By X. Knut. Dana College.

Toxoplasmosis rapeseed oil in Spain and dimerised l-tryptophan for should be excluded by serology erectafil 20 mg low price. Environmental factors may also be rel- evant in isolated cases; changes like those of systemic Treatment sclerosis have affected workers exposed to polyvinyl Systemic steroids discount erectafil online master card, often in high doses (e purchase generic erectafil line. Fibrosis of the lungs leads to dyspnoea generic erectafil 20mg with amex, and brosis of the heart to congestive failure. The kidneys are involved late, but this has a grave prognosis in chronic graft-vs. Complications Investigations Most complications are caused by the involvement of The diagnosis is made clinically because histological organs other than the skin, but ulcers of the ngertips abnormalities are seldom present until the physical and calcinosis are distressing (Fig. Barium studies are best avoided as obstruc- Differential diagnosis tion may follow poor evacuation. Other contrast media Other causes of Raynaud s phenomenon are given are available. The differential diagnosis includes of muscle enzymes and immunoglobulin levels, and chilblains (p. Changes like those of progressive systemic sclerosis Systemic steroids, salicylates, antimalarials and long- affect workers exposed to polyvinyl chloride mono- term penicillin are used, but are not of proven value. The mnemonic stands for Calcinosis, Raynaud s phenomenon, oEsophageal dysmotility, Sclerodactyly and Telangiectasia. Telan- giectasia is peri-ungual on the ngers and at, mat- like or rectangular on the face. Many patients with this syndrome develop a diffuse progressive systemic sclerosis after months or years. Localized areas of skin become indurated, sometimes after an upper respiratory tract infection or prolonged renal function. Recently, there have been sinophilia are present and a deep skin biopsy, which promising reports of the efcacy of ultraviolet A-1 includes muscle, shows that the fascia overlying the (340 400 nm) phototherapy for affected skin in muscle is thickened. The disease responds promptly to systemic steroids; the long-term prognosis is good but disability in the short term can be severe. In a young child this can lead to facial Morphoea is a localized form of scleroderma with hemiatrophy. Its prognosis is usu- condition may cause stenosis of the urethral meatus, ally good, and the brosis slowly clears leaving slight and adhesions between the foreskin and glans of the depression and hyperpigmentation. Alopecia is mild and the hair fall mimics Many think that this condition is related to morphoea, telogen efuvium. About 25% of non-indurated white shiny macules, sometimes with patients have a small vessel vasculitis with palpable obvious plugging in the follicular openings. Women purpura, leg ulcers and painful dermal nodules on the are affected far more often than men and, although hands or elbows. Many show Raynaud s phenomenon, any area of skin can be involved, the classical ivory- arthritis, serositis and myositis. The skin lesions (keratoderma blenorrhagicum) are psoriasis-like red scaling plaques, often studded with vesicles and pus- Investigations tules, seen most often on the feet. The toes are red and Patients with mixed connective tissue disease have anti- swollen, and the nails thicken. Psoriasiform plaques bodies in high titre directed against one or more extract- may also occur on the penis and scrotum, with redness able nuclear antigens. Only one-third of patients have subepidermal immunoglobulin deposits in involved skin. The most common skin causes but a similar appearance: some are listed in manifestations are marble-like nodules near joints. Rest, elevation of affected Supercial and migratory thrombophlebitis extremities and local heat often help symptoms. Advances in Dermatology 6, 309 into the systemic circulation to cause fat in the skin 329. For con- venience, disorders of the blood vessels are grouped according to the size and type of the vessels affected. Disorders involving small blood vessels Acrocyanosis This type of poor circulation, often familial, is more common in females than males. The condition is caused by arteriolar constriction and dilatation of the subpapil- toes and, rarely, ears (Fig. They arrive with lary venous plexus, and to cold-induced increases in winter and are induced by cold. Chilblains are caused by a combination of arteriolar and venular constriction, the latter predom- inating on rewarming with exudation of uid into the Erythrocyanosis tissues. Purple-red remedies rarely work, but the oral calcium channel mottled discoloration is seen over the buttocks, thighs blocker nifedipidine may be useful (p. Cold provokes it and causes an unpleas- blood pressure should be monitored at the start of ant burning sensation. The vasodilator nicoti- erythrocyanosis may be the site where other disorders namide (500 mg three times daily) may be helpful will settle in the future, e. Palmar erythema Widespread This may be an isolated nding in a normal person or Caused by infection (bacterial or viral) be familial. Sometimes it is seen in pregnancy, liver Drug reactions disease or rheumatoid arthritis. Often associated with Connective tissue diseases spider telangiectases (see below), it may be caused by Underlying malignancy (e. Borrelia burgdorferi) Telangiectases This term refers to permanently dilatated and visible or caused by a myeloproliferative disease (e. They appear as linear, punctate cythaemia rubra vera or thrombocythaemia), lupus or stellate crimson-purple markings. The common erythematosus, rheumatoid arthritis, diabetes, degen- causes are given in Table 11. If the diagnosis is in doubt, press on the central feeding vessel with the corner Erythemas of a glass slide and the entire lesion will disappear. Erythema accompanies all inammatory skin condi- Spider naevi are seen frequently on the faces of tions, but the term the erythemas is usually applied normal children, and may erupt in pregnancy or to a group of conditions with redness but without prim- be the presenting sign of liver disease, with many