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Develop human Train primary health-care Create a network of national Train specialists in advanced resources workers training centres for physicians buy amoxil with paypal, treatment skills Initiate higher professional psychiatrists buy amoxil 500mg mastercard, nurses buy amoxil without prescription, training programmes for psychologists and social doctors and nurses in geriatric workers psychiatry and medicine Develop training and resource centres 8 buy amoxil 500 mg on line. Link with other Initiate community, school and Strengthen community Extend occupational health sectors workplace dementia awareness programmes services to people with early programmes dementia Encourage the activities of Provide special facilities in the nongovernmental organizations workplace for caregivers of people with dementia Initiate evidence-based mental health promotion programmes in collaboration with other sectors 9. Monitor Include dementia in basic health Institute surveillance for early Develop advanced monitoring community information systems dementia in the community systems health Survey high-risk population Monitor effectiveness of groups preventive programmes 10. Support more Conduct studies in primary Institute effectiveness and Extend research on the causes research health-care settings on the cost effectiveness studies for of dementia prevalence, course, outcome community management of Carry out research on service and impact of dementia in the dementia delivery community Investigate evidence on the prevention of dementia a Based on overall recommendations from The world health report 2001 (32). Caregivers of patients with Alzheimer s disease: a qualitative study from the Indian 10/66 Dementia Research Network. Association of apolipoprotein E allele e4 with late-onset familial and sporadic Alzheimer s disease. Predictive value of apolipoprotein E genotyping in Alzheimer s disease: results of an autopsy series and an analysis of several combined studies. Alzheimer s disease in the National Academy of Sciences-National Research Council Registry of Aging Twin Veterans. Prevalence of Alzheimer s disease and vascular dementia: association with education. Head trauma as a risk factor for Alzheimer s disease: a collaborative re-analysis of case-control studies. Synergistic effects of traumatic head injury and apolipoprotein-epsilon 4 in patients with Alzheimer s disease. Depressed mood and the incidence of Alzheimer s disease in the elderly living in the community. Atherosclerosis, apolipoprotein E, and prevalence of dementia and Alzheimer s disease in the Rotterdam Study. Smoking and risk of dementia and Alzheimer s disease in a population-based cohort study: the Rotterdam Study. Midlife vascular risk factors and Alzheimer s disease in later life: longitudinal, population based study. Methodological issues in population-based research into dementia in developing countries. Prevalence of Alzheimer s disease and dementia in two communities: Nigerian Africans and African Americans. Incidence of dementia and Alzheimer disease in 2 communities: Yoruba residing in Ibadan, Nigeria, and African Americans residing in Indianapolis, Indiana. Is mental health economics important in geriatric psychiatry in developing countries? According to the Brazilian 2000 census, there remainder are in the hands of a private system. Primary are 10 million people aged 65 years and over, correspond- care is provided primarily by the Family Health Programme, ing to about 6% of the whole population. It is predicted in which health professionals go to the patient s home for that by 2050 the elderly population will have increased by periodic health evaluation and management; however, this over 300%, whereas the population as a whole will have in- programme covers only 40% of the population. Brazil has also one of the highest (geriatricians, psychiatrists and neurologists) see referred rates of urbanization in the world with almost one third of patients as outpatients and inpatients. Long-term care is the whole population living in only three metropolitan ar- scarce and is mostly provided by religious organizations eas (So Paulo, Rio de Janeiro and Belo Horizonte), as well for those with severe disability and limited family support. Dementia in Brazil Brazilian Psychiatric Association has a Geriatric Psychia- is still a hidden problem and there is little awareness of it. Several regional nongovernmental organizations are relatively advantaged because of the means-tested work to support people with dementia and their caregivers; non-contributory pension benets for older Brazilians, in- these are united in a federation Federao Brasileira de troduced in the 1990s. Carers experi- ter medical care and low fertility have made the elderly ence signicant burdens and health strain. India has of carers are female and around 50% are spouses who are over one billion people, 16% of the world s population: it themselves quite old. People with dementia