Hepatitis Ebook

Alternative Hepatitis C Treatments

The therapeutic goals of Natural treatment for Hepatitis C are as follows: Decrease iral load Normalize liver enzyme levels. Enhance/regulate immune system function. Strengthen and promote healthy liver function. Protect the liver, prevent further damage. Virological response; i.e. viral clearance, viral reduction or elimination of the virus. Starve the virus by limiting levels of iron. Optimizing cellular levels of glutathione in the body, making detoxification of the liver possible and enhancing the immune system. Stimulate regeneration of the damaged liver cells. Use of antioxidants to combat the effects of free-radicals generated by the virus. Reduce inflammation. Slow viral replication. Replace all of the inflammation-damaged liver cells. Regulate immune function/prevent auto-immune problems. Cancer preventative measures. Reverse fibrosis to prevent and improve cirrhosis

Alternative Hepatitis C Treatments Summary


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Epidemiology And Etiology Hepatitis A

Hepatitis A affects 1.4 million people yearly worldwide.1 The prevalence is highest in underdeveloped countries including Africa, parts of South America, the Middle East, and Southeast Asia. Australia, parts of western and northern Europe, Japan, and the The number of infections and hospitalizations due to HAV infection annually have decreased markedly since the introduction of the hepatitis A vaccine in 1996. ,5 Table 24-1 Risk Factors for Acquiring Viral Hepatitis Hepatitis A Hepatitis B and D Household contacts with acute hepatitis B with open cuts Health care providers in contact with contaminated needles Patients undergoing dialysis Hepatitis C Hepatitis E To date, there are no documented cases of chronic hepatitis A.1,4 Death associated with HAV is rare and is mostly associated with fulminant hepatitis, with which approximately 100 people die annually.4 Hepatitis B Hepatitis B is a bloodborne infection affecting more than 2 billion people worldwide. Approximately 400 million...

Hepatitis Associated with Delta Agent Etiology

A fourth hepatitis virus, the delta agent, is unable to grow independently it grows only in cells that are also infected with hepatitis B. Its defect is an inability to make coat protein, and it must, therefore, wrap itself in the surface protein of another virus to become infectious. As has been noted, hepatitis B produces large quantities of coat protein in this way, delta can attain very high titers in the blood. Envelopment in the other's coat also gives delta the advantage of hepatitis B virus's freedom from immune attack, and the fact that hepatitis B is commonly persistent in infected persons gives delta a reasonably large field in which to forage. Like hepatitis A, but not B, delta virus has an RNA genome. It does produce one distinctive protein that permits serologic identification of the infection. Wrapped in the hepatitis B coat, it is intermediate in size between A and B, at 36 nanometers. Delta virus has been found in most countries of Europe and North America as well as...

Detection of Hcv Rna Using the Amplicor Hcv Test Version

The AMPLICOR HCV test is for use only with serum or plasma specimens. For serum samples, collect blood in VACUTAINER serum separator tubes (Becton-Dickinson no. 367784 or 367789), and for plasma, collect blood in tubes containing EDTA (lavender top, Becton-Dickinson no. 6454 or equivalent) or acid citrate dextrose (yellow top, Becton Dickinson no. 4606 or equivalent) as the anticoagulant. Specimens collected in tubes containing heparin as the anticoagulant are unsuitable for this test. 3. Negative human plasma nonreactive by antibody tests for HCV, human immunodeficiency virus-1 (HIV-1) and HIV-2, and HBsAg ProClin 300 (Rohm and Haas). 4. Positive control noninfectious in vitro transcribed RNA containing HCV sequences, synthetic poly rA RNA, EDTA, sodium azide. 6. Internal control noninfectious in vitro transcribed RNA containing HCV primerbinding sequences and a unique probe-binding region, synthetic poly rA RNA, EDTA, sodium azide (see Note 1). 1. HCV DNA probe-coated microwell...

Clinical Presentation And Diagnosis Diagnosis of Viral Hepatitis

Diagnosing viral hepatitis may be difficult because most infected individuals are asymptomatic.4,10,12,13 Because symptoms cannot identify the specific type of hepatitis, laboratory serologies must be obtained (Table 24-2). In addition, liver function tests may be obtained to assess the extent of cholestatic and hepatocellular injury. However, the definitive test to determine the amount of damage and inflammation of hepatic cells is a liver biopsy. Hepatitis A The diagnosis of hepatitis A is made by detecting immuno-globulin antibody to the capsid proteins of the HAV. The presence of IgM anti-HAV in the serum indicates an acute infection. IgM appears approximately 3 weeks after exposure and becomes undetectable within 6 months. In contrast, IgG anti-HAV appears in the serum at approximately the same time IgM anti-HAV develops but indicates protection and lifelong immunity against hepatitis A.1 Hepatitis B Hepatitis B is diagnosed when HBsAg is detectable in the serum. The nucleocapsid...

Prevention And Treatment Of Viral Hepatitis Desired Outcomes

General desired outcomes for treating hepatitis are to (a) prevent the spread of the disease (b) prevent and treat symptoms (c) suppress viral replication (d) normalize hepatic aminotransferases (e) improve histology on liver biopsy and (f) decrease morbidity and mortality by preventing cirrhosis, HCC, and ESLD. For hepatitis B, additional treatment goals include (a) seroconversion or loss of HBsAg (b) seroconversion or loss of HBeAg and (c) achieving undetectable HBV DNA levels. Additional goals for chronic hepatitis C include achieving undetectable HCV RNA 6 months post hepatitis C therapy by obtaining a sustained virologic response (SVR)26 Managing viral hepatitis involves both prevention and treatment. Prevention of hepatitis A and B (and indirectly for hepatitis D) can be achieved with immune globulin or vaccines. Acute viral hepatitis A, B, C, D, and E are primarily managed with supportive care. Individuals with mild to moderate symptoms rarely require hospitalization....

Enterically Transmitted NonA NonB Hepatitis Etnanbh

ET-NANBH is a virus structurally similar to but immunologically distinct from hepatitis A. It has recently been associated with a number of previously inexplicable hepatitis epidemics. As yet the virus has not been grown in culture, but it can be serially passed through monkeys and has been identified by electron microscopy. Biochemical characterization remains to be done. Most epidemics attributed to ET-NANBH have occurred in less developed countries at times when even the normally limited sanitation procedures have broken down. Most of these have been in South Asia, but there have also been epidemics in the southern former Soviet Union, in refugee camps in Somaliland, and in Mexican villages, where water supplies became grossly contaminated. All ages are commonly affected, but there may actually be a preponderance of adult cases. These circumstances suggest that ET-NANBH virus is less infectious than hepatitis A and that, even in conditions of generally poor sanitation, most people...

Hepatitis C VirusNS3 HSVNS3

Hepatitis C virus (HCV) is the main cause of both sporadic and post-transfusion non-A, non-B hepatitis (Kumar et al., 1997). The viral-encoded non-structural protein 3 (NS3) is a serine protease that has protease, nucleoside triphosphate, and helicase activities and therefore represents a good target for inhibition of HCV. A selection was performed with a library bearing a 120-nucleotide random region and after six rounds of selection, two aptamers were identified that bound to NS3 and inhibited its helicase and protease activities in vitro (Kumar et al., 1997). In order to identify an aptamer with specificity for the NS3 active site, Fukuda et al. (2000) performed a selection to the truncated polypeptide ANS3. Using a RNA library with a 30-nucleotide random region, they performed nine While the aptamers were divided into three families based on their sequence similarity, they all retained a GA(A U)UGGGAC conserved region. These aptamers bound to ANS3 with a Kd of 10 nmol L and...

Genotyping HCV Using LiPa InnoliPa Hcv Ii

The most convenient source of amplicons for the LiPA assay is the PCR products from the AMPLICOR HCV 2.0 assay. Alternatively, RT-PCR of HCV can be performed using primers supplied by Innogenetics. The following protocol uses AMPLICOR HCV 2.0 PCR products. Fig. 1. Type- and subtype-specific probe location on the INNO-LiPA HCV II strip. Fig. 1. Type- and subtype-specific probe location on the INNO-LiPA HCV II strip.

Hepatitis Serology

Hepatitis A virus (HAV), hepatitis B virus (HBV), and less often hepatitis C virus (HCV) are the usual causes of acute viral hepatitis. A person with symptoms of acute hepatitis should have these four hepatitis serologies performed immunoglobulin M (IgM) anti-HAV, hepatitis B surface antigen (HBsAg), IgM anti-HBc, and anti-HCV. At present, stool and blood assays for HAV antigen are not available. The diagnosis of hepatitis A is made by the detection of IgM anti-HAV during acute illness. A positive anti-HAV with only IgG anti-HAV indicates previous infection. In hepatitis B, HBsAg is the earliest serologic marker of infection and is present before elevation of the aminotrans-ferases. If HBsAg is present for more than 6 months, the patient should be considered chronically infected (carrier). Antibodies to HBsAg (anti-HBs) indicate immunity to hepatitis B and appear several weeks to months after HBsAg disappears. The gap between the presence of HBsAg and anti-HBs is a window period...

Hepatitis A Vaccine

Hepatitis A virus (HAV) is usually transmitted person to person through the fecal-oral route and by ingestion of contaminated food or water, but it has rarely been transmitted by transfusion of blood or blood products. Two HAV inactivated vaccines, HAVRIX and VAQTA, are licensed in the United States for use in children age 1 year and older. TWINRIX is a combined hepatitis A and hepatitis B vaccine licensed for use in persons at least 18 years old. Physicians should consult the package insert for proper dosing because there are different formulations of these vaccines. Childhood vaccination against HAV is recommended for all U.S. children 12 to 23 months of age and should be considered for unimmunized children ages 2 to 18 years old. Indications for immunization with hepatitis A vaccine include travel to or residence in countries or areas endemic for hepatitis A, residence in Native American or Alaskan Native communities with high rates of HAV infection, persons who receive...