ary scaling. Liver function should viral infections such as toxic shock syndrome and be checked in those with many spider naevi. If no cause is obvious, the rash is often called a without local anaesthesia or with a pulsed dye laser toxic or reactive erythema (Table 11. When erythema is associated with oedema ( urticated erythema ) it becomes palpable. Livedo reticularis This cyanosis of the skin is net-like or marbled and Figurate erythemas caused by stasis in the capillaries furthest from their These are chronic eruptions, made up of bizarre ser- arterial supply: at the periphery of the inverted cone piginous and erythematous rings. Primary telangiectasia Hereditary haemorrhagic telangiectasia Autosomal dominant Nose and gastointestinal bleeds Lesions on face Ataxia telangiectasia Autosomal recessive Telangiectases develop between the ages of 3 and 5 years Cerebellar ataxia Recurrent respiratory infections Immunological abnormalities Generalized essential telangiectasia Runs benign course No other associations Unilateral naevoid telangiectasia May occur in pregnancy or in females on oral contraceptive Secondary telangiectasia Atrophy Seen on exposed skin of elderly, after topical steroid applications, after X- irradiation and with poikiloderma Connective tissue disorders Always worth inspecting nail folds. Mat-like on the face in systemic sclerosis Prolonged vasodilatation For example, with rosacea and with venous hypertension Mastocytosis Accompanying a rare and diffuse variant Liver disease Multiple spider telangiectases are common Drugs Nifedipine Table 11. Physiological Cutis marmorata Vessel wall disease Atherosclerosis Antiphospholipid syndrome Connective tissue disorders (especially polyarteritis, livedo Some patients with an apparently idiopathic livedo vasculitis and systemic lupus reticularis develop progressive disease in their peri- erythematosus) pheral, cerebral, coronary and renal arteries. Others, Syphilis usually women, have multiple arterial or venous Tuberculosis thrombo-embolic episodes accompanying livedo Hyperviscosity states Polycythaemia/thrombocythaemia reticularis. Recurrent spontaneous abortions and Macroglobulinaemia intrauterine fetal growth retardation are also features. Physiological Emotional Menopausal Foods Hot drinks Spicy foods Additives (monosodium glutamate) Alcohol (especially in Oriental people) Drugs Vasodilatators including nicotinic acid Bromocriptine Calcium channel blockers including nifedipine Disulram Chlorpropamide + alcohol (diabetics) Pathological Rosacea (p. It is possible that menopausal ush- This appearance is also determined by the underlying ing is mediated by central mechanisms involving vascular network. Hot ushes can usually be helped by with variable scaling, is caused by damage from long- oestrogen replacement. Ethanol is broken down to acetalde- the leg, it gives a clue to the side of the re on which hyde by alcohol dehydrogenase and acetaldehyde is granny likes to sit (Fig. The condition is com- metabolized to acetic acid by aldehyde dehydrogenase mon in northern Europe ( tinker s tartan ), but rare in (Fig. Oriental people not only may have a high-activity variant of alcohol dehydrogenase but also defective aldehyde dehydrogenase.

Without reliable indicators a picture of a situation or developments may remain ambiguous buy erectafil without prescription. The lack of standardisation both in indicator definitions and methods of measurement has hindered international comparisons (Koponen & Aromaa 2006) 20mg erectafil amex. It also includes sexual health buy erectafil cheap, the purpose of which is the enhancement of life and personal relationships generic 20mg erectafil, and not merely counseling and care related to reproductive and sexually transmitted diseases. For each indicator there is an operational definition, justification for selection, criteria for selection, data sources and (when appropriated) references. A systematic review of factors associated with teenage pregnancy in European Union (Imamura, 2007). Results came from 4444 studies identified and screened, 20 met the inclusion criteria. The well-recognized factors of socioeconomic disadvantage disrupted family structure and low educational level and aspiration appear consistently associated with teenage pregnancy. However, surprisingly for some of us, evidence that access to services in itself is a protective factor remains inconsistent. Although further association with diverse risk-taking behaviours and lifestyle, sexual health knowledge, attitudes and behaviour are reported, the independent effects of these factors too remain unclear. Another conclusion resulting from the systematic review was that included studies varied widely in terms of methods and definitions used. First, we cannot synthesize or generalize key findings as to how all these factors interact with one another and which factors are the most significant. Future research ensuring comparability and generalizability of results related to teenage sexual health outcomes will help gain insight into the international variation in observed pregnancy rates and better inform interventions (Imamura, 2007). Friends, books and magazines were the most important source of information on puberty for every country. School teachers appeared as one of he most important sources of information of sexual and reproductive systems of men and women. In every country the large majority of respondents had already had a boy or girl friend: 76. More than 47% (between 47% in Estonia and 58% in Belgium) respondents had already had heterosexual intercourse. However, some outcomes of this apparently similar sexual and reproductive behaviour of young people is obviously different when considering the same four Member States. Teenage pregnancy is a good example, with rates, 1n 2005, varying between 6% in Portugal and 2 % in Belgium (Estonia with 4 % and Czech Republic 1 %). This seems to be due to either one of the following reason: contraceptive failure (Portugal, for instance, having a huge use of emergency contraception, with sales increasing enormously from 80. This is, of