Ada Hamosh, M.D., M.P.H.

• Dr. Frank V. Sutland Professor of Pediatric Genetics
• Professor of Genetic Medicine

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0002818/ada-hamosh

A Cochrane review (Herxheimer & Petrie erectile dysfunction doctor in jacksonville fl purchase kamagra gold 100mg mastercard, 2002) found melatonin to be effective in reducing jet lag erectile dysfunction pump uk cheap kamagra gold 100 mg online. It has to be taken at bedtime after darkness has fallen on the first day of travel erectile dysfunction zoloft kamagra gold 100 mg sale, then again in the same way on the second erectile dysfunction doctor new orleans order kamagra gold uk, and any subsequent day of travel erectile dysfunction doctor in columbus ohio cheap kamagra gold 100mg with amex. Once at the final destination erectile dysfunction treatment for heart patients generic kamagra gold 100 mg with visa, it should be taken for the following few days at the same time. Practical prescribing and product selection Prescribing information relating to medicines for insomnia is discussed and summarized in Table 5. Antihistamines used for insomnia are first-generation antihistamines and interact with other sedating medication, resulting in potentiation of sedation. Additionally, they possess antimuscarinic side effects, which commonly lead to dry mouth and possibly to constipation. It is these antimuscarinic properties that mean that patients with glaucoma and prostate enlargement should ideally avoid their use because it could lead to increased intraocular pressure and precipitation of urinary retention. Complementary therapies these products are used by a substantial number of patients as a self-care measure (Byrne, 2006; Pearson et al. Herbal remedies containing hops, German chamomile, skullcap, wild lettuce, lavender, passiflora and valerian are available. Most information available in the literature relates to the hypothesised actions of chemical constituents or studies in animals. Valerian appears to be the only product in which more than one trial has been conducted on humans. There is a growing body of evidence that it is more effective than placebo for mild depression and is comparable in effect to tricyclic antidepressants. If depression is suspected, the patient should be referred for further assessment. Nytol is available as tablets (two tablets [Nytol] or one tablet [Nytol one-a-night]) or liquid (10 mg/5 mL) and Nightcalm as a once-daily capsule. Promethazine Proprietary brands of promethazine available to the public include Sominex (20 mg) and Phenergan (10 or 25 mg). Adults and children older than 16 years should take one tablet 1 hour before bedtime. Evaluation of temazepam and diphenhydramine as hypnotics in a nursing home population. Meta-analysis of quantitative sleep parameters from childhood to old age in healthy individuals: Developing normative sleep values across the human lifespan. Insomnia, trouble sleeping, and complementary and alternative medicine: Analysis of the 2002 national health interview survey data. Sleep habits, insomnia, and daytime sleepiness in a large and healthy community-based sample of New Zealanders. The efficacy and safety of exogenous melatonin for primary sleep disorders: A meta-analysis. Symptoms rarely occur in isolation, and other symptoms are usually present to help aid in the differential diagnosis. Most cases will have a gastrointestinal origin, with viral gastroenteritis and food poisoning being the most common acute cause in all age groups. Questioning the patient about associated symptoms should be made to eliminate other conditions (Table 5. As such, their prevalence and epidemiology are dictated by the underlying condition causing the symptoms. Clinical features associated with gastroenteritis Gastroenteritis is characterized by acute onset, vomiting, and/or diarrhoea and systemic illness. Most cases, regardless of the infecting pathogen, resolve in a few days and rarely last more than 10 days. In children under 5 years old over 60% of cases are viral in origin, with rotavirus and small, round, structured viruses most commonly identified. Bacterial gastroenteritis presents with similar symptoms, although fever is usually a more prominent feature. In food poisoning, violent vomiting and diarrhoea within 24 hours of eating contaminated food is usual. Aetiology Two main mechanisms are involved in inducing nausea and vomiting-neurological and peripheral. Nausea occurs because activity in the vomiting centre (located in the medulla oblongata) increases. Information received from the receptor cells in the walls of the gastrointestinal tract and parts of the nervous system reach a threshold value that induces the vomiting reflex. Additionally, further input is received at the vomiting centre from an area known as the chemoreceptor trigger zone. This is highly sensitive to certain circulating chemicals; for example, substances released by damaged tissues as a result of bacterial infection. Conditions to eliminate Gastritis Gastritis is often alcohol- or medicine-induced and can present as acute or chronic nausea and vomiting. Arriving at a differential diagnosis Nausea and/or vomiting are common