The 2002 Official Patient's Sourcebook on Diarrhea: A Revised and Updated Directory for the Internet Age

THE 2002 OFFICIAL PATIENT’S SOURCEBOOK

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J AMES N. P ARKER , M.D. AND P HILIP M. P ARKER , P H .D., E DITORS

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ICON Health Publications ICON Group International, Inc. 4370 La Jolla Village Drive, 4th Floor San Diego, CA 92122 USA Copyright Ó2002 by ICON Group International, Inc. Copyright Ó2002 by ICON Group International, Inc. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission from the publisher. Printed in the United States of America. Last digit indicates print number: 10 9 8 7 6 4 5 3 2 1

Publisher, Health Care: Tiffany LaRochelle Editor(s): James Parker, M.D., Philip Parker, Ph.D. Publisher’s note: The ideas, procedures, and suggestions contained in this book are not intended as a substitute for consultation with your physician. All matters regarding your health require medical supervision. As new medical or scientific information becomes available from academic and clinical research, recommended treatments and drug therapies may undergo changes. The authors, editors, and publisher have attempted to make the information in this book up to date and accurate in accord with accepted standards at the time of publication. The authors, editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of this book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation, in close consultation with a qualified physician. The reader is advised to always check product information (package inserts) for changes and new information regarding dose and contraindications before taking any drug or pharmacological product. Caution is especially urged when using new or infrequently ordered drugs, herbal remedies, vitamins and supplements, alternative therapies, complementary therapies and medicines, and integrative medical treatments. Cataloging-in-Publication Data Parker, James N., 1961Parker, Philip M., 1960The 2002 Official Patient’s Sourcebook on Diarrhea: A Revised and Updated Directory for the Internet Age/James N. Parker and Philip M. Parker, editors p. cm. Includes bibliographical references, glossary and index. ISBN: 0-597-83266-8 1. Diarrhea-Popular works. I. Title.

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Disclaimer This publication is not intended to be used for the diagnosis or treatment of a health problem or as a substitute for consultation with licensed medical professionals. It is sold with the understanding that the publisher, editors, and authors are not engaging in the rendering of medical, psychological, financial, legal, or other professional services. References to any entity, product, service, or source of information that may be contained in this publication should not be considered an endorsement, either direct or implied, by the publisher, editors or authors. ICON Group International, Inc., the editors, or the authors are not responsible for the content of any Web pages nor publications referenced in this publication.

Copyright Notice If a physician wishes to copy limited passages from this sourcebook for patient use, this right is automatically granted without written permission from ICON Group International, Inc. (ICON Group). However, all of ICON Group publications are copyrighted. With exception to the above, copying our publications in whole or in part, for whatever reason, is a violation of copyright laws and can lead to penalties and fines. Should you want to copy tables, graphs or other materials, please contact us to request permission (e-mail: [email protected]). ICON Group often grants permission for very limited reproduction of our publications for internal use, press releases, and academic research. Such reproduction requires confirmed permission from ICON Group International Inc. The disclaimer above must accompany all reproductions, in whole or in part, of this sourcebook.

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Dedication To the healthcare professionals dedicating their time and efforts to the study of diarrhea.

Acknowledgements The collective knowledge generated from academic and applied research summarized in various references has been critical in the creation of this sourcebook which is best viewed as a comprehensive compilation and collection of information prepared by various official agencies which directly or indirectly are dedicated to the study of diarrhea. All of the Official Patient’s Sourcebooks draw from various agencies and institutions associated with the United States Department of Health and Human Services, and in particular, the Office of the Secretary of Health and Human Services (OS), the Administration for Children and Families (ACF), the Administration on Aging (AOA), the Agency for Healthcare Research and Quality (AHRQ), the Agency for Toxic Substances and Disease Registry (ATSDR), the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), the Healthcare Financing Administration (HCFA), the Health Resources and Services Administration (HRSA), the Indian Health Service (IHS), the institutions of the National Institutes of Health (NIH), the Program Support Center (PSC), and the Substance Abuse and Mental Health Services Administration (SAMHSA). In addition to these sources, information gathered from the National Library of Medicine, the United States Patent Office, the European Union, and their related organizations has been invaluable in the creation of this sourcebook. Some of the work represented was financially supported by the Research and Development Committee at INSEAD. This support is gratefully acknowledged. Finally, special thanks are owed to Tiffany LaRochelle for her excellent editorial support.

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About the Editors James N. Parker, M.D. Dr. James N. Parker received his Bachelor of Science degree in Psychobiology from the University of California, Riverside and his M.D. from the University of California, San Diego. In addition to authoring numerous research publications, he has lectured at various academic institutions. Dr. Parker is the medical editor for the Official Patient’s Sourcebook series published by ICON Health Publications.

Philip M. Parker, Ph.D. Philip M. Parker is the Eli Lilly Chair Professor of Innovation, Business and Society at INSEAD (Fontainebleau, France and Singapore). Dr. Parker has also been Professor at the University of California, San Diego and has taught courses at Harvard University, the Hong Kong University of Science and Technology, the Massachusetts Institute of Technology, Stanford University, and UCLA. Dr. Parker is the associate editor for the Official Patient’s Sourcebook series published by ICON Health Publications.

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About ICON Health Publications In addition to diarrhea, Official Patient’s Sourcebooks are available for the following related topics: ·

The Official Patient's Sourcebook on Appendicitis

·

The Official Patient's Sourcebook on Autoimmune Hepatitis

·

The Official Patient's Sourcebook on Bacteria and Foorborne Illness

·

The Official Patient's Sourcebook on Barrett's Esophagus

·

The Official Patient's Sourcebook on Celiac Disease

·

The Official Patient's Sourcebook on Cirrhosis of the Liver

·

The Official Patient's Sourcebook on Constipation

·

The Official Patient's Sourcebook on Crohn Disease

·

The Official Patient's Sourcebook on Cyclic Vomiting Syndrome

·

The Official Patient's Sourcebook on Diverticular Disease

·

The Official Patient's Sourcebook on Fecal Incontinence

·

The Official Patient's Sourcebook on Gallstones

·

The Official Patient's Sourcebook on Gas

·

The Official Patient's Sourcebook on Gastritis

·

The Official Patient's Sourcebook on Gastroparesis

·

The Official Patient's Sourcebook on Hemolytic Uremic Syndrome

·

The Official Patient's Sourcebook on Hemorrhoids

·

The Official Patient's Sourcebook on Hepatitis a

·

The Official Patient's Sourcebook on Hepatitis B

·

The Official Patient's Sourcebook on Hepatitis C

·

The Official Patient's Sourcebook on Hiatal Hernia

·

The Official Patient's Sourcebook on Hirschsprung

·

The Official Patient's Sourcebook on Indigestion

·

The Official Patient's Sourcebook on Inguinal Hernia

·

The Official Patient's Sourcebook on Intestinal Pseudo-obstruction

·

The Official Patient's Sourcebook on Irritable Bowel Syndrome

·

The Official Patient's Sourcebook on Lactose Intolerance

·

The Official Patient's Sourcebook on Ménétrier

·

The Official Patient's Sourcebook on Pancreatitis

·

The Official Patient's Sourcebook on Peptic Ulcer

·

The Official Patient's Sourcebook on Porphyria

·

The Official Patient's Sourcebook on Primary Biliary Cirrhosis

·

The Official Patient's Sourcebook on Primary Sclerosing Cholangitis

·

The Official Patient's Sourcebook on Proctitis

·

The Official Patient's Sourcebook on Rapid Gastric Emptying

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·

The Official Patient's Sourcebook on Short Bowel Syndrome

·

The Official Patient's Sourcebook on Ulcerative Colitis

·

The Official Patient's Sourcebook on Whipple Disease

·

The Official Patient's Sourcebook on Wilson's Disease

·

The Official Patient's Sourcebook on Zollinger-ellison Syndrome

To discover more about ICON Health Publications, simply check with your preferred online booksellers, including Barnes & Noble.com and Amazon.com which currently carry all of our titles. Or, feel free to contact us directly for bulk purchases or institutional discounts: ICON Group International, Inc. 4370 La Jolla Village Drive, Fourth Floor San Diego, CA 92122 USA Fax: 858-546-4341 Web site: www.icongrouponline.com/health

Contents

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Table of Contents INTRODUCTION ................................................................................................................................. 1 Overview ....................................................................................................................................... 1 Organization ................................................................................................................................. 3 Scope.............................................................................................................................................. 3 Moving Forward............................................................................................................................ 5 PART I: THE ESSENTIALS ............................................................................................................. 7 CHAPTER 1. THE ESSENTIALS ON DIARRHEA: GUIDELINES ............................................................ 9 Overview ....................................................................................................................................... 9 What Is Diarrhea? ....................................................................................................................... 11 What Causes Diarrhea?............................................................................................................... 11 What Are the Symptoms? ........................................................................................................... 12 Diarrhea in Children ................................................................................................................... 12 What Is Dehydration? ................................................................................................................. 13 When Should a Doctor Be Consulted? ........................................................................................ 14 What Tests Might the Doctor Do? .............................................................................................. 14 What Is the Treatment?............................................................................................................... 15 Preventing Dehydration.............................................................................................................. 15 Tips about Food ........................................................................................................................... 15 Preventing Traveler’s Diarrhea................................................................................................... 16 Points to Remember..................................................................................................................... 16 More Guideline Sources .............................................................................................................. 17 Vocabulary Builder...................................................................................................................... 25 CHAPTER 2. SEEKING GUIDANCE ................................................................................................... 31 Overview ..................................................................................................................................... 31 Associations and Diarrhea........................................................................................................... 31 Finding More Associations ......................................................................................................... 33 Finding Doctors........................................................................................................................... 35 Selecting Your Doctor ................................................................................................................. 36 Working with Your Doctor ......................................................................................................... 37 Broader Health-Related Resources .............................................................................................. 38 Vocabulary Builder...................................................................................................................... 38 CHAPTER 3. CLINICAL TRIALS AND DIARRHEA............................................................................. 41 Overview ..................................................................................................................................... 41 Recent Trials on Diarrhea ........................................................................................................... 44 Benefits and Risks........................................................................................................................ 47 Keeping Current on Clinical Trials ............................................................................................. 50 General References....................................................................................................................... 51 Vocabulary Builder...................................................................................................................... 52 PART II: ADDITIONAL RESOURCES AND ADVANCED MATERIAL ........................... 57 CHAPTER 4. STUDIES ON DIARRHEA .............................................................................................. 59 Overview ..................................................................................................................................... 59 The Combined Health Information Database .............................................................................. 59 Federally-Funded Research on Diarrhea ..................................................................................... 63 E-Journals: PubMed Central ....................................................................................................... 78 The National Library of Medicine: PubMed................................................................................ 85 Vocabulary Builder...................................................................................................................... 85 CHAPTER 5. PATENTS ON DIARRHEA ......................................................................................... 95 Overview ..................................................................................................................................... 95 Patents on Diarrhea..................................................................................................................... 96

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Contents Patent Applications on Diarrhea............................................................................................... 112 Keeping Current ........................................................................................................................ 113 Vocabulary Builder.................................................................................................................... 113 CHAPTER 6. BOOKS ON DIARRHEA .............................................................................................. 119 Overview ................................................................................................................................... 119 Book Summaries: Federal Agencies ........................................................................................... 119 Book Summaries: Online Booksellers ........................................................................................ 126 The National Library of Medicine Book Index........................................................................... 129 Chapters on Diarrhea ................................................................................................................ 131 Directories ................................................................................................................................. 133 General Home References .......................................................................................................... 135 Vocabulary Builder.................................................................................................................... 136 CHAPTER 7. MULTIMEDIA ON DIARRHEA.................................................................................... 139 Overview ................................................................................................................................... 139 Video Recordings....................................................................................................................... 139 Audio Recordings ...................................................................................................................... 142 Bibliography: Multimedia on Diarrhea ..................................................................................... 143 Vocabulary Builder.................................................................................................................... 145 CHAPTER 8. PERIODICALS AND NEWS ON DIARRHEA................................................................. 147 Overview ................................................................................................................................... 147 News Services & Press Releases ................................................................................................ 147 Newsletters on Diarrhea............................................................................................................ 154 Newsletter Articles .................................................................................................................... 155 Academic Periodicals covering Diarrhea................................................................................... 159 Vocabulary Builder.................................................................................................................... 160 CHAPTER 9. PHYSICIAN GUIDELINES AND DATABASES .............................................................. 163 Overview ................................................................................................................................... 163 NIH Guidelines ......................................................................................................................... 163 NIH Databases .......................................................................................................................... 164 Other Commercial Databases .................................................................................................... 168 The Genome Project and Diarrhea ............................................................................................ 169 Specialized References ............................................................................................................... 173 Vocabulary Builder.................................................................................................................... 174 CHAPTER 10. DISSERTATIONS ON DIARRHEA .............................................................................. 177 Overview ................................................................................................................................... 177 Dissertations on Diarrhea ......................................................................................................... 177 Keeping Current ........................................................................................................................ 179 Vocabulary Builder.................................................................................................................... 179

PART III. APPENDICES .............................................................................................................. 181 APPENDIX A. RESEARCHING YOUR MEDICATIONS ..................................................................... 183 Overview ................................................................................................................................... 183 Your Medications: The Basics ................................................................................................... 183 Learning More about Your Medications ................................................................................... 185 Commercial Databases............................................................................................................... 192 Contraindications and Interactions (Hidden Dangers)............................................................. 206 A Final Warning ....................................................................................................................... 207 General References..................................................................................................................... 207 Vocabulary Builder.................................................................................................................... 208 APPENDIX B. RESEARCHING ALTERNATIVE MEDICINE ............................................................... 215 Overview ................................................................................................................................... 215 What Is CAM? .......................................................................................................................... 215 What Are the Domains of Alternative Medicine? ..................................................................... 216 Can Alternatives Affect My Treatment?................................................................................... 219

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Finding CAM References on Diarrhea...................................................................................... 220 Additional Web Resources......................................................................................................... 231 General References..................................................................................................................... 232 APPENDIX C. RESEARCHING NUTRITION..................................................................................... 235 Overview ................................................................................................................................... 235 Food and Nutrition: General Principles .................................................................................... 235 Finding Studies on Diarrhea ..................................................................................................... 240 Federal Resources on Nutrition................................................................................................. 242 Additional Web Resources......................................................................................................... 243 Vocabulary Builder.................................................................................................................... 243 APPENDIX D. FINDING MEDICAL LIBRARIES ............................................................................... 245 Overview ................................................................................................................................... 245 Preparation ................................................................................................................................ 245 Finding a Local Medical Library ............................................................................................... 246 Medical Libraries Open to the Public ........................................................................................ 246 APPENDIX E. NIH CONSENSUS STATEMENT ON TRAVELERS’ DIARRHEA ................................. 253 Overview ................................................................................................................................... 253 What Is Travelers’ Diarrhea? .................................................................................................... 254 Epidemiology of Travelers’ Diarrhea ......................................................................................... 255 What Causes Travelers’ Diarrhea?............................................................................................ 256 Effective Prevention Measures for Travelers’ Diarrhea ............................................................ 259 Effective Treatment Measures for Travelers’ Diarrhea ............................................................. 260 Precautions in Children and Pregnant Women ........................................................................ 262 Summary Recommendation for Treatment ............................................................................... 262 What Should Be the Direction of Future Research?.................................................................. 263 Conclusion................................................................................................................................. 265 Vocabulary Builder.................................................................................................................... 265 ONLINE GLOSSARIES ............................................................................................................... 269 Online Dictionary Directories................................................................................................... 275 DIARRHEA GLOSSARY ............................................................................................................. 277 General Dictionaries and Glossaries ......................................................................................... 311 INDEX.............................................................................................................................................. 313

Introduction

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INTRODUCTION Overview Dr. C. Everett Koop, former U.S. Surgeon General, once said, “The best prescription is knowledge.”1 The Agency for Healthcare Research and Quality (AHRQ) of the National Institutes of Health (NIH) echoes this view and recommends that every patient incorporate education into the treatment process. According to the AHRQ: Finding out more about your condition is a good place to start. By contacting groups that support your condition, visiting your local library, and searching on the Internet, you can find good information to help guide your treatment decisions. Some information may be hard to find—especially if you don’t know where to look.2 As the AHRQ mentions, finding the right information is not an obvious task. Though many physicians and public officials had thought that the emergence of the Internet would do much to assist patients in obtaining reliable information, in March 2001 the National Institutes of Health issued the following warning: The number of Web sites offering health-related resources grows every day. Many sites provide valuable information, while others may have information that is unreliable or misleading.3

Quotation from http://www.drkoop.com. The Agency for Healthcare Research and Quality (AHRQ): http://www.ahcpr.gov/consumer/diaginfo.htm. 3 From the NIH, National Cancer Institute (NCI): http://cancertrials.nci.nih.gov/beyond/evaluating.html. 1 2

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Diarrhea

Since the late 1990s, physicians have seen a general increase in patient Internet usage rates. Patients frequently enter their doctor’s offices with printed Web pages of home remedies in the guise of latest medical research. This scenario is so common that doctors often spend more time dispelling misleading information than guiding patients through sound therapies. The Official Patient’s Sourcebook on Diarrhea has been created for patients who have decided to make education and research an integral part of the treatment process. The pages that follow will tell you where and how to look for information covering virtually all topics related to diarrhea, from the essentials to the most advanced areas of research. The title of this book includes the word “official.” This reflects the fact that the sourcebook draws from public, academic, government, and peerreviewed research. Selected readings from various agencies are reproduced to give you some of the latest official information available to date on diarrhea. Given patients’ increasing sophistication in using the Internet, abundant references to reliable Internet-based resources are provided throughout this sourcebook. Where possible, guidance is provided on how to obtain free-ofcharge, primary research results as well as more detailed information via the Internet. E-book and electronic versions of this sourcebook are fully interactive with each of the Internet sites mentioned (clicking on a hyperlink automatically opens your browser to the site indicated). Hard copy users of this sourcebook can type cited Web addresses directly into their browsers to obtain access to the corresponding sites. Since we are working with ICON Health Publications, hard copy Sourcebooks are frequently updated and printed on demand to ensure that the information provided is current. In addition to extensive references accessible via the Internet, every chapter presents a “Vocabulary Builder.” Many health guides offer glossaries of technical or uncommon terms in an appendix. In editing this sourcebook, we have decided to place a smaller glossary within each chapter that covers terms used in that chapter. Given the technical nature of some chapters, you may need to revisit many sections. Building one’s vocabulary of medical terms in such a gradual manner has been shown to improve the learning process. We must emphasize that no sourcebook on diarrhea should affirm that a specific diagnostic procedure or treatment discussed in a research study, patent, or doctoral dissertation is “correct” or your best option. This sourcebook is no exception. Each patient is unique. Deciding on appropriate

Introduction

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options is always up to the patient in consultation with their physician and healthcare providers.

Organization This sourcebook is organized into three parts. Part I explores basic techniques to researching diarrhea (e.g. finding guidelines on diagnosis, treatments, and prognosis), followed by a number of topics, including information on how to get in touch with organizations, associations, or other patient networks dedicated to diarrhea. It also gives you sources of information that can help you find a doctor in your local area specializing in diagnosing and treating diarrhea. Collectively, the material presented in Part I is a complete primer on basic research topics for patients with diarrhea. Part II moves on to advanced research dedicated to diarrhea. Part II is intended for those willing to invest many hours of hard work and study. It is here that we direct you to the latest scientific and applied research on diarrhea. When possible, contact names, links via the Internet, and summaries are provided. It is in Part II where the vocabulary process becomes important as authors publishing advanced research frequently use highly specialized language. In general, every attempt is made to recommend “free-to-use” options. Part III provides appendices of useful background reading for all patients with diarrhea or related disorders. The appendices are dedicated to more pragmatic issues faced by many patients with diarrhea. Accessing materials via medical libraries may be the only option for some readers, so a guide is provided for finding local medical libraries which are open to the public. Part III, therefore, focuses on advice that goes beyond the biological and scientific issues facing patients with diarrhea.

Scope While this sourcebook covers diarrhea, your doctor, research publications, and specialists may refer to your condition using a variety of terms. Therefore, you should understand that diarrhea is often considered a synonym or a condition closely related to the following: ·

Bacterial Diarrhea

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Bacterial Gastroenteritis

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Campylobacter Enteritis

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Diarrhea

·

Diarrhea Associated with Drugs

·

Epidemic Diarrhea

·

Factitious Diarrhea

·

Hill Diarrhea

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Loose Bowels

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Rice Water Diarrhea

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The Runs

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Traveler's Diarrhea

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Tropical Diarrhea

In addition to synonyms and related conditions, physicians may refer to diarrhea using certain coding systems. The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) is the most commonly used system of classification for the world’s illnesses. Your physician may use this coding system as an administrative or tracking tool. The following classification is commonly used for diarrhea:4 ·

005.9 food poisoning, unspecified

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007.9 unspecified protozoal intestinal disease

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009.2 infectious diarrhea

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009.3 diarrhea of presumed infectious origin

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306.4 gastrointestinal

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558.2 toxic gastroenteritis and colitis

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558.9 unspecific noninfectious gastroenteritis and colitis

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564.4 other postoperative functional disorders

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564.5 functional diarrhea

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787.91 diarrhea

For the purposes of this sourcebook, we have attempted to be as inclusive as possible, looking for official information for all of the synonyms relevant to diarrhea. You may find it useful to refer to synonyms when accessing databases or interacting with healthcare professionals and medical librarians. 4 This list is based on the official version of the World Health Organization’s 9th Revision, International Classification of Diseases (ICD-9). According to the National Technical Information Service, “ICD-9CM extensions, interpretations, modifications, addenda, or errata other than those approved by the U.S. Public Health Service and the Health Care Financing Administration are not to be considered official and should not be utilized. Continuous maintenance of the ICD-9-CM is the responsibility of the federal government.”

Introduction

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Moving Forward Since the 1980s, the world has seen a proliferation of healthcare guides covering most illnesses and conditions. Some are written by patients or their family members. These generally take a layperson’s approach to understanding and coping with an illness or disorder. They can be uplifting, encouraging, and highly supportive. Other guides are authored by physicians or other healthcare providers who have a more clinical outlook. Each of these two styles of guide has its purpose and can be quite useful. As editors, we have chosen a third route. We have chosen to expose you to as many sources of official and peer-reviewed information as practical, for the purpose of educating you about basic and advanced knowledge as recognized by medical science today. You can think of this sourcebook as your personal Internet age reference librarian. Why “Internet age”? All too often, patients with diarrhea will log on to the Internet, type words into a search engine, and receive several Web site listings which are mostly irrelevant or redundant. These patients are left to wonder where the relevant information is, and how to obtain it. Since only the smallest fraction of information dealing with diarrhea is even indexed in search engines, a non-systematic approach often leads to frustration and disappointment. With this sourcebook, we hope to direct you to the information you need that you would not likely find using popular Web directories. Beyond Web listings, in many cases we will reproduce brief summaries or abstracts of available reference materials. These abstracts often contain distilled information on topics of discussion. While we focus on the more scientific aspects of diarrhea, there is, of course, the emotional side to consider. Later in the sourcebook, we provide a chapter dedicated to helping you find peer groups and associations that can provide additional support beyond research produced by medical science. We hope that the choices we have made give you the most options available in moving forward. In this way, we wish you the best in your efforts to incorporate this educational approach into your treatment plan. The Editors

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PART I: THE ESSENTIALS

ABOUT PART I Part I has been edited to give you access to what we feel are “the essentials” on diarrhea. The essentials of a symptom typically include the definition or description of the symptom, a discussion of who it affects, the diseases that are associated with a given symptom, tests or diagnostic procedures that might be specific to the symptom, and treatments for the symptom. Your doctor or healthcare provider may have already explained the essentials of diarrhea to you or even given you a pamphlet or brochure describing diarrhea. Now you are searching for more in-depth information. As editors, we have decided, nevertheless, to include a discussion on where to find essential information that can complement what your doctor has already told you. In this section we recommend a process, not a particular Web site or reference book. The process ensures that, as you search the Web, you gain background information in such a way as to maximize your understanding.

Guidelines

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CHAPTER 1. THE ESSENTIALS ON DIARRHEA: GUIDELINES Overview Official agencies, as well as federally-funded institutions supported by national grants, frequently publish a variety of guidelines on diarrhea. These are typically called “Fact Sheets” or “Guidelines.” They can take the form of a brochure, information kit, pamphlet, or flyer. Often they are only a few pages in length. The great advantage of guidelines over other sources is that they are often written with the patient in mind. Since new guidelines on diarrhea can appear at any moment and be published by a number of sources, the best approach to finding guidelines is to systematically scan the Internet-based services that post them.

The National Institutes of Health (NIH)5 The National Institutes of Health (NIH) is the first place to search for relatively current patient guidelines and fact sheets on diarrhea. Originally founded in 1887, the NIH is one of the world’s foremost medical research centers and the federal focal point for medical research in the United States. At any given time, the NIH supports some 35,000 research grants at universities, medical schools, and other research and training institutions, both nationally and internationally. The rosters of those who have conducted research or who have received NIH support over the years include the world’s most illustrious scientists and physicians. Among them are 97 scientists who have won the Nobel Prize for achievement in medicine.

5

Adapted from the NIH: http://www.nih.gov/about/NIHoverview.html.

10 Diarrhea

There is no guarantee that any one Institute will have a guideline on a specific condition or disease, though the National Institutes of Health collectively publish over 600 guidelines for both common and rare conditions and disorders. The best way to access NIH guidelines is via the Internet. Although the NIH is organized into many different Institutes and Offices, the following is a list of key Web sites where you are most likely to find NIH clinical guidelines and publications dealing with diarrhea and associated conditions: ·

Office of the Director (OD); guidelines consolidated across agencies available at http://www.nih.gov/health/consumer/conkey.htm

·

National Library of Medicine (NLM); extensive encyclopedia (A.D.A.M., Inc.) with guidelines available at http://www.nlm.nih.gov/medlineplus/healthtopics.html

·

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK); guidelines available at http://www.niddk.nih.gov/health/health.htm

Among these, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) is particularly noteworthy. The NIDDK’s mission is to conduct and support research on many of the most serious diseases affecting public health.6 The Institute supports much of the clinical research on the diseases of internal medicine and related subspecialty fields as well as many basic science disciplines. The NIDDK’s Division of Intramural Research encompasses the broad spectrum of metabolic diseases such as diabetes, inborn errors of metabolism, endocrine disorders, mineral metabolism, digestive diseases, nutrition, urology and renal disease, and hematology. Basic research studies include biochemistry, nutrition, pathology, histochemistry, chemistry, physical, chemical, and molecular biology, pharmacology, and toxicology. NIDDK extramural research is organized into divisions of program areas: ·

Division of Diabetes, Endocrinology, and Metabolic Diseases

·

Division of Digestive Diseases and Nutrition

·

Division of Kidney, Urologic, and Hematologic Diseases

The Division of Extramural Activities provides administrative support and overall coordination. A fifth division, the Division of Nutrition Research Coordination, coordinates government nutrition research efforts. The This paragraph has been adapted from the NIDDK: http://www.niddk.nih.gov/welcome/mission.htm. “Adapted” signifies that a passage is reproduced exactly or slightly edited for this book. 6

Guidelines 11

Institute supports basic and clinical research through investigator-initiated grants, program project and center grants, and career development and training awards. The Institute also supports research and development projects and large-scale clinical trials through contracts. The following patient guideline was recently published by the NIDDK on diarrhea.

What Is Diarrhea?7 Diarrhea--loose, watery stools occurring more than three times in one day--is a common problem that usually lasts a day or two and goes away on its own without any special treatment. However, prolonged diarrhea can be a sign of other problems. Diarrhea can cause dehydration, which means the body lacks enough fluid to function properly. Dehydration is particularly dangerous in children and the elderly, and it must be treated promptly to avoid serious health problems. Dehydration is discussed below. People of all ages can get diarrhea. The average adult has a bout of diarrhea about four times a year.

What Causes Diarrhea? Diarrhea may be caused by a temporary problem, like an infection, or a chronic problem, like an intestinal disease. A few of the more common causes of diarrhea are: ·

Bacterial infections. Several types of bacteria, consumed through contaminated food or water, can cause diarrhea. Common culprits include Campylobacter, Salmonella, Shigella, and Escherichia coli.

·

Viral infections. Many viruses cause diarrhea, including rotavirus, Norwalk virus, cytomegalovirus, herpes simplex virus, and viral hepatitis.

·

Food intolerances. Some people are unable to digest a component of food, such as lactose, the sugar found in milk.

·

Parasites. Parasites can enter the body through food or water and settle in the digestive system. Parasites that cause diarrhea include Giardia lamblia, Entamoeba histolytica, and Cryptosporidium.

Adapted from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK): http://www.niddk.nih.gov/health/digest/pubs/diarrhea/diarrhea.htm. 7

12 Diarrhea

·

Reaction to medicines, such as antibiotics, blood pressure medications, and antacids containing magnesium.

·

Intestinal diseases, like inflammatory bowel disease or celiac disease.

·

Functional bowel disorders, such as irritable bowel syndrome, in which the intestines do not work normally.

Some people develop diarrhea after stomach surgery or removal of the gallbladder. The reason may be a change in how quickly food moves through the digestive system after stomach surgery or an increase in bile in the colon that can occur after gallbladder surgery. In many cases, the cause of diarrhea cannot be found. As long as diarrhea goes away on its own, an extensive search for the cause is not usually necessary. People who visit foreign countries are at risk for traveler’s diarrhea, which is caused by eating food or drinking water contaminated with bacteria, viruses, or, sometimes, parasites. Traveler’s diarrhea is a particular problem for people visiting developing countries. Visitors to the United States, Canada, most European countries, Japan, Australia, and New Zealand do not face much risk for traveler’s diarrhea.

What Are the Symptoms? Diarrhea may be accompanied by cramping abdominal pain, bloating, nausea, or an urgent need to use the bathroom. Depending on the cause, a person may have a fever or bloody stools. Diarrhea can be either acute or chronic. The acute form, which lasts less than 3 weeks, is usually related to a bacterial, viral, or parasitic infection. Chronic diarrhea lasts more than 3 weeks and is usually related to functional disorders like irritable bowel syndrome or diseases like celiac disease or inflammatory bowel disease.

Diarrhea in Children Children can have acute (short-term) or chronic (long-term) forms of diarrhea. Causes include bacteria, viruses, parasites, medications, functional disorders, and food sensitivities. Infection with the rotavirus is the most

Guidelines 13

common cause of acute childhood diarrhea. Rotavirus diarrhea usually resolves in 5 to 8 days. Medications to treat diarrhea in adults can be dangerous to children and should be given only under a doctor’s guidance. Diarrhea can be dangerous in newborns and infants. In small children, severe diarrhea lasting just a day or two can lead to dehydration. Because a child can die from dehydration within a few days, the main treatment for diarrhea in children is rehydration. Rehydration is discussed below. Take your child to the doctor if any of the following symptoms appear: ·

Stools containing blood or pus, or black stools

·

Temperature above 101.4 degrees Fahrenheit

·

No improvement after 24 hours

·

Signs of dehydration (see below)

What Is Dehydration? General signs of dehydration include ·

Thirst

·

Less frequent urination

·

Dry skin

·

Fatigue

·

Light-headedness

·

Dark colored urine

Signs of dehydration in children include ·

Dry mouth and tongue

·

No tears when crying

·

No wet diapers for 3 hours or more

·

Sunken abdomen, eyes, or cheeks

·

High fever

·

Listlessness or irritability

14 Diarrhea

·

Skin that does not flatten when pinched and released

If you suspect that you or your child is dehydrated, call the doctor immediately. Severe dehydration may require hospitalization.

When Should a Doctor Be Consulted? Although usually not harmful, diarrhea can become dangerous or signal a more serious problem. You should see the doctor if ·

You have diarrhea for more than 3 days.

·

You have severe pain in the abdomen or rectum.

·

You have a fever of 102 degrees Fahrenheit or higher.

·

You see blood in your stool or have black, tarry stools.

·

You have signs of dehydration.

If your child has diarrhea, do not hesitate to call the doctor for advice. Diarrhea can be dangerous in children if too much fluid is lost and not replaced quickly.

What Tests Might the Doctor Do? Diagnostic tests to find the cause of diarrhea include the following: ·

Medical history and physical examination. The doctor will need to know about your eating habits and medication use and will examine you for signs of illness.

·

Stool culture. Lab technicians analyze a sample of stool to check for bacteria, parasites, or other signs of disease or infection.

·

Blood tests. Blood tests can be helpful in ruling out certain diseases.

·

Fasting tests. To find out if a food intolerance or allergy is causing the diarrhea, the doctor may ask you to avoid lactose (found in milk products), carbohydrates, wheat, or other foods to see whether the diarrhea responds to a change in diet.

·

Sigmoidoscopy. For this test, the doctor uses a special instrument to look at the inside of the rectum and lower part of the colon.

Guidelines 15

·

Colonoscopy. This test is similar to sigmoidoscopy, but the doctor looks at the entire colon.

What Is the Treatment? In most cases, replacing lost fluid to prevent dehydration is the only treatment necessary. Medicines that stop diarrhea may be helpful in some cases, but they are not recommended for people whose diarrhea is from a bacterial infection or parasite--stopping the diarrhea traps the organism in the intestines, prolonging the problem. Instead, doctors usually prescribe antibiotics. Viral causes are either treated with medication or left to run their course, depending on the severity and type of the virus.

Preventing Dehydration Dehydration occurs when the body has lost too much fluid and electrolytes (the salts potassium and sodium). The fluid and electrolytes lost during diarrhea need to be replaced promptly--the body cannot function properly without them. Dehydration is particularly dangerous for children, who can die from it within a matter of days. Although water is extremely important in preventing dehydration, it does not contain electrolytes. To maintain electrolyte levels, you could have broth or soups, which contain sodium, and fruit juices, soft fruits, or vegetables, which contain potassium. For children, doctors often recommend a special rehydration solution that contains the nutrients they need. You can buy this solution in the grocery store without a prescription. Examples include Pedialyte, Ceralyte, and Infalyte.

Tips about Food Until diarrhea subsides, try to avoid milk products and foods that are greasy, high-fiber, or very sweet. These foods tend to aggravate diarrhea. As you improve, you can add soft, bland foods to your diet, including bananas, plain rice, boiled potatoes, toast, crackers, cooked carrots, and

16 Diarrhea

baked chicken without the skin or fat. For children, the pediatrician may recommend what is called the BRAT diet: bananas, rice, applesauce, and toast.

Preventing Traveler’s Diarrhea Traveler’s diarrhea happens when you consume food or water contaminated with bacteria, viruses, or parasites. You can take the following precautions to prevent traveler’s diarrhea when you go abroad: ·

Do not drink any tap water, not even when brushing your teeth.

·

Do not drink unpasteurized milk or dairy products.

·

Do not use ice made from tap water.

·

Avoid all raw fruits and vegetables (including lettuce and fruit salad) unless they can be peeled and you peel them yourself.

·

Do not eat raw or rare meat and fish.

·

Do not eat meat or shellfish that is not hot when served to you.

·

Do not eat food from street vendors.

You can safely drink bottled water (if you are the one to break the seal), carbonated soft drinks, and hot drinks like coffee or tea. Depending on where you are going and how long you are staying, your doctor may recommend that you take antibiotics before leaving to protect you from possible infection.

Points to Remember ·

Diarrhea is a common problem that usually resolves on its own.

·

Diarrhea is dangerous if a person becomes dehydrated.

·

Causes include viral, bacterial, or parasitic infections; food intolerance; reactions to medicine; intestinal diseases; and functional bowel disorders.

·

Treatment involves replacing lost fluids and electrolytes. Depending on the cause of the problem, a person might also need medication to stop the diarrhea or treat an infection. Children may need an oral rehydration solution to replace lost fluids and electrolytes.

Guidelines 17

·

Call the doctor if a person with diarrhea has severe pain in the abdomen or rectum, a fever of 102 degrees Fahrenheit or higher, blood in the stool, signs of dehydration, or diarrhea for more than 3 days.

More Guideline Sources The guideline above on diarrhea is only one example of the kind of material that you can find online and free of charge. The remainder of this chapter will direct you to other sources which either publish or can help you find additional guidelines on topics related to diarrhea. Many of the guidelines listed below address topics that may be of particular relevance to your specific situation or of special interest to only some patients with diarrhea. Due to space limitations these sources are listed in a concise manner. Do not hesitate to consult the following sources by either using the Internet hyperlink provided, or, in cases where the contact information is provided, contacting the publisher or author directly.

Topic Pages: MEDLINEplus For patients wishing to go beyond guidelines published by specific Institutes of the NIH, the National Library of Medicine has created a vast and patientoriented healthcare information portal called MEDLINEplus. Within this Internet-based system are “health topic pages.” You can think of a health topic page as a guide to patient guides. To access this system, log on to http://www.nlm.nih.gov/medlineplus/healthtopics.html. From there you can either search using the alphabetical index or browse by broad topic areas. Recently, MEDLINEplus listed the following as being relevant to diarrhea: ·

Guides On diarrhea Diarrhea http://www.nlm.nih.gov/medlineplus/diarrhea.html

·

Other Guides Drug-induced diarrhea http://www.nlm.nih.gov/medlineplus/ency/article/000293.htm Bacterial gastroenteritis http://www.nlm.nih.gov/medlineplus/ency/article/000254.htm

18 Diarrhea

Within the health topic page dedicated to diarrhea, the following was recently recommended to patients: ·

General/Overviews Diarrhea Source: Mayo Foundation for Medical Education and Research http://www.mayoclinic.com/invoke.cfm?id=DS00292

·

Diagnosis/Symptoms Diarrhea: Self-Care Flowcharts Source: American Academy of Family Physicians http://familydoctor.org/flowcharts/534.html Elimination Problems in Infants and Children: Self-Care Flowcharts Source: American Academy of Family Physicians http://familydoctor.org/flowcharts/533.html Radiography-Lower GI Tract Source: American College of Radiology, Radiological Society of North America http://www.radiologyinfo.org/content/lower_gi.htm

·

Specific Conditions/Aspects Brainerd Diarrhea Source: National Center for Infectious Diseases http://www.cdc.gov/ncidod/dbmd/diseaseinfo/brainerddiarrhea_ g.htm Chronic Diarrhea Source: National Center for Infectious Diseases, Division of Parasitic Diseases http://www.cdc.gov/ncidod/dpd/parasites/diarrhea/factsht_chron ic_diarrhea.htm Preventing Dehydration From Diarrhea Source: American Medical Association http://www.medem.com/medlb/article_detaillb.cfm?article_ID=ZZ ZSDZ72AKC&sub_cat=195 Travelers' Diarrhea: Frequently Asked Questions Source: Centers for Disease Control and Prevention http://www.cdc.gov/ncidod/dbmd/diseaseinfo/travelersdiarrhea_ g.htm

Guidelines 19

Viral Diarrhea Source: American Academy of Pediatrics http://www.medem.com/medlb/article_detaillb.cfm?article_ID=ZZ ZEK4KYQ7C&sub_cat=286 ·

Children Childhood Diarrhea: Messages for Parents Source: Centers for Disease Control and Prevention http://www.cdc.gov/od/oc/parents/ Gastrointestinal Infections and Diarrhea Source: Nemours Foundation http://kidshealth.org/parent/medical/digestive/gastrointestinal.ht ml Vomiting and Diarrhea: Helping Your Child Through Sickness Source: American Academy of Family Physicians http://familydoctor.org/healthfacts/196/ What You Should Know About... Diarrheal Diseases in the Child Care Setting Source: National Center for Infectious Diseases http://www.cdc.gov/ncidod/hip/abc/facts10.htm

·

From the National Institutes of Health Diarrhea Source: National Digestive Diseases Information Clearinghouse http://www.niddk.nih.gov/health/digest/pubs/diarrhea/diarrhea. htm

·

Organizations National Institute of Allergy and Infectious Diseases http://www.niaid.nih.gov/ National Institute of Diabetes and Digestive and Kidney Diseases http://www.niddk.nih.gov/

·

Research Bacteria in Condiment Sauces on Tables in Mexican-Style Restaurants in Guadalajara, Mexico, and Houston, Texas Source: American College of Physicians http://www.annals.org/issues/v136n12/fpdf/200206180-00005.pdf

20 Diarrhea

If you do not find topics of interest when browsing health topic pages, then you can choose to use the advanced search utility of MEDLINEplus at the following: http://www.nlm.nih.gov/medlineplus/advancedsearch.html. This utility is similar to the NIH Search Utility, with the exception that it only includes material linked within the MEDLINEplus system (mostly patient-oriented information). It also has the disadvantage of generating unstructured results. We recommend, therefore, that you use this method only if you have a very targeted search.

The Combined Health Information Database (CHID) CHID Online is a reference tool that maintains a database directory of thousands of journal articles and patient education guidelines on diarrhea and related conditions. One of the advantages of CHID over other sources is that it offers summaries that describe the guidelines available, including contact information and pricing. CHID’s general Web site is http://chid.nih.gov/. To search this database, go to http://chid.nih.gov/detail/detail.html. In particular, you can use the advanced search options to look up pamphlets, reports, brochures, and information kits. The following was recently posted in this archive: ·

Gastrointestinal Tract in Scleroderma Source: Danvers, MA: Scleroderma Foundation. 1999. 6 p. Contact: Available from Scleroderma Foundation. 12 Kent Way, Suite 101, Byfield, MA 01922. (800) 722-4673 or (978) 463-5843. Fax (978) 4635809. E-mail: [email protected]. Website: www.scleroderma.org. PRICE: Single copy $1.00. Summary: This pamphlet provides people who have scleroderma with information on its gastrointestinal tract manifestations. The pamphlet focuses on manifestations involving the mouth, esophagus, stomach, and small intestine and large intestines. People who have scleroderma may experience dry mouth, which may lead to impairment of early digestion and occurrence of dental caries and periodontitis. Involvement of the esophagus may cause heartburn, difficulty with swallowing, and aspiration. Stomach involvement occurs in only 10 percent of patients, but it can be associated with bloating, satiety, abdominal pain, nausea, and vomiting. Involvement of the small intestine may cause nausea, vomiting, bloating, diarrhea, and malabsorption, while muscle impairment of the large intestine may result in constipation, bloating, and diarrhea. The pamphlet also includes a glossary of terms. 1 figure.

Guidelines 21

·

Diarrhea: Steps to Recovery Source: San Bruno, CA: StayWell Company. 1999. [2 p.]. Contact: Available from StayWell Company. Order Department, 1100 Grundy Lane, San Bruno, CA 94066-9821. (800) 333-3032. Fax (650) 2444512. E-mail: [email protected]. Website: www.staywell.com. PRICE: $17.95 for pack of 50; plus shipping and handling. Summary: This patient education brochure describes diarrhea and its treatment. Written in nontechnical language, the brochure first defines diarrhea as bowel movements that occur more frequently or are more watery than usual. Symptoms of diarrhea include looser, more watery stools than normal, more frequent stools than normal, more urgent need to pass stool, and pain or spasms in the digestive tract. Things that may irritate the digestive tract and lead to diarrhea include harmful bacteria or viruses or medications. Certain foods can cause diarrhea in some people; stress and anxiety can lead to diarrhea in others. Diagnosis will include the patient's medical history and some diagnostic tests such as stool sample testing and sigmoidoscopy. Treatment of the diarrhea depends on its cause. Diarrhea caused by infection needs to be treated by eradicating the underlying infection. Other treatment options can include an increase in drinking fluids, prescription medications, fasting, and following the BRAT (bananas, rice, applesauce, toast) diet. The brochure reminds readers to contact their health care provider if they have severe pain, high fever or bloody stool, or symptoms of dehydration. One section of the brochure illustrates and describes the physiology of normal bowel movements and what happens in diarrhea. The last page of the brochure summarizes the recommendations for recovering from diarrhea. The brochure is illustrated with full color line drawings. 6 figures.

·

International Foundation for Functional Gastrointestinal Disorders: Who We Are Source: Milwaukee, WI: International Foundation for Functional Gastrointestinal Disorders. 1997. 2 p. Contact: Available from International Foundation for Functional Gastrointestinal Disorders (IFFGD). P.O. Box 170864, Milwaukee, WI 53217. (888) 964-2001 or (414) 964-1799. Fax (414) 964-7176. E-mail: [email protected]. Website: www.iffgd.org. PRICE: Single copy free. Summary: The International Foundation for Functional Gastrointestinal Disorders (formerly the International Foundation for Bowel Dysfunction) is a nonprofit organization formed to address the issues surrounding life with bowel dysfunction. Functional gastrointestinal (GI) disorders

22 Diarrhea

include irritable bowel syndrome (IBS), incontinence, diarrhea, constipation, pelvic floor pain, anorectal pain, abdominal bloating or pain, esophageal disorders, gastroduodenal disorders, and biliary disorders. This brief brochure reviews the objectives and activities of the IFFGD, which offers educational services to affected people and works with the health and care provider community to research and share information. The brochure includes the names and locations of the organization's board of directors and advisory board.