course, a pilot study conducted at high-school, needed to be followed by further and larger studies with a core module of sexual and reproductive health (e. Ideally, the population that, in some countries, already drop-out from school at this age one of the high-risk groups should be included. It is also more difficult to identify evidence based knowledge of eventual different risk factors associated to different age groups. An important issue concerns teenage pregnancy when it results from a wanted decision and not from contraceptive failure. This happens sometimes mostly among ethic minorities and lower class populations and creates a need for specific approach to prevent it, if possible. It should here be understood that for a considerable number of health professionals the huge majority of young teenage pregnancies should be prevented, for health, social and emotional reasons. Portugal and Belgium) the law specifically forbids that national health data can be disaggregated by their ethnical provenance. One understands that this was done in order to prevent eventual racist or chauvinist politics. But under a Public Health point of view this becomes a serious difficulty to document the need for a specific intervention targeted at those groups. Also, in the youth pilot survey about sexual health, some socio-economic and ethnical inequalities were probably not detected. First, because of the sampling itself: students attending the high-school answering a questionnaire during the classes. Young people (probably, mostly from ethical minorities) that already drop out from the school (in certain cases those with high risk sexual behaviours) were missed. As far as total fertility rate is considered, again the consensual clinical and health policy- makers feeling is that the rate is higher for several ethical minorities and among some of the lowest socio-economic levels. Indeed, it is accepted that fertility rate is often higher among these sub-groups. This indicator should be considered together with the mean maternal age at first childbirth, because usually it is accepted that the first one is one of the consequences of the second one: if a woman has her first childbirth at the end of her twenties, most probably she will not have many children. However, in Poland, an extremely low fertility rate coexists with a relatively young maternal age at the first childbirth (24. Whatever the relationship between these two indicators is, the total fertility rate in the eight countries considered in this study ranged from 1. Under an epidemiologic and Public Health perspective, having the first term pregnancy after 30 years old is a recognized increased risk factor for breast cancer. This indicator by no way necessarily reflects direct contraceptive failure due to both induced abortion and intended pregnancy among some adolescents. But, anyway, the reasons for such a huge discrepancy among different Member States have to carefully be analyzed and critically understood in the context of specific health and cultural contexts and environments of each region, community and country. In certain cases the same disease can affect more than one single recommended indicator. Also, mean age at first intercourse and contraceptive use at first intercourse can be linked with age-specific birth rate in teenagers. Contraceptive failure is obviously related to induced abortion, two important indicators of sexual morbidity, even when the induced abortion is safe, legal and rare. As already mentioned, mothers are increasingly delivering their first child at older ages. Maternal and fetal problems are well known: increased incidence of dystocic deliveries (e. More difficult to evaluate in all its extension is the morbidity linked to an unpleasant sexual life. Sexual and reproductive health is an important measure of the general health and social well being of a population. Moreover, the scope of sexual and reproductive health extends across the life span (from adolescence to the ageing) and across several Public Health domains. In order that sound evidence based politics can be taken on these issues, some more evidence based knowledge and wisdom is needed, overcoming existing ignorance and misconceptions. This can be done with small adaptations and will be a reliable approach to teenagers specific needs and autonomy. Monitoring reproductive health in Europe what are the best indicators of reproductive health? Factors associated with teenage pregnancy in the European Union countries: a systematic review. Special issue of European Journal of Obstetrics & Gynecology and Reproductive Biology 111 Suppl 1:S5- S14, 2003. Gissler M, Dumitrescu A, Addor V: Improving the performance of National Health Information Systems: the 2002-2003 reform in Finland from an international perspective. Monitoring health in Europe: opportunities, challenges, and progress Eur J Public Health 13 (supplement 3): 1-4, 2003. The generic term for such indicators is health expectancies and they are summary measures of population health combining information on survival with the prevalence of a health measure (Robine 2006). The most common health measure used is disability, producing disability-free life expectancy. Background to health expectancies Research on health expectancies dates back to the 1960s. Being independent of the size of populations and of their age structure, health expectancies allow direct comparison of the different groups that make up populations: e. Since that time health expectancies have been increasingly used in developed countries to assess the evolution of a population s health status, in particular that of older people (Robine et al. However comparison between countries remained almost impossible due to national differences in the morbidity data collected, particularly in the study design, the health concepts used and the wording of questions. In total 10 instruments were proposed with their exact wording in English (Box 1). The set allows in theory the computation of many health expectancies covering the totality of the conceptual framework of the measurement of population health.

