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To explain how systemic mycoses are diagnosed and provide an example of how fungal infections can be misdiagnosed prostate size buy 60 pills speman visa. General Concepts Primary versus opportunistic fungal pathogens the organisms that cause systemic infections are responsible for the increasing numbers of fungal infections mens health vasectomy buy speman 60 pills overnight delivery. Organisms that cause systemic infections androgen insensitivity syndrome hormones order speman with amex, or infections that affect the entire body prostate cancer life expectancy purchase genuine speman, have traditionally been divided into two categories termed primary fungal pathogens and opportunistic fungal pathogens man health 4 life purchase speman now. Primary fungal pathogens are those that are capable of causing infections in hosts that are not immunocompromised, or otherwise do not have host defense defects. Opportunistic fungal pathogens on the other hand, cause diseases that are manifested almost exclusively in patients debilitated by some other underlying non-fungal cause and whose normal defense mechanisms are impaired. Both the primary pathogens, as well as opportunists, cause more frequent and severe infections in compromised hosts. Classic Thermal Dimorphism the primary fungal pathogens grow in nature as soil saprophytes, usually in filamentous growth forms that produce conidial spores, and usually in defined geographic areas. When their conidia are inhaled, the organisms adapt to and grow in an environment that is unnatural from their perspective, and major changes in cell shape and metabolism occur. Infection for the fungus is a “blind alley” in that spores are not produced in infected hosts. Thermal dimorphism is demonstrated in the laboratory by growth as yeasts (or spherules in the case of Coccidioides sp) at 37°C and growth in hyphal form with characteristic conidia at 25°C. Mortality rates range from <1 to 75% depending on immune status of the host and therapy. A travel history for all patients exhibiting illness is now a necessity in our global interactive world and fungal infections play an important role in differential diagnosis. Tissue macrophages become activated and fuse to “wall off” fungi from surrounding host tissue by forming a granuloma. However, if the host becomes immunocompromised, the granuloma may dissociate, releasing live fungi into the tissues. General Properties the disease is caused by two highly related species, Coccidioides immitis and C. Spherules consisting of large (12 100 micron) thick-walled structures containing numerous endospores, are formed in the host. Coccidioidomycosis is endemic in certain areas of North, Central and South America. Arizona and southern California (where the disease gets it name) are endemic areas. Pathogenesis Inhaled arthroconidia lodge in the alveoli and develop into spherules in the tissues. If a protective response is not generated, endospores may gain entry into the blood, lodge in host tissue and produce spherules. A small number of cases progress to a chronic pulmonary form characterized by cavity formation. Disseminated disease occurs more commonly in those with immunosuppression, but can occur in immunocompetent adults as well. Epidemiology and Patient Populations of Special Interest Coccidioides only occurs naturally in the Western hemisphere. Hyperendemic areas include Kern, Tulare, and Fresno counties in the San Joaquin Valley of California, and Pima, Pinal, and Maricopa counties in Arizona. Natural events such as earthquakes and dust storms often stir up fungal particles and increase the number of infections. Person with occupations that expose them to soil are also at increased risk in endemic areas. The risk of disseminated disease in females increases during the third trimester of pregnancy. The increase in travel to these warm climates has extended the need for clinicians to be aware of their patients travel history and the signs and symptoms of these endemic mycoses. It is not uncommon for initial diagnoses of lung cancer to be made in patients with Coccidioides or Histoplasma infections. Organisms can be cultured on Sabouraud’s agar; demonstration of dimorphism and the tissue form is necessary for identification. The environmental form produces arthrospores that are hazardous to laboratory workers. Complement fixing IgG antibodies develop later; titers increase with disseminated disease. Antibodies disappear with resolution of disease and persist with continuing infection. General Properties the environmental growth form consists of septate, branching hyphae that bear spores (2 6 m in diameter) called microconidia. Macroconidia (8 14 microns) with characteristic morphology (tuberculate) are also produced. An important virulence property is the ability to grow within macrophages (see below). Pathogenesis Inhaled spores (microconidia) reach the small bronchioles or alveoli and germinate after 2 3 days. Yeasts proliferate within macrophages which migrate to the