could be easily incorporated into the model. In the above example, we might also have measured the use of bronchodilators for all 70 subjects, as a risk factor for dying in hospital.

Central Nervous System Stimulants

CNS stimulants can be classified as Psychomotor stimulants compounds that display a stimulatory effect primarily on brain functions and which activate mental and physical activity of the organism. They are made up of methylxanthines (caffeine, theophylline, pentoxifyllin), amphetamines (dextroamphetamine, methamphetamine), and also methylphenidate and pemoline. Respiratory stimulants or analeptics compounds, which cause certain activations of mental and physical activity of the organism, and primarily excite the vasomotor and respiratory centers of the medulla (doxapram, almitrine).Drugs that suppress appetite or anorectics drugs that activate mental and physical activity of the organism, but primarily accentuate the excitatory center of satiation in the hypothalamus (phentermine, diethylpropion).In order to increase mental capability, nootropics drugs that increase the functional state of the brain are sometimes used, the effect of which is associated with blood flow and metabolism...

Soporific Agents Hypnotics and Sedative Drugs

Insomnia is a symptom, and its proper treatment depends on finding the cause of sleeplessness and treating the underlying etiology. The most common type of insomnia is transient insomnia due to acute situational factors. The typical factor is stress. Chronic insomnia is most commonly caused by psychiatric disorders. Numerous medical disorders can cause insomnia. Many drugs have been implicated as causing insomnia alcohol, antihypertensives, antineoplastics, -blockers, caffeine, corticosteroids, levodopa, nicotine, oral contraceptives, phenytoin, protriptyline, selective serotonin reuptake inhibitors (SSRIs), stimulants, theophylline, and thyroid hormones. The underlying cause or causes of insomnia should be treated whenever possible. The primary indication for use of hypnotic agents in patients with insomnia is transient sleep disruption caused by acute stress.

Systemic Considerations

Drugs can adversely affect tracheal reconstruction. Regular aspirin dosage causes, at most, a brief delay in operation. Many patients with tracheal stenosis or tumor are misdiagnosed and treated for adult-onset asthma with steroids at increasing dosage. Operative failure in 2 patients receiving 40 to 50 mg day of prednisone was characterized not by acute anastomotic separation but by slow restenosis. Re-resection was successfully accomplished, long after prednisone was discontinued. The findings suggested a gradual distraction and elongation of the anastomosis, which might be expected to result from the usual anasto-motic tension acting in the absence of a prompt and vigorous healing response. Patients should be weaned from steroids prior to tracheal reconstruction, but they should usually receive short-term stress doses of steroid perioperatively. The patient's airway is maintained by repeated dilations or by a tracheostomy or T tube during weaning from corticosteroids. Tracheal...

Th1 versus Th2 Chemokine Receptor Profiles

Clinical evidence tends to support the Th1 Th2 differential chemokine receptor paradigm, represented primarily as CXCR3 versus CCR4. Pulmonary CCR4+CD4+ cells and levels of CCL17 and CCL22 were significantly increased in asthmatic children versus children with nonasthmatic chronic cough or without airway disease. In asthmatic children, CCR4+CD4+ cells correlated positively with levels of CCL17, CCL22, serum IgE levels, and negatively with FEV 1 (forced expiratory volume in the first second of exhalation, a measure of lung function). Conversely, CXCR3+CD8+ cells and levels of CXCL11 were significantly increased in children with nonatopic chronic cough compared with the other groups (2). These results have been recapitulated in segmental allergen challenge studies. In asthmatics, a majority of T cells in post-allergen challenge biopsies expressed CCR4 (3,4). Expression of the CCR4 ligands CCL22 and CCL17 was also upregulated on airway epithelial cells upon allergen challenge (3). CCR4...

Flexible Bronchoscopy

Bronchoscopy Form

The flexible bronchoscope does not replace the rigid instrument in diagnosis nor in management of airway lesions, but it is a very useful adjunctive tool. It should be used liberally by pulmonologists to rule out organic obstruction in patients thought to have adult onset asthma, to clarify the origin of hemoptysis (however minor), and to investigate the possible causes of recurrent or unyielding volume loss, atelectasis, or pneu-monitis. Intubation, for any reason, is facilitated by using the flexible bronchoscope as a guide. Difficult intubations are made simple in this way. Traumatic tracheal separation may respond to this technique.