Haemoglobin level and platelet count as well as spleen and liver volume were monitored buy generic erectafil 20 mg online. Although results did not reach statistical signicance trusted 20 mg erectafil, positive results were seen in some patients generic erectafil 20 mg without prescription, suggest- ing a follow-up study is warranted generic erectafil 20mg with amex. In general, these assays tend to be more complex and dicult to utilise in large screening campaigns. They do, however, provide an eective way to prioritise compounds that have been identied via various screening strat- egies, and provide important information on mechanism of action. First, Western blot analysis is used to separate cellular proteins based on molecular weight, followed by detection and quantitation using chemiluminescence- or uorescence-based techniques. It is important to point out that increased protein levels, even increases in the fully mature isoforms, do not necessarily indicate that the mutant enzyme is active in situ and able to metabolise accumulated lysosomal substrates; other assays are necessary for these purposes (vide infra). As lysosomal hydrolases tend to have highest activity in an acidic environment, these assays typically utilise low pH buers to minimise metabolism of the articial substrates by related cellular hydrolases that have higher pH optima. Alternatively, parallel assays can be run in the presence of selective inhibitors that can help quantify the contribution of substrate metabolism by non-lysosomal enzymes. Subcellular fractionation is the classical method for monitoring protein tracking. As an alternative, and as discussed above, proteolytic processing of precursor proteins into mature forms can be used as an indirect marker for protein tracking, provided that the processing is coupled to tracking. As glycosylated proteins trac through the secretory pathway, their glycan chains are modied and remodelled by resident glycosyltransferases and glycosidases;58 such changes can be detected by protein glycosylation anal- ysis. Identifying compounds that are eective chaperones but weak lysosomal inhibitors would greatly aid in the development of good development candidates. An alternate and complementary approach is to select for compounds that rapidly leave the lysosome (and the cell) aer the decient enzyme has tracked to the lysosome. An enzyme assay that measures activity in the lysosomes of intact, living cells (i. This was substantially lower anity than when measured using puried enzyme in a cell-free inhibition assay ( 44 nM at pH 5. Similar assays have been developed for several other lysosomal enzymes including a-Gal A, b-Hex and b-galactosidase. Lastly, in situ cell-based assays have been reported that monitor reduction of endogenous substrate levels in patient-derived cells. Unfortunately, the development of these assays presents signicant challenges and only a few have been reported. In contrast, incubation with 34 for 10 consecutive days resulted in a net increase of 15 35% in GlcCer levels. While few if any of the current animal models possess all of these properties, some valuable information can be obtained from those that are available. This model was used to demonstrate dose-depen- dent increases in enzyme activity as well as a reduction in substrate burden in heart, skin and kidney following daily oral administration of 40. However, more important was the observation that less frequent administration using a regimen comprised of 4 consecutive days with drug followed by 3 days without drug (i. This decrease was observed only in animals in which administration was initiated by 2 months of age; administration to older animals did not show the same positive eects. More importantly, a statistically signicant improvement in neurological function was also observed following administration to 2 month-old mice. While therapies developed over the last 10 15 years represent a major step forward, most individuals suering with these diseases still have few, if any, choices for promising therapy. In addition, the cost of existing treatments is a nancial burden to the overall healthcare system. The development of more ecient and higher throughput substrate reduction models, both in vitro and in vivo, would also be extremely helpful in this regard. View Online Pharmacological Chaperones to Correct Enzyme Folding, Cellular Tracking 161 24. View Online Pharmacological Chaperones to Correct Enzyme Folding, Cellular Tracking 163 71. Up-to-date safety and ecacy information on Elaprase can be found in the current summary of product characteristics and prescribing information for Elaprase. In the most severe cases, central nervous system involvement leads to mental retardation and progressive neurologic decline. The name for the nal drug product formulation of idursulfase for human use is Elaprase (Shire Human Genetic Therapies, Inc. These factors included the ability of the cells to grow continuously under manufacturing conditions, viral sequence prole and capacity for a full range of human post-translational modications. Over the years, the accumulated passaging and mutagenesis caused addi- tional genetic changes that led to an immortal phenotype with biochemical deciencies (e. For example, some such cell lines were shown to be free of detectable viruses or viral sequences, and were capable of a full range of human post-trans- lational modications. Protein manufacturing in human cell lines, as compared to non-human cell lines, can result in the production of proteins with human glycosylation. For example, carbohydrate chains on proteins are capable of binding to specic receptors present on cell surfaces where they can initiate a signal transduction cascade oen similar to those observed with growth factors. This human cell platform has been used to successfully develop epoetin delta,19 agalsidase alfa,22 velaglucerase alfa23 and idursulfase. To generate a cell line suitable for the production of idursulfase, an expression construct was introduced into a continuous human cell line. A Master and Working Cell Bank was manufactured and subjected to comprehensive viral safety testing. To