are often ne- is estimated that the growth in the elderly population is glected, ridiculed and abused. In this project, a exible, stepped-care intervention According to a recent consensus, the prevalence of de- was adopted to empower the carers with knowledge and mentia in India is 1. The context of the large population and demographic transition, intervention was implemented by locally trained home the total numbers are estimated to more than treble in the care advisers under supervision. The public decreasing the stress of looking after a person with demen- health and socioeconomic implications are enormous. There is a need to make dementia a public the role of caregivers are also working and cannot spend health priority and create a network of home care advisers as much time caring for the elderly. Dementia is considered to provide supportive and educational interventions for the as a normal part of ageing and is not perceived as requiring family caregivers through the primary health-care system medical care. According to United Nations es- are poor, so that many elderly people who retire do not re- timates, it is likely that the gure of 0. Recently the Federal Government has the whole population) people over 60 years of age in 2000 introduced a contributory pension scheme, but in the past will have more than trebled by 2040 (1. No effective alternatives have is being piloted only among certain Federal civil servants. Assessing the extent of dementia among this huge, Specialist health services are in short supply. In 2005 varied and shifting population is not easy, but what little there were only about 77 psychiatrists and three occupa- research has been done suggests prevalence rates for de- tional therapists in the country. Specialist social workers are few and Nigerians is only just beginning: for example in the past work under severe limitations. There are no specialist ser- three years, old-age mental health clinics have been es- vices for the elderly (geriatric or psychogeriatric services, tablished at two universities. There is no formal training meals on wheels, respite care or drop-in centres) and few for geriatric medicine and psychiatry. The term is also applied to a large group of 63 Research conditions characterized by common symptoms 64 Education and training called epileptic seizures, which may occur in the 65 Partnerships within and beyond the health system context of a brain insult that can be systemic, toxic 67 Conclusions and recommendations or metabolic. These events (called provoked or acute symptomatic seizures) are presumed to be an acute manifestation of the insult and may not recur when the underlying cause has been removed or the acute phase has elapsed. Epilepsy has been dened as a disorder of the brain characterized by an enduring predisposition to generate epileptic seizures, and by the neurobiological, cognitive, psychological and social consequences of this condition. The denition of epilepsy requires the occurrence of at least one epileptic seizure (1). An epileptic seizure is dened as a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain (1). These denitions recognize that a diagnosis of epilepsy implies the existence of a persistent epileptogenic abnormality that is present whether seizures occur or not, as well as that there may be consequences of this persistent abnormality other than the occurrence of seizures that can cause continuous disability between seizure occurrence (interictally). Because it is often dif- cult to identify denitively an enduring predisposition to generate epileptic seizures, a common operational denition of epilepsy is the occurrence of two or more non-provoked epileptic seizures more than 24 hours apart. Differential diagnosis of transient events that could represent epileptic seizures involves rst determining that the events are epileptic, then distinguishing between provoked epileptic seizures and a chronic epileptic condition. Febrile seizures in infants and young children and withdrawal seizures in alcoholics are common examples of provoked seizures that do not require a diagnosis of epilepsy. If seizures are recurrent, it is next necessary to search for an underlying treatable cause. If such a cause cannot be found, or if it is treated and seizures persist, then treatment of seizures is guided by diagnosis of the specic seizure type(s), and syndrome if present (see Box 3. Etiology and risk factors Epileptic conditions are multifactorial disorders, and it is useful to discuss three important factors. Anyone with a functioning brain is capable of having a seizure; however, seizures occur more easily in some people than in others. The ease with which a seizure can be provoked, or an epileptic condition can be induced, is referred to as a threshold. Individual differences in threshold are largely attributable to genetic variations but could also be acquired, such as certain types of perinatal injuries, which can alter threshold. Threshold is a dy- namic phenomenon; it varies throughout the day, it also changes in relation to hormonal inuences neurological disorders: a public health approach 57 during the menstrual cycle in women. Stimulant drugs lower seizure threshold and sedative drugs increase it; however, withdrawal from sedative drugs can lower threshold and provoke seizures.