symptoms of many disorders, including infection, acute alcohol ingestion, anxiety, severe pain and labyrinth and cardiovascular causes. Nausea and vomiting associated with headaches Vomiting and especially nausea are common symptoms in patients who suffer from migraines. However, for all three conditions, abdominal pain would be the presenting symptom, not nausea and vomiting. Early morning vomiting is often associated with pregnancy or excess alcohol intake. If vomiting occurs immediately after food, this suggests gastritis, and if vomiting begins 1 or more hours after eating, peptic ulcers are possible. Acute cases of gastroenteritis will normally have other associated symptoms, such as diarrhoea, fever and abdominal discomfort. If infection is due to food contamination, other people are often affected at the same time. Presence of abdominal pain Timing of nausea and vomiting Signs of infection 116 Central nervous system of headache, such as raised intracranial pressure, can also cause nausea and vomiting. Nausea and vomiting in infants (1 month to 1 year old) In the first year of life, the most common causes of nausea and vomiting are feeding problems and gastrointestinal and urinary tract infections. Regurgitation is an effortless backflow of small amounts of liquid and food between meals or at feeding times; vomiting is the forceful expulsion of gastric contents. The infant will usually have a fever and be generally unwell if vomiting is associated with infection. If projectile vomiting occurs in an infant younger than 3 months, pyloric stenosis should be considered. Due to the higher risk of dehydration in this age group, it is prudent to refer to a doctor if symptoms persist for more than 24 hours. Nausea and vomiting in children (1 to 12 years old) Children under 12 years old who experience nausea and vomiting will usually have gastroenteritis, fever, or otitis media. In most cases, the conditions are self-limiting, and medication designed to reduce pain and temperature (analgesia) and replace fluid (oral rehydration therapy) will help resolve symptoms. Pregnancy Pregnancy should always be considered in women of childbearing age if nausea and vomiting occur in the absence of other symptoms. Medicine-induced nausea and vomiting Many medications can cause nausea and vomiting. If medication is suspected then the pharmacist should contact the prescriber to discuss alternative treatment options. Unfortunately, in 2014, domperidone was reclassified back to prescription-only status over fears about its potential cardiac side effects. The multiple-choice questions are designed to test knowledge and application of knowledge; the case studies allow this knowledge to be put in context in patient scenarios. Which of the questions listed below would be most discriminatory in assessing if it were a migraine or tension-type headache Knowing this information, what headache conditions cannot be ruled out based on location Migraine Temporal arteritis Subarachnoid haemorrhage Sinusitis Cluster headache Which sign or symptom warrants referral Headache lasting 7 to 10 days Headache described as vice-like Headache associated with the workplace environment Headache in children younger than 12 years, with no sign of infection. From the list of symptoms below, which would indicate referral for a patient suffering with headache Flashing or flickering lights Pins and needles in the arms Scalp tenderness Symptoms that improve as the day progresses Symptoms that last longer than 1 week 5. Change in work shift patterns Acute stressful situations Foreign travel Excessive caffeine intake None of the above 5. She tells you that the pain has been present for the last 24 hours and is at the front of her head, and she has felt a little sick. Symptoms more than 48 hours in an adult Symptoms more than 24 hours in an 18-month-old Symptoms more than 24 hours in a 9-month-old Symptoms less than 24 hours in an adult Symptoms less than 48 hours in an adult 5. In which condition listed below is nausea and vomiting most commonly seen in this age group Which one of the following symptoms require you to make an urgent referral to the doctor Sinusitis Cluster headache Migraine Temporal arteritis Meningitis Tension-type headache Subarachnoid haemorrhage Medication overuse headache Glaucoma Select, from A to I, which statement is most closely associated with the above conditions: 5. Migraine Temporal arteritis Subarachnoid haemorrhage Sinusitis Cluster headache 5. Eye strain (b) and sinusitis (d), although common causes of headache, are far less prevalent than tension headache. Symptoms of scalp tenderness (c) are suggestive of temporal arteritis, a condition that warrants referral. Lancing (a) could be trigeminal neuralgia, orbital and boring (b) indicates cluster headache, frontal and dull suggests sinusitis (c), and a temporal location suggests temporal arteritis (d). Location (d) is also a good question to ask because approximately 70% of patients with migraine have onesided pain, whereas tension-type headache is usually bilateral. Severity (a) is subjective and, although useful, needs to be quantified by using some form of scale. If workplace implicated (c), the