support clinical testing and commercial manufacturing, a conventional chromatographic purication process was developed that includes a virus removal lter and the entire manufacturing process was scaled appropriately. The enzyme contains eight N-linked glycosylation sites that are occupied by oligosaccharide chains, including complex, hybrid and high-mannose type oligosaccharide chains. The enzyme activity of idursul- fase is dependent on the post-translational modication of a specic cysteine (C59) to formylglycine. The post- translational modication of the active site cysteine-59 to formylglycine- 59 is also marked. Due to the intracellular compartmentalisation of lysosomes, the pharmacodynamic activity of idursulfase is dependent upon internalisation of the enzyme into the lysosomes. The binding of idursulfase via M6P moieties to cell surface M6P receptors provides a receptor-mediated uptake mechanism for this enzyme. M6P residues on the oligosaccharide chains of idursulfase allow specic binding of the enzyme to the M6P receptors on the cell surface, leading to cellular internalisation of the enzyme and subsequent targeting to intracel- lular lysosomes. Sialylation of the complex and hybrid oligosaccharide chains on idursulfase reduces uptake by hepatic asialoglycoprotein receptors and thereby prevents rapid elimination of idursulfase from the body. Studies to determine the pharmacokinetic properties of idursulfase in animal models (mice, rats and monkeys) have shown that idursulfase has a biphasic serum elimination prole with mean elimination half-lives of about 5 6 hours. Based on phar- macokinetic studies in monkeys, it is likely that serum clearance mecha- nisms (e. Tissue half-lives were similar for the major organs and were approximately 1 2 days for liver, kidney, heart, spleen and bone (including marrow). The accumulation and retention of idursulfase in these organs and tissues was consistent with the distribution of M6P receptors in tissues and organs in mammals. Non-clinical data revealed no special hazard for humans based on a conventional 6 month, repeat-dose toxicity study in cynomolgus monkeys, 1 in which a no adverse eect level of at least 12. Single-dose acute toxicology studies were also performed in rats and cynomolgus monkeys, establishing a no adverse eect level of at least 20 1 mg kg for both species. A male fertility study was performed in rats, which revealed no evidence of impaired male fertility. Information from these studies was supportive of the selected idursulfase therapeutic doses and regimens used in human clinical trials. Treatment with Ceredase was associated with clinical improvement, as evi- denced by increases in haemoglobin concentration and platelet count, as well as reductions in hepatic and splenic volume. The approval of Cerezyme was based on a randomised double-blind trial comparing 15 patients treated with Cerezyme with 15 patients receiving Ceredase over a period of 6 9 months. Two studies were conducted to demonstrate the ecacy of Replagal and to support its licensure. In contrast to the Fabrazyme pivotal study, the goal of these two studies was to demonstrate the ecacy of Replagal based on clinically important end points. Compared with placebo patients, patients treated with Aldurazyme showed improvements of 5.

In a presumed high percentage of the world s population without immunity to this deadly virus purchase erectafil 20 mg mastercard. Diagnosis is usually presumptive; antibody rash and continues until all scabs separate from the titers rise after 2 weeks erectafil 20mg generic. Treatment: is shed from lesions in the oropharynx and on the a) Gentamicin is the drug of choice;doxycycline skin buy erectafil 20 mg line, producing airborne droplets and skin fragments and streptomycin are alternatives purchase generic erectafil from india. Prophylaxis: compared with chickenpox and measles; secondary a) Treat within 24 hours of exposure with cases occur most commonly in household contacts ciprooxacin or doxycycline for 14 days. Mortality rate is 30% (lower than for pulmonary remain infectious for months at room temperature. These changes are accompanied by About the Epidemiology of Smallpox the formation of papular skin lesions. Patients are infectious from the onset of rash until scabs separate from the skin. This clinical prodrome are inactivated by chlorine, ammonia, iodine, lasts 2 to 4 days and is caused by high-level viremia. The gerous biologic weapon: distribution of skin lesions is centrifugal that is, lesions are rst seen on the distal extremities and face Infection can be aerosol-spread, and the virions can and then progress to the trunk). The skin lesions progress in a synchro- susceptible civilian and military populations. Infec- containing airborne droplets and dust particles are tious particles bud from the cell surface. Epithelial cells are particularly susceptible, accounting for the prominent a) Disseminates to all tissues. Chick- enpox lesions are also irregular in shape and size, and are usually supercial. Smallpox lesions have smooth borders, are of similar size, and often extend to the dermis. The vesicles of smallpox feel shot-like; chick- enpox vesicles are soft and collapse easily. A particular problem from an epidemiologic stand- point is the potential for failure to recognize relatively mild cases of smallpox in people with partial immunity. Adult with severe smallpox mal studies, the tyrosine kinase inhibitor imatinib has skin lesions. View been shown to reduce the spread of the closely related of individual raised skin lesions, all at a similar stage of Vaccinia virus. Three clinical characteristics are most helpful in differentiating the two diseases: 1. Febrile prodrome over 2 to 4 days is associated First, chickenpox is usually not associated with a sig- with high-level viremia. Skin lesions are centrifugal (begin on the extrem- Second, the lesions of chickenpox and of smallpox ities later moving to the trunk) with smallpox begin in different locations. In chickenpox, lesions are versus centripetal (begin on the trunk and later rst seen on the trunk, and they often spare the face. Synchronous