mediastinal lymph nodes, spleen and liver. Yeasts proliferate for 9 15 days prior to the onset of host cell mediated immune responses. Yeast cells are usually found intracellularly, but may be found extracellularly in cases of overwhelming histoplasmosis. Epithelial cells may also be infected, perhaps serving as a reservoir of infection. The ability of yeasts to survive and replicate intracellularly within macrophages is a virulence property. The yeasts increase the pH of the phagolysosome by producing bicarbonate and ammonia, which inactivates host degradative enzymes. The organism may be spread widely throughout the body within macrophages prior to the onset of protective immunity. Immunity Histoplasma may infect an immune competent individual and survive inside of macrophages and epithelial cells. Interactions between macrophages of the innate system and T cells of the adaptive system are critical for protection. Acute pulmonary histoplasmosis is a self-limited flu-like illness in immunocompetent hosts that usually goes unrecognized. Chronic pulmonary histoplasmosis is an opportunistic disease often mistaken for tuberculosis. Structural defects in the lung allow fungal colonization in abnormal pulmonary spaces. Epidemiology and Patient Populations of Special Interest the most highly endemic areas include eastern United States (Ohio, Mississippi, and St. Immunocompromised patients are more at risk to developing symptoms after a primary infection. Reactivation of disease is also a common manifestation in immune compromised individuals. African histolasmosis is an emerging infectious disease and found in central and western Africa between the latitudes 15 N and 10 S. Diagnosis For disseminated histoplasmosis, a Wright stained smear of peripheral blood is almost always positive for intracellular yeasts within macrophages. The organism may also be isolated from blood cultures Demonstration of organisms in infected tissue using a fungal stain and identification in laboratory cultures are used for diagnosis. Organisms can be cultured on special media and may be isolated from blood cultures in disseminated histoplasmosis. Demonstration of dimorphism is necessary for identification along with the presence of tuberculate macroconidia in mold cultures. General properties At 37°C, growth occurs as large yeasts with characteristic morphology. The yeasts are 5 30 microns in diameter with single buds having a characteristic broad base. The environmental distribution is difficult to define because of the lack of a specific, sensitive skin test. Sporadic cases suggest that endemic regions surround the Mississippi and Ohio river basins and are also present in the Carolinas. A high frequency of clinical disease is found following exposure of unexposed hosts to B. Blastomycosis is a common infection of dogs in endemic zones, and canine infections are often severe or lethal. Pathogenesis Humans and other mammals are primarily infected by inhalation of spores from hyphae in soil where B. At 37°C, in the host, conidial spores transform into pathogenic yeast-phase cells, which multiply within the lung and may disseminate via the bloodstream and lymphatics to visceral organs. Yeast forms replicate readily in macrophages until the macrophages are activated by cytokines from T cells. Inhaled conidia transform into yeast in the alveoli inducing an acute-inflammatory response that includes macrophages and neutrophils resulting in granuloma formation. Cell mediated immunity driven by antigen specific Tlymphocytes and lymphokine activated macrophages are key to control of the disease. Acute infection may resolve spontaneously, but progressive disease involving the lungs and/or other organs develops in many patients. Hyperendemic areas include areas with warm moist soil that is often sandy and acidic or in woody areas. Dogs are highly susceptible to blastmycoses and can be sentinels at outbreak points. A recent ongoing outbreak is occurring in Wisconsin in the Hmong population for unknown reasons. Paracoccidioides brasiliensis and paracoccidioidomycosis (South American blastomycosis) *Be aware of this organism for patients that have traveled to or are endemic to South America. There are many similarities in regards to pathogenesis and immunity with the other systemic mycoses. General Properties At 37°C, growth occurs as large yeasts with characteristic morphology. The yeasts are thick-walled with multiple buds having a characteristic wagon wheel appearance. Summary of treatment of systemic fungal pathogens Infections that are mild are likely to be cured without therapy. Immune compromised patients are at high risk for re-activation of disease and severe disseminated infections. To recognize the recent emergence of Cryptococcocis in the Northwestern United States To name encapsulated pathogenic fungi, the chemical composition of the capsule and its role in virulence. To define the major diagnostic test in use for invasive aspergillosis To define the key immunological protective mechanisms for each opportunistic fungal pathogen.