cause needs exploring but does not warrant referral; headache associated with upper respiratory tract infections (e) are commonly seen. Age is an important consideration, and younger patients should be viewed with greater caution in management, especially the very young. Haematoma (e) can cause sickness but the duration of symptoms is too short for this to be considered. Other conditions listed do not have sickness as a symptom, although temporal arteritis (b) can cause malaise. Feeding difficulties (e) are Answers 121 commonly associated with food regurgitation rather than with nausea and vomiting. Otitis media (a) does occur in this age group but nausea and vomiting are not common. Sinusitis occurs as a result of a previous infection, whereas headache associated with meningitis is one of the symptoms of the infection itself. Nasal congestion associated with headache is not common, and the only conditions listed where this would be seen are sinusitis (A) and cluster headache (B). The pain is described as severe, so this indicates cluster headache as being the most likely diagnosis. Meningitis (E), tension-type headache (F) and medication overuse headache (H) are more generalized in nature. Migraine Sinusitis Space occupying lesion Temporal arteritis Tension-type headache a. Cluster headache Sinusitis Subarachnoid haemorrhage Tension headache Trigeminal neuralgia Questions 5. Generalized Occipital Orbital Temporal Frontal Select, from A to E, which of the above locations: 5. Medicines (d) can cause this but is specific to certain classes, and this question is very generic. Options a and c do tend to cause nausea and vomiting if experienced, but gastroenteritis is more prevalent. Associated nasal congestion is common with cluster headache, so d can be excluded. Symptoms of cluster headache are generalized and severity of pain could produce nausea and vomiting but this is not common. Headache in young children with no identifiable cause (d) would be unusual and requires further evaluation. Rationale: Cluster headache is associated with the front of the head, meaning C to E are most likely. Cluster headache is much more common in men and temporal arteritis is more associated with elderly women. Below summarizes the expected findings for questions when related to the different conditions that can be seen by community pharmacists. Migraine Usually Associated with unilateral menstrual cycle and weekends; throbbing pain and nausea. We see that his symptoms most closely match tensiontype headache, which may (or may not) be triggered by extra pressure at work (represents symptom match). Given that epidemiology states that this is the most common cause of headache, this strongly points to this being the diagnosis. After talking with him, you find out the following: He has no symptoms suggestive of infection, and although he has a computer-based job that can cause eye strain, the pattern of symptoms does not fit. Migraine is therefore most probable and supported by stress experienced at work because migraine can be triggered by stress.

The floor of the nasopharynx is an imaginary horizontal line from the level of the palate to the posterior pharyngeal wall erectile dysfunction ed treatment buy kamagra gold american express. The distribution and frequency of occurrence of stratified squamous epithelium erectile dysfunction statistics purchase discount kamagra gold on-line, intermediate (transitional) epithelium erectile dysfunction drug mechanism buy generic kamagra gold canada, and ciliated epithelium within the nasopharynx have been mapped and outlined by Ali342; they appear to be fairly constant between the ages of 10 and 50 years erectile dysfunction age 25 generic kamagra gold 100 mg. One of the most important areas erectile dysfunction medication cheap generic 100 mg kamagra gold with visa, from a pathologic standpoint erectile dysfunction my age is 24 discount 100 mg kamagra gold, is the lateral wall of the nasopharynx. The lateral wall contains the site of the opening of the eustachian tube, which forms a triangular prominence, the torus tubarius with adjacent tonsillar tissue. The fossa is formed by a herniation of the nasopharyngeal mucosa through a deficiency between the skull base and the most superior fibers of the superior constrictor muscle. The other two chains frequently receiving drainage from the nasopharynx are the cervical chain and the spinal accessory nodes. Other common sites of metastasis from the nasopharynx are the lymph nodes of the retropharyngeal space. Patients may present with a variety of symptoms: serous otitis media, nasal obstruction, tinnitus, facial numbness, epistaxis, or cervical adenopathy commonly seen in the apex of the posterior cervical triangle (level 5, see Chapter 11 for description of levels). These two subclassified groups have overlapping histologic features and similar epidemiologic and biological characteristics (frequent lymph node involvement and distant metastases) rendering the subclassification of no clinical or prognostic value. The cell margins are indistinct, imparting a characteristic syncytial growth pattern, and the cells may be arranged in irregular masses or as loosely connected