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Those who stated they were aware of the term antibiotic resistance were asked from which sources they had heard about it best purchase for amoxil. The source cited by the largest number of respondents in all 12 countries surveyed is a doctor or nurse (50%) 500mg amoxil overnight delivery, followed by the media (41%) buy amoxil master card, and then a family member or friend (23%) purchase amoxil 250mg visa. Percentages of responses from all respondents to Where did you hear about the term antibiotic resistance? Percentages of all respondents who answered true to the question Antibiotic resistance occurs when your body becomes resistant to antibiotics and they no longer work as well by country surveyed. The survey shows some significant differences in findings between countries surveyed in relation to the statement which is best understood Many infections are becoming increasingly resistant to treatment by antibiotics. In contrast, 30% of respondents in Sudan think that this statement is false, while 43% of respondents in Barbados and 30% of respondents in Egypt state they do not know the answer to this question. Percentages of responses from all respondents to Many infections are becoming increasingly resistant to treatment by antibiotics by country surveyed. People should not keep and use antibiotics later was the least commonly agreed to, though a significant majority (70%) still thought this has a part to play. Percentages of all respondents who answered yes to Do you think the following actions would help address the problem of antibiotic resistance? However in Viet Nam, 13% of respondents disagree with this statement, compared to an overall average of 6%. Additionally, almost one quarter (23%) of survey respondents in China neither agree nor disagree with this statement. Percentage of responses from all respondents to People should use antibiotics only when prescribed by country surveyed. Respondents in Indonesia are least likely to agree, at 64%, and the highest proportion of respondents disagreeing with this statement was in Viet Nam at 16%. Percentage of responses from all respondents to Farmers should give fewer antibiotics to animals by country surveyed. Percentage of responses from all respondents to Governments should reward the development of new antibiotics by country surveyed. Percentage of responses from all respondents to Doctors should only prescribe antibiotics when needed by country surveyed. Percentage of responses from all respondents to Pharmaceutical companies should develop new antibiotics by country income classification. It is also important to note that 57% agree that There is not much people like me can do to stop antibiotic resistance with only 18% disagreeing with this statement, and therefore indicating that they believe they do have a part to play. Percentage of responses from all respondents to statements surrounding attitudes towards antibiotic resistance. There are some significant variations in the findings between the countries surveyed and socio-demographic groups in relation to some of these statements, which are explored further below. In contrast, only 33% of respondents in Serbia and 27% of respondents in Barbados agree that antibiotic resistance is one of the biggest problems in the world, with more than one quarter in each country disagreeing and almost half neither agreeing nor disagreeing with this statement. Percentage of responses from all respondents to Antibiotic resistance is one of the biggest problems the world faces by country surveyed. More than one third of respondents in the Russian Federation (36%), Serbia (35%) and South Africa (36%) are also uncertain. In contrast, 89% of respondents in Sudan agree that experts will solve the problem, as well as 81% of Nigerian respondents. Percentage of responses from all respondents to Medical experts will solve the problem of antibiotic resistance before it becomes too serious by country surveyed. Percentage of responses from all respondents to I am not at risk of getting an antibiotic-resistant infection, as long as I take my antibiotics correctly by country income classification. The majority of respondents (62%) think that antibiotics are widely used in agriculture in their country. Respondents in Serbia (53%), Indonesia (52%) and Barbados (40%) are least likely to agree with this statement. Percentage of responses from all respondents to Do you think antibiotics are widely used in agriculture in your country? These findings can both help shape future public awareness efforts and aid evaluation of the impact of these efforts. Although antibiotic resistance occurs naturally, overuse and