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Bioavailability the proportion of an administered drug absorbed into the bloodstream prostate neoplasm generic 60 pills speman visa, indicating the physiological concentration of that drug prostate gland enlargement discount 60pills speman fast delivery. Blind Trial mens health bodyweight workout buy discount speman on line, Singleor DoubleSee Single-Blind and Double-Blind Bronchitis Inflammation of the airways (bronchi) which connect the trachea to prostate cancer wiki order online speman the lungs androgen hormone key order speman no prescription. Bronchi are lined with stratified ciliated columnar epithelium, possess a lamina propria and are composed of longitudinal networks of elastic fibers. Calcineurin has been implicated in a wide variety of biological responses including lymphocyte activation, neuronal and muscle development, neurite outgrowth and morphogenesis of vertebrate heart valves. This cell does not mature noramlly and eventually die but it divides prolifically. Cancers arising from epithelial cells are called carcinomas and those arising from mesenchymal tissues are called sarcomas. Corticosteroids A class of steroid hormones that are produced in the adrenal cortex and are involved in many physiologic processes including among others stress responses, immune responses, inflammation, carbohydrate metabolism, protein catabolism, electrolyte homeostasis and behavior. The class includes both glucocorticoids and mineralocorticoids although corticosteroid is often used synonymously for glucocorticoid. The word is thought to originate from the Greek "koryza" which means boiling over from the head. Crossover Trial A clinical study in which subjects receive two or more drugs separated by drug-free periods. This can result in structural and functional abnormalities including changes in vascular permeability and gene expression in the retina. Usually the comparison is between an experimental drug and a placebo or a standard comparison agent. See also Upstream Dysplasia Pathological abnormality of development such as an alteration in size, shape and organization of adult cells. See also Efficacy Efficacy the therapeutic effect of an intervention as demonstrated or observed in a controlled setting, such as a clinical trial. Also known as vomiting, this reflex can be triggered by various endogenous or exogenous factors. Epithelium the cellular avascular tissue layer that covers all free cutaneous, mucous and serous surfaces. G G-Protein One of several mediators of activated cell surface receptors and their enzymes and ion channels. These second messengers in turn regulate the behavior of other intracellular target proteins, leading to the desired cellular response. G-Protein-Coupled Receptor Cell surface receptors that are coupled to G proteins. Activation can result in potent anti-inflammatory activity as well as regulation of several cardiovascular, metabolic, immunologic and homeostatic responses. It regulates several cardiovascular, metabolic, immunologic and homeostatic responses. Headache Diffuse pain experienced in various regions of the head, not limited to the area of distribution of any single nerve. The name is derived from its capacity to agglutinate red blood cells at neutral pH. There are 15 hemagglutinin (H) subtypes of which only 3 (H1, H2 and H3) are associated with human illness. The surface coat is added on in the cytoplasm and, for unknown reasons, is produced in large quantities. Symptoms of hepatitis C may not manifest until the chronic stage and include jaundice, fatigue, abdominal pain, loss of appetite, intermittent nausea and vomiting. Infection with hepatitis C has also been associated with increased risk of primary hepatocellular carcinoma. The virion consists of a nucleocapsid core and two envelope proteins within the lipid bilayer. Hepatitis, Fulminant A rare syndrome usually associated with hepatitis B and, in rare cases, with hepatitis A or E. The liver parenchyma undergoes massive necrosis and the organ size decreases significantly. The virus is spread via sexual contact with an infected individual, exposure to contaminated blood. Examples are hyaline cartilage and hyaline hyphae present in fungus such as Aspergillosis spp. I Immune System An integrated group of various cell types and the soluble molecules they secrete. Immunization, Passive A means to produce a temporary immune response against an infectious agent or toxin by giving preformed antibodies actively produced in another person or animal in the form of serum or gamma globulin. Immunocompromised Used to describe persons with an underdeveloped (as in the very young) or impaired immune system. Immunogenic See Antigenic Immunoglobulin (Ig) A subgroup of globulins that are classified as alpha, beta and gamma according to lipid or carbohydrate content and physiological function. Serum Igs belong to the gamma group and constitute a family of glycoproteins that bind antigens. Immunoglobulin A (IgA) Major class of immunoglobulins found in mammalian serum, body fluids. The Fabs include the antigen combining sites while the Fc region consists of the remaining constant sequence domains of the heavy chains and contains cell binding and complement binding sites. IgGs act on pathogens via agglutination, opsonization, activation of complement-mediated reactions against cellular pathogens and/or neutralization. IgG2 