cells in a lymphoid stroma. The arrows indicate pathways of tumor spread into adjacent structures and sinuses via the intricate sinonasal labyrinth. The paranasal sinuses comprise the maxillary, frontal, ethmoidal, and sphenoidal sinuses. It is divided anteriorly into the nasal vestibule and posteriorly into the nasal antrum with turbinates. The nasal vestibule is bordered inferiorly by the palatine process of the maxilla and medially by the septal cartilage, and the superior and lateral walls are composed of the soft tissue of the nasal ala. The softtissue lining of the vestibule is an extension of integument, with its keratinizing stratified squamous epithelium and secondary appendages. This lining extends for approximately 1 to 2 cm from the external rim of the nose into the nares. Just beyond the limen nasi (which is a ridge across the roof of the nasal cavity formed by a border of the upper lateral cartilage) is roughly the location of the mucocutaneous junction. The superior, middle, and inferior turbinates (conchae), which have associated meatuses, hang into the nasal lumen along the lateral walls of the nasal cavity. The roof is formed by the cribriform plate, the sphenoid bone, and the frontal bone. Posteriorly, the conchae end approximately 1 cm anterior to the choanal orifice, which is a continuum of the posterior aspect of the nasal cavity into the anterior opening of the nasopharynx. The ethmoid labyrinth in the adult is a completely pneumonized lattice of approximately 3 to 18 cells per side. The lateral wall of the ethmoid sinus is the medial wall (lamina papyracea) of the orbit, and the medial wall of the ethmoid sinus forms the lateral wall of the nose and attachment for the middle turbinate. Because of the close proximity of the adjacent nasal passages and sinuses, the ethmoid sinus is the second most frequently involved sinus by tumor extension, after the maxillary sinus. The maxillary sinus (antrum of Highmore) is the largest of the sinuses and encompasses the majority of the corpus of the maxilla. The walls of the maxillary sinus that abut the nasal cavity and orbit are thin, whereas those of the anterior and posterior walls are relatively thick. The apices of the premolars and molars of the maxilla protrude into the maxillary sinus and are covered by a thin plate of bone. The ostium from the maxillary sinus leads into an area within the middle meatus and is situated at the superior aspect of the maxillary sinus. The position of this ostium is unfavorable for drainage of the sinus while in an upright position. The lacking specific clinical symptoms were noted to delay diagnoses from 3 to 14 months in one series. The lymphatic drainage of the ethmoid labyrinth is to the superior cervical nodes, and some drain directly posteriorly to the retropharyngeal nodes. In 1938 Ohngren405 proposed a theoretical plane from the medial canthus of the eye to the angle of the mandible, which created an anteroinferior (infrastructure) and a posterosuperior (suprastructure) to the maxillary sinus area. This hypothetical division has clinical relevance because the infrastructure tumors present early, therefore good prognosis, whereas the suprastructure tumors usually present after extensive tumor growth has occurred. In the histologic classification of the nasal cavity and paranasal sinuses, there has historically been some confusing and controversial terminology. The synonyms for nonkeratinizing carcinoma have included cylindrical cell carcinoma (Ringertz squamous carcinoma), transitional cell carcinoma,406 and schneiderian carcinoma. Reference to cylindrical cell carcinoma can be found in the literature around 1900 as a histologic type of nasal carcinoma, but it was fully described by Ringertz407 in 1938. The histologic description rendered by Ringertz described a sometimes papillary nonkeratinizing epithelial tumor that invaginated into the stroma. The invaginating epithelial growths had a palisading basal layer forming a crisp demarcation at the epithelium-stroma interface and forming a ribbon or garlandlike pattern with central zones of necrosis. In the American literature more than a decade earlier, Quick and Cutler408 introduced the James Ewing term transitional cell carcinoma for a category of upper airway tumors that "exhibited transitional epithelial characteristics with cylindrical or cuboidal cells free of keratosis. Transitional was chosen because of the histologic resemblance of the malignant epithelium to that of transitional epithelium of the urogenital tract. The strands of polymorphic cells that make up the tumor show a well-defined interface with the adjacent stroma. B, At higher magnification, the polymorphous nature of the cells and the cylindrical aspect of basal and suprabasal cells are clearly shown. As mentioned previously, the correct classification of these tumors is complicated, as histologic examination, immunohistochemical staining, and molecular analysis are needed to classify the tumor. Moreover, the histology of cylindrical cell carcinoma may mimic that of inverted papilloma. For patients with carcinoma of the sinonasal area, the probability of surviving for 5 years is approximately 50%. For