Michele P Mohajer BM BS FRCOG MD
Where anxiety underlies social difficulties arthritis in neck causing numbness cheap indocin online, carries increased risks of mortality and morbidity yucca for arthritis in dogs purchase generic indocin online. Having epilepsy may mean coping with additional children and young people may benefit from individual and group psychological interventions aimed hidden deficits such as language and memory problems arthritis in lower back and groin indocin 75mg, or with other co-morbidities rheumatoid arthritis in feet symptoms purchase indocin with mastercard. For some, these may People with epilepsy may need guidance and practical support to increase their social connections. But for others, epileptic attacks may involve bizarre behaviours, dis to rted Community engagement activities have been found to be an effective way of establishing and broadening awareness and perception, and embarrassing aspects such as incontinence. Sport and other leisure activities provide social engagement opportunities and blanket may erode self confidence and self-esteem. The failure of surgical treatment, particularly when this follows several years of freedom from seizures, Neuropsychol. Anxiety and depression are over-represented in individuals with epilepsy but are under-treated 23. A survey of professionals identified managing the psychological and emotional the perspectives of professionals. Improved training of health professionals is indicated, as are resources for public awareness campaigns. Emotional adjustment difficulties are more likely to develop in the context of incomplete and inaccurate information. People need pertinent, individually tailored information about seizures, treatment and lifestyle choices. An earlier age of seizure onset is correlated with poorer cognitive function although the evidence base is compromised by methodical heterogeneity with relatively few prospective studies. Children with epilepsy have significantly higher rates of school-based interventions such as summer school and use of tu to rs2. Berg et al reported that 25% of children with new onset idiopathic epilepsies require special education services prior to clinical seizure onset3. The association between specific epilepsy syndromes and cognitive comorbidities may better reflect the neural network phenotype. The cognitive profile is broader than language areas with subtle deficits in attention and executive functioning5. However, verbal and visual memory, processing speed, naming and language function are also compromised suggestive of a network model extending beyond prefrontal circuits6. The cause of epilepsy and the associated neuropathology often dictates the cognitive phenotype. For example, periventricular nodular hetero to pia is associated with both epilepsy and dyslexia. Aberrant cortical to cortical white matter integrity has been found to be correlated with poor reading fluency8 whilst abnormal connections between the hetero to pia and overlying cortex was related to longer seizure duration9. However, extratemporal cortical structural abnormalities in frontal, parietal and occipital cortex are reported as well as in subcortical and cerebellar regions with cognitive deficits extending beyond memory and incorporating executive function10,11. Age related brain development and atrophy contribute to the cognitive vulnerability in epilepsy. In healthy children, grey matter volumes decline with concomitant white matter volume increases12. However, children with epilepsy often exhibit abnormalities in brain structure at or near the time of seizure onset and an altered development trajec to ry early in the course of epilepsy13. However, it remains uncertain as to what degree of altered brain development is causal to cognitive abnormities and whether these changes are permanent upon remission of seizures and cessation of treatment. Dynamic mapping of human cortical 15 development during childhood through early adulthood. Patients with epilepsy have a lower baseline cognitive reserve circuitry and executive dysfunction in recent-onset juvenile myoclonic epilepsy. Neuropathology of the blood-brain barrier and pharmaco-resistance in human epilepsy. Neurofibrillary tangle pathology and Braak staging in chronic epilepsy in relation to traumatic brain injury and hippocampal sclerosis: a post-mortem study. Chronic temporal lobe epilepsy: a neurodevelopmental or progressivelydementing diseasefi Cognitive prognosis in chronic paroxysmal depolarizations of neurons producing a rapid succession of action potentials lasting temporal lobe epilepsy. Enhanced oscilla to ry activity in the hippocampal-prefrontal network is related to short-term memory function after early-life seizures. For example, in rats exposed to early life seizures, impairments in hippocampal-dependent tasks are noted in adulthood. Cognitive rehabilitation in adults including simple external aids such as diaries, calendars or computer-assisted apps along with online or face 2 face self-management programmes can be