misuse of antibiotics in humans and animals is accelerating the process. For this reason, it is critical that people understand the problem, and the way in which they can change their behaviour. They show that although people recognize the problem, they do not fully understand what causes it, or what they can do about it. Antibiotic use The results of the survey questions on antibiotic use demonstrate how frequently antibiotics are taken, with a considerable majority of respondents (65%) across the 12 countries reporting having taken them within the past six months. This rises to 76% in Egypt, the country with the highest number of respondents reporting having taken antibiotics in the past six months, including 54% having taken them within the past month. Even in Barbados the country in which respondents reported the lowest use in the past six months the number stands at 35%. This prevalence is highly relevant to public campaigns on antibiotic resistance both because high levels of use contribute to the problem, and because it demonstrates just how many people it could impact in a short time frame if the antibiotics they are taking become increasingly ineffective. The results of the survey questions on how people obtained antibiotics and whether they got advice on how to take them show that a sizeable majority of respondents across the countries surveyed state that they got their last course of antibiotics, or a prescription for them, from a doctor or nurse (81%), and that they received advice from a medical professional on how to take them (86%). These factors indicate that the antibiotics are more likely to be taken to treat an appropriate condition and in the appropriate fashion, both of which are important in the context of tackling antibiotic resistance. Respondents were asked to indicate whether they thought the statement It s okay to use antibiotics that were given to a friend or family member, as long as they were used to treat the same illness was true or false. Although it is in fact a false statement, one quarter (25%) of respondents across the 12 countries included in the survey believe that this statement is true, though there is considerable variation in the findings between countries. While only 10% of respondents in Barbados think the statement is true, this rises to 37% in Nigeria. Across the 12 countries surveyed, respondents in rural areas, those with lower levels of education and those in lower income countries are more likely to think that this statement is true. Further investigations are needed in order to check if there is a link between broader issues around access to health care and medicine, and the affordability of antibiotics and other drugs for these groups. There is even more evidence of misunderstanding around the second statement shown to respondents: It s okay to buy the same antibiotics, or request these from a doctor, if you re sick and they helped you get better when you had the same symptoms before. Across the 12 countries included in the survey, 43% think this false statement is in fact true. However, close to one third (32%) of respondents surveyed across the 12 countries believe that they should stop taking the antibiotics when they feel better, and this rises to 62% in Sudan. Younger respondents and those in rural areas across the 12 countries, as well as those in lower income countries, are more likely to think they should stop taking antibiotics when they feel better. Understanding which conditions can be treated with antibiotics is also important, as the use of antibiotics for conditions which are not in fact treatable with these medicines is another contributor to misuse, and therefore to the development of resistance. Respondents were asked to indicate which of a list of medical conditions could be treated with antibiotics the list included both conditions that can and cannot be treated with antibiotics. Antibiotics are used to treat bacterial infections, whereas colds and flu are caused by viruses and therefore are not treatable with antibiotics. Further to this, we see that in Sudan, Egypt and India, three quarters or more of respondents think colds and flu can be treated with antibiotics. Younger respondents and those with lower levels of education are also more likely to think antibiotics should be taken for colds and flu. In combination, these survey findings related to the appropriate use of antibiotics suggest that action which effectively builds understanding of how and when to take antibiotics and what they should be used for particularly targeting groups among whom misunderstandings seem to be most prevalent is critical. The survey explored levels of awareness and understanding by asking respondents whether they had heard of a series of commonly used terms relating to the issue. The results show high levels of familiarity (more than two thirds of respondents) with three of the terms: antibiotic resistance, drug resistance and antibiotic-resistant bacteria. Levels of awareness of the terms is not uniform across the countries surveyed however for example, while 89% of respondents in Mexico are aware of the term antibiotic resistance, only 21% of those in Egypt are. Those who were aware of any or all of the terms were asked where they had heard the term. It is, of course, important that the public is not only aware of the issue, but also understands it. The survey sought to establish levels of understanding by asking respondents to indicate whether a series of statements around antibiotic use were true or false. Similarly to the survey findings related to appropriate antibiotic use, the results suggest that there are high levels of misunderstanding in this area.