The National Guideline Clearinghouse™ The National Guideline Clearinghouse™ offers hundreds of evidence-based clinical practice guidelines published in the United States and other countries. You can search their site located at http://www.guideline.gov by using the keyword “diarrhea” or synonyms. The following was recently posted: ·

American Gastroenterological Association medical position statement: guidelines for the management of malnutrition and cachexia, chronic diarrhea, and hepatobiliary disease in patients with human immunodeficiency virus infection. Source: American Gastroenterological Association.; 1996 December (reviewed 2001); 31 pages http://www.guideline.gov/FRAMESETS/guideline_fs.asp?guideline=00 0041&sSearch_string=diarrhea

·

Practice guidelines for the management of infectious diarrhea. Source: Infectious Diseases Society of America.; 2001 February; 21 pages http://www.guideline.gov/FRAMESETS/guideline_fs.asp?guideline=00 2017&sSearch_string=diarrhea

Healthfinder™ Healthfinder™ is an additional source sponsored by the U.S. Department of Health and Human Services which offers links to hundreds of other sites that contain healthcare information. This Web site is located at http://www.healthfinder.gov. Again, keyword searches can be used to find guidelines. The following was recently found in this database:

Guidelines 23

·

Brainerd Diarrhea Summary: This online mini fact sheet provides basic information on brainerd diarrhea, a gastrointestinal disorder. The fact sheet includes information about symptoms, diagnosis and treatment. Source: National Center for Infectious Diseases, Centers for Disease Control and Prevention http://www.healthfinder.gov/scripts/recordpass.asp?RecordType=0&R ecordID=2086

·

Campylobacter Summary: This document provides answers to consumers' questions about Campylobacter -- the most common bacterial cause of diarrheal illness in the United States. Source: National Center for Infectious Diseases, Centers for Disease Control and Prevention http://www.healthfinder.gov/scripts/recordpass.asp?RecordType=0&R ecordID=3880

·

Childhood Diarrhea: Messages for Parents Summary: This consumer health information brochure describes diarrhea symptoms, causes, spread and treatment and prevention. Source: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services http://www.healthfinder.gov/scripts/recordpass.asp?RecordType=0&R ecordID=5070

·

Lotronex Information Summary: This page presents information for women using the prescription drug Lotronex (alosetron hydrochloride) for treatment of the diarrhea-predominant form of irritable bowel syndrome (IBS). Source: Center for Drug Evaluation and Research, U.S. Food and Drug Administration http://www.healthfinder.gov/scripts/recordpass.asp?RecordType=0&R ecordID=5504

24 Diarrhea

·

Sigmoidoscopy Summary: Basic information about sigmoidoscopy -- a medical procedure that allows a physician to look at the inside of the large intestine to determine the cause of diarrhea, abdominal pain and constipation, Source: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health http://www.healthfinder.gov/scripts/recordpass.asp?RecordType=0&R ecordID=4977 The NIH Search Utility

After browsing the references listed at the beginning of this chapter, you may want to explore the NIH Search Utility. This allows you to search for documents on over 100 selected Web sites that comprise the NIH-WEBSPACE. Each of these servers is “crawled” and indexed on an ongoing basis. Your search will produce a list of various documents, all of which will relate in some way to diarrhea. The drawbacks of this approach are that the information is not organized by theme and that the references are often a mix of information for professionals and patients. Nevertheless, a large number of the listed Web sites provide useful background information. We can only recommend this route, therefore, for relatively rare or specific conditions or disorders, or when using highly targeted searches. To use the NIH search utility, visit the following Web page: http://search.nih.gov/index.html.

Additional Web Sources A number of Web sites that often link to government sites are available to the public. These can also point you in the direction of essential information. The following is a representative sample: ·

AOL: http://search.aol.com/cat.adp?id=168&layer=&from=subcats

·

drkoop.comÒ: http://www.drkoop.com/conditions/ency/index.html

·

Family Village: http://www.familyvillage.wisc.edu/specific.htm

·

Google: http://directory.google.com/Top/Health/Conditions_and_Diseases/

·

Med Help International: http://www.medhelp.org/HealthTopics/A.html

Guidelines 25

·

Open Directory Project: http://dmoz.org/Health/Conditions_and_Diseases/

·

Yahoo.com: http://dir.yahoo.com/Health/Diseases_and_Conditions/

·

WebMDÒHealth: http://my.webmd.com/health_topics

Vocabulary Builder The material in this chapter may have contained a number of unfamiliar words. The following Vocabulary Builder introduces you to terms used in this chapter that have not been covered in the previous chapter: Abdomen: That portion of the body that lies between the thorax and the pelvis. [NIH] Acetaminophen: Analgesic antipyretic derivative of acetanilide. It has weak anti-inflammatory properties and is used as a common analgesic, but may cause liver, blood cell, and kidney damage. [NIH] Anorectal: Pertaining to the anus and rectum or to the junction region between the two. [EU] Antibiotic: A chemical substance produced by a microorganism which has the capacity, in dilute solutions, to inhibit the growth of or to kill other microorganisms. Antibiotics that are sufficiently nontoxic to the host are used as chemotherapeutic agents in the treatment of infectious diseases of man, animals and plants. [EU] Antiviral: Destroying viruses or suppressing their replication. [EU] Anxiety: The unpleasant emotional state consisting of psychophysiological responses to anticipation of unreal or imagined danger, ostensibly resulting from unrecognized intrapsychic conflict. Physiological concomitants include increased heart rate, altered respiration rate, sweating, trembling, weakness, and fatigue; psychological concomitants include feelings of impending danger, powerlessness, apprehension, and tension. [EU] Apnea: A transient absence of spontaneous respiration. [NIH] Aspiration: The act of inhaling. [EU] Bile: An emulsifying agent produced in the liver and secreted into the duodenum. Its composition includes bile acids and salts, cholesterol, and electrolytes. It aids digestion of fats in the duodenum. [NIH] Biliary: Pertaining to the bile, to the bile ducts, or to the gallbladder. [EU] Cachexia: A profound and marked state of constitutional disorder; general ill health and malnutrition. [EU]

26 Diarrhea

Campylobacter: A genus of bacteria found in the reproductive organs, intestinal tract, and oral cavity of animals and man. Some species are pathogenic. [NIH] Carbohydrate: An aldehyde or ketone derivative of a polyhydric alcohol, particularly of the pentahydric and hexahydric alcohols. They are so named because the hydrogen and oxygen are usually in the proportion to form water, (CH2O)n. The most important carbohydrates are the starches, sugars, celluloses, and gums. They are classified into mono-, di-, tri-, poly- and heterosaccharides. [EU] Character: In current usage, approximately equivalent to personality. The sum of the relatively fixed personality traits and habitual modes of response of an individual. [NIH] Chronic: Persisting over a long period of time. [EU] Coagulation: 1. the process of clot formation. 2. in colloid chemistry, the solidification of a sol into a gelatinous mass; an alteration of a disperse phase or of a dissolved solid which causes the separation of the system into a liquid phase and an insoluble mass called the clot or curd. Coagulation is usually irreversible. 3. in surgery, the disruption of tissue by physical means to form an amorphous residuum, as in electrocoagulation and photocoagulation. [EU] Colitis: Inflammation of the colon. [EU] Colonoscopy: Endoscopic examination, therapy or surgery of the luminal surface of the colon. [NIH] Colorectal: Pertaining to or affecting the colon and rectum. [EU] Constipation: Infrequent or difficult evacuation of the faeces. [EU] Cryosurgery: The use of freezing as a special surgical technique to destroy or excise tissue. [NIH] Cryptosporidium: A genus of coccidian parasites of the family cryptosporidiidae, found in the intestinal epithelium of many vertebrates including humans. [NIH] Cytomegalovirus: A genus of the family herpesviridae, subfamily betaherpesvirinae, infecting the salivary glands, liver, spleen, lungs, eyes, and other organs, in which they produce characteristically enlarged cells with intranuclear inclusions. Infection with Cytomegalovirus is also seen as an opportunistic infection in AIDS. [NIH] Defecation: The normal process of elimination of fecal material from the rectum. [NIH] Dehydration: The condition that results from excessive loss of body water. Called also anhydration, deaquation and hypohydration. [EU] Diarrhea: Passage of excessively liquid or excessively frequent stools. [NIH]

Guidelines 27

Digestion: The process of breakdown of food for metabolism and use by the body. [NIH] Electrolyte: A substance that dissociates into ions when fused or in solution, and thus becomes capable of conducting electricity; an ionic solute. [EU] Endocrinology: A subspecialty of internal medicine concerned with the metabolism, physiology, and disorders of the endocrine system. [NIH] Enema: A clyster or injection; a liquid injected or to be injected into the rectum. [EU] Entamoeba: A genus of ameboid protozoa characterized by the presence of beaded chromatin on the inner surface of the nuclear membrane. Its organisms are parasitic in invertebrates and vertebrates, including humans. [NIH]

Enzyme: A protein molecule that catalyses chemical reactions of other substances without itself being destroyed or altered upon completion of the reactions. Enzymes are classified according to the recommendations of the Nomenclature Committee of the International Union of Biochemistry. Each enzyme is assigned a recommended name and an Enzyme Commission (EC) number. They are divided into six main groups; oxidoreductases, transferases, hydrolases, lyases, isomerases, and ligases. [EU] Escherichia: A genus of gram-negative, facultatively anaerobic, rod-shaped bacteria whose organisms occur in the lower part of the intestine of warmblooded animals. The species are either nonpathogenic or opportunistic pathogens. [NIH] Fatigue: The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. [NIH] Fissure: Any cleft or groove, normal or otherwise; especially a deep fold in the cerebral cortex which involves the entire thickness of the brain wall. [EU] Flushing: A transient reddening of the face that may be due to fever, certain drugs, exertion, stress, or a disease process. [NIH] Gastroduodenal: Pertaining to or communicating with the stomach and duodenum, as a gastroduodenal fistula. [EU] Gastrostomy: Creation of an artificial external opening into the stomach for nutritional support or gastrointestinal compression. [NIH] Giardia: A genus of flagellate intestinal protozoa parasitic in various vertebrates, including humans. Characteristics include the presence of four pairs of flagella arising from a complicated system of axonemes and cysts that are ellipsoidal to ovoidal in shape. [NIH] Heartburn: Substernal pain or burning sensation, usually associated with regurgitation of gastric juice into the esophagus. [NIH]

28 Diarrhea

Hematology: A subspecialty of internal medicine concerned with morphology, physiology, and pathology of the blood and blood-forming tissues. [NIH] Hemorrhoids: Varicosities of the hemorrhoidal venous plexuses. [NIH] Hepatitis: Inflammation of the liver. [EU] Hepatobiliary: Pertaining to the liver and the bile or the biliary ducts. [EU] Herpes: Any inflammatory skin disease caused by a herpesvirus and characterized by the formation of clusters of small vesicles. When used alone, the term may refer to herpes simplex or to herpes zoster. [EU] Incontinence: Inability to control excretory functions, as defecation (faecal i.) or urination (urinary i.). [EU] Inflammation: A pathological process characterized by injury or destruction of tissues caused by a variety of cytologic and chemical reactions. It is usually manifested by typical signs of pain, heat, redness, swelling, and loss of function. [NIH] Intestines: The section of the alimentary canal from the stomach to the anus. It includes the large intestine and small intestine. [NIH] Jaundice: A clinical manifestation of hyperbilirubinemia, consisting of deposition of bile pigments in the skin, resulting in a yellowish staining of the skin and mucous membranes. [NIH] Malabsorption: Impaired intestinal absorption of nutrients. [EU] Molecular: Of, pertaining to, or composed of molecules : a very small mass of matter. [EU] Motility: The ability to move spontaneously. [EU] Nausea: An unpleasant sensation, vaguely referred to the epigastrium and abdomen, and often culminating in vomiting. [EU] Oral: Pertaining to the mouth, taken through or applied in the mouth, as an oral medication or an oral thermometer. [EU] Parasitic: Pertaining to, of the nature of, or caused by a parasite. [EU] Pediatrics: A medical specialty concerned with maintaining health and providing medical care to children from birth to adolescence. [NIH] Potassium: An element that is in the alkali group of metals. It has an atomic symbol K, atomic number 19, and atomic weight 39.10. It is the chief cation in the intracellular fluid of muscle and other cells. Potassium ion is a strong electrolyte and it plays a significant role in the regulation of fluid volume and maintenance of the water-electrolyte balance. [NIH] Radiology: A specialty concerned with the use of x-ray and other forms of radiant energy in the diagnosis and treatment of disease. [NIH]

Guidelines 29

Rehydration: The restoration of water or of fluid content to a body or to substance which has become dehydrated. [EU] Remission: A diminution or abatement of the symptoms of a disease; also the period during which such diminution occurs. [EU] Rotavirus: A genus of reoviridae, causing acute gastroenteritis in birds and mammals, including humans. Transmission is horizontal and by environmental contamination. [NIH] Salmonella: A genus of gram-negative, facultatively anaerobic, rod-shaped bacteria that utilizes citrate as a sole carbon source. It is pathogenic for humans, causing enteric fevers, gastroenteritis, and bacteremia. Food poisoning is the most common clinical manifestation. Organisms within this genus are separated on the basis of antigenic characteristics, sugar fermentation patterns, and bacteriophage susceptibility. [NIH] Sedentary: 1. sitting habitually; of inactive habits. 2. pertaining to a sitting posture. [EU] Seizures: Clinical or subclinical disturbances of cortical function due to a sudden, abnormal, excessive, and disorganized discharge of brain cells. Clinical manifestations include abnormal motor, sensory and psychic phenomena. Recurrent seizures are usually referred to as EPILEPSY or "seizure disorder." [NIH] Senna: Preparations of Cassia senna L. and C. angustifolia of the Leguminosae. They contain sennosides, which are anthraquinone type cathartics and are used in many different preparations as laxatives. [NIH] Sigmoidoscopy: Endoscopic examination, therapy or surgery of the sigmoid flexure. [NIH] Spectrum: A charted band of wavelengths of electromagnetic vibrations obtained by refraction and diffraction. By extension, a measurable range of activity, such as the range of bacteria affected by an antibiotic (antibacterial s.) or the complete range of manifestations of a disease. [EU] Stomach: An organ of digestion situated in the left upper quadrant of the abdomen between the termination of the esophagus and the beginning of the duodenum. [NIH] Toxicology: The science concerned with the detection, chemical composition, and pharmacologic action of toxic substances or poisons and the treatment and prevention of toxic manifestations. [NIH] Urology: A surgical specialty concerned with the study, diagnosis, and treatment of diseases of the urinary tract in both sexes and the genital tract in the male. It includes the specialty of andrology which addresses both male genital diseases and male infertility. [NIH] Viruses: Minute infectious agents whose genomes are composed of DNA or

30 Diarrhea

RNA, but not both. They are characterized by a lack of independent metabolism and the inability to replicate outside living host cells. [NIH] Withdrawal: 1. a pathological retreat from interpersonal contact and social involvement, as may occur in schizophrenia, depression, or schizoid avoidant and schizotypal personality disorders. 2. (DSM III-R) a substancespecific organic brain syndrome that follows the cessation of use or reduction in intake of a psychoactive substance that had been regularly used to induce a state of intoxication. [EU]

Seeking Guidance 31

CHAPTER 2. SEEKING GUIDANCE Overview Some patients are comforted by the knowledge that a number of organizations dedicate their resources to helping people with diarrhea. These associations can become invaluable sources of information and advice. Many associations offer aftercare support, financial assistance, and other important services. Furthermore, healthcare research has shown that support groups often help people to better cope with their conditions.8 In addition to support groups, your physician can be a valuable source of guidance and support. Therefore, finding a physician that can work with your unique situation is a very important aspect of your care. In this chapter, we direct you to resources that can help you find patient organizations and medical specialists. We begin by describing how to find associations and peer groups that can help you better understand and cope with diarrhea. The chapter ends with a discussion on how to find a doctor that is right for you.

Associations and Diarrhea As mentioned by the Agency for Healthcare Research and Quality, sometimes the emotional side of a condition or disorder can be as taxing as the physical side.9 You may have fears or feel overwhelmed by your situation. Everyone has different ways of dealing with disease or physical injury. Your attitude, your expectations, and how well you cope with your Churches, synagogues, and other houses of worship might also have groups that can offer you the social support you need. 9 This section has been adapted from http://www.ahcpr.gov/consumer/diaginf5.htm. 8

32 Diarrhea

condition can all influence your well-being. This is true for both minor conditions and serious illnesses. For example, a study on female breast cancer survivors revealed that women who participated in support groups lived longer and experienced better quality of life when compared with women who did not participate. In the support group, women learned coping skills and had the opportunity to share their feelings with other women in the same situation. In addition to associations or groups that your doctor might recommend, we suggest that you consider the following list (if there is a fee for an association, you may want to check with your insurance provider to find out if the cost will be covered): ·

International Foundation for Functional Gastrointestinal Disorders Address: International Foundation for Functional Gastrointestinal Disorders P.O. Box 17864, Milwaukee, WI 53217 Telephone: (414) 964-1799 Toll-free: (888) 964-2001 Fax: (414) 964-7176 Email: [email protected] Web Site: http://www.iffgd.or Background: The International Foundation for Functional Gastrointestinal Disorders (IFFGD) is a nonprofit educational and research organization dedicated to addressing the issues affecting individuals with functional gastrointestinal (GI) disorders. These disorders include irritable bowel syndrome (IBS), incontinence, diarrhea, constipation, pelvic floor pain, anorectal pain, abdominal bloating or pain, esophageal disorders, gastroduodenal disorders, and biliary disorders. Founded in 1990 and consisting of approximately 20,000 members, IFFGD offers support to affected individuals and their families. The Foundation also works with the medical, health care, and research communities to increase awareness of these disorders and to promote research efforts to improve diagnosis and treatment. Educational materials include a quarterly newsletter entitled 'Participate' and several fact sheets on various gastrointestinal disorders and their treatment alternatives. IFFGD also distributes a 'Personal Daily Diary' that is designed to help individuals with gastrointestinal disorders gain a more complete understanding of their condition through the regular recording of important details. Relevant area(s) of interest: Constipation, Diarrhea, Irritable Bowel Syndrome

Seeking Guidance 33

·

Intestinal Disease Foundation Address: Intestinal Disease Foundation 1323 Forbes Avenue, Suite 200, Pittsburgh, PA 15219 Telephone: (412) 261-5888 Toll-free: (888) 964-2001 Fax: (412) 471-272 Background: The Intestinal Disease Foundation (IDF) is an international not- for-profit organization dedicated to providing information, assistance, and mutual support to individuals with chronic intestinal illnesses including irritable bowel syndrome, diverticular disease, ulcerative colitis, Crohn's disease, and short-bowel syndrome. Established in 1986 and consisting of 1,400 members in the United States and abroad, IDF promotes healing by encouraging individuals to assume an active role in their own treatment through a positive mental attitude founded on shared experiences. This is facilitated by a telephone network of individuals with intestinal illnesses who provide support, encouragement, and information. The Foundation publishes a quarterly newsletter entitled 'Intestinal Fortitude' as well as a variety of informational brochures and educational materials on chronic intestinal diseases and conditions. Relevant area(s) of interest: Diarrhea, Diverticular Disease, Irritable Bowel Syndrome, Lactose Intolerance, Proctitis, Short Bowel Syndrome

Finding More Associations There are a number of directories that list additional medical associations that you may find useful. While not all of these directories will provide different information than what is listed above, by consulting all of them, you will have nearly exhausted all sources for patient associations.

The National Health Information Center (NHIC) The National Health Information Center (NHIC) offers a free referral service to help people find organizations that provide information about diarrhea. For more information, see the NHIC’s Web site at http://www.health.gov/NHIC/ or contact an information specialist by calling 1-800-336-4797.

34 Diarrhea

DIRLINE A comprehensive source of information on associations is the DIRLINE database maintained by the National Library of Medicine. The database comprises some 10,000 records of organizations, research centers, and government institutes and associations which primarily focus on health and biomedicine. DIRLINE is available via the Internet at the following Web site: http://dirline.nlm.nih.gov/. Simply type in “diarrhea” (or a synonym) or the name of a topic, and the site will list information contained in the database on all relevant organizations.

The Combined Health Information Database Another comprehensive source of information on healthcare associations is the Combined Health Information Database. Using the “Detailed Search” option, you will need to limit your search to “Organizations” and “diarrhea”. Type the following hyperlink into your Web browser: http://chid.nih.gov/detail/detail.html. To find associations, use the drop boxes at the bottom of the search page where “You may refine your search by.” For publication date, select “All Years.” Then, select your preferred language and the format option “Organization Resource Sheet.” By making these selections and typing in “diarrhea” (or synonyms) into the “For these words:” box, you will only receive results on organizations dealing with diarrhea. You should check back periodically with this database since it is updated every 3 months. The National Organization for Rare Disorders, Inc. The National Organization for Rare Disorders, Inc. has prepared a Web site that provides, at no charge, lists of associations organized by specific conditions and diseases. You can access this database at the following Web site: http://www.rarediseases.org/cgi-bin/nord/searchpage. Select the option called “Organizational Database (ODB)” and type “diarrhea” (or a synonym) in the search box. Online Support Groups In addition to support groups, commercial Internet service providers offer forums and chat rooms for people with different illnesses and conditions. WebMDÒ, for example, offers such a service at their Web site:

Seeking Guidance 35

http://boards.webmd.com/roundtable. These online self-help communities can help you connect with a network of people whose concerns are similar to yours. Online support groups are places where people can talk informally. If you read about a novel approach, consult with your doctor or other healthcare providers, as the treatments or discoveries you hear about may not be scientifically proven to be safe and effective.

Finding Doctors One of the most important aspects of your treatment will be the relationship between you and your doctor or specialist. All patients with diarrhea must go through the process of selecting a physician. While this process will vary from person to person, the Agency for Healthcare Research and Quality makes a number of suggestions, including the following:10 ·

If you are in a managed care plan, check the plan’s list of doctors first.

·

Ask doctors or other health professionals who work with doctors, such as hospital nurses, for referrals.

·

Call a hospital’s doctor referral service, but keep in mind that these services usually refer you to doctors on staff at that particular hospital. The services do not have information on the quality of care that these doctors provide.

·

Some local medical societies offer lists of member doctors. Again, these lists do not have information on the quality of care that these doctors provide.

Additional steps you can take to locate doctors include the following: ·

Check with the associations listed earlier in this chapter.

·

Information on doctors in some states is available on the Internet at http://www.docboard.org. This Web site is run by “Administrators in Medicine,” a group of state medical board directors.

·

The American Board of Medical Specialties can tell you if your doctor is board certified. “Certified” means that the doctor has completed a training program in a specialty and has passed an exam, or “board,” to assess his or her knowledge, skills, and experience to provide quality patient care in that specialty. Primary care doctors may also be certified as specialists. The AMBS Web site is located at

10

This section is adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm.

36 Diarrhea

http://www.abms.org/newsearch.asp.11 You can also contact the ABMS by phone at 1-866-ASK-ABMS. ·

You can call the American Medical Association (AMA) at 800-665-2882 for information on training, specialties, and board certification for many licensed doctors in the United States. This information also can be found in “Physician Select” at the AMA’s Web site: http://www.amaassn.org/aps/amahg.htm.

If the previous sources did not meet your needs, you may want to log on to the Web site of the National Organization for Rare Disorders (NORD) at http://www.rarediseases.org/. NORD maintains a database of doctors with expertise in various rare conditions and diseases. The Metabolic Information Network (MIN), 800-945-2188, also maintains a database of physicians with expertise in various metabolic diseases.

Selecting Your Doctor12 When you have compiled a list of prospective doctors, call each of their offices. First, ask if the doctor accepts your health insurance plan and if he or she is taking new patients. If the doctor is not covered by your plan, ask yourself if you are prepared to pay the extra costs. The next step is to schedule a visit with your chosen physician. During the first visit you will have the opportunity to evaluate your doctor and to find out if you feel comfortable with him or her. Ask yourself, did the doctor: ·

Give me a chance to ask questions about diarrhea?

·

Really listen to my questions?

·

Answer in terms I understood?

·

Show respect for me?

·

Ask me questions?

·

Make me feel comfortable?

·

Address the health problem(s) I came with?

·

Ask me my preferences about different kinds of treatments for diarrhea?

·

Spend enough time with me?

While board certification is a good measure of a doctor’s knowledge, it is possible to receive quality care from doctors who are not board certified. 12 This section has been adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm. 11

Seeking Guidance 37

Trust your instincts when deciding if the doctor is right for you. But remember, it might take time for the relationship to develop. It takes more than one visit for you and your doctor to get to know each other.

Working with Your Doctor13 Research has shown that patients who have good relationships with their doctors tend to be more satisfied with their care and have better results. Here are some tips to help you and your doctor become partners: ·

You know important things about your symptoms and your health history. Tell your doctor what you think he or she needs to know.

·

It is important to tell your doctor personal information, even if it makes you feel embarrassed or uncomfortable.

·

Bring a “health history” list with you (and keep it up to date).

·

Always bring any medications you are currently taking with you to the appointment, or you can bring a list of your medications including dosage and frequency information. Talk about any allergies or reactions you have had to your medications.

·

Tell your doctor about any natural or alternative medicines you are taking.

·

Bring other medical information, such as x-ray films, test results, and medical records.

·

Ask questions. If you don’t, your doctor will assume that you understood everything that was said.

·

Write down your questions before your visit. List the most important ones first to make sure that they are addressed.

·

Consider bringing a friend with you to the appointment to help you ask questions. This person can also help you understand and/or remember the answers.

·

Ask your doctor to draw pictures if you think that this would help you understand.

·

Take notes. Some doctors do not mind if you bring a tape recorder to help you remember things, but always ask first.

This section has been adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm.

13

38 Diarrhea

·

Let your doctor know if you need more time. If there is not time that day, perhaps you can speak to a nurse or physician assistant on staff or schedule a telephone appointment.

·

Take information home. Ask for written instructions. Your doctor may also have brochures and audio and videotapes that can help you.

·

After leaving the doctor’s office, take responsibility for your care. If you have questions, call. If your symptoms get worse or if you have problems with your medication, call. If you had tests and do not hear from your doctor, call for your test results. If your doctor recommended that you have certain tests, schedule an appointment to get them done. If your doctor said you should see an additional specialist, make an appointment.

By following these steps, you will enhance the relationship you will have with your physician.

Broader Health-Related Resources In addition to the references above, the NIH has set up guidance Web sites that can help patients find healthcare professionals. These include:14 ·

Caregivers: http://www.nlm.nih.gov/medlineplus/caregivers.html

·

Choosing a Doctor or Healthcare Service: http://www.nlm.nih.gov/medlineplus/choosingadoctororhealthcareserv ice.html

·

Hospitals and Health Facilities: http://www.nlm.nih.gov/medlineplus/healthfacilities.html

Vocabulary Builder The following vocabulary builder provides definitions of words used in this chapter that have not been defined in previous chapters: Anemia: A reduction in the number of circulating erythrocytes or in the quantity of hemoglobin. [NIH] You can access this information at: http://www.nlm.nih.gov/medlineplus/healthsystem.html.

14

Seeking Guidance 39

Blister: Visible accumulations of fluid within or beneath the epidermis. [NIH] Dermatitis: Inflammation of the skin. [EU] Gluten: The protein of wheat and other grains which gives to the dough its tough elastic character. [EU] Ileitis: Inflammation of the ileum. [EU] Immunity: The condition of being immune; the protection against infectious disease conferred either by the immune response generated by immunization or previous infection or by other nonimmunologic factors (innate i.). [EU] Incubation: The development of an infectious disease from the entrance of the pathogen to the appearance of clinical symptoms. [EU] Ingestion: The act of taking food, medicines, etc., into the body, by mouth. [EU]

Pancreas: An organ behind the lower part of the stomach that is about the size of a hand. It makes insulin so that the body can use glucose (sugar) for energy. It also makes enzymes that help the body digest food. Spread all over the pancreas are areas called the islets of Langerhans. The cells in these areas each have a special purpose. The alpha cells make glucagon, which raises the level of glucose in the blood; the beta cells make insulin; the delta cells make somatostatin. There are also the PP cells and the D1 cells, about which little is known. [NIH] Proctitis: Inflammation of the rectum. [EU] Progressive: Advancing; going forward; going from bad to worse; increasing in scope or severity. [EU] Secretion: 1. the process of elaborating a specific product as a result of the activity of a gland; this activity may range from separating a specific substance of the blood to the elaboration of a new chemical substance. 2. any substance produced by secretion. [EU] Sweat: The fluid excreted by the sweat glands. It consists of water containing sodium chloride, phosphate, urea, ammonia, and other waste products. [NIH] Thrombocytopenia: Decrease in the number of blood platelets. [EU] Tryptophan: An essential amino acid that is necessary for normal growth in infants and for nitrogen balance in adults. It is a precursor serotonin and niacin. [NIH] Ulceration: 1. the formation or development of an ulcer. 2. an ulcer. [EU]

Clinical Trials 41

CHAPTER 3. CLINICAL TRIALS AND DIARRHEA Overview Very few medical conditions have a single treatment. The basic treatment guidelines that your physician has discussed with you, or those that you have found using the techniques discussed in Chapter 1, may provide you with all that you will require. For some patients, current treatments can be enhanced with new or innovative techniques currently under investigation. In this chapter, we will describe how clinical trials work and show you how to keep informed of trials concerning diarrhea.

What Is a Clinical Trial?15 Clinical trials involve the participation of people in medical research. Most medical research begins with studies in test tubes and on animals. Treatments that show promise in these early studies may then be tried with people. The only sure way to find out whether a new treatment is safe, effective, and better than other treatments for diarrhea is to try it on patients in a clinical trial.

What Kinds of Clinical Trials Are There? Clinical trials are carried out in three phases:

The discussion in this chapter has been adapted from the NIH and the NEI: www.nei.nih.gov/netrials/ctivr.htm.

15

42 Diarrhea

·

Phase I. Researchers first conduct Phase I trials with small numbers of patients and healthy volunteers. If the new treatment is a medication, researchers also try to determine how much of it can be given safely.

·

Phase II. Researchers conduct Phase II trials in small numbers of patients to find out the effect of a new treatment on diarrhea.

·

Phase III. Finally, researchers conduct Phase III trials to find out how new treatments for diarrhea compare with standard treatments already being used. Phase III trials also help to determine if new treatments have any side effects. These trials--which may involve hundreds, perhaps thousands, of people--can also compare new treatments with no treatment. How Is a Clinical Trial Conducted?

Various organizations support clinical trials at medical centers, hospitals, universities, and doctors’ offices across the United States. The “principal investigator” is the researcher in charge of the study at each facility participating in the clinical trial. Most clinical trial researchers are medical doctors, academic researchers, and specialists. The “clinic coordinator” knows all about how the study works and makes all the arrangements for your visits. All doctors and researchers who take part in the study on diarrhea carefully follow a detailed treatment plan called a protocol. This plan fully explains how the doctors will treat you in the study. The “protocol” ensures that all patients are treated in the same way, no matter where they receive care. Clinical trials are controlled. This means that researchers compare the effects of the new treatment with those of the standard treatment. In some cases, when no standard treatment exists, the new treatment is compared with no treatment. Patients who receive the new treatment are in the treatment group. Patients who receive a standard treatment or no treatment are in the “control” group. In some clinical trials, patients in the treatment group get a new medication while those in the control group get a placebo. A placebo is a harmless substance, a “dummy” pill, that has no effect on diarrhea. In other clinical trials, where a new surgery or device (not a medicine) is being tested, patients in the control group may receive a “sham treatment.” This treatment, like a placebo, has no effect on diarrhea and does not harm patients. Researchers assign patients “randomly” to the treatment or control group. This is like flipping a coin to decide which patients are in each group. If you

Clinical Trials 43

choose to participate in a clinical trial, you will not know which group you will be appointed to. The chance of any patient getting the new treatment is about 50 percent. You cannot request to receive the new treatment instead of the placebo or sham treatment. Often, you will not know until the study is over whether you have been in the treatment group or the control group. This is called a “masked” study. In some trials, neither doctors nor patients know who is getting which treatment. This is called a “double masked” study. These types of trials help to ensure that the perceptions of the patients or doctors will not affect the study results. Natural History Studies Unlike clinical trials in which patient volunteers may receive new treatments, natural history studies provide important information to researchers on how diarrhea develops over time. A natural history study follows patient volunteers to see how factors such as age, sex, race, or family history might make some people more or less at risk for diarrhea. A natural history study may also tell researchers if diet, lifestyle, or occupation affects how a disease or disorder develops and progresses. Results from these studies provide information that helps answer questions such as: How fast will a condition or disorder usually progress? How bad will the condition become? Will treatment be needed? What Is Expected of Patients in a Clinical Trial? Not everyone can take part in a clinical trial for a specific condition or disorder. Each study enrolls patients with certain features or eligibility criteria. These criteria may include the type and stage of a condition or disorder, as well as, the age and previous treatment history of the patient. You or your doctor can contact the sponsoring organization to find out more about specific clinical trials and their eligibility criteria. If you are interested in joining a clinical trial, your doctor must contact one of the trial’s investigators and provide details about your diagnosis and medical history. If you participate in a clinical trial, you may be required to have a number of medical tests. You may also need to take medications and/or undergo surgery. Depending upon the treatment and the examination procedure, you may be required to receive inpatient hospital care. Or, you may have to return to the medical facility for follow-up examinations. These exams help find out how well the treatment is working. Follow-up studies can take months or years. However, the success of the clinical trial often depends on

44 Diarrhea

learning what happens to patients over a long period of time. Only patients who continue to return for follow-up examinations can provide this important long-term information.

Recent Trials on Diarrhea The National Institutes of Health and other organizations sponsor trials on various conditions and disorders. Because funding for research goes to the medical areas that show promising research opportunities, it is not possible for the NIH or others to sponsor clinical trials for every disease and disorder at all times. The following lists recent trials dedicated to diarrhea.16 If the trial listed by the NIH is still recruiting, you may be eligible. If it is no longer recruiting or has been completed, then you can contact the sponsors to learn more about the study and, if published, the results. Further information on the trial is available at the Web site indicated. Please note that some trials may no longer be recruiting patients or are otherwise closed. Before contacting sponsors of a clinical trial, consult with your physician who can help you determine if you might benefit from participation. ·

A phase II, randomized, open-label, controlled, dose-elevation, multicenter trial of an investigational drug for the prevention of diarrhea associated with Irinotecan/5FU/Leucovorin chemotherapy in patients with previously untreated metastatic colorectal cancer Condition(s): Colorectal Neoplasms; Diarrhea Study Status: This study is currently recruiting patients. Purpose - Excerpt: The study will combine a new investigational drug with standard anti-cancer drugs for the treatment of advanced colorectal cancer. The standard and approved treatment for colorectal cancer is to undergo chemotherapy with a combination of irinotecan (also known as CPT-11, Camptosar), 5-fluorouracil (also known as 5-FU), and leucovorin (also known as LV). This is known as the triple therapy. One of the major side effects of CPT-11/5-FU/LV chemotherapy treatment is diarrhea. The purpose of this research study is to see whether adding this investigational drug to the standard treatment for advanced colorectal cancer can reduce the amount of diarrhea a patient experiences. This study will also determine if adding the investigational drug to triple therapy has a positive effect on tumors. Contact(s): see Web site below Web Site:

16

These are listed at www.ClinicalTrials.gov.

Clinical Trials 45

http://clinicaltrials.gov/ct/gui/show/NCT00040391;jsessionid=D225A1 2009E47222F0732694B3723632 ·

A Study of GT160-246 Versus Vancomycin in Patients with Clostridium difficile-Associated Diarrhea Condition(s): Clostridium difficile-Associated Diarrhea; Clostridium Enterocolitis; Clostridium Difficile Diarrhea; Antibiotic-Associated Colitis; Antibiotic-Associated Diarrhea Study Status: This study is currently recruiting patients. Sponsor(s): GelTex Pharmaceuticals Purpose - Excerpt: Approximately 300 patients will be entered into this study taking place throughout the United States, Canada and the United Kingdom. This study aims to determine if an investigational drug is safe and effective for treating the symptoms of C. difficile-associated diarrhea and lowering the risk of repeat episodes of diarrhea. The investigational drug will be evaluated in comparison to current standard antibiotic treatment, so all patients will receive active medication. All study-related care is provided including doctor visits, physical exams, laboratory tests and study medication. Total length of participation is approximately 10 weeks. Phase(s): Phase II Study Type: Interventional Contact(s): see Web site below Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00034294;jsessionid=D225A1 2009E47222F0732694B3723632

·

A Study to Evaluate the Use of Nitazoxanide to Treat Cryptosporidiosis (Diarrhea Caused by the Parasite Cryptosporidium) Condition(s): Cryptosporidiosis; HIV Infections Study Status: This study is currently recruiting patients. Sponsor(s): Romark Laboratories L.C. Purpose - Excerpt: The purpose of this study is to see if nitazoxanide (NTZ) can be used to treat AIDS patients suffering from cryptosporidiosis (diarrhea caused by the parasite Cryptosporidium). Study Type: Interventional Contact(s): Florida; Romark Laboratories LC, Tampa, Florida, 33607, United States; Recruiting; Julie Ryner 813-282-8544 Web Site:

46 Diarrhea

http://clinicaltrials.gov/ct/gui/show/NCT00002158;jsessionid=D225A1 2009E47222F0732694B3723632 ·

Acupuncture and Moxa: A RCT for Chronic Diarrhea in HIV Patients Condition(s): HIV Infections Study Status: This study is currently recruiting patients. Sponsor(s): National Center for Complementary and Alternative Medicine (NCCAM); National Institute of Nursing Research (NINR) Purpose - Excerpt: The objective of this study is to test alternative treatment strategies to reduce the frequency of chronic diarrhea among HIV positive individuals. 60 percent of patients with HIV disease in the U.S. will have diarrhea at some point in their illness. Although in general many of the opportunistic infections (OI's) associated with HIV have decreased due to new "drug cocktails", many of these drugs, however, have diarrhea as a side effect. In Asian countries, acupuncture (including moxibustion) has been widely used for the treatment of various gastrointestinal (GI) disorders. However, there are no published studies that test treatment protocols using acupuncture or moxibustion on patients with HIV experiencing chronic diarrhea. Phase(s): Phase II Study Type: Interventional Contact(s): Ann M. Chung 212-305-3041 [email protected]; New York; Columbia University, New York, New York, United States; Recruiting. Study chairs or principal investigators: Joyce K. Anastasi, PhD,RN,LAc, Principal Investigator; School of Nursing Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00010491;jsessionid=D225A1 2009E47222F0732694B3723632

·

For Prevention of Diarrhea in Patients Diagnosed with Metastatic Colorectal Cancer Treated with Chemotherapy Condition(s): Neoplasm Metastasis; Colorectal Neoplasms Study Status: This study is currently recruiting patients. Purpose - Excerpt: The Diarrhea Prevention with an investigational drug trial, will evaluate whether adding an investigational drug to the standard treatment for advanced colorectal cancer can reduce the amount of diarrhea a patient experiences. The standard and approved treatment for patients with metastatic colorectal cancer is repeated cycles of chemotherapy consisting of a combination of irinotecan (also known as

Clinical Trials 47

CPT-11, Camptosar), 5-fluorouracil (also known as 5FU), and leucovorin (also known as LV). Preclinical data from animal models suggest that the investigational drug may offer an effective means for preventing CPT11/5FU/LV-induced diarrhea. It is also hypothesized that the investigational drug-mediated anti-angiogenesis could induce a favorable tumor response. Contact(s): see Web site below Web Site: http://clinicaltrials.gov/ct/gui/show/NCT00037180;jsessionid=D225A1 2009E47222F0732694B3723632

Benefits and Risks17 What Are the Benefits of Participating in a Clinical Trial? If you are interested in a clinical trial, it is important to realize that your participation can bring many benefits to you and society at large: ·

A new treatment could be more effective than the current treatment for diarrhea. Although only half of the participants in a clinical trial receive the experimental treatment, if the new treatment is proved to be more effective and safer than the current treatment, then those patients who did not receive the new treatment during the clinical trial may be among the first to benefit from it when the study is over.

·

If the treatment is effective, then it may improve health or prevent diseases or disorders.

·

Clinical trial patients receive the highest quality of medical care. Experts watch them closely during the study and may continue to follow them after the study is over.

·

People who take part in trials contribute to scientific discoveries that may help other people with diarrhea. In cases where certain conditions or disorders run in families, your participation may lead to better care or prevention for your family members.

This section has been adapted from ClinicalTrials.gov, a service of the National Institutes of Health: http://www.clinicaltrials.gov/ct/gui/c/a1r/info/whatis?JServSessionIdzone_ct=9jmun6f2 91. 17

48 Diarrhea

The Informed Consent Once you agree to take part in a clinical trial, you will be asked to sign an “informed consent.” This document explains a clinical trial’s risks and benefits, the researcher’s expectations of you, and your rights as a patient. What Are the Risks? Clinical trials may involve risks as well as benefits. Whether or not a new treatment will work cannot be known ahead of time. There is always a chance that a new treatment may not work better than a standard treatment. There is also the possibility that it may be harmful. The treatment you receive may cause side effects that are serious enough to require medical attention. How Is Patient Safety Protected? Clinical trials can raise fears of the unknown. Understanding the safeguards that protect patients can ease some of these fears. Before a clinical trial begins, researchers must get approval from their hospital’s Institutional Review Board (IRB), an advisory group that makes sure a clinical trial is designed to protect patient safety. During a clinical trial, doctors will closely watch you to see if the treatment is working and if you are experiencing any side effects. All the results are carefully recorded and reviewed. In many cases, experts from the Data and Safety Monitoring Committee carefully monitor each clinical trial and can recommend that a study be stopped at any time. You will only be asked to take part in a clinical trial as a volunteer giving informed consent.

What Are a Patient’s Rights in a Clinical Trial? If you are eligible for a clinical trial, you will be given information to help you decide whether or not you want to participate. As a patient, you have the right to: ·

Information on all known risks and benefits of the treatments in the study.

·

Know how the researchers plan to carry out the study, for how long, and where.

·

Know what is expected of you.

Clinical Trials 49

·

Know any costs involved for you or your insurance provider.

·

Know before any of your medical or personal information is shared with other researchers involved in the clinical trial.

·

Talk openly with doctors and ask any questions.

After you join a clinical trial, you have the right to: ·

Leave the study at any time. Participation is strictly voluntary. However, you should not enroll if you do not plan to complete the study.

·

Receive any new information about the new treatment.

·

Continue to ask questions and get answers.

·

Maintain your privacy. Your name will not appear in any reports based on the study.

·

Know whether you participated in the treatment group or the control group (once the study has been completed).

What about Costs? In some clinical trials, the research facility pays for treatment costs and other associated expenses. You or your insurance provider may have to pay for costs that are considered standard care. These things may include inpatient hospital care, laboratory and other tests, and medical procedures. You also may need to pay for travel between your home and the clinic. You should find out about costs before committing to participation in the trial. If you have health insurance, find out exactly what it will cover. If you don’t have health insurance, or if your insurance company will not cover your costs, talk to the clinic staff about other options for covering the cost of your care. What Questions Should You Ask before Deciding to Join a Clinical Trial? Questions you should ask when thinking about joining a clinical trial include the following: ·

What is the purpose of the clinical trial?

·

What are the standard treatments for diarrhea? Why do researchers think the new treatment may be better? What is likely to happen to me with or without the new treatment?

50 Diarrhea

·

What tests and treatments will I need? Will I need surgery? Medication? Hospitalization?

·

How long will the treatment last? How often will I have to come back for follow-up exams?

·

What are the treatment’s possible benefits to my condition? What are the short- and long-term risks? What are the possible side effects?

·

Will the treatment be uncomfortable? Will it make me feel sick? If so, for how long?

·

How will my health be monitored?

·

Where will I need to go for the clinical trial? How will I get there?

·

How much will it cost to be in the study? What costs are covered by the study? How much will my health insurance cover?

·

Will I be able to see my own doctor? Who will be in charge of my care?

·

Will taking part in the study affect my daily life? Do I have time to participate?

·

How do I feel about taking part in a clinical trial? Are there family members or friends who may benefit from my contributions to new medical knowledge?