Hepatitis B Vaccine

Hepatitis B virus (HBV) is endemic in Southeast Asia, the Pacific Islands, China, Africa, parts of the Middle East, and the Amazon Basin. More than 350 million people worldwide have chronic HBV infection. Although transmission in U.S. children is less likely because of high coverage with HBV vaccine, the risk of perinatal transmission of HBV from an infected mother to her infant varies from 10 to as high as 90 , depending on whether the mother is negative or positive for hepatitis B e antigen (HBeAg) (CDC Pink Book, 2009, 99-122). Immunization with the pediatric formulations of hepatitis B vaccine is recommended for all infants soon after birth or before hospital discharge. HBV vaccine should be given to newborns of mothers positive for hepatitis B surface antigen (HBsAg) or infants of mothers whose HBsAg status is unknown. An infant born to an HBsAg-positive mother should receive an initial dose of 5 .g Recombivax HB or 10 .g Engerix-B and 0.5 mL of hepatitis B immune globulin (HBIG)...

Hepatitis A

Hepatitis A is caused by an RNA virus 27 nanometers in diameter. It is very similar to poliovirus in general structure and also in its ability to spread through fecal contamination of food and water. The virus is fastidious in its host range. It is known to infect only humans, apes, and marmosets. The virus of hepatitis A is essentially worldwide in distribution but is much commoner where drinking water is unsafe and sanitation inadequate. The prevalence of disease is often inversely related to the prevalence of virus. In less-developed countries, most people become immune through infection in childhood, often with no apparent illness. Persons from developed countries, however, especially when traveling in less-developed areas, are likely to become infected as adults with serious consequences. Hepatitis A is manifested by general malaise, loss of appetite, and often jaundice. Specific diagnosis can be confirmed only by electron-microscopic examination of feces or, more practically, by...

Hepatitis B

The cause of hepatitis B is a very unusual virus. Most important, it is unusually stable and can withstand boiling temperatures and drying without inactivation. Although the virus is of moderate size, 45 nanometer in diameter, it The stability of hepatitis B virus means that it can persist on any article that is contaminated with blood, most significantly used needles and surgical instruments. In developed countries, it has usually been transmitted in this way. Precautions have reduced the incidence of this disease in most of the population, but it continues to be a serious problem among intravenous drug abusers. Hepatitis B can also be sexually transmitted. It is excreted in the semen and transmitted from male to female and from male to male in this way. Because the heterosexual transmission does not form a complete cycle, this has been less of a problem among heterosexuals than in the male homosexual communities of Europe and North America. The most serious pattern of hepatitis B...

Hepatitis C

The virus of hepatitis C has been neither seen nor cultured. However, in 1989, a strand of RNA from the blood of an infected chimpanzee was transcribed into DNA. Propagated into a bacterial clone, this DNA codes for an antigen that crossreacts with the agent of an important transfusion-transmitted hepatitis virus. The discoverers suggested that this hepatitis C virus might be structurally similar to the virus of yellow fever or equine encephalitis. This implies that the virus genetic material was the original RNA strand, not DNA. Hepatitis C is inactivated by chloroform, showing that, unlike the viruses of hepatitis A and B, it has a lipid-containing envelope. The agent of some other transfusion-transmitted non-A, non-B hepatitis is resistant to chloroform, indicating the existence of at least one more unidentified agent of this disease. Wherever hepatitis A and B have been distinguished, a residuum of non-A, non-B cases has remained. Some of these cases are associated with blood...

Infectious Hepatitis

Hepatitis literally refers to any inflammation of the liver. Even when restricted by the term infectious, it has many causes, including malaria and many viruses including that of yellow fever. By convention, however, infectious hepatitis usually refers to a small group of diseases caused by several unrelated viruses, whose most obvious and most consistent symptoms are due to liver damage. Because these diseases are unrelated, except in liver involvement, they will be treated individually. Only their early undifferentiated history can be reviewed in general terms. Even the distinction between infectious and noninfectious hepatitis is a problem. Autoimmune chronic active hepatitis will not be considered here, although there is evidence of viral involvement in triggering the autoimmune reaction. Liver cancer will be included as a late consequence of infection with hepatitis B virus, because that seems to be the main cause. Other clinically similar diseases that are not covered here are...

Hepatitis B Etiology

The cause of hepatitis B is a very unusual virus. Most important, it is unusually stable and can withstand boiling temperatures and drying without inac-tivation. Although the virus is of moderate size, 45 nm in diameter, it has the smallest DNA genome known. It accomplishes all its necessary functions by using overlapping stretches of the same genetic information to produce different proteins. The protein that is used for the external surface of the virus is produced in such great excess that the host immune system cannot cope, and becomes paralyzed. To reproduce itself, the virus first makes a copy of its genome in RNA, then recopies that back into DNA. The virus DNA can be integrated into the human genetic material, to provide a secure resting place for the virus and, perhaps, to interfere with the host's growth control mechanism and cause cancer. The stability of hepatitis B virus means that it can persist on any article that is contaminated with blood, most significantly, used...

Hepatitis C Etiology

The virus of hepatitis C has neither been seen nor cultured to the time of writing. However, in 1989, a 3,000-kiloDalton strand of RNA from the blood of an experimentally infected chimpanzee was transcribed into DNA by Qui-Lim Choo and his associates. Propagated into a bacterial clone, this DNA codes for an antigen that crossreacts with the agent of an important transfusion-transmitted hepatitis virus. The discoverers suggested that this hepatitis C Virus might be structurally similar to the virus of yellow fever or equine encephalitis. This implies that the virus genetic material was the original RNA strand, not DNA. Hepatitis C is inactivated by chloroform, showing that, unlike the viruses of hepatitis A or B, it has a lipid-containing envelope. The agent of some other transfusion-transmitted non-A, non-B hepatitis is resistant to chloroform, indicating the existence of at least one more unidentified agent of this disease. Wherever hepatitis A and B have been distinguished, a...


Hepatitis is defined as acute inflammation of hepatic parenchyma. In the United States the most common types of hepatitis are secondary to viral etiologies and are labeled as hepatitis A, B, and C. Table 38-3 outlines the various serologic markers for viral hepatitis. Viral hepatitis is less frequently attributed to Epstein-Barr virus, toxoplasmosis, and cytomegalovirus. Additional causes of hepatitis include bacterial and fungal sources, autoimmune and metabolic disorders, toxic poisoning, and various hepatotoxic medications (e.g., isoniazid, acetaminophen) and alternative supplements. Acetaminophen overdose should be considered in acute nonviral hepatitis and treated immediately with n-ace-tylcysteine to avoid permanent hepatic damage and death. Patients presenting with acute hepatitis often exhibit low-grade fever, fatigue, lethargy, anorexia, RUQ pain, nausea, vomiting, diarrhea, arthralgias and myalgias, and in severe cases, dark urine and jaundice. Serum bilirubin,...

Hepatitis A Etiology

Hepatitis A is caused by an RNA virus 27 nanometers in diameter. It is very similar to poliovirus in general structure and also in its ability to spread The virus of hepatitis A is essentially worldwide in its distribution, but it is very much commoner where drinking water is unsafe and sanitation inadequate. Like poliomyelitis, however, the prevalence of disease is often inversely related to the prevalence of virus. In the less developed countries most people become immune through infection in childhood, often with no apparent illness. In semideveloped countries, porcelain water filters may be used to remove the causes of acute bacterial and protozoal diseases, but not the cause of hepatitis virus. Persons from developed countries, especially when traveling in lesser developed areas, are likely to become infected as adults with serious consequences. Hepatitis A is manifested by general malaise, loss of appetite, and often, jaundice. Definitive diagnosis of hepatitis requires the...

Viral Hepatitis

Identify modes of transmission and risk factors among the major types of viral hepatitis. 3. Evaluate hepatic serologies to understand how the type of hepatitis is diagnosed. 4. Create treatment goals for a patient with viral hepatitis. 5. Recommend an appropriate pharmacotherapy for prevention of viral hepatitis. 6. Develop a pharmaceutical care plan for treatment of viral hepatitis. 7. Formulate a monitoring plan to assess adverse effects of pharmacotherapy for viral hepatitis.

Chemiluminescence Detection of CFLP Patterns

B., Ringpis, F. M., Pottathil, M. R., Marshall, D. J., de Arruda, M., Murvine, C., Fors, L., Pottathil, R. M., and Barathur, R. R. (1998) Algorithmic approach to high-throughput molecular screening for alpha interferon-resistant genotypes in hepatitis C patients. J. Clin. Microbiol. 36, 1895-1901. 11. Marshall, D. J., Heisler, L. M., Lyamichev, V., Murvine, C., Olive, D. M., Ehrlich, G. D., Neri, B. P., and de Arruda, M. (1997) Determination of hepatitis C virus genotypes in the United States by Cleavase Fragment Length Polymorphism analysis. J. Clin. Microbiol. 35, 3156-3162.