development with smallpox versus That is, the distribution of chickenpox lesions is asynchronous development with chickenpox. Lesions progress in unison from macular to and later on the distal extremities and face rather papular to vesicular to crusting, feel shot-like, than centrifugal (like smallpox). Two additional antiviral drugs are individuals having one of the foregoing conditions. One interferes with a specic host Other complications reported during the recent vacci- signal transduction pathway required for viral spread, nation of 38,000 rst responders included myocarditis and the other blocks synthesis of a vital poxvirus pro- or pericarditis, cardiac ischemic events and postvacci- tein. Mortality be protective, but the large volume required for intra- is highest in very young and very old patients. Place- The identication of a smallpox case represents a pub- ment in a negative air-pressure room, with the door lic health emergency, and public health officials closed, is recommended. Transport of exposed individuals as quickly as possible is recom- the patient should be limited. Large numbers The vaccine contains Vaccinia virus (cowpox virus) of patients would quickly overwhelm isolation facili- and is administered by intradermal inoculation using ties and would necessitate separate temporary isola- a bifurcated needle. Medical management of biological infection, immunosuppression, or a history or presence casualties: handbook. Pathology and pathogenesis About the Diagnosis,Treatment, and of bioterrorism-related inhalational anthrax. Minimally symptomatic patients may spread bioterrorism-related anthrax, United States, 2001: epidemio- disease; they need to be recognized and iso- logic ndings. Infected patients should be strictly isolated:use inhalational anthrax: the rst 10 cases reported in the United States. Management of anthrax menin- a) Live Vaccinia virus is given by intradermal gitis. Short-course postexposure c) Vaccinia immune globulin is protective, but antibiotic prophylaxis combined with vaccination protects impractical for large numbers of patients. Adverse events associated ing of a rapid diagnostic test for bubonic and pneumonic with smallpox vaccination in the United States, January plague. Development of a recombinant vaccine against aerosolized genesis by inhibition of Abl-family tyrosine kinases. Top- Tularemia ical cidofovir is more effective than is parenteral therapy for treatment of progressive vaccinia in immunocompromised Centers for Disease Control and Prevention. Tularemia as a bio- control of poxvirus infections through inhibition of cellular sig- logical weapon: medical and public health management. Serious Viral Illnesses in the 15 Adult Patient Time Recommended to Complete: 1 day Sankar Swaminathan M. What are the major complications of each of other inuenza viruses,and why should we worry? Transmission occurs via the respiratory route Chickenpox is a manifestation of primary infection; and requires close contact even though the virus is zoster is caused by reactivation of latent infection. Since then, dramatic reductions in chickenpox ment of zoster is not associated with exposure to other incidence have been reported. Nev- with zoster may themselves be capable of transmitting ertheless, 10% of the adult population is estimated to be the virus to susceptible individuals. Zoster occasionally at risk for infection, and 10% of cases occur in patients occurs in younger individuals, particularly those who over the age of 13 years. Nevertheless, from 1990 to 1994, Clinical Manifestation of Chickenpox approximately 100 deaths each year in the United States were attributed to chickenpox and its complications. Chickenpox infected 3 to 4 million people annu- despite the availability of a vaccine. The overall risk of ally (10% adults) in the United States before vac- death is about 15 times higher in adults than in children, cine availability; zoster, 500,000 annually. Highly infectious, spreads person-to-person by deaths in adults are a result of the development of vis- air droplets; zoster represents reactivation. Chickenpox primarily infects the skin: not been clearly identied) and infects the reticuloen- a) Preceded by a mild prodrome. Viremia ensues, followed by diffuse b) Lesions have a centripetal distribution seeding of the skin, internal organs, and nervous system. As viral replication proceeds and inltration by c) Zoster ophthalmicus involves the cornea; polymorphonuclear leukocytes occurs, the lesions appear can be sight-threatening. Successive crops of lesions occur over several days, with complete healing by 10 to 14 days in uncomplicated cases. Zoster presents as a local- The diagnosis of chickenpox can usually be made on ized eruption along the course of one or more der- clinical grounds, based on the characteristics described matomes, most commonly the thoracic or lumbar. Since the eradication of all known natural rash, which is often preceded by localized pain, begins human reservoirs of smallpox and the discontinuation as erythematous papules that evolve into vesicles. The of universal vaccination, the clinical diagnosis of chick- vesicles may coalesce into large, conuent blisters with a enpox has been relatively straightforward. Healing occurs over the the possibility of smallpox as a biologic weapon and course of 2 weeks, although permanent skin changes resumption of vaccination of larger segments of the such as discoloration and scarring may occur. The constellation of lesions in the external auditory canal, diagnosis can be made on the basis of the history and loss of taste, and facial palsy is termed Ramsay Hunt identication of the virus in vesicle uid. These clinical varicella pneumonitis occurs in adults, it is lesions are often found on the palms, soles, and oral often associated with high morbidity and mortality. The difcult, with the primary alternative diagnosis being disease can be particularly severe in pregnant women herpes simplex virus. Antibody-based assays number of skin lesions have been identified as risk performed on lesion scrapings or vesicle uid may also factors for the development of varicella pneumonia.