Interpreting a computer output

We must first create a new variable Asthma 1 for asthmatics and Asthma 0 for non-asthmatics and create a new variable AsthmaHt AsthmaXHeight for the interaction of asthma and height. Some packages can do both of these automatically if one declares asthma as a factor or as categorical , and fits a term such as Asthma*Height in the model. Table 2.3 Output from computer program fitting height and asthma status and their interaction to deadspace from Table 2.1. Height 1.192565 Asthma 95.47263 AsthmaHt -.7782494 _cons -99.46241 We fit three independent variables Height, Asthma and AsthmaHt on Deadspace. This is equivalent to model (2.4), and is shown in Figure 2.3. The computer program gives two sections of output. The first part refers to fit of the overall model.The F(3,11) 37.08 is what is known as an F statistic (after the statistician Fisher), which depends on two numbers which are known as the degrees of freedom. The first, k, is the number of parameters in the model (excluding the...

Acquired Tracheobronchoesophageal Fistulae

Calcification Bronchus

The H-fistula without atresia may be difficult to diagnose and may go undetected until adulthood (Figure 4-68). The majority of tracheobronchoesophageal fistulae in adults are acquired. Such acquired fistulae result from several causes, including 1) malignancy of the esophagus, trachea, bronchi, thyroid, and lymphomas 2) radiation injury 3) fungal infections such as histoplasmosis and actinomycosis, tuberculosis, syphilis, and bacterial infections (Figure 4-69) and 4) traumatic causes such as those from mechanical ventilation with cuffed tubes and indwelling nasogastric tubes, blunt or penetrating trauma, lye burns of the esophagus, instrumentation, or esophageal foreign bodies (Figure 4-70). The diagnosis of a fistula can be established with the judicious use of an esophagogram, using low osmolar contrast material. High osmolar contrast should be avoided, because if the lung becomes flooded with contrast, life-threatening pulmonary edema and bronchospasm...

Believers in Wilsons Thyroid Syndrome

In Wilson's syndrome literature such as his book Wilson's Thyroid Syndrome A Reversible Thyroid Problem (1991), published by the Wilson's Syndrome Foundation (which also appears on the Wilson's Syndrome website), more than thirty-seven symptoms as well as others are listed as part of the condition. There are few people, healthy or not, who could say that they don't have at least a few of the symptoms on the list. And while some of these symptoms can be due to genuine hypothyroidism, some of the symptoms describe completely unrelated problems, such as asthma. Wilson's list of symptoms also mimic those that you'll find under the following conditions neurasthenia, chronic fatigue, fibromyalgia, multiple chemical sensitivity, chronic Epstein-Barr disease, and chronic candidiasis. Since these conditions typically describe people with chronic malaise, in search of an answer to their malaise, it is suspicious and convenient that Wilson's syndrome seems to offer an answer which, however, is...

Systemic Chemotherapy

These laboratory findings correlate with clinical observations. Children with asthma on long-term steroid therapy at higher doses experience greater depression, anxiety, and verbal memory deficits 50 . Associated mood and behavior changes range from irritability to depression and psychosis 51 . Among healthy volunteers, administration of high dose steroids resulted in a spectrum of behavior changes as well as reduced cognitive function 52 .

Chemotherapy Clinical Manifestations

Interstitial pneumonitis Non-cardiogenic pulmonary edema Fibrosis Bronchospasm Other Agents. Acute pulmonary effects have occurred with cytosine arabinoside (noncardiogenic pulmonary edema) 3,52 and vinca alkaloids in association with mitomycin (bronchospasm or interstitial pneumonitis) 24, 48 , but delayed pulmonary toxicity has not been described. Hypersensitivity reactions to the antimetabolites (methotrexate,

Intrathecal Chemotherapy

Raymond-Speden et al. compared ALL patients with chronic asthmatics. This study demonstrated that the detrimental effects of intrathecal chemotherapy are independent of the limitations of having a chronic disease (i.e., missed school, reduced energy levels, etc.) 42 . When comparing children with leukemia who received systemic and intrathecal CNS-directed therapy and children diagnosed with solid tumors who received systemic chemotherapy alone, the former group exhibited more severe problems on academic tests involving reading, spelling, and arithmetic, and these problems only became apparent 3 years post-diagnosis 43 .

Clinical Characteristics

As the airway narrows, wheezing occurs, followed by frank stridor. Classically, an upper tracheal obstruction outside of the thorax will present with severe inspiratory stridor, and a low intrathoracic stenosis with expiratory wheezing. Usually, stridor may be produced in either phase on deep breathing with effort. Later, the wheeze is present at rest. A marked inspiratory high-pitched sound may be heard across the room even when the patient is quietly seated. When stridor becomes audible at rest, a high degree of obstruction is usually present, with the airway measuring less than 6 or 7 mm in diameter. At this point, action is urgently demanded. The stridor is elicited by having the patient breathe in slowly and deeply through an open mouth, and then forcing the breath out rapidly, with mouth still open. An attempt to inspire deeply and suddenly will often lead to severe coughing. Auscultation over the trachea and upper chest will further identify stridor. It may be heightened by the...