helpful, although the evidence for consistent and sustained benefit is mixed. Language in benign childhood epilepsy with centro-temporal spikes abbreviated form: rolandic epilepsy and language. Neuropsychological profile of patients with juvenile myoclonic epilepsy: a controlled study of 50 patients. A structural basis for reading fluency: white matter defects in a genetic brain malformation. Neurodevelopmental vulnerability of the corpus callosum to childhood onset localization-related epilepsy. Following this, edi to rials and reviews have been published on a regular basis, all highlighting what was hither to a lack of familiarity with the current literature and urgent need for evidence-based guidelines. There seems now to be little doubt that epilepsy patients are at increased risk of fractures and metabolic bone disease, to an extent that we should be at least discussing with our patients. But many issues remain unresolved, including which of the multiple mechanisms are most important, whether newer drugs offer advantages over older drugs, how best we should identify those most at risk, and what preventive treatment should be offered. This chapter reviews the currently available literature and discusses recommendations based on this. Definitions and assessment the primary symp to m of metabolic bone disease is an increased incidence of fracture. There is considerable individual variability, of which 80% is due to hereditary fac to rs including sex and ethnicity (Caucasian women have the highest incidence of osteopenia, with Afro-Americans relatively protected)8. Serum levels of 25-hydroxy vitamin D are usually measured, and the lower limit of normal is now 30nmol/L, but a recommendation that in individuals with other risk fac to rs, including those on antiepileptic drugs, a level of at least 50nmol/L should be maintained. Thus, populations who are housebound/institutionalised, or those who avoid sunlight for cultural reasons, will by default rely more on dietary sources and will be at risk of deficiency. Intestinal, liver, renal or cardiopulmonary diseases are also risk fac to rs due to secondary effects. Importantly, many of these did not have known risk fac to rs and thus would have been missed without screening. The bone isoform of serum alkaline phosphatase is the most commonly measured but is relatively insensitive as a screening test. There are several serum markers of bone formation, including osteocalcin (a non-collagenous matrix protein secreted by osteoblasts) and circulating peptides of type I collagen. Similarly, serum levels of peptides representing degraded products from osteoclastic activity. Bone turnover is increased during growth periods and fracture repair and such markers have been correlated with his to logy from bone biopsy in both health and disease16. Further research is required before they can be used to detect at-risk individuals or moni to r treatment, so they will not be discussed here. Values can be obtained for whole bones or joints, or bone cortex or trabecular bone alone. Values taken from sites of potential fracture, ideally the to tal hip There are many reasons why patients with epilepsy might be at increased risk of bone disease, including score, are considered the most valid. The spine is not suitable for diagnostic purposes but can be used reduced exposure to sunlight (housebound/institutionalised), frequent falls, and lower physical activity to follow treatment effects. Results are usually expressed as T scores, representing the number of standard levels in patients with active epilepsy. It found the overall incidence of fractures to be doubled in epilepsy patients compared to age and sex matched controls. Although it has high specificity, the sensitivity is low (approximately 50%)12, 24,25 this was also the conclusion from recent meta-analysis studies, with the highest relative risks meaning that half of fractures will occur in patients said not to have osteoporosis on this measure.
Other respira to ry support modalities should gastros to my or oesophageal replacement surgery (gastric pull-up) be instigated as required arthritis diet not to eat discount generic indocin canada, according to standard indications arthritis medication beginning with m buy cheapest indocin and indocin. The aliphatics are not readily infection (persistent fever or a fever that develops after 24 hours arthritis knee levels order indocin 50mg amex. The aspirated hydrocarbons Paraquat ingestion remains a problem in a large number of countries curing arthritis diet book purchase indocin amex. This Most of these cases are intentional suicide attempts (73% in a can occur even in the absence of vomiting or impaired consciousness Malaysian study) or occupational exposure and therefore not that and as little as 1ml aspirated hydrocarbon can result in a chemical frequently seen in the paediatric population. After oral ingestion, patients develop a severe gastroenteritis with oral, oesophageal and Parafn is often sold or s to red in unlabeled containers which may be gastric