Universal infection control

Second, there are many potential sources of infection, most of them unrecognised. For example, carriers of hepatitis B virus frequently appear clinically well and are unaware of their carrier status. Similarly, patients could be colonised by antibiotic resistant bacteria, such as methicillin resistant Staphylococcus aureus (MRSA), with no outward clinical signs or symptoms. Thus any patient, regardless of background or medical history, must be considered to pose an infection risk. Sharps injuries are common among staff performing surgical procedures and many go unreported to occupational health departments and so are not followed up. However, occupationally acquired infections with hepatitis B and C viruses, and with HIV, have been recorded following needlestick injuries and related sharps accidents. It is, therefore, essential that healthcare workers are encouraged to seek appropriate management following such incidents. The principles of management of needlestick and related...

Occupationally acquired infections

The main concern of healthcare workers relates to the risk of infection with blood-borne viruses, notably HIV. Hepatitis B remains the major infectious occupational hazard for surgeons and other healthcare workers who, prior to the availability of a vaccine, were up to ten times more likely to become infected than members of the general population. Table 7.4 summarises the relative risks of infection with HIV and hepatitis B virus. Hepatitis B virus is far more infectious than HIV and it is fortunate that most healthcare workers respond to the hepatitis B vaccine, thereby gaining protection. The occupational risk of infection with hepatitis C virus is not yet clear but several recent studies suggest that the overall risk is low. However, well-documented Table 7.4 The relative risks of occupational infection with HIV and hepatitis B virus (HSV) 'The risk of infection with hepatitis B virus depends on whether the source patient is a high-risk carrier

Management of sharps injuries

Ideally, blood should be taken at the time of the accident from the healthcare worker and the titre of anti-HBs antibody measured. Residual serum is stored so that it is available in the future for HIV and hepatitis C virus antibody testing, if necessary. Although the concept of approaching the source patient is controversial, ideally blood should also be collected from this individual. Appropriate discussion and counselling are obviously essential but, if consent is given, the blood can be screened for hepatitis markers and HIV antibody, which in most cases will be negative. Such information can be very reassuring to a healthcare worker who has sustained an injury, but no pressure should be exerted on the source patient to donate the appropriate sample. Immediate treatment for the healthcare worker might include passive immunisation for a hepatitis B vaccine

Healthcare workers infected with bloodborne viruses

There is strong epidemiological evidence that healthcare workers who are high-risk carriers of hepatitis B virus, as defined earlier, can transmit hepatitis B to patients if they There is increasing epidemiological evidence that hepatitis C virus can be transmitted from seropositive healthcare workers to patients during exposure-prone procedures. UK guidelines published in 2002 place restrictions on the clinical activities of healthcare workers who are infected with hepatitis C (HCV RNA positive).

Associated Neurological Findings

Decreased position, vibratory, temperature, and pain appreciation occurs in several neuropathies associated with hyposmia. These include diabetes, the neuropathy of renal and hepatic failures, and a large variety of toxic neuropathies. In patients with pernicious anemia, the large myelinated central fibers carrying position and vibration senses are preferentially affected. In the context of hepatitis, the acquired immune deficiency syndrome (AIDS), and other virus-related illnesses, hyposmia can occur along with an ascending polyneuropathy of the Guillain-Barre type. In seizure patients with uncal or temporal lobe foci that induce dysosmic auras, altered sensations in a hemibody distribution can occur as part of the seizure or as a postictal transient sequela.

Damage Selection Experiments with Ribozymes

A wealth of information has been accumulated on ribozymes since their discovery nearly 20 years ago. Most of the studies can be fitted into one of the three main lines of research (1) characterization of known ribozymes (that is, inferring the structure and mechanisms of catalysis Lilley, 1999) (2) modification of natural ribozymes to be used in therapeutics (Sullenger and Gilboa, 2002) and (3) in vitro evolution of novel ribozymes (Joyce, 1998, 2002 Landweber et al., 1998 Spir-in, 2002). The characterization of ribozymes frequently involved mutagenesis experiments, where the enzymatic activity of certain mutants was measured in order to get insight into either the structure of the molecule or the mechanism of catalysis. While not directed toward the study of fitness landscapes, these experiments certainly contain a wealth of empirical information necessary for assembling the realistic fitness landscape of the studied ribozyme. Albeit all naturally occurring ribozymes are being...

Health Care Infection Control Practices

Students and clinicians are frequently exposed to patients with hepatitis or acquired immunodeficiency syndrome. Clinicians' fear of these diseases often interferes with the development of a good doctor-patient relationship. Once clearly defined procedures are implemented to ensure the safety of health-care workers, this fear can be better handled. 12. All health-care providers who have direct contact with patients should complete the hepatitis B vaccine series. In certain populations, testing for immunity before vaccination may be indicated. Typical preemployment Student Health Service screening includes a purified protein derivative (for tuberculosis) and various serologic testing, including testing for hepatitis B virus.

Epidemiology And Etiology

Cirrhosis is the result of long-term insult to the liver, so damage is typically not evident clinically until the fourth decade of life. Chronic liver disease and cirrhosis combined were the 12th leading cause of death in the United States in 2002. In patients between the ages of 25 and 64 years, damage from excessive alcohol use accounted for over one-half of the deaths. Alcoholic liver disease and viral hepatitis C are the most common causes of cirrhosis in the United States, whereas hepatitis B accounts for the majority of cases worldwide. Once cirrhosis is diagnosed, the disease progression is relentless, regardless of the initial insult to the liver. Infection with one or more strains of viral hepatitis causes an acute inflammation of the liver, whereas chronic infection with hepatitis B or C can lead to cirrhosis. Hepatitis B and C are common in IV drug users and can also be transmitted through sexual contact, but many cases of hepatitis C are idiopathic.6,7 See Chapter 24...

Diseases and Disease Ecology of the Modern Period in Southeast Asia

In the same year, South Vietnamese disease specialists identified malaria and plague as their greatest problems and categorized endemic infections as follows bacteriological (cholera, salmonellosis, bacillary dysentery, and typhoid), parasitic (amebiasis, ascariasis, hookworm infections, gnathostomiasis, strongyloidiasis, diphyllobothriasis, spargano-sis, and taeniasis), viral (hemorrhagic fever and dengue fever, smallpox, infectious hepatitis, Japanese B encephalitis, and rabies), bacterial (leprosy and venereal diseases), and mycotic (cutaneous mycoses) (South East Asian Centre for Tropical Medicine 1967). The ecology of disease in Southeast Asia is currently in a period of rapid and significant change, the beginning of which is usually dated around 1970. For one thing, except for infants and children under 5 years, infectious diseases are no longer a significant threat to health. Tuberculosis remains a hazard for the aged population (which has grown), and malaria remains endemic in...

Routes of transmission of infection

The routes of transmission by which pathogens can be transferred from the source of infection to the host can be either airborne by contact or percutaneous. Airborne transmission involves the spread of infections such as influenza and TB via water droplets. Contact transmission can involve direct person-to-person transmission from the source to a susceptible host (as with MRSA), or can involve contact with body fluids such as faecal material (C. difficile), equipment such as endoscopes, or food. Percutaneous transmission can occur via insect vectors (malaria) intravascular lines (MRSA) or as a result of sharps injuries (hepatitis B, HIV).

Aptamers to the Peptide Antibiotic Viomycin

A very interesting family of RNA-binding antibiotics are the tuberactinomycins, whose most prominent member, viomycin, is shown in Table 5.1. Viomycin is a basic peptide composed of six amino acids - two serines and four unusual amino acids, derivatives of alanine, arginine, lysine, and propionic acid. Its core structure forms a 16-membered ring with an intramolecular hydrogen bond between the a-amide proton of the guanidine moiety and the carboxyl oxygen of the serine residue 1. These peptides are not synthesized by the translational machinery, but by non-ribosomal peptide synthetases, a large family of complex and fascinating enzymes existing in microorganisms (Walsh, 2004). Viomycin is a member of the tuberactinomycin family of antibiotics, which were mainly used to fight tuberculosis. Viomycin has a single binding site at the interface of the ri-bosomal subunits and interferes with several stages of protein synthesis. It inhibits translation initiation, tRNA binding and...

Chemical Modification of Proteins

When proteins are being developed as drugs, the pharmacokinetic (PK) and pharmacodynamic (PD) properties of proteins can be improved by the chemical modification of the protein structure. A particularly promising strategy is the introduction of PEG moieties, known as PEGylation, which can help reducing immunogenicity, increasing the circulatory time by reducing renal clearance and also provide water solubility to hydrophobic drugs and proteins. PEGylation is generally performed by the reaction of a reactive derivative of PEG with the target protein, typically with side chains of amino acids such as lysine or cysteine, or by reaction at the C- or N-terminal of the protein or pep-tide. PEGylated proteins entered the market in the 1990s and today a number of therapeutic proteins are marketed as PEGylated derivatives including PEGylated a-interferons (see also Chapter 24), which are used in the treatment of hepatitis C the PEGylated a-interferon is injected only once a week, compared to...

Health Promotion Activities and Information for

Routine fetal heart auscultation, urinalysis, and assessment of maternal weight, blood pressure, and fundal height generally are recommended, although the supportive evidence varies (Kirkham et al., 2005). Women should be offered ABO and Rh blood typing and screening for anemia during the first prenatal visit. Genetic counseling and testing should be offered to couples with a family history of genetic disorders, a previously affected fetus or child, or a history of recurrent miscarriage. All women should be offered prenatal serum marker screening for neural tube defects and aneu-ploidy. Women at increased risk for aneuploidy should be offered amniocentesis or chorionic villus sampling (CVS). Counseling about the limitations and risks of these tests, as well as their psychologic implications, is necessary. Folic acid supplementation beginning in the preconception period and early pregnancy reduces the incidence of neural tube defects. Laboratory testing during the first prenatal visit...