Epidemiological Aspects

Young adults aged 20-44 years, mainly in Europe. Carefully validated questionnaires were used in populations who were selcected in an identical manner in all the study centred12. The findings were confirmed by lung function tests and analysis of IgE antibodies to allergens in representative subpopulation13 The International Study of Asthma and Allergy (ISAAC) comprised almost 800,000 children aged 6 7 and 13 14 years in over 150 centres in over 50 countries over the world14-17 Both the ECRHS and the ISAAC confirmed that that there are large variations in the prevalence of allergy and that these variations can not be explained by similar variations in any known life style and other environmental factors.

Recognising The Need For Ventilatory Support

In addition to this resistive work, reduced respiratory system compliance associated with operating towards the top of the pressure-volume curve is combined with decreased mechanical efficiency of the diaphragm at high lung volumes. Premature expiratory closure of small airways, either because of lack of support in emphysema or functional narrowing from airway inflammation or smooth muscle contraction, results in impaired gas exchange. Positive end expiratory intrathoracic pressure so called intrinsic PEEP further loads the inspiratory muscles. Recruitment of abdominal muscles during expiration is common. This may not increase expiratory airflow as dynamic expiratory resistance, the choke effect, may occur and will then only accentuate gas trapping. Sudden relaxation of abdominal muscle contraction at end expiration, a feature of the failing patient, may be employed to unload the inspiratory muscles by natural recoil at the start of inspiration.25 Additionally, as respiratory rate...

Topical drug delivery to the ventilated patient

Mechanical ventilation, whether invasive or non-invasive, may compromise the delivery of bronchodilator aerosols. The amount of nebulised drug reaching the airways depends on the nebuliser design, driving gas flow, characteristics of the ventilator tubing, and the size of the endotracheal tube.47 71 Drug delivery may vary from 0 to 42 in ventilated patients.72 The presence of humidification alone may reduce drug deposition by as much as 40 , but may be reversed by the addition of a spacer device.73 74 Both ultrasonic and jet nebulis-ers are effective in ventilated patients.75 Nebulisers may, however, be a source of bacterial contamination.76

Noisy breathing in sleep

Sleep apnoeas usually follow many years of loud snoring and are associated with a change in the pattern of the noise. At the end of the apnoea the airway snaps open with a loud snorting or similar noise. The variety of irregular snoring noises indicates how many different patterns of hypopnoea, apnoea and arousal can occur. Acoustic frequency analysis of these noises shows them to be distinct from simple snoring, and a stridor-like character suggests that the obstruction is arising at laryngeal level. Noisy breathing during sleep can be confused with asthma or stridor, and in children with grunting.

The Influence of Genetic Variations on Drug Effects in Other Diseases

In the field of lung diseases the impact of pharmacogenetics has attracted considerable interest especially related to asthma therapy. The pharmacological strategies toward asthma are directed against bronchoconstriction as well as inflammation and genetic variations in key target molecules for drug action have been identified. Thus, SNPs in the genes for the P2-adrenoceptor and adenylyl cyclase as well as changes in the promoter for the 5-lipoxygenase gene have been related to altered drug response. Patients homozygous for the Arg-16 genotype affecting the amino acid residue 16 in the P2-adrenoceptor were reported to be more susceptible to asthma exacerbations and these patients improved when discontinuing the P2-adrenoceptor agonist treatment and The P2-adrenoceptor mediates its signaling through activation of adenylyl cyclase, and it was recently reported that the polymorphism Met772 in the adenylyl cyclase subtype 9 increased signaling exerted by the P2-adrenoceptor under certain...

Evidence from Human Studies

Experimental animal models have been informative to understand the mechanism of fibrosis and appear to replicate some patterns observed in human disease. Data from human subjects relating to chemokines and chemokine receptor expression in fibrosis correlates with that from animal studies. Human lung epithelial cells from patients with idiopathic pulmonary fibrosis strongly express CCL2 mRNA and its protein product, CCL2, in contrast with those cells from healthy patients (98). Schmidt et al. correlate observations from human and animal studies within the same study and show that both models support a role for fibrocytes in pulmonary fibrosis in the context of bronchial asthma (33). In patients with allergen-induced asthma, endobronchial biopsies (that were performed after antigen challenge) show airway fibrosis is associated with the presence of fibrocytes (33). Similar to murine fibroblasts, human fibro-cytes isolated from human peripheral blood express CD45, collagen I, and CXCR4...