differs from the rest in that it cannot be transferred across the placenta and IgG4 does not fix complement. Immunologic Memory the capacity of an organism to mediate effective responses to previously encountered antigens. They have not metastasized beyond the original site where the tumor was discovered. Local reactions at the site of injury cause immune cells to be recruited into the area, leading to the destruction and removal of the affected tissues and to wound repair. Necrotizing bronchitis and interstitial pneumonia are seen with severe influenza and account for the susceptibility of patients to secondary bacterial pneumonia due to Streptococcus pneumoniae, Haemophilus influenzae and Staphylococcus 44 aureus. Inoculum Cells or viruses added to start a culture or infect a culture of cells, respectively. Interferons have been classified into three main subtypes (alpha, beta and gamma) based on interaction with antibodies, chemical properties and cellular origin. Both isotypes are secreted by monocytes, macrophages and/or accessory cells early during an immune response and they activate T and B cells, stimulate T cell proliferation and enhance T and B cell responses to antigens. These cytokines are associated with many immune regulatory effects and are associated with mediation of proinflammatory and allergic responses. It is the only cytokine that can induce T helper 1 (Th1) and T helper 2 (Th2) cell polarization depending on immunologic context. It is currently under investigation as an immunotherapeutic cancer agent and as an angiogenic factor. In particular, this cytokine is suspected to be involved in the activation and maintenance of the Th17 subset of inflammatory T cells. It may also be involved in the pathogenesis of asthma by enhancing the effects of other cytokines and inflammatory mediators. The effect of including this gene can be provide information about a specific disease or condition. Leukocyte A member of a heterogeneous cell population, also known as white blood cells, found in various tissues and circulating blood that is formed in myelopoietic, lymphoid and reticular portions of the reticuloendothelial system. Pathologic lymphocytosis occurs in chronic inflammation, recovery from acute infection, lymphocytic leukemia and hypoadrenocorticism and indicates a strong immune stimulus of chronic duration from a bacterial infection, viremia or immune-mediated disease. Symptoms of infection include flu-like illness with signs and symptoms of pneumonia. Mutation Damage or change in a gene or chromosome so that transcription is altered. An example is Mycoplasma pneumoniae is responsible for pneumonia in humans and some domestic animals. The ribonucleosides are adenosine, guanosine, cytidine and uridine and the deoxyribosides are deoxyadenosine, deoxyguanosine, deoxycytidine and deoxythymidine. This staus gives the manufacturer a seven-year right to exclusively market the compound. Pandemic A global epidemic of an especially strong and highly infectious virus, newly infectious for humans, with the potential to cause many cases of illness and death due to a lack of acquired immunity in the human population. The trials evaluate doses determined in animal studies that are only 1/100th of those expected to be required for therapeutic effect. It also occurs in individuals treated with steroids, the elderly or premature or debilitated babies. Pneumonia is a form of acute respiratory infection that inflames the alveoli in the lungs which in healthy individuals fill with air during inhalation. When infected, these air sacs may fill with fluid or pus, leading to symptoms such cough with phlegm, fever, chills, chest pain and difficulty breathing. The mixture is cooled to 60fiC, allowing the artificial primers to wind to the ends of the template chains. Polymerization the linkage of glucose units into chains in cellulose or starch molecules. Polymorphonuclear Leukocytes White blood cells with multilobed nuclei and cytoplasmic granules. They include neutrophils (granules stain with neutral dyes), eosinophils (granules stain with eosin) and basophils (granules stain with basic dyes). Preclinical Studies Experimental in vitro and/or in vivo testing in animals performed prior to clinical studies to determine the biological activity and safety of an agent. Prognosis An assessment of the likely outcome of the disease judged from general experience of the disease and the age and condition of the individual patient. Prophylaxis, Active Administration of an antigenic agent to actively stimulate an immune mechanism. See also Protease Q R Recombinant Describes a cell or an individual with a new combination of genes not found together in either parent; it usually refers to linked genes. Rhinitis An inflammation of the nasal passage which is characterized by frequent and/or repetitive sneezing, runny or congested nose and itchiness of the nose, eyes and throat and may also be associated with headache, impaired smell, postnasal drip, conjunctival symptoms and sinusitis. These viruses are responsible for the common cold virus and foot-and-mouth disease. They can be divided into endoribonucleases and exoribonucleases which include further sub-classes. Ribonucleotide A nucleotide in which a purine or pyrimidine base is linked to a ribose molecule. Ribosomes are free in the cytoplasm and often attached to the membrane of the endoplasmic reticulum.