ulceration. As little as 10ml may be of a burning sensation in the mouth and the bad taste of the liquid. Tose who survive the initial phase develop pulmonary fbrosis page 280 Update in Anaesthesia | Treatment strategies are aimed at prevention of absorption, deactivate organophosphates) enhancement of elimination and prevention of pulmonary damage. Close observation is required as rebound organophosphate to xicity may occur due to their lipid solubility. Low FiO2 should be used as high concentrations carbon monoxide of oxygen lead to worse pulmonary to xicity. Paraquat accumulates Carbon monoxide is produced through incomplete combustion in the lung where it generates superoxide anions through the processes. It also reduces oxygen delivery by The organophosphates and carbamates are cholinesterase inhibi to rs, competing with O2 for binding to Hb and altering the shape of the thereby eliciting cholinergic signs and symp to ms. They can be absorbed HbO2 dissociation curve (making the curve less sigmoidal, a shift to by ingestion, inhalation or via the skin. Tus a less severe clinical picture of shorter Carbon monoxide causes injury by hypoxia, with symp to ms referable duration is presented. Neurological of prolonged efect) recovery depends on the duration of hypoxic coma. Also probably the commonest life, but access and transfer times to a hyperbaric chamber make drug to be ingested deliberately in overdose. Pulmonary oedema, acute renal failure, hypokalaemia, treatment of arrhythmias and correction of acid/base and hypoglycaemia and hypothrombinaemia may also develop. Diazepam Management of aspirin / salicylate poisoning 5-10mg iv is used to control the fts. In overdose, salicylates may form concretions in the s to mach and delay absorption. Patients need to be followed up as some of the neuropsychiatric complications may take weeks to develop. Ideally should be done on admission this may cause direct lung, skin and conjunctival injury. Most commonly seen in victims of smoke inhalation as a combustion product of polyurethane foams. Patients surviving to reach hospital are unlikely to have sufered signifcant poisoning. Patients present with vomiting, Paracetamol ingestion is common but seldom leads to severe to xicity diarrhoea, abdominal pain, haematemesis and rectal bleeding in the in children due to the diluted concentration of the paediatric early phase (0-2 hours). The children at risk are those with glutathione (up to 12 hours) during which a deceptive recovery occurs. This depletion, such as children with cystic fbrosis, adolescents with is followed by a life-threatening period during which coma, fts, eating disorders and those also on enzyme inducing agents such as jaundice, hepatic failure renal failure, clotting abnormalities, anticonvulsants. The liver is the main target organ in paracetamol hypoglycaemia and cardiovascular collapse may occur. Patients are generally asymp to matic up to 24 hours post Patients alive 72 hours after ingestion usually make a full recovery. Hepatic Late complications of gut stricture, gastric fbrosis and pyloric necrosis becomes apparent in 24-36 hours with right subchondral obstruction have been reported. Oral methionine may be used if the patient is allergic to acetylcysteine and is also a suitable alternative in remote areas Give 1 gram im every 6-12 hours for children (2g for if vomiting is not a problem. The clinical features can be divided in to hyperglycaemia, hypotension and seizures. Lignocaine components/com virtual library/media/0bcfbeac632c1b044303ba appears to have little efect on ventricular ec to py. Nervous system to xicity includes drowsiness, Chemical Safety: Poisoning Prevention and Management ( Cardiovascular to xicity includes sinus tachycardia, hypotension, conduction abnormalities and arrhythmias. Safety incidents across the breadth of [Haynes et al] anaesthesia [not just paediatrics as for Wake Up Safe] are shared from across England and Wales. Links from here to Update in Anaesthesia, to application/needs assessment for a Lifebox pulse Tu to rial of the Week, and many other resources. Keeping a logbook of your cases can help you refect on and improve your practice, as well as being a requirement in some countries. The results Illustrated online tu to rials on a range of regional anaesthesia that children given fuid at maintainance rate did better than techniques. Requires free registration [email address iPhone and iPad users have a wide choice of medical apps. Works with Google Chrome and Firefox phone apps are more limited, but Android versions of some of these browsers but not Internet Explorer. Specifcally paediatric anaesthesia Free copies of latest guidelines available from the itunes onlinelibrary. Review and Examples of free issues [accessed 08/08/2013] include: screenshots at.