Survival analysis in action

Oddy et al.6 looked at the association between breast feeding and developing asthma in a cohort of children to six years of age. The outcome was the age at developing asthma and they used Cox regression to examine the relationship with breast feeding and to adjust for confounding factors sex, gestational age, being of Aboriginal descent and smoking in the household. They stated that regression models were subjected to standard tests for goodness-of-fit including an investigation of the need for additional polynomial or interaction terms, an analysis of residuals, and tests of regression leverage and influence . They found that other milk introduced before four months was a risk factor for earlier asthma (hazard ratio 1.22, 95 CI 1.03 to 1.43, P 0.02).

Ask the mother of a child with suspected TB for the childs road to health card growth card If the card is available

In the absence of these clues, TB is less likely. However, always take a clear history and examine the child carefully. There may be clues to other diagnoses, such as asthma or an inhaled foreign body. Note the nutritional state of the child and look for signs of HIV infection (see Chapter 7). Examine the chest.There may be unexpected findings, such as consolidation or pleural effusion. A child with these abnormalities who does not look acutely unwell (e.g. no signs of respiratory distress such as tachypnoea) and has not recently had antibiotics is more likely to have TB rather than the more common bacterial pneumonias. Finally, do not forget to examine the heart. Otherwise children with cardiac failure due to congenital heart disease, rheumatic heart disease or cardiomyopathy may be misdiagnosed as having PTB.

Hermes C Grillo MD

Primary tracheal neoplasms are still often diagnosed long after the onset of symptoms or signs, particularly in the absence of hemoptysis. Benign neoplasms may be unrecognized for many months or even for several years. The duration of symptoms for malignant lesions prior to diagnosis is 6 to 18 months, reflecting more rapid growth, and especially, onset of hemoptysis. Even pulmonologists remain unfamiliar with tracheal tumors because of their rarity and a corresponding dearth of information about their occurrence and behavior. Reassured by a chest radiograph, which is often read as normal, the physician assigns the reason for wheezing and exertional dyspnea caused by a tumor to adult onset asthma or to chronic lung disease. Inappropriate treatment, once the lesion has been recognized, is an equally serious problem. It is still not widely appreciated that modern techniques of tracheal surgery, combined with radiotherapy, can produce cure or long-term palliation in many patients with...

The Influence Of Maternal Immunity

Maternal IgG antibodies are transplacentally transferred via an active transport, providing a passive protection for infections in the baby. High levels of cord blood IgG antibodies to P -lactoglobulin have been reported to protect against the development ofcow's milk allergy, although this was not confirmed in another study33 Low levels of IgG antibodies to cat and birch in cord blood are associated with an increased prevalence of sensitvityto cat, as well as asthma at 8 years of age34 .If high levels of maternal allergen-specific IgG antibodies indeed are protective, this may be an alternative explanation to the observations in several epidemiological studies showing an increased risk for allergy to seasonal allergens in children born before the relevant pollen6-7. Birth at this time of the year would provide low levels of cord serum IgG antibodies. Furthermore, high levels of IgG anti-IgE antibodies in cord blood are associated with less allergy during the first 18 months of life,...

Team And Individual Expertise

Many assessments and investigations are often initiated by complaints or reports of illness related to the indoor environment. More recently, surveys for fungal and microbial contamination have become routine as a part of due diligence in real estate transactions, whether residential, commercial, or industrial. If health complaints, personal injury, or health-related issues are alleged, medical and public health professionals, including physicians, must be included in the team. Specialty board-certified physicians, such as occupational health physicians, allergists, immuno-logists, pulmonolgists, infectious disease specialists, and epidemiologists, are some of the medical experts considered. Most physicians have limited experience in diagnosing patients with mold or microbial exposure. In fact, the University of Connecticut Health Science Center published a document titled Guidance for Clinicians on the Recognition and Management of Health Effects Related to Mold Exposure and Moisture...

Clinical Experience

Figure 19-4 (continued) E, Principal cores of tumor removed from the carina and main bronchi. F, A second patient with adenoid cystic carcinoma at the carina. The patient was on high doses of prednisone following misdiagnosis as asthma. G, Following bronchoscopic coring, both main bronchi are open. A period of rapid weaning from the prednisone followed, prior to carinal resection and reconstruction, which was accompanied by stress doses ofcorticosteroids.