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The serum branes by osmosis 250 mg amoxil otc, such that the cells would swell up and potassium must be rechecked frequently purchase 250mg amoxil free shipping, e buy cheap amoxil 500 mg on line. Itshouldberememberedthatdextroseisrapidly Intravenous uids metabolised by the liver; hence giving dextrose solu- Intravenous uids may be necessary for rapid uid re- tion is the equivalent of giving water to the extra- placement purchase generic amoxil, e. If insufcient sodium is in patients who are unable to eat and drink or who giveninconjunction, or the kidneys do not excrete the are unable to maintain adequate intake in the face of free water, hyponatraemia results. When prescribing in- problem, often because of inappropriate use of dex- travenous uids certain points should be remembered: trose or dextrosaline and because stress from trauma r Are intravenous uids the best form of uid replace- or surgery as well as diseases such as cardiac failure ment? For example, containhigh-molecular-weightcomponentsthattend blood loss should be replaced with a blood transfusion to be retained in the intravascular compartment. Additional potassium replacement is sure) of the circulation and draws uid back into the often needed in bowel obstruction, but may be dan- vascular compartment from the extracellular space. There has been no consistent drugs or intravenous nutritional supplements (total demonstrable benet of using colloid over crystalloid parenteral nutrition). The Fluid regimens: These should consist of maintenance choice of uid given and the rate of administration uids (which covers normal urinary, stool and insensible depend on the patient, any continued losses and all losses) and replacement uids for additional losses and patients must have continued assessment of their uid to correct any pre-existing dehydration. Bothhypokalaemiaandhyper- blood as shown by the equation and so acutely com- kalaemia (see page 7) are potentially life-threatening and pensates for acidosis. The kidney is able to potassium is dangerous, so even in hypokalaemia no compensate for this, by increasing its reabsorption of more than 10 mmol/h is recommended (except in se- bicarbonate in the proximal tubule. The pH is rst examined to see if the patient is acidotic or Atypical daily maintenance regime for a 70 kg man with alkalotic. The base In general, dextrosaline is not suitable for mainte- excess is dened as the amount of H+ ions that would be nance, as it provides insufcient sodium and tends requiredtoreturnthepHofthebloodto7. Replacement uids base excess signies a metabolic alkalosis (hydrogen ions generally need to be 0. In chronic respiratory be remembered that intravenous uids do not provide acidosis renal reabsorption of bicarbonate will reduce any signicant nutrition. Normally r Acidosiswithlowbicarbonateandnegativebaseexcess hydrogen (H+)ions are buffered by two main systems: denes a metabolic acidosis. If the patient is able the r Proteins including haemoglobin comprise a xed respiration will increase to reduce carbon dioxide and buffering system. Causes of metabolic aci- Pathophysiology dosisincludesalicylatepoisoning(seepage528),lactic Hypercalcaemia prevents membrane depolarisation acidosis or diabetic ketoacidosis (see page 460). Al- leadingtocentralnervoussystemeffects,decreasedmus- ternatively failure to excrete acid or increased loss of cle power and reduced gut mobility. Hyperkalaemia may occur as an im- rate;itcan cause acute or chronic renal failure; it can also portant complication (see page 7) particularly if there causenephrogenicdiabetesinsipidus(seepage445),uri- is also acute renal failure. This may result from any cause of hyperven- ening of the Q T interval but this is not associated with tilation including stroke, subarachnoid haemorrhage, an increased risk of cardiac arrhythmias. Early symptoms be caused by loss of acid from the gastrointestinal are often insidious, including loss of appetite, fatigue, tract (e. Hypokalaemia may occur toms of hypercalcaemia can be summarised as bones, (see page 8). Deposition of calcium in heart valves, coronary Aetiology arteries and other blood vessels may occur. Hyper- Important causes of hypercalcaemia are given in tension is relatively common, possibly due to renal im- Table 1. More