Collaborative Functions of Angiopoietins and VEGFs

Highly polarized expression pattern of Ang-1 in developing peripheral vessels. Dark field (a, c, e, g, i, k) and bright field (b, d, f, h, j, l) are shown. (a, b) At E9.5, Ang-1 expression is restricted to the ventral mesenchymal smooth muscle wall of the anterior cardinal vein (ACV) (yellow arrowheads) prior to communication with the common cardinal vein. The rest of the anterior cardinal vein wall does not express Ang-1 (blue arrowhead). (c, d) Upon communication of the common cardinal vein (CCV) and anterior cardinal vein at E10.5, Ang-1 expression is detected in the medial wall of these vessels (yellow arrowheads). The lateral wall is negative for Ang-1 expression (blue arrowhead). (e, f As the umbilical vein (UV) and common cardinal vein join at E10.5, Ang-1 expression is seen in the medial wall (yellow arrowheads), whereas the rest of the vessel wall is negative (blue arrowheads). (g, h) Expression is seen in the wall and surrounding mesenchyme of the heptocardiac vein...

Exposure assessment models

Exposure models are necessary to generate assessment criteria such as SGVs, which indicate the concentration of a substance present in soil that may result in a daily intake equal to, or less than, a health criteria value (HCV) (Box 10.3). The exposure pathways present on a given site are identified by constructing a conceptual model indicating potential pollution linkages (Figure 10.2) with degrees of risk associated with them. In 2009, the Environment Agency released an updated CLEA model (Environment Agency 2009b). The model uses generic assumptions about chemical fate and transport in the environment and a generic conceptual model for site conditions and human behaviour to estimate exposure to contaminants for those living, working, and playing on contaminated sites over long periods. The CLEA model has been used to generate SGVs by comparing the estimated exposure with HCVs.

Box 103 Health criteria values Environment Agency 2009c

For substances that exhibit threshold effects, health criteria values (HCVs) take the form of tolerable daily soil intakes (TDSIs), which may be better described as tolerable daily intakes from soil. The approach taken for a given substance is to initially identify a tolerable daily intake (TDI), which is expressed as mass of substance per unit mass of body weight per day. This is typically extrapolated from a no observable adverse effect level (NOAEL), often identified from animal experiments. Once this has been identified, a number of uncertainty factors may be applied to account for variability in response resulting from factors such as inter- and intraspecies variation. If a NOAEL is not available for a given substance, the lowest observable adverse effect level (LOAEL) may be adopted with the application of an additional uncertainty factor. Once a TDI has been identified, the mean daily intake (MDI) of substances from sources other than soil is identified (drinking water and food...

Derivation of health criteria value

Toxicological input criteria are central to human health risk assessment in contaminated soil. These are referred to as HCVs in the UK (Box 10.3) and as reference concentrations (RfCs) in the USA. The relationship between SGVs and HCVs is that SGVs are produced using HCVs and the estimates of the amount of substance an individual would take in as a result of exposure to soil. In the context of UK, SGVs provide a link between the concentration of a particular contaminant in the soil and the health risks defined at the HCV under the defined conditions. HCVs are toxicological benchmarks to an assessor on the level of long-term exposure to individual chemicals in soil that are tolerable or pose a minimal risk (Environment Agency 2009c). They are determined from a review of the evidence from occupational and environmental epidemiological studies, animal studies, and from scientific understanding of the mechanisms of absorption, transport, metabolism, excretion, and toxicity of chemicals...

Consideration of chemical bioavailabilitybioaccessibility data

HCVs used in risk assessments of land contamination are generally derived from toxicological or epidemiological studies. For example, the HCV for arsenic is based on epidemiological studies of people exposed via drinking water. In oral toxicological studies, chemicals may be administered via different media, such as drinking water, gavage, and capsules. HCVs tend to assume that a chemical is equally bioavailable in all media. However, this assumption might not be true for soil contaminants because of the binding to soil particles and or chemical entry inside the soil mineral lattice, which may cause bioavailability to differ between the soil types, chemicals, and chemical forms (Environment Agency 2005 Saikat 2006).

Susceptibility to Infection

Heterozygous and homozygous deficiency of MBL has been shown to be associated with several types of immunodeficiencies. A primary immunodeficiency characterized by defective yeast opsonization was described 20 years before the molecular defect that was identified as the codon 54 mutation in the MBL (3,4). Many studies have now been published, including two large studies that included 229 and 345 children with unknown primary immunodeficiencies (5,6), which have demonstrated significant associations for both homozygous and heterozygous MBL mutations with increased risk of infection. In the largest study, of the 17 homozygous MBL deficient patients identified, 13 presented with severe infections including septicemia, cellulitis and boils, severe tonsillitis, and otitis media. Homozygous MBL mutations have also been reported to be a factor in susceptibility to Mycobacterium tuberculosis and avium, Trypanosoma cruzi, Klebsiella, Ctyptococcus neoformans, other fungal infections, hepatitis...

Clinical Manifestations and Diagnosis

Clinically cirrhosis may be latent (5 to 10 percent of cases), well compensated, or active and decompensated. The clinical features depend on the underlying etiology and the appearance of the two cardinal manifestations, portal hypertension and hepatocellular failure. As cirrhosis usually evolves over a period of several years, the course may be intermittent with therapeutic intervention such as with corticosteroids or with temporary cessation of injury. During the early phase of disease, patients often present with nonspecific symptoms and signs including malaise, lethargy, anorexia, loss of libido, and weight gain. Incidental laboratory findings of abnormal liver function tests, positive hepatitis B serology and hypergammaglobulinemia, and incidental physical findings such as icterus, hepatomegaly, gynecomastia, and spider nevi may point to the presence of cirrhosis. With the progression of disease, portal hypertension and hepatocellular failure invariably supervene. These two...

Nonsteroidal Anti Inflammatory Drugs

Taneous injections, the cost, and the availability of insurance coverage. ' In general, biologic DMARDs should be avoided in patients with serious infections, demyelinat-ing disorders (e.g., multiple sclerosis or optic neuritis) or hepatitis. TNF antagonists should be avoided in patients with heart failure.18

Biological Properties of Aptamers Targeted to Nucleic Acids

RNA aptamers giving rise to ALIL complexes with the HCV mRNA were also evaluated from the standpoint of their biological interest. The aptamers targeted to the SL1 structure in the 3'-UTR and to the domains II and IV of the IRES showed a weak or no effect on in vitro translation of HCV IRES-dependent mRNA translation (Aldaz-Carroll et al., 2002 Tallet-Lopez et al., 2003). The anti-SL1 aptamer also had no effect on RNA replication with the viral RNA-depen-dent RNA polymerase in an in vitro assay (Staedel and Astier-Gin, unpublished results). In contrast, the aptamer selected against the IIId domain of the IRES induced a decrease of luciferase activity both in a cell-free assay and in HeLa cells transiently transfected with a construct in which the reporter gene was under the control of the HCV IRES (Kikuchi et al., 2005). The transfection of 0.5 pmol of the aptamer reduced the luciferase activity to 45 . This effect was moderately specific. Whereas no effect was observed when RNA from...

Incubation period Up to 7 days

Pathogenesis Bacteria penetrate broken skin and mucous membranes and replicate in the liver and kidney, causing hepatitis, acute renal failure and intravascular coagulation. Leptospira can be excreted in the animal's urine for months or years after recovery. Clinical signs Pyrexia, vomiting, shock, interstitial nephritis and hepatitis. Signs dependent on animal's age, immunity and environmental factors.

Impact of Duty Hours on Resident Well Being

A major risk of percutaneous injury is exposure to blood-borne pathogens (e.g., HIV and hepatitis B and C). A retrospective review to assess whether resident exposure to blood-borne pathogens varied during a given 24-hour period found that residents (n 782) were exposed more often at night (Parks et al., 2000). Exposures resulted from needle punctures (75 percent of incidents), cuts (13 percent), and splashes of infected body fluids (12 percent). Over a 5-year period (November 1993-July 1998), the overall relative risk of accidental exposure to these pathogens was 1.5 times higher during nighttime hours (6 p.m.-6 a.m.) than during the day (6 a.m.-6 p.m.) the highest rate tended to occur from midnight to 1 a.m., and the lowest from 6 a.m. to 7 a.m. Exposures were concentrated in five specialties an-esthesiology (30 percent), internal medicine (20 percent), surgery (16 percent), OB GYN (11 percent), and pediatrics (5 percent) and rarely occurred in outpatient clinics. First- and...

Biologic issues affecting applicability

Consider racial or ethnic differences that may alter the risk for the outcome. Angiotensin-Converting Enzyme (ACE) inhibitors (a class of antihypertensives) increase the risk of angioedema. The risk is three times higher in blacks than in whites 8 . The odds of developing hepatitis with isoniazid use is lower among Asians who are fast acetylators of the drug 9 .

The Catalytic Spectrum of Ribozymes

Seven natural types of oligonucleotides with catalytic properties are known hammerhead, hairpin, hepatitis delta virus, ribonuclease P, varkud satellite ribozyme, group I intron, and group II intron (Doudna and Cech, 2002). Catalysis through natural ribozymes is restricted to hydrolysis and transesterification reactions at in-

Medical Overview and Epidemiology

Hepatitis C is a common blood-borne infection that when left untreated can lead to cirrhosis, hepatic encephalopathy, and death and is a leading cause of chronic liver disease, liver transplantation, and hepatocellular carcinoma (Saunders 2008). The presentation of hepatitis C infection is variable, with most acutely infected people being asymptomatic (70 -80 ), although they may have elevated liver enzymes. The most common symptoms of acute infection include fever, malaise, loss of appetite, jaundice, fatigue, nausea and vomiting, dark urine, and joint pain (Dieperink et al. 2000). With chronic infection, the most common presentations include jaundice, encephalopathy, or ascites. In the pediatric population, those who use injectable drugs and those born to infected mothers are at highest risk, with approximately 4 of children born to mothers with hepatitis C going on to develop hepatitis C (Saunders 2008).