Selection of Appropriate Antihypertensive Therapy

Several comorbid medical conditions also direct the physician in choosing an appropriate antihypertensive medication. For example, use of beta-blockers is contraindicated in patients with asthma, and heart failure patients should not be prescribed calcium channel blockers (Kaplan, 2002). Likewise, because use of diuretics can create complications for patients with diabetes or gout, these agents should be used sparingly in these cases.

Outlook For The Future

Despite technical problems that still persist, the use of genetics-based analytical methods is already well established and is widely expected to play an increasingly important role in clinical diagnostic microbiology and environmental microbiology as well as other areas in the future. Further improvements and progress toward the elimination of many of these technical problems will undoubtedly continue to occur. Future progress in the development and use of molecular methods for indoor environmental analyses, however, will likely occur only to the extent that they demonstrate socioeconomic value. PCR analyses, for example, remain relatively expensive and require major investments for instrumentation compared with currently used culture-based and microscopic analysis methods. Therefore, it is likely that this and other nucleic acid-based testing methods will have to demonstrate a value-added factor over the traditional methods. The groundwork for this has already been established by...

Endotracheal intubation

Cardiopulmonary arrest and deteriorating consciousness are absolute indications for intubation and assisted ventilation. Hypercapnia, acidosis, and clinical signs of severe disease at presentation may not require immediate intubation before an aggressive trial of conventional bronchodilator therapy.57 58 Conversely, progressive deterioration with increasing distress or physical exhaustion may warrant intubation and mechanical ventilation without the presence of hypercapnia. The process of intubation begins with explanation and reassurance for the patient, followed by pre-oxygenation. The asthmatic patient is often dehydrated and the combination of PEEPi, the loss of endogenous catecholamines, and the vasodilating properties of the anaesthetic agents can cause catastrophic hypotension.59 60 Volume resuscitation before induction of anaesthesia can limit the degree of hypotension but vasoconstrictors such as ephedrine or metaraminol should be at hand.

Cicatricial Stenosis Neoplastic Obstruction

A frequent complication and presentation of tracheal disease is obstruction. Failure to recognize critical degrees of obstruction can lead to death. As noted elsewhere, a tracheal obstruction due either to benign stenosis or neoplasia, in patients who have radiologically normal lung fields, is frequently diagnosed as adult onset asthma, allowing obstruction to reach a critical level. In an emergent state, a small mucous plug or bleeding can easily cause fatal obstruction. Airway obstruction may produce unyielding pneumonia. Prompt treatment is necessary. Acute obstruction due to trauma is dealt with in Chapter 9, Tracheal and Bronchial Trauma. Obstructions from benign stenosis or neoplasia are each managed differently.

Health Effects Of Indoor Fungal And Bacterial Growth

It is well established that fungi and bacteria have known health effects in humans.3'12'25 Many species of fungi and bacteria can cause infections. They also produce a wide range of chemical byproducts, from microbial volatile organic compounds (MVOCs), endotoxins, and fungal glucans, to mycotoxins. Fungi include allergens and triggers of asthma. Fungal glucans are inflammatory in the lung and have been reported to be associated with headaches. Mycotoxins have a wide range of health effects, primarily in ingestion exposures. Although airborne

Assessment Clinical Findings

Acquired stenosis due to intubation for ventilation is signaled by shortness of breath on exertion and stridor in the wake of a history of intubation, usually for respiratory support, with or without tracheosto-my. Children diagnosed with asthma, who fail to respond to treatment, must be suspected of an organic airway lesion. If the child has been previously ventilated, the working diagnosis should be airway stenosis, until proved otherwise.

Types of data

Data can be divided into two main types quantitative and qualitative. Quantitative data tends to be either continuous variables that one can measure, such as height, weight or blood pressure, or discrete such as numbers of children per family, or numbers of attacks of asthma per child per month.Thus count data are discrete and quantitative. Continuous variables are often described as having a Normal distribution, or being non-Normal. Having a Normal distribution means that if you plotted a histogram of the data it would follow a particular bell-shaped curve. In practice, provided the data cluster about a single central point, and the distribution is symmetric about this point, it would commonly be considered close enough to Normal for most tests requiring Normality to be valid. Here one would expect the mean and median to be close. Non-Normal distributions tend to have asymmetric distributions (skewed) and the means and medians differ. Examples of non-Normally distributed variables...