These challenges increase the uncertainty that a research programme will lead to a new therapy purchase erectafil with paypal, resulting in historically less investment into these therapies generic 20 mg erectafil overnight delivery. An interesting example was raised by Tambuyzer cheap 20mg erectafil mastercard,8 who highlighted that for Gaucher disease patients in Germany best erectafil 20mg, only around 5% of all possible patients are being treated despite treatments being available for more than 15 years. This example also highlights the diculties of obtaining accurate prevalence data for rare diseases, and how variable dierent sources of these data are. Certain rare diseases are also known to have very dierent prevalence rates in View Online Denitions, History and Regulatory Framework for Rare Diseases and Orphan Drugs 5 dierent populations and geographical regions, for example the glycogen storage disease Pompe disease, which can range in prevalence from 1 in 200 000 in Caucasians to as much as 1 in 14 000 in African Americans. While provisions vary from country to country, the key incentives created under various orphan drug regulations generally include marketing exclusivity, which prevents similars from competing with the original approved product during the exclusive period but is in no way intended to create a monopoly if clinical dierentiation can be demonstrated. For example, several small molecule treatments (imatinib, dasatinib and nilotinib) have been approved in parallel for chronic myeloid leukaemia. There is also support for sponsors taking their orphan drug through the regulatory approval process in the form of fee waivers, additional scientic advice and expedited review. These incentives have successfully increased drug development activities within the orphan drug space. Orphan drugs can oer faster development timelines, lower R&D costs, lower marketing costs and lower risk of generic competition. An analysis has suggested that orphan drug approval rates were greater than those of mainstream drugs, and the proportion of overall new drug approvals in recent years that are orphan drugs has steadily grown. The Orphan Drug Act sought to encourage development of drugs, diagnostics and vaccines intended to improve the treatment options for rare diseases by designating them as an orphan drug. Orphan drug designation does not imply that a medicine is safe, eective or legal to develop and manufacture, but simply that the sponsor qualies for certain benets in the course of the drug development process. An orphan-designated product may subsequently gain market approval only if data derived from clinical trials demonstrate the safety and ecacy of the product. Orphan designation confers certain benets to a sponsor; 50% tax credits for clinical development costs, exemption from application user fees, subsidies for conducting clinical trials and market exclusivity for 7 years. In the decade leading up to the Orphan Drug Act being passed, only 10 products for rare diseases received marketing approved while in the period since, more than 10 prod- ucts have received marketing approval every year, and to date some 430 orphan products for rare diseases have been approved. The number of designations has increased markedly in the last decade to an average of well over 100 per year, reective of generally increased interest from R&D companies in rare diseases. This picture is of course atypical in a period where overall drug approval rates have fallen, and therefore the proportion of orphan drugs being approved as a percentage of overall drug approvals is actually rising and appear to have higher approval rates than more mainstream drug applica- tions in recent years. These regulatory guidelines can therefore be described as very successfully stimulating orphan drug development. However, the Orphan Drug Act and its sister regulations in other regions have sparked some controversy, not least through the advent of blockbuster orphans. Some studies have identied orphan drugs that generate signicantly more revenue through o-label use than for any orphan indication. One of the most commercially successful orphan drugs is imatinib (Gleevec), with sales in excess of $4. It is also clear that for small market sizes and rst-in-class medicines, a sponsor needs to embark on a R&D programme in the knowledge that their invest- ment can be recouped, which does imply higher drug pricing, without which many of the products invented to date may never have come to market. It should also be highlighted that the legislation as it applies to orphan drug development makes no explicit provision for enhancing basic research into rare diseases, their diagnosis or which diseases receive drug development attention in which order. This is particularly important as previously approved compounds will already have completed pre-clinical toxicity testing and been deemed to have demonstrated pharmacological activity in another disease indication. Taken together, all drugs that have been previously approved for any disease indication by a regulatory authority oers a signicant resource for rare disease research, having cleared many of the hurdles that oen lead to attrition in the drug development process. There are more than 200 drugs that have a current orphan drug designation and benet from market authorisation for some disease indication, but of course this is but a small fraction of the totality of approved drugs that could have some utility against a rare disease. View Online Denitions, History and Regulatory Framework for Rare Diseases and Orphan Drugs 11 An example of a drug that was approved for a mainstream indication and subsequently approved for a rare disease is sildenal from Pzer (as Viagra, approved for the treatment of male erectile dysfunction in 1998), which was approved for the treatment of pulmonary arterial hypertension in 2005 as Revatio. Examples of drugs that were initially launched as orphan drugs and then were