patients with antral and ethmoidal disease, the probability of surviving 5 years is 48% and 68%, respectively. Owing to the nature of their anatomical proximity, accurate identification of a primary tumor site may be difficult; however, identification of the primary site has prognostic significance. It communicates superiorly with the oropharynx and inferiorly with the larynx and esophagus. The superior border of the hypopharynx is an imaginary horizontal line drawn across at the level of the tip of the epiglottis. The inferior boundary is defined anteriorly by the aryepiglottic folds, which lead to the endolarynx, and posteriorly by the inlet to the cervical esophagus. The hypopharynx is divided into three regions: the paired pyriform sinuses or recesses, the posterior pharyngeal wall, and the postcricoid region. The pyriform sinuses are bilaterally elongated, pear-shaped, three-walled gutters that open into the hypopharyngeal cavity and extend anteriorly and laterally on either side of the larynx. The medial wall of the pyriform sinus is separated from the ventricle of the larynx and outer aspect of the cricoid cartilage by a thin submucosal layer of muscle. Inferiorly, the pyriform sinus is in continuum with the entryway into the esophagus. The posterior pharyngeal wall joins the lateral limits of the pyriform sinus and inferiorly, the cervical esophagus. The postcricoid region is a funnel-shaped area extending from the level of the arytenoid cartilages to the inferior border of the cricoid cartilage. The epithelium is nonkeratinizing; however, when subjected to chronic irritation, orthokeratinization or parakeratinization may be found. Within the submucosa are seromucinous glands, scattered lymphoid aggregates, and a rich anastomosing network of lymphatics. Carcinomas of the hypopharynx generally have a poor prognosis, primarily because of a combination of unrestricted area for tumor growth, multifocality, and extensive lymphatic network. Carcinoma of this area may extend inferiorly, involving the esophagus and trachea and thus necessitating the removal of a portion of the trachea. Eighteen percent will have bilateral cervical node metastases, and most local recurrences are caused by unrecognized involvement of the paratracheal nodes. The majority of lesions involve the pyriform sinus, and combined therapy is recommended, with the exception of T1 and T2 lesions (single-modality therapy). The value of adjunctive chemotherapy in pyriform sinus malignancy is still unclear. Embryologically, the supraglottic region is derived from the third and fourth branchial arches (buccopharyngeal anlage), and the glottic and subglottic regions originate from the fifth branchial arch (laryngotracheal anlage). The supraglottic region extends from the tip of the epiglottis superiorly to the ventricle inferiorly and is one compartment. The supraglottic area has frequently been subdivided into the suprahyoid and infrahyoid areas. Those carcinomas in the suprahyoid area (tip of epiglottic rim of aryepiglottic folds and arytenoids) tend to have a worse prognosis than infrahyoid tumors and behave similarly to hypopharyngeal tumors. The supraglottic larynx lymphatics drain laterally and superiorly through the thyrohyoid membrane and drain into the subdigastric and superior jugular nodes. The glottis includes the paired true vocal cords and the anterior and posterior commissure. The anterior commissure tendon (Broyles ligament) is an important band of fibrous tissue that contains certain lymphatics and blood vessels and attaches to the thyroid cartilage devoid of the tumor-resistant perichondrium. The epithelium present at the transitioning interface of these two types of epithelium is referred to as intermediate epithelium. B, Histologic section showing the presence of metaplastic ventricular epithelium (left) and an extensive area of intermediate epithelium (right). The transitional zone of intermediate epithelium has a slightly disordered appearance. The lymphatic drainage from these two areas is lateral and inferior through the cricothyroid membrane to the paratracheal nodes, deep cervical nodes, and prelaryngeal (Delphian) node. Both lingual and superior portions of the laryngeal aspects of the epiglottis are covered by nonkeratinized stratified squamous epithelium. The stratified squamous epithelium on the inferior laryngeal aspect of the epiglottis merges with respiratorytype epithelium. The vibratory edge of the true vocal cord is lined by a nonkeratinizing stratified squamous epithelium. The interface between the ciliated columnar epithelium of the ventricle and the stratified squamous epithelium of the true vocal cord is often abrupt. There may be a transitional zone where the epithelium may appear disorganized and thickened and the cells may have enlarged basaloid features; however, mitotic figures are confined to the basal cell layer. This space extends from subjacent to the supraglottic mucosal surface to the quadrangular membrane and inferiorly to the lower edge of the vestibular ligaments and petiole. The space is bordered laterally by the quadrangular membrane and the laryngeal surface of the epiglottic cartilage. The preepiglottic