As is often true of helminthic infections, low worm-loads may cause few or no symptoms. Large numbers of larvae in the lungs may produce ascaris pneumonitis, with symptoms resembling pneumonia. Allergic reactions can cause asthma attacks. Larvae can reach atypical (ectopic) sites such as the brain, eye, or kidney, where they may produce grave, life-threatening conditions, but such events are fortunately rare. Adult worms in the intestine can cause fever, abdominal discomfort, diarrhea, and allergic reactions to their proteins. Fever may induce worms to wander to the larynx, where they can cause suffocation, or to exit the mouth or nostrils. Heavy infection robs the host of nutrients, and tangled masses of worms can result in fatal intestinal obstruction if not treated promptly. Intestinal ascariasis is especially serious in young children. In the Third World, ascariasis may produce signs of protein-energy malnutrition in many children and often...

The paired ttest

Consider a two-period, two-treatment cross-over trial in asthma comparing an active treatment (A) and a placebo treatment (B) in which the following PEF (l min) data, in terms of the value at the end of each period, were obtained (Table 4.1). Table 4.1 Data from a cross-over trial in asthma (hypothetical) Table 4.1 Data from a cross-over trial in asthma (hypothetical)


Xanthines are alkaloids and while caffeine (1, 3, 7-trimethylxanthine) is a trimethylxanthine, theophylline and theobromine are dimethylxanthines. They are all well absorbed from the gastro-intestinal tract. The peak blood level of caffeine is reached 30 -60 min after ingestion. It has a plasma half-life of 3-4 h although there is considerable inter-individual variability. It is prolonged in pregnancy and with the oral contraceptive pill.

Study Design

Data for this report came from the Tucson Children's Respiratory Study (CRS), a prospective longitudinal study ofrisk factors for the development ofasthma in childhood. Healthy newborns (n 1246)and their families, not selected for allergy history, were enrolled at birth from 1980-1984.7 Data on parental characteristics (ethnicity, education, physician diagnosed asthma, smoking) was obtained by questionnaire at enrollment. Infant feeding information was obtained prospectively, from forms completed by physicians at well child visits, and retrospectively, from parent completed questionnaires when the child was 1.6 years old. Prospective data were given priority. Children were categorized with regard to duration of exclusive breastfeeding (never breastfed, breastfed exclusively 4months). Parents were asked by questionnaire at ages 6, 9, and 11 years whether a doctor had ever said that the child had asthma, and whether the child wheezed in the past year. Children were considered to have...

Postoperative Care

Optimum medical treatment is required to reduce mucosal inflammation and subsequent stenosis or obstruction and hence ensure a successful outcome. A combination of postoperative antibiotics for 10 days, high-dose mucolytics, intranasal steroid sprays and twice daily nasal saline irrigations using syringe or mechanized irrigation devices is recommended. In highly refractory cases such as hyperplastic sinusitis and nasal polyposis, asthma, Samter's triad, or eosin-ophilia with or without polyposis, patients may benefit from short-term tapering doses of oral steroids. Endoscopic debridement of nasal crusts in the clinic 1 week postoperatively and every 2 weeks thereaf


Hyperplastic rhinosinusitis with nasal polyps represents a reactive, inflammatory disease that results in nasal obstruction, hyposmia, recurrent sinus infection, recalcitrant sinus infections, headache, and asthma exacerbations. Allergies as well as conditions like cystic fibrosis and Samter's triad can all play a role in the hyperreactive disorder. Medical therapy can provide relief in some patients, but a considerable number of patients require surgical intervention to establish a patent sinonasal cavity. Surgical intervention requires careful planning and attentive surgical technique. Preservation and identification of normal anatomic structures is essential. Success rates with a single surgery and adequate postoperative medical therapy can approach between 85 and 90 .

Fixed Stenosis

Patients commonly present with increasing dyspnea. They may note exacerbation with respiratory infections, and certainly decreased exercise capacity. Other presenting symptoms may be hemoptysis, persistent bronchitis, goiter or neck masses, or superior vena cava (SVC) syndrome. Patients may also be identified after difficulty with routine intubation (an endotracheal tube would not pass), or when persistent asthma finally precipitates bronchoscopy or pulmonary function tests for assessment. It is distressingly common for patients with tracheal lesions to have been mistakenly treated for the much more common bronchospastic disease.


Concomitant administration of carbamazepine with oral contraceptives, warfarin, theophylline, doxycycline, haloperidol, TCAs, or valproic acid leads to decreased plasma levels of these other drugs. Concomitant administration of drugs that inhibit the P450 system will increase plasma levels of carbamazepine. This includes fluoxetine, cimetidine, erythromycin, isoniazid, calcium channel blockers, and propoxyphene. Concomitant administration of phenobarbitol, phenytoin, and primidone causes a decrease in carbamazepine levels through induction of the P450 enzymes.