Keeping Current on Clinical Trials Various government agencies maintain databases on trials. The U.S. National Institutes of Health, through the National Library of Medicine, has developed ClinicalTrials.gov to provide patients, family members, and physicians with current information about clinical research across the broadest number of diseases and conditions. The site was launched in February 2000 and currently contains approximately 5,700 clinical studies in over 59,000 locations worldwide, with most studies being conducted in the United States. ClinicalTrials.gov receives about 2 million hits per month and hosts approximately 5,400 visitors daily. To access this database, simply go to their Web site (www.clinicaltrials.gov) and search by “diarrhea” (or synonyms). While ClinicalTrials.gov is the most comprehensive listing of NIH-supported clinical trials available, not all trials are in the database. The database is updated regularly, so clinical trials are continually being added. The

Clinical Trials 51

following is a list of specialty databases affiliated with the National Institutes of Health that offer additional information on trials: ·

For clinical studies at the Warren Grant Magnuson Clinical Center located in Bethesda, Maryland, visit their Web site: http://clinicalstudies.info.nih.gov/

·

For clinical studies conducted at the Bayview Campus in Baltimore, Maryland, visit their Web site: http://www.jhbmc.jhu.edu/studies/index.html

·

For trials on diseases of the digestive system and kidneys, and diabetes, visit the National Institute of Diabetes and Digestive and Kidney Diseases: http://www.niddk.nih.gov/patient/patient.htm

General References The following references describe clinical trials and experimental medical research. They have been selected to ensure that they are likely to be available from your local or online bookseller or university medical library. These references are usually written for healthcare professionals, so you may consider consulting with a librarian or bookseller who might recommend a particular reference. The following includes some of the most readily available references (sorted alphabetically by title; hyperlinks provide rankings, information and reviews at Amazon.com): ·

A Guide to Patient Recruitment : Today’s Best Practices & Proven Strategies by Diana L. Anderson; Paperback - 350 pages (2001), CenterWatch, Inc.; ISBN: 1930624115; http://www.amazon.com/exec/obidos/ASIN/1930624115/icongroupinterna

·

A Step-By-Step Guide to Clinical Trials by Marilyn Mulay, R.N., M.S., OCN; Spiral-bound - 143 pages Spiral edition (2001), Jones & Bartlett Pub; ISBN: 0763715697; http://www.amazon.com/exec/obidos/ASIN/0763715697/icongroupinterna

·

The CenterWatch Directory of Drugs in Clinical Trials by CenterWatch; Paperback - 656 pages (2000), CenterWatch, Inc.; ISBN: 0967302935; http://www.amazon.com/exec/obidos/ASIN/0967302935/icongroupinterna

·

The Complete Guide to Informed Consent in Clinical Trials by Terry Hartnett (Editor); Paperback - 164 pages (2000), PharmSource Information Services, Inc.; ISBN: 0970153309; http://www.amazon.com/exec/obidos/ASIN/0970153309/icongroupinterna

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·

Dictionary for Clinical Trials by Simon Day; Paperback - 228 pages (1999), John Wiley & Sons; ISBN: 0471985961; http://www.amazon.com/exec/obidos/ASIN/0471985961/icongroupinterna

·

Extending Medicare Reimbursement in Clinical Trials by Institute of Medicine Staff (Editor), et al; Paperback 1st edition (2000), National Academy Press; ISBN: 0309068886; http://www.amazon.com/exec/obidos/ASIN/0309068886/icongroupinterna

·

Handbook of Clinical Trials by Marcus Flather (Editor); Paperback (2001), Remedica Pub Ltd; ISBN: 1901346293; http://www.amazon.com/exec/obidos/ASIN/1901346293/icongroupinterna

Vocabulary Builder The following vocabulary builder gives definitions of words used in this chapter that have not been defined in previous chapters: Anaphylactic: Pertaining to anaphylaxis. [EU] Antibody: An immunoglobulin molecule that has a specific amino acid sequence by virtue of which it interacts only with the antigen that induced its synthesis in cells of the lymphoid series (especially plasma cells), or with antigen closely related to it. Antibodies are classified according to their ode of action as agglutinins, bacteriolysins, haemolysins, opsonins, precipitins, etc. [EU] Antihistamine: A drug that counteracts the action of histamine. The antihistamines are of two types. The conventional ones, as those used in allergies, block the H1 histamine receptors, whereas the others block the H2 receptors. Called also antihistaminic. [EU] Antimicrobial: Killing microorganisms, or suppressing their multiplication or growth. [EU] Azithromycin: A semi-synthetic macrolide antibiotic structurally related to erythromycin. It has been used in the treatment of Mycobacterium avium intracellulare infections, toxoplasmosis, and cryptosporidiosis. [NIH] Biopsy: The removal and examination, usually microscopic, of tissue from the living body, performed to establish precise diagnosis. [EU] Capsules: Hard or soft soluble containers used for the oral administration of medicine. [NIH] Catheter: A tubular, flexible, surgical instrument for withdrawing fluids from (or introducing fluids into) a cavity of the body, especially one for introduction into the bladder through the urethra for the withdraw of urine.

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[EU]

Cervical: Pertaining to the neck, or to the neck of any organ or structure. [EU] Chemotherapy: The treatment of disease by means of chemicals that have a specific toxic effect upon the disease - producing microorganisms or that selectively destroy cancerous tissue. [EU] Clostridium: A genus of motile or nonmotile gram-positive bacteria of the family bacillaceae. Many species have been identified with some being pathogenic. They occur in water, soil, and in the intestinal tract of humans and lower animals. [NIH] Cryptosporidiosis: Parasitic intestinal infection with severe diarrhea caused by a protozoan, cryptosporidium. It occurs in both animals and humans. [NIH] Endoscopy: Visual inspection of any cavity of the body by means of an endoscope. [EU] Enterocolitis: Inflammation involving both the small intestine and the colon; see also enteritis. [EU] Fluorouracil: A pyrimidine analog that acts as an antineoplastic antimetabolite and also has immunosuppressant. It interferes with DNA synthesis by blocking the thymidylate synthetase conversion of deoxyuridylic acid to thymidylic acid. [NIH] Leucovorin: The active metabolite of folic acid. Leucovorin is used principally as its calcium salt as an antidote to folic acid antagonists which block the conversion of folic acid to folinic acid. [NIH] Leukapheresis: The preparation of leukocyte concentrates with the return of red cells and leukocyte-poor plasma to the donor. [NIH] Mastocytosis: A group of diseases resulting from proliferation of mast cells. [NIH]

Metastasis: 1. the transfer of disease from one organ or part to another not directly connected with it. It may be due either to the transfer of pathogenic microorganisms (e.g., tubercle bacilli) or to transfer of cells, as in malignant tumours. The capacity to metastasize is a characteristic of all malignant tumours. 2. Pl. metastases. A growth of pathogenic microorganisms or of abnormal cells distant from the site primarily involved by the morbid process. [EU] Microgram: A unit of mass (weight) of the metric system, being onemillionth of a gram (10-6 gm.) or one one-thousandth of a milligram (10-3 mg.). [EU] Modulator: A specific inductor that brings out characteristics peculiar to a definite region. [EU] Neoplasms: New abnormal growth of tissue. Malignant neoplasms show a greater degree of anaplasia and have the properties of invasion and

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metastasis, compared to benign neoplasms. [NIH] Octreotide: A potent, long-acting somatostatin octapeptide analog which has a wide range of physiological actions. It inhibits growth hormone secretion, is effective in the treatment of hormone-secreting tumors from various organs, and has beneficial effects in the management of many pathological states including diabetes mellitus, orthostatic hypertension, hyperinsulinism, hypergastrinemia, and small bowel fistula. [NIH] Paromomycin: An oligosaccharide antibiotic produced by various Streptomyces. [NIH] Pharmacokinetics: The action of drugs in the body over a period of time, including the processes of absorption, distribution, localization in tissues, biotransformation, and excretion. [EU] Preclinical: Before a disease becomes clinically recognizable. [EU] Prostate: A gland in males that surrounds the neck of the bladder and the urethra. It secretes a substance that liquifies coagulated semen. It is situated in the pelvic cavity behind the lower part of the pubic symphysis, above the deep layer of the triangular ligament, and rests upon the rectum. [NIH] Protozoan: 1. any individual of the protozoa; protozoon. 2. of or pertaining to the protozoa; protozoal. [EU] Pulse: The rhythmical expansion and contraction of an artery produced by waves of pressure caused by the ejection of blood from the left ventricle of the heart as it contracts. [NIH] Refractory: Not readily yielding to treatment. [EU] Saccharomyces: A genus of ascomycetous fungi Saccharomycetaceae, order saccharomycetales. [NIH]

of the

family

Saliva: The clear, viscous fluid secreted by the salivary glands and mucous glands of the mouth. It contains mucins, water, organic salts, and ptylin. [NIH] Sarcoma: A tumour made up of a substance like the embryonic connective tissue; tissue composed of closely packed cells embedded in a fibrillar or homogeneous substance. Sarcomas are often highly malignant. [EU] Serum: The clear portion of any body fluid; the clear fluid moistening serous membranes. 2. blood serum; the clear liquid that separates from blood on clotting. 3. immune serum; blood serum from an immunized animal used for passive immunization; an antiserum; antitoxin, or antivenin. [EU] Spiramycin: A macrolide antibiotic produced by Streptomyces ambofaciens. The drug is effective against gram-positive aerobic pathogens, N. gonorrhoeae, and staphylococci. It is used to treat infections caused by bacteria and Toxoplasma gondii. [NIH] Spirometry: Measurement of volume of air inhaled or exhaled by the lung. [NIH]

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Urinalysis: Examination of urine by chemical, physical, or microscopic means. Routine urinalysis usually includes performing chemical screening tests, determining specific gravity, observing any unusual color or odor, screening for bacteriuria, and examining the sediment microscopically. [NIH] Vaginal: 1. of the nature of a sheath; ensheathing. 2. pertaining to the vagina. 3. pertaining to the tunica vaginalis testis. [EU] Vancomycin: Antibacterial obtained from Streptomyces orientalis. It is a glycopeptide related to ristocetin that inhibits bacterial cell wall assembly and is toxic to kidneys and the inner ear. [NIH]

57

PART II: ADDITIONAL RESOURCES AND ADVANCED MATERIAL

ABOUT PART II In Part II, we introduce you to additional resources and advanced research on diarrhea. All too often, patients who conduct their own research are overwhelmed by the difficulty in finding and organizing information. The purpose of the following chapters is to provide you an organized and structured format to help you find additional information resources on diarrhea. In Part II, as in Part I, our objective is not to interpret the latest advances on diarrhea or render an opinion. Rather, our goal is to give you access to original research and to increase your awareness of sources you may not have already considered. In this way, you will come across the advanced materials often referred to in pamphlets, books, or other general works. Once again, some of this material is technical in nature, so consultation with a professional familiar with diarrhea is suggested.

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CHAPTER 4. STUDIES ON DIARRHEA Overview Every year, academic studies are published on diarrhea or related conditions. Broadly speaking, there are two types of studies. The first are peer reviewed. Generally, the content of these studies has been reviewed by scientists or physicians. Peer-reviewed studies are typically published in scientific journals and are usually available at medical libraries. The second type of studies is non-peer reviewed. These works include summary articles that do not use or report scientific results. These often appear in the popular press, newsletters, or similar periodicals. In this chapter, we will show you how to locate peer-reviewed references and studies on diarrhea. We will begin by discussing research that has been summarized and is free to view by the public via the Internet. We then show you how to generate a bibliography on diarrhea and teach you how to keep current on new studies as they are published or undertaken by the scientific community.

The Combined Health Information Database The Combined Health Information Database summarizes studies across numerous federal agencies. To limit your investigation to research studies and diarrhea, you will need to use the advanced search options. First, go to http://chid.nih.gov/index.html. From there, select the “Detailed Search” option (or go directly to that page with the following hyperlink: http://chid.nih.gov/detail/detail.html). The trick in extracting studies is found in the drop boxes at the bottom of the search page where “You may refine your search by.” Select the dates and language you prefer, and the

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format option “Journal Article.” At the top of the search form, select the number of records you would like to see (we recommend 100) and check the box to display “whole records.” We recommend that you type in “diarrhea” (or synonyms) into the “For these words:” box. Consider using the option “anywhere in record” to make your search as broad as possible. If you want to limit the search to only a particular field, such as the title of the journal, then select this option in the “Search in these fields” drop box. The following is a sample of what you can expect from this type of search: ·

Systemic Amyloidosis and the Gastrointestinal Tract Source: Gastroenterology Clinics of North America. 27(3): 595-614. September 1998. Summary: This journal article provides health professionals with information on gastrointestinal involvement in systemic amyloidosis. This disease, of which there are five main types, is not a single disease but results from a variety of different diseases. Gastrointestinal manifestations are commonly reported in systemic amyloidosis. Each type of amyloid has its own unique gastrointestinal manifestations. The disease affects every part of the gastrointestinal tract from the mouth to the anus. Oral amyloidosis can produce various symptoms, including toothache, paresthesia, bony swelling, pathologic fractures, soft nodular mucosal lesions, and macroglossia. Patients who have esophageal involvement usually present with dysphagia and symptoms of esophageal reflux. Gastric involvement usually causes gastroparesis, epigastric pain, gastric outlet obstruction, gastric amyloid tumors, peptic ulceration, hematemesis, and melena. Diarrhea, constipation, malabsorption, pseudo-obstruction, bleeding, and vascular insufficiency are common if the small intestine is affected by amyloid deposition. Colonic amyloid can present with many of these same problems. Amyloidosis can also affect the liver and pancreas. The definitive diagnosis of amyloidosis is made through tissue biopsy. Amyloid has a characteristic roentographic and endoscopic appearance. An uncommon but serious complication of long-term inflammatory bowel disease is acquired systemic amyloidosis. This type of amyloidosis is similar to that associated with certain other chronic inflammatory diseases. There are now some effective ways of treating patients with this type of amyloidosis. Familial Mediterranean fever-associated amyloidosis is a genetically transmitted disease. Although the gastrointestinal tract is a site of amyloid deposition early in the course of familial Mediterranean fever amyloidosis, it is not clear when amyloidosis of the gastrointestinal tract becomes clinically overt. Treatments for amyloidosis include chemotherapy for AL amyloidosis, colchicine for AA amyloidosis, and

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liver transplantation for familial amyloid neuropathy. 2 figures, 1 table, and 82 references. ·

Dealing with Irregularity: Constipation, Diarrhea, Excessive Gas and Foul-Smelling Gas Source: Digestive Health and Nutrition. 3(1): 16-20. January-February 2001. Contact: Available from American Gastroenterological Association. 7910 Woodmont Avenue, 7th Floor, Bethesda, MD 20814. (877) DHN-4YOU or (301) 654-2055, ext. 650. E-mail: [email protected]. Summary: This article offers strategies for dealing with problems of bowel irregularity, including constipation, diarrhea, excessive gas, and foul-smelling gas. The author notes that bowel habits vary greatly among individuals, so each person's perception of whether there even is a problem and how to deal with it best is different. The author stresses that too little fiber and liquid in the diet are by far the most common reasons for constipation among people living in western cultures. The fiber found in foods such as fruits, grains, and vegetables adds bulk to the stool, making it easier to move through the colon (large intestine). Liquids add both bulk and fluid to the stool. Exercise helps prevent constipation by maintaining energy levels and promoting intestinal activity. A number of pain medications; antidepressants; antacids that contain aluminum; diuretics; and antiinflammatory and antiseizure medications are some of the many medications that can contribute to constipation. Changes in routines can also cause irregularity. The author explores the role of aging as a cause of constipation. Laxatives are an effective remedy for constipation, but they should be used with caution. As with constipation, diarrhea means different things to different people. Bacterial and viral infections are the most common causes of acute diarrhea; food intolerance is another frequent cause of both diarrhea and gas. Regardless of the cause, diarrhea usually lasts only a few days and ends on its own without the need for medical attention. The author reviews the concerns regarding dehydration, which can be a consequence of diarrhea, particularly in children and in the elderly. Gas comes from two sources: swallowed air and the breakdown of certain undigested foods in the large intestine. Simple ways of reducing the gas from swallowed air include eating and drinking more slowly, not chewing gum, and having dentures properly fitted. For episodes of excessive or smelly intestinal gas, the use of a food diary may help identify the offending items. The author concludes by reiterating the importance of adequate fiber and fluid intake. The websites of four information resource organizations are listed.

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·

Chronic Diarrhea: Differential Diagnosis and Management Source: Consultant. 41(1): 53-57. January 2001. Contact: Available from Cliggott Publishing Company. 55 Holly Hill Lane, Box 4010, Greenwich, CT 06831-0010. (203) 661-0600. Summary: Diarrhea that lasts longer than 4 weeks is considered chronic. This article reviews the differential diagnosis and management of patients with chronic diarrhea. Physicians are advised to first examine the patient for signs of fluid and nutritional depletion. Patients should be asked about exacerbating and alleviating factors, diet, drug use, recent travel, abdominal pain, weight loss, and stool characteristics. Blood in the diarrhea may implicate malignancy or chronic inflammatory bowel disease; food particles or oil in the stool may indicate maldigestion or malabsorption. Fecal leukocytes suggest inflammation, and eosinophilia is seen with neoplasms, allergy, collagen vascular diseases, parasitic infestation, and colitis. Stool analysis for fecal weight, osmotic gap, fat, occult blood, pH, and laxative abuse is often important in making the diagnosis. A 24 hour stool collection weighing less than 200 grams suggests incontinence, irritable bowel syndrome (IBS), or rectal disease, but not true diarrhea. Stool weight of more than 500 grams is rare with IBS; weight of less than 1,000 grams rules out pancreatic cholera syndrome. When the weight exceeds 2,000 grams per day, patients usually require intravenous fluids. Treatment options include bismuth subsalicylate, opiates, bulking agents, kaolin attapulgite, anticholinergics, and cholestyramine. 1 figure. 3 tables. 15 references.

·

Diarrhea and Malabsorption in the Elderly Source: Gastroenterology Clinics of North America. 30(2): 427-444. June 2001. Contact: Available from W.B. Saunders Company. 6277 Sea Harbor Drive, Orlando, FL 32821-9816. (800) 654-2452. Summary: Diarrhea from infectious organisms is common in the elderly and leads to frequent hospitalizations and a relatively high mortality (death) rate in this population. Diarrhea can be a disabling manifestation of several systemic disorders, including diabetes mellitus, and drug induced diarrhea is particularly common in advanced age. This article, from a special issue on gastrointestinal (GI) disorders in the elderly, addresses diarrhea and malabsorption in the elderly. Although the physiologic functions of intestinal digestion and absorption of macronutrients and most micronutrients are not decreased simply as a function of aging, malabsorptive diseases including chronic pancreatitis and celiac disease (gluten intolerance) are more common in the elderly

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than has been realized in the past. A particular potential cause of covert malabsorption of macro and micronutrients in older patients is bacterial overgrowth, which may occur in the absence of 'blind loops.' The impact of silent malabsorption on the nutritional health of older patients may be more severe than in the young. Physicians who care for elderly patients are cautioned to be alert to the possible presence of diarrhea and malabsorption. Older patients may not admit to having chronic diarrhea, particularly if they are also incontinent. When an intestinal infection and potential medication-induced gastrointestinal disturbances have been excluded, the differential diagnosis of diarrhea in the elderly is the same as in the young. In the elderly, micronutrient deficiency is a common presenting clinical picture; because the symptoms of malabsorption are covert, the diagnosis often is delayed and nutritional deficiencies are more common and more severe than in the young. 1 table. 102 references.

Federally-Funded Research on Diarrhea The U.S. Government supports a variety of research studies relating to diarrhea and associated conditions. These studies are tracked by the Office of Extramural Research at the National Institutes of Health.18 CRISP (Computerized Retrieval of Information on Scientific Projects) is a searchable database of federally-funded biomedical research projects conducted at universities, hospitals, and other institutions. Visit the CRISP Web site at http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket. You can perform targeted searches by various criteria including geography, date, as well as topics related to diarrhea and related conditions. For most of the studies, the agencies reporting into CRISP provide summaries or abstracts. As opposed to clinical trial research using patients, many federally-funded studies use animals or simulated models to explore diarrhea and related conditions. In some cases, therefore, it may be difficult to understand how some basic or fundamental research could eventually translate into medical practice. The following sample is typical of the type of information found when searching the CRISP database for diarrhea:

18 Healthcare projects are funded by the National Institutes of Health (NIH), Substance Abuse and Mental Health Services (SAMHSA), Health Resources and Services Administration (HRSA), Food and Drug Administration (FDA), Centers for Disease Control and Prevention (CDCP), Agency for Healthcare Research and Quality (AHRQ), and Office of Assistant Secretary of Health (OASH).

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·

Project Title: Absorption, Secretion, Malabsorption and Diarrhea Principal Investigator & Institution: Fordtran, John S.; ; Baylor Research Institute 3434 Live Oak St, Ste 125 Dallas, Tx 75204 Timing: Fiscal Year 2000; Project Start 1-SEP-1985; Project End 0-NOV2002 Summary: The major subject of our research is chronic diarrhea, which is important for several reasons. First, the symptom is highly disabling. Second, its etiology may be hard to determine. And third, current therapies often do not bring relief. To help remedy these problems, we have established a center for the study of diarrhea and/or malabsorption syndrome. We study the physiology of absorption/secretion, the pathophysiology of diarrhea and malabsorption, and we study patients with intractable diarrhea/malabsorption. During the last 11 years we have lyophilized stool from each patient, specimens weighing kilograms are reduced to solids that can be stored in small plastic vials. When new ideas arise we can go to our stool bank and examine specimens from 100 or more patients, to test a hypothesis or to answer a question. Our research techniques includes metabolic balance methods to measure net gastrointestinal absorption or secretin of nutrients, minerals and electrolytes; or steady state intestinal perfusion which allows detailed examination of mucosal absorption or secretion rate in the jejunum, ileum and colon. Observations in patients often lead to research ideas in volunteers and vice versa. Some of our specific goals for the next five years are as follows: 1) to develop the hypothesis that inhibition of normal gastrointestinal secretions can be beneficial in the therapy of diarrhea; 2) to search for drug that inhibit active intestinal secretion of chloride, as a method for treatment of secretory diarrhea; 3) to explore the pathogenesis of idiopathic chronic diarrhea, especially in regard to ileal malabsorption of sodium chloride and bile acids; 4) to study the pathogenesis of diarrhea when it occurs as part of "Gulf War Syndrome"; 5) to evaluate the hypothesis that conjugated bile acid replacement therapy is beneficial to patients with Short Bowel Syndrome; 6) to develop more accurate methods for the measurement of caloric losses due to carbohydrate, fat and protein malabsorption; 7) to determine the physical factors which control fecal consistency; and 8) to determine the mechanisms by which gastrointestinal diseases result in disorders of acid-base balance and potassium depletion. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket

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Project Title: Epidemiology, Predisposing Factors, Etiologies of Prolonged Diarrhea Principal Investigator & Institution: Guerrant, Richard L.; Professor; University of Virginia Charlottesville Box 400195 Charlottesville, Va 22904 Timing: Fiscal Year 2000 Summary: With the improved understanding and control of acute diarrheal illnesses, prolonged diarrheal illnesses and now emerging as a leading cause of morbidity and mortality. However, the epidemiology, etiology and pathogenesis of prolonged diarrheal remain very poorly understood. Several investigators have described bacterial overgrowth in the upper small bowel of patients with prolonged diarrhea or malnutrition; however, their specific nature and role in causing disease remain unknown. Based on studies with colonizing, non-toxigenic E. coli in piglets (19) and in human volunteers (20), we have recently demonstrated that the non-toxigenic, human colonizing E. coli strain 1392+ (CFA/II) but not the CFA/II negative derivative, colonizes the small intestine in large numbers and causes prolonged diarrhea in a rabbit model (17), establishing that colonization per se can cause prolonged small intestinal net secretion and diarrhea. We postulate that prolonged diarrhea is more common than generally recognized, has significant predisposing risk factors, and that combinations of specific infections (such as C. pylori gastritis with achlorhydria, and small bowel colonization with specific colonizing bacteria) derange small bowel electrolyte and nutrient absorption in susceptible hosts to cause prolonged diarrhea. Our overall objective is to determine the epidemiology, predisposing factors, etiologies, and pathogenesis of prolonged diarrhea in a highly endemic area, the tropical, developing Northeast of Brazil. We shall follow a cohort of infants born in an urban favela (slum) in Fortaleza, Ceara for frequency, risk factors, potential etiologies and the sequence of events leading to prolonged diarrhea (>14d). We shall conduct detailed fecal studies of 500 cases of all diarrhea and 100 cases of prolonged illness (to include 50 cases of sequential sampling of cases that become prolonged), then conduct intubation and balance studies of 50 children and 30 adults with prolonged diarrhea (>14, <30 days) and controls to examine potential etiologies (including quantitative cultures of adherent flora), host differences, and functional derangements. We shall determine the role and mechanisms by which colonizing Enterobacteriaciae either alone or in concert with other agents such as C. pylori or rotaviruses may contribute to prolonged intestinal dysfunction and malnourishing diarrhea. These studies will define potential risk factors and the sequence of events that lead to prolonged

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diarrhea, its etiologies and the key host factors and functional derangements that must be considered in controlling this important problem. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Mechanism and Therapies for HAART Induced Diarrhea Principal Investigator & Institution: Sipos, Tibor; President; Digestive Care, Inc. Ben Franklin Technology Center Bethlehem, Nj 18015 Timing: Fiscal Year 2001; Project Start 1-MAY-2001; Project End 1-OCT2001 Summary: (provided by applicant): The overall objective of this project is to establish the scientific rationale for the exogenous administration of a bicarbonate-buffered and enteric-coated pancrelipase to human immunodeficiency virus (HIV) positive patients who experience diarrhea due to High Activity Antiretroviral Therapy (HAART). As a side effect of HAART, many HIV patients experience mild to severe diarrhea with greasy and oily stool that is similar to the one experienced by cystic fibrosis (CF) patients. Drug induced diarrhea causes maldigestion of food, malabsorption of fat-soluble vitamins and nutrients, reduces the absorption of exogenously administered drugs, and leads to reduced immunocompetence. The technical approach for establishing the scientific rationale for the use of a bicarbonate-buffered and entericcoated pancrelipase for the treatment of diarrhea and steatorrhea in HIV positive patients is to demonstrate that the HAART drugs interfere with any one of the key digestive processes that are responsible for handling the breakdown of fats and lipids, i.e., lipase/colipase and enterokinase catalyzed activation of zymogens to active enzymes. To achieve this goal the inhibitory effect of HAART drugs on pancreatic lipase/colipase, proteases and activation of prolipase to active lipase will be determined by employing specific enzyme assays. The results of these inhibitory studies will help to elucidate how these antiretroviral drugs interfere with the digestive activity of pancreatic lipase/colipase and the zymogen activation cascade that leads to HAART induced diarrhea and steatorrhea. Furthermore, the information gained from these in vitro studies will establish the therapeutic rationale for initiating the Phase II clinical program. The objective of the Phase II program is to demonstrate the efficacy of the exogenously administered bicarbonate-buffered and enteric-coated pancrelipase to HIV positive patients for the treatment of diarrhea due to HAART. PROPOSED COMMERCIAL APPLICATION: NOT AVAILABLE Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket

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Project Title: Nelfinavir Induced Diarrhea--Secretory Vs Nonsecretory Principal Investigator & Institution: Flexner, Charles W.; Associate Professor; Johns Hopkins University 3400 N Charles St Baltimore, Md 21218 Timing: Fiscal Year 2000; Project Start 1-OCT-1975; Project End 0-NOV2004 Summary: The objective of this study is to determine the mechanism of nelfinavir-associated diarrhea in HIV-infected individuals. Diarrhea was defined as 300 grams/24 hours. Prior to hospitalization, patients were screened with a 24-hour stool collection. Stool specimens were analyzed for ova and parasite, culture, and C. difficile toxin. Subjects were placed in a lactose free diet 5 days prior to coming in to the hospital and during the inpatient phase (in order to eliminate other potential causes of diarrhea). Eligible patients were hospitalized for a 48-hour stool collection. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket

·

Project Title: Nosocomial Diarrhea in Northeastern Brazil Principal Investigator & Institution: Lima, Noelia; ; University of Virginia Charlottesville Box 400195 Charlottesville, Va 22904 Timing: Fiscal Year 2000 Summary: Nosocomial infections (NI) are increasingly recognized causes of morbidity, added hospital costs, and mortality in industrialized countries. Limited available data in developing countries suggest that NI are common and nosocomial diarrhea (ND) appears to be severe and common illness in these countries (1). The objective of this project is to establish and validate an active NI surveillance system at the Hospital Walter Cantidio in the Northeastern Brazil, and thereby determine the epidemiology, possible predisposing risk factors, clinical outcome, added hospital days and costs of ND. The first six months of this project will be used to train the infection control team and set up the NI surveillance system. After this period we shall validate the system with a thrice weekly review of all hospital records and conduct prospective surveillance of all NI and a case-control study of ND over 4 years in this hospital. The last six months of this study will be used to complete the laboratory work and analysis of the data for publication. The NI surveillance will be conducted by three trained nurses each visiting one third of the hospital wards twice a week to consult the nursing care plan book (kept on each ward) to identify high risk patients for NI and patients with ND. Once a high risk patient or a ND case has been selected his medical charts will be reviewed by the nurse to determine the

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presence of NI or ND, and collect data in a standardized NI form containing information about NI and ND. To study the frequency, potential etiologies and impact of ND in addition to analysis of the surveillance data, fecal specimens from 200 randomized cases of active diarrhea and 200 matched controls without diarrhea will be reviewed and demographic data and risk factors for ND extracted for comparison with diarrhea cases. This project will establish and validate an active infection surveillance program at the Walter Cantidio Hospital and will determine the epidemiology, morbidity, mortality, potential etiologies and impact of ND and its relationship with other NI. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: NSP4 Stimulated Ion Channels and Age-Dependent Diarrhea Principal Investigator & Institution: Morris, Andrew P.; Integr Biol/Pharm/Physiology; University of Texas Hlth Sci Ctr Houston Box 20036 Houston, Tx 77225 Timing: Fiscal Year 2002; Project Start 5-FEB-2002; Project End 1-JAN2007 Summary: (provided by applicant): Rotaviruses are a major cause of lifethreatening diarrhea in infants and children worldwide. Following viral infection, diarrhea is seen associated with pathophysiological changes in mucosal fluid and electrolyte balance. My group has focused on defining a new pathophysiological component to diarrhea. We have shown that a rotaviral non-structural protein called NSP4 induces diarrhea in both normal and cystic fibrosis mouse pups accompanied by calcium-sensitive chloride secretory current generation by gastrointestinal mucosa. Neither diarrhea nor anion secretion occur in adult mice. At the sub-cellular level, NSP4 causes phospholipase C sensitive intracellular calcium (Ca2+)i mobilization and calcium-sensitive halide influx into mucosal crypts. NSP4-induced (Ca2+)i mobilization (our assay for receptor occupancy) is not age-dependent. Thus, we hypothesize that NSP4 activates and agedependent calcium-sensitive chloride channel in pup mucosa causing chloride secretion, and secretory diarrhea. We propose studies in native cells to identify and characterize the electrophysiological and pharmacological properties of the chloride channel, and thus unequivocally demonstrate a role for this conductance in NSP4 mediated age-dependent cellular halide influx. We intend to identify the cellular signaling mechanisms coupling NSP4 mediated changes in (Ca2+)i to this conductance. These mechanistic studies may identify novel targets for pharmacological intervention with clear clinical relevance. These goals will provide the cellular basis for the age-dependent secretory diarrhea

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and may identify a molecular target for rotaviral-induced transepithelial anion secretion. They will also translate facts established for the biophysics of calcium-activated chloride channel expression in cultured epithelial cell-lines into the fields of clinical medicine and disease. In doing so, our results will provide an excellent possibility for development of new therapies for rotaviral gastroenteritis, and for other infectious diseases in children where altered mucosal (Ca2+)i homeostasis occurs. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Regulation of HIK1 in Secretory Diarrhea Principal Investigator & Institution: Devor, Daniel C.; Cell Biology and Physiology; University of Pittsburgh at Pittsburgh 4200 5Th Ave Pittsburgh, Pa 15260 Timing: Fiscal Year 2000; Project Start 1-MAR-1999; Project End 1-JAN2002 Summary: Calcium-mediated agonists are important modulators of intestinal secretory diarrhea acting alone (e.g., Vibrio parahaemolyticus toxin) or in synergism with cAMP-mediated agonists. Medical costs associated with infectious diarrhea are estimated at $23 billion annually in the United States. A critical step in the Cl-secretory process is the activation of a basolateral membrane Ca/2-activated K+ channel (K/Ca). Thus, our long term goals are to understand the physiological regulation of this K/Ca as well as to clarify the role of pharmacological modulators of K/Ca in disease. There is a clear dissociation between the Cl-secretory response and intracellular Ca/2+ during Ca/2+-mediated Cl- secretion suggesting that second messengers other than Ca/2 are important modulators of this K/Ca. We demonstrate that the recently cloned intermediate conductance K/Ca (hIKl) os expressed in both human colonic and airway epithelial and this channel is activated by PKAdependent phosphorylation. The first major aim of this proposal is to define the mechanism whereby phosphorylation of hIKl modulates its Ca/2+- dependent regulation. We will study hiKl heterologously expressed in Xenopus oocytes using both two-electrode voltage-clamp (TEVC) and excised patch-clamp techniques. We will mutate the single PKA phosphorylation consensus site to demonstrate that phosphorylation of this serine is critical in modulating the Ca/2+dependent activation of hIKl. We will also study endogenous hIKl in colonic and airway epithelia, using excised patch- clamp techniques, to determine which phospatases are important in dephosphorylating hIKl. These studies will allow for a complete understanding of how increasing cellular cAMP modulates K/Ca and hence the Cl-secretory response

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associated with diarrhea involving cAMP- and Ca/2+-dependent agonists. Clotrimazone is a potent blocker of hIKl in colonic epithelia, suggesting that clotrimazole may be useful as an antidiarrheal. Also, clotrimazone is known to block the Gardos channel in red blood cells. As inhibition of the Gardos channel prevents RBC sickling, clotrimazone is being evaluated for clinical efficacy in the treatment of sickle cell anemia. Indeed, it appears as the Gardos channel of RBCs is hIKl. Thus, the second major aim of this proposal is to define, at a molecular level, the mechanism by which clotrimazone inhibits hIKl. We have narrowed the binding site down using chimeric constructs between hIKl and the related SK channels. We will construct additional chimeras before using point mutations to define the amino acids which determine the clotrimazone binding site. These studies will be carried out using TEVC and excised patch-clamp techniques. A complete understanding of the mechanism of clotrimazone block will be important for the treatment of sickle cell anemia and, potentially, diarrhea. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Role of Cytokines in Persistant Diarrhea Principal Investigator & Institution: Lima, Aldo A.; ; Federal University of Bahia Rua Augusto Viana Salvador, Timing: Fiscal Year 2000 Summary: Despite advances in the diagnosis and control of acute diarrhea, persistent diarrhea has emerged as a major cause of morbidity and mortality that is poorly understood. In our studies in Fortaleza amidst Brazil's impoverished Northeast, we find that persistent diarrhea causes over 30% of all diarrhea morbidity and over 50% of all diarrhea mortality. Furthermore, we have recently found that persistent diarrhea severely disrupts intestinal barrier function, is caused by emerging pathogens including Cryptosporidium and enteroaggregative E. coli, and predisposes to a prolonged, 2-3-fold increase in post illness diarrhea burden over several months after the persistent diarrheal illness. Yet little is known about the pathogenesis or therapy of this quietly devastating disease. New methods now enable the study of inflammatory markers and cytokines which are found in a growing range of enteric infections and may be involved in the disruption of intestinal barrier function and in the prolonged post illness increased diarrhea burden. In addition, recently developed noninvasive methods to assess disrupted intestinal barrier function now enable us to study the role of cytokines in this barrier disruption and its repair by novel, functionally directed glutamine derivatives and micronutrients. We postulate that the major causes of persistent diarrhea are associated with increased enteric

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proinflammatory cytokines that may disrupt intestinal epithelial barrier function, that disease expression with persistent diarrhea is determined by cellular immunity, and that a new, stable glutamine derivative and micronutrients will speed the repair of disrupted intestinal barrier function. We therefore propose to build upon the unique strengths in this TMRC Consortium to (A) characterize the role of cytokines in the immunopathogenesis of major enteric protozoal and bacterial infections that cause persistent diarrhea in children and in patients with AIDS, (B) define the cellular immunologic determinants of persistent diarrhea in a population of children at a high risk for Cryptosporidium, enteroaggregative E. coli and other enteric infections and (C) to evaluate the immediate and long-term benefits of the new stable tripeptide alanylglutaminyl-glutamine and vitamin A and zinc in the repair of disrupted epithelial function. These areas opened by our new TMRC consortium uniquely address the roles of cytokines and cellular immunity in the immunopathogenesis of as well as novel approaches to intestinal repair in cryptosporidial, enteroaggregative E. coli and other persistent diarrheal illnesses. In addition to bridging outstanding institutions in the highly endemic Northeast of Brazil for heavy tropical disease burdens, these studies hold great promise for improving the control of this major global threat to health and its potentially devastating nutritional impact throughout developing, tropical areas. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Enhancing the Immunogenicity of Human Rotavirus Vaccines Principal Investigator & Institution: Saif, Linda J.; Food Animal Hlth Research Prog; Ohio State University 1800 Cannon Dr, Rm 1210 Columbus, Oh 43210 Timing: Fiscal Year 2000; Project Start 0-SEP-1992; Project End 0-JUN2002 Summary: Rotavirus (RV) is the major cause of severe gastroenteritis in infants and young children worldwide. The failure of rotavirus vaccines to consistently induce protection against disease in infants and animals underscores a need for more effective vaccines. Our goal is an improved understanding of disease pathogenesis and mucosal immune responses to human rotaviruses (HRV) and identification of correlates of protective immunity in the gnotobiotic (Gn) pig model. The Gn pig is an ideal animal model because of its susceptibility to infection and disease (including intestinal lesions) with HRV, a lack of previous exposure or maternal antibodies to RV and its similarity to human infants in size, milk diet, gastrointestinal physiology and ontogeny of mucosal immune

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responses. To study disease pathogenesis, the putative role of the RV nonstructural protein, NSP4 as a viral enterotoxin and virulence determinant or target for induction of protective immune responses will be investigated in Gn pigs inoculated with recombinant NSP4 and NSP 4 peptides from virulent and attenuated pairs of RV. Expression of NSP4 and induction of immune responses to NSP4 will be further analyzed in Gn pigs infected with the respective virulent and attenuated pairs of HRV. In previous studies, the magnitude of the intestinal igA antibody secreting cell and lymphoproliferative immune responses coincided with the degree of RV replication and diarrhea induction, and were positively correlated with the level of protection induced. Hence we will further explore the role that viral replication and virulence (lesions and/or diarrhea) play in induction of mucosal immunity and protection against HRV. To assess which viral proteins are targets of protective immunity, B cell responses to RV and to RV structural and nonstructural proteins will be measured by virus neutralization, ELISA and ELISPOT assays and T cell responses will be examined by lymphoproliferative assays and analysis of cytokine profiles (RT- PCR,ELISA,ELISPOT). The type, magnitude, kinetics and correlation with protection of these mucosal immune responses will be compared in Gn pigs inoculated orally with virulent HRV (induces diarrhea and lesions and mimics natural infection) or candidate HRV vaccines including: attenuated HRV (no diarrhea or lesions); or the viral subunits, NSP4 (from virulent RV, induces diarrhea; attenuated RV, no diarrhea) and rotavirus-like particles (VLP) (no diarrhea or lesions), and challenged with virulent homotypic HRV. Finally we will examine if selected immunoenhancers (microencapsulation, mucosal adjuvants) can augment the mucosal immune responses to the attenuated and subunit HRV vaccines and increase vaccine efficacy in the Gn pig model. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Healthy Choices Study Principal Investigator & Institution: Anastasi, Joyce K.; ; Columbia University Health Sciences Ogc New York, Ny 10032 Timing: Fiscal Year 2000 Summary: This proposal tests a dietary intervention of combined dietary knowledge and behavior change training to reduce the frequency of diarrhea related to malabsorption among HIV positive individuals. Diarrhea is a common symptom of HIV disease affecting 50% to 90% of patients at some point in their illness. Chronic diarrhea related to malabsorption will lead to loss of work, reduction in quality of life (QOL), restriction of personal freedom and malnutrition if uncorrected.

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To reduce the frequency of diarrhea among HIV infected patients, effective physiologic interventions and theoretically based interventions are needed. Studies that use elemental formula preparations do not address the issue of palatability that supports long-term adherence to the diet needed by patients with HIV that have diarrhea. This study utilizes a diet program based on normal foods, that pilot data suggest is effective at improving the symptom of diarrhea related to malabsorption in HIV patients. This study tests the effectiveness of a dietary intervention using normal food to reduce the frequency of diarrhea episodes and improve stool consistency in a randomized, single blind, parallel groups, controlled clinical trial. The approach to the intervention draws on Ajzen's theory of planned behavior. Subjects in the study are HIV infected person with diarrhea related to malabsorption who are averaging three or more diarrhea episodes per day over a seven day baseline phase. Subjects are enrolled in a 24-week intervention trial located at The Irving Center for Clincal Research at Columbia Presbyterian Medical Center. Subjects are randomized to one of two treatment conditions. Condition 1 receives combined dietary knowledge concerning the effects of various foods on malabsorption diarrhea and cognitive/behavioral skill training which underlie dietary behavior change; Condition 2, the control condition receives an intevention program which focuses on HIV self-care which is neither dietary knowledge nor skill building training. Subjects assigned to conditions 1 or 2 complete daily bowel movement, food and antidiarrheal medication data collection diaries for 24 weeks and attend scheduled protocol sessions at weeks 1,2,3,8,16, and 24. Both conditions are identical in duration and intensity and involve various interractive learning activities. All interventions are implemented by nurses. Nurses are key health professionals in the effort to manage the symptoms of HIV Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Micronutrients and Enteric Infection in African Children Principal Investigator & Institution: Bennish, Michael L.; Director; New England Medical Center Hospitals 750 Washington St Boston, Ma 02111 Timing: Fiscal Year 2001; Project Start 5-SEP-1999; Project End 0-JUN2004 Summary: Enteric infections remain a leading cause of childhood mortality in developing countries. In regions where HIV infection is prevalent, enteric infections and persistent diarrhea have even greater public health importance. Little is known, however, about the pattern of enteric infection in children in regions where HIV infection is common, and how infection is related to HIV activity as measured by plasma HIV

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RNA, or host immunocompetence, as determined by CD4 counts. Although micronutrient supplementation, including provision of vitamin A and zinc, are being promoted as effective means of reducing infectious diarrhea morbidity and prevalence, little is know about their efficacy in achieving these goals in African children, or in children who are HIV infected. This study had the following specific aims: 1) To determine the pathogen-specific pattern of enteric infections in HIV-infected and uninfected children living in rural South Africa, with a particular focus on infection with Cryptosporidium parvum and other protozoan pathogens. 2) To determine if infection with specific pathogens is associated with the development of persistent diarrhea lasting greater than 14 days; 3) To determine the efficacy of two micronutrient supplements; a) a mixture containing Vitamins A, C, E, and selenium; and b) the same micronutrient supplement with the addition of zinc, on the prevalent days of diarrhea in both HIV-infected and HIV- uninfected children.; 4) To determine if micronutrient supplementation improves gut integrity as measured by the mannitol-lactulose permeability test. 5) Based upon these findings to develop recommendations for use of micronutrient supplements in Africa and other regions with a high HIVseroprevalence. To answer these questions we propose enrolling and studying three cohorts of children living in a rural region of South Africa over a three-year period; 1) 78 HIV-infected children; 2) 120 HIVuninfected children born to HIV-infected mothers; 3) 120 HIV-uninfected children born to mothers without HIV infection. Children will be ascertained at three months of age and followed until age 2 years. Micronutrient supplementation will be given from enrollment until age 12 months. Children will be visited weekly by field staff, and diarrhea and other morbidity recorded. Stool for detection of enteric pathogens, including Salmonella, Shigella, Campylobacter, diarrheagenic E. coli (determined using probes for virulence genes), rotavirus, enteric adenoviruses 40/41, astroviruses and Norwalk virus, and the protozoan pathogens C. parvum (including genotyping of strains), Cyclospora cayetanensis, and Enterocytozoon bieneusi will be obtained from children when they have diarrhea, and from a subset of well children. Anthropometry will be measured regularly, and bioimpedance will be performed to determine body composition. A non-invasive test of gut permeability (the lactulose-mannitol test) will be performed on all children while they are receiving micronutrient supplementation. The study sample size is calculated to allow a determination of a 20 percent difference in prevalent days of diarrhea between the placebo treated group and the two micronutrient supplemented groups. This study will also allow us to determine risk factors for persistent diarrhea, and to

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develop algorithms for the management of infectious diarrhea in a region where HIV infection is common. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Physiologic Membrane Traffic Regulation: Intestinal CFTR Principal Investigator & Institution: Ameen, Nadia A.; Pediatrics; University of Miami Box 016159 Miami, Fl 33101 Timing: Fiscal Year 2002; Project Start 5-MAR-2002; Project End 8-FEB2007 Summary: This proposal addresses critical issues that will directly influence the treatment of two important gastrointestinal diseases: cystic fibrosis (CF) and secretory diarrhea. Both diseases target the small intestine and are linked by the cystic fibrosis transmembrane conductance regulator (CFTR) chloride channel. Current information implicates up-regulation of CFTR in the pathogenesis of secretory diarrhea and down-regulation in CF pathogenesis. Nonetheless, the mechanisms that regulate CFTR are still poorly understood. Though cAMP and cGMP- dependent phosphorylation regulates CFTR, membrane traffic also regulates CFTR and appears to be important to the pathogenesis of both secretory diarrhea and CF. However, the physiologic role of this potentially important mechanism remains unknown. Studies testing the role of CFTR membrane traffic and its role in the regulation of anion secretion using cultured cells are conflicting. Furthermore, little has been done to understand the role of this important protein using natural endogenously CFTR-expressing tissues. This proposal will employ morphologic and biochemical cell biologic techniques in conjunction with electrophysiology and natural intestinal tissues to determine a role for membrane traffic in regulated CFTR and other potential alternate chloride channels and anion transport. Studies will primarily be performed in rat because of the similarity in intestinal distribution of CFTR to the human. These investigations will be complemented by studies in the normal and CF human intestine, and transgenic CFTR mouse intestinal tissues. Light and electron microscopic immunolocalzation techniques will identify the cell-specific sites of CFTR membrane traffic and chloride secretion. Functional biochemical techniques such biotinylation/immunoprecipitation will complement morphologic studied to investigate a role for membrane traffic. The studies and approaches outlined in this proposal are designed to achieve several goals: first to understand processes relevant to human physiology and disease pathogenesis, second to provide therapeutic avenues to correct defective traffic in CF and secretory diarrhea and third to use

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these skills to develop a career as an independent clinician scientist. This will be achieved by a comprehensive program to acquire both technical and intellectual skills from a cadre of distinguished and outstanding mentors and to draw on the scientific environments of various disciplines both in her home based institution and outside centers of excellence in related field of study. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket ·