Psychosocial Adjustment

The neuropsychiatric effects of hepatitis most notably symptoms of fatigue, depression, and cognitive dysfunction (Ozkan et al. 2006) have long been recognized, although pediatric-specific research is limited. Fatigue is reported to occur in more than 50 of patients with hepatitis C (Saunders 2008). The presence of comorbid depression has a significant negative impact on health-related quality of life in those with hepatitis C (Ozkan et al. 2006), and rates of depression as high as 30 have been reported in untreated patients with hepatitis C (Die-perink et al. 2000 Saunders 2008). Patients infected with hepatitis C have also been reported to have subcortical frontal cerebral dysfunction that manifests as impaired concentration and slow processing prior to the development of cirrhosis and hepatic enceph-alopathy (Perry et al. 2008 Saunders 2008).

Evidence Based Treatment Approaches

Current treatments for hepatitis C include ribavirin and pegylated interferon alpha. The use of interferon alpha is complicated by numerous well-known side effects, including early flulike symptoms, elevated triglycerides, gastrointestinal symptoms, dermato-logical disorders, and neuropsychiatric symptoms that include depressed mood, poor concentration, loss of appetite, fatigue, hostility, and suicidal ideation (Dieperink et al. 2000). Depression has been reported to develop in as many as 39 -45 of patients receiving interferon alpha (Capuron et al. 2003 Lotrich et al. 2007). Pegylated interferon, when compared with conventional interferon, does not protect against depression (Lotrich et al. 2007). The use of interferon alpha has also been associated with completed suicide (Fukunishi et al. 1998 Jans-sen et al. 1994). The risk of depression and suicidal ideation may continue after withdrawal from interferon alpha. Patients with hepatitis C should be monitored routinely for depressive...

Concluding Comments

The gut has its own intrinsic nervous system and is in active communication with the brain and central nervous system. Therefore, it is not especially surprising to note that disorders of gastrointestinal function exist in the absence of evidence of tissue damage, with the relationship between FGIDs and gastrointestinal diseases such as Crohn's disease perhaps being analogous to that between common psychiatric disorders such as anxiety or mood disorders and neurological diseases such as multiple sclerosis. FGIDs are indeed common, impairing, and strongly associated with anxiety and depressive disorders new treatments share common features with treatment regimens that are successful in the management of emotional disorders and migraine headache. Psychiatric symptoms and disorders, particularly depression, are also commonly comorbid with gastrointestinal diseases such as IBD and hepatitis C, sometimes in relation to associated treatments such as corticosteroids and interferon alpha.

Occupational Safety and Health Administration Final Rule on Occupational Exposure to Bloodborne Pathogen OSHA

In 1991, OSHA proposed the Bloodborne Pathogen Final Rule - which is a standard designed to eliminate or minimize occupational exposure to hepatitis B virus (HBV), human immunodeficiency virus (HIV) and other blood borne pathogens and became effective in March 1992. This standard was developed in response to the determination that employees face a significant health risk as the result of occupational exposure to blood and other potentially infectious materials because they may contain blood borne pathogens. The Agency further concluded that this exposure could be minimized or eliminated using a combination of engineering and work practice, controls including the use of personal protective clothing. The OSHA Occupational Exposure to Blood borne Pathogens Final Rule (1991) mandates the principles of universal precautions, mandates performance levels, and allows employers to specify what personal protective equipment is required and when it must be used. With the implementation of this...

Oxycontin and Other Opiates

Drug users who inject opiates (and other drugs for that matter) can obtain serious infections associated with using contaminated and dirty needles. These include ugly skin abscesses, hepatitis, tuberculosis, and AIDS. They are also at higher risk for sexually transmitted diseases. Opiate drugs work by stimulating receptors for the opioid peptide neurotransmitters such as enkephalin and endorphin, which are chemicals that occur naturally in the brain.

Abd El Salam El Askary

Erative bone disease, hepatitis B or C, sexually transmitted disease, autoimmune deficiency, or other medical problems that might lead to cross-infection. Therefore, the first priority must be given to thorough donor screening, which involves a traceable medical, demographic, and social history. Other disadvantages of allo-grafts include the risk of rejection, high rate of infection, nonunion, risk of rapid resorption, and problems related to the considerable technical precision required to pack and hold the graft in place in bleeding sites.

Additional Resources

Bleach kits (containing bleach and instructions for cleaning equipment) are distributed to make drug injection less dangerous. Bleach does not kill the pathogen that causes hepatitis and is also not totally effective in eliminating HIV however, such kits do reduce the likelihood of other infections being passed through sharing of dirty equipment.

Students with Communicable Diseases

State and local school boards have the power and authority to adopt regulations to safeguard the health and safety of students. Schools may require vaccinations or immunizations prior to school attendance, and they may deny school access to children who pose a health threat to others (Reutter, 1994). The difficulty with serious long-term communicable diseases is in determining whether the health threat posed by the infected child is significant enough to outweigh the child's right to schooling in the least restrictive and most normal setting. Because of current interest and concern, the discussion here focuses on students with acquired immunodeficiency syndrome (AIDS) human immunodeficiency virus (HIV), but the issues raised are pertinent to other communicable diseases (e.g., hepatitis B). We discuss AIDS HIV as a handicapping condition under Section 504 of the Rehabilitation Act of 1973 and IDEA, and the obligation of school personnel to safeguard the privacy of pupils with...

Lymphocyte Disorders Lymphocytosis

Lymphocytosis can be classified as primary (malignant) or secondary (reactive). Primary lymphocytosis is defined in the context of an acute or chronic lymphoproliferative disorder, often caused by dysregulation of lymphocyte development and production. Leukemias (chronic lymphocytic, acute lymphocytic, hairy cell), lymphoma, and B-cell lymphocy-tosis are examples of primary or malignant lymphocytosis. Secondary lymphocytosis is defined as a lymphocytosis in a patient who does not have a known hematologic disorder and in whom the lymphocyte count is expected to return to normal in less than 2 months after cessation of the inciting condition. Reactive lymphocytosis can sometimes be mistaken for a primary or malignant lymphocytosis when examining the peripheral blood smear, particularly in infectious mononucleosis with a marked increase in larger, atypical, or transformed lymphocytes. Other causes of secondary lym-phocytosis may generate small lymphocytes, as in pertussis. Viral...

Obstetrician Without Sufficient Experience 1986

The last dose was given on the morning she was delivered by elective Cesarean section. Her obstetrician-gynecologist had recently completed his residency training but was not yet board-certified. Moreover, he had not discussed her management with any board-certified obstetrician-gynecologist, and had no other suitably qualified surgeon in attendance. The Cesarean operation was carried out through a low transverse abdominal incision, but surgery proved to be difficult. After the baby was delivered, the uterus failed to contract, and she hemorrhaged profusely. In these circumstances, it would have been usual to give Methergine (methyler-gonovine) and or Pitocin (oxytocin) to promote uterine contraction. No Methergine was given half a dose of Pitocin may have been given, but it was not documented in the medical notes or on the drug chart. A hysterectomy was carried out, but the bleeding continued. Her bladder was damaged and she developed hematuria. A urological surgeon was then called,...

Evidence Based Treatment

In general, the same psychotropic medications can be used in the HIV-infected child as in the general population. However, bone marrow suppression, hepatitis, and pancreatitis may cause treatment-limiting toxicities and affect metabolism of antiretrovirals, particularly protease inhibitors. Treatment with psychotropic medications is part of comprehensive multidisciplinary care and multimodal treatment to improve the quality of life for pe-diatric HIV AIDS patients by decreasing discomfort and increasing functioning.

The winter months Health Care Workers

Most health care workers are at risk for exposure to many diseases in the normal course of their work. Additionally, health care workers may transmit vaccine-preventable diseases to their patients. At the time of employment and on a regular basis, health care workers should be screened for immunity to measles, mumps, rubella, and varicella if found to be nonimmune, the measles, mumps, and rubella, and varicella vaccines should be administered. The hepatitis B series should be given if not already completed. Tetanus should be updated and given every 10 years. Health care personnel in hospitals and ambulatory settings with direct patient contact should receive Tdap if not already received an interval as short as 2 years from the last tetanus-containing vaccine should be used.

Safety and Tolerability

Another common toxicity is the rapid depletion of normal antigen-positive B-lymphocytes from blood, bone marrow and lymph nodes of the recipient, lasting between six and nine months following the last administration of rituximab. In the case of short rituximab treatment, this depletion does not compromise immunity immunoglobulins do not decrease significantly, and patients do not have an increased risk for infections during and after rituximab therapy (Grillo-Lopez, Hedrick, Rashford and Benyunes 2002 Kimby 2005) except for some viruses like herpes virus, cytomegalovirus, or hepatitis B virus. Maintenance treatment, particularly after autologous transplant, might be associated with a decrease in immu-noglobulins (Lim, Zhang, Wang, Esler, Beggs, Pruitt, Hancock and Townsend 2004) and late toxicity (Kimby 2005).