repurposed for broader indications include rituximab from Gen- entech (as Rituxan, initially approved for the treatment of non-Hodgkin lymphomas in 1997) and epoetin alpha from Amgen (as Epogen initially approved for the treatment of anaemia in 1989). Nitisinone is a 4-hydroxyphenyl pyruvate oxidase inhibitor that interrupts the formation of excess tyrosine in the blood and helps to prevent liver damage in children with hereditary tyrosinemia. Applications of all of these technologies to the treatment of rare diseases are illustrated below. The origins of the small molecule agents that are currently approved as a rare disease treatment again mirrors those of more mainstream small molecule drugs, and include phenotypic screens, high- throughput single target screens and natural product semi-synthesis as well as drug repurposing. An interesting example of how small molecule therapies (and their delivery methods) have evolved through the years comes from the portfolio of approved products for the treatment of pulmonary arterial hypertension. This was fol- lowed by the small molecule endothelin receptor antagonists, for example bosentan, which are taken orally. More recently, synthetic derivatives of prostaglandins have been developed using advances in formulation and drug delivery, for example the inhaled iloprost. Initially, murine mAbs were manufactured using hybridoma technology, but due to toxicity and variable immunologic response have since been replaced by other, more human versions. Chimeric mAbs are murine-based in which the mAb constant region is replaced by a human equivalent. Chimeric mAb drugs include iniximab, a mAb that targets tumour necrosis factor and decreases intestinal inam- mation in Crohn s disease. Humanised mAbs are human antibody-based, in which murine hyper- variable regions are graed on. Example products of this type that have been developed for rare diseases include Soliris, for the treatment of paroxysmal nocturnal haemoglobinuria. Human mAbs are produced by vaccinating transgenic mice, which contain human genes, with the antigen of choice, leading to the production of fully human mAbs. An example is Ilaris, which is approved for the treatment of cryopyrin-associated periodic syndrome. Most oen this is an endogenous protein, for example human growth hormone (marketed as Somatropin) that stimulates cell production and growth in conditions such as growth hormone disorders and paediatric growth disorders. More recent examples include Amgen s Neupogen, a granulocyte colony-stimulating factor analogue that is used to stimulate neutrophil production in patients with neutropenia. Initially, the replacement enzymes were isolated from human organs, but enzyme yields were oen low and View Online Denitions, History and Regulatory Framework for Rare Diseases and Orphan Drugs 13 ultimately recombinant versions were developed. The University of London, in partnership with Orphan Technologies, is continuing to develop the approach following the demonstration of ecacy in a small pilot study. In many ways the viral vector delivery system is critical to the success of the approach. Most importantly, they are safe and non-pathogenic, and can produce an eect that lasts for years. Other monogenic diseases that are being tar- geted by the Sangamo technology include sickle cell anaemia, Gaucher disease and beta thalassaemia. Stem cells have the unique ability to renew themselves continuously and could be applied to the supply of native-like cell types for screening purposes, used to repair mutated systems caused by a rare disease before being transplanted back into the patient or directly targeting disease-producing cell types (e. The biotechnology company Bluebird Bio has clinical stage assets based on genetically altered haematopoietic stem cells for the treatment of adre- noleukodystrophy and beta thalassaemia. In this section, examples of what the orphan drugs actually are, when they were approved, which modality they concern and which rare disease they are used to treat is now detailed. One can see from the table that through the 30 years of orphan drug approvals, a range of therapeutic modalities are represented and a large cross-section of the industry are represented as sponsors of orphan drug development programmes. A large range of rare diseases have been served by the drug approvals shown in the table, but when one considers the breadth of total rare disease space (>7000), the products shown in the table only cover a tiny percentage of all rare diseases. It is important to point out that the prevalence data compiled in the table was obtained from several sources, including Orpha- net,41 Eurordis42 and is quite variable, most likely because accurate gures in many cases are lacking. One can see that some categories, for example lysosomal, genetic and respiratory disorders, are reasonably well served by the drugs displayed in Table 1. It is also notable that while for many of the diseases listed in the table, adenite causative link has been elucidated, in many more cases there is no denitive molecular target for the disease. In some cases, even where a molecular target is implicated it is not always known in detail exactly how this creates the disease state. The largest proportion of drugs target blood disorders, with approximately half of all disease classes showing no drug approval. Estimated prevalence Disease per 100 000 Causative link Lysosomal storage disorders Fabry disease 1. Blood disorders still account for a signicant number of orphan drugs, but neurological disorders are also now well represented. It is also notable that almost all rare disease classes are populated, although within each class of disease the proportion of all diseases that are targeted by an orphan drug remains small. This is probably driven, at least in part, by the recent advances in genetic screening and analysis technologies, and a signicant increase in under- standing of the genetic basis for some diseases.