Project Title: Resistant Starch: Adjunct to Oral Rehydration Solution Principal Investigator & Institution: Binder, Henry J.; Professor of Medicine; Internal Medicine; Yale University New Haven, Ct 06520 Timing: Fiscal Year 2000; Project Start 0-SEP-1999; Project End 1-AUG2002 Summary: Oral rehydration therapy (ORT) of diarrhea, while effective in correcting dehydration, is poorly accepted in many communities. One significant reason for this is the inability of conventional ORT to shorten diarrhea or reduce fecal fluid losses. The recent demonstration that short chain fatty acid (SCFA) stimulation of colonic Na-CI absorption is not inhibited by cyclic AMP suggested the possibility that colonic SCFA could provide an adjunct to standard ORT. We have recently found that resistant starch (i.e. starch that is relatively resistant to amylase), which is metabolized to SCFA in the colon, significantly reduces duration of diarrhea in adults with cholera. Since children often have diarrhea due to causes other than cholera, the proposed study will evaluate whether ORT with resistant starch will reduce fecal fluid losses and the duration of diarrhea in children with acute diarrhea. Two hundred and fifty-eight children with diarrhea and mild to moderate dehydration will be randomized to receive either standard treatment with glucose-ORS or treatment with glucose-ORS containing resistant maize starch 50 g/l. Both groups will be treated according to a standardized protocol recommended by the W.H.O., including refeeding after 4 hours of initial rehydration. The end-points will include measurement of fecal volumes and the time from admission to the last unformed stool, assessed by an observer who is blinded to the treatment received. Treatment failures will be categorized and recorded. If resistant starch is found to reduce fecal volumes and/or duration of diarrhea, this innovative therapy must then be tested in the community for acceptance. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket

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Project Title: Virulence in Enteroaggregative E Coli Principal Investigator & Institution: Nataro, James P.; Professor; Pediatrics; University of Maryland Balt Prof School Professional Schools Baltimore, Md 21201 Timing: Fiscal Year 2000; Project Start 1-AUG-2000; Project End 1-JUL2005 Summary: Enteroaggregative Escherichia coli (EAEC) is an increasingly recognized pathogen of human diarrhea. This organism has been implicated in sporadic diarrhea in developing and industrialized countries, in the persistent diarrhea syndrome in AIDS patients and children in the developing world, in traveler's diarrhea, and in various diarrheal outbreaks. The PI discovered this pathotype of diarrheagenic E. coli and has been the leader in describing the pathogenesis and epidemiology of this organism, This is a competing continuation of our fundamental work on the pathogenesis of EAEC infection. Overall, our objectives are to advance knowledge of EAEC pathogenesis, to better define true EAEC pathogens, to refine diagnostic methods and to identify protective immunogen. The three aims of this proposal seek to extend the most important and promising aspects of the work funded under the current award. Aim 1: Characterization of EAEC adhesion-Aggregation is the defining characterization of EAEC. Our observations suggest that aggregative adherence (AA) is a prelude to biofilm formation, which occurs in vivo and which can be modeled in vitro. In this aim, we will further elucidate fundamental aspects of EAEC adherence. Aim 2: The Regulation of EAEC virulence- AggR is a highly prevalent and conserved activator of AAF expression. However, nothing else is known of the regulation of EAEC virulence. Beginning with AggR, we will expand our studies of EAEC gene regulation. Aim 3: Reconstructing EAEC-We will use in vitro organ culture and T84 cell models of EAEC infection to answer the question: what genes are necessary and sufficient to confer the effects that we observe? The work under this award will greatly advance the current state of knowledge of EAEC and will result in the identification of pathogenetic mechanisms, of diagnostic reagents and in vaccine candidates. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket

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E-Journals: PubMed Central19 PubMed Central (PMC) is a digital archive of life sciences journal literature developed and managed by the National Center for Biotechnology Information (NCBI) at the U.S. National Library of Medicine (NLM).20 Access to this growing archive of e-journals is free and unrestricted.21 To search, go to http://www.pubmedcentral.nih.gov/index.html#search, and type “diarrhea” (or synonyms) into the search box. This search gives you access to full-text articles. The following is a sample of items found for diarrhea in the PubMed Central database: ·

Case-Control Study of Enteropathogens Associated with Childhood Diarrhea in Dhaka, Bangladesh by M. John Albert, A. S. G. Faruque, S. M. Faruque, R. B. Sack, and D. Mahalanabis; 1999 November http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=85667&ren dertype=external

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Changes in Human Ecology and Behavior in Relation to the Emergence of Diarrheal Diseases, Including Cholera by MM Levine and OS Levine; 1994 March 29 http://www.pubmedcentral.nih.gov/articlerender.fcgi?rendertype=abst ract&artid=43377

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Characterization of a Toxin A-Negative, Toxin B-Positive Strain of Clostridium difficile Responsible for a Nosocomial Outbreak of Clostridium difficile-Associated Diarrhea by Michelle J. Alfa, Amin Kabani, David Lyerly, Scott Moncrief, Laurie M. Neville, Ali Al-Barrak, Godfrey K. H. Harding, Brenda Dyck, Karen Olekson, and John M. Embil; 2000 July http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=87004&ren dertype=external

Adapted from the National Library of Medicine: http://www.pubmedcentral.nih.gov/about/intro.html. 20 With PubMed Central, NCBI is taking the lead in preservation and maintenance of open access to electronic literature, just as NLM has done for decades with printed biomedical literature. PubMed Central aims to become a world-class library of the digital age. 21 The value of PubMed Central, in addition to its role as an archive, lies the availability of data from diverse sources stored in a common format in a single repository. Many journals already have online publishing operations, and there is a growing tendency to publish material online only, to the exclusion of print. 19

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Characterization of Chloramphenicol and Florfenicol Resistance in Escherichia coli Associated with Bovine Diarrhea by David G. White, Charlene Hudson, John J. Maurer, Sherry Ayers, Shaohua Zhao, Margie D. Lee, Lance Bolton, Thomas Foley, and Julie Sherwood; 2000 December http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=87642&ren dertype=external

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Characterization of Escherichia coli Strains from Cases of Childhood Diarrhea in Provincial Southwestern Nigeria by Iruka N. Okeke, Adebayo Lamikanra, Hartmut Steinruck, and James B. Kaper; 2000 January http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=86005&ren dertype=external

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Characterization of Group C Rotaviruses Associated with Diarrhea Outbreaks in Feeder Pigs by Yunjeong Kim, Kyeong-Ok Chang, Barbara Straw, and Linda J. Saif; 1999 May http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=84810&ren dertype=external

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Diarrhea in Children under 5 Years of Age from Ifakara, Tanzania: a Case-Control Study by J. Gascon, M. Vargas, D. Schellenberg, H. Urassa, C. Casals, E. Kahigwa, J. J. Aponte, H. Mshinda, and J. Vila; 2000 December http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=87621&ren dertype=external

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Diarrheagenic Escherichia coli and Acute and Persistent Diarrhea in Returned Travelers by C. Schultsz, J. van den Ende, F. Cobelens, T. Vervoort, A. van Gompel, J. C. F. M. Wetsteyn, and J. Dankert; 2000 October http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=87435&ren dertype=external

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Enteric Virus Infections and Diarrhea in Healthy and Human Immunodeficiency Virus-Infected Children by Mary B. Liste, Ivelisse Natera, Jose A. Suarez, Flor H. Pujol, Ferdinando Liprandi, and Juan E. Ludert; 2000 August http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=87134&ren dertype=external

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Epidemiological Study of pap Genes among Diarrheagenic or Septicemic Escherichia coli Strains Producing CS31A and F17 Adhesins and Characterization of Pap31A Fimbriae by Yolande Bertin, Jean-Pierre Girardeau, Arlette Darfeuille-Michaud, and Christine Martin; 2000 April http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=86476&ren dertype=external

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Escherichia coli O157:H7 and O157:H[minus sign] Strains That Do Not Produce Shiga Toxin: Phenotypic and Genetic Characterization of Isolates Associated with Diarrhea and Hemolytic-Uremic Syndrome by H. Schmidt, J. Scheef, H. I. Huppertz, M. Frosch, and H. Karch; 1999 November http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=85676&ren dertype=external

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Etiology of Children's Diarrhea in Montevideo, Uruguay: Associated Pathogens and Unusual Isolates by M. E. Torres, M. C. Pirez, F. Schelotto, G. Varela, V. Parodi, F. Allende, E. Falconi, L. Dell'Acqua, P. Gaione, M. V. Mendez, A. M. Ferrari, A. Montano, E. Zanetta, A. M. Acuna, H. Chiparelli, and E. Ingold; 2001 June http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=88101&ren dertype=external

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Evaluation of Methods for Detection of Toxins in Specimens of Feces Submitted for Diagnosis of Clostridium difficile- Associated Diarrhea by Don O'Connor, Pearl Hynes, Martin Cormican, Edward Collins, Geraldine Corbett-Feeney, and Michael Cassidy; 2001 August http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=88248&ren dertype=external

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Genetic Characterization of Cryptosporidium Strains from 218 Patients with Diarrhea Diagnosed as Having Sporadic Cryptosporidiosis by J. McLauchlin, S. Pedraza-Diaz, C. Amar-Hoetzeneder, and G. L. Nichols; 1999 October http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=85515&ren dertype=external

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Genotyping of Enterotoxigenic Clostridium perfringens Fecal Isolates Associated with Antibiotic-Associated Diarrhea and Food Poisoning in North America by Shauna G. Sparks, Robert J. Carman, Mahfuzur R. Sarker, and Bruce A. McClane; 2001 March http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=87845&ren dertype=external

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Helicobacter canadensis sp. nov. Isolated from Humans with Diarrhea as an Example of an Emerging Pathogen by James G. Fox, Chih Ching Chien, Floyd E. Dewhirst, Bruce J. Paster, Zeli Shen, Pasquale L. Melito, David L. Woodward, and Frank G. Rodgers; 2000 July http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=86964&ren dertype=external

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Imino sugars inhibit the formation and secretion of bovine viral diarrhea virus, a pestivirus model of hepatitis C virus: Implications for the development of broad spectrum anti-hepatitis virus agents by

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Nicole Zitzmann, Anand S. Mehta, Sandra Carrouee, Terry D. Butters, Frances M. Platt, John McCauley, Baruch S. Blumberg, Raymond A. Dwek, and Timothy M. Block; 1999 October 12 http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=18380 ·

Isolation of Helicobacter canis from a Colony of Bengal Cats with Endemic Diarrhea by Janet E. Foley, Stanley L. Marks, Linda Munson, Ann Melli, Floyd E. Dewhirst, Shilu Yu, Zeli Shen, and James G. Fox; 1999 October http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=85546&ren dertype=external

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Molecular Analysis of H Antigens Reveals that Human Diarrheagenic Escherichia coli O26 Strains That Carry the eae Gene Belong to the H11 Clonal Complex by Wen-Lan Zhang, Martina Bielaszewska, Jochen Bockemuhl, Herbert Schmidt, Flemming Scheutz, and Helge Karch; 2000 August http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=87168&ren dertype=external

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Molecular Diagnosis of an Enterocytozoon bieneusi Human Genotype C Infection in a Moderately Immunosuppressed Human Immunodeficiency Virus- Seronegative Liver-Transplant Recipient with Severe Chronic Diarrhea by Andreas Sing, Karin Tybus, Jurgen Heesemann, and Alexander Mathis; 2001 June http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=88153&ren dertype=external

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Note:Detection of Microsporidia in Travelers with Diarrhea by A. Muller, R. Bialek, A. Kamper, G. Fatkenheuer, B. Salzberger, and C. Franzen; 2001 April http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=87986&ren dertype=external

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Note:Epidemiology of Recurrences or Reinfections of Clostridium difficile-Associated Diarrhea by Frederic Barbut, Anne Richard, Kheira Hamadi, Valerie Chomette, Beatrice Burghoffer, and Jean-Claude Petit; 2000 June http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=86814&ren dertype=external

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Note:Genetic Diversity among Escherichia coli Isolates Carrying f18 Genes from Pigs with Porcine Postweaning Diarrhea and Edema Disease by Bela Nagy, Richard A. Wilson, and Thomas S. Whittam; 1999 May http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=84864&ren dertype=external

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Note:High-Pathogenicity Island of Yersinia spp. in Escherichia coli Strains Isolated from Diarrhea Patients in China by Jian-guo Xu, Bokun Cheng, Xuanqin Wen, Shuyu Cui, and Changyun Ye; 2000 December http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=87663&ren dertype=external

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Note:Laboratory Diagnosis of Clostridium difficile-Associated Diarrhea and Colitis: Usefulness of Premier Cytoclone A +B Enzyme Immunoassay for Combined Detection of Stool Toxins and Toxigenic C. difficile Strains by Alain Lozniewski, Christian Rabaud, Emmanuelle Dotto, Michele Weber, and Francine Mory; 2001 May http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=88068&ren dertype=external

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Note:Prevalence of Enterotoxigenic Bacteroides fragilis in Children with Diarrhea in Japan by Naoki Kato, Chengxu Liu, Haru Kato, Kunitomo Watanabe, Haruhi Nakamura, Naoichi Iwai, and Kazue Ueno; 1999 March http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=84562&ren dertype=external

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Note:Rapid Receptor-Clustering Assay To Detect Uropathogenic and Diarrheal Escherichia coli Isolates Bearing Adhesins of the Dr Family by P. Goluszko, R. Selvarangan, B. J. Nowicki, S. Nowicki, A. Hart, E. Pawelczyk, and K. Nguyen; 2001 June http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=88135&ren dertype=external

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Note:Relationship of Genetic Type of Shiga Toxin to Manifestation of Bloody Diarrhea due to Enterohemorrhagic Escherichia coli Serogroup O157 Isolates in Osaka City, Japan by Y. Nishikawa, Z. Zhou, A. Hase, J. Ogasawara, T. Cheasty, and K. Haruki; 2000 June http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=86837&ren dertype=external

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Note:Rotavirus Strains Bearing Genotype G9 or P[9] Recovered from Brazilian Children with Diarrhea from 1997 to 1999 by Norma Santos, Eduardo M. Volotao, Caroline C. Soares, Maria Carolina M. Albuquerque, Fabiano M. da Silva, Tatiane R. B. de Carvalho, Claudio F. A. Pereira, Vladimir Chizhikov, and Yasutaka Hoshino; 2001 March http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=87894&ren dertype=external

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Note:Single-Tube Single-Enzyme Reverse Transcriptase PCR Assay for Detection of Bovine Viral Diarrhea Virus in Pooled Bovine Serum by Daniel Weinstock, Bodreddigari Bhudevi, and Anthony E. Castro; 2001 January http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=87727&ren dertype=external

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Note:Typing of Bovine Viral Diarrhea Viruses Directly from Blood of Persistently Infected Cattle by Multiplex PCR by S. A. Gilbert, K. M. Burton, S. E. Prins, and D. Deregt; 1999 June http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=85017&ren dertype=external

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Note:VP4 and VP7 Genotyping by Reverse Transcription-PCR of Human Rotavirus in Mexican Children with Acute Diarrhea by Araceli Rodriguez Castillo, Andres Velasco Villa, Jose Ernesto Ramirez Gonzalez, Elvira Mayen Pimentel, Martin Melo Munguia, Benita Diaz de Jesus, Hiram Olivera Diaz, and Herlinda Garcia Lozano; 2000 October http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=87499&ren dertype=external

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NSP4 Gene Analysis of Rotaviruses Recovered from Infected Children with and without Diarrhea by Chun-Nan Lee, Yu-Lan Wang, ChuanLiang Kao, Chih-Ling Zao, Chin-Yun Lee, and Hsiao-Neng Chen; 2000 December http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=87623&ren dertype=external

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Pathogenesis of Primary Respiratory Disease Induced by Isolates from a New Genetic Cluster of Bovine Viral Diarrhea Virus Type I by C. Baule, G. Kulcsar, K. Belak, M. Albert, C. Mittelholzer, T. Soos, L. Kucsera, and S. Belak; 2001 January http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=87694&ren dertype=external

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Phenotypic Diversity of Enterotoxigenic Escherichia coli Strains from a Community-Based Study of Pediatric Diarrhea in Periurban Egypt by Leonard F. Peruski, Jr., Bradford A. Kay, Remon Abu El-Yazeed, Sahar H. El-Etr, Alejandro Cravioto, Thomas F. Wierzba, Malla Rao, Nemat ElGhorab, Hind Shaheen, Sami B. Khalil, Karim Kamal, Momtaz O. Wasfy, Ann-Mari Svennerholm, John D. Clemens, and Stephen J. Savarino; 1999 September http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=85425&ren dertype=external

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Predominant Staphylococcus aureus Isolated from AntibioticAssociated Diarrhea Is Clinically Relevant and Produces Enterotoxin A

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and the Bicomponent Toxin LukE-LukD by Alain Gravet, Murielle Rondeau, Colette Harf-Monteil, Fabienne Grunenberger, Henri Monteil, Jean-Michel Scheftel, and Gilles Prevost; 1999 December http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=85868&ren dertype=external ·

Prevalence of Diarrheagenic Escherichia coli in Finns with or without Diarrhea during a Round-the-World Trip by Markku Keskimaki, Leena Mattila, Heikki Peltola, and Anja Siitonen; 2000 December http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=87616&ren dertype=external

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Prevalence of Enterotoxin Genes in Aeromonas spp. Isolated From Children with Diarrhea, Healthy Controls, and the Environment by M. John Albert, M. Ansaruzzaman, Kaisar A. Talukder, Ashok K. Chopra, Inger Kuhn, Motiur Rahman, A. S. G. Faruque, M. Sirajul Islam, R. Bradley Sack, and Roland Mollby; 2000 October http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=87476&ren dertype=external

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Prevalence of Shigella Enterotoxins 1 and 2 among Shigella Strains Isolated from Patients with Traveler's Diarrhea by Martha Vargas, Joaquim Gascon, Maria Teresa Jimenez De Anta, and Jordi Vila; 1999 November http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=85705&ren dertype=external

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Prevalence of Toxin Types and Colonization Factors in Enterotoxigenic Escherichia coli Isolated during a 2-Year Period from Diarrheal Patients in Bangladesh by Firdausi Qadri, Swadesh Kumar Das, A. S. G. Faruque, George J. Fuchs, M. John Albert, R. Bradley Sack, and Ann-Mari Svennerholm; 2000 January http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=86010&ren dertype=external

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Prototypal Diarrheagenic Strains of Hafnia alvei Are Actually Members of the Genus Escherichia by J. Michael Janda, Sharon L. Abbott, and M. John Albert; 1999 August http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=85237&ren dertype=external

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The Gene for Congenital Chloride Diarrhea Maps Close to but is Distinct from the Gene for Cystic Fibrosis Transmembrane Conductance Regulator by J Kere, P Sistonen, C Holmberg, and ADL Chapelle; 1993 November 15 http://www.pubmedcentral.nih.gov/articlerender.fcgi?rendertype=abst ract&artid=47842

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The National Library of Medicine: PubMed One of the quickest and most comprehensive ways to find academic studies in both English and other languages is to use PubMed, maintained by the National Library of Medicine. The advantage of PubMed over previously mentioned sources is that it covers a greater number of domestic and foreign references. It is also free to the public.22 If the publisher has a Web site that offers full text of its journals, PubMed will provide links to that site, as well as to sites offering other related data. User registration, a subscription fee, or some other type of fee may be required to access the full text of articles in some journals. To generate your own bibliography of studies dealing with diarrhea, simply go to the PubMed Web site at www.ncbi.nlm.nih.gov/pubmed. Type “diarrhea” (or synonyms) into the search box, and click “Go.”

Vocabulary Builder Absenteeism: Chronic absence from work or other duty. [NIH] Achlorhydria: A lack of hydrochloric acid in gastric juice despite stimulation of gastric secretion. [NIH] Adjuvant: A substance which aids another, such as an auxiliary remedy; in immunology, nonspecific stimulator (e.g., BCG vaccine) of the immune response. [EU] Aeromonas: A genus of gram-negative, facultatively anaerobic, rod-shaped bacteria that occurs singly, in pairs, or in short chains. Its organisms are found in fresh water and sewage and are pathogenic to humans, frogs, and fish. [NIH] Algorithms: A procedure consisting of a sequence of algebraic formulas and/or logical steps to calculate or determine a given task. [NIH] Alimentary: Pertaining to food or nutritive material, or to the organs of digestion. [EU] Aluminum: A metallic element that has the atomic number 13, atomic symbol Al, and atomic weight 26.98. [NIH] PubMed was developed by the National Center for Biotechnology Information (NCBI) at the National Library of Medicine (NLM) at the National Institutes of Health (NIH). The PubMed database was developed in conjunction with publishers of biomedical literature as a search tool for accessing literature citations and linking to full-text journal articles at Web sites of participating publishers. Publishers that participate in PubMed supply NLM with their citations electronically prior to or at the time of publication.

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Anastomosis: An opening created by surgical, traumatic or pathological means between two normally separate spaces or organs. [EU] Anomalies: Birth defects; abnormalities. [NIH] Anorexia: Lack or loss of the appetite for food. [EU] Anthropometry: The technique that deals with the measurement of the size, weight, and proportions of the human or other primate body. [NIH] Antibodies: Proteins that the body makes to protect itself from foreign substances. In diabetes, the body sometimes makes antibodies to work against pork or beef insulins because they are not exactly the same as human insulin or because they have impurities. The antibodies can keep the insulin from working well and may even cause the person with diabetes to have an allergic or bad reaction to the beef or pork insulins. [NIH] Anticholinergic: An agent that blocks the parasympathetic nerves. Called also parasympatholytic. [EU] Antidepressant: An agent that stimulates the mood of a depressed patient, including tricyclic antidepressants and monoamine oxidase inhibitors. [EU] Antigens: Substances that cause an immune response in the body. The body "sees" the antigens as harmful or foreign. To fight them, the body produces antibodies, which attack and try to eliminate the antigens. [NIH] Antispasmodic: An agent that relieves spasm. [EU] Anus: The distal or terminal orifice of the alimentary canal. [EU] Ascariasis: Infection by nematodes of the genus ASCARIS. Ingestion of infective eggs causes diarrhea and pneumonitis. Its distribution is more prevalent in areas of poor sanitation and where human feces are used for fertilizer. [NIH] Assay: Determination of the amount of a particular constituent of a mixture, or of the biological or pharmacological potency of a drug. [EU] Bacillus: A genus of bacteria of the family Bacillaceae, including large aerobic or facultatively anaerobic, spore-forming, rod-shaped cells, the great majority of which are gram-positive and motile. The genus is separated into 48 species, of which three are pathogenic, or potentially pathogenic, and the remainder are saprophytic soil forms. Many organisms historically called Bacillus are now classified in other genera. [EU] Bacteroides: A genus of gram-negative, anaerobic, rod-shaped bacteria. Its organisms are normal inhabitants of the oral, respiratory, intestinal, and urogenital cavities of humans, animals, and insects. Some species may be pathogenic. [NIH] Benign: Not malignant; not recurrent; favourable for recovery. [EU] Biochemical: Relating to biochemistry; characterized by, produced by, or

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involving chemical reactions in living organisms. [EU] Biotinylation: Incorporation of biotinyl groups into molecules. [NIH] Bismuth: A metallic element that has the atomic symbol Bi, atomic number 83 and atomic weight 208.98. [NIH] Budesonide: A glucocorticoid used in the management of asthma, the treatment of various skin disorders, and allergic rhinitis. [NIH] Carboplatin: An organoplatinum compound that possesses antineoplastic activity. [NIH] Carcinoma: A malignant new growth made up of epithelial cells tending to infiltrate the surrounding tissues and give rise to metastases. [EU] Chimera: An individual that contains cell populations derived from different zygotes. [NIH] Cholera: An acute diarrheal disease endemic in India and Southeast Asia whose causative agent is vibrio cholerae. This condition can lead to severe dehydration in a matter of hours unless quickly treated. [NIH] Clotrimazole: An imidazole derivative with a broad spectrum of antimycotic activity. It inhibits biosynthesis of the sterol ergostol, an important component of fungal cell membranes. Its action leads to increased membrane permeability and apparent disruption of enzyme systems bound to the membrane. [NIH] Collagen: The protein substance of the white fibres (collagenous fibres) of skin, tendon, bone, cartilage, and all other connective tissue; composed of molecules of tropocollagen (q.v.), it is converted into gelatin by boiling. collagenous pertaining to collagen; forming or producing collagen. [EU] Conjugated: Acting or operating as if joined; simultaneous. [EU] Cyclic: Pertaining to or occurring in a cycle or cycles; the term is applied to chemical compounds that contain a ring of atoms in the nucleus. [EU] Cyclospora: A genus of coccidian parasites in the family eimeriidae. Cyclospora cayetanensis is pathogenic in humans, probably transmitted via the fecal-oral route, and causes nausea and diarrhea. [NIH] Cytokines: Non-antibody proteins secreted by inflammatory leukocytes and some non-leukocytic cells, that act as intercellular mediators. They differ from classical hormones in that they are produced by a number of tissue or cell types rather than by specialized glands. They generally act locally in a paracrine or autocrine rather than endocrine manner. [NIH] Dentures: An appliance used as an artificial or prosthetic replacement for missing teeth and adjacent tissues. It does not include crowns, dental abutments, nor tooth, artificial. [NIH] Diverticulum:

A pathological condition manifested as a pouch or sac

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opening from a tubular or sacular organ. [NIH] Dysphagia: Difficulty in swallowing. [EU] Edema: Excessive amount of watery fluid accumulated in the intercellular spaces, most commonly present in subcutaneous tissue. [NIH] Electrophysiological: Pertaining to electrophysiology, that is a branch of physiology that is concerned with the electric phenomena associated with living bodies and involved in their functional activity. [EU] Endemic: Present or usually prevalent in a population or geographical area at all times; said of a disease or agent. Called also endemial. [EU] Endogenous: Developing or originating within the organisms or arising from causes within the organism. [EU] Enterocytozoon: A genus of parasitic protozoa in the family Enterocytozoonidae, which infects humans. Enterocytozoon bieneusi has been found in the intestines of patients with AIDS. [NIH] Enterotoxins: Substances that are toxic to the intestinal tract causing vomiting, diarrhea, etc.; most common enterotoxins are produced by bacteria. [NIH] Eosinophilia: The formation and accumulation of an abnormally large number of eosinophils in the blood. [EU] Epigastric: Pertaining to the epigastrium. [EU] Ethnopharmacology: The study of the actions and properties of drugs, usually derived from medicinal plants, indigenous to a population or ethnic group. [NIH] Evacuation: An emptying, as of the bowels. [EU] Exogenous: Developed or originating outside the organism, as exogenous disease. [EU] Fats: One of the three main classes of foods and a source of energy in the body. Fats help the body use some vitamins and keep the skin healthy. They also serve as energy stores for the body. In food, there are two types of fats: saturated and unsaturated. [NIH] Feces: The excrement discharged from the intestines, consisting of bacteria, cells exfoliated from the intestines, secretions, chiefly of the liver, and a small amount of food residue. [EU] Fibrosis: The formation of fibrous tissue; fibroid or fibrous degeneration [EU] Gastritis: Inflammation of the stomach. [EU] Genotype: The genetic constitution of the individual; the characterization of the genes. [NIH] Glucose: D-glucose, a monosaccharide (hexose), C6H12O6, also known as

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dextrose (q.v.), found in certain foodstuffs, especially fruits, and in the normal blood of all animals. It is the end product of carbohydrate metabolism and is the chief source of energy for living organisms, its utilization being controlled by insulin. Excess glucose is converted to glycogen and stored in the liver and muscles for use as needed and, beyond that, is converted to fat and stored as adipose tissue. Glucose appears in the urine in diabetes mellitus. [EU] Glutamine: A non-essential amino acid present abundantly throught the body and is involved in many metabolic processes. It is synthesized from glutamic acid and ammonia. It is the principal carrier of nitrogen in the body and is an important energy source for many cells. [NIH] Hematemesis: Vomiting of blood. [NIH] Hepatocellular: Pertaining to or affecting liver cells. [EU] Homeostasis: A tendency to stability in the normal body states (internal environment) of the organism. It is achieved by a system of control mechanisms activated by negative feedback; e.g. a high level of carbon dioxide in extracellular fluid triggers increased pulmonary ventilation, which in turn causes a decrease in carbon dioxide concentration. [EU] Hyperplasia: The abnormal multiplication or increase in the number of normal cells in normal arrangement in a tissue. [EU] Hypersensitivity: A state of altered reactivity in which the body reacts with an exaggerated immune response to a foreign substance. Hypersensitivity reactions are classified as immediate or delayed, types I and IV, respectively, in the Gell and Coombs classification (q.v.) of immune responses. [EU] Idiopathic: Of the nature of an idiopathy; self-originated; of unknown causation. [EU] Ileostomy: Surgical creation of an external opening into the ileum for fecal diversion or drainage. Loop or tube procedures are most often employed. [NIH]

Ileus: Obstruction of the intestines. [EU] Immunoassay: Immunochemical assay or detection of a substance by serologic or immunologic methods. Usually the substance being studied serves as antigen both in antibody production and in measurement of antibody by the test substance. [NIH] Immunocompetence: The ability of lymphoid cells to mount a humoral or cellular immune response when challenged by antigen. [NIH] Induction: The act or process of inducing or causing to occur, especially the production of a specific morphogenetic effect in the developing embryo through the influence of evocators or organizers, or the production of anaesthesia or unconsciousness by use of appropriate agents. [EU]

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Intubation: The insertion of a tube into a body canal or hollow organ, as into the trachea or stomach. [EU] Jejunum: That portion of the small intestine which extends from the duodenum to the ileum; called also intestinum jejunum. [EU] Lesion: Any pathological or traumatic discontinuity of tissue or loss of function of a part. [EU] Lipid: Any of a heterogeneous group of flats and fatlike substances characterized by being water-insoluble and being extractable by nonpolar (or fat) solvents such as alcohol, ether, chloroform, benzene, etc. All contain as a major constituent aliphatic hydrocarbons. The lipids, which are easily stored in the body, serve as a source of fuel, are an important constituent of cell structure, and serve other biological functions. Lipids may be considered to include fatty acids, neutral fats, waxes, and steroids. Compound lipids comprise the glycolipids, lipoproteins, and phospholipids. [EU] Mannitol: A diuretic and renal diagnostic aid related to sorbitol. It has little significant energy value as it is largely eliminated from the body before any metabolism can take place. It can be used to treat oliguria associated with kidney failure or other manifestations of inadequate renal function and has been used for determination of glomerular filtration rate. Mannitol is also commonly used as a research tool in cell biological studies, usually to control osmolarity. [NIH] Melena: 1. the passage of dark, pitchy, and grumous stools stained with blood pigments or with altered blood. 2. black vomit. [EU] Membrane: A thin layer of tissue which covers a surface, lines a cavity or divides a space or organ. [EU] Micronutrients: Essential dietary elements or organic compounds that are required in only small quantities for normal physiologic processes to occur. [NIH]

Mobilization: The process of making a fixed part or stored substance mobile, as by separating a part from surrounding structures to make it accessible for an operative procedure or by causing release into the circulation for body use of a substance stored in the body. [EU] Mucus: The free slime of the mucous membranes, composed of secretion of the glands, along with various inorganic salts, desquamated cells, and leucocytes. [EU] Nelfinavir: A potent HIV protease inhibitor. It is used in combination with other antiviral drugs in the treatment of HIV in both adults and children. [NIH]

Neomycin: Antibiotic complex produced by Streptomyces fradiae. It is composed of neomycins A, B, and C. It acts by inhibiting translation during protein synthesis. [NIH]

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Neuropathy: A general term denoting functional disturbances and/or pathological changes in the peripheral nervous system. The etiology may be known e.g. arsenical n., diabetic n., ischemic n., traumatic n.) or unknown. Encephalopathy and myelopathy are corresponding terms relating to involvement of the brain and spinal cord, respectively. The term is also used to designate noninflammatory lesions in the peripheral nervous system, in contrast to inflammatory lesions (neuritis). [EU] Neutralization: An act or process of neutralizing. [EU] Nosocomial: Pertaining to or originating in the hospital, said of an infection not present or incubating prior to admittance to the hospital, but generally occurring 72 hours after admittance; the term is usually used to refer to patient disease, but hospital personnel may also acquire nosocomial infection. [EU] Occult: Obscure; concealed from observation, difficult to understand. [EU] Oocytes: Female germ cells in stages between the prophase of the first maturation division and the completion of the second maturation division. [NIH]

Opiate: A remedy containing or derived from opium; also any drug that induces sleep. [EU] Osmotic: Pertaining to or of the nature of osmosis (= the passage of pure solvent from a solution of lesser to one of greater solute concentration when the two solutions are separated by a membrane which selectively prevents the passage of solute molecules, but is permeable to the solvent). [EU] Paclitaxel: Antineoplastic agent isolated from the bark of the Pacific yew tree, Taxus brevifolia. Paclitaxel stabilizes microtubules in their polymerized form and thus mimics the action of the proto-oncogene proteins C-MOS. [NIH] Pancreatitis: Inflammation (pain, tenderness) of the pancreas; it can make the pancreas stop working. It is caused by drinking too much alcohol, by disease in the gallbladder, or by a virus. [NIH] Pancrelipase: A preparation of hog pancreatic enzymes standardized for lipase content. [NIH] Pathologic: 1. indicative of or caused by a morbid condition. 2. pertaining to pathology (= branch of medicine that treats the essential nature of the disease, especially the structural and functional changes in tissues and organs of the body caused by the disease). [EU] Peptic: Pertaining to pepsin or to digestion; related to the action of gastric juices. [EU] Perfusion: 1. the act of pouring over or through, especially the passage of a fluid through the vessels of a specific organ. 2. a liquid poured over or through an organ or tissue. [EU]

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Phosphorylation: The introduction of a phosphoryl group into a compound through the formation of an ester bond between the compound and a phosphorus moiety. [NIH] Physiologic: Normal; not pathologic; characteristic of or conforming to the normal functioning or state of the body or a tissue or organ; physiological. [EU]

Pneumonia: Inflammation of the lungs with consolidation. [EU] Podophyllum: A genus of poisonous American herbs, family Berberidaceae. The roots yield podophyllotoxins and other pharmacologically important agents. The plant was formerly used as a cholagogue and cathartic. It is different from the European mandrake, mandragora. [NIH] Poisoning: A condition or physical state produced by the ingestion, injection or inhalation of, or exposure to a deleterious agent. [NIH] Postoperative: Occurring after a surgical operation. [EU] Preoperative: Preceding an operation. [EU] Prevalence: The number of people in a given group or population who are reported to have a disease. [NIH] Protease: Proteinase (= any enzyme that catalyses the splitting of interior peptide bonds in a protein). [EU] Proteins: Polymers of amino acids linked by peptide bonds. The specific sequence of amino acids determines the shape and function of the protein. [NIH]

Proxy: A person authorized to decide or act for another person, for example, a person having durable power of attorney. [NIH] Psychotherapy: A generic term for the treatment of mental illness or emotional disturbances primarily by verbal or nonverbal communication. [NIH]

Purpura: Purplish or brownish red discoloration, easily visible through the epidermis, caused by hemorrhage into the tissues. [NIH] Radium: Radium. A radioactive element of the alkaline earth series of metals. It has the atomic symbol Ra, atomic number 88, and atomic weight 226. Radium is the product of the disintegration of uranium and is present in pitchblende and all ores containing uranium. It is used clinically as a source of beta and gamma-rays in radiotherapy, particularly brachytherapy. [NIH] Reagent: A substance employed to produce a chemical reaction so as to detect, measure, produce, etc., other substances. [EU] Receptor: 1. a molecular structure within a cell or on the surface characterized by (1) selective binding of a specific substance and (2) a specific physiologic effect that accompanies the binding, e.g., cell-surface receptors for peptide hormones, neurotransmitters, antigens, complement

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fragments, and immunoglobulins and cytoplasmic receptors for steroid hormones. 2. a sensory nerve terminal that responds to stimuli of various kinds. [EU] Recombinant: 1. a cell or an individual with a new combination of genes not found together in either parent; usually applied to linked genes. [EU] Recurrence: The return of a sign, symptom, or disease after a remission. [NIH] Reflux: A backward or return flow. [EU] Reinfection: A second infection by the same pathogenic agent, or a second infection of an organ such as the kidney by a different pathogenic agent. [EU] Relaxant: 1. lessening or reducing tension. 2. an agent that lessens tension. [EU]

Respiratory: Pertaining to respiration. [EU] Selenium: An element with the atomic symbol Se, atomic number 34, and atomic weight 78.96. It is an essential micronutrient for mammals and other animals but is toxic in large amounts. Selenium protects intracellular structures against oxidative damage. It is an essential component of glutathione peroxidase. [NIH] Serine: A non-essential amino acid occurring in natural form as the Lisomer. It is synthesized from glycine or threonine. It is involved in the biosynthesis of purines, pyrimidines, and other amino acids. [NIH] Sporadic: Neither endemic nor epidemic; occurring occasionally in a random or isolated manner. [EU] Staphylococcus: A genus of gram-positive, facultatively anaerobic, coccoid bacteria. Its organisms occur singly, in pairs, and in tetrads and characteristically divide in more than one plane to form irregular clusters. Natural populations of Staphylococcus are membranes of warm-blooded animals. Some species are opportunistic pathogens of humans and animals. [NIH]

Symptomatic: 1. pertaining to or of the nature of a symptom. 2. indicative (of a particular disease or disorder). 3. exhibiting the symptoms of a particular disease but having a different cause. 4. directed at the allying of symptoms, as symptomatic treatment. [EU] Systemic: Pertaining to or affecting the body as a whole. [EU] Toxin: A poison; frequently used to refer specifically to a protein produced by some higher plants, certain animals, and pathogenic bacteria, which is highly toxic for other living organisms. Such substances are differentiated from the simple chemical poisons and the vegetable alkaloids by their high molecular weight and antigenicity. [EU] Transplantation: The grafting of tissues taken from the patient's own body or from another. [EU]

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Trimebutine: Proposed spasmolytic with possible local anesthetic action used in gastrointestinal disorders. [NIH] Vaccine: A suspension of attenuated or killed microorganisms (bacteria, viruses, or rickettsiae), administered for the prevention, amelioration or treatment of infectious diseases. [EU] Vascular: Pertaining to blood vessels or indicative of a copious blood supply. [EU] Vial: A small bottle. [EU] Vibrio: A genus of vibrionaceae, made up of short, slightly curved, motile, gram-negative rods. Various species produce cholera and other gastrointestinal disorders as well as abortion in sheep and cattle. [NIH] Virulence: The degree of pathogenicity within a group or species of microorganisms or viruses as indicated by case fatality rates and/or the ability of the organism to invade the tissues of the host. [NIH] Visceral: , from viscus a viscus) pertaining to a viscus. [EU] Warfarin: An anticoagulant that acts by inhibiting the synthesis of vitamin K-dependent coagulation factors. Warfarin is indicated for the prophylaxis and/or treatment of venous thrombosis and its extension, pulmonary embolism, and atrial fibrillation with embolization. It is also used as an adjunct in the prophylaxis of systemic embolism after myocardial infarction. Warfarin is also used as a rodenticide. [NIH] Xenopus: An aquatic genus of the family, Pipidae, occurring in Africa and distinguished by having black horny claws on three inner hind toes. [NIH] Yersinia: A genus of gram-negative, facultatively anaerobic rod- to coccobacillus-shaped bacteria that occurs in a broad spectrum of habitats. [NIH]

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CHAPTER 5. PATENTS ON DIARRHEA Overview You can learn about innovations relating to diarrhea by reading recent patents and patent applications. Patents can be physical innovations (e.g. chemicals, pharmaceuticals, medical equipment) or processes (e.g. treatments or diagnostic procedures). The United States Patent and Trademark Office defines a patent as a grant of a property right to the inventor, issued by the Patent and Trademark Office.23 Patents, therefore, are intellectual property. For the United States, the term of a new patent is 20 years from the date when the patent application was filed. If the inventor wishes to receive economic benefits, it is likely that the invention will become commercially available to patients with diarrhea within 20 years of the initial filing. It is important to understand, therefore, that an inventor’s patent does not indicate that a product or service is or will be commercially available to patients with diarrhea. The patent implies only that the inventor has “the right to exclude others from making, using, offering for sale, or selling” the invention in the United States. While this relates to U.S. patents, similar rules govern foreign patents. In this chapter, we show you how to locate information on patents and their inventors. If you find a patent that is particularly interesting to you, contact the inventor or the assignee for further information.

23Adapted

from The U. S. Patent and Trademark Office: http://www.uspto.gov/web/offices/pac/doc/general/whatis.htm.