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It is important that the patient’s overall health be assessed at each treatment visit and that any questions resulting from the patient’s or their caregiver’s reading of the Medication Guide be discussed. Instruct patients of the importance of contacting their doctors if they develop any symptoms of an infection, including tuberculosis and reactivation of hepatitis B virus infections. Advise patients to report any symptoms of a cytopenia such as bruising, bleeding or persistent fever. If you do not know if you have lived in an area where histoplasmosis, coccidioidomycosis, or blastomycosis is common, ask your doctor. If your baby receives a live vaccine within 6 months after birth, your baby may develop infections with serious complications that can lead to death. Make sure to discuss with your doctor when you will receive infusions and to come in for all your infusions and follow-up appointments. Tell your doctor about all the medicines you take, including prescription and non-prescription medicines, vitamins, and herbal supplements. These include any other medicines to treat Crohn’s disease, ulcerative colitis, rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis or psoriasis. Keep a list of your medicines and show them to your doctor and pharmacist when you get a new medicine. In some cases, patients have died as a result of hepatitis B virus being reactivated. Liver Injury In rare cases, some patients taking infliximab products have developed serious liver problems. Tell your doctor if you o have a fever that does not go away o look very pale o bruise or bleed very easily Nervous System Disorders In rare cases, patients taking infliximab products have developed problems with their nervous system. Signs of an allergic reaction can include: o hives (red, raised, itchy patches of skin) o high or low blood pressure o difficulty breathing o fever o chest pain o chills Some patients treated with infliximab products have had delayed allergic reactions. The delayed reactions occurred 3 to 12 days after receiving treatment with infliximab products. Tell your doctor if you develop red scaly patches or raised bumps on the skin that are filled with pus. The side effects that happened more in children were: anemia (low red blood cells), leukopenia (low white blood cells), flushing (redness or blushing), viral infections, neutropenia (low neutrophils, the white blood cells that fight infection), bone fracture, bacterial infection and allergic reactions of the breathing tract. You can find more information about this on the Pharmaceutical Services Negotiating Committee website The time scale is only a guide and your own professional judgement on the severity of the symptoms and the general health of the patient will be useful to guide them. By undertaking these activities, you will find that the practical tips and learning points from them will prove extremely valuable in your day to day work as they allow you the opportunity to put your learning into practice. When you see this box in the text, an exemplar case study is presented to you to read and refiect on. These case studies describe real life scenarios that have been presented to community pharmacists and how the pharmacist responded. This will also allow you opportunities to put your learning into practice as you work through the course. Since each module covers a discreet topic, you can complete the modules in any order you wish. Pharmacists and pharmacy technicians in Scotland will also be able to keep up to date through websites such as In the presence of such symptoms investigations would be performed to exclude oesophageal and gastric carcinoma. Alginates (see below) H2 antagonists such as ranitidine and cimetidine, suppress acid secretion as a result of histamine H2 receptor blockade. It can travel down either arm but this is not a very useful distinguishing feature. Practical Tips It is not known whether losing weight, head of the bed in GorD and found stopping smoking, reducing the intake small improvements in self-reported of alcohol, caffeine or fatty foods will symptoms. Colic is excessive crying in an otherwise healthy baby and is defned as being present when babies cry for at least three hours a day, for three days a week, for at least three weeks. Anti foaming agents, simethicone, for example, contained in Dentinox and Infacol . It is not systemically absorbed and therefore is safe from birth and may be an option to offer to a parent who is keen to give a treatment. It can particularly be a problem during pregnancy, with prevalence reported as high as 38%. Differential diagnoses Intestinal obstruction, such as faecal impaction, requires referral. Treatment options the bnF recommends that laxatives should generally be avoided except where straining will exacerbate a condition (such as angina) or increase the risk of rectal bleeding as in haemorrhoids. Drug treatment may be appropriate if these have not helped, or if there is druginduced constipation which cannot be resolved by reviewing the causative drug. Gastro-IntestInal system the gut and increasing faecal mass, therefore stimulating peristalsis. Stimulant laxatives, for example, senna and bisacodyl, act by stimulating