Fractalkine CX3CL1 and its receptor CX3CR1 are the lone members of the CX3C family of chemokines. CX3CL1 can function both as an adhesion molecule in its membrane form and as a soluble chemokine, as it is attached to the cell membrane by an adhesion molecule-like stalk (109,110). CX3CR1 CX3CL1 has been studied extensively in atherosclerosis and kidney disease, but it may play a role in allergic disease as well. Serum CX3CL1 and expression of CX3CR1 by T cells were increased in asthmatic patients (111). Additionally, soluble CX3CL1 was upregulated in BAL after allergen challenge, as was membrane-bound CX3CL1 on endothelial and epithelial cells (111). Thus, CX3CL1 may provide a significant bound molecule allowing a solid phase chemokine gradient to be readily established. It has also been reported that fractalkine is produced by airway smooth muscle cells and may contribute to mast cell recruitment in asthma (112). Thus, there is some evidence that frac-talkine CX3CL1 and its receptor...


A history of mechanical ventilation or ICU admission is a well documented indicator of subsequent near fatal asthma.2 3 Women and smokers are also over-represented in both life threatening attacks and asthma deaths.3-5 It is believed that patients who have had a life threatening attack and those who die are from a similar demographic group. In a large study of patients admitted with a near fatal episode, two thirds of subsequent severe attacks or deaths had occurred within a year.2 5 Interestingly, the association between asthma deaths and b agonist use is still debated and there has been concern that the use of long acting b agonists may increase asthma mortality.6 This has not been confirmed in studies monitoring their use.7 8 In contrast, there is a consensus that underuse of anti-inflammatory treatment in the period leading up to the acute severe attack worsens prognosis.9 Unfortunately, a proportion of asthmatic patients die despite reaching hospital alive. Such deaths can...

Selecting samples

Once an adequate sample size has been calculated, the method by which the sample is chosen may be straightforward. For example, in a hospital-based clinical trial, eligible patients would normally be recruited consecutively until the required number had been obtained and in a case-control study of patients with asthma from a general practice it might be


Intensive care treatment of the poorly responsive asthmatic patient should include high concentrations of inspired oxygen, continuous nebulisation of b agonists, intravenous corticosteroids, and respiratory support.27-29 Clinicians must be aware of the need to optimise oxygenation and avoid dehydration and hypokalaemia. Unrestricted high concentrations of oxygen (60-100 ) must be administered to abolish hypoxaemia,27 30 unlike the patient with chronic obstructive lung disease where controlled limited oxygen is indicated.

Potassium Disorders

Approximately 2 percent of normal adults, 21 percent of hospitalized patients, 25 percent of patients taking 50 mg of hydrochlorothiazide daily, and nearly 100 percent of patients taking more than one class of diuretic have hypokalemia. y Although acute hypokalemia is an uncommon cause of weakness, certain scenarios increase its risk of development, including rapid correction of systemic acidosis (e.g., hyperventilation, bicarbonate administration), postoperative patients unable to take food by mouth (because K excretion cannot be stopped), and the chronic use of beta-2 agonists (e.g., asthmatics).


J Immunol 168 5507-5513 Burkly L, Hession C, Ogata L, Reilly C, Marconi LA, Olson D, Tizard R, Cate R, Lo D (1995) Expression of relB is required for the development of thymic medulla and dendritic cells. Nature 373 531-536 D'Amico A, Wu L (2003) The early progenitors of mouse dendritic cells and plasmacytoid predendritic cells are within the bone marrow hemopoietic precursors expressing Flt3. J Exp Med 198 293-303 Fainaru O, Woolf E, Lotem J, Yarmus M, Brenner O, Goldenberg D, Negreanu V, Bernstein Y, Levanon D, Jung S, Groner Y (2004) Runx3 regulates mouse TGF-beta-mediated dendritic cell function and its absence results in airway inflammation. EMBO J 23 969-979 Fortunel NO, Otu HH, Ng HH, Chen J, Mu X, Chevassut T, Li X, Joseph M, Bailey C, Hatzfeld JA, Hatzfeld A, Usta F, Vega VB, Long PM, Libermann TA, Lim B (2003) Comment on 'Sternness' transcriptional profiling of embryonic and adult stem cells and a stem cell molecular signature . Science 302 393b


Eosinophils are so-called because of their strong affinity for the acidic dye eosin, which is related to their content in highly toxic basic proteins. Major basic protein (MBP) is located in the core of the granules, whereas eosinophil cat-ionic proteins (ECPs), eosinophil-derived neurotoxin (EDN), and eosinophil peroxidase (EPO) are located in their matrix (Fig. 2). MBP is highly toxic to bronchial epithelium and may contribute to the respiratory epithelial damage of patients with severe asthma (7). The granule components are also powerful toxins to multicellular parasites. As a likely reflection of those properties, the eosinophils are involved in allergic and parasitic diseases. An interesting link between these proteins and hsp has been found by Rosenberg et al., who reported the specific and high-affinity binding of GroEL (the prokaryote homologue of hsp 60) to recombinant ECP and EDN, suggesting that hsp may chaperone these proteins in vivo (8).