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Patents on Diarrhea By performing a patent search focusing on diarrhea, you can obtain information such as the title of the invention, the names of the inventor(s), the assignee(s) or the company that owns or controls the patent, a short abstract that summarizes the patent, and a few excerpts from the description of the patent. The abstract of a patent tends to be more technical in nature, while the description is often written for the public. Full patent descriptions contain much more information than is presented here (e.g. claims, references, figures, diagrams, etc.). We will tell you how to obtain this information later in the chapter. The following is an example of the type of information that you can expect to obtain from a patent search on diarrhea: ·

Attenuated forms of bovine viral diarrhea virus Inventor(s): Cao; Xuemei (East Lyme, CT), Sheppard; Michael G. (Stonington, CT) Assignee(s): Pfizer Inc. (New York, NY), Pfizer Products Inc. (Groton, CT) Patent Number: 6,410,299 Date filed: August 29, 2000 Abstract: The present invention is directed to a method of producing attenuated forms of bovine viral diarrhea (BVD) virus by mutating the N.sup.pro protease gene. The invention includes the attenuated viruses made by this method, antibodies generated using these viruses, and vaccines that can be used for immunizing cattle. Excerpt(s): The present invention is directed to methods of producing an attenuated form of bovine viral diarrhea (BVD) virus by inactivating a specific gene in the viral genome. The attenuated virus, or the mutated viral genome, can be used to produce antibody against BVD virus or in vaccines designed to protect cattle from viral infection. ... Bovine viral diarrhea (BVD) virus is classified in the pestivirus genus and Flaviviridae family. It is closely related to viruses causing border disease in sheep and classical swine fever. Infected cattle exhibit "mucosal disease" which is characterized by elevated temperature, diarrhea, coughing and ulcerations of the alimentary mucosa (Olafson, et al., Cornell Vet. 36:205213 (1946); Ramsey, et al., North Am. Vet. 34:629-633 (1953)). The BVD virus is capable of crossing the placenta of pregnant cattle and may result in the birth of persistently infected (PI) calves (Malmquist, J. Am. Vet. Med. Assoc. 152:763-768 (1968); Ross, et al., J. Am. Vet. Med. Assoc. 188:618-619 (1986)). These calves are immunotolerant to the virus and persistently viremic for the rest of their lives. They provide a source for

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outbreaks of mucosal disease (Liess, et al., Dtsch. Tieraerztl. Wschr. 81:481-487 (1974)) and are highly predisposed to infection with microorganisms causing diseases such as pneumonia or enteric disease (Barber, et al., Vet. Rec. 117:459-464 (1985)). ... The terms "induction of an immune response," and the like, are used broadly herein to include the induction of, or increase in, any immune-based response in cattle in response to vaccination, including either an antibody or cell-mediated immune response, or both, that serves to protect the vaccinated animal against BVD virus. The terms "protective immunity," "protective immune response," "protect,", and the like, as used herein, are not limited to absolute prevention of bovine viral diarrhea in cattle, or absolute prevention of infection of cattle by BVD virus, but are intended to also refer to any reduction in the degree or rate of infection by the pathogen, or any reduction in the severity of the disease or in any symptom or condition resulting from infection with the pathogen as compared to that occurring in an unvaccinated, infected control animal. Web site: http://www.delphion.com/details?pn=US06410299__ ·

Method and composition for treatment of infant diarrhea Inventor(s): Postaire; Eric (Vanves, FR), Bouley; Christine (Vaucresson, FR), Guerin-Danan; Corinne (Paris, FR), Andrieux; Claude (Paris, FR) Assignee(s): Compagnie Gervais Danone (Levallois-Perret, FR) Patent Number: 6,399,055 Date filed: October 27, 1998 Abstract: L. casei DN 114-001 is a bacterial agent known for its utility in the fermentation of milk products. A fermented milk product comprising as the sole bacterial agent L. casei DN 114-001 is effective in reducing the number of rotavirus associated diarrhea episodes experienced by infants up to 24 months of age. In particular, the number of rotavirus associated diarrhea episodes, as well as their severity and duration is reduced in children receiving milk products fermented with L. casei DN 114-001, present in the fermented milk product in amounts of at least 10.sup.6 CFU/g. L. casei may be the sole bacterial agent present in the fermented milk product, and yet effective reduction of diarrhea episodes associated with rotavirus infection is obtained. Excerpt(s): This invention pertains to a composition comprising an effective amount of a publically available bacterial strain, Lactobacillus casei strain DN 114-001 as an aid to resisting rotavirus infection and diarrhea associated therewith, as well as reducing the severity and persistence of rotavirus diarrhea, in children up to 24 months of age. The

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invention also pertains to a method of supplementing the nutrition of infants up to 24 months of age with a fermented milk product fermented by L. casei DN 114-001 on a daily basis, as a diarrhea preventive, and in an effort to reduce frequency, severity and duration of diarrheal episodes. Importantly, L. casei DN 114-001 is effective, alone, as the sole bacterial agent in addressing diarrhea in infants up to 24 months of age. ... Group A rotavirus is the leading cause of diarrhea among children aged 6 to 24 months worldwide. Rotavirus associated diarrhea causes 870,000 deaths/year principally in developing countries (1). Symptoms are watery diarrhea, frequently associated with severe dehydration (2) and malabsorption of nutrients (3, 4). Limited investigations by mucosal biopsy of infected infants have shown that rotavirus principally infects the cells of the small intestine. Introduction of fermented milk products in infant diet has been proposed for the prevention or treatment of acute diarrhea (4, 5-10). These products contribute to a well balanced diet and contain lactic acid bacteria (LAB) which are known for their healthful influence, especially in infants (11). Clinical and experimental studies have reported preventive and protective effects of LAB consumption on rotavirus diarrhea. Incidence of diarrhea and rotavirus shedding have been reduced in infants receiving the bacterial association Streptococcus thermophilus and Bifidobacterium bifidum (12). After oral rehydration, a significant reduction of diarrheal symptoms have been observed when infants consumed Lactobacillus casei strain GG (13-15), Lactobacillus reuteri (15) or a milk fermented by Bifidobacterium longum (16). The mechanisms involved in this protection remain poorly understood. ... In a previous study, we have developed a germ-free suckling rat model to study group A rotavirus associated diarrhea (17). In this model, 5-day old infected rats developed a 6-day diarrhea characterized by watery feces containing rotavirus antigens. Histological analyses have demonstrates that rotavirus infects enterocytes and induces cellular vacuolation in the small intestine. Clinical and histopathological analyses were assessed in infected suckling rats supplemented by a milk fermented by the Lactobacillus casei strain DN 114-001, which has been previously involved in a beneficial effect on diarrhea in children (18). Web site: http://www.delphion.com/details?pn=US06399055__

Patents 99

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Use of 11-phenyl-dibenzazepine compounds to treat diarrhea or scours Inventor(s): Lencer; Wayne I. (Jamaica Plains, MA), Brugnara; Carlo (Newton Highlands, MA), Alper; Seth (Jamaica Plain, MA) Assignee(s): Children's Medical Center Corporation (Boston, MA), Beth Israel Deaconess Medical Center (Boston, MA) Patent Number: 6,291,449 Date filed: September 23, 1998 Abstract: A method and product for treating and preventing diarrhea and scours is provided. The method involves treating a subject who has diarrhea, or scours, or is at risk of getting diarrhea or scours with an aromatic compound of the invention. The products of the invention are a veterinary preparation of the aromatic compound of the invention and an anti-scours agent, and a pharmaceutical preparation of the aromatic compound of the invention and an anti-diarrheal agent. Excerpt(s): The present invention relates to methods and products for reducing chloride secretion using aromatic organic compounds. In particular the invention relates to methods of treating diarrhea and scours by administering substituted 11-phenyl-dibenaazepine compounds and analogues thereof. ... Acute and chronic diarrheas represent a major medical problem in many areas of the world. Diarrhea is both a significant factor in malnutrition and the leading cause of death (5,000,000 deaths/year) in children less than five years old. Secretory diarrheas are also a dangerous condition in patients of acquired immunodeficiency syndrome (AIDS) and chronic inflammatory bowel disease (IBD). 16 million travelers to developing countries from industrialized nations every year develop diarrhea, with the severity and number of cases of diarrhea varying depending on the country and area of travel. The major medical consequences of diarrheal diseases include dehydration, acidosis, death and impaired growth. ... Diarrhea in barn animals and pets such as cows, pigs and horses, sheep, goats, cats and dogs, also known as scours, is a major cause of death in these animals. Diarrhea can result from any major transition, such as weaning or physical movement. One form of diarrhea is characterized by diarrhea in response to a bacterial or viral infection and generally occurs within the first few hours of the animal's life. Web site: http://www.delphion.com/details?pn=US06291449__

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Treatment of diarrhea caused by enteropathogenic Escherichia coli Inventor(s): Yanmaele; Rosa P. (Edmonton, CA), Armstrong; Glen D. (Edmonton, CA) Assignee(s): The Governs of the University of Alberta (Edmonton, CA) Patent Number: 6,291,435 Date filed: March 1, 2000 Abstract: This invention relates to compositions and methods useful to treat diarrhea, especially diarrhea and related conditions initiated or mediated by enteropathogenic E. coli (EPEC), using oligosaccharide compositions. This invention also relates to compositions and methods to reduce the virulence of an EPEC organism. Excerpt(s): This invention relates to treatment of diarrhea, particularly diarrhea caused by enteropathogenic Escherichia coli (EPEC). More specifically, the invention concerns compositions and methods which may be used to prevent EPEC infection or ameliorate symptoms caused by EPEC infection. ... Enteropathogenic Escherichia coli (EPEC) is a significant cause of diarrhea world-wide, with disease occuring most frequently in developing countries [1-3]. In these countries, disease occurs regularly in hospitals and clinics, as well as in the general community. EPEC outbreaks in developed countries, on the other hand, usually consist of sporadic, isolated incidents which are localized to neonatal nurseries of hospitals or day-care centers. Infants less than 6 months of age are most often affected, although EPEC is also capable of causing disease in children and adults. The transmission of EPEC infections is thought to occur primarily by the fecal-oral route as a result of contact with infected individuals or with contaminated surfaces or food. The isolation of EPEC from asymptomatic individuals has led to speculation that some individuals may be carriers who can also spread infection. ... Clinical symptoms of EPEC infection in children consist of diarrhea which varies in duration (days to months) and severity [3,4]. In addition to profuse watery stool, symptoms include dehydration, fever, vomiting and weight loss. In protracted or severe cases, disease is often associated with the delayed growth of children, metabolic acidosis (decrease in blood pH resulting from a loss of bicarbonate [5,6]) and, in extreme cases, death. Adults participating in volunteer studies of EPEC infection displayed symptoms similar to those observed in children, but of shorter duration. Web site: http://www.delphion.com/details?pn=US06291435__

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Diarylsulfonylureas for use in treating secretory diarrhea Inventor(s): Schultz; Bruce D (Wamego, KS) Assignee(s): Eli Lilly and Company (Indianapolis, IN) Patent Number: 6,281,240 Date filed: January 31, 2000 Abstract: This invention provides methods of treating secretory diarrhea or cystic fibrosis in a mammal which comprises administering to a mammal in need thereof an effective amount of diarylsulfonylurea. This invention also describes specific diarylsulfonylureas for use in treating secretory diarrhea or cystic fibrosis. Excerpt(s): The present understanding of the underlying pathophysiological mechanism of acute secretory diarrhea is growing steadily. Secretory diarrhea can accompany gastrointestinal disorders such as inflammatory bowel disease. Acute diarrhea is a world-wide problem, and easily accounts for over a million deaths per year. Medical and pharmacological textbooks generally delineate two classifications for anti-diarrheal medications. The first group are known as astringents. The second group are opium derivatives. While such medications have met with some degree of success, it is an alarming fact that drug development specifically targeting diarrheal disease has been, until recently, almost nonexistent. ... Probably the most significant event in the treatment of diarrheal disease in the past one hundred years has been the use of oral glucose-electrolyte solutions. But, there still is a need recognized by world-wide health organizations for continuing effort in diarrhea therapies. ... Recent studies of electrolyte transport by intestinal mucosa have provided valuable information concerning the regulation of biochemical events involved in diarrhea. While there is still much refinement work needed, it has now become apparent that a method of treatment of diarrhea would be to control electrolyte transport, particularly chloride secretion. Web site: http://www.delphion.com/details?pn=US06281240__

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Berberine alkaloids as a treatment for chronic protozoally induced diarrhea Inventor(s): McDevitt; Joseph T. (Villanova, PA) Assignee(s): PRM Pharmaceuticals, Inc. (Ardmore, PA) Patent Number: 6,280,768 Date filed: July 1, 1997

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Abstract: A method for the treatment or prevention of chronic diarrhea caused by protozoa, especially microsporidia and cryptosporidia, in a patient is disclosed which method comprises administering to the patient an effective amount of a berberine alkaloid. The administration of the berberine alkaloid may be in combination with one or more antiprotozoal agents other than berberine. Excerpt(s): Diarrhea is generally described according to several criteria: duration (acute vs. chronic), clinical description (frequency, water content, presence of blood), and etiology. Chronic diarrhea has been described as two to three or more loose or watery stools per day for a period of at least 30 days. ... It is important to distinguish chronic diarrhea from acute diarrhea. Chronic diarrhea is a distinct clinical entity from acute diarrhea that, if unchecked, results in morphological and functional pathology in the intestine. As opposed to acute diarrhea, histological examination of the chronically infected small intestinal mucosa reveals villus atrophy, crypt hypertrophy, and decreased mitosis. Chronic diarrhea leads to malabsorption, weight loss and cachexia. Both the World Health Organization (WHO) and the Center for Disease Control (CDC) have recognized this condition as the "Diarrhea Wasting Syndrome". ... It is often possible to trace the cause of the clinical symptoms of chronic diarrhea in immunosuppressed patients to one or more organisms found in the intestinal tract. In these immunosuppressed individuals, microbes which are relatively harmless to the normal individual take advantage of the very weak immune response to establish a persistent opportunistic infective state. For example, in immunosuppressed patients, such as those with Acquired Immunodeficiency Syndrome (AIDS), chronic diarrhea has been ascribed to the presence of the HIV virus itself, to cytomegalovirus, to the presence of various toxic bacteria, and frequently to infection by pathogenic protozoa. Prevalent among the pathogenic protozoa associated with the presence of diarrhea in immunosuppressed patients are intracellular microsporidia and cryptosporidia (Goodgame, R. W. Ann. Int. Med. 124:429-441 (1996)). In healthy individuals, microsporidial and cryptosporidial infections are self-limiting but immunosuppressed patients can not mount an effective enough immune response to eliminate the causative organism. Web site: http://www.delphion.com/details?pn=US06280768__

Patents 103

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Bovine viral diarrhea virus II vaccine and method of immunization Inventor(s): van den Hurk; Jan (Saskatoon, CA), Tijssen; Peter (Pointe Claire, CA) Assignee(s): Biostar, Inc. (Saskatoon, CA) Patent Number: 6,015,795 Date filed: January 19, 1998 Abstract: This invention relates to the identification of Bovine Viral Diarrhea Virus group II (BVDV-II) nucleic acid sequences (e.g., gp53 sequences), to methods of using the nucleic acid sequences for detecting BVD-II virus in animal sera, to polypeptide viral antigens derived from the sequences and immunoreactive with sera from animals infected with Bovine Viral Diarrhea group II (BVD-II) virus, to polynucleotide sequences which encode these polypeptide antigens, to an expression system capable of producing the polypeptide antigens, to vaccines containing the polypeptide antigens, to methods of using the polypeptide antigens for detecting BVD-II virus antibodies in animal sera, and to antibodies directed against these polypeptide antigens. Excerpt(s): This invention relates to the identification of Bovine Viral Diarrhea Virus group II (BVDV-II), to the isolation of BVDV-II nucleic and amino acid sequences, and to diagnostic and therapeutic methods applicable to BVDV-II. ... Bovine viral diarrhea virus (BVDV) is a small enveloped positive-stranded RNA virus and is classified, along with hog cholera virus (HOCV) and sheep border disease virus (BDV), in the pestivirus genus. Pestiviruses were previously classified in the Togaviridae family (Fenner, 1975), but studies on their genomic organization (Collett, et al., 1988b,c) allowed their reclassification within the Flaviviridae family along with the flavivirus and hepatitis C virus (HCV) groups (Francki, et al., 1991). However, more recent studies on genomic organization, virion composition, and genomic RNA structure (Thiel, et al., 1991; Brock, et al., 1992) suggest, instead, a distinct family for pestiviruses. ... In one aspect, the invention includes a method of detecting a pestivirus or nucleic acid thereof in a nucleic acid-containing sample. The method includes combining the sample with a polynucleotide probe that specifically hybridizes with a polynucleotide fragment having a sequence encoding a Bovine Viral Diarrhea Virus Group II (BVDV-II) gp 53 protein, such as SEQ ID NO:1, and detecting the presence of pestivirus nucleic acid/probe complexes formed by hybridization of the probe to a complimentary target. The detection of such complexes indicates the presence of a pestivirus or nucleic acid thereof in the sample. In specific embodiments, the sample may include serum or fecal material obtained from an animal, such as a ruminant (e.g.,

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cow or goat) or a pig, and the pestivirus may be a BVD-II or a BD virus. In one embodiment, the detecting may be accomplished by hybridization of a probe containing at least one reporter moiety. Reporter moieties may include those utilized in standard detection methods, such as labeling the probe by biotinylation or radioactive isotopes. Negative-sense oligonucleotide probes and oligonucleotide primers specific for BVDV-II gp53 polynucleotides are also defined by the present invention. Both the probes and primers can be derived from the above-described BVDV-II gp53 coding sequences. In another embodiment, the detecting includes amplifying the viral sequences using, for example, polymerase chain reaction. Web site: http://www.delphion.com/details?pn=US06015795__ ·

Plasmid bearing a cDNA copy of the genome of bovine viral diarrhea virus, chimeric derivatives thereof, and method of producing an infectious bovine viral diarrhea virus using said plasmid Inventor(s): Donis; Ruben O. (Lincoln, NE), Vassilev; Ventzislav B. (Lincoln, NE) Assignee(s): Board of Regents of University of Nebraska (Lincoln, NE) Patent Number: 6,001,613 Date filed: May 21, 1997 Abstract: A plasmid bearing a cDNA copy of the genome of bovine viral diarrhea virus (BVDV), chimeric derivatives of the plasmid and a method of producing an infectious bovine viral diarrhea virus using the plasmid are disclosed. The invention relates to a plasmid DNA molecule that replicates easily in E. coli and contains a sufficient portion of the genome of BVDV, cloned as cDNA, to be a suitable template to produce RNA in vitro which, upon transfection into bovine cells, gives rise to infectious BVDV. The BVDV created by the process of the invention can be engineered for use as a vector in many advantageous applications. Excerpt(s): The bovine viral diarrhea virus, or BVDV, is the prototype species in the Pestivirus genus of the Flaviviridae. Positive strand RNA viruses, such as the poliovirus and the BVDV, have a genome consisting of a single molecule of RNA. Pure RNA extracted from either highly concentrated and purified poliovirus or BVDV can be transfected into a susceptible cell, which results in the production of infectious progeny virus by the cell. A homogeneous preparation of viral RNA molecules is infectious upon transfection. Web site: http://www.delphion.com/details?pn=US06001613__

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Method for treating diarrhea Inventor(s): Ishizuka; Masaaki (Mishima, JP), Maeda; Kenji (Meguro-ku, JP), Takeuchi; Tomio (Shinagawa-ku, JP), Toko; Toshiyuki (Itano-gun, JP), Shiraishi; Tadayoshi (Takasago, JP) Assignee(s): Zaidan Hojin Biseibutsu Kagaku Kenkyu Kai (Tokyo, JP), Taino Pharmaceutical Co., Ltd. (Tokyo, JP), Kanegafuchi Kagaku Kogyo Kabushiki Kaisha (Osaka, JP) Patent Number: 5,952,380 Date filed: March 27, 1997 Abstract: A pharmaceutical composition for treating diarrhea comprising an anti-diarrhea effective amount of conagenin or a salt thereof, and a pharmaceutically acceptable carrier. The pharmaceutical composition is particularly useful against diarrhea caused by the administration of cancer chemotherapeutic agents. Excerpt(s): The present invention relates to an agent for preventing and treating diarrhea, and particularly to a pharmaceutical agent for preventing and treating a diarrheic symptom caused by administration of cancer chemotherapeutics. ... Diarrhea often develops as a side-effect disorder during the clinical treatment course by pharmacotherapy, whose typical symptom is characterized by the frequent defecation of liquid or liquid-like stools. In particular, the diarrhea due to the administration of cancer chemotherapeutics is often so serious that most patients with such a diarrhea symptom are no longer allowed to receive the further continuous treatment. Furthermore, this diarrhea endangers the patient's physical strength and nourishment, leading to slowing down the recovery pace from leukopenia, thrombocytopenia and the like, symptoms caused by administration of cancer chemotherapeutics. ... There are already various chemotherapeutics widely used, for example, antimetabolites, such as 5-fluorouracil and derivatives thereof such as 5fluorouracil, doxifluridine and tegafur, 5-fluorouridine, and methotrexate, compounds derived from plants, such as camptothecin, etoposide and vincristin sulfate, alkylating agents such as cyclophosphamide, anticancer antibiotics such as adriamycin and mitomycin C, cisplatin, and carboplatin, but these chemotherapeutics are known to commonly cause the foregoing diarrhea when used. In particular, this side effect is serious in the cases that its onset has been caused by, in particular, the continuous intravenous drip infusion of 5fluorouracil or the administration of 5-fluorodeoxyuridine, doxifluridine, tegafur, cyclophosphamide, vincristine sulfate or irinotecan. So far, little is known about the detailed mechanism of diarrhea development. However, as far as cancer chemotherapeutics are concerned, it is

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speculated that diarrhea might be influenced pathologically by factors such as a direct affection to digestive tract mucosa, namely, chemical changes of mucosal cells, and further changes of enterobacterial flora. Yet there has been no established effective means for improving diarrheric symptom due to cancer chemotherapy, though effort is continued by some attempts such as alleviation of the diarrhea by changes in the usage and dose of cancer chemotherapeutics, improvement in their preparations, modification and conversion of compounds. Web site: http://www.delphion.com/details?pn=US05952380__ ·

Method and formula for the prevention of diarrhea Inventor(s): Halpin-Dohnalek; Margaret Ione (Worthington, OH), Hilty; Milo Duane (Lewis Center, OH), Bynum; Douglas Gene (Columbus, OH) Assignee(s): Abbott Laboratories (Abbott Park, IL) Patent Number: 5,902,578 Date filed: March 25, 1996 Abstract: A novel method for the prevention of infectious diarrhea or diarrhea caused by antibiotic therapy is disclosed. The method comprises the steps of 1) mixing a powder comprising viable cultures of the probiotic organisms Lactobacillus reuteri, Lactobacillus acidophilus and Bifidobacieriurn infantis with a liquid; and 2) enterally administering the mixture to a mammal or a human. In a preferred embodiment at least 10.sup.6 CFU (colony forming units) of each probiotic organism is consumed per day. The invention also relates to pills or capsules containing the probiotic system (Lactobacillus reuteri, Lactobacillus acidophilus and Bifidobacterium infantis) in a freeze dried or lyophilized form. The invention also relates to a novel powdered nutritional formula for the prevention of diarrhea that comprises protein, fat, carbohydrates and the microorganisms Lactobacillus reuteri, Lactobacillus acidophilis and Bifidobacterium infantis. In a preferred embodiment the powdered nutritional formula is a nutritionally complete infant formula. A large clinical study has shown that the probiotic system according to the invention when provided in a non-fermented form is efficacious in the prevention of diarrhea. Also disclosed is a method for manufacturing the formula of the invention. Excerpt(s): The present invention relates generally to a method of preventing diarrhea associated with infectious agents such as rotavirus, or diarrhea associated with antibiotic therapies. More specifically, this invention relates to a powdered infant nutritional that contains the probiotic organisms Lactobacillus reuteri, Lactobacillus acidophillus and

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Bifidobacterium infantis. Administration of at least 10.sup.6 CFU of each probiotic organism in a 24 hour period has been shown to be effective in the prevention of diarrhea. ... Diarrhea is one of the most common health problems in the world, and even in developed countries is one of the most common infectious diseases. Diarrhea is also one of the most common health problems during childhood. While it has been suggested to administer fermented milk products in the treatment of diarrhea (for example rotavirus associated diarrhea), the medical community continues to seek improved methods or products which would be useful in the prevention of the disease. ... In recent years, rotavirus and other enteric viruses have been identified as a major cause of acute diarrhea in infants and young children attending daycare centers. There is an acute need, both domestically and in third world countries, for products and methods that would be effective in preventing infectious diarrhea and diarrhea associated with antibiotic therapy. Web site: http://www.delphion.com/details?pn=US05902578__ ·

Methods and products for treating diarrhea and scours: use of clotrimazole and related aromatic compounds Inventor(s): Lencer; Wayne I. (Jamaica Plain, MA), Brugnara; Carlo (Newton Highlands, MA), Alper; Seth (Jamaica Plain, MA) Assignee(s): Children's Hospital (Boston, MA) Patent Number: 5,889,038 Date filed: March 20, 1996 Abstract: A method and product for treating and preventing diarrhea and scours is provided. The method involves treating a subject who has diarrhea, or scours, or is at risk of getting diarrhea or scours with an aromatic compound of the invention. The products of the invention are a veterinary preparation of the aromatic compound of the invention and an anti-scours agent, and a pharmaceutical preparation of the aromatic compound of the invention and an anti-diarrheal agent. Excerpt(s): Acute and chronic diarrheas represent a major medical problem in many areas of the world. Diarrhea is both a significant factor in malnutrition and the leading cause of death (5,000,000 deaths/year) in children less than five years old. Secretory diarrheas are also a dangerous condition in patients of acquired immunodeficiency syndrome (AIDS) and chronic inflammatory bowel disease (IBD). 16 million travelers to developing countries from industrialized nations every year develop diarrhea, with the severity and number of cases of diarrhea varying depending on the country and area of travel. The major medical

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consequences of diarrheal diseases include dehydration, acidosis, death and impaired growth. ... Diarrhea in barn animals and pets such as cows, pigs and horses, sheep, goats, cats and dogs, also known as scours, is a major cause of death in these animals. Diarrhea can result from any major transition, such as weaning or physical movement. One form of diarrhea is characterized by diarrhea in response to a bacterial or viral infection and generally occurs within the first few hours of the animal's life. ... Although the major consequences of diarrheal diseases are very similar, there are numerous causes of diarrhea. Secretory and exudative diarrhea are primarily caused by bacterial or viral infections. The most common diarrheal causing bacteria is enterotoxogenic E-coli (ETEC) having the K99 pilus antigen. Common viral causes of diarrhea include rotavirus and coronavirus. Other infectious agents include cryptosporidium, giardia lamblia, and salmonella, among others. Web site: http://www.delphion.com/details?pn=US05889038__ ·

Treatment of diarrhea Inventor(s): Casas; Ivan A. (Raleigh, NC), Mollstam; Bo (Lerum, SE) Assignee(s): Biogaia Biologics AB (Stockholm, SE) Patent Number: 5,837,238 Date filed: June 5, 1996 Abstract: A therapeutic method of treating diarrhea of a patient, such as that caused by rotavirus in which a liquid suspension of one or more strains of Lactobacillus reuteni is administered to the patient. Preferably the L. reuteri is isolated from an animal of the same species as the animal to which the therapy is being given. Preferably at least about 10.sup.7 cells of L. reuteri, and most preferably, at least 10.sup.8 cells, are administrated per day, over a period of one to seven days, depending on the severity of the gastroenteritis. The result is a rapid, dramatic reduction in animal's diarrhea and vomiting, previously not found using other therapies. Excerpt(s): Normal microflora is important in the protection of the host against diseases of the gastrointestinal (GI) tract (Fuller, R., Gut 1991;32:439-42; Salminen, S. et al., Dig Dis Sci 1992;10:227-38). During periods of acute diarrhea, the normal gastrointestinal microflora is radically changed. These changes include decreasing numbers of Lactobacilli, Bacteroides and Bifidobacteria (Saiminen S. et al., Dig Dis Sci 1992;10:227-38; Tazume S. et al., Clin Infect Dis 1993;16(2 suppl):77-82S; Mitsuoka T., in Wood B J B, London:Elsevier Applied Science 1992, 1:69114; Salminen S. et al., Chemotherapy, in press.). ... Several studies have

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indicated that the administration of probiotic agents may modulate the microbial balance of the host and attenuate acute periods of diarrhea (Pearce J. L. et al., J. Pediatr 1974;84:261-2; Brunser O. et al., Acta Paediator Scand 1989;78:259-64; Boudraa G. et al., J Pediatr Gastroenterol Nutr 1990; 11:509-12). Lactobacillus casei strain GG (LcGG) has been shown to promote clinical recovery from rotavirus gastroenteritis in children and enhance intestinal immune responses (Isolauri E. et al., Pediatrics 1991;88:90-7; Kaila M. et al., Int Pediatr Research Foundation, Inc. 1992;32:141-4; Majamaa H. et al., J Pediatr Gastroenterol Nutr 1995;20:333-8). Other commercially available preparations of lactic acid bacteria, such as, L. casei subsp. rhamnosus (Lactophilus), L. delbruckii subsp. bulgaricus and others are also being used for the treatment of acute diarrhea, even though their efficacy has not been formally demonstrated (Majamaa H. et al., J Pediatr Gastroenterol Nutr 1995;20:333-8). L. reuteri has been shown to be safe on exogenous administration to healthy humans (Wolf B. W. et al., Micro Ecology Health Dis 1995;8:41-50) and has shown therapeutic potential in a rat model of colitis (Fabia R. et al., Scand J Gastroenterol 1993;28:155-62). ... The invention herein is a method for treatment of diarrhea utilizing one or more strains of Lactobacillus reuteri isolated from an animal of the same species as the animal to which the therapy is being given. Preferably at least about 10.sup.7 cells of L. reuteri are administrated over a period of at least one day, depending on the severity of the gastroenteritis. The result is a rapid, dramatic reduction in the animal's diarrhea and vomiting, previously not found using other therapies. Web site: http://www.delphion.com/details?pn=US05837238__ ·

Use of indigestible oligosaccharides to prevent gastrointestinal infections and reduce duration of diarrhea in humans Inventor(s): Dohnalek; Margaret Ione Halpin (Worthington, OH), Ostrom; Karin Margaret (Reynoldsburg, OH), Hilty; Milo Duane (Lewis Center, OH) Assignee(s): Abbott Laboratories (Abbott Park, IL) Patent Number: 5,827,526 Date filed: June 12, 1996 Abstract: A method is provided for reducing the duration of diarrhea and recurrent episodes of diarrhea in humans by enterally administering indigestible oligosaccharides prophylactically. More specifically, the present invention relates to a method using indigestible oligosaccharides or fructooligosaccharides (FOS) to reduce the duration and recurrence of

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diarrhea in a human wherein between 0.5 grams and 5 grams of at least one FOS selected from the group consisting of 1-kestose, nystose, and 1.sup.F -.beta.-fructofuranosyl nystose is administered to said human per day. The indigestible oligosaccharides can be produced through enzymatic synthesis, chemical techniques or isolated from plant materials and are administered in the form of a nutritional product, candy, tablets, chewing gum, lozenges, milk, yogurts, fermented products and the like. Excerpt(s): The present invention relates to a method of reducing duration of diarrhea by enterally administering to humans indigestible oligosaccharides. ... Fructooligosaccharides (FOS) are natural substances composes primarily of fructose molecules. They belong to a group of carbohydrates that occur in many different plants. FOS are indigestible oligosaccharides that pass through the small intestine without being digested, reaching the large intestine where they are selectively fermented by certain microorganisms. As used in this application and the claims, the terms FOS and indigestible oligosaccharides are interchangeable. FOS can be utilized efficiently by lactobacilli and bifidobacteria, species of bacteria that are beneficial for human health (Hidaka et al.). Selective fermentation of FOS by bifidobacteria leads to an increase in the presence of these bacteria and to the production of acetic acid and lactic acid as fermentation endproducts, resulting in a lower pH in the digestive tract and providing a means to prevent the overgrowth of harmful bacterial like Escherichia coli, Clostridium perfringens and Clostridium difficile. (Hidaka et al., "Fructooligosaccharides: Enzymatic Preparation and Biofunctions", Journal of Carbohydrate Chemistry 10(4): 509-522, 1991). Fermentation of FOS can also lead to an increase in the presence of short chain fatty acids and the suppression of undesirable microorganisms such as Clostridium perfringens, C. difficile, or E. coli and the toxins they produce (Hidaka et al. "Fructooligosaccharides: Enzymatic Preparation and Biofunctions", Journal of Carbohydrate Chemistry 10(4): 509-522, 1991). Indigestible oligosaccharides such as FOS can be added to a nutritional product to create an environment in the gastrointestinal tract that is not conducive to the growth of microbial pathogens. Such a nutritional product can also be useful in the prevention of diarrhea caused by these pathogens. ... Richards et al. (WO 94/27618) discloses a method for the treatment and prevention of diarrhea comprising administration of a caramel prepared according to U.S. Pat. No. 5,318,794 or U.S. Pat. No. 5,206,355. These patents disclose a method for the preparation of trisaccharides and a fructoglucan sucrose polymer. WO 94/27618 provides examples of infants and adults suffering from diarrhea who were treated with the caramels. The present invention is, by contrast, directed to a method for decreasing the duration of diarrhea episodes by the administration of products containing the

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fructooligosaccharides GF.sub.2, GF.sub.3 and GF.sub.4. WO 94/27618 claims a method for treatment or prevention of diarrhea, but only gives examples of treatment. The present invention relates to prophylactic use of FOS to shorten duration of diarrhea. Web site: http://www.delphion.com/details?pn=US05827526__ ·

Treatment of enterotoxigenic diarrhea with 2-substituted adenosine derivatives Inventor(s): Waldman; Scott A. (Ardmore, PA), Parkinson; Scott J. (Grimsby, CA) Assignee(s): Thomas Jefferson University (Philadelphia, PA) Patent Number: 5,817,641 Date filed: April 3, 1997 Abstract: Methods of therapeutically treating individuals suffering from diarrhea comprising the step of administering to such individuals who are suffering from diarrhea, an effective amount of a 2-substituted adenine nucleotide or 2-substituted adenine nucleoside are disclosed. Methods of prophylactically treating individuals to prevent diarrhea comprising the step of administering to individuals who are susceptible to experiencing diarrhea, an effective amount of a 2-substituted adenine nucleotide or 2-substituted adenine nucleoside are disclosed. Excerpt(s): The present invention relates to methods of preventing and treating diarrhea by administering compounds which interfere with the adenine nucleotide-dependent guanylyl cyclase C pathways to an individual at risk of or suffering from diarrhea. ... Bacteria such as E. coli produce a toxin which is resistant to degradation at high temperatures, called the heat-stable enterotoxin (ST). This toxin induces secretion of fluid in the intestine, resulting in diarrhea in individuals infected with these organisms. Indeed, this toxin is a major cause of diarrheal disease in developing countries and a leading cause of morbidity and mortality in the pediatric population worldwide. The toxin induces diarrhea by binding to specific protein receptors in the membranes of intestinal cells which triggers a cascade of biochemical processes eventually leading to fluid secretion into the intestinal lumen. Infectious diarrhea is the fourth leading cause of morbidity and mortality worldwide and the leading cause of morbidity and mortality in the pediatric population. STproducing bacteria account for the majority of these cases. ... Some of the details concerning the cascade of biochemical events in intestinal membranes leading from binding of toxin to the initiation of secretion have been elucidated. Toxin-receptor interaction results in the activation

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of an enzyme, guanylyl cyclase, which produces a small molecule cyclic GMP. Cyclic GMP directly mediates increased secretion of fluid and electrolytes into the intestine and, consequently, diarrhea. Web site: http://www.delphion.com/details?pn=US05817641__

Patent Applications on Diarrhea As of December 2000, U.S. patent applications are open to public viewing.24 Applications are patent requests which have yet to be granted (the process to achieve a patent can take several years). The following patent applications have been filed since December 2000 relating to diarrhea: ·

Bovine viral diarrhea virus serum antigen capture Inventor(s): Huchzermeier, Roy ; (Fayetteville, NY), Dubovi, Edward Joseph ; (Ithaca, NY) Correspondence: Michael L. Goldman; NIXON PEABODY LLP; Clinton Square; P. O. Box 31051; Rochester; NY; 14603; US Patent Application Number: 20010051332 Date filed: December 1, 2000 Abstract: The invention disclosed herein presents an antigen-capture immunoassay that utilizes serum, plasma, milk, urine, saliva, or other bodily fluid samples to identify cattle infected with the Bovine Viral Diarrhea Virus (BVDV). The results of this assay allow an effective, reliable, quick, and cost efficient way to identify, and thereby remove, infected cattle and/or other ruminants from otherwise uninfected herds. The BVD virus causes an acute enteric disease with a variety of clinical manifestations, and is closely related to sheep border disease virus (BDV) and hog cholera virus (HCV). The traditional method of detecting infected animals, including persistently infected (PI) carriers, has been through the use of virus isolation procedures. While this older test methodology can detect infected animals, the virus isolation test can only be performed by highly trained technicians in a highly specialized laboratory facility. The kit disclosed herein uses ELISA methodology, employs the BVDV antigen specific monoclonal antibody 15.c.5, and requires at least 100 .mu.l of sample per assay. Excerpt(s): The invention pertains to the field of immunoassay tests for viral infection. More particularly, the invention pertains to the development of an antigen-capture immunoassay which can use serum,

24

This has been a common practice outside the United States prior to December 2000.

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plasma, milk, mucosal fluid, or urine samples to identify animals infected with the bovine viral diarrhea virus. ... Bovine viral diarrhea virus ("BVDV") currently represents a major threat to the cattle industry. First described over fifty years ago, this pathogen has been found to be both highly virulent and easily spread. Considered a primary pathogen of the bovine enteric, respiratory, reproductive, and immune systems, BVDV continues to cause significant economic losses to the cattle industry worldwide. Recent outbreaks have occurred in Canada, the US, and throughout the world. To help combat these problems, a simpler, more cost effective method of BVDV detection, capable of yielding results in a timely fashion, is needed to better control the spread of the BVDV virus within the cattle population. Such a diagnostic tool is particularly important in light of the ineffectiveness of currently available BVDV vaccines. Web site: http://appft1.uspto.gov/netahtml/PTO/search-bool.html

Keeping Current In order to stay informed about patents and patent applications dealing with diarrhea, you can access the U.S. Patent Office archive via the Internet at no cost to you. This archive is available at the following Web address: http://www.uspto.gov/main/patents.htm. Under “Services,” click on “Search Patents.” You will see two broad options: (1) Patent Grants, and (2) Patent Applications. To see a list of granted patents, perform the following steps: Under “Patent Grants,” click “Quick Search.” Then, type “diarrhea” (or synonyms) into the “Term 1” box. After clicking on the search button, scroll down to see the various patents which have been granted to date on diarrhea. You can also use this procedure to view pending patent applications concerning diarrhea. Simply go back to the following Web address: http://www.uspto.gov/main/patents.htm. Under “Services,” click on “Search Patents.” Select “Quick Search” under “Patent Applications.” Then proceed with the steps listed above.

Vocabulary Builder Acidosis: Too much acid in the body. For a person with diabetes, this can lead to diabetic ketoacidosis. [NIH] Adenine: A purine base and a fundamental unit of adenine nucleotides. [NIH] Adenosine:

A nucleoside that is composed of adenine and d-ribose.

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Adenosine or adenosine derivatives play many important biological roles in addition to being components of DNA and RNA. Adenosine itself is a neurotransmitter. [NIH] Alkaloid: One of a large group of nitrogenous basis substances found in plants. They are usually very bitter and many are pharmacologically active. Examples are atropine, caffeine, coniine, morphine, nicotine, quinine, strychnine. The term is also applied to synthetic substances (artificial a's) which have structures similar to plant alkaloids, such as procaine. [EU] Aromatic: Having a spicy odour. [EU] Astringent: Causing contraction, usually locally after topical application. [EU] Asymptomatic: No symptoms; no clear sign of disease present. [NIH] Atrophy: A wasting away; a diminution in the size of a cell, tissue, organ, or part. [EU] Berberine: An alkaloid from Hydrastis canadensis L., Berberidaceae. It is also found in many other plants. It is relatively toxic parenterally, but has been used orally for various parasitic and fungal infections and as antidiarrheal. [NIH] Bifidobacterium: A rod-shaped, gram-positive, non-acid-fast, non-sporeforming, non-motile bacterium that is a genus of the family actinomycetaceae. It inhabits the intestines and feces of humans as well as the human vagina. [NIH] Camptothecin: An alkaloid isolated from the stem wood of the Chinese tree, Camptotheca acuminata. This compound selectively inhibits the nuclear enzyme DNA topoisomerase. Several semisynthetic analogs of camptothecin have demonstrated antitumor activity. [NIH] Chemotherapeutics: Noun plural but singular or plural in constructions : chemotherapy. [EU] Cisplatin: An inorganic and water-soluble platinum complex. After undergoing hydrolysis, it reacts with DNA to produce both intra and interstrand crosslinks. These crosslinks appear to impair replication and transcription of DNA. The cytotoxicity of cisplatin correlates with cellular arrest in the G2 phase of the cell cycle. [NIH] Coronavirus: A genus of the family coronaviridae which causes respiratory or gastrointestinal disease in a variety of vertebrates. [NIH] Cyclophosphamide: Precursor of an alkylating nitrogen mustard antineoplastic and immunosuppressive agent that must be activated in the liver to form the active aldophosphamide. It is used in the treatment of lymphomas, leukemias, etc. Its side effect, alopecia, has been made use of in defleecing sheep. Cyclophosphamide may also cause sterility, birth defects, mutations, and cancer. [NIH]

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Etoposide: A semisynthetic derivative of podophyllotoxin that exhibits antitumor activity. Etoposide inhibits DNA synthesis by forming a complex with topoisomerase II and DNA. This complex induces breaks in double stranded DNA and prevents repair by topoisomerase II binding. Accumulated breaks in DNA prevent entry into the mitotic phase of cell division, and lead to cell death. Etoposide acts primarily in the G2 and S phases of the cell cycle. [NIH] Fermentation: An enzyme-induced chemical change in organic compounds that takes place in the absence of oxygen. The change usually results in the production of ethanol or lactic acid, and the production of energy. [NIH] Flaviviridae: A family of RNA viruses, some formerly classified under Togoviridae, many of which cause disease in humans and domestic animals. The three genera are flavivirus, pestivirus, and hepatitis C-like viruses. [NIH] Flavivirus: A genus of flaviviridae, also known as Group B arbovirus, containing several subgroups and species. Most are arboviruses transmitted by mosquitoes or ticks. The type species is yellow fever virus. [NIH] Fructose: A type of sugar found in many fruits and vegetables and in honey. Fructose is used to sweeten some diet foods. It is considered a nutritive sweetener because it has calories. [NIH] Homogeneous: Consisting of or composed of similar elements or ingredients; of a uniform quality throughout. [EU] Hybridization: The genetic process of crossbreeding to produce a hybrid. Hybrid nucleic acids can be formed by nucleic acid hybridization of DNA and RNA molecules. Protein Hybridization allows for hybrid proteins to be formed from polypeptide chains. [NIH] Hypertrophy: Nutrition) the enlargement or overgrowth of an organ or part due to an increase in size of its constituent cells. [EU] Immunization: The induction of immunity. [EU] Infusion: The therapeutic introduction of a fluid other than blood, as saline solution, solution, into a vein. [EU] Lumen: The cavity or channel within a tube or tubular organ. [EU] Membranes: Thin layers of tissue which cover parts of the body, separate adjacent cavities, or connect adjacent structures. [NIH] Methotrexate: An antineoplastic antimetabolite with immunosuppressant properties. It is an inhibitor of dihydrofolate reductase and prevents the formation of tetrahydrofolate, necessary for synthesis of thymidylate, an essential component of DNA. [NIH] Microorganism: A microscopic organism; those of medical interest include bacteria, viruses, fungi and protozoa. [EU]

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Mitomycin: An antineoplastic antibiotic produced by Streptomyces caespitosus. It acts as a bi- or trifunctional alkylating agent causing crosslinking of DNA and inhibition of DNA synthesis. [NIH] Mitosis: A method of indirect cell division by means of which the two daughter nuclei normally receive identical complements of the number of chromosomes of the somatic cells of the species. [NIH] Neonatal: Pertaining to the first four weeks after birth. [EU] Nurseries: Facilities which provide care for infants. [NIH] Oligosaccharides: Carbohydrates consisting of between two and ten monosaccharides connected by either an alpha- or beta-glycosidic link. They are found throughout nature in both the free and bound form. [NIH] Placenta: A highly vascular fetal organ through which the fetus absorbs oxygen and other nutrients and excretes carbon dioxide and other wastes. It begins to form about the eighth day of gestation when the blastocyst adheres to the decidua. [NIH] Polypeptide: A peptide which on hydrolysis yields more than two amino acids; called tripeptides, tetrapeptides, etc. according to the number of amino acids contained. [EU] Ruminants: A suborder of the order artiodactyla whose members have the distinguishing feature of a four-chambered stomach. Horns or antlers are usually present, at least in males. [NIH] Species: A taxonomic category subordinate to a genus (or subgenus) and superior to a subspecies or variety, composed of individuals possessing common characters distinguishing them from other categories of individuals of the same taxonomic level. In taxonomic nomenclature, species are designated by the genus name followed by a Latin or Latinized adjective or noun. [EU] Streptococcus: A genus of gram-positive, coccoid bacteria whose organisms occur in pairs or chains. No endospores are produced. Many species exist as commensals or parasites on man or animals with some being highly pathogenic. A few species are saprophytes and occur in the natural environment. [NIH] Vaccination: The introduction of vaccine into the body for the purpose of inducing immunity. Coined originally to apply to the injection of smallpox vaccine, the term has come to mean any immunizing procedure in which vaccine is injected. [EU] Virion: The infective system of a virus, composed of the viral genome, a protein core, and a protein coat called a capsid, which may be naked or enclosed in a lipoprotein envelope called the peplos. [NIH]

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Books 119

CHAPTER 6. BOOKS ON DIARRHEA Overview This chapter provides bibliographic book references relating to diarrhea. You have many options to locate books on diarrhea. The simplest method is to go to your local bookseller and inquire about titles that they have in stock or can special order for you. Some patients, however, feel uncomfortable approaching their local booksellers and prefer online sources (e.g. www.amazon.com and www.bn.com). In addition to online booksellers, excellent sources for book titles on diarrhea include the Combined Health Information Database and the National Library of Medicine. Once you have found a title that interests you, visit your local public or medical library to see if it is available for loan.

Book Summaries: Federal Agencies The Combined Health Information Database collects various book abstracts from a variety of healthcare institutions and federal agencies. To access these summaries, go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. You will need to use the “Detailed Search” option. To find book summaries, use the drop boxes at the bottom of the search page where “You may refine your search by.” Select the dates and language you prefer. For the format option, select “Monograph/Book.” Now type “diarrhea” (or synonyms) into the “For these words:” box. You will only receive results on books. You should check back periodically with this database which is updated every 3 months. The following is a typical result when searching for books on diarrhea:

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·

20 Common Problems in Gastroenterology Source: New York, NY: McGraw-Hill, Inc. 2002. 317 p. Contact: Available from McGraw-Hill, Inc. 1221 Avenue of the Americas, New York, NY 10020. (612) 832-7869. Website: www.bookstore.mcgrawhill.com. PRICE: $45.00;plus shipping and handling. ISBN: 0070220557. Summary: This text is one from a series that provides concise, practical information for health care professionals. This book focuses on the most common gastroenterological problems encountered in a primary practice setting and represents a selection of 20 clinical issues that every practitioner of primary care and general gastroenterology will encounter on a regular basis. The chapters are organized to support rapid access to the information necessary to evaluate and treat most patients with these problems. The text features three sections: general gastroenterology, gastrointestinal (GI) bleeding, and hepatic (liver) and biliary problems. Twenty chapters cover heartburn, nausea and vomiting, dysphagia (swallowing difficulties), weight loss, dyspepsia, chronic abdominal pain (functional GI disorders), acute abdominal pain, acute upper GI bleeding, acute lower GI bleeding, occult (hidden) bleeding and iron deficiency anemia, flatulence (gasiness), acute diarrhea in adults, constipation, colorectal cancer screening, anal pain, viral hepatitis, right upper quadrant pain (gallbladder disease and its complications), liver masses, abnormal liver function tests, and biliary obstruction. Each chapter includes a chapter outline for quick reference, the text itself, a diagnostic and treatment algorithm, and selected references. The text concludes with a subject index. Color photographs are provided in a special section; black and white photographs, figures, and charts illustrate the volume.