In addition treat arthritis at home buy cheap indocin 25 mg on line, pilots and other licence holders now have better access to relevant information than was the case previously arthritis pain behind knee indocin 50mg. However rheumatoid arthritis memes purchase genuine indocin, the chapter is retained in this Third Edition of the Manual as it may provide useful information to some arthritis in dogs glucosamine dosage proven 75 mg indocin, especially inexperienced or trainee pilots. Many deficiencies can be compensated: short sight, for example, by wearing spectacles or contact lenses. The pilot himself has responsibility for determining his fitness prior to entering the cockpit for flight. Conditions such as acute infections, anaemias and peptic ulcers are disqualifying while they last. Your brain has no built-in alarm system to let you know when you are not getting enough oxygen. The symp to ms are slow but progressive, insidious in onset, and become marked at altitudes above 10 000 ft (3 300 m). Typical regulations demand a minimum of 8 to 24 hours of abstinence from alcohol before reporting for duty. Your body metabolizes alcohol at a fixed rate, and coffee or medication does not affect this. Following general anaesthesia, a period of at least 48 hours should be spent on the ground. Pilots should have an instruc to r demonstrate manoeuvres which will produce disorientation. Once experienced, later unanticipated incidents of disorientation can be overcome as long as instruments (for pilots trained to use them) or reliable ground references are available. Light, flickering at certain frequencies, from four to twenty times per second, can produce unpleasant reactions in some persons. It may take several days to fully recover and clear the body of the carbon monoxide. To avoid eye fatigue in bright light, use colour-neutral (rather than coloured) sunglass lenses as this will permit normal colour discrimination. If you need to use correcting lenses for good vision (for near or distant vision) make sure you keep a spare pair of spectacles within easy reach, so that you can easily find them if you lose or break your first pair, or develop problems with contact lenses if you wear them. Certain persons (whether pilots or passengers) have difficulty balancing the air pressure on either side of the ear drum while descending. Problems arise if a head cold or throat inflammation keeps the Eustachian tube (from the middle ear to the throat) from opening properly. The development of panic in inexperienced pilots is a process which can give rise to a vicious circle with unwise and precipi to us actions resulting in increased anxiety. As a general rule, individuals should not fly within 12-48 hours following diving using compressed air, the difference depending mainly on the duration and how deep the dive(s) were. Occasionally a medical emergency arises as a result of compressed air diving, when a diver has been unable to adequately decompress before surfacing. In some of these cases air-evacuation is the only feasible method of getting the patient to a recompression chamber in time to treat the condition. Select 100 per cent oxygen, check the oxygen supply, oxygen equipment and flow mechanism. If the symp to ms persist, consciously slow the breathing rate until symp to ms clear and then resume normal breathing rate. An infected air traveler can be virtually anywhere on earth within a day or two, often within the incubation period of many important communicable diseases, such as the various sub-types of influenza. Public health specialists (supported by infectious disease specialists) are experts in aspects of communicable disease such as incubation periods, virulence, disinfection, diagnosis and protective measures, and they are likely to play the lead role in any national pandemic preparedness plan. Aviation medicine specialists clearly need the advice of such experts when developing a preparedness plan specific to aviation. In particular, the aircraft cabin environment varies from other modes of transport with respect to aspects such as reduced air pressure, reduced humidity and specialized environmental control systems. However, when read from an aviation perspective, these guidelines appeared to provide insufficient detail to enable the aviation sec to r to adequately manage individual cases that might be detected on board an aircraft in flight; nor did the guidelines explain how aviation could continue to operate in the event that staffing at airports and on aircraft was dramatically reduced because of the effects of illness. The United States Centers for Disease Control and Prevention also provided support. This Annex deals primarily with global harmonization of cus to ms and immigration procedures and associated health-related to pics. The Declaration of Health requires the pilot-in-command to identify individuals on board who may be suffering from a communicable disease. Whilst recording such information on paper can be useful, a better way would be to utilize electronic systems, with the potentially infected traveler completing the required information on line. One of the main aims of the project is to foster development of communication links and collaborative partnerships between the public health and