than 80% of cases are due to malignancy pairment and also related to calcium-induced vasocon- or primary hyperparathyroidism (see page 446). The serum calcium should be checked and r Bisphosphonates can be used, which inhibit bone corrected for serum albumin because only the ionised turnoverandthereforereduceserumcalcium. Serum phos- Aetiology phate may be helpful, as it tends to be low in ma- Hypocalcaemia may be caused by r vitamin D deciency, lignancy or primary hyperparathyroidism but high in r hypoparathyroidism (after parathyroidectomy, thy- other causes. Pathophysiology r Patients should be assessed for uid status and any Hypocalcaemia causes increased membrane potentials, dehydration corrected. Rehydration reduces calcium which means that cells are more easily depolarised levels by a dilutional effect and by increasing renal and therefore causes prolongation of the Q T interval, clearance. Intravenous saline is often needed because which predisposes to cardiac arrhythmias. It may also many patients feel too nauseous to tolerate sufcient cause refractory hypotension and neuromuscular prob- oral uids and polyuria is common due to nephro- lems include tetany, seizures and emotional lability or genic diabetes insipidus. The preoperative assessment Neuromuscular manifestations Underlying any decision to perform surgery is a recog- Early symptoms include circumoral numbness, paraes- nition of the balance between the risk of the procedure thesiae of the extremities and muscle cramps. All patients un- but less specic symptoms include fatigue, irritability, dergo a preoperative assessment (history, examination confusion and depression. Myopathy with muscle weak- and appropriate investigations) both to review the diag- ness and wasting may be present. Carpopedal spasm nosis and need for surgery, and to identify any coexisting and seizures are signs of severe hypocalcaemia. Elici- disease that may increase the likelihood of perioperative tation of Trousseau s sign and Chvostek s signs should complications. In general any concerns regarding coex- be attempted, although it can be negative even in severe isting disease or tness for surgery should be discussed hypocalcaemia: with the anaesthetist who makes the nal decision re- r Trousseau s sign: Carpal spasm induced by ination of garding tness for anaesthesia. Cardiac disease by history, examination and, where appropriate, failure may occur. Elective surgery should be deferred by at caemia to guide management and to look for the under- least 6 months wherever possible. The serum calcium should be checked and r Hypertension should be controlled prior to any elec- corrected for serum albumin (see above). Blood should tive surgery to reduce the risk of myocardial infarction also be sent for magnesium, phosphate, U&Es and for or stroke. Chronic or complex arrhythmias should be Management discussedwithacardiologistpriortosurgerywherever This depends on the severity, whether acute or chronic possible. Mild hypocalcaemia is treated r Patients with signs and symptoms of cardiac failure with oral supplements of calcium and magnesium should have their therapy optimised prior to surgery where appropriate. Severe hypocalcaemia may be life- and require special attention to perioperative uid threatening and the rst priority is resuscitation as balance. Calcium gluconate contains only a third of the with a history of bacterial endocarditis should have amount of calcium as calcium chloride but is less irritat- prophylactic oral or intravenous antibiotic cover for ing to the peripheral veins. Patients must be asked pulmonary embolism, is a signicant postoperative about smoking and where possible should be encour- risk. Risk factors include previous history of throm- aged to stop smoking at least 6 weeks prior to surgery. Wherever possi- cated unless there are acute respiratory signs or severe ble, risk factors should be identied and modied (in- chronic respiratory disease with no lm in the last cluding stopping the combined oral contraceptive pill 12 months. Preop- coagulant or antiplatelet medication and chronic liver eratively all therapy should be optimised; pre- and disease may cause perioperative bleeding. Postopera- with known coagulation factor or vitamin K decien- tive analgesia should allow pain free ventilation and cies may require perioperative replacement therapy. Coagulation deciencies should be corrected tervention, but should have perioperative blood glu- prior to surgery and careful uid balance is essential. The patient s alcohol intake should be elicited; symp- r Patients on oral hypoglycaemic agents should omit toms of withdrawal from alcohol may occur during a their drugs on the morning of surgery (unless under- hospital admission. In more major surgery, or Pre-existing renal impairment predisposes to the devel- when patients are to remain nil by mouth for a pro- opment of acute tubular necrosis. Hypotension should longed period, intravenous dextrose and variable dose be avoided and urinary output