space is triangular and bounded superiorly by the hyoepiglottic ligament, anteriorly by the thyrohyoid membrane, and posteriorly by the epiglottis. There are foramina in the infrahyoid epiglottic cartilage that allow tumor spread from the laryngeal side of the epiglottis into this space and thus outside the larynx. The paraglottic space is the largest connecting spatial structure within the laryngeal soft tissues. This space surrounds the whole of the ventricles lateral to the quadrangular membrane and medial to perichondrium of the thyroid cartilage and is limited inferiorly by the elastic conus and the cricothyroid membrane. Recently described are elastic and fibroelastic membranes that are subjacent to ventricular mucosa and in continuity with the elastic conus and quadrangular membrane,445 thus providing a continuous elastic membrane that bridges the supraglottis and glottic areas. Tumors entering this space have the potential to spread to the preepiglottic space; thus, a glottic or subglottic lesion could gain access to the supraglottic region. The Reinke space is of particular interest in that it is the smallest space to be described within the larynx and lies between the vocal cord fold epithelium and the vocal ligament. Its widest extent is in the craniocaudal direction in the middle third of the vocal folds. The upper boundary is made up of the vocal ligament and elastic conus (fibers from the vocal ligament), which reaches the lower edge of the cricoid cartilage and extends into the submucosal region of the trachea. With this information, it should be noted that there is no vertical separation of the lymphatic drainage of the larynx into the left and right sides, and, therefore as clinically observed, contralateral metastasis may be seen. In discussing the spread of laryngeal carcinoma, it should be noted that traditionally the tumors have been divided by site: supraglottic, glottic, transglottic, and subglottic. The supraglottic tumors involve the false vocal cord, the ventricle, and the epiglottis (laryngeal or lingual aspects) and represent approximately 30% to 35% of laryngeal tumors. Invasion of cartilage is exceedingly rare, restricted only to those cases in which the cartilage has undergone osseous metaplasia. Tumors of the glottic area are the most frequent, accounting for approximately 60% to 65% of laryngeal carcinomas. Five-year disease-free rates for T1 carcinomas (localized to the vocal cord) have been reported as high as 90%.

The review concluded that laxatives do increase the number of bowel movements and erectile dysfunction needle injection buy discount kamagra gold on-line, in 9 of 11 trials studying overall symptom control erectile dysfunction meds list order 100mg kamagra gold with visa, laxatives performed significantly better than placebo impotence reasons and treatment cheap kamagra gold 100mg without a prescription. Unfortunately erectile dysfunction treatment karachi purchase genuine kamagra gold on-line, because of a lack of comparative trial data causes of erectile dysfunction in 60s cheap 100 mg kamagra gold with mastercard, the review could not conclude which laxative was most efficacious erectile dysfunction symptoms kamagra gold 100 mg free shipping. A more recent review of both stimulant and nonstimulant laxatives in functional constipation also found that all laxative classes are superior to placebo (Par e & Fedorak, 2014). Practical prescribing and product selection Evidence base for over-the-counter medication For uncomplicated constipation, nondrug treatment is advocated as first-line treatment for all patient groups because simple dietary and lifestyle modifications (increasing exercise) will relieve most acute cases of constipation. Dietary fibre increases stool bulk, stool water content, and colonic bacterial load. Fibre intake should be increased to approximately 30 g/day in the form of fruit, vegetables, cereals, grain foods, and whole-grain bread. It is important to remind patients that adequate fluid intake (2 L/day) is needed when following a high-fibre diet; patients might experience excessive gas production, colicky abdominal pain, and bloating. Despite their widespread use, surprisingly few well-designed trials have substantiated clinical efficacy. A systematic review in 1997 identified 36 trials involving 1815 participants who met their inclusion criteria; it involved 25 different laxatives representing all four classes (Tramonte et al. Twenty of the trials compared laxative against placebo or regular diet, 13 of which Prescribing information relating to the medicines used for constipation is discussed and summarized in Table 7. The discussion that follows does, however, make reference to dosing in children younger than 6 years as some products can be used in this age group. In addition, they encourage the proliferation of colonic bacteria, and this helps further increase faecal bulk and stool softness. Patients should be advised to increase their fluid intake while taking bulk-forming medicines. They are well tolerated in pregnancy and breastfeeding and have no teratogenic effects. Ispaghula husk (Fybogel) Ispaghula husk has to be reconstituted with water before taking. The