aviation sec to rs. Depending on the communications facilities available to the airline representative or operating agency, it may not be possible to communicate with the aircraft until it is closer to its destination. Urinary symp to ms are usually combined with cloudy or even bloody urine and pain (lower abdomen, groin and perineum). The different spectrum of presentation is currently grouped in four distinct categories (acute bacterial prostatitis, chronic bacterial prostatitis, chronic pelvic pain syndrome and asymp to matic) that combine symp to ms and etiology. There is a clear need for awareness to properly diagnose prostatitis patients and further research is required to identify potential new strategies for treatment and eventual chemo prevention in high-risk subgroup of patients. We also expose deficits in the literature and underscore the need to incorporate new research techniques to properly identify the wide spectrum of clinical presentation in to more specific phenotypes and provide the best treatment possible [1,2]. In sexually active men, Neisseria gonorrhoeae and Chlamydia trachomatis should also be considered as pathogenic agents. Transrectal prostate biopsies can cause infections which have been reduced to between 0. However, the incidence of prostatitis has increased mainly due to fluoroquinolone-resistant bacteria and extended spectrum beta-lactamase producing E. Chronic pain may start after chronic peripheral inflammation or nerve injury and remain subsequent to tissue healing, becoming harmful. Chronic pelvic pain includes a combination of visceral and referred somatic pain and also the involvement of central sensitization in the spinal cord and brain, especially on the dorsal horn of the spinal cord. These findings suggest that the chronic presence of pelvic pain leaves specific brain neural imprints that persist for years. Central sensitization is caused by chemical and ana to mical changes leading to hyperexcitability in the dorsal horn cells from persistent afferent C fiber bombardment by painful stimuli. Chronic pain is induced and maintained by media to rs released by immune cells (macrophages, lymphocytes, and mast cells), neurons and glial cells that trigger peripheral and central sensitization, that, when activated, secrete cy to kines that recruit more leukocytes augmenting tissue cell infiltration and enhancing prostate inflammation and chronic pelvic pain development. Many investiga to rs have proposed neuromuscular etiology in inflamma to ry and non-inflamma to ry prostatitis.
Infestation may also occur by exposed again arthritis in hands fingers symptoms cheap indocin 25 mg on-line, usually within one to four childcare centres and residential sharing clothing arthritis pain at night order indocin overnight delivery, to wels arthritis in my fingers symptoms indocin 25 mg for sale, and bedding arthritis relief xtreme buy discount indocin 50 mg. Linen, blankets and clothing Residents and/or staff should be treated exposure to scabies and be treated can also be dry cleaned or placed in a with Permethrin 5% cream. Close hour, or sealed in a plastic bag for one including face, hair, behind ears and contacts include: week before laundering. In these circumstances the Everyone identified as needing treatment use of to pical steroids. Betnovate should ideally be treated within the same cream, Elecon cream) may be necessary. Early patients or those experiencing rapid transmission from children to adults and investigations have pointed in the clinical deterioration, both of which no reports of transmission from children direction of certain animal species (palm usually occur during the second week of to other children. For the different methods available for probable cases will be placed under this reason only close contacts are disinfecting include: active surveillance and isolated in an sought to implement public health appropriate setting. Two-thirds of the cases and most of the before eating and food handling and after Complications include to xic megacolon deaths worldwide are in children less to ilet use, especially in young children and reactive arthritis. Treatment is usually supportive for mild Illness is usually self-limited and lasts Reservoir illnesses. These cases should obtained, or until at least 48 hours after be reported immediately to the the diarrhoea has ceased and rigid Department of Human Services. The remaining two are firm papules on the second day of the known as haemorrhagic and malignant rash. This was a direct Common smallpox begins with maximal size and the lesions then consequence of the Global Smallpox symp to ms of fever (100%), headache commence to flatten. Preventive measures clear that an outbreak would be of the Australian Government Department Body fluids are also infectious and care is extreme public concern requiring action of Health and Ageing has s to ckpiled a needed for the disposal of clinical waste. The smallpox outbreak, preparedness, every effort must be made by relevant Department will dispatch a smallpox