should be monitored so intravenousshortactinginsulinshouldbeconsidered. Close In patients requiring emergency surgery there may not monitoring of blood sugar and urine for ketones is be enough time to identify and correct all coexistent essential. It is however essential to identify any cardiac, should convert back to regular subcutaneous insulin respiratory, metabolic or endocrine disease, which may therapy. Any anaemia, uid and nutrition may cause signicant injury if extravasation electrolyte imbalance or cardiac failure should be cor- occurs. Other complications of parenteral nutrition rected prior to surgery wherever possible. Specic guidelines regarding the use of perioperative an- tibiotic prophylaxis vary between hospitals but these are Postoperative complications generally used if there is a signicant risk of surgical site infection.

It is probably due to severe irritation of the cough receptors by the initial viral infection of the airways best amoxil 500 mg, and subsequent inability of the inflamed area to heal because of persistent coughing that continues to irritate the lining of the respiratory tract cheap 500 mg amoxil with amex. For severe cough purchase amoxil online from canada, a 1-2 week course of oral steroid therapy (with prednisone discount amoxil 500 mg, for example) is often effective. This rise in the incidence of whooping cough is likely due to the waning of immunity that was acquired by adults who had infection prior to the availability of the pertussis vaccine in the 1950s, and, the waning of immunity provided by vaccines that were administered more than a decade previously. Some cases of subacute cough will persist beyond eight weeks and therefore will fulfill the definition of chronic cough. Chronic cough is a serious issue not only because it exposes an underlying illness, but also because of its effect on an individual s quality of life. Many patients who have suffered from chronic cough for months or years become socially isolated, afraid to go out in public for fear of a severe coughing attack drawing unwanted attention. Further worsening the situation is the effect that an individual s chronic cough can have on spouses, family members and coworkers. It is not surprising, therefore, that a recent study demonstrated a very high incidence of symptoms of depression among patients presenting to a specialized cough center for evaluation and treatment. Cough may result from the inciting inflammatory process stimulating cough receptors in the upper airway, or from mucus dripping down into the back of the throat and mechanically inducing cough. Asthma Studies have shown that asthma may account for approximately 25% of cases of chronic cough in adults. Asthma may be suggested as the cause of chronic cough if the typical associated symptoms of shortness of breath and/or wheezing are present. The treatment of chronic cough due to asthma is identical to that of the typical form of the disease: inhaled bronchodilators and inhaled steroids. Studies have shown, however, that up to eight weeks of therapy with an inhaled steroid may be required for resolution of cough. Recent evidence suggests that cough-variant asthma should also be treated with chronic anti-inflammatory therapy to prevent irreversible changes. Eosinophilic bronchitis differs from asthma in that there is no demonstrable reversibility of airway obstruction with inhaled bronchodilators, and there is no hyperresponsiveenss to methacholine, both of which are hallmarks of asthma. The mere presence of acid refluxing from the stomach into the distal esophagus may stimulate nerve endings to trigger an esophageal-tracheobronchial reflex resulting in cough. Alternatively (or, additionally), acid may travel further up the esophagus and penetrate the upper airway (larynx) to stimulate cough receptors. In this subgroup of patients, cough may be due to the reflux of non-acid material into the esophagus. In such cases, additional treatment in the form of prokinetic therapy is required with medications such as metaclopramide. The prokinetic agent limits the reflux of gastric contents into the esophagus and works together with the acid suppressing medication. A procedure called a laporoscopic Nissen fundoplication surgically tightens the junction between the stomach and esophagus to prevent reflux. Unfortunately, the procedure has not proven to be completely effective since some patients achieve only a partial or temporary response. Anecdotal experience suggests that cough due to smoking will resolve or significantly improve within four weeks of quitting. If cough does not resolve after four weeks of abstinence from tobacco, other causes need to be evaluated. Interestingly, research studies have shown that smokers have a diminished cough reflex sensitivity compared to nonsmokers. This is probably due to chronic cigarette smoke-induced desensitization of cough receptors lining the respiratory tract. Furthermore, after as little as two weeks of smoking cessation, the cough reflex