adult dose is three to six tablets twice daily, and each dose should be taken with at least 300 mL of liquid. Adults and children older than 12 years should take one or two sachets or heaped 5-mL spoonsful once or twice daily after meals. The granules should be placed dry on the tongue and swallowed immediately with plenty of water or a cool drink. It is this action that presumably causes abdominal pain and is the main side effect associated with stimulant laxatives. Additionally, stimulant laxatives are associated with the possibility of nerve damage with long-term use Sterculia (Normacol and Normacol Plus granules or sachets) Both Sterculia products contain 62% Sterculia, but Normacol Plus also contains 8% Frangula. Gently push the suppository, pointed end first, into your back passage with your finger. Sachets containing ispaghula husk Prolonged use of lactulose Lactulose taste Bisacodyl Once the granules have been mixed with water, the drink should be taken as soon as the effervescence subsides because the drink sets and becomes undrinkable. The sweet taste is unpalatable to many patients, especially if high doses need to be taken. Bisacodyl tablets are enteric-coated, and patients should be told to avoid taking antacids and milk at the same time because the coating can be broken down, leading to dyspepsia and gastric irritation. Any very slim person who is regularly purchasing laxatives should be politely asked about why they are taking the laxatives. Stool softeners are the slowest in onset, taking up to 3 days or more to have an effect. Fibre supplementation and bulk-forming agents are considered to be safe and should therefore be first-line treatments wherever possible. Stimulant laxatives are more effective than bulkforming laxatives but are more likely to cause diarrhoea and abdominal pain. There is little evidence on the beneficial effect of combining different classes of laxatives. Avoid drinks with caffeine Combining laxatives and are the most commonly abused laxatives. Their onset in action is quicker than other laxative classes, with patients experiencing a bowel movement in 6 to 12 hours when taken orally. They can be taken by all patient groups, have no drug interactions, and are safe in pregnancy and breastfeeding. However, because of their ability to cause muscle contractions, they are best avoided in pregnancy, if possible. Glycerol suppositories Glycerol suppositories are normally used when a bowel movement is needed quickly. The 1-g suppositories are designed for infants, the 2-g for children and the 4-g for adults. Bisacodyl (Dulcolax) Bisacodyl is available as tablets or suppositories and can be given to patients older than 4 years. These are as follows: adults and children older than 12 years should take 15 mg each day (two tablets or 10 mL), preferably at bedtime; children older than 6 years should take half the adult dose (7. Docusate sodium Docusate sodium is a nonionic surfactant that has stoolsoftening properties, which allow penetration of intestinal fluids into the faecal mass. Adults and children older than 12 years should take up to 500 mg daily in divided doses. In contrast to liquid paraffin, docusate sodium seems to be almost free of any side effects. They can be taken by all patient groups, have no drug interactions and are safely used in pregnancy and breastfeeding. Systematic review of stimulant and nonstimulant laxatives for the treatment of functional constipation. The relationship of presenting physical complaints to depressive symptoms in primary care patients. Constipation in an elderly community: A study of prevalence and potential risk factors. The dose for adults is initially 15 mL (adjusted upwards depending on response), for children between 5 and 17 years, the dose is 5 to 20 mL, for those between 1 and 4 years, the dose is 2. It has been reported that up to 20% of patients experience troublesome flatulence and cramps, although these often settle after a few days. Magnesium salts Magnesium, when used as a laxative, is usually given as magnesium hydroxide. Stool softeners (liquid paraffin and docusate sodium) Liquid paraffin has traditionally been used to treat constipation. However, the adverse side effect profile of liquid paraffin now means that it should not be recommended because other, safer medicines are available. Psychological factors also influence symptom reporting and consultation, and some studies have shown that patients who suffer from higher levels of stress or depression experience worse symptoms compared with other patients. Symptoms of diarrhoea and constipation appear to be linked with hyperactivity of the small intestine and colon in response to food ingestion and parasympathomimetic drugs. Excessive parasympathomimetic activity might account for mucus associated with the stool. It most commonly affects people between 20 and 30 years old, and onset after the age of 50 years is unusual. Altered defecation, constipation or diarrhoea, with associated bloating is also normally present. Many factors can contribute to disease expression and include motility dysfunction, diet and genetics. The patient might have a history of being well for a number of weeks or