colonic nerves to increase intestinal motility. Liquid paraffn is classed as a stool softener but is not now recommended due to anal seepage, small risk of lipoid pneumonia (rare) and malabsorption of fat-soluble vitamins. Special considerations: constipation in children many children suffer from constipation at some time in their lives and it will generally resolve without treatment. In these circumstances, there is limited evidence to support the use of a stool softener, along with lifestyle advice. Laxative dependence Prolonged laxative use leads to the degeneration of the myenteric plexus of the colon. Diarrhoea is a common side effect of many prescribed drugs and this should be ruled out or the need for ongoing treatment reviewed. Ideally diarrhoea should be referred to a include fruit juices and soups, which doctor for a routine appointment. Traveller’s diarrhoea People may seek advice in advance, about treatment of diarrhoea whilst on holiday. Persistent or bloody diarrhoea on return from travel should be referred for investigation and it is useful to ask travellers what part of the world they were travelling in. It is more prevalent in women and frst cases are often reported from the age of 30 to 50 years. If the rectal bleeding is severe or associated with any systemic symptoms then urgent referral is needed. Differential diagnoses other conditions which may present with similar symptoms are diverticulitis, anxiety, premenstrual syndrome and endometriosis. However, the nature of the condition is that it may ‘fare up’ now and again and sufferers may seek treatment. Anti-spasmodic agents, eg mebeverine, alverine citrate are used for abdominal pain. They may involve the skin lined lower anal canal and the external haemorrhoidal venous plexus to become visible externally. Haemorrhoids are associated with pain and discomfort, mucous discharge which can irritate the perineum and partial incontinence. Pregnancy, diarrhoea, constipation, prolonged straining and hereditary factors are all associated with the development of haemorrhoids. For patients aged 60 years and over, refer if symptoms present alone or together and have persisted for longer than 3 weeks. Bulk forming laxatives may be a useful management option in order to reduce the need for straining on defecation. Her new job has disrupted her normal eating patterns as she is on the move a lot more and doesn’t eat as regularly or as healthily as usual. It is likely that this is a case of irritable bowel syndrome, because of the age, presence of constipation and bloating, and stress of job change and lifestyle as a possible precipitating factor. Drinking plenty of fuids and getting into healthier eating habits will also be useful. In patients aged 60 years and over, either symptom presenting for longer than six weeks requires referral. Cough may be classifed as • productive: phlegm is produced and the cough refex expels the phlegm • dry: no phlegm production cough is most commonly associated with upper respiratory tract infections and is usually mild and self-limiting. Differential diagnoses in asthmatics, cough may be a sign of poorly controlled asthma therefore it is important to gain a good impression of the patient’s understanding of their condition. Anti-tussives containing codeine or opioid derivatives are not recommended in children and should be avoided altogether in children under the age of 6 years. Sedative antihistamines such as diphenhydramine suppress the cough and cause drowsiness (which may refect their main mode of action). Diphenhydramine) the effectiveness of these medicines in will no longer be available for children children aged over 6 years. Paracetamol is the frst line choice; its anti-pyretic and analgesic properties will help to relieve symptoms. Vitamin C in large daily doses (more than 1g daily) may provide a modest beneft in terms of reducing the duration of cold symptoms. Echinacea: recent randomised controlled trials have shown no beneft in either adults or children. Zinc lozenges: there is no strong evidence of effcacy although interest has grown in zinc as a treatment for the common cold and many claims for its effectiveness have been made. Database of Systematic Reviews 2007, Issue 1 MeReC: the management of common infections in primary care Volume 17 Number 3 December 2006 40 Responding to Minor Ailments 3. Differential diagnoses persistent (perennial) allergic rhinitis, where symptoms occur all year round, is mainly due to house dust mite or domestic pets. Azelastine (Aller-eze ) is licensed for sale for adults and children over the age of 5 years. Where rhinitis is the main symptom, intranasal corticosteroids should be the frst line choice as they are more effective than oral antihistamines in reducing total nasal symptoms particularly nasal congestion and sneezing and can also improve eye symptoms. Sodium cromoglicate is a mast cell stabiliser available as eye drops and nasal spray. Homoeopathic treatment: some trials have found homoeopathic treatment to be better than placebo but further trials are needed. Special considerations: Pregnancy pregnancy often exacerbates rhinitis but care is needed in selection of drugs to relieve symptoms.

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