Clinical Use and Adverse Effects of Specific Antiepileptic Drugs

Felbamate was approved in the United States in 1993 for the treatment of partial seizures in adults and as adjunctive therapy in children with the Lennox-Gastaut's syndrome. Just over 1 year later, the FDA recommended limiting its use due to its association with aplastic anemia. Currently, the FDA recommends that felbamate be used only in situations in which the risk of seizures exceeds the risks of the drug. As of December, 1995, there have been 31 cases of aplastic anemia reported, including 10 fatalities, and numerous cases of hepatitis. The mechanism of action of felbamate is unknown, although it likely has multiple actions including blockade of voltage-gated Na+ channels, potentiation of GABA transmission, and inhibition of excitatory neurotransmission through interaction with the NMDA receptor. Felbamate is effective against partial and generalized seizures, including absences. Common adverse effects include insomnia, weight loss, nausea, anorexia, dizziness, and lethargy....

Adult Onset of Illness

When the kimono designer Itchiku Kubota (Japanese, b. 1917) was having a second exhibition of his art at age 60, he contracted acute hepatitis. While in the hospital Kubota thought about his work and decided to develop a new style of kimono design combining ancient Japanese techniques with French Impressionism and scenes of nature. Kubota, who became very successful, spoke about the influence of having hepatitis saying, This was the time of deepest import in my life as an artist. Pierre-Auguste Renoir (French, 1841-1919) started to develop rheumatoid arthritis at age 56 and despite his efforts at exercise, the illness progressed. Sitting in a wheelchair with swollen immobile fingers, Renoir continued to work. With small gauze pouches to hold his brushes, the artist moved his arms rather than his wrists to make art. His son Jean Renoir admired his father's determination and said, The more intolerable his suffering became, the more he painted.

Anucort 25 mg prpctocort 30 my

Ulting in pancreatitis, fever, rash, hepatitis, and leukopenia. ' ' Patients should be tested for activity of thiopurine methyltransferase, the major enzyme responsible for metabolism of azathioprine. Deficiency or reduced activity of thiopurine methyltransferase may result in excess toxicity from azathioprine and 6-MP. Disadvantages of anti-TNF biologic therapy include need for parenteral administration, significant drug cost, and potential for serious adverse effects. Adverse effects may include infusion-related reactions such as fever, chest pain, hypotension, and dyspnea. All of the TNF-a inhibitors have also been associated with reactivation of serious infections, particularly intracellular pathogens such as tuberculosis, as well as hepatitis B.16,22 These agents should not be used in patients with current infections, and patients should be screened for tuberculosis prior to initiating therapy. Exacerbation of heart failure is also a potential adverse effect, and biologic agents...

Notion Of Bucco-dental Superinfections

A study was conducted on 60 patients who were chronic carriers of hepatitis B or C. The essential oils of Cinnamomum camphora ct 1,8-cineole, Daucus carota, Ledum groelandicum, Laurus nobilis, Helichrysum italicum, Thymus vulgaris ct thujanol, and Melaleuca quinquenervia were used orally in various combinations. They were used as a monotherapy or as a complement to allopathic treatment. The objectives of treatment were normalization of transaminase levels, reduction of viral load, and stabilization or regression of fibrosis. There was an improvement of 100 , when patients with hepatitis C were given bitherapy with essential oils. With essential oil monotherapy, improvements were noted in 64 of patients with hepatitis C and there were two cures of hepatitis B (Giraud-Robert, 2005).

Hereditary C2 Deficiency

The effect of homozygous C2 deficiency on the clearance of immune complexes has been studied (54). A patient with C2 deficiency was injected with hepatitis B surface antigen-anti-HbsAg immune complexes labeled with I123. The patient's uptake of complexes in the liver, spleen, and clearance of the complexes from the circulation was studied pre- and post- fresh-frozen plasma treatment. When her C2 and CH50 levels were zero, the complexes were rapidly taken up by the liver and cleared from the circulation. No binding of the complexes was seen in the spleen or on the RBCs via CR1. After treatment with fresh frozen plasma, which normalized her complement levels, the complexes cleared from the circulation more slowly and 20 of the complexes were found in the spleen. These studies suggest that uptake of immune complexes by the spleen is complement dependent and abnormal processing of immune complexes by complement-deficient patients may take place.

Identification of Sperm Oxidative Stress from Clinical History

Male Infertility Causes Mnemonics

Infective causes for sperm oxidative stress include local infections such as Male Accessory Gland Infection (MAGI) or systemic infections such as Hepatitis, HIV, TB and Malaria. Leukocytes are professional producers of free radicals, releasing ROS at relatively high concentrations to destroy infective pathogens. Therefore, it is not surprising that activation of the immune system within the male reproductive tract is likely to result in sperm oxidative damage. Up to 50 of men will experience prostatitis at some point in their lives, with prostatitis becoming chronic in 10 of men 50 . Bacteria responsible for prostate infection may originate from the urinary tract or can be sexually transmitted 51 . Typical non-STD pathogens include streptococci (Streptococcus viridans and S. pyogens), coagulase-negative staphylococci (Staphylococcus epidermidis, S. haemolyticus), gram-negative bacteria (Escherichia coli, Proteus mirabilis) and atypical mycoplasma strains (Ureaplasma urealyticum,...

Tumors of Salivary Gland Lymph Nodes

Waldeyer Ring Pathology

Patients with Sjogren's syndrome, AIDS, and hepatitis C have an increased risk of developing salivary lymphomas. In a review of 463 cases of Sjogren's syndrome, 27 patients had a diagnosis of lymphoma (5.8 ) (Tonami, Matoba, and Kuginuki et al. 2003). In this series 26 of the 27 patients had non-Hodgkin's lymphoma including 6 mucosa-associated lymphoid tissue (MALT) lymphomas and only 1 patient had Hodgkin's lymphoma. At the initial presentation 14 (52 ) of patients had extra-nodal disease, with 9 of 27 (33 ) in the salivary glands. However, 21 patients (78 ) had nodal involvement, mostly in the cervical nodes. Masaki and Sugai (2004) also reported a figure of 5 of Stage III Sjogren's patients developing lymphomas that are thought to arise from lymphoepithelial lesions. The B cells in these lesions become activated by interactions between CD40L and CD40 with progression from polyclonal lymphoprolifera-tion, to monoclonal lymphoproliferation, to MALT lymphoma, and finally to high-grade...

Guillain Barre Syndrome

Vaccine) increased the incidence of Guillain-Barre syndrome by a factor of eight. Warnings about Guillain-Barre syndrome continue to be given with annual influenza vaccinations. The hepatitis B vaccine derived from pooled plasma was also associated with Guillain-Barre syndrome however, Guillain-Barre has not been reported with use of the currently available hepatitis B vaccines produced through recombinant DNA technology. Most recently, Guillain-Barre syndrome has been reported to occur with the meningococcal conjugate vaccine.

Chronic Inflammatory Demyelinating Polyradiculoneuropathy

There is no conclusive evidence that CIDP patients have a higher incidence of other medical conditions, including autoimmune disorders. However, associated disorders, including systemic lupus erythematosus, Hashimoto's thyroiditis, thyrotoxicosis, chronic active hepatitis, inflammatory bowel disease, urticaria, eczema, and psoriasis do occur in some CIDP patients.y A CIDP-like disorder may occur in the setting of monoclonal gammopathies of uncertain significance (MGUS), as well as with multiple myeloma, osteosclerotic myeloma and other lymphoproliferative disorders. These disorders are discussed as distinct entities in the following sections.

Is it Dangerous to Have Multiple Anesthetics in a Short Period of Time

Halothane Hepatitis (the National Halothane Study) was undertaken to resolve the question.2 Charts of more than 850,000 anesthetics delivered between 1959 and 1962 were reviewed with the purpose of determining if cases of severe liver injury were caused by halothane or related to the multitude of other factors known to cause liver damage and hepatitis. The National Halothane Study concluded that although massive liver damage following halothane exposure can occur, it is exceedingly rare.3 The risk of this complication is greater with multiple exposures to halothane vapor and in the patient with obesity. Fatal liver damage following exposure to halothane was calculated to be approximately one in 35,000 anesthetics.4 In fact, the number of patients who suffered nonanesthesia-related liver damage following surgery far exceeded the number of patients who had reportedly suffered liver damage from halothane vapor. Halothane hepatitis was found to be an extraordinarily rare occurrence in...

Apical Loop Internal Loop Interactions

The presence of purine-purine pairs closing the loop of RNA hairpins giving rise to kissing complexes both in naturally interacting RNA species (the DIS element of HIV-1) and in selected RNA motifs (aptamers to TAR or to tRNAPhe) suggested that this might be a rule for generating stable loop-loop interactions. Indeed the substitution of a GC pair by a G,A combination at the top of the stem of the hairpin RNA I' stabilized its interaction with RNA II', two stem-loops derived from the structure involved in plasmid Col E1 replication (Duconge et al., 2000). However, the rational design according to these rules of a kissing hairpin potentially able to interact with the SL1 structure of the HCV mRNA (i.e. a hairpin with a loop complementary to that of SL1 framed by G and A residues) led to a complex of weak stability. Therefore, not every loop is prone to kissing complex formation. Such ALIL-forming aptamers have been independently selected in our laboratory against three different targets...