months in between bouts of symptoms. It is therefore not very discriminatory; however, the patient will probably have experienced similar abdominal pain in the past. Any change in the nature and severity of the pain is best referred for further evaluation. For further information on other conditions that cause pain in the lower abdomen, see the abdominal pain section. Periodicity Presence of abdominal pain Location of pain Diarrhoea and constipation 198 Gastroenterology mucus tends to be visible on the stools. Patients might also complain of increased stool frequency but pass normal or pellet-like stools. If diet is deemed a major contributor towards symptoms, food avoidance can be tried. Suspected food products must be excluded from the diet for a minimum of 2 weeks and then gradually reintroduced to determine whether the food item triggers symptoms. Both laxatives and diarrhoeals can be taken on a regular basis using the lowest effective dose. Refer for further investigation Associated with malabsorption syndromes Urgency of referral As soon as practicable A Cochrane review (Ruepert et al. However, as the authors acknowledged, antispasmodics are pharmacologically diverse and, in their review, it was not possible to include all compounds (due to a limited number of studies) at subgroup analysis. No data were reviewed for alverine, and only one trial was included that considered mebeverine. In this report, 75 trials were reviewed, involving 71 different herbal medicines versus placebo or conventional pharmacological treatment. Reduce intake of so-called resistant starch often found in processed or recooked foods. Most trials were, however, deemed to be of poor methodological quality and the authors concluded that findings should be interpreted with caution. However, the authors noted that there was potential publication bias in the review, with an overrepresentation of small positive studies; therefore, these estimates of efficacy were likely to be overestimates. Conclusions from a recent systematic review by the British Dietetic Association (McKenzie et al. Buscopan Cramps can be given to children over the age of 6 (one tablet, three times a day). It is a quaternary derivative of hyoscine, so it does not readily cross the blood-brain barrier; therefore, sedation is not normally experienced, although it might cause dry mouth and skin rash, but these are uncommon. Because of its anticholinergic effects, it is best avoided with other medicines that also have anticholinergic effects; for example, antihistamines, tricyclic antidepressants, neuroleptics and disopyramide. It should also be avoided in patients with glaucoma, myasthenia gravis and prostate enlargement. Relaxation therapy and cognitive behavioural therapy A 2009 Cochrane review concluded that cognitive-behavioural therapy might be effective, although studies included in the review were of poor quality (Zijdenbos et al. Haemorrhoids 201 known to interact with other medicines, has no cautions in its use, and can be given in pregnancy and breastfeeding, although there is a lack of detailed studies. It is associated with very few side effects, although allergic reactions have been reported, but their frequency has not been established. Metaanalysis of smooth muscle relaxants in the treatment of irritable bowel syndrome. Treatment of irritable bowel syndrome with lorazepam, hyoscine butylbromide and ispaghula husk. A general practice study to compare alverine citrate with mebeverine hydrochloride in the treatment of irritable bowel syndrome. Effects of stressful life events on bowel symptoms: Subjects with irritable bowel syndrome compared with subjects without bowel dysfunction. Alverine Adults and children over 12 years should take one or two capsules, three times a day. Like mebeverine, alverine (Spasmonal) is not known to interact with other medicines, has no cautions in its use, and can be given in pregnancy and whilst breastfeeding. It has no interactions with other medicines and can be used by all patient groups. Rash, nausea, headache, dizziness, itching and allergic reactions have been reported but their incidence is unknown. The dosage is one capsule, three times a day, before food, which can be increased to two capsules, three times a day, for severe symptoms. It can cause heartburn and allergic rashes but the incidence of these are difficult to determine. It is safe to use in pregnancy but, in theory, can decrease breast milk production. Systematic review of systematic reviews and evidence-based practice guidelines for the use of probiotics in the management of irritable bowel syndrome in adults (2016 update). Comparison of the therapeutic effect of wheat bran, mebeverine and placebo in patients with the irritable bowel syndrome. The efficacy of probiotics in the treatment of irritable bowel syndrome: A systematic review. Bulking agents, antispasmodics and antidepressants for the treatment of irritable bowel syndrome. Patients might feel embarrassed talking about symptoms, and it is therefore important that any requests for advice are treated sympathetically and away from others to avoid embarrassing the patient.

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