Among the cytokines produced by the eosinophil, transforming growth factor p (TGF-p) is a candidate of particular interest. Indeed, TGF-P increases the expression of members of the hsp 70 and hsp 90 families in cultured chicken embryo cells (17). It has been suggested that the induction of hsps by TGF-p is mediated by the increase in protein synthesis which enhances the requirement for chaperoning. TGF-P released by eosinophils in asthma may thus be the mediator for hsp induction. In Carrington's disease, eosinophils express TGF-a (18). However, it has not yet been determined whether TGF is differentially secreted in the two eosinophil-mediated pulmonary diseases mentioned above (asthma and Carrington's disease) or whether TGF-a has the same effects on hsp synthesis than TGF-p. Other cytokines may also be involved in this upregulation. Interleukin-1 (IL-1) selectively induces hsp synthesis in pancreatic p cells, which may relate to the ability of IL-1 to induce oxidative stress in...

Cigarette Smoking

Cigarette smoking may be active or passive. The latter occurs in smokers and nonsmokers, in the same environment as a smoker. Passive smoking increases the risk of lung cancer by 26 and of ischaemic heart disease by 23 . In addition, passive smoking is linked with an increased incidence of asthma and chest infections in children.


Over the last several decades, many investigators have been successful in identifying genes responsible for, or at least associated with, specific diseases. In most of these cases there is a single gene or a few causal genes involved, and the consequences of genetic differences are easy to diagnose. The candidate-gene approach to determining individual responsiveness to drugs does not appear to have had the anticipated impact. Family-based linkage studies may be more valuable in mapping genes associated with therapy response in common, but genetically complex, diseases such as asthma.2 Mapping the susceptibility genes for complex human traits is inevitably a huge challenge and novel molecular and statistical approaches are needed to reveal the molecular basis for variations in responsiveness to therapy or susceptibility to potential adverse effects.

Swallowing disorders

Choking during sleep has several other causes. The most common is vocal cord adduction triggered by gastro-oesophageal reflux. Waking feeling unable to breathe in or out or to speak is often terrifying. The sensation of choking is located in the throat and may last for a few seconds or up to a minute. There is often a need to get out of bed and drink a glass of water and occasionally consciousness may be lost. The attacks may recur several times over a few weeks, before going into remission. They can be relieved by antiacid secretion preparations, e.g. high-dose proton pump inhibitors. These episodes may be confused with the sensation of choking with obstructive sleep apnoeas, although this is briefer, nocturnal asthma, and vocal cord adduction due to, for instance, motor neurone disease. The 'sleep choking syndrome' probably does not exist as a discrete entity.


Cause decreased and disturbed sleep with suppression of REM sleep. Antipsychotic drugs with sedative effects can cause decreased sleep latency, increased total sleep time, and improved sleep continuity. Firstgeneration antihistamines (H1 antagonists) might produce daytime sleepiness and worsen OSA symptoms. This effect can be avoided by replacing them with second-generation antihistamines. Some anti-depressant drugs have sedative effects. Sedative and hypnotic drugs can worsen sleep apnea, as does alcohol consumption. -adrenergic blockers may cause daytime sleepiness owing to fragmentation of sleep, while a-adrenergic agonists, such as methyldopa and clonidine, may cause sedation. All stimulants, such as caffeine, theophylline, amphetamine, and cocaine, increase wakefulness and withdrawal of these agents may produce severe hypersomnia in chronic use. Alcohol consumption can increase snoring and worsen sleep apnea. It is also a major cause of sleep disruption. Always consider alcohol...

Severe Burns

Early endotracheal intubation is warranted at the first indication of inhalation injury. All patients with inhalation injury should be placed on humidified oxygen. Steroids are warranted only in the presence of bronchospasm. Bronchoscopy can confirm large airway injury, and lung scans can detect small airway damage.

Coping with Asthma

Coping with Asthma

If you suffer with asthma, you will no doubt be familiar with the uncomfortable sensations as your bronchial tubes begin to narrow and your muscles around them start to tighten. A sticky mucus known as phlegm begins to produce and increase within your bronchial tubes and you begin to wheeze, cough and struggle to breathe.

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