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Pediatric Gastrointestinal Disease. 2nd ed Source: Philadelphia, PA: W.B. Saunders Company. 1999. 823 p. Contact: Available from W.B. Saunders Company. Book Order Fulfillment Department, 11830 Westline Industrial Drive, Saint Louis, MO 63146-9988. (800) 545-2522 or (314) 453-7010. Fax (800) 568-5136 or (314) 453-7095. E-mail: [email protected]. Website: customerservice.wbsaunders.com. PRICE: $155.00 plus shipping and handling. ISBN: 0721674615. Summary: This medical textbook covers all facets of clinical pediatric gastrointestinal disease. The text emphasizes a clinical focus and incorporates anatomy and physiology considerations into each chapter rather than a separate section. The book is organized into distinct sections, starting with the common clinical problems and followed by organ specific diseases. General chapters on clinical problems cover

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chronic abdominal pain of childhood and adolescence, vomiting, diarrhea, constipation and encopresis (fecal soiling), failure to thrive, gastrointestinal hemorrhage, eating disorders and obesity, jaundice, ascites, caustic ingestion and foreign bodies, abdominal masses in pediatric patients, and abdominal surgical emergencies. Sections on diseases of the esophagus, stomach, and the small and large bowel (intestine) are followed by chapters reviewing the clinical facets of pediatric liver disease. Specific chapters include gastrointestinal reflux, achalasia and other motor disorders, congenital anomalies, gastric motility disorders, bezoars (a mass of food, hair or other components found in the stomach or intestine), maldigestion and malabsorption, celiac disease, short bowel syndrome, enteric parasites, Crohn's disease, ulcerative colitis, polyps, appendicitis, hernia, Hirschsprung's disease, neoplasms (cancerous and noncancerous), hepatitis, gallbladder diseases, and liver transplantation. The last two sections review diseases of the pancreas and basic nutrition in children, including pancreatitis, cystic fibrosis, nutritional assessment, parenteral (outside the digestive system, for example, intravenous nutrition) and enteral nutrition, and the management of diarrhea. Each chapter offers black and white photographs and figures and concludes with extensive references. A detailed subject index concludes the text. ·

Clinical Practice of Gastroenterology. Volume One Source: Philadelphia, PA: Current Medicine. 1999. 783 p. Contact: Available from W.B. Saunders Company. Order Fulfillment, 6277 Sea Harbor Drive, Orlando, FL 32887. (800) 545-2522. Fax (800) 8746418 or (407) 352-3445. Website: www.wbsaunders.com. PRICE: $235.00 plus shipping and handling. ISBN: 0443065209 (two volume set); 0443065217 (volume 1); 0443065225 (volume 2). Summary: This lengthy textbook brings practitioners up to date on the complexities of gastroenterology practice, focusing on the essentials of patient care. This first volume includes 86 chapters in four sections: esophagus, stomach and duodenum, small bowel, and colon. Specific topics include normal esophageal physiology, gastroesophageal reflux disease (GERD), motor disorders of the esophagus, esophageal foreign bodies, esophagitis, esophageal trauma, esophageal surgery, gastric and duodenal histology and histopathology, gastroduodenal motility and motility disorders, abdominal pain, nausea and vomiting, dyspepsia (heartburn), Helicobacter pylori, gastric and duodenal ulcer, gastric cancer, gastric infection, gastric surgery, small intestine anatomy and physiology, symptoms and signs of small bowel disease, maldigestion and malabsorption, intestinal obstruction and pseudoobstruction,

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immunologic disorders, small intestinal malignancies (cancer), short bowel syndrome, Whipple's disease, infectious diarrhea, parasitic diseases of the small intestine, foodborne diseases of the small intestine, gastroenteritis, Crohn's disease, anatomy and physiology of the colon, irritable bowel syndrome (IBS), secretory diarrhea, constipation and fecal impaction, fecal incontinence, gas and flatulence, gastrointestinal bleeding, colitis (including ulcerative colitis), diverticulitis and diverticular hemorrhage, appendicitis, benign tumors of the colon and polyposis syndrome, malignant tumors of the colon, and anorectal disorders. The chapters include figures, algorithms, charts, graphs, radiographs, endoscopic pictures, intraoperative photographs, photomicrographs, tables, and extensive references. The volume concludes with a detailed subject index and a section of color plates. ·

Gastroenterology and Hepatology: The Comprehensive Visual Reference. Volume 4: Pediatric GI Problems Source: Philadelphia, PA: Current Medicine. 1997. [200 p.]. Contact: Available from Current Medicine. 400 Market Street, Suite 700, Philadelphia, PA 19106. (800) 427-1796 or (215) 574-2266. Fax (215) 5742270. E-mail: [email protected]. Website: current-medicine.com. PRICE: $125.00 plus shipping and handling. ISBN: 0443078521. Summary: This atlas is one in an 8-volume collection of images that pictorially displays the gastrointestinal tract, liver, biliary tree, and pancreas in health and disease, both in children and adults. This volume includes 11 chapters on pediatric gastrointestinal (GI) problems, each written by experts in their respective fields. Topics include the newborn, nutrition, neonatal surgery and the acute abdomen, gastroesophageal reflux, peptic ulcer disease and Helicobacter pylori related gastroduodenal disease, diarrheal disease in infants and children, pediatric inflammatory bowel disease (IBD) and functional bowel disorders, cystic fibrosis, anorectal malformations, and pediatric liver disease. The editor emphasizes that, in pediatric gastroenterology, there is an emphasis on assuring optimal nutritional support for every child because a child's potential for growth and development must be maximized, even in the presence of digestive disease. The chapters emphasize the medical, surgical, and nutritional management care of infants and children with gastrointestinal and liver disease. The format of the atlas is visual images supported by relatively brief text. Tables, charts, diagrams, and photomicrographs are used extensively.

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Gastroenterology and Hepatology: The Comprehensive Visual Reference. Volume 7: Small Intestine Source: Philadelphia, PA: Current Medicine. 1997. [200 p.]. Contact: Available from Current Medicine. 400 Market Street, Suite 700, Philadelphia, PA 19106. (800) 427-1796 or (215) 574-2266. Fax (215) 5742270. E-mail: [email protected]. Website: current-medicine.com. PRICE: $125.00 plus shipping and handling. ISBN: 0443078653. Summary: This atlas is one in an 8-volume collection of images that pictorially displays the gastrointestinal tract, liver, biliary tree, and pancreas in health and disease, both in children and adults. This volume includes 12 chapters on the small intestine. Topics covered include functional anatomy (including fluid and electrolyte absorption), nutrient digestion and absorption, small-bowel motility, secretory diarrhea, nutrient malabsorption, gastric and small intestinal motility disorders, Crohn's disease of the small intestine, neoplastic diseases (cancer), small bowel bleeding, mesenteric vascular insufficiency, small bowel transplantation, and infections of the intestine. The format of the atlas is visual images supported by relatively brief text. Tables, charts, diagrams, and photomicrographs are used extensively. A subject index concludes the volume.

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Pediatric Clinical Gastroenterology. 4th ed Source: St. Louis, MO: Mosby-Year Book, Inc. 1995. 1065 p. Contact: Available from Mosby-Year Book, Inc. 11830 Westline Industrial Drive. St. Louis, MO 63146. (800) 426-4545 or (800) 325-4177 or (314) 8728370. Fax (314) 432-1380. PRICE: $100 (as of 1995). ISBN: 0815174063. Summary: This textbook of pediatric clinical gastroenterology presents 37 chapters in 5 sections: symptoms and signs; diseases of the gastrointestinal tract; diseases of the liver; diseases of the pancreas; and nutritional support. Specific topics include gastrointestinal (GI) emergencies of the neonate; intestinal obstruction; sucking and swallowing disorders; diseases of the esophagus; disorders of the stomach and duodenum; diarrheal disorders; carbohydrate intolerance; malabsorption syndrome; protein losing gastroenteropathy; immune homeostasis and the gut; inflammatory bowel diseases; constipation, fecal incontinence, and proctologic conditions; functional recurrent abdominal pain; parasitic and fungal disease of the GI tract; neonatal unconjugated hyperbilirubinemias; neonatal hepatitis; prolonged obstructive jaundice; acute and chronic viral hepatitis; bacterial, rickettsial, and parasitic infections and infestations; fulminant hepatic failure and hepatic coma; cirrhosis; portal hypertension; inborn errors of

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metabolism; hepatic tumors; liver transplantation; congenital anomalies and heredity disorders; cystic fibrosis; pancreatitis and pancreatic tumors; energy and nutrient requirements; infant feeding; and enteral and parenteral alimentation. Each chapter includes numerous references and a subject index concludes the volume. ·

Escherichia Coli 0157:H7: Diarrheal Illness and Hemolytic-Uremic Syndrome Source: Research Triangle Park, NC: Glaxo Wellcome Inc. 1995. 24 p. Contact: Available from Glaxo Wellcome Educational Resource Center. 5 Moore Drive, Research Triangle Park, NC 27709. (800) 824-2896. PRICE: Single copy free; available to health care professionals only. Order Number GVL231. Summary: This monograph familiarizes readers with diarrheal illness and hemolytic-uremic syndrome (HUS), associated with Escherichia coli 0157:H7. Topics include the epidemiology of illness caused by enterohemorrhagic E. coli, including HUS; methods for isolating and identifying this pathogen and establishing the diagnosis of HUS; treatment for individuals with enterohemorrhagic E. coli-induced illness; and methods for preventing this illness. One section provides information for patients about E. coli 0157:H7. The monograph concludes with a multiple-choice self-test, with which readers can qualify for continuing medical education (CME) credits. 2 figures. 3 tables. 32 references. (AA-M).

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Understanding Indigestion and Other Tummy Troubles Source: Woollahra, New South Wales, Australia: Health Books, Gore and Osment Publications. 1993. 64 p. Contact: Available from Health Books, Gore and Osment Publications, Private Box 427, 150 Queen Street, Woollahra, NSW 2025, Australia. (02) 361-5244. Fax (02) 360-7558. PRICE: $9.95 (as of 1995). ISBN: 187553136X. Summary: This book presents basic information on the causes and treatments of common stomach and digestive tract ailments. After an introductory section that reviews the anatomy and physiology of the gastrointestinal (GI) tract, the book features nine chapters on the following topics: indigestion; ulcers; food poisoning and other causes of upset stomachs and diarrhea; irritable bowel syndrome (IBS); inflammatory bowel disease (IBD); dealing with diverticular disease; bowel cancer; other GI problems, including hiccups, gas, hepatitis, food allergies, appendicitis, and sexually transmitted diseases of the bowel; and children's GI problems, including colic, food intolerance,

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gastroenteritis, reflux, celiac disease, constipation, IBS, IBD, polyps, and phantom pains. The book is written in clear, easy-to-understand language and focuses on practical, self-care tips for many of the disorders covered. ·

Diarrheal Diseases Source: New York, NY: Elsevier Science Publishing Company, Inc. 1991. 554 p. Contact: Available from Elsevier Science Publishing Company, Inc. Book Order Department, 655 Avenue of the Americas, New York, NY 10010. (212) 989-5800. PRICE: $72. ISBN: 0444015736. Summary: This book addresses the subject of diarrheal diseases in a comprehensive manner. It is divided into four sections: the physiology of intestinal fluid transport; the pathophysiology of diarrheal diseases, including the role of inflammatory mediators, virus-gut interactions, how nutrient malabsorption leads to diarrhea, how bacterial enterotoxins cause diarrhea, and the role of motility disorders; a broad spectrum of clinical disease states from congenital diarrheas to ileostomy diarrhea; and therapeutic modalities, including antibiotics, vaccines, oral rehydration therapy, and antidiarrheal drugs. Each of the 22 chapters contains numerous figures, tables, and references. A detailed subject index is included. 2712 references.

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Textbook of Secretory Diarrhea Source: New York, NY: Raven Press. 1990. 454 p. Contact: Available from Raven Press. 1185 Avenue of the Americas, Dept. 5B, New York, NY 10036. (800) 777-2836 or (212) 930-9500. Fax (212) 8693495. PRICE: $129 plus shipping (as of 1995). ISBN: 0881676667. Summary: This book is a compendium of current knowledge of secretory diarrhea. The authors provide comprehensive coverage of the subject including information on the physiological basis of intestinal transport, the most prevalent clinical features of secretory diarrhea, and therapeutic modalities. Thirty-one chapters, each authored by different experts, are grouped into five sections: regulation of electrolyte and water transport; cellular mechanisms of electrolyte transport by enterocytes; signal transduction through the enterocyte cell membrane; clinical causes of secretory diarrhea, and therapeutic options in secretory diarrhea. A detailed subject index is included. 3539 references.

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Book Summaries: Online Booksellers Commercial Internet-based booksellers, such as Amazon.com and Barnes & Noble.com, offer summaries which have been supplied by each title’s publisher. Some summaries also include customer reviews. Your local bookseller may have access to in-house and commercial databases that index all published books (e.g. Books in PrintÒ). The following have been recently listed with online booksellers as relating to diarrhea (sorted alphabetically by title; follow the hyperlink to view more details at Amazon.com): ·

Reducing Diarrhea in Tube-Fed Patients (Using Research to Improve Nursing Practice) by Jo Anne Horsley (1981); ISBN: 0808913263; http://www.amazon.com/exec/obidos/ASIN/0808913263/icongroupin terna

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Laboratory Diagnosis in Neonatal Calf and Pig Diarrhea. Ed by P.W. De Leeuw. Result of Eec Meeting Held Lelystad, the Netherlands, 1980: Proceedings by Workshop on Diagnostic Techniques for Enteropathogenic Agents associat (1981); ISBN: 9024725275; http://www.amazon.com/exec/obidos/ASIN/9024725275/icongroupin terna

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Physicians' Guide to the Etiology and Treatment of Diarrhea by Horacio Jinich, Theodoro Hersh (1982); ISBN: 0874892686; http://www.amazon.com/exec/obidos/ASIN/0874892686/icongroupin terna

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Virus Infections of the Gastrointestinal Tract by David A. J. Tyrrell (Editor) (1982); ISBN: 0824715675; http://www.amazon.com/exec/obidos/ASIN/0824715675/icongroupin terna

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Acute Diarrhea: Its Nutritional Consequences in Children by Joseph A. Bellanti (Editor) (1983); ISBN: 0890049912; http://www.amazon.com/exec/obidos/ASIN/0890049912/icongroupin terna

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Advances in Research on Cholera and Related Diarrheas (New Perspectives in Clinical Microbiology : 6) by S. Kuwahara (Editor), N. F. Pierce (Editor) (1983); ISBN: 089838592X; http://www.amazon.com/exec/obidos/ASIN/089838592X/icongroupi nterna

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Diarrhea and Malnutrition: Interactions, Mechanisms and Interventions by Lincoln C. and Scrimshaw, Nevin S. Chen (Editor) (1983); ISBN: 030641046X;

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http://www.amazon.com/exec/obidos/ASIN/030641046X/icongroupi nterna ·

Oral Rehydration Therapy: An Annotated Bibliography (Scientific Publication 445) by Michael J. McQuestion (1983); ISBN: 9275114455; http://www.amazon.com/exec/obidos/ASIN/9275114455/icongroupin terna

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Antibiotic Associated Diarrhea and Colitis: The Role of Clostridium Difficile by S. Peter Borriello (Editor) (1984); ISBN: 0898386233; http://www.amazon.com/exec/obidos/ASIN/0898386233/icongroupin terna

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International Symposium on Enteric Infections in Man and Animals: Standardization of Immunological Procedures by International Symposium on Enteric Infections in Man and Animals: stan (1984); ISBN: 380553714X; http://www.amazon.com/exec/obidos/ASIN/380553714X/icongroupi nterna

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Chronic Diarrhea in Children (Nestle Nutrition Workshop Series : V. 6) by Emanuel Lebenthal (Editor) (1984); ISBN: 0890043191; http://www.amazon.com/exec/obidos/ASIN/0890043191/icongroupin terna

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Diarrheal Disease and Malnutrition: A Clinical Update by Michael Gracey (Editor) (1985); ISBN: 0443028923; http://www.amazon.com/exec/obidos/ASIN/0443028923/icongroupin terna

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Bacterial Diarrheal Diseases (New Perspectives in Clinical Microbiology) by Y. Takeda (Editor) (1985); ISBN: 0898386810; http://www.amazon.com/exec/obidos/ASIN/0898386810/icongroupin terna

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Diarrhea and Malnutrition in Childhood by J.A. Walker-Smith, A.S. McNeish (1986); ISBN: 0407004017; http://www.amazon.com/exec/obidos/ASIN/0407004017/icongroupin terna

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Infectious Diarrhea in the Young: Strategies for Control in Humans and Animals (International Congress Series, 674) by Saul Tzipori (Editor) (1986); ISBN: 0444807209; http://www.amazon.com/exec/obidos/ASIN/0444807209/icongroupin terna

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The Rational Use of Drugs in the Management of Acute Diarrhea in Children (1987); ISBN: 9241561424;

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http://www.amazon.com/exec/obidos/ASIN/9241561424/icongroupin terna ·

Applied Nutritional Principles in Health and Disease (World View of Nutrition and Dietetics, Vol 53) by Geoffrey H. Bourne (Editor) (1987); ISBN: 3805546815; http://www.amazon.com/exec/obidos/ASIN/3805546815/icongroupin terna

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Viral Diarrheas of Man and Animals by Linda J. Saif, Kenneth W. Theil (Editor) (1990); ISBN: 0849366402; http://www.amazon.com/exec/obidos/ASIN/0849366402/icongroupin terna

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Textbook of Secretory Diarrhea by Emanuel Lebenthal, Michael E. Duffey (Editor) (1990); ISBN: 0881676667; http://www.amazon.com/exec/obidos/ASIN/0881676667/icongroupin terna

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Diarrhea by Michael Gracey (Editor) (1991); ISBN: 0849388198; http://www.amazon.com/exec/obidos/ASIN/0849388198/icongroupin terna

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Diarrheal Diseases (1991); ISBN: 0444015736; http://www.amazon.com/exec/obidos/ASIN/0444015736/icongroupin terna

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Malnutrition in Chronic Diet-Associated Infantile Diarrhea: Diagnosis and Management (Bristol-Myers Squibb/Mead Johnson Nutrition Symposia, Vol. 8) by Carlos H. Lifschitz, Buford L. Nichols (Editor) (1991); ISBN: 012450020X; http://www.amazon.com/exec/obidos/ASIN/012450020X/icongroupi nterna

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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases: Part II: Diet and Activity During Pregnancy and Lactation by Institute of Medicine (1992); ISBN: 0309040922; http://www.amazon.com/exec/obidos/ASIN/0309040922/icongroupin terna

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Cumitechs 12a Laboratory Diagnosis of Bacterial Diarrhea (1992); ISBN: 9992264535; http://www.amazon.com/exec/obidos/ASIN/9992264535/icongroupin terna

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The Management and Prevention of Diarrhea: Practical Guidelines by World Health Organization Staff (Editor) (1993); ISBN: 9241544546; http://www.amazon.com/exec/obidos/ASIN/9241544546/icongroupin terna

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The Evaluation and Treatment of the Patient With Diarrhea by Paul F. Miskovitz, Arnold M. Rochwarger (1993); ISBN: 1563720590; http://www.amazon.com/exec/obidos/ASIN/1563720590/icongroupin terna

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Traveler's Diarrhea: Recent Advances ('Chemotherapy', Vol 41, Supplement 1) by C. Scarpignato, P. Rampal (Editor) (1995); ISBN: 3805561253; http://www.amazon.com/exec/obidos/ASIN/3805561253/icongroupin terna

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Preventing Travelers' Diarrhea (Nuts 'N' Bolts Guide) by Donald Sullivan (1995); ISBN: 0897321766; http://www.amazon.com/exec/obidos/ASIN/0897321766/icongroupin terna

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Diarrheal Disease (Nestle Nutrition Workshop Series, Vol. 38) by Michael Gracey (Editor), John A. Walker-Smith (Editor) (1997); ISBN: 0397587716; http://www.amazon.com/exec/obidos/ASIN/0397587716/icongroupin terna

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Clostridium Difficile: Its Role in Intestinal Disease by Rial D. Rolfe (Editor), Sydney M. Finegold (Editor) (1997); ISBN: 0125934106; http://www.amazon.com/exec/obidos/ASIN/0125934106/icongroupin terna

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Diarrhea, Diarrhea: And Other School Poems for Children by Sigmund A. Boloz, et al (1998); ISBN: 1886635153; http://www.amazon.com/exec/obidos/ASIN/1886635153/icongroupin terna

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Environment, Health and Population Displacement: Development and Change in Mozambique's Diarrhoeal Disease Ecology (The Making of Modern Africa) by Andrew E. Collins (1998); ISBN: 1840143290; http://www.amazon.com/exec/obidos/ASIN/1840143290/icongroupin terna

The National Library of Medicine Book Index The National Library of Medicine at the National Institutes of Health has a massive database of books published on healthcare and biomedicine. Go to the following Internet site, http://locatorplus.gov/, and then select “Search LOCATORplus.” Once you are in the search area, simply type “diarrhea” (or synonyms) into the search box, and select “books only.” From there, results

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can be sorted by publication date, author, or relevance. The following was recently catalogued by the National Library of Medicine:25 ·

Child health care behaviors among Mayan women in Guatemala. Knowledge, attitudes and practices in relation to infant and child feeding, diarrhea and dehydration, acute respiratory infections, and immunization. Author: E. Saenz de Tejada, E.R. Calderon; Year: 1997; Arlington, Virginia, Partnership for Child Health Care, Basic Support for Institutionalizing Child Survival [BASICS], 1997

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Contemporary issues in childhood diarrhoea and malnutrition. Author: edited by Zulfiqar Ahmed Bhutta; Year: 2000; Oxford; New York: Oxford University Press, 2000; ISBN: 0195791495 http://www.amazon.com/exec/obidos/ASIN/0195791495/icongroupin terna

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Description of child illness and treatment behavior in Guatemala. Author: P. Heuveline, N. Goldman; Year: 1998; Princeton, New Jersey, Princeton University, Office of Population Research, 1998

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Diarrhoeal diseases: research perspectives. Author: edited by N. Appaji Rao, N.K. Ganguly; Year: 2000; New Delhi: Indian National Science Academy: Narosa Pub. House, c2000; ISBN: 8173193436

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Finalizing the evaluation and validity studies of the INCAP cholera. Author: diarrhea distance education course, Guatemala City, Guatemala, November 30 - December 10, 1997 / B.R. Burkhalter; Year: 1997; Arlington, Virginia, Partnership for Child Health Care, Basic Support for Institutionalizing Child Survival [BASICS], 1997

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Implementation and evaluation of a distance education course on the management of cholera and diarrheal diseases. Author: R. Flores, J. Robles, B.R. Burkhalter; Year: 1998; Arlington, Virginia, Partnership for Child Health Care, Basic Support for Institutionalizing Child Survival [BASICS], 1998

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Integrated Management of Childhood Illness. IMCI bibliography. No. 2. Author: Biesbrouck, Martine; Year: 1999; Washington, D.C., PAHO, 1999

In addition to LOCATORPlus, in collaboration with authors and publishers, the National Center for Biotechnology Information (NCBI) is adapting biomedical books for the Web. The books may be accessed in two ways: (1) by searching directly using any search term or phrase (in the same way as the bibliographic database PubMed), or (2) by following the links to PubMed abstracts. Each PubMed abstract has a “Books” button that displays a facsimile of the abstract in which some phrases are hypertext links. These phrases are also found in the books available at NCBI. Click on hyperlinked results in the list of books in which the phrase is found. Currently, the majority of the links are between the books and PubMed. In the future, more links will be created between the books and other types of information, such as gene and protein sequences and macromolecular structures. See http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Books.

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Life for my child: diarrhea and acute respiratory infections: a study into health behaviour of mothers in Nyangana district, Namibia: an anthropological field-research. Author: Martine Biesbrouck; Year: 1997; [Utrecht]: Dept. of Cultural Anthropology, University of Utrecht; Windhoek: Unitwin Network for Southern Africa, Ecumenical Institute of Namibia, University of Namibia, Social Science Division, Faculty of Humanities and Social Science, 1997; ISBN: 9051872984

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Nutritional management of acute diarrhea in infants and children. Author: Subcommittee on Nutrition and Diarrheal Diseases Control, Committee on International Nutrition Programs, Food and Nutrition Board, Commission on Life Sciences, National Research Council; Year: 1985; Washington, D.C.: National Academy Press, 1985

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Operations research project on improving private practitioner case management of childhood illnesses: Bihar, India. January 15, 1997. Author: S. Chakraborty; Year: 1997; Arlington, Virginia, Partnership for Child Health Care, Basic Support for Institutionalizing Child Survival [BASICS], 1997

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Participatory action research approach for the reduction of child diarrhea in a slum area of Bangkok. Author: by Sungkom Jongpiputvanich, Suriya Veeravongs, Wathana Wongsekiarttirat; Year: 1991; Bangkok: Dept. of Pediatrics and Unit of Clinical Epidemiology, Faculty of Medicine, Chulalongkorn University and Social Research Institute, Chulalingkorn University, [1991]; ISBN: 9745819441

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Review of 1997 diarrheal diseases training and planning of 1997. Author: 1998 acute respiratory infections activities, Almaty, Bishkek, Osh, Fergana, Tashkent, Almaty, November 5-29, 1997 / V. Maleev; Year: 1997; Arlington, Virginia, Partnership for Child Health Care, Basic Support for Institutionalizing Child Survival [BASICS], 1997

Chapters on Diarrhea Frequently, diarrhea will be discussed within a book, perhaps within a specific chapter. In order to find chapters that are specifically dealing with diarrhea, an excellent source of abstracts is the Combined Health Information Database. You will need to limit your search to book chapters and diarrhea using the “Detailed Search” option. Go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. To find book chapters, use the drop boxes at the bottom of the search page where “You may refine your search by.” Select the dates and language you prefer, and the format option “Book Chapter.” By making these selections and typing in “diarrhea” (or synonyms) into the “For these words:” box, you will only receive results on

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chapters in books. The following is a typical result when searching for book chapters on diarrhea: ·

Diarrhea Following Small Bowel Resection Source: in Bayless, T.M. and Hanauer, S.B. Advanced Therapy of Inflammatory Bowel Disease. Hamilton, Ontario: B.C. Decker Inc. 2001. p. 471-474. Contact: Available from B.C. Decker Inc. 20 Hughson Street South, P.O. Box 620, L.C.D. 1 Hamilton, Ontario L8N 3K7. (905) 522-7017 or (800) 5687281. Fax (905) 522-7839. Email: [email protected]. Website: www.bcdecker.com. PRICE: $129.00 plus shipping and handling. ISBN: 1550091220. Summary: This chapter on diarrhea following small bowel resection (removal) for Crohn's disease is from the second edition of a book devoted to the details of medical, surgical, and supportive management of patients with Crohn's disease (CD) and ulcerative colitis (UC), together known as inflammatory bowel disease (IBD). In intestinal diseases, such as CD and colitis, the normal orderly process of absorption is disrupted, and malabsorption of fluid and electrolytes may cause diarrhea. These intestinal diseases also may result in nutrient malabsorption and the consequences of malnutrition. Intestinal resection permanently removes one or more segments of the intestine. The extent of the absorptive defect depends upon which segment has been removed, how extensive the resection has been, and the ability of other segments to compensate for the missing functions of that segment. Diarrhea can develop shortly after recovery from surgery and refeeding, or some time after recovery from surgery. The time of onset after surgery is an important clue to the possible cause of the diarrhea, thus, careful patient history is crucial for appropriate diagnosis. If a specific problem, such as bacterial overgrowth, is identified, specific treatment can be applied and may substantially improve the situation. Often a specific treatable entity cannot be diagnosed and nonspecific treatment must be applied. Nonspecific treatment can provide significant improvement in symptoms and allow for use of the absorptive surface of the intestine in a more efficient fashion. Nonspecific treatments include diet therapy (reduction in fat intake, frequent feedings, dietary supplements, reduced caffeine intake); antidiarrheal medications; stool modifying agents; adjunctive medications; and replacement therapy (oral rehydration solution, vitamins). 4 tables. 8 references.

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Acute Diarrhea in Adults Source: Edmundowicz, S.A., ed. 20 Common Problems in Gastroenterology. New York, NY: McGraw-Hill, Inc. 2002. p. 159-176. Contact: Available from McGraw-Hill, Inc. 1221 Avenue of the Americas, New York, NY 10020. (612) 832-7869. Website: www.bookstore.mcgrawhill.com. PRICE: $45.00;plus shipping and handling. ISBN: 0070220557. Summary: Acute diarrhea is an increase in stool liquidity or a decrease in consistency, often associated with an increase in stool frequency and volume compared with the patient's usual bowel habits. Diarrhea persisting beyond 4 weeks is regarded as chronic. This chapter on acute diarrhea in adults is from a book that focuses on the most common gastroenterological problems encountered in a primary practice setting. The chapter is organized to support rapid access to the information necessary to evaluate and treat most patients with this problems. Topics include definition and epidemiology; the general approach to patients with acute diarrhea; key history and physical examination points; ancillary tests, including stool examination, stool ova (eggs) and parasite examination; infectious agents, including viral diarrheas, bacterial diarrhea, toxin-induced diarrhea, inflammatory diarrhea due to invasive organisms, parasitic diseases, hospital-acquired diarrhea, traveler's diarrhea, diarrhea in the immunocompromised host, medications as a cause of diarrhea, idiopathic inflammatory bowel disease (IBD), diarrhea in runners, alcohol-induced diarrhea, and the emergence of new diarrheal syndromes and pathogens; patient management, including fluid and electrolyte replacement and food restriction; medications, including adsorbents, antimotility agents, antimicrobials, and antiemetics; patient education; and emerging concepts and controversies. The chapter includes an outline for quick reference, the text itself, a diagnostic and treatment algorithm, and selected references. 1 figure. 9 tables. 25 references.

Directories In addition to the references and resources discussed earlier in this chapter, a number of directories relating to diarrhea have been published that consolidate information across various sources. These too might be useful in gaining access to additional guidance on diarrhea. The Combined Health

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Information Database lists the following, which you may wish to consult in your local medical library:26 ·

Directory of Plain Language Health Information Source: Ottawa, Ontario: Canadian Public Health Association. 1999. 104 p. Contact: Available from Canadian Public Health Association. 400-1565 Carling Avenue, Ottawa, Ontario, K1Z 8R1. (613) 725-3769. Fax (613) 7259826. E-mail: [email protected]. PRICE: $19.95 plus shipping and handling. Also available at www.pls.cpha.ca for free. ISBN: 189432403X. Summary: Patient education materials are often written at a level that is higher than the reading level of the people who need the materials. This directory lists 'plain language' patient education materials. An extensive introductory chapter in the directory describes how patient education materials are evaluated and offers specific information about the best strategies to create plain language materials. Each piece of health information in the directory is rated according to its design assessment, in order to help readers make informed decisions about choosing materials. Part I is a list of health subjects presented in alphabetical order, in the style of a typical index. The page number after a listing notes where to find that piece of health information in Part II. Part II is a list of organizations and their contact information. Below the contact information is a list of the plain language health titles produced by the organization. Each title is grouped under a grade level heading, is numbered, and has a design rating. Part III is an alphabetical list of all the organizations in Part II. Materials related to digestive system diseases include allergies, constipation and soiling in children, cholesterol, hepatitis, constipation, diabetes and diet therapy, exercise for weight control, food choices, nutrition, heart health, immunization, low fat cooking, nausea, vomiting, diarrhea, smoking, and weight loss. Appendices to the directory include a guide to the S.M.O.G. readability formula, clear design tips, and plain language tips. The Directory is also available at www.pls.cpha.ca on the Internet.

You will need to limit your search to “Directories” and diarrhea using the “Detailed Search” option. Go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. To find directories, use the drop boxes at the bottom of the search page where “You may refine your search by”. For publication date, select “All Years”, select language and the format option “Directory”. By making these selections and typing in “diarrhea” (or synonyms) into the “For these words:” box, you will only receive results on directories dealing with diarrhea. You should check back periodically with this database as it is updated every three months.

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General Home References In addition to references for diarrhea, you may want a general home medical guide that spans all aspects of home healthcare. The following list is a recent sample of such guides (sorted alphabetically by title; hyperlinks provide rankings, information, and reviews at Amazon.com): · The Digestive System (21st Century Health and Wellness) by Regina Avraham; Library Binding (February 2000), Chelsea House Publishing (Library); ISBN: 0791055264; http://www.amazon.com/exec/obidos/ASIN/0791055264/icongroupinterna · American College of Physicians Complete Home Medical Guide (with Interactive Human Anatomy CD-ROM) by David R. Goldmann (Editor), American College of Physicians; Hardcover - 1104 pages, Book & CD-Rom edition (1999), DK Publishing; ISBN: 0789444127; http://www.amazon.com/exec/obidos/ASIN/0789444127/icongroupinterna · The American Medical Association Guide to Home Caregiving by the American Medical Association (Editor); Paperback - 256 pages 1 edition (2001), John Wiley & Sons; ISBN: 0471414093; http://www.amazon.com/exec/obidos/ASIN/0471414093/icongroupinterna · Anatomica : The Complete Home Medical Reference by Peter Forrestal (Editor); Hardcover (2000), Book Sales; ISBN: 1740480309; http://www.amazon.com/exec/obidos/ASIN/1740480309/icongroupinterna · The HarperCollins Illustrated Medical Dictionary : The Complete Home Medical Dictionary by Ida G. Dox, et al; Paperback - 656 pages 4th edition (2001), Harper Resource; ISBN: 0062736469; http://www.amazon.com/exec/obidos/ASIN/0062736469/icongroupinterna · Mayo Clinic Guide to Self-Care: Answers for Everyday Health Problems by Philip Hagen, M.D. (Editor), et al; Paperback - 279 pages, 2nd edition (December 15, 1999), Kensington Publishing Corp.; ISBN: 0962786578; http://www.amazon.com/exec/obidos/ASIN/0962786578/icongroupinterna · The Merck Manual of Medical Information : Home Edition (Merck Manual of Medical Information Home Edition (Trade Paper) by Robert Berkow (Editor), Mark H. Beers, M.D. (Editor); Paperback - 1536 pages (2000), Pocket Books; ISBN: 0671027263; http://www.amazon.com/exec/obidos/ASIN/0671027263/icongroupinterna

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Vocabulary Builder Adolescence: The period of life beginning with the appearance of secondary sex characteristics and terminating with the cessation of somatic growth. The years usually referred to as adolescence lie between 13 and 18 years of age. [NIH]

Amitriptyline: Tricyclic antidepressant with anticholinergic and sedative properties. It appears to prevent the re-uptake of norepinephrine and serotonin at nerve terminals, thus potentiating the action of these neurotransmitters. Amitriptyline also appears to antaganize cholinergic and alpha-1 adrenergic responses to bioactive amines. [NIH] Anthropology: The science devoted to the comparative study of man. [NIH] Antiemetic: An agent that prevents or alleviates nausea and vomiting. Also antinauseant. [EU] Appendicitis: Acute inflammation of the vermiform appendix. [NIH] Ascites: Effusion and accumulation of serous fluid in the abdominal cavity; called also abdominal or peritoneal dropsy, hydroperitonia, and hydrops abdominis. [EU] Bezoars: Concretions of swallowed hair, fruit or vegetable fibers, or similar substances found in the alimentary canal. [NIH] Caustic: An escharotic or corrosive agent. Called also cauterant. [EU] Cholesterol: The principal sterol of all higher animals, distributed in body tissues, especially the brain and spinal cord, and in animal fats and oils. [NIH] Cirrhosis: Liver disease characterized pathologically by loss of the normal microscopic lobular architecture, with fibrosis and nodular regeneration. The term is sometimes used to refer to chronic interstitial inflammation of any organ. [EU] Colic: Paroxysms of pain. This condition usually occurs in the abdominal region but may occur in other body regions as well. [NIH] Cutaneous: Pertaining to the skin; dermal; dermic. [EU] Desipramine: A tricyclic dibenzazepine compound that potentiates neurotransmission. Desipramine selectively blocks reuptake of norepinephrine from the neural synapse, and also appears to impair serotonin transport. This compound also possesses minor anticholingeric activity, through its affinity to muscarinic receptors. [NIH] Diarrhoea: Abnormal frequency and liquidity of faecal discharges. [EU] Dietetics: The study and regulation of the diet. [NIH] Diverticulitis: Inflammation of a diverticulum, especially inflammation related to colonic diverticula, which may undergo perforation with abscess

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formation. Sometimes called left-sided or L-sides appendicitis. [EU] Duodenum: The first or proximal portion of the small intestine, extending from the pylorus to the jejunum; so called because it is about 12 fingerbreadths in length. [EU] Dyspepsia: Impairment of the power of function of digestion; usually applied to epigastric discomfort following meals. [EU] Encopresis: Incontinence of feces not due to organic defect or illness. [NIH] Epidemic: Occurring suddenly in numbers clearly in excess of normal expectancy; said especially of infectious diseases but applied also to any disease, injury, or other health-related event occurring in such outbreaks. [EU] Esophagitis: Inflammation, acute or chronic, of the esophagus caused by bacteria, chemicals, or trauma. [NIH] Flatulence: The presence of excessive amounts of air or gases in the stomach or intestine, leading to distention of the organs. [EU] Hemorrhage: Bleeding or escape of blood from a vessel. [NIH] Hepatic: Pertaining to the liver. [EU] Heredity: 1. the genetic transmission of a particular quality or trait from parent to offspring. 2. the genetic constitution of an individual. [EU] Hernia: (he protrusion of a loop or knuckle of an organ or tissue through an abnormal opening. [EU] Hiccup: A spasm of the diaphragm that causes a sudden inhalation followed by rapid closure of the glottis which produces a sound. [NIH] Hoarseness: An unnaturally deep or rough quality of voice. [NIH] Hyperbilirubinemia: Pathologic process consisting of an abnormal increase in the amount of bilirubin in the circulating blood, which may result in jaundice. [NIH] Hypertension: Persistently high arterial blood pressure. Various criteria for its threshold have been suggested, ranging from 140 mm. Hg systolic and 90 mm. Hg diastolic to as high as 200 mm. Hg systolic and 110 mm. Hg diastolic. Hypertension may have no known cause (essential or idiopathic h.) or be associated with other primary diseases (secondary h.). [EU] Infantile: Pertaining to an infant or to infancy. [EU] Malformation: A morphologic defect resulting from an intrinsically abnormal developmental process. [EU] Malignant: Tending to become progressively worse and to result in death. Having the properties of anaplasia, invasion, and metastasis; said of tumours. [EU] Mediator: An object or substance by which something is mediated, such as

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(1) a structure of the nervous system that transmits impulses eliciting a specific response; (2) a chemical substance (transmitter substance) that induces activity in an excitable tissue, such as nerve or muscle; or (3) a substance released from cells as the result of the interaction of antigen with antibody or by the action of antigen with a sensitized lymphocyte. [EU] Megacolon: An abnormally large or dilated colon; the condition may be congenital or acquired, acute or chronic. [EU] Mesenteric: Pertaining to the mesentery : a membranous fold attaching various organs to the body wall. [EU] Microbiology: The study of microorganisms such as fungi, bacteria, algae, archaea, and viruses. [NIH] Monotherapy: A therapy which uses only one drug. [EU] Neoplastic: Pertaining to or like a neoplasm (= any new and abnormal growth); pertaining to neoplasia (= the formation of a neoplasm). [EU] Nicotine: Nicotine is highly toxic alkaloid. It is the prototypical agonist at nicotinic cholinergic receptors where it dramatically stimulates neurons and ultimately blocks synaptic transmission. Nicotine is also important medically because of its presence in tobacco smoke. [NIH] Osteoporosis: Reduction in the amount of bone mass, leading to fractures after minimal trauma. [EU] Parenteral: Not through the alimentary canal but rather by injection through some other route, as subcutaneous, intramuscular, intraorbital, intracapsular, intraspinal, intrasternal, intravenous, etc. [EU] Perforation: 1. the act of boring or piercing through a part. 2. a hole made through a part or substance. [EU] Premenstrual: Occurring before menstruation. [EU] Psychology: The science dealing with the study of mental processes and behavior in man and animals. [NIH] Resection: Excision of a portion or all of an organ or other structure. [EU] Sphincter: A ringlike band of muscle fibres that constricts a passage or closes a natural orifice; called also musculus sphincter. [EU] Toxicity: The quality of being poisonous, especially the degree of virulence of a toxic microbe or of a poison. [EU] Tricyclic: Containing three fused rings or closed chains in the molecular structure. [EU]

Multimedia 139

CHAPTER 7. MULTIMEDIA ON DIARRHEA Overview Information on diarrhea can come in a variety of formats. Among multimedia sources, video productions, slides, audiotapes, and computer databases are often available. In this chapter, we show you how to keep current on multimedia sources of information on diarrhea. We start with sources that have been summarized by federal agencies, and then show you how to find bibliographic information catalogued by the National Library of Medicine. If you see an interesting item, visit your local medical library to check on the availability of the title.

Video Recordings Most disorders do not have a video dedicated to them. If they do, they are often rather technical in nature. An excellent source of multimedia information on diarrhea is the Combined Health Information Database. You will need to limit your search to “video recording” and “diarrhea” using the “Detailed Search” option. Go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. To find video productions, use the drop boxes at the bottom of the search page where “You may refine your search by.” Select the dates and language you prefer, and the format option “Videorecording (videotape, videocassette, etc.).” By making these selections and typing “diarrhea” (or synonyms) into the “For these words:” box, you will only receive results on video productions. The following is a typical result when searching for video recordings on diarrhea:

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·

Gastroenterology for the Primary Care Physician Source: Mount Laurel, NJ: CME Conference Video, Inc. 1994. (instructional package). Contact: Available from CME Conference Video, Inc. 2000 Crawford Place, Suite 100, Mount Laurel, NJ 08054. (800) 284-8433. Fax (800) 2845964. PRICE: $450 plus $12.25 shipping and handling (as of 1995); group practice package available. Program No. 153. Summary: This continuing education course is designed to update internists, family practitioners, and other primary care physicians on new developments in gastroenterology. The format of the course focuses on case presentations emphasizing important and evolving concepts in gastroenterology. The emphasis is on practical diagnostic and therapeutic choices and the development of cost effective management algorithms. Topics include hepatitis C, non-cardiac chest pain, psychopharmacologic approaches to acid reduction, peptic ulcer disease, Helicobacter pylori, risk factors for NSAID injury, Clostridium difficile, travelers' diarrhea, constipation in the elderly, pancreatitis, endoscopic ultrasound, gastroesophageal reflux disease, Barrett's esophagus, liver disease, GI manifestations in AIDS, esophagitis, fecal incontinence, diagnostic testing, irritable bowel syndrome, inflammatory bowel disease, drug therapy, chronic diarrhea, gallstone disease, colon cancer, cirrhosis, and ascites. The program offers 11 hours of AMA-PRA Category 1 credit. (AA-M).

·

Approach to the Patient with Chronic Diarrhea Source: Secaucus, NJ: Network for Continuing Medical Education (NCME). 1993. Contact: Available from NCME. One Harmon Plaza, Secaucus, NJ 07094. (800) 223-0272 or, in New Jersey, (800) 624-2102, or (201) 867-3550. PRICE: $20 for 2-week rental or $50 for purchase. Available only to NCME subscribers; subscriber fees as of 1995 are $1,920 for VHS subscription, $2,120 for U-matic subscription. Summary: In this continuing education program, Dr. Asher Kornbluth guides viewers through the approach to the patient with chronic diarrhea. In the first section, Dr. Kornbluth presents a definition of chronic diarrhea, emphasizes the importance of obtaining a comprehensive, accurate patient history, and reviews the categories of chronic diarrhea, including altered motility, osmotic, inflammatory, secretory, and factitious. He briefly reviews conditions that may cause fecal incontinence, including advanced age, diabetes, and neuromuscular disease, and comments on HIV-associated diarrhea. In the second section,

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he reviews the diagnostic tests used to confirm the diagnosis, including stool examination tests such as culture and sensitivity; the upper GI series; the use of sigmoidoscopy; and endoscopy. The endoscopic differences between ulcerative colitis and Crohn's disease are demonstrated. Dr. Kornbluth concludes with a discussion of the drug treatments available and the indications for each, including opiates and their derivatives, absorbants, anticholinergic agents, agents for treating inflammatory bowel disease (IBD), and octreotide. The video program confers CME credit. (AA-M). ·

Managing Diarrhea and Fecal Incontinence Source: Libertyville, IL: Hollister Incorporated. 1992. (videocassette). Contact: Available from Hollister Incorporated. 2000 Hollister Drive, Libertyville, IL 60048. (800) 323-4060. PRICE: Single copy free. Summary: This videotape program guides nurses in managing diarrhea and fecal incontinence. The program features comments from various physicians and enterostomal therapy nurses. Topics include the timeconsuming nature of dealing with fecal incontinence, psychosocial factors, fecal incontinence in institutionalized patients, the etiology of fecal incontinence and diarrhea, patient assessment, the nursing role, and the drawbacks of three treatment methods currently in use (diapers, absorbent pads, and rectal tubes). The program then introduces a new product from Hollister, the drainable fecal incontinence collector, and describes its advantages.

·

Diagnosis and Management of HIV-Associated Gastrointestinal Disorders Source: Atlanta, GA: Emory University Office of Medical Television. 1990. (videocassette). Contact: Available from Robert W. Woodruff Health Sciences Center, Emory University. Office of Medical Television, 1364 Clifton Road, Box M-16, Atlanta, GA 30322. (404) 727-9797. Fax (404) 727-9798. PRICE: $75.00 (as of 1996). Also available for rental; contact producer for current fee. Item Number 90-19. Summary: This continuing education videotape familiarizes gastroenterologists, internists, and infectious disease consultants with the diagnosis and management of HIV-associated gastrointestinal (GI) disorders. Dr. Mel Wilcox begins the tape by reviewing esophageal manifestations, the diarrheal syndrome, and the hepatobiliary manifestations of AIDS. Dr. Wilcox reviews the data regarding the costeffectiveness of different intensities in the evaluation of these problems.

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The program concludes with a discussion of a syndrome compatible with sclerosing cholangitis and the contribution of CMV and Cryptosporidium to biliary disease in patients with HIV infection. (AA-M).

Audio Recordings The Combined Health Information Database contains abstracts on audio productions. To search CHID, go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. To find audio productions, use the drop boxes at the bottom of the search page where “You may refine your search by.” Select the dates and language you prefer, and the format option “Sound Recordings.” By making these selections and typing “diarrhea” (or synonyms) into the “For these words:” box, you will only receive results on sound recordings (again, most conditions and disorders do not have results, so do not expect to find many). The following is a typical result when searching for sound recordings on diarrhea: ·

[1991 Digestive Disease Week Sessions Audiocassettes] Source: Timonium, MD: Milner-Fenwick, Inc. 1991. (audiocassettes). Contact: Available from AGA Audiovisual Materials in Gastroenterology and Liver Disease. c/o Milner-Fenwick, Inc., 2125 Greenspring Drive, Timonium, MD 21093-3100. (800) 432-8433. PRICE: $14.95 per cassette; discount available for complete series. Summary: These audiocassettes reproduce clinical symposia, research forums, and lectures from the Digestive Disease Week (DDW) 1991 conference, held in New Orleans, LA. Topics available include Helicobacter pylori, gastrointestinal tract disorders in pregnancy, new approaches to biliary tract disease, controversies in the management of pancreatitis, an update on hepatitis C, controversies in the management of pancreatic pseudocysts, the management of irritable bowel syndrome (IBS), the use of somatostatin to treat diarrheal disorders, and recurrent Crohn's disease. Topics in the lectures include: the diagnosis and management of recurrent acute pancreatitis, the regulation of human pancreatic secretion, the use of interleukin 1, the pathophysiology of osmotic and carbohydrate-induced diarrhea, and the management of intractable ascites.