care response and management. Staphylococci have prolonged School exclusion: for impetigo due to to xins in to the blood stream. Added All known or suspected cases in a infection control precautions may be nursery should be isolated. Lesions must be Routine contact tracing is not usually covered with a watertight dressing. There is an increased risk of than 4 per 100 000 per year, with a case isolation of the organism from infected infection in varicella (chickenpox). A questionnaire is sent to the stillbirth, premature delivery and becoming more commonly used for diagnosing doc to r to collect additional perinatal death. Dark field microscopy is a difficult in response to syphilis and also to a Infectious agent technique and requires an experienced relatively large number of other the spirochaete Treponema pallidum, opera to r for reliable results. The minimised by the screening of all extent of contact tracing depends on the Incubation period donated blood in Australia. The incubation period is from ten days to Period of communicability For primary syphilis, all persons having three months and is usually three weeks. It is the faeces of an infected person or Taenia saginata infections are often commonly seen in parts of Latin through the ingestion of contaminated asymp to matic apart from the anal America, Africa, South East Asia and food or water. Many tissues asymp to matic, but the larval stage of Period of communicability and organs may be infected by the larval T. Eggs may remain Method of diagnosis Humans are the definitive host for both viable in the environment for months. The blue book: Guidelines forthe control of infectious diseases 225 Tetanus Vic to rian statu to ry requirement Laryngeal spasm is a very serious Tetanus is still common in developing Tetanus (Group B disease) must be complication which may occur at any countries with low immunisation rates notified in writing within five days of stage and can cause sudden asphyxia. Clinical features Labora to ry confirmation of tetanus Reservoir Tetanus is an acute, potentially fatal infection is often difficult. For further information on the management of bites and other tetanus prone wounds, consult the current edition of Therapeutic guidelines: antibiotic (Therapeutic Guidelines Limited). In general, mainly through eating small infected Infectious agent to xoplasma-specific IgG antibody mammals including rodents and birds, Toxoplasma gondii is a pro to zoal disease. Tissue cysts remain can reactivate in the immunosuppressed Testing paired sera taken two weeks viable for long periods. In early Toxoplasmosis occurs worldwide in particularly kittens, or other animals. Transplacental Toxoplasmosis acquired after birth severe complications for the foetus. Infection later in Tissue cysts in meat remain infective for Cats should only be fed with dry, canned pregnancy results in a higher infection as long as the meat is edible and under or boiled food and should be discouraged rate but generally less severe disease. However, direct contact with cats is rarely the Diagnosis and treatment during Susceptibility and resistance cause of infection. Cats are generally pregnancy appears to reduce the effects Everyone is susceptible to infection. Typhoid and paratyphoid infections occur Preventive measures Identification worldwide. A combination hepatitis A and typhoid Method of diagnosis Mode of transmission injectable vaccine is also available. Serology in the form of the water used), raw vegetables, salads and advised to exercise care in selecting food Widal test is no longer routinely used. However, strains resistant to high risk work or patient care until they chloramphenicol, amoxycillin and co have had three consecutive negative Outbreak measures trimoxazole are common in south Asia. All cases are intensively investigated, Failure to respond to ciprofloxacin has Control of contacts whether sporadic or part of a cluster. Follow-up of all patients is conducted by Use of typhoid vaccine for contacts is the Department of Human Services to Additional sources of information not generally recommended. The blue book: Guidelines forthe control of infectious diseases 233 Viral gastroenteritis (not rotavirus) Vic to rian statu to ry requirement Incubation period person to person contact. Special settings Specific pro to cols for the management of outbreaks in special settings are available from the Communicable Diseases Section of the Department of Human Services. Appropriate specimens Dengue haemorrhagic fever and yellow are: and treatment is commenced as early as fever are discussed elsewhere. Other the incubation period varies according to the reservoir for Lassa fever virus is a symp to ms include retrosternal chest pain, the causative agent: rodent known as the multimammate rat cough, abdominal pain, diarrhoea, of the genus Mas to mys spp. 50mg indocin overnight delivery. 5 Worst Foods For Arthritis And Joint Pain.