Ascites In Pathophysiology In Book

Portal Vein Anatomy

The course of alcoholic liver disease moves through several distinct phases from development of fatty liver to the development of alcoholic hepatitis and cirrhosis. Fatty liver and alcoholic hepatitis may be reversible with cessation of alcohol intake, but cirrhosis itself is irreversible. Although the scarring of cirrhosis is permanent, main

Levocarnitinein Libido

Adverse effects of, 423, 1426, 1427t-1428t, 1437t in chronic hepatitis B, 423 dosage of, 423, 1427t-1428t drug interactions of, 1427t-1428t in HIV infection, 1426, 1427t-1428t, 1434 mechanism of action of, 1421f resistance to, 423 Lamotrigine, 828t in prevention of cluster headaches, 591 psoriasis and, 1080 in schizoaffective disorder, 646 seizures with, 522 teratogenic effects of, 824 Liver abscess, amebic, 295-297 Liver biopsy, in viral hepatitis, 416 Liver cancer, epidemiology of, 1446 Liver disease viral hepatitis and, 413, 418 erectile dysfunction with, 885t in inflammatory bowel disease, 344 obstructive, 2361 oral contraceptives and, 846 with parenteral nutrition, 1696 in sickle cell anemia disease, 1145t Liver failure DIC with, 1131t nausea and vomiting with, 358t protein requirement in, 1689t respiratory alkalosis in, 504t treatment of, enteral nutrition, 1702t, 1710 tuberculosis and, 1261 Liver transplantation. See also Solid-organ transplantation acute rejection, signs and...

Intracranial Granulomatous Arteritis or Primary Angiitis of the Central Nervous System

Other small-vessel vasculitides such as Wegener's granulomatosis have presented as temporal or CNS vasculitis. Pulmonary lesions should be helpful in this differential. y GCA occurs in an older population than PACNS. Those patients with PACNS affecting large and small arteries are older than those with small vessel involvement alone. Immunologic or epitope changes may be related to age. y Infections and more systemic forms of vasculitis need to be considered in the differential diagnosis of PACNS. Tuberculosis and other mycobacteria, meningovascular syphilis, fungal infections, hepatitis B, and herpes ophthalmicus are other possibilities. y Drugs, particularly stimulants, can cause a vasculitis. Noninflammatory vascu- lopathies such as fibromuscular dysplasia and moyamoya may be considered and these diagnoses are best addressed by angiography. 8

Dermatomyositis and Polymyositis

IVIg is an expensive, relatively safe, and promising treatment for DM and PM. The dose is 2 g kg, divided over 2 to 5 days initially, then 0.4 g kg given at intervals based upon the clinical response. The exact mechanism of action is not clear but is felt to affect circulating autoantibodies, the autoimmune target, or complement activation. Side effects include increased serum viscosity with potentiation of thromboembolic events, aseptic meningitis, rash, anaphylaxis in IgA-deficient individuals, and a low risk of transmissible diseases such as hepatitis C. Many patients who have failed other treatments may respond to IVIg. Plasmapheresis has been shown ineffective in a controlled clinical trial.

Sample WriteUp of a Newborns History

Tinea Cruris With Menstrual Period

This 2830-g female infant was born at 38 2 7 weeks to a 47-year-old G1 P0-0-0-0 mother by NSVD (normal spontaneous vaginal delivery) at 1 35 am on 1 16 2008. The pregnancy was complicated by chronic hypertension, for which the mother was treated with Aldomet (methyldopa). The mother is O+ and hepatitis B surface antigen, syphilis, HIV, and Chlamydia negative. Amniocentesis at 14 weeks revealed a 47,XX trisomy 21 karyotype. The mother continued the pregnancy, despite the amniocentesis results, explaining that she ''wanted to know what I would be facing beforehand.'' At 36 weeks, a vaginal culture for group B streptococcus was negative. Mother went into labor at 38+ weeks she developed malignant hypertension unresponsive to magnesium sulfate, so a C-section (cesarean section) was performed under general anesthesia after 17 hours of labor. Rupture of membranes was at delivery. The baby's Apgar scores were 5 and 8, with points off for tone, reflex, respiratory effort, and color at 1...

Toxicities and Management of Preparative Regimens

Must occur in the absence of other causes of post-transplant liver failure, including GVHD, viral hepatitis, fungal abscesses, or drug reactions. Most cases of sinusoidal obstruction syndrome occur within three weeks of HSCT and clinical diagnosis can be confirmed histologically via liver biopsy.

Single Strand Conformation Polymorphism Analysis of Mutations in Exons 48 of the TP53 Gene

The TP53 tumor suppressor gene coding for a nuclear phosphoprotein involved in cellular stress responses is the most frequently mutated gene in human cancers described so far (1-4). Mutations are found throughout the gene but most frequently within the highly conserved middle region (exons 5-8) that encodes for the DNA-binding central region of the gene critical for the major function of TP53 protein as a transcriptional activator (5). The mutation spectrum of the TP53 gene varies from one tumor type to another with typical hot-spot codons for mutations (1-2,6). For instance, codons 157, 248, and 273 are frequently mutated in cigarette smoking-associated lung cancer, whereas mutations in codon 175 are rare. This codon, on the other hand, is often mutated in breast and colon cancer. In some cases, typical mutations can be linked with environmental exposures, such as CC TT double mutation with UV radiation (7) and codon 249 AGG AGT mutation with aflatoxin B1 and hepatitis B virus (8)....

Future Prospects for Aptamer Therapeutics

Anwar, A., Ali, N., Tanveer, R., Siddiqui, A. (2000). Demonstration of functional requirement of polypyrimidine tract-binding protein by SELEX RNA during hepatitis C virus internal ribosome entry site-mediated translation initiation. J Biol Chem 275, 34231-34235. Biroccio, A., Hamm, J., Incitti, I., De Francesco, R., Tomei, L. (2002). Selection of RNA aptamers that are specific and high-affinity ligands of the hepatitis C virus RNA-dependent RNA polymerase. J Virol 76, 3688-3696. Kumar, P. K., Machida, K., Urvil, P. T., Ka-kiuchi, N., Vishnuvardhan, D., Shimotoh-no, K., Taira, K., Nishikawa, S. (1997). Isolation of RNA aptamers specific to the NS3 protein of hepatitis C virus from a pool of completely random RNA. Virology 237, 270282.

Epstein Barr Virus and Cytomegalovirus

Athletes with infectious mononucleosis must be managed carefully to avoid their participation in sports that could result in abdominal trauma. Other risks associated with infectious mononucleosis include upper airway obstruction, asymptomatic transaminase elevation, throm-bocytopenia, and rash after the administration of ampicillin or amoxicillin. Routinely obtaining transaminase levels in patients without clinical hepatitis is of little value and can increase the overall cost of management.

Diseases of the Premodern Period in Japan

In addition to the plentiful information on diseases supplied by court histories, literature, and other records, medical texts and an encyclopedia called the Wamyo ruiju sho also list medical terminology (Hattori 1945). Among the infections included are idiopathic cholera (shiri yori kuchi yori koku yamai, kakuran), leprosy (raibyd), elephantiasis igeju), bronchitis (shiwabuki yami), hepatitis (kibamu yamai), dropsy (harafukuru yamai), asca-rids (kaichu), threadworms (gyochu), meningitis (fubyo), infantile dysentery (shoji kakuran), diphtheria (bahi), bronchial asthma (zensoku), epilepsy (tenkari), chronic nephritis (shokatsu), tonsilitis (kdhi), osteomyelitis (fukotsuso), thyroiditis (ei), erysipelas (tandokuso), ringworm (senso), gastritis (iso), palsy (kuchi yugamu), and scabies (kaiso). Records from the era 700-1050 also have led scholars to infer the existence of cancer, pneumonia, tapeworms, rheumatoid arthritis, and hookworms.

Scarlet Fever Clinical Summary

Scarlet fever manifests as erythematous macules and papules that result from an erythrogenic toxin produced by group A 13-hemolytic Streptococcus. The most common site for invasion by this organism is the pharynx and occasionally skin or perianal areas. The disease usually occurs in children (2-10 years of age) and less commonly in adults. The typical presentation of scarlet fever includes fever, headache, sore throat, nausea, vomiting, and malaise followed by the scarlatiniform rash. The rash is typically erythematous it blanches (in severe cases may include petechiae), and owing to the grouping of the fine papules gives the skin a rough, sandpaper-like texture. It initially occurs centrally on the face, often with perioral sparing, neck, and upper trunk but quickly becomes generalized and typically desquamates after 5 to 7 days. On the tongue, a thick, white coat and swollen papillae give the appearance of a strawberry ( strawberry tongue ). Palatal petechiae and tender anterior...

Polyarteritis Nodosa Churg Strauss and Overlap Syndromes

Classic polyarteritis nodosa (PAN) is a necrotizing, nodular vasculitis that preferentially affects medium and small arteries, and sometimes arterioles. The pathophysiology is believed to be deposition of immune complexes in the involved arteries. PAN is associated with a number of infections, particularly hepatitis B, tuberculosis, and streptococcus. In those cases associated with hepatitis B, hepatitis B surface antigen IgM, and complement can be demonstrated in the vasculitic lesions. In most cases, however, no association with an infectious agent can be demonstrated. y Evaluation. The ESR is typically elevated in PAN patients, averaging 60 mm hr. y Other laboratory studies may show leukocytosis, anemia, thrombocytosis, and abnormal urinary sediments. Hepatitis B surface antibody is seen in a subset of patients. pANCA is detected in almost 20 percent of PAN patients, and it has been suggested that these pANCA-positive PAN patients may actually have...