becomes measurably more sensitive, even in subjects who had been smoking for many years. Indeed, cigarette smoke-induced suppression of the cough reflex might explain why smokers are more inclined to suffer respiratory tract infections compared to nonsmokers. This has been shown in studies of healthy subjects21,22 and in patients with chronic cough. This is the only class of drugs known to cause cough, and does so in 5 - 20% of patients taking these medications. In most patients, cough will resolve within one week, although in a subgroup of individuals, the cough may linger for several months. Within several months of the attack, it was observed that many of those exposed developed a persistent cough, eventually termed World Trade Center cough. Ambulatory care visits to physician offices, hospital outpatient departments, and emergency departments: United States, 1999-2000. Effect of the second-generation antihistamine, fexofenadine, on cough reflex sensitivity and pulmonary function. Application and validation of a computerized cough acquisition system for objective monitoring of acute cough: a meta-analysis. Chronic persistent cough: experience in diagnosis and outcome using an anatomic diagnostic protocol. Interpretation of positive results of a methacholine inhalation challenge and 1 week of inhaled bronchodilator use in diagnosing and treating cough-variant asthma. Antitussive effect of the leukotriene receptor antagonist zafirlukast in subjects with cough-variant asthma. Eosinophilic airway inflammation as an underlying mechanism of undiagnosed prolonged cough in primary healthcare patients. Chronic cough due to gastroesophageal reflux disease: efficacy of antireflux surgery. Sex-related differences in cough reflex sensitivity in patients with chronic cough. However, in the setting of a man-made or natural disaster, dust clouds are generated with high concentrations of airborne particulates over a wide size distribution. The increased minute ventilation required for evacuation and subsequent rescue or recovery (i. Toxic combustion products can have profound effects on the respiratory system, causing acute symptoms, physiologic changes, and chronic diseases. The frequency, severity, and duration of smoke exposures appear to be important determinants of clinical outcomes, as well as individual host susceptibility factors. Although the complexities of exposure assessment and unpredictable nature of fires have permitted only limited evaluation of acute dose-response relationships and even less refined assessments of the long-term effects of smoke inhalation, many important observations have been made about the acute and chronic effects of smoke inhalation in fire fighters. Several studies have examined changes in fire fighters lung function in conjunction with measures of airway reactivity. Sheppard and co-workers measured baseline airway reactivity to methacholine in 29 fire fighters, and then followed pre-shift, post-shift, and post-fire spirometry over an eight-week period. Sherman and co-workers performed spirometry and methacholine challenge testing before and after firefighting activities in 18 Seattle fire fighters. The finding of increased airway responsiveness in fire fighters suggests that they may be at risk for accelerated loss of ventilatory function. Chia and co-workers exposed 10 new fire fighter recruits and 10 experienced fire fighters with normal airway reactivity to smoke in a chamber without respiratory protection. However, 80% of the experienced fire fighters developed increased airway reactivity. The authors suggested smoke-induced chronic injury or inflammation of the pulmonary epithelium in experienced fire fighters might lead to increased risk of airway reactivity. The authors speculated that airway obstruction following smoke inhalation might be more common and persistent than generally recognized. Recent studies of fire victims using bronchoalveolar lavage have provided insights into the cellular and biochemical effects of smoke inhalation. Following smoke inhalation, significant numbers of neutrophils are recruited to the airways. In patients with inhalation injury and cutaneous burns, increased numbers of both alveolar macrophages and neutrophils have been demonstrated in the airways; the alveolar macrophage may further contribute to the inflammatory response by elaborating additional cytokines such as tumor necrosis factor and interleukin-1, interleukin-6, and leukotriene B4. Although preliminary, these findings suggest potential mechanisms for the decrements in lung function and increases in airway reactivity demonstrated in epidemiologic investigations. Longitudinal studies of lung function in fire fighters have provided conflicting results. The authors concluded that selection factors within the fire department and increased use of personal respiratory protective equipment were important in reducing the effects of smoke inhalation; significant attrition in follow-up cohorts may also have influenced the results.