An important distinction when considering these data is whether the effects are seen in an e-cigarette user who had never used combustible to bacco cigarettes (usually children or youth) or in a combustible to bacco cigarette user arthritis diet uk order 50mg indocin amex, with and without pre-existing to bacco-related disease arthritis spine diet 50 mg indocin with amex, usually adults rheumatoid arthritis zandu order indocin 25 mg online. The committee reviewed evidence on the effects of e-cigarettes in several health domains: dependence arthritis tylenol dosage discount indocin line, cardiovascular, cancer, respira to ry diseases, oral diseases, maternal and foetal outcomes, and injuries and poisonings. Although the amount of literature is relatively scant and complicated by the multiple types of e-cigarettes in use even within a given study, the committee made 26 conclusions about the effects of e-cigarettes on health. There is substantial evidence that e-cigarette aerosols can induce acute endothelial cell dysfunction, although the long-term consequences and outcomes on these parameters with long-term exposure to e-cigarette aerosol are uncertain. There is substantial evidence that components of e-cigarette aerosols can promote formation of reactive oxygen species/oxidative stress. Although this supports the biological plausibility of tissue injury and disease from long-term exposure to e-cigarette aerosols, generation of reactive oxygen species and oxidative stress induction is generally lower from e-cigarettes than from combustible to bacco cigarette smoke. There is substantial evidence that e-cigarette use results in symp to ms of dependence on e-cigarettes. There is moderate evidence that risk and severity of dependence are lower for e-cigarettes than combustible to bacco cigarettes. There is moderate evidence that variability in e-cigarette product characteristics (nicotine concentration, flavouring, device type, and brand) is an important determinant of risk and severity of e-cigarette dependence. There is no available evidence whether or not e-cigarette use is associated with clinical cardiovascular outcomes (coronary heart disease, stroke, and peripheral artery disease) and subclinical atherosclerosis (carotid intima media-thickness and coronary artery calcification). There is substantial evidence that heart rate, increases after nicotine intake from e-cigarettes. There is moderate evidence that dias to lic blood pressure increases after nicotine intake from e-cigarettes. There is limited evidence that e-cigarette use is associated with a short-term increase in sys to lic blood pressure, changes in biomarkers of oxidative stress, increased endothelial dysfunction and arterial stiffness, and au to nomic control. There is insufficient evidence that e-cigarette use is associated with long-term changes in heart rate, blood pressure, and cardiac geometry and function. There is no available evidence whether or not e-cigarette use is associated with intermediate cancer endpoints in humans. This holds true for comparisons of e-cigarette use compared with combustible to bacco cigarettes and e-cigarette use compared with no use of to bacco products. There is limited evidence from in vivo animal studies using intermediate biomarkers of cancer to support the hypothesis that long-term e-cigarette use could increase the risk of cancer; there is no available evidence from adequate long-term animal bioassays of e-cigarette aerosol exposures to inform cancer risk. There is substantial evidence that some chemicals present in e-cigarette aerosols. This supports the biological plausibility that long-term exposure to e-cigarette aerosols could increase risk of cancer and adverse reproductive outcomes. There is no available evidence whether or not e-cigarettes cause respira to ry diseases in humans. There is limited evidence for improvement in lung function and respira to ry symp to ms among adult smokers with asthma who switch to e-cigarettes completely or in part (dual use). There is moderate evidence for increased cough and wheeze in adolescents who use e-cigarettes and an association with e-cigarette use and an increase in asthma exacerbations. There is limited evidence of adverse effects of e-cigarette exposure on the respira to ry system from animal and in vitro studies. There is limited evidence suggesting that switching to e-cigarettes will improve periodontal disease in smokers. There is limited evidence suggesting that nicotine and non-nicotine containing e-cigarette aerosol can adversely affect cell viability and cause cell damage of oral tissue in non-smokers. There is no available evidence whether or not e-cigarettes affect pregnancy outcomes. There is insufficient evidence whether or not maternal e-cigarette use affects fetal development. There is conclusive evidence that e-cigarette devices can explode and cause burns and projectile injuries. Such risk is significantly increased when batteries are of poor quality, s to red improperly or are being modified by users. There is conclusive evidence that intentional or accidental exposure to e-liquids (from drinking, eye contact, or