Acute Pharyngitis and Tonsillitis

Epstein-Barr virus (EBV) as a cause of pharyngitis can mimic GABHS infection. It can also occur concurrently with GABHS infection. Studies have shown the two infections occurring together in 2 to 33 of cases. Prodromal symptoms to severe sore throat include malaise, anorexia, chills, and headache. Fatigue, lymphadenopathy, and hepatosplenomegaly can follow in 5 to 14 days. Pharyngitis with tonsillar hypertrophy and a membranous white tonsillar exudate lasts 5 to 10 days. Lymphadenopathy and hepatosplenomegaly can persist 3 to 6 weeks. Contact sports should be avoided for 6 weeks because of the possibility of splenic rupture. Complications that occur in less than 2 of patients with EBV infection include throm-bocytopenia, hemolytic anemia, Guillain-Barre syndrome, Bell's palsy, transverse myelitis, and aseptic meningitis. Hepatitis can be seen in 20 to 50 of patients with EBV infection.

Structural Constraints Imposed by Ritualization

Ritualized Practices of Mental Health Consumers. It is important to consider the routinized practices of individuals with mental illness themselves and the impact that these practices can have on recovery. A body of research has documented that unhealthy lifestyles, including lack of exercise, smoking, and high-fat dietary intake predominate among people with schizophrenia these unhealthy practices exceed those of the general population, even when controlling for socioeconomic status, (e.g., Brown, Birtwistle, Roe, & Thompson, 1999). Time-use studies have also documented how greater reliance on passive leisure activities (such as watching television) characterizes the daily routines of people with schizophrenia (Hayes & Halford, 1996), even when compared with unemployed individuals from the general population. Other studies have documented some of the risky lifestyle practices associated with people with severe mental illness who abuse substances, such as panhandling and prostitution...

Differential Diagnosis of Hypoglycemia

Sulfonylureas And Hypoglycemia Visits

Glyucos e-6-phosphatas e Liver phosphorylase Pyruvate carboxylase Phosphoenoipyruvate carboxykinase Fructose 1,6-biphosphate Glycogen synthetase Substrate deficiency Ketotic hypoglycemia of infancy Severe malnutrition, muscie wasting Late pregnancy Acquired liver disease Hepatic congestion Severe hepatitis Cirrhosis Drugs Alcohol Propranolol Salicylates

Von Willebrand disease

The loading dose is 40-60 IU kg, and this can be followed by repeat doses every 12-24 h to maintain vWF activity (vWF RCoF) 50 . All currently available concentrates are derived from plasma. As at least one viral inactivation step is included in their manufacture, they are unlikely to transmit hepatitis or HIV, but there is still a risk of parvovirus infection.

Pharmacologic Therapy

Mechanistically, APAP is believed to inhibit prostaglandin synthesis in the CNS and block pain impulses in the periphery. APAP is well tolerated at usual doses and has few clinically significant drug interactions except causing increased hypoprothrombinemic response to warfarin in patients receiving APAP doses of more than 2,000 mg per day. The maximum recommended dose for patients with normal renal and hepatic function is 4,000 mg per day. Hepatotoxicity has been reported with excessive use and overdose, and the risk of this adverse effect increases in those with hepatitis or chronic alcohol use, as well as those who binge drink or are in a fasting state. Regular chronic use of APAP has been associated with chronic renal failure, but reports are conflicting. For these reasons, the maximum dose should be reduced by 50 to 75 in patients with renal dysfunction or hepatic disease and in those who engage in excessive alcohol use.

Varicella Chickenpox Clinical Summary

Chickenpox results from primary infection with varicella zoster virus and is characterized by a generalized pruritic vesicular rash, fever, and mild systemic symptoms. The skin lesions have an abrupt onset, develop in crops, start on the trunk and spread outward, and evolve from erythematous, pruritic macules to papules and vesicles (rarely bullae) that finally crust over within 48 hours. The classic lesions are teardrop vesicles surrounded by an erythematous ring ( dewdrop on a rose petal ). The most common complication of varicella is occasional secondary bacterial infection, usually with Streptococcus pyogenes or Staphylococcus aureus. Other complications from varicella include encephalitis, glomerulonephritis, hepatitis, pneumonia, arthritis, and meningitis. Cerebellitis (manifested clinically as ataxia) may develop and is usually self-limited. Although several illnesses can present with vesiculobullous lesions, the typical case of varicella is seldom confused with other problems....

Primary Care of SUD Patients

The primary care of SUD patients must take into account the systemic effects of the drug(s) ingested, route of administration, methods of drug procurement, illicit drug-prescription drug interactions, and typically, higher rates of nonad-herence to follow-up and prescribed regimens (Ries et al., 2009). Infectious diseases (e.g., HIV, hepatitis B and C, tuberculosis) and sexually transmitted infections (e.g., gonorrhea,

Category C Severely Symptomatic

Initial laboratory studies should include CD4+ CD8+ counts (absolute cell counts and percentages) and, if possible, HIV-1 RNA levels. CBC with differential count, electrolyte and liver function panel, hepatitis screen, reactive protein reagin (RPR) or VDRL, anti-toxoplasma IgG antibodies purified protein derivative (PPD) with anergy panel, and chest x-ray should also be obtained. Ophthalmological, dental, and gynecological examinations (including a PAP smear, chlamydia and gonorrhea studies) should be pursued. The stage of HIV-1 infection will then determine follow-up, prophylaxis, and therapeutic strategies.

Clinical Manifestations

A variety of other rare infections with the gonococcus have been documented. Adults occasionally develop gonococcal conjunctivitis, with a potential for more serious ocular involvement, through direct (i.e., hand-to-eye) contact with infected secretions. Gonococcal endocarditis, myocarditis, hepatitis, and meningitis may occur as part of the disseminated syndrome. Perihepatitis (termed the Fitz-Hugh-Curtis syndrome) has traditionally been attributed to gonococcal infection in the upper right quadrant, usually in association with classic PID. Recent evidence, however, indicates that the syndrome is more often associated with chlamydial, rather than gonococcal, infection.

Hypersensitivity Reactions

Type III reactions are mediated by formation of antigen-antibody or immune complexes and subsequent complement activation. Deposition of immune complexes near the site of antigen entry causes release of lytic enzymes by accumulated neutrophils and results in localized tissue damage. The formation of circulating immune complexes is involved in several conditions, including allergies to penicillin, infectious diseases such as hepatitis and autoimmune diseases such as rheumatoid arthritis.

The Lectin Pathway in Health and Disease

Inhibition of the lectin pathway may represent a therapeutic strategy for ischemia-reperfusion injury (Collard et al., 2000 Petersen et al., 2000 Montalto et al., 2001 Lekowski et al., 2001) and other complement-mediated disease states, such as in chronic hepatitis C (Dumestre-Perard et al., 2002). An alternative approach to targeting MBL is to develop a specific inhibitor for MASP-2 and thereby block the activation of the lectin pathway.

Arthritis of Systemic Disease

B19 is responsible for erythema infectiosum and can also cause polyarthritis, especially in the hands, knees, and ankles. HIV infection sometimes causes symmetric polyarthritis, spondy-litis, or acute oligoarthritis. Hepatitis B and C can cause acute symmetric polyarthritis in large and small joints. Inflammation in a few large joints and back pain are among the earliest symptoms of infective endocarditis in about 25 of patients with this disorder (Totemchokchyakarn and Ball, 1996).

Treatment of the Underlying Cause of Sperm Oxidative Stress

While as yet untested by clinical trials, the effective treatment of systemic diseases linked with oxidative stress (diabetes, Hepatitis B C, HIV, malaria, haemo-chromatosis, haemoglobinopathies, inflammatory bowel disease, psoriasis, rheumatoid arthritis, depression) is likely to reduce overall oxidative stress in the body and benefit sperm function. It is therefore ideal that patients delay conception until after these systemic diseases are under effective control, unless the medications used to achieve control have a detrimental effect on sperm function (e.g. meth-otrexate treatment of inflammatory conditions).

Androgeninduced liver disorders

A consistent adverse feature of pharmacological androgen therapy, regardless of indication, is the risk of androgen-induced liver disorders (Ishak and Zimmerman 1987). These involve biochemical effects on hepatic function, hepatotoxicity (hepatitic or cholestatic) and liver tumor development (benign or malignant) and peliosis hepatis. These risks are a class-specific adverse effect of 17a-alkylated androgens, especially when used orally but no reliable estimates of the incidence or prevalence are available. The East German national sports doping programme involving oral 17a-alkylated androgens resulted in deaths from liver failure and chronic liver disease (Franke and Berendonk 1997). Every marketed 17a-alkylated androgen is associated with hepatotoxicity, whereas other androgens (1-methyl androgens, nandrolone, testosterone, dihydrotestosterone) are not hepatotoxic. Cholestasis and functional impairment of liver function (BSP retention, antipyrine clearance) are consistently impaired...

Processing Of Blood For Transfusion

Strict medical selection of donors minimizes infection risks to the recipient in addition to ensuring donor safety. Furthermore, in the UK, all blood donations are screened for hepatitis B, hepatitis C, HIV-1 and HIV-2 and syphilis. These measures have resulted in an almost negligible risk of transfusion-transmitted disease, which will be reduced even further when donors are screened by polymerase chain reaction (PCR) assays, which should further shorten the window periods.

Postoperative Hepatic Dysfunction

Chloroform was the first anaesthetic agent to be suspected of causing hepatic damage. In large doses, chloroform is a direct hepatotoxin, and after anaesthesia a hepatitis-like syndrome, with histological evidence of centrilobular hepatic necrosis, occurred occasionally. Methoxyflurane was also associated with hepatic damage, causing a syndrome clinically similar to viral hepatitis. Two of the volatile agents in current use have been implicated in cases of postoperative hepatic dysfunction.