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Bibliography: Multimedia on Diarrhea The National Library of Medicine is a rich source of information on healthcare-related multimedia productions including slides, computer software, and databases. To access the multimedia database, go to the following Web site: http://locatorplus.gov/. Select “Search LOCATORplus.” Once in the search area, simply type in diarrhea (or synonyms). Then, in the option box provided below the search box, select “Audiovisuals and Computer Files.” From there, you can choose to sort results by publication date, author, or relevance. The following multimedia has been indexed on diarrhea. For more information, follow the hyperlink indicated: ·

Approach to the patient with chronic diarrhea. Source: Asher Kornbluth; Year: 1992; Format: Videorecording; Secaucus, N.J.: Network for Continuing Medical Education, 1992

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Bacterial and parasitic causes of diarrhea . Year: 1985; Format: Slide; [Columbus, Ohio]: Center for Continuing Medical Education, the Ohio State University College of Medicine, [1985]

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Chronic diarrhea : efficient evaluation and management. Source: Michael D. Brown; Year: 2000; Format: Videorecording; Secaucus, N.J.: Network for Continuing Medical Education, c2000

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Chronic diarrhea in infants and children. Source: Department of Pediatrics, Emory University, School of Medicine; Year: 1980; Format: Videorecording; Atlanta: Emory Medical Television Network: [for loan or sale by A. W. Calhoun Medical Library], 1980

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Diagnosing diarrhea : recorded at DDW 1995 in San Diego. Source: AGA, American Gastroenterological Association; Year: 1995; Format: Sound recording; [Bethesda, Md.]: The Association, [1995?]

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Diarrhea : causes and management. Source: Marshfield Clinic [and] Saint Joseph's Hospital; Year: 1993; Format: Videorecording; Marshfield, WI: The Clinic, [1993]

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Diarrheal diseases : a review of normal physiology, pathophysiology, and approach to treatment. Source: authors, Eugene B. Chang, Henry J. Binder; Year: 1992; Format: Slide; [Bethesda, Md.]: American Gastroenterological Association, c1992

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Diarrheogenic tumors. Source: Department of Pediatrics, Emory University, School of Medicine; Year: 1980; Format: Videorecording; Atlanta: Emory Medical Television Network: [for loan or sale by A. W. Calhoun Medical Library], 1980

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Diarrhoea management. Source: Foundation for Teaching Aids at Low Cost; Year: 1982; Format: Slide; Chelmsford, Essex, UK: Graves Medical Audiovisual Library, [1982]

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Diarrhoeal diseases. Source: The Wellcome Trust; Year: 1998; Format: Electronic resource; Wallingford, Oxon; New York: CABI Publishing, CAB International, 1998

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Emporiatric enteritis : lessons learned from students in Mexico. Source: presented by the Department of Medicine, Emory University, School of Medicine; Year: 1986; Format: Videorecording; Atlanta, Ga.: The University, 1986

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General diarrhea. Source: [produced by] Hahnemann Medical College & Hospital and World Video Corp; Year: 1981; Format: Videorecording; [S.l.]: Medcare Associates, c1981

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GI grand rounds : the 70-year-old with COPD, pneumonia, and diarrhea. Source: with Eugene M. Bozymski; Year: 1987; Format: Videorecording; Secaucus, N.J.: Network for Continuing Medical Education, 1987

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Good travel, good health. Source: Frank J. Bia, Maria D. Mileno; Year: 1999; Format: Videorecording; Secaucus, N.J.: Network for Continuing Medical Education, c1999

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Infectious diarrhea. Source: presented by the Department of Medicine, Emory University, School of Medicine; Year: 1985; Format: Videorecording; Atlanta, Ga.: The University, 1985

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Infectious diarrhea. Source: [presented by] CME Productions, Inc., in cooperation with the Infectious Disease Section, Yale University, School of Medicine; Year: 1981; Format: Videorecording; [S.l.]: CME Productions, c1981

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Management of diarrheal disorders in the HIV+ patient. Source: [presented by] the Working Group on Gastrointestinal Disorders in the HIV+ Patient; sponsored by the American College of Gastroenterology and the Physicians Association for AIDS Car; Year: 1992; Format: Videorecording; Charleston, S.C.: Health Communications Network, Medical University of South Carolina, c1992

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Oral rehydration. Source: presented by the Department of Pediatrics, Emory University, School of Medicine; Year: 1986; Format: Videorecording; Atlanta, Ga.: The University, 1986

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Pathophysiology of diarrhea. Source: American Gastroenterological Association; Year: 1979; Format: Slide; [Thorofare, N. J.]: The Association; [Timonium, Md.: for sale by Milner-Fenwick], c1979

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Pathophysiology of osmostic. Source: carbohydrate-induced diarrhea [sound recording]: recorded at DDW 1991 in New Orleans; Year: 1991; Format: I.e. osmotic; [Bethesda, Md.]: American Gastroenterological Association, [1991]

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Patient with diarrhea and vomiting. Source: produced by HumRRO, Human Resources Research Organization and Video Software Associates; Year: 1985; Format: Videorecording; San Diego, CA.: Intelligent Images, c1985

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Pharmacology of the symptomatic treatment of diarrhea. Source: American Gastroenterological Association, in cooperation with the National Library of Medicine, National Medical Audiovisual Center; Year: 1978; Format: Slide; Atlanta: The Center, 1978

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Secretory diarrhea : pathogenesis and therapy. Year: 1986; Format: Slide; [Columbus, Ohio]: Ohio Medical Education Network, [1986]

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Special features of infectious diarrhea in infants. Source: American Gastroenterological Association, in cooperation with the National Library of Medicine, National Medical Audiovisual Center; Year: 1978; Format: Slide; Atlanta: The Center, 1978

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Traveller's diarrhea, Campylobacter gastroenteritis and cholera in the U.S.A. Source: presented by Department of Medicine, Emory University, School of Medicine; Year: 1982; Format: Videorecording; Atlanta, Ga.: Emory Medical Television Network, 1982

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Use of somatostatin to treat diarrheal disorders : recorded at DDW 1991 in New Orleans. Year: 1991; Format: Sound recording; [Bethesda, Md.]: American Gastroenterological Association, 1991

Vocabulary Builder Cardiac: Pertaining to the heart. [EU] Cholangitis: Inflammation of a bile duct. [EU] Degenerative: Undergoing degeneration : tending to degenerate; having the character of or involving degeneration; causing or tending to cause degeneration. [EU] Hepatomegaly: Enlargement of the liver. [EU] Neuromuscular: Pertaining to muscles and nerves. [EU] Perianal: Located around the anus. [EU] Somatostatin: A polypeptide hormone produced in the hypothalamus, and other tissues and organs. It inhibits the release of human growth hormone, and also modulates important physiological functions of the kidney,

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pancreas, and gastrointestinal tract. Somatostatin receptors are widely expressed throughout the body. Somatostatin also acts as a neurotransmitter in the central and peripheral nervous systems. [NIH]

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CHAPTER 8. PERIODICALS AND NEWS ON DIARRHEA Overview Keeping up on the news relating to diarrhea can be challenging. Subscribing to targeted periodicals can be an effective way to stay abreast of recent developments on diarrhea. Periodicals include newsletters, magazines, and academic journals. In this chapter, we suggest a number of news sources and present various periodicals that cover diarrhea beyond and including those which are published by patient associations mentioned earlier. We will first focus on news services, and then on periodicals. News services, press releases, and newsletters generally use more accessible language, so if you do chose to subscribe to one of the more technical periodicals, make sure that it uses language you can easily follow.

News Services & Press Releases Well before articles show up in newsletters or the popular press, they may appear in the form of a press release or a public relations announcement. One of the simplest ways of tracking press releases on diarrhea is to search the news wires. News wires are used by professional journalists, and have existed since the invention of the telegraph. Today, there are several major “wires” that are used by companies, universities, and other organizations to announce new medical breakthroughs. In the following sample of sources, we will briefly describe how to access each service. These services only post recent news intended for public viewing.

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PR Newswire Perhaps the broadest of the wires is PR Newswire Association, Inc. To access this archive, simply go to http://www.prnewswire.com. Below the search box, select the option “The last 30 days.” In the search box, type “diarrhea” or synonyms. The search results are shown by order of relevance. When reading these press releases, do not forget that the sponsor of the release may be a company or organization that is trying to sell a particular product or therapy. Their views, therefore, may be biased. The following is typical of press releases that can be found on PR Newswire: ·

Lotronex(R) Tablets to Be Re-Introduced for Women With Severe Diarrhea-Predominant IBS Summary: RESEARCH TRIANGLE PARK, N.C., June 7 /PRNewswire/ - Today the U.S. Food and Drug Administration (FDA) approved the Supplemental New Drug Application (sNDA) for Lotronex(R) (alosetron hydrochloride) Tablets which provides for the re-introduction of the medicine to the marketplace under restricted conditions of use. Lotronex Tablets will be indicated specifically for use in women with severe diarrhea-predominant irritable bowel syndrome who have failed to respond to conventional therapy, whose IBS symptoms are chronic and who have had other gastrointestinal medical conditions that could explain their symptoms ruled out. Symptoms that make diarrheapredominant IBS severe are frequent and serious abdominal pain, fecal incontinence or the uncontrolled urge to have a bowel movement, or curtailment of daily activities because of IBS. Serious gastrointestinal events, specifically ischemic colitis and complications of constipation, have been reported in association with the use of Lotronex. These events have resulted in hospitalization, blood transfusion and/or surgery and some fatalities. In clinical trials, about three women in 1,000 developed ischemic colitis over six months. Lotronex was voluntarily withdrawn by GSK in November 2000 when the company and the FDA were unable to agree on a Risk Management Plan that would guide appropriate use of Lotronex without presenting undue obstacles to patients. However, GSK and the FDA resumed discussions in January 2001, after thousands of patients who had successfully used Lotronex implored both the company and the Agency to work out a plan that would allow them access to Lotronex. These discussions culminated with the submission of the Supplemental

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Application. The return of a drug that was voluntarily withdrawn from the market is virtually unprecedented. The approval comes six weeks after a joint FDA advisory panel of members of the GI Drugs Advisory Committee and the Drug Safety and Risk Management Subcommittee recommended that the FDA consider re-introduction of Lotronex under marketing restrictions. The committee requested that the Agency and company develop a plan to achieve this goal. "We are pleased with the significant efforts that both we and the FDA put into finding a resolution," said Peter Traber, M.D. Senior Vice President and Chief Medical Officer at GlaxoSmithKline. "We and the FDA always had the same goal during our discussions - to provide an effective medicine to appropriate patients. We are pleased to have been able to work out a risk management plan that will allow the most severely affected IBS patients access to Lotronex. "Clearly, the beneficiaries from today's announcement are the patients who will benefit from Lotronex," Dr. Traber said. "The patients who wrote letters and e-mails, made phone calls and especially those who came in person to provide compelling and impassioned testimony at the advisory committee meeting deserve a great deal of credit for getting GSK and the FDA to resolve all of the issues leading to the reintroduction of this product." GSK is working now to resume manufacture of Lotronex and to finalize details of how the risk management plan will be implemented. In addition, with the risk management framework now in place, GSK will develop the supporting physician and pharmacist-directed educational materials. "We intend to make the product available as soon as we can finalize the components of the risk management plan, including approval of materials by the FDA, and complete the steps required for manufacturing," Traber said. Risk Management Plan The risk management plan approved today by the FDA includes, among other elements: * Updated warnings in product labeling, including a Medication Guide for patients that explains to patients what to do if they get constipated or have signs of ischemic colitis.

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* A lower starting dose than previously approved.

* A prescribing program for physicians to be enrolled into, based on self-attestation of qualifications and acceptance of certain responsibilities in prescribing the medicine.

* An agreement for patients to sign, attesting that they are informed about risks and benefits of Lotronex and agree to follow directions that are elements of the plan.

* Stickers affixed on all prescriptions for Lotronex to alert pharmacists that the prescribing physician is enrolled in the Prescribing Program for Lotronex (PPL).

* Directions to prescribers for active follow-up and management of patients.

* Measures to actively monitor and evaluate the plan.

Continued studies GSK has committed to post-marketing (Phase IV) studies that would evaluate the safety and efficacy of lower doses of Lotronex and of taking Lotronex on an "as needed" basis. GSK will also conduct further studies to investigate the etiology of ischemic colitis and small bowel ischemia. In addition, the company will monitor the risk management program. Irritable bowel syndrome is a chronic, recurring condition that affects an estimated 18.5 million Americans, approximately 67% (12.4 M) of whom are women. Although the cause is unknown, IBS is characterized by multiple symptoms that include chronic or recurrent abdominal pain and discomfort and irregular bowel function, such as diarrhea, constipation or alternating diarrhea and constipation. Approximately 30% of women with IBS have diarrhea-predominant IBS (3.7 million). Lotronex is indicated for women with severe diarrhea predominant IBS and the severe form of IBS is thought to affect up to 5% of this population.

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Background on Lotronex Lotronex received FDA approval for marketing in the U.S. on February 9, 2000. On November 28, 2000, after extensive discussion with the FDA, GlaxoSmithKline voluntarily withdrew Lotronex from the U.S. market. In December 2001, GSK filed a supplemental application seeking FDA approval to allow the reintroduction of Lotronex tablets, under modified conditions of use and with restrictions imposed by a risk management plan, for women with diarrhea-predominant IBS who have failed with other therapy. London-based GlaxoSmithKline, with U.S. headquarters in Research Triangle Park, N.C., and Philadelphia, is one of the world's leading research-based pharmaceutical and healthcare companies.

Reuters The Reuters’ Medical News database can be very useful in exploring news archives relating to diarrhea. While some of the listed articles are free to view, others can be purchased for a nominal fee. To access this archive, go to http://www.reutershealth.com/frame2/arch.html and search by “diarrhea” (or synonyms). The following was recently listed in this archive for diarrhea: ·

Camptosar labeling updated to stress warnings about diarrhea Source: Reuters Industry Breifing Date: July 03, 2002 http://www.reuters.gov/archive/2002/07/03/business/links/20020703 rglt005.html

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Lactobacilli ameliorate acute childhood diarrhea when administered early Source: Reuters Medical News Date: June 19, 2002 http://www.reuters.gov/archive/2002/06/19/professional/links/20020 619clin009.html

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Probiotics can prevent antibiotic-associated diarrhea Source: Reuters Industry Breifing Date: June 06, 2002 http://www.reuters.gov/archive/2002/06/06/business/links/20020606 clin009.html

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·

G2 strain of rotavirus associated with diarrhea outbreaks in adults Source: Reuters Medical News Date: June 04, 2002 http://www.reuters.gov/archive/2002/06/04/professional/links/20020 604epid001.html

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'Good' bacteria help kids with diarrhea Source: Reuters Health eLine Date: May 30, 2002 http://www.reuters.gov/archive/2002/05/30/eline/links/20020530elin 013.html

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Zinc shown effective for treating acute diarrhea in young children Source: Reuters Industry Breifing Date: May 24, 2002 http://www.reuters.gov/archive/2002/05/24/business/links/20020524 clin012.html

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New child diarrhea therapy will save millions -UN Source: Reuters Health eLine Date: May 08, 2002 http://www.reuters.gov/archive/2002/05/08/eline/links/20020508elin 031.html

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Zinc combats diarrhea in kids in developing nations Source: Reuters Health eLine Date: May 07, 2002 http://www.reuters.gov/archive/2002/05/07/eline/links/20020507elin 022.html

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Patch vaccine could prevent traveler's diarrhea Source: Reuters Health eLine Date: April 03, 2002 http://www.reuters.gov/archive/2002/04/03/eline/links/20020403elin 040.html

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Lactobacillus supplements may help remedy diarrhea Source: Reuters Health eLine Date: April 01, 2002 http://www.reuters.gov/archive/2002/04/01/eline/links/20020401elin 011.html

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PowderJect files travelers' diarrhea vaccine in EU Source: Reuters Industry Breifing Date: March 11, 2002 http://www.reuters.gov/archive/2002/03/11/business/links/20020311 rglt002.html

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·

Salix files for US approval of travelers' diarrhea treatment Source: Reuters Industry Breifing Date: December 27, 2001 http://www.reuters.gov/archive/2001/12/27/business/links/20011227 rglt003.html

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Rifaximin could replace ciprofloxacin as first choice for traveler's diarrhea Source: Reuters Industry Breifing Date: December 20, 2001 http://www.reuters.gov/archive/2001/12/20/business/links/20011220 clin003.html

The NIH Within MEDLINEplus, the NIH has made an agreement with the New York Times Syndicate, the AP News Service, and Reuters to deliver news that can be browsed by the public. Search news releases at http://www.nlm.nih.gov/medlineplus/alphanews_a.html. MEDLINEplus allows you to browse across an alphabetical index. Or you can search by date at the following Web page: http://www.nlm.nih.gov/medlineplus/newsbydate.html. Often, news items are indexed by MEDLINEplus within their search engine.

Business Wire Business Wire is similar to PR Newswire. To access this archive, simply go to http://www.businesswire.com. You can scan the news by industry category or company name.

Internet Wire Internet Wire is more focused on technology than the other wires. To access this site, go to http://www.internetwire.com and use the “Search Archive” option. Type in “diarrhea” (or synonyms). As this service is oriented to technology, you may wish to search for press releases covering diagnostic procedures or tests that you may have read about.

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Search Engines Free-to-view news can also be found in the news section of your favorite search engines (see the health news page at Yahoo: http://dir.yahoo.com/Health/News_and_Media/, or use this Web site’s general news search page http://news.yahoo.com/. Type in “diarrhea” (or synonyms). If you know the name of a company that is relevant to diarrhea, you can go to any stock trading Web site (such as www.etrade.com) and search for the company name there. News items across various news sources are reported on indicated hyperlinks.

BBC Covering news from a more European perspective, the British Broadcasting Corporation (BBC) allows the public free access to their news archive located at http://www.bbc.co.uk/. Search by “diarrhea” (or synonyms).

Newsletters on Diarrhea Given their focus on current and relevant developments, newsletters are often more useful to patients than academic articles. You can find newsletters using the Combined Health Information Database (CHID). You will need to use the “Detailed Search” option. To access CHID, go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. Your investigation must limit the search to “Newsletter” and “diarrhea.” Go to the bottom of the search page where “You may refine your search by.” Select the dates and language that you prefer. For the format option, select “Newsletter.” By making these selections and typing in “diarrhea” or synonyms into the “For these words:” box, you will only receive results on newsletters. The following list was generated using the options described above: ·

Bowel Management Medication Source: Pull-Thru Network News. 2(3): 4-5. Spring 1993. Contact: Available from Greater New York Pull-Thru Network. c/o Scott and Karen Brownlow, 4 Woody Lane, West Port, CT 06880. (201) 2217530. Summary: This newsletter article provides information for parents about using various bowel management medications in their children. The introduction discusses the problems with differentiating between

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medications; the variety of medications on the market; how the FDA approves drugs; long-term usage and possible side effects; and using generic products. The remainder of the article is divided into two sections: laxatives and antidiarrheals. The laxative section covers bulkforming laxatives, hyperosmotic laxatives (saline), lubricants, stimulant (contact) laxatives, and stool softeners. The antidiarrheal sections discusses opiates, polycarbophil, loperamide hydrochloride, aluminum powder (hydrated), bismuth subsalicylate, attapulgite, kaolin, activated charcoal, lactobacillus, and pectin. For each agent discussed, the author provides the brand name of product(s) that include that agent. The article concludes with a list of books and the address and telephone number for the National Digestive Diseases Information Clearinghouse for obtaining additional information.

Newsletter Articles If you choose not to subscribe to a newsletter, you can nevertheless find references to newsletter articles. We recommend that you use the Combined Health Information Database, while limiting your search criteria to “newsletter articles.” Again, you will need to use the “Detailed Search” option. Go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. Go to the bottom of the search page where “You may refine your search by.” Select the dates and language that you prefer. For the format option, select “Newsletter Article.” By making these selections, and typing in “diarrhea” (or synonyms) into the “For these words:” box, you will only receive results on newsletter articles. You should check back periodically with this database as it is updated every 3 months. The following is a typical result when searching for newsletter articles on diarrhea: ·

Childhood Defecation Disorders: Constipation and Soiling Source: Participate. 9(3): 4-6. Fall 2000. Contact: Available from International Foundation for Functional Gastrointestinal Disorders (IFFGD). P.O. Box 170864, Milwaukee, WI 53217. (888) 964-2001 or (414) 964-1799. Fax (414) 964-7176. E-mail: [email protected]. Website: www.iffgd.org. Summary: This article is the second in a two part series on pediatric functional gastrointestinal (GI) disorders that may prompt parents to bring their child to the doctor for constipation or fecal soiling. In this article, the author focuses on non retentive fecal soiling and functional

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fecal retention. Functional refers to a disorder where the primary problem is not due to disease or visible tissue damage or inflammation; in this article, the author uses functional to refer to symptoms that occur within the expected range of the body's behavior. Functional fecal retention is defined in children by the passage of large or enormous bowel movements at intervals less than twice per week, and the attempt to avoid having bowel movements on purpose. Accompanying symptoms include soiling of the underclothes, irritability, abdominal cramps, and decreased appetite. Functional fecal retention begins when there is a painful bowel movement and the child learns to fear the urge to have a bowel movement. After diagnosis, treatment goals include family and patient education, medication as necessary to assure painless defecation, and the provision of continued availability and interest in the child's problem. Fecal soiling refers to passage of bowel movements into the underclothing, or other inappropriate places. Fecal soiling commonly accompanies functional fecal retention, or after a chronic problem with diarrhea. Functional non retentive (not associated with fecal retention) fecal soiling is diagnosed in children older than 4, who have bowel movements in places and at times that are inappropriate, at least once a week for 3 months, in the absence of a disease to explain it. Treatment goals are to help the parent to understand that there is no medical disease, and to accept a referral to a mental health professional. Parents need guidance to understand that soiling is a symptom of emotional upset, not simply bad behavior. 1 table. ·

Dietary Factors in Gastrointestinal Diseases Source: Networking News. 20(4): 1, 5, 10. Summer 1999. Contact: Available from Nutrition Education for the Public. ADA/DPG 52, Bill Evers, 2971 Soldiers Home Road, West Lafayette, IN 47906-1660. Summary: This newsletter article reviews the role of dietary factors in gastrointestinal diseases. Many factors have been implicated to produce worsening of symptoms of functional gastrointestinal disorders (FGID), such as irritable bowel syndrome (IBS), including stress and diet. The author discusses several specific diseases that are associated with adverse reactions to food. The common complaints that are associated with reactions to food are: bloating, heartburn, dyspepsia, excessive gas, diarrhea, and constipation. Some of these diseases (gastroesophageal reflux disease, celiac disease, food allergies, and lactose intolerance) are associated with specific dietary therapies that improve symptoms; each is summarized briefly. The author also discusses a rare syndrome, called eosinophilic gastroenteritis, which is treated with prednisone therapy. All of these diseases have characteristics that differentiate them from

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functional GI disorders (those without a clear underlying pathology). The author notes that a symptoms diary collected over 2 to 3 weeks can help determine the relationship of the symptoms to foods. Many individuals with FGID believe that specific foods are responsible for their symptoms, yet no clear resolution of symptoms occurs when the offending foods are eliminated. An elimination diet should be performed with the help of a health professional, since unmonitored elimination diets can produce malnutrition. 8 references. ·

Dietary Strategies for Coping with the Gastrointestinal Discomforts of Cancer Therapy Source: Intestinal Fortitude. 8(4): 3. 1998. Contact: Available from Intestinal Disease Foundation. 1323 Forbes Avenue, Suite 200, Pittsburgh, PA 15219. (412) 261-5888. Summary: Many patients experience gastrointestinal discomfort as a result of cancer therapy. This brief newsletter article offers strategies for coping with these discomforts. The author recommends tips for six problems: nausea and vomiting, lactose intolerance, heartburn, constipation, diarrhea and cramping, and intestinal gas. In each section, the author provides specific strategies and foods to try. Strategies include eating small amounts of food, increasing fiber and fluid intake, avoiding potentially irritating foods (especially caffeine-containing products and alcohol), and undertaking light exercise. The author encourages readers to try the various suggestions and determine what succeeds in each individual situation.

·

Assessment of the Gastrointestinal Tract Source: Support Line. 19(2): 3-7. April 1997. Contact: Available from Dietitians in Nutrition Support. American Dietetic Association (ADA), 216 West Jackson Boulevard, Suite 800, Chicago, IL 60606-6995. Summary: This article on assessment of the gastrointestinal (GI) tract is one in a series designed to enhance registered dietitians' knowledge of physical examination as it relates to their practice in the field of nutrition support. The author stresses that assessment of the GI tract is a critical component of the overall physical assessment of patients. Many decisions that nutrition support practitioners must make in providing and continuing therapy depend on the status of the GI tract. The author discusses obtaining a patient's medical history, and encourages readers to include questions about the patient's prior medical history, family history, and socioeconomic history. The next step in an overall patient

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assessment is to focus on the main symptoms. The author discusses the etiology and classification of acute and chronic diarrhea, the anatomy of the abdomen, physical assessment beginning with an oral examination, the abdominal exam (inspection, auscultation, percussion, and palpation), diagnostic tests, and laboratory tests. The most common GI diagnostic tests are abdominal x-rays, endoscopy, ultrasound, and computed tomography (CT scan). Laboratory tests most often consist of blood and stool tests. The author stresses that physical assessment and examination cannot be learned solely from reading an article; they must be taught in a formal setting, practiced, and then performed daily to maintain proficiency. 4 tables. 13 references. (AA-M). ·

Toddler's Diarrhea Source: Newsletter for People With Lactose Intolerance and Milk Allergy. p. 9-10. December-January 1995-1996. Contact: Available from Newsletter for People With Lactose Intolerance and Milk Allergy. P.O. Box 3129, Ann Arbor, MI 48106-3129. (313) 5729134. Summary: This newsletter article presents information about toddlers' diarrhea, a common type of chronic diarrhea in children. Topics include how toddlers' diarrhea differs from other forms of diarrhea, the need for continued fluids or oral rehydration therapy, possible contributing factors, the role of food allergy in diarrhea, and problems with diarrhea in day care centers. The author provides parents with specific suggestions for managing and preventing toddlers' diarrhea.

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Controlling Incontinence by Controlling Diarrhea: The Role of Diet Source: Intestinal Fortitude. 6(3): 7-10. Winter 1995-1996. Contact: Available from Intestinal Disease Foundation. 1323 Forbes Avenue, Suite 200, Pittsburgh, PA 15219. (412) 261-5888. Summary: This article helps patients understand the role of diet in controlling fecal incontinence, notably by controlling diarrhea. Topics include diarrhea and nutritional deficiencies; the role of meal size and composition; preservatives, alcohol, and caffeine; dietary fat, dietary fiber, and adequate fluids; the special role of pectin; and meal time recommendations. For each topic, the author provides specific suggestions for readers to incorporate into their meal habits.

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Academic Periodicals covering Diarrhea Academic periodicals can be a highly technical yet valuable source of information on diarrhea. We have compiled the following list of periodicals known to publish articles relating to diarrhea and which are currently indexed within the National Library of Medicine’s PubMed database (follow hyperlinks to view more information, summaries, etc., for each). In addition to these sources, to keep current on articles written on diarrhea published by any of the periodicals listed below, you can simply follow the hyperlink indicated or go to the following Web site: www.ncbi.nlm.nih.gov/pubmed. Type the periodical’s name into the search box to find the latest studies published. If you want complete details about the historical contents of a periodical, you can also visit the Web site: http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi. Here, type in the name of the journal or its abbreviation, and you will receive an index of published articles. At http://locatorplus.gov/ you can retrieve more indexing information on medical periodicals (e.g. the name of the publisher). Select the button “Search LOCATORplus.” Then type in the name of the journal and select the advanced search option “Journal Title Search.” The following is a sample of periodicals which publish articles on diarrhea: ·

Journal of Alternative and Complementary Medicine (New York, N. . . (J Altern Complement Med) http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi?field=0®exp=Jo urnal+of+Alternative+and+Complementary+Medicine+(New+York,+N. +.+&dispmax=20&dispstart=0

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Journal of Gastroenterology and Hepatology. (J Gastroenterol Hepatol) http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi?field=0®exp=Jo urnal+of+Gastroenterology+and+Hepatology&dispmax=20&dispstart=0

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Social Science & Medicine (1982). (Soc Sci Med) http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi?field=0®exp=So cial+Science+&+Medicine+(1982)&dispmax=20&dispstart=0

·

The Annals of Pharmacotherapy. (Ann Pharmacother) http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi?field=0®exp=Th e+Annals+of+Pharmacotherapy&dispmax=20&dispstart=0

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Vocabulary Builder Auscultation: The act of listening for sounds within the body, chiefly for ascertaining the condition of the lungs, heart, pleura, abdomen and other organs, and for the detection of pregnancy. [EU] Barium: An element of the alkaline earth group of metals. It has an atomic symbol Ba, atomic number 56, and atomic weight 138. All of its acid-soluble salts are poisonous. [NIH] Ciprofloxacin: A carboxyfluoroquinoline antimicrobial agent that is effective against a wide range of microorganisms. It has been successfully and safely used in the treatment of resistant respiratory, skin, bone, joint, gastrointestinal, urinary, and genital infections. [NIH] Filtration: The passage of a liquid through a filter, accomplished by gravity, pressure, or vacuum (suction). [EU] Intermittent: Occurring at separated intervals; having periods of cessation of activity. [EU] Ischemia: Deficiency of blood in a part, due to functional constriction or actual obstruction of a blood vessel. [EU] Lymphoma: Any neoplastic disorder of the lymphoid tissue, the term lymphoma often is used alone to denote malignant lymphoma. [EU] Nitrogen: An element with the atomic symbol N, atomic number 7, and atomic weight 14. Nitrogen exists as a diatomic gas and makes up about 78% of the earth's atmosphere by volume. It is a constituent of proteins and nucleic acids and found in all living cells. [NIH] Palpation: Application of fingers with light pressure to the surface of the body to determine consistence of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. [NIH] Pharmacist: A person trained to prepare and distribute medicines and to give information about them. [NIH] Prednisone: A synthetic anti-inflammatory glucocorticoid derived from cortisone. It is biologically inert and converted to prednisolone in the liver. [NIH]

Psychiatric: Pertaining to or within the purview of psychiatry. [EU] Saline: Salty; of the nature of a salt; containing a salt or salts. [EU] Sarcoidosis: An idiopathic systemic inflammatory granulomatous disorder comprised of epithelioid and multinucleated giant cells with little necrosis. It usually invades the lungs with fibrosis and may also involve lymph nodes, skin, liver, spleen, eyes, phalangeal bones, and parotid glands. [NIH] Stimulant: 1. producing stimulation; especially producing stimulation by

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causing tension on muscle fibre through the nervous tissue. 2. an agent or remedy that produces stimulation. [EU] Tomography: The recording of internal body images at a predetermined plane by means of the tomograph; called also body section roentgenography. [EU]

Transfusion: The introduction of whole blood or blood component directly into the blood stream. [EU]

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CHAPTER 9. PHYSICIAN GUIDELINES AND DATABASES Overview Doctors and medical researchers rely on a number of information sources to help patients with their conditions. Many will subscribe to journals or newsletters published by their professional associations or refer to specialized textbooks or clinical guides published for the medical profession. In this chapter, we focus on databases and Internet-based guidelines created or written for this professional audience.

NIH Guidelines For the more common disorders, the National Institutes of Health publish guidelines that are frequently consulted by physicians. Publications are typically written by one or more of the various NIH Institutes. For physician guidelines, commonly referred to as “clinical” or “professional” guidelines, you can visit the following Institutes: ·

Office of the Director (OD); guidelines consolidated across agencies available at http://www.nih.gov/health/consumer/conkey.htm

·

National Institute of General Medical Sciences (NIGMS); fact sheets available at http://www.nigms.nih.gov/news/facts/

·

National Library of Medicine (NLM); extensive encyclopedia (A.D.A.M., Inc.) with guidelines: http://www.nlm.nih.gov/medlineplus/healthtopics.html

·

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK); guidelines available at http://www.niddk.nih.gov/health/health.htm

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NIH Databases In addition to the various Institutes of Health that publish professional guidelines, the NIH has designed a number of databases for professionals.27 Physician-oriented resources provide a wide variety of information related to the biomedical and health sciences, both past and present. The format of these resources varies. Searchable databases, bibliographic citations, full text articles (when available), archival collections, and images are all available. The following are referenced by the National Library of Medicine:28 ·

Bioethics: Access to published literature on the ethical, legal and public policy issues surrounding healthcare and biomedical research. This information is provided in conjunction with the Kennedy Institute of Ethics located at Georgetown University, Washington, D.C.: http://www.nlm.nih.gov/databases/databases_bioethics.html

·

HIV/AIDS Resources: Describes various links and databases dedicated to HIV/AIDS research: http://www.nlm.nih.gov/pubs/factsheets/aidsinfs.html

·

NLM Online Exhibitions: Describes “Exhibitions in the History of Medicine”: http://www.nlm.nih.gov/exhibition/exhibition.html. Additional resources for historical scholarship in medicine: http://www.nlm.nih.gov/hmd/hmd.html

·

Biotechnology Information: Access to public databases. The National Center for Biotechnology Information conducts research in computational biology, develops software tools for analyzing genome data, and disseminates biomedical information for the better understanding of molecular processes affecting human health and disease: http://www.ncbi.nlm.nih.gov/

·

Population Information: The National Library of Medicine provides access to worldwide coverage of population, family planning, and related health issues, including family planning technology and programs, fertility, and population law and policy: http://www.nlm.nih.gov/databases/databases_population.html

·

Cancer Information: Access to caner-oriented databases: http://www.nlm.nih.gov/databases/databases_cancer.html

Remember, for the general public, the National Library of Medicine recommends the databases referenced in MEDLINEplus (http://medlineplus.gov/ or http://www.nlm.nih.gov/medlineplus/databases.html). 28 See http://www.nlm.nih.gov/databases/databases.html. 27

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·

Profiles in Science: Offering the archival collections of prominent twentieth-century biomedical scientists to the public through modern digital technology: http://www.profiles.nlm.nih.gov/

·

Chemical Information: Provides links to various chemical databases and references: http://sis.nlm.nih.gov/Chem/ChemMain.html

·

Clinical Alerts: Reports the release of findings from the NIH-funded clinical trials where such release could significantly affect morbidity and mortality: http://www.nlm.nih.gov/databases/alerts/clinical_alerts.html

·

Space Life Sciences: Provides links and information to space-based research (including NASA): http://www.nlm.nih.gov/databases/databases_space.html

·

MEDLINE: Bibliographic database covering the fields of medicine, nursing, dentistry, veterinary medicine, the healthcare system, and the pre-clinical sciences: http://www.nlm.nih.gov/databases/databases_medline.html

·

Toxicology and Environmental Health Information (TOXNET): Databases covering toxicology and environmental health: http://sis.nlm.nih.gov/Tox/ToxMain.html

·

Visible Human Interface: Anatomically detailed, three-dimensional representations of normal male and female human bodies: http://www.nlm.nih.gov/research/visible/visible_human.html

While all of the above references may be of interest to physicians who study and treat diarrhea, the following are particularly noteworthy.

The Combined Health Information Database A comprehensive source of information on clinical guidelines written for professionals is the Combined Health Information Database. You will need to limit your search to “Brochure/Pamphlet,” “Fact Sheet,” or “Information Package” and diarrhea using the “Detailed Search” option. Go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. To find associations, use the drop boxes at the bottom of the search page where “You may refine your search by.” For the publication date, select “All Years,” select your preferred language, and the format option “Fact Sheet.” By making these selections and typing “diarrhea” (or synonyms) into the “For these words:” box above, you will only receive results on fact sheets dealing with diarrhea. The following is a sample result:

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·

Management of Acute Diarrhea in Children: Oral Rehydration, Maintenance, and Nutritional Therapy Source: MMWR. Morbidity and Mortality Weekly Report. 41(RR-16): 120. October 16, 1992. Summary: This report is the Centers for Disease Control and Prevention's (CDC) first statement about the importance of oral therapy for rehydration and maintenance of children with dehydrating diarrhea, as well as for nutritional support. The authors review the proper management of diarrhea in children. The report includes recommendations prepared by CDC, with input from a panel of pediatric and diarrheal management experts. The authors stress that, in the United States, improvements in the management of children with diarrhea could lead to a noticeable decrease in hospitalization and mortality. 4 tables. 92 references. The NLM Gateway29

The NLM (National Library of Medicine) Gateway is a Web-based system that lets users search simultaneously in multiple retrieval systems at the U.S. National Library of Medicine (NLM). It allows users of NLM services to initiate searches from one Web interface, providing “one-stop searching” for many of NLM’s information resources or databases.30 One target audience for the Gateway is the Internet user who is new to NLM’s online resources and does not know what information is available or how best to search for it. This audience may include physicians and other healthcare providers, researchers, librarians, students, and, increasingly, patients, their families, and the public.31 To use the NLM Gateway, simply go to the search site at http://gateway.nlm.nih.gov/gw/Cmd. Type “diarrhea” (or synonyms) into the search box and click “Search.” The results will be presented in a tabular form, indicating the number of references in each database category. Adapted from NLM: http://gateway.nlm.nih.gov/gw/Cmd?Overview.x. The NLM Gateway is currently being developed by the Lister Hill National Center for Biomedical Communications (LHNCBC) at the National Library of Medicine (NLM) of the National Institutes of Health (NIH). 31 Other users may find the Gateway useful for an overall search of NLM’s information resources. Some searchers may locate what they need immediately, while others will utilize the Gateway as an adjunct tool to other NLM search services such as PubMed® and MEDLINEplus®. The Gateway connects users with multiple NLM retrieval systems while also providing a search interface for its own collections. These collections include various types of information that do not logically belong in PubMed, LOCATORplus, or other established NLM retrieval systems (e.g., meeting announcements and pre-1966 journal citations). The Gateway will provide access to the information found in an increasing number of NLM retrieval systems in several phases. 29 30

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Results Summary Category Items Found Journal Articles 343118 Books / Periodicals / Audio Visual 2561 Consumer Health 292 Meeting Abstracts 3093 Other Collections 100 Total 349164

HSTAT32 HSTAT is a free, Web-based resource that provides access to full-text documents used in healthcare decision-making.33 HSTAT’s audience includes healthcare providers, health service researchers, policy makers, insurance companies, consumers, and the information professionals who serve these groups. HSTAT provides access to a wide variety of publications, including clinical practice guidelines, quick-reference guides for clinicians, consumer health brochures, evidence reports and technology assessments from the Agency for Healthcare Research and Quality (AHRQ), as well as AHRQ’s Put Prevention Into Practice.34 Simply search by “diarrhea” (or synonyms) at the following Web site: http://text.nlm.nih.gov.

Coffee Break: Tutorials for Biologists35 Some patients may wish to have access to a general healthcare site that takes a scientific view of the news and covers recent breakthroughs in biology that Adapted from HSTAT: http://www.nlm.nih.gov/pubs/factsheets/hstat.html. The HSTAT URL is http://hstat.nlm.nih.gov/. 34 Other important documents in HSTAT include: the National Institutes of Health (NIH) Consensus Conference Reports and Technology Assessment Reports; the HIV/AIDS Treatment Information Service (ATIS) resource documents; the Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Treatment (SAMHSA/CSAT) Treatment Improvement Protocols (TIP) and Center for Substance Abuse Prevention (SAMHSA/CSAP) Prevention Enhancement Protocols System (PEPS); the Public Health Service (PHS) Preventive Services Task Force’s Guide to Clinical Preventive Services; the independent, nonfederal Task Force on Community Services Guide to Community Preventive Services; and the Health Technology Advisory Committee (HTAC) of the Minnesota Health Care Commission (MHCC) health technology evaluations. 35 Adapted from http://www.ncbi.nlm.nih.gov/Coffeebreak/Archive/FAQ.html. 32 33

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may one day assist physicians in developing treatments. To this end, we recommend “Coffee Break,” a collection of short reports on recent biological discoveries. Each report incorporates interactive tutorials that demonstrate how bioinformatics tools are used as a part of the research process. Currently, all Coffee Breaks are written by NCBI staff.36 Each report is about 400 words and is usually based on a discovery reported in one or more articles from recently published, peer-reviewed literature.37 This site has new articles every few weeks, so it can be considered an online magazine of sorts, and intended for general background information. You can access the Coffee Break Web site at the following hyperlink: http://www.ncbi.nlm.nih.gov/Coffeebreak/.

Other Commercial Databases In addition to resources maintained by official agencies, other databases exist that are commercial ventures addressing medical professionals. Here are a few examples that may interest you: ·

CliniWeb International: Index and table of contents to selected clinical information on the Internet; see http://www.ohsu.edu/cliniweb/.

·

Image Engine: Multimedia electronic medical record system that integrates a wide range of digitized clinical images with textual data stored in the University of Pittsburgh Medical Center’s MARS electronic medical record system; see the following Web site: http://www.cml.upmc.edu/cml/imageengine/imageEngine.html.

·

Medical World Search: Searches full text from thousands of selected medical sites on the Internet; see http://www.mwsearch.com/.

·

MedWeaver: Prototype system that allows users to search differential diagnoses for any list of signs and symptoms, to search medical literature, and to explore relevant Web sites; see http://www.med.virginia.edu/~wmd4n/medweaver.html.

·

Metaphrase: Middleware component intended for use by both caregivers and medical records personnel. It converts the informal language

The figure that accompanies each article is frequently supplied by an expert external to NCBI, in which case the source of the figure is cited. The result is an interactive tutorial that tells a biological story. 37 After a brief introduction that sets the work described into a broader context, the report focuses on how a molecular understanding can provide explanations of observed biology and lead to therapies for diseases. Each vignette is accompanied by a figure and hypertext links that lead to a series of pages that interactively show how NCBI tools and resources are used in the research process. 36

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generally used by caregivers into terms from formal, controlled vocabularies; see the following Web site: http://www.lexical.com/Metaphrase.html.

The Genome Project and Diarrhea With all the discussion in the press about the Human Genome Project, it is only natural that physicians, researchers, and patients want to know about how human genes relate to diarrhea. In the following section, we will discuss databases and references used by physicians and scientists who work in this area.

Online Mendelian Inheritance in Man (OMIM) The Online Mendelian Inheritance in Man (OMIM) database is a catalog of human genes and genetic disorders authored and edited by Dr. Victor A. McKusick and his colleagues at Johns Hopkins and elsewhere. OMIM was developed for the World Wide Web by the National Center for Biotechnology Information (NCBI).38 The database contains textual information, pictures, and reference information. It also contains copious links to NCBI’s Entrez database of MEDLINE articles and sequence information. To search the database, go to http://www.ncbi.nlm.nih.gov/Omim/searchomim.html. Type “diarrhea” (or synonyms) in the search box, and click “Submit Search.” If too many results appear, you can narrow the search by adding the word “clinical.” Each report will have additional links to related research and databases. By following these links, especially the link titled “Database Links,” you will be exposed to numerous specialized databases that are largely used by the scientific community. These databases are overly technical and seldom used by the general public, but offer an abundance of information. The following is an example of the results you can obtain from the OMIM for diarrhea: ·

Chloride Diarrhea, Familial Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?214700

Adapted from http://www.ncbi.nlm.nih.gov/. Established in 1988 as a national resource for molecular biology information, NCBI creates public databases, conducts research in computational biology, develops software tools for analyzing genome data, and disseminates biomedical information--all for the better understanding of molecular processes affecting human health and disease.

38

170 Diarrhea

·

Diarrhea, Chronic, with Villous Atrophy Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?520100

·

Diarrhea, Fatal Infantile, with Abnormal Hair Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?222470

·

Diarrhea, Glucose-stimulated Secretory, with Common Variable Immunodeficiency Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?125890

·

Sodium Diarrhea, Congenital Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?270420 Genes and Disease (NCBI - Map)

The Genes and Disease database is produced by the National Center for Biotechnology Information of the National Library of Medicine at the National Institutes of Health. This Web site categorizes each disorder by the system of the body associated with it. Go to http://www.ncbi.nlm.nih.gov/disease/, and browse the system pages to have a full view of important conditions linked to human genes. Since this site is regularly updated, you may wish to re-visit it from time to time. The following systems and associated disorders are addressed: ·

Immune System: Fights invaders. Examples: Asthma, autoimmune polyglandular syndrome, Crohn’s disease, DiGeorge syndrome, familial Mediterranean fever, immunodeficiency with Hyper-IgM, severe combined immunodeficiency. Web site: http://www.ncbi.nlm.nih.gov/disease/Immune.html

·

Metabolism: Food and energy. Examples: Adreno-leukodystrophy, Atherosclerosis, Best disease, Gaucher disease, Glucose galactose malabsorption, Gyrate atrophy, Juvenile onset diabetes, Obesity, Paroxysmal nocturnal hemoglobinuria, Phenylketonuria, Refsum disease, Tangier disease, Tay-Sachs disease. Web site: http://www.ncbi.nlm.nih.gov/disease/Metabolism.html

·

Muscle and Bone: Movement and growth. Examples: Duchenne muscular dystrophy, Ellis-van Creveld syndrome, Marfan syndrome, myotonic dystrophy, spinal muscular atrophy. Web site: http://www.ncbi.nlm.nih.gov/disease/Muscle.html

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·

Signals: Cellular messages. Examples: Ataxia telangiectasia, Baldness, Cockayne syndrome, Glaucoma, SRY: sex determination, Tuberous sclerosis, Waardenburg syndrome, Werner syndrome. Web site: http://www.ncbi.nlm.nih.gov/disease/Signals.html

·

Transporters: Pumps and channels. Examples: Cystic Fibrosis, deafness, diastrophic dysplasia, Hemophilia A, long-QT syndrome, Menkes syndrome, Pendred syndrome, polycystic kidney disease, sickle cell anemia, Wilson’s disease, Zellweger syndrome. Web site: http://www.ncbi.nlm.nih.gov/disease/Transporters.html

Entrez Entrez is a search and retrieval system that integrates several linked databases at the National Center for Biotechnology Information (NCBI). These databases include nucleotide sequences, protein sequences, macromolecular structures, whole genomes, and MEDLINE through PubMed. Entrez provides access to the following databases: ·

PubMed: Biomedical literature (PubMed), Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed

·

Nucleotide Sequence Database (Genbank): Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Nucleotide

·

Protein Sequence Database: Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Protein

·

Structure: Three-dimensional macromolecular structures, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Structure

·

Genome: Complete genome assemblies, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Genome

·

PopSet: Population study data sets, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Popset

·

OMIM: Online Mendelian Inheritance in Man, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=OMIM

·

Taxonomy: Organisms in GenBank, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Taxonomy

·

Books: Online books, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=books

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·

ProbeSet: Gene Expression Omnibus (GEO), Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=geo

·

3D Domains: Domains from Entrez Structure, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=geo

·

NCBI’s Protein Sequence Information Survey Results: Web site: http://www.ncbi.nlm.nih.gov/About/proteinsurvey/

To access the Entrez system at the National Center for Biotechnology Information, go to http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=genom e, and then select the database that you would like to search. The databases available are listed in the drop box next to “Search.” In the box next to “for,” enter “diarrhea” (or synonyms) and click “Go.”