dermal contact) can result in adverse health effects including but not limited to seizures, anoxic brain injury, vomiting, and lactic acidosis. There is conclusive evidence that intentionally or unintentionally drinking or injecting e-liquids can be fatal. Taken to gether, the evidence reviewed by the committee suggests that e-cigarettes are not without physiological activity in humans, but the implications for long-term effects on morbidity and mortality are not yet clear. Use of e-cigarettes instead of combustible to bacco cigarettes by those with existing respira to ry disease might be less harmful. This requires that to bacco products introduced on the market after 15 February 2007 be shown to have a net population health benefit to users and non users of the product. Operationally, if a product caused more people to begin harmful to bacco use and fewer people to quit to bacco use, even if the product itself poses less risk to the user than other products, it could be determined that the product poses a public health burden and would be kept off the market. Thus, the to bacco control field must pay close attention to the effects of e-cigarette use on initiation and cessation of combustible to bacco use, regardless of the effects of e-cigarettes on health outcomes. Although the studies reviewed had limitations, the committee was able to make seven conclusions: Conclusion 16-1. There is substantial evidence that e-cigarette use increases risk of ever using combustible to bacco cigarettes among youth and young adults. Among youth and young adult e-cigarette users who ever use combustible to bacco cigarettes, there is moderate evidence that e-cigarette use increases the frequency and intensity of subsequent combustible to bacco cigarette smoking. Among youth and young adult e-cigarette users who ever use combustible to bacco cigarettes, there is limited evidence that e-cigarette use increases, in the near term, the duration of subsequent combustible to bacco cigarette smoking. Overall, there is limited evidence that e-cigarettes may be effective aids to promote smoking cessation. While the overall evidence from observational trials is mixed, there is moderate evidence from observational studies that more frequent use of e-cigarettes is associated with increased likelihood of cessation. Taken to gether the evidence suggests that while e-cigarettes might cause youth who use them to transition to use of combustible to bacco products, they might increase adult cessation of combustible to bacco cigarettes. There is substantial evidence that completely switching from regular use of combustible to bacco cigarettes to e-cigarettes results in reduced short-term adverse health outcomes in several organ systems. There is no available evidence whether or not long-term e-cigarette use among smokers (dual use) changes morbidity or mortality compared with those who only smoke combustible to bacco cigarettes. There is insufficient evidence that e-cigarette use changes short-term adverse health outcomes in several organ systems in smokers who continue to smoke combustible to bacco cigarettes (dual users). There is moderate evidence that second-hand exposure to nicotine and particulates is lower from e-cigarettes compared with combustible to bacco cigarettes. The evidence about harm reduction suggests that across a range of studies and outcomes, e-cigarettes pose less risk to an individual than combustible to bacco cigarettes. A firm conclusion can be made, and the limitations to the evidence, including chance, bias, and confounding fac to rs, can be ruled out with reasonable confidence. Substantial evidence: There are several supportive findings from good-quality observational studies or controlled trials with few or no credible opposing findings. A firm conclusion can be made, but minor limitations, including chance, bias, and confounding fac to rs, cannot be ruled out with reasonable confidence. Moderate evidence: There are several supportive findings from fair-quality studies with few or no credible opposing findings. A general conclusion can be made, but limitations, including chance, bias, and confounding fac to rs, cannot be ruled out with reasonable confidence. Limited evidence: There are supportive findings from fair-quality studies or mixed findings with most favouring one conclusion. A conclusion can be made, but there is significant uncertainty due to chance, bias, and confounding fac to rs. No conclusion can be made because of substantial uncertainty due to chance, bias, and confounding fac to rs. Varying the assumptions, and updating these estimates for 2016, resulted in an upper bound estimate of around 57,000 additional quitters annually resulting from e-cigarettes (lower bound around 22,000). While caution is needed with these figures, the evidence suggests that e-cigarettes have contributed tens of thousands of additional quitters in England. However, fewer smokers use an e-cigarette as part of a quit attempt with a S to p Smoking Service compared with licensed medication. |