Jablonski’s Multiple Congenital Anomaly/Mental Retardation (MCA/MR) Syndromes Database39 This online resource can be quite useful. It has been developed to facilitate the identification and differentiation of syndromic entities. Special attention is given to the type of information that is usually limited or completely omitted in existing reference sources due to space limitations of the printed form. At the following Web site you can also search across syndromes using an alphabetical index: http://www.nlm.nih.gov/mesh/jablonski/syndrome_toc/toc_a.html. You can search by keywords at this Web site: http://www.nlm.nih.gov/mesh/jablonski/syndrome_db.html. The Genome Database40 Established at Johns Hopkins University in Baltimore, Maryland in 1990, the Genome Database (GDB) is the official central repository for genomic mapping data resulting from the Human Genome Initiative. In the spring of 1999, the Bioinformatics Supercomputing Centre (BiSC) at the Hospital for Sick Children in Toronto, Ontario assumed the management of GDB. The Adapted from the National Library of Medicine: http://www.nlm.nih.gov/mesh/jablonski/about_syndrome.html. 40 Adapted from the Genome Database: http://gdbwww.gdb.org/gdb/aboutGDB.html#mission. 39

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Human Genome Initiative is a worldwide research effort focusing on structural analysis of human DNA to determine the location and sequence of the estimated 100,000 human genes. In support of this project, GDB stores and curates data generated by researchers worldwide who are engaged in the mapping effort of the Human Genome Project (HGP). GDB’s mission is to provide scientists with an encyclopedia of the human genome which is continually revised and updated to reflect the current state of scientific knowledge. Although GDB has historically focused on gene mapping, its focus will broaden as the Genome Project moves from mapping to sequence, and finally, to functional analysis. To access the GDB, simply go to the following hyperlink: http://www.gdb.org/. Search “All Biological Data” by “Keyword.” Type “diarrhea” (or synonyms) into the search box, and review the results. If more than one word is used in the search box, then separate each one with the word “and” or “or” (using “or” might be useful when using synonyms). This database is extremely technical as it was created for specialists. The articles are the results which are the most accessible to non-professionals and often listed under the heading “Citations.” The contact names are also accessible to non-professionals.

Specialized References The following books are specialized references written for professionals interested in diarrhea (sorted alphabetically by title, hyperlinks provide rankings, information, and reviews at Amazon.com): · Blackwell’s Primary Care Essentials: Gastointestinal Disease by David W. Hay; Paperback, 1st edition (December 15, 2001), Blackwell Science Inc; ISBN: 0632045035; http://www.amazon.com/exec/obidos/ASIN/0632045035/icongroupinterna · Gastrointestinal Problems by Martin S. Lipsky, M.D. (Editor), Richard Sadovsky, M.D. (Editor); Paperback - 194 pages, 1st edition (August 15, 2000), Lippincott, Williams & Wilkins Publishers; ISBN: 0781720540; http://www.amazon.com/exec/obidos/ASIN/0781720540/icongroupinterna · Rome II: The Functional Gastrointestinal Disorders by Douglas A. Drossman (Editor); Paperback - 800 pages, 2nd edition (March 1, 2000), Degnon Associates Inc.; ISBN: 0965683729; http://www.amazon.com/exec/obidos/ASIN/0965683729/icongroupinterna

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Vocabulary Builder Atropine: A toxic alkaloid, originally from Atropa belladonna, but found in other plants, mainly Solanaceae. [NIH] Blindness: The inability to see or the loss or absence of perception of visual stimuli. This condition may be the result of eye diseases; optic nerve diseases; optic chiasm diseases; or brain diseases affecting the visual pathways or occipital lobe. [NIH] Clarithromycin: A semisynthetic macrolide antibiotic derived from erythromycin that is active against a variety of microorganisms. It can inhibit protein synthesis in bacteria by reversibly binding to the 50S ribosomal subunits. This inhibits the translocation of aminoacyl transfer-RNA and prevents peptide chain elongation. [NIH] Codeine: An opioid analgesic related to morphine but with less potent analgesic properties and mild sedative effects. It also acts centrally to suppress cough. [NIH] Condoms: A sheath that is worn over the penis during sexual behavior in order to prevent pregnancy or spread of sexually transmitted disease. [NIH] Confusion: Disturbed orientation in regard to time, place, or person, sometimes accompanied by disordered consciousness. [EU] Contamination: The soiling or pollution by inferior material, as by the introduction of organisms into a wound, or sewage into a stream. [EU] Dementia: An acquired organic mental disorder with loss of intellectual abilities of sufficient severity to interfere with social or occupational functioning. The dysfunction is multifaceted and involves memory, behavior, personality, judgment, attention, spatial relations, language, abstract thought, and other executive functions. The intellectual decline is usually progressive, and initially spares the level of consciousness. [NIH] Diphenoxylate: A meperidine congener used as an antidiarrheal, usually in combination with atropine. At high doses, it acts like morphine. Its unesterified metabolite difenoxin has similar properties and is used similarly. It has little or no analgesic activity. [NIH] Fleas: Parasitic, blood-sucking, wingless insects comprising the order Siphonaptera. [NIH] Groin: The external junctural region between the lower part of the abdomen and the thigh. [NIH] Indinavir: A potent and specific HIV protease inhibitor that appears to have good oral bioavailability. [NIH] Lipoxygenase:

An enzyme of the oxidoreductase class that catalyzes

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reactions between linoleate and other fatty acids and oxygen to form hydroperoxy-fatty acid derivatives. Related enzymes in this class include the arachidonate lipoxygenases, arachidonate 5-lipoxygenase, arachidonate 12lipoxygenase, and arachidonate 15-lipoxygenase. EC 1.13.11.12. [NIH] Mycobacterium: An organism of the genus Mycobacterium. [EU] Psychotropic: Exerting an effect upon the mind; capable of modifying mental activity; usually applied to drugs that effect the mental state. [EU] Rifabutin: A broad-spectrum antibiotic that is being used as prophylaxis against disseminated Mycobacterium avium complex infection in HIVpositive patients. [NIH] Ritonavir: An HIV protease inhibitor that works by interfering with the reproductive cycle of HIV. [NIH] Saquinavir: An HIV protease inhibitor which acts as an analog of an HIV protease cleavage site. It is a highly specific inhibitor of HIV-1 and HIV-2 proteases. [NIH] Topical: Pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied. [EU] Tuberculosis: Any of the infectious diseases of man and other animals caused by species of mycobacterium. [NIH]

Dissertations 177

CHAPTER 10. DISSERTATIONS ON DIARRHEA Overview University researchers are active in studying almost all known disorders and conditions. The result of research is often published in the form of Doctoral or Master’s dissertations. You should understand, therefore, that applied diagnostic procedures and/or therapies can take many years to develop after the thesis that proposed the new technique or approach was written. In this chapter, we will give you a bibliography on recent dissertations relating to diarrhea. You can read about these in more detail using the Internet or your local medical library. We will also provide you with information on how to use the Internet to stay current on dissertations.

Dissertations on Diarrhea ProQuest Digital Dissertations is the largest archive of academic dissertations available. From this archive, we have compiled the following list covering dissertations devoted to diarrhea. You will see that the information provided includes the dissertation’s title, its author, and the author’s institution. To read more about the following, simply use the Internet address indicated. The following covers recent dissertations dealing with diarrhea: ·

A Study of Diarrheal Illness and Its Correlates among Infants in Day Care in the Fifteen Southernmost Counties of Illinois by Eichholz, Barbara, Phd from Southern Illinois University at Carbondale, 1986, 110 pages http://wwwlib.umi.com/dissertations/fullcit/8622974

178 Diarrhea

·

An Examination of the Effects of the Mother's Education and Household Exposure to Disease on Childhood Diarrheal Morbidity in Sudan by Sultan, Dawood Hussein, Phd from The Louisiana State University and Agricultural and Mechanical Col., 1996, 160 pages http://wwwlib.umi.com/dissertations/fullcit/9706366

·

Case-control Study of Association of Maternal Recall of Diarrhea or Use of Antimicrobials in the Periconceptional Period and Neural Tube Defects by Felkner, Marilyn Moss; Drph from The Univ. of Texas H.s.c. at Houston Sch. of Public Health, 2001, 70 pages http://wwwlib.umi.com/dissertations/fullcit/3027645

·

Components of Infant and Childhood Mortality in West Africa: a Study of Health Care Practices, Breastfeeding Behavior and Its Interaction with Diarrhea, in Ghana and Nigeria by Ahiadeke, Clement, Phd from Cornell University, 1996, 254 pages http://wwwlib.umi.com/dissertations/fullcit/9624870

·

Determinants of Childhood Diarrhea Morbidity and Mortality in Bobo-dioulasso, Burkina Faso by Nacro, Kourtoum, Phd from The Florida State University, 1993, 186 pages http://wwwlib.umi.com/dissertations/fullcit/9402508

·

Early Childhood Diarrhea and Primary School Performance in the Northern Areas of Pakistan by Mitchell, Jonathan Eric, Phd from University of Colorado at Boulder, 1998, 254 pages http://wwwlib.umi.com/dissertations/fullcit/9916817

·

Environmental, Social-cultural, and Health Factors Associated with Diarrhea in Santa Cruz Mixtepec, Juxtlahuaca, Oaxaca, Mexico (growth, Contamination, Parasites, Vectors, Anthropometrics) by Butler, Paula Merrell, Phd from The University of Tennessee, 1985, 165 pages http://wwwlib.umi.com/dissertations/fullcit/8600012

·

Feeding, Weaning, and Diarrhea Illness in Young Hausa Children in Niger: Village Practice and Educational Implications (young Children, Culturally Relevant Education) by Keith, Nancy Jean, Phd from Michigan State University, 1991, 321 pages http://wwwlib.umi.com/dissertations/fullcit/9129467

·

Identification of Virulence Factors of Noncytopathic Bovine Viral Diarrhea Virus Type 2 by Goens, Sharon Denise; Phd from University of Guelph (canada), 2001, 212 pages http://wwwlib.umi.com/dissertations/fullcit/NQ61976

Dissertations 179

·

Illness of the Child: the Cultural Context of Childhood Diarrhea in Northeast Brazil by Nations, Marilyn Kay, Phd from University of California, Berkeley, 1982, 189 pages http://wwwlib.umi.com/dissertations/fullcit/8300729

Keeping Current As previously mentioned, an effective way to stay current on dissertations dedicated to diarrhea is to use the database called ProQuest Digital Dissertations via the Internet, located at the following Web address: http://wwwlib.umi.com/dissertations. The site allows you to freely access the last two years of citations and abstracts. Ask your medical librarian if the library has full and unlimited access to this database. From the library, you should be able to do more complete searches than with the limited 2-year access available to the general public.

Vocabulary Builder Neural: 1. pertaining to a nerve or to the nerves. 2. situated in the region of the spinal axis, as the neutral arch. [EU]

181

PART III. APPENDICES

ABOUT PART III Part III is a collection of appendices on general medical topics which may be of interest to patients with diarrhea and related conditions.

Researching Your Medications 183

APPENDIX A. RESEARCHING YOUR MEDICATIONS Overview There are a number of sources available on new or existing medications which could be prescribed to patients with diarrhea. While a number of hard copy or CD-Rom resources are available to patients and physicians for research purposes, a more flexible method is to use Internet-based databases. In this chapter, we will begin with a general overview of medications. We will then proceed to outline official recommendations on how you should view your medications. You may also want to research medications that you are currently taking for other conditions as they may interact with medications for diarrhea. Research can give you information on the side effects, interactions, and limitations of prescription drugs used in the treatment of diarrhea. Broadly speaking, there are two sources of information on approved medications: public sources and private sources. We will emphasize free-to-use public sources.

Your Medications: The Basics41 The Agency for Health Care Research and Quality has published extremely useful guidelines on how you can best participate in the medication aspects of diarrhea. Taking medicines is not always as simple as swallowing a pill. It can involve many steps and decisions each day. The AHCRQ recommends that patients with diarrhea take part in treatment decisions. Do not be afraid to ask questions and talk about your concerns. By taking a moment to ask questions early, you may avoid problems later. Here are some points to cover each time a new medicine is prescribed: 41

This section is adapted from AHCRQ: http://www.ahcpr.gov/consumer/ncpiebro.htm.

184 Diarrhea

·

Ask about all parts of your treatment, including diet changes, exercise, and medicines.

·

Ask about the risks and benefits of each medicine or other treatment you might receive.

·

Ask how often you or your doctor will check for side effects from a given medication.

Do not hesitate to ask what is important to you about your medicines. You may want a medicine with the fewest side effects, or the fewest doses to take each day. You may care most about cost, or how the medicine might affect how you live or work. Or, you may want the medicine your doctor believes will work the best. Telling your doctor will help him or her select the best treatment for you. Do not be afraid to “bother” your doctor with your concerns and questions about medications for diarrhea. You can also talk to a nurse or a pharmacist. They can help you better understand your treatment plan. Feel free to bring a friend or family member with you when you visit your doctor. Talking over your options with someone you trust can help you make better choices, especially if you are not feeling well. Specifically, ask your doctor the following: ·

The name of the medicine and what it is supposed to do.

·

How and when to take the medicine, how much to take, and for how long.

·

What food, drinks, other medicines, or activities you should avoid while taking the medicine.

·

What side effects the medicine may have, and what to do if they occur.

·

If you can get a refill, and how often.

·

About any terms or directions you do not understand.

·

What to do if you miss a dose.

·

If there is written information you can take home (most pharmacies have information sheets on your prescription medicines; some even offer large-print or Spanish versions).

Do not forget to tell your doctor about all the medicines you are currently taking (not just those for diarrhea). This includes prescription medicines and the medicines that you buy over the counter. Then your doctor can avoid giving you a new medicine that may not work well with the medications you take now. When talking to your doctor, you may wish to prepare a list of

Researching Your Medications 185

medicines you currently take, the reason you take them, and how you take them. Be sure to include the following information for each: ·

Name of medicine

·

Reason taken

·

Dosage

·

Time(s) of day

Also include any over-the-counter medicines, such as: ·

Laxatives

·

Diet pills

·

Vitamins

·

Cold medicine

·

Aspirin or other pain, headache, or fever medicine

·

Cough medicine

·

Allergy relief medicine

·

Antacids

·

Sleeping pills

·

Others (include names)

Learning More about Your Medications Because of historical investments by various organizations and the emergence of the Internet, it has become rather simple to learn about the medications your doctor has recommended for diarrhea. One such source is the United States Pharmacopeia. In 1820, eleven physicians met in Washington, D.C. to establish the first compendium of standard drugs for the United States. They called this compendium the “U.S. Pharmacopeia (USP).” Today, the USP is a non-profit organization consisting of 800 volunteer scientists, eleven elected officials, and 400 representatives of state associations and colleges of medicine and pharmacy. The USP is located in Rockville, Maryland, and its home page is located at www.usp.org. The USP currently provides standards for over 3,700 medications. The resulting USP DIÒ Advice for the PatientÒ can be accessed through the National Library of Medicine of the National Institutes of Health. The database is partially

186 Diarrhea

derived from lists of federally approved medications in the Food and Drug Administration’s (FDA) Drug Approvals database.42 While the FDA database is rather large and difficult to navigate, the Phamacopeia is both user-friendly and free to use. It covers more than 9,000 prescription and over-the-counter medications. To access this database, simply type the following hyperlink into your Web browser: http://www.nlm.nih.gov/medlineplus/druginformation.html. To view examples of a given medication (brand names, category, description, preparation, proper use, precautions, side effects, etc.), simply follow the hyperlinks indicated within the United States Pharmacopoeia (USP). It is important to read the disclaimer by the USP (http://www.nlm.nih.gov/medlineplus/drugdisclaimer.html) before using the information provided. Of course, we as editors cannot be certain as to what medications you are taking. Therefore, we have compiled a list of medications associated with the treatment of diarrhea. Once again, due to space limitations, we only list a sample of medications and provide hyperlinks to ample documentation (e.g. typical dosage, side effects, drug-interaction risks, etc.). The following drugs have been mentioned in the Pharmacopeia and other sources as being potentially applicable to diarrhea: Allopurinol ·

Systemic - U.S. Brands: Aloprim; Zyloprim http://www.nlm.nih.gov/medlineplus/druginfo/allopurinolsyste mic202021.html

Alosetron ·

Systemic - U.S. Brands: Lotronex http://www.nlm.nih.gov/medlineplus/druginfo/alosetronsystem ic500107.html

Anastrozole ·

Systemic - U.S. Brands: Arimidex http://www.nlm.nih.gov/medlineplus/druginfo/anastrozolesyste mic203659.html

Though cumbersome, the FDA database can be freely browsed at the following site: www.fda.gov/cder/da/da.htm.

42

Researching Your Medications 187

Anticholinergics/Antispasmodics ·

Systemic - U.S. Brands: Anaspaz; A-Spas S/L; Banthine; Bentyl; Cantil; Cystospaz; Cystospaz-M; Donnamar; ED-SPAZ; Gastrosed; Homapin; Levbid; Levsin; Levsin/SL; Levsinex Timecaps; ProBanthine; Quarzan; Robinul; Robinul Forte; Symax SL; TransdermScop http://www.nlm.nih.gov/medlineplus/druginfo/anticholinergics antispasmodics202049.html

Antidiabetic Agents, Sulfonylurea ·

Systemic - U.S. Brands: Amaryl; DiaBeta; Diabinese; Dymelor; Glucotrol; Glucotrol XL; Glynase PresTab; Micronase; Orinase; Tolinase http://www.nlm.nih.gov/medlineplus/druginfo/antidiabeticagen tssulfonylurea202742.html

Anti-Inflammatory Drugs, Nonsteroidal ·

Systemic - U.S. Brands: Actron; Advil; Advil Caplets; Advil, Children's; Aleve; Anaprox; Anaprox DS; Ansaid; Bayer Select Ibuprofen Pain Relief Formula Caplets; Cataflam; Clinoril; Cotylbutazone; Cramp End; Daypro; Dolgesic; Dolobid; ECNaprosyn; Excedrin IB; Excedrin IB Caple http://www.nlm.nih.gov/medlineplus/druginfo/antiinflammator ydrugsnonsteroi202743.html

Ascorbic Acid (Vitamin C) ·

Systemic - U.S. Brands: Ascorbicap; Cecon; Cee-500; Cemill; Cenolate; Cetane; Cevi-Bid; Flavorcee; Ortho/CS; Sunkist http://www.nlm.nih.gov/medlineplus/druginfo/ascorbicacidvita mincsystemic202071.html

Attapulgite ·

Oral - U.S. Brands: Diar-Aid; Diarrest; Diasorb; Diatrol; Donnagel; Kaopectate; Kaopek; K-Pek; Parepectolin; Rheaban http://www.nlm.nih.gov/medlineplus/druginfo/attapulgiteoral2 02076.html

Beta-Carotene ·

Systemic - U.S. Brands: Lumitene; Max-Caro http://www.nlm.nih.gov/medlineplus/druginfo/betacarotenesys temic202623.html

188 Diarrhea

Bismuth Subsalicylate ·

Oral - U.S. Brands: Bismatrol; Pepto-Bismol http://www.nlm.nih.gov/medlineplus/druginfo/bismuthsubsalic ylateoral202092.html

Carbohydrates and Electrolytes ·

Systemic - U.S. Brands: Infalyte; Kao Lectrolyte; Naturalyte; Oralyte; Pedialyte; Pedialyte Freezer Pops; Rehydralyte; Resol$ http://www.nlm.nih.gov/medlineplus/druginfo/carbohydratesa ndelectrolytessy202112.html

Charcoal, Activated ·

Oral - U.S. Brands: Actidose with Sorbitol; Actidose-Aqua; CharcoAid; CharcoAid 2000; CharcoAid G; Insta-Char in an Aqueous Base; Insta-Char in an Aqueous Base with Cherry Flavor; Insta-Char Pediatric in an Aqueous Base with Cherry Flavor; InstaChar Pediatric with Cherry http://www.nlm.nih.gov/medlineplus/druginfo/charcoalactivate doral202120.html

Cholestyramine ·

Oral - U.S. Brands: Questran http://www.nlm.nih.gov/medlineplus/druginfo/cholestyramine oral202137.html

Colestipol ·

Oral - U.S. Brands: Colestid http://www.nlm.nih.gov/medlineplus/druginfo/colestipoloral20 2161.html

Copper Supplements ·

Systemic - U.S. Brands: Note: http://www.nlm.nih.gov/medlineplus/druginfo/coppersupplem entssystemic202164.html

Cromolyn ·

Oral - U.S. Brands: Gastrocrom http://www.nlm.nih.gov/medlineplus/druginfo/cromolynoral20 2169.html

Researching Your Medications 189

Difenoxin and Atropine ·

Systemic - U.S. Brands: Motofen http://www.nlm.nih.gov/medlineplus/druginfo/difenoxinandatr opinesystemic202193.html

Diphenoxylate and Atropine ·

Systemic - U.S. Brands: Lofene; Logen; Lomocot; Lomotil; Lonox; Vi-Atro http://www.nlm.nih.gov/medlineplus/druginfo/diphenoxylatea ndatropinesystem202200.html

Diuretics, Loop ·

Systemic - U.S. Brands: Bumex; Edecrin; Lasix; Myrosemide http://www.nlm.nih.gov/medlineplus/druginfo/diureticsloopsys temic202205.html

Folic Acid (Vitamin B 9 ) ·

Systemic - U.S. Brands: Folvite http://www.nlm.nih.gov/medlineplus/druginfo/folicacidvitamin b9systemic202250.html

Furazolidone ·

Oral - U.S. Brands: Furoxone http://www.nlm.nih.gov/medlineplus/druginfo/furazolidoneora l202252.html

Hydroxyurea ·

Systemic - U.S. Brands: Droxia; Hydrea http://www.nlm.nih.gov/medlineplus/druginfo/hydroxyureasys temic202291.html

Insulin ·

Systemic - U.S. Brands: Humulin 50/50; Humulin 70/30; Humulin 70/30 Pen; Humulin L; Humulin N; Humulin N Pen; Humulin R; Humulin R, Regular U-500 (Concentrated); Humulin U; Lente; Lente Iletin II; Novolin 70/30; Novolin 70/30 PenFill; Novolin 70/30 Prefilled; Novolin L; Novoli http://www.nlm.nih.gov/medlineplus/druginfo/insulinsystemic 203298.html

190 Diarrhea

Ivermectin ·

Systemic - U.S. Brands: Stromectol http://www.nlm.nih.gov/medlineplus/druginfo/ivermectinsyste mic202311.html

Kaolin and Pectin ·

Oral - U.S. Brands: Kao-Spen; Kapectolin; K-P http://www.nlm.nih.gov/medlineplus/druginfo/kaolinandpectin oral202313.html

Laxatives ·

Oral - U.S. Brands: Afko-Lube; Afko-Lube Lax 40; Agoral Marshmallow; Agoral Raspberry; Alaxin; Alophen; Alphamul; Alramucil Orange; Alramucil Regular; Bilagog; Bilax; Bisac-Evac; Black-Draught; Black-Draught Lax-Senna; Carter's Little Pills; Cholac; Chronulac; Cillium; Cit http://www.nlm.nih.gov/medlineplus/druginfo/laxativesoral202 319.html

Loperamide ·

Oral - U.S. Brands: Imodium http://www.nlm.nih.gov/medlineplus/druginfo/loperamideoral2 02332.html

Magnesium Supplements ·

Systemic - U.S. Brands: Almora; Chloromag; Citroma; Concentrated Phillips' Milk of Magnesia; Mag-200; Mag-L-100; Magonate; Mag-Ox 400; Mag-Tab SR; Magtrate; Maox; MGP; Phillips' Chewable Tablets; Phillips' Milk of Magnesia; Slow-Mag; Uro-Mag http://www.nlm.nih.gov/medlineplus/druginfo/magnesiumsup plementssystemic202644.html Metformin ·

Systemic - U.S. Brands: Glucophage http://www.nlm.nih.gov/medlineplus/druginfo/metforminsyste mic202756.html

Metronidazole ·

Systemic - U.S. Brands: Flagyl; Protostat http://www.nlm.nih.gov/medlineplus/druginfo/metronidazoles ystemic202365.html

Researching Your Medications 191

Misoprostol ·

Systemic - U.S. Brands: Cytotec http://www.nlm.nih.gov/medlineplus/druginfo/misoprostolsyst emic202375.html

Narcotic Analgesics for Pain Relief ·

Systemic - U.S. Brands: Astramorph PF; Buprenex; Cotanal-65; Darvon; Darvon-N; Demerol; Dilaudid; Dilaudid-5; Dilaudid-HP; Dolophine; Duramorph; Hydrostat IR; Kadian; Levo-Dromoran; M S Contin; Methadose; MS/L; MS/L Concentrate; MS/S; MSIR; Nubain; Numorphan; OMS Concentrate; http://www.nlm.nih.gov/medlineplus/druginfo/narcoticanalgesi csforpainrelie202390.html

Niacin (Vitamin B 3 ) ·

Systemic - U.S. Brands: Endur-Acin; Nia-Bid; Niac; Niacels; Niacor; Nico-400; Nicobid Tempules; Nicolar; Nicotinex Elixir; SloNiacin http://www.nlm.nih.gov/medlineplus/druginfo/niacinvitaminb3 systemic202405.html

Niacin for High Cholesterol ·

Systemic - U.S. Brands: Endur-Acin; Nia-Bid; Niac; Niacels; Niacor; Nico-400; Nicolar; Slo-Niacin http://www.nlm.nih.gov/medlineplus/druginfo/niacinforhighch olesterolsystem202404.html

Octreotide ·

Systemic - U.S. Brands: Sandostatin http://www.nlm.nih.gov/medlineplus/druginfo/octreotidesyste mic202421.html

Penicillins and Beta-Lactamase Inhibitors ·

Systemic - U.S. Brands: Augmentin; Timentin; Unasyn; Zosyn http://www.nlm.nih.gov/medlineplus/druginfo/penicillinsandbe talactamaseinh202705.html

Polyethylene Glycol and Electrolytes ·

Local - U.S. Brands: Co-Lav; Colovage; Colyte; Colyte-flavored; Go-Evac; GoLYTELY; NuLYTELY; OCL http://www.nlm.nih.gov/medlineplus/druginfo/polyethylenegly colandelectroly202636.html

192 Diarrhea

Potassium Iodide ·

Systemic - U.S. Brands: Pima http://www.nlm.nih.gov/medlineplus/druginfo/potassiumiodid esystemic202472.html

Pyridoxine (Vitamin B 6 ) ·

Systemic - U.S. Brands: Beesix; Doxine; Nestrex; Pyri; Rodex http://www.nlm.nih.gov/medlineplus/druginfo/pyridoxinevita minb6systemic202493.html

Sulfonamides and Trimethoprim ·

Systemic - U.S. Brands: Bactrim; Bactrim DS; Bactrim I.V.; Bactrim Pediatric; Cofatrim Forte; Cotrim; Cotrim DS; Cotrim Pediatric; Septra; Septra DS; Septra Grape Suspension; Septra I.V.; Septra Suspension; Sulfatrim; Sulfatrim Pediatric; Sulfatrim S/S; Sulfatrim Suspension; S http://www.nlm.nih.gov/medlineplus/druginfo/sulfonamidesan dtrimethoprimsys202781.html

Thiamine (Vitamin B 1 ) ·

Systemic - U.S. Brands: Biamine http://www.nlm.nih.gov/medlineplus/druginfo/thiaminevitami nb1systemic202560.html

Vancomycin ·

Oral - U.S. Brands: Vancocin http://www.nlm.nih.gov/medlineplus/druginfo/vancomycinoral 202589.html

Commercial Databases In addition to the medications listed in the USP above, a number of commercial sites are available by subscription to physicians and their institutions. You may be able to access these sources from your local medical library or your doctor’s office.

Researching Your Medications 193

Reuters Health Drug Database The Reuters Health Drug Database can be searched by keyword at the hyperlink: http://www.reutershealth.com/frame2/drug.html. The following medications are listed in the Reuters’ database as associated with diarrhea (including those with contraindications):43 ·

Albuterol http://www.reutershealth.com/atoz/html/Albuterol.htm

·

Alendronate Sodium http://www.reutershealth.com/atoz/html/Alendronate_Sodium.htm

·

Alfentanil HCl http://www.reutershealth.com/atoz/html/Alfentanil_HCl.htm

·

Allopurinol http://www.reutershealth.com/atoz/html/Allopurinol.htm

·

Alprazolam http://www.reutershealth.com/atoz/html/Alprazolam.htm

·

Alprostadil http://www.reutershealth.com/atoz/html/Alprostadil.htm

·

Amikacin Sulfate http://www.reutershealth.com/atoz/html/Amikacin_Sulfate.htm

·

Amiloride HCl http://www.reutershealth.com/atoz/html/Amiloride_HCl.htm

·

Aminocaproic Acid http://www.reutershealth.com/atoz/html/Aminocaproic_Acid.htm

·

Aminophylline http://www.reutershealth.com/atoz/html/Aminophylline.htm

·

Aminophylline(Theophylline Ethylenediamine) http://www.reutershealth.com/atoz/html/Aminophylline(Theophyllin e_Ethylenediamine).htm

·

Aminosalicylate Sodium http://www.reutershealth.com/atoz/html/Aminosalicylate_Sodium.ht m

·

Aminosalicylate Sodium (Para-Aminosalicylate Sodium;PAS) http://www.reutershealth.com/atoz/html/Aminosalicylate_Sodium_(P ara-Aminosalicylate_Sodium;PAS).htm

43

Adapted from A to Z Drug Facts by Facts and Comparisons.

194 Diarrhea

·

Amiodarone http://www.reutershealth.com/atoz/html/Amiodarone.htm

·

Amitriptyline HCl http://www.reutershealth.com/atoz/html/Amitriptyline_HCl.htm

·

Amoxapine http://www.reutershealth.com/atoz/html/Amoxapine.htm

·

Amoxicillin http://www.reutershealth.com/atoz/html/Amoxicillin.htm

·

Amphetamine http://www.reutershealth.com/atoz/html/Amphetamine.htm

·

Amphetamine (Racemic Amphetamine Sulfate) http://www.reutershealth.com/atoz/html/Amphetamine_(Racemic_A mphetamine_Sulfate).htm

·

Amphotericin B http://www.reutershealth.com/atoz/html/Amphotericin_B.htm

·

Ampicillin http://www.reutershealth.com/atoz/html/Ampicillin.htm

·

Ampicillin Sodium Sulbactam Sodium http://www.reutershealth.com/atoz/html/Ampicillin_Sodium_Sulbact am_Sodium.htm

·

Amprenavir http://www.reutershealth.com/atoz/html/Amprenavir.htm

·

Amyl Nitrite http://www.reutershealth.com/atoz/html/Amyl_Nitrite.htm

·

Ascorbic Acid http://www.reutershealth.com/atoz/html/Ascorbic_Acid.htm

·

Ascorbic Acid(Vitamin C) http://www.reutershealth.com/atoz/html/Ascorbic_Acid(Vitamin_C).h tm

·

Atenolol http://www.reutershealth.com/atoz/html/Atenolol.htm

·

Atenolol Chlorthalidone http://www.reutershealth.com/atoz/html/Atenolol_Chlorthalidone.ht m

·

Atorvastatin Calcium http://www.reutershealth.com/atoz/html/Atorvastatin_Calcium.htm

Researching Your Medications 195

·

Atovaquone http://www.reutershealth.com/atoz/html/Atovaquone.htm

·

Atropine Sulfate Scopolamine Hydrobromide Hyoscyamine Sulfate Phenobarbital http://www.reutershealth.com/atoz/html/Atropine_Sulfate_Scopolami ne_Hydrobromide_Hyoscyamine_Sulfate_Phenobarbital.htm

·

Cetirizine http://www.reutershealth.com/atoz/html/Cetirizine.htm

·

Charcoal activated http://www.reutershealth.com/atoz/html/Charcoal_activated.htm

·

Chlordiazepoxide Amitriptyline http://www.reutershealth.com/atoz/html/Chlordiazepoxide_Amitript yline.htm

·

Chloroquine http://www.reutershealth.com/atoz/html/Chloroquine.htm

·

Chlorpheniramine Maleate http://www.reutershealth.com/atoz/html/Chlorpheniramine_Maleate. htm

·

Cimetidine http://www.reutershealth.com/atoz/html/Cimetidine.htm

·

Ciprofloxacin http://www.reutershealth.com/atoz/html/Ciprofloxacin.htm

·

Citalopram http://www.reutershealth.com/atoz/html/Citalopram.htm

·

Clarithromycin http://www.reutershealth.com/atoz/html/Clarithromycin.htm

·

Clomipramine HCl http://www.reutershealth.com/atoz/html/Clomipramine_HCl.htm

·

Clonazepam http://www.reutershealth.com/atoz/html/Clonazepam.htm

·

Clonidine HCl http://www.reutershealth.com/atoz/html/Clonidine_HCl.htm

·

Clopidogrel http://www.reutershealth.com/atoz/html/Clopidogrel.htm

·

Clorazepate Dipotassium http://www.reutershealth.com/atoz/html/Clorazepate_Dipotassium.ht m

196 Diarrhea

·

Corticotropin (Adrenocorticotropic hormone; ACTH) http://www.reutershealth.com/atoz/html/Corticotropin_(Adrenocortic otropic_hormone;_ACTH).htm

·

Cortisone (Cortisone Acetate) http://www.reutershealth.com/atoz/html/Cortisone_(Cortisone_Acetat e).htm

·

Cromolyn Sodium (Disodium Cromoglycate) http://www.reutershealth.com/atoz/html/Cromolyn_Sodium_(Disodi um_Cromoglycate).htm

·

Cyclosporine(Cyclosporin A) http://www.reutershealth.com/atoz/html/Cyclosporine(Cyclosporin_ A).htm

·

Didanosine http://www.reutershealth.com/atoz/html/Didanosine.htm

·

Doxycycline http://www.reutershealth.com/atoz/html/Doxycycline.htm

·

Edetate Disodium http://www.reutershealth.com/atoz/html/Edetate_Disodium.htm

·

Edetate Disodium(EDTA) http://www.reutershealth.com/atoz/html/Edetate_Disodium(EDTA).h tm

·

Edrophonium Chloride http://www.reutershealth.com/atoz/html/Edrophonium_Chloride.htm

·

Efavirenz http://www.reutershealth.com/atoz/html/Efavirenz.htm

·

Enalapril Maleate http://www.reutershealth.com/atoz/html/Enalapril_Maleate.htm

·

Enalapril Maleate Hydrochlorothiazide http://www.reutershealth.com/atoz/html/Enalapril_Maleate_Hydroch lorothiazide.htm

·

Enoxacin http://www.reutershealth.com/atoz/html/Enoxacin.htm

·

Entacapone http://www.reutershealth.com/atoz/html/Entacapone.htm

·

Epoetin Alfa http://www.reutershealth.com/atoz/html/Epoetin_Alfa.htm

Researching Your Medications 197

·

Epoetin Alfa(Erythropoietin; EPO) http://www.reutershealth.com/atoz/html/Epoetin_Alfa(Erythropoietin ;_EPO).htm

·

Epoprostenol Sodium http://www.reutershealth.com/atoz/html/Epoprostenol_Sodium.htm

·

Erythromycin http://www.reutershealth.com/atoz/html/Erythromycin.htm

·

Erythromycin Ethylsuccinate Sulfisoxazole http://www.reutershealth.com/atoz/html/Erythromycin_Ethylsuccinat e_Sulfisoxazole.htm

·

Esmolol HCl http://www.reutershealth.com/atoz/html/Esmolol_HCl.htm

·

Esomeprazole Magnesium http://www.reutershealth.com/atoz/html/Esomeprazole_Magnesium. htm

·

Estradiol http://www.reutershealth.com/atoz/html/Estradiol.htm

·

Estrogens Conjugated http://www.reutershealth.com/atoz/html/Estrogens_Conjugated.htm

·

Estropipate http://www.reutershealth.com/atoz/html/Estropipate.htm

·

Estropipate (Piperazine Estrone Sulfate) http://www.reutershealth.com/atoz/html/Estropipate_(Piperazine_Est rone_Sulfate).htm

·

Ethacrynic Acid http://www.reutershealth.com/atoz/html/Ethacrynic_Acid.htm

·

Ethacrynic Acid (Ethacrynate) http://www.reutershealth.com/atoz/html/Ethacrynic_Acid_(Ethacryna te).htm

·

Etidronate Disodium http://www.reutershealth.com/atoz/html/Etidronate_Disodium.htm

·

Etodolac http://www.reutershealth.com/atoz/html/Etodolac.htm

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Famotidine http://www.reutershealth.com/atoz/html/Famotidine.htm

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Felbamate http://www.reutershealth.com/atoz/html/Felbamate.htm

198 Diarrhea

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Felodipine http://www.reutershealth.com/atoz/html/Felodipine.htm

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Fenofibrate http://www.reutershealth.com/atoz/html/Fenofibrate.htm

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Fenoprofen Calcium http://www.reutershealth.com/atoz/html/Fenoprofen_Calcium.htm

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Fentanyl Transdermal System http://www.reutershealth.com/atoz/html/Fentanyl_Transdermal_Syst em.htm

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Ferrous Salts http://www.reutershealth.com/atoz/html/Ferrous_Salts.htm

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Flecainide Acetate http://www.reutershealth.com/atoz/html/Flecainide_Acetate.htm

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Fluconazole http://www.reutershealth.com/atoz/html/Fluconazole.htm

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Flucytosine http://www.reutershealth.com/atoz/html/Flucytosine.htm

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Fluoxetine HCl http://www.reutershealth.com/atoz/html/Fluoxetine_HCl.htm

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Flurazepam HCl http://www.reutershealth.com/atoz/html/Flurazepam_HCl.htm

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Flurbiprofen http://www.reutershealth.com/atoz/html/Flurbiprofen.htm

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Fluticasone Propionate http://www.reutershealth.com/atoz/html/Fluticasone_Propionate.htm

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Fluvastatin http://www.reutershealth.com/atoz/html/Fluvastatin.htm

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Fluvoxamine Maleate http://www.reutershealth.com/atoz/html/Fluvoxamine_Maleate.htm

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Foscarnet Sodium http://www.reutershealth.com/atoz/html/Foscarnet_Sodium.htm

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Foscarnet Sodium (Phosphonoformic Acid) http://www.reutershealth.com/atoz/html/Foscarnet_Sodium_(Phosph onoformic_Acid).htm

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Fosfomycin Tromethamine http://www.reutershealth.com/atoz/html/Fosfomycin_Tromethamine. htm

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Fosinopril Sodium http://www.reutershealth.com/atoz/html/Fosinopril_Sodium.htm

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Furosemide http://www.reutershealth.com/atoz/html/Furosemide.htm

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Gabapentin http://www.reutershealth.com/atoz/html/Gabapentin.htm

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Galantamine Hydrobromide http://www.reutershealth.com/atoz/html/Galantamine_Hydrobromid e.htm

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Gallium Nitrate http://www.reutershealth.com/atoz/html/Gallium_Nitrate.htm

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Ganciclovir http://www.reutershealth.com/atoz/html/Ganciclovir.htm

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Ganciclovir (DHPG) http://www.reutershealth.com/atoz/html/Ganciclovir_(DHPG).htm

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Gemfibrozil http://www.reutershealth.com/atoz/html/Gemfibrozil.htm

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Glatiramer Acetate http://www.reutershealth.com/atoz/html/Glatiramer_Acetate.htm

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Glimepiride http://www.reutershealth.com/atoz/html/Glimepiride.htm

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Glipizide http://www.reutershealth.com/atoz/html/Glipizide.htm

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Glucagon http://www.reutershealth.com/atoz/html/Glucagon.htm

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Glyburide http://www.reutershealth.com/atoz/html/Glyburide.htm

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Glycopyrrolate http://www.reutershealth.com/atoz/html/Glycopyrrolate.htm

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Gold Sodium Thiomalate http://www.reutershealth.com/atoz/html/Gold_Sodium_Thiomalate.h tm

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Goserelin Acetate http://www.reutershealth.com/atoz/html/Goserelin_Acetate.htm

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Griseofulvin http://www.reutershealth.com/atoz/html/Griseofulvin.htm

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Guanabenz Acetate http://www.reutershealth.com/atoz/html/Guanabenz_Acetate.htm

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Guanethidine Monosulfate http://www.reutershealth.com/atoz/html/Guanethidine_Monosulfate. htm

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Guanfacine HCl http://www.reutershealth.com/atoz/html/Guanfacine_HCl.htm

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Haemophilus b Conjugate Vaccine http://www.reutershealth.com/atoz/html/Haemophilus_b_Conjugate_ Vaccine.htm

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Haloperidol http://www.reutershealth.com/atoz/html/Haloperidol.htm

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Hepatitis B Vaccine http://www.reutershealth.com/atoz/html/Hepatitis_B_Vaccine.htm

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Hydralazine HCI http://www.reutershealth.com/atoz/html/Hydralazine_HCI.htm

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Hydrochlorothiazide Triamterene(HCTZ Triamterene) http://www.reutershealth.com/atoz/html/Hydrochlorothiazide_Triamt erene(HCTZ_Triamterene).htm

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Hydrochlorothiazide(HCTZ) http://www.reutershealth.com/atoz/html/Hydrochlorothiazide(HCTZ) .htm

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Hydrocortisone (Cortisol) http://www.reutershealth.com/atoz/html/Hydrocortisone_(Cortisol).ht m

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Hydromorphone HCl http://www.reutershealth.com/atoz/html/Hydromorphone_HCl.htm

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Hydroxychloroquine Sulfate http://www.reutershealth.com/atoz/html/Hydroxychloroquine_Sulfat e.htm

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Hydroxyurea http://www.reutershealth.com/atoz/html/Hydroxyurea.htm

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Ibuprofen http://www.reutershealth.com/atoz/html/Ibuprofen.htm

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Imipenem-Cilastatin http://www.reutershealth.com/atoz/html/Imipenem-Cilastatin.htm

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Imipramine HCl http://www.reutershealth.com/atoz/html/Imipramine_HCl.htm

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Indapamide http://www.reutershealth.com/atoz/html/Indapamide.htm

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Indinavir Sulfate http://www.reutershealth.com/atoz/html/Indinavir_Sulfate.htm

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Indomethacin http://www.reutershealth.com/atoz/html/Indomethacin.htm

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Infliximab http://www.reutershealth.com/atoz/html/Infliximab.htm

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Insulin http://www.reutershealth.com/atoz/html/Insulin.htm

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Interferon Alfacon-I http://www.reutershealth.com/atoz/html/Interferon_Alfacon-I.htm

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Interferon Alfa-n3 http://www.reutershealth.com/atoz/html/Interferon_Alfa-n3.htm

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Interferon beta-1a http://www.reutershealth.com/atoz/html/Interferon_beta-1a.htm

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Interferon Beta-1b (rIFN-B) http://www.reutershealth.com/atoz/html/Interferon_Beta-1b_(rIFNB).htm

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Interferon Beta-1b(rIFN-B) http://www.reutershealth.com/atoz/html/Interferon_Beta-1b(rIFNB).htm

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Interferon Gamma-1b http://www.reutershealth.com/atoz/html/Interferon_Gamma-1b.htm

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Iodine http://www.reutershealth.com/atoz/html/Iodine.htm

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Ipecac Syrup http://www.reutershealth.com/atoz/html/Ipecac_Syrup.htm

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Ipratropium Bromide Albuterol Sulfate http://www.reutershealth.com/atoz/html/Ipratropium_Bromide_Albu terol_Sulfate.htm

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Iron Sucrose http://www.reutershealth.com/atoz/html/Iron_Sucrose.htm

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Isoniazid (Isonicotinic Acid Hydrazide; INH) http://www.reutershealth.com/atoz/html/Isoniazid_(Isonicotinic_Acid _Hydrazide;_INH).htm

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Isosorbide Dinitrate http://www.reutershealth.com/atoz/html/Isosorbide_Dinitrate.htm

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Isosorbide Mononitrate http://www.reutershealth.com/atoz/html/Isosorbide_Mononitrate.htm

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Isotretinoin http://www.reutershealth.com/atoz/html/Isotretinoin.htm

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Isradipine http://www.reutershealth.com/atoz/html/Isradipine.htm

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Itraconazole http://www.reutershealth.com/atoz/html/Itraconazole.htm

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Kanamycin Sulfate http://www.reutershealth.com/atoz/html/Kanamycin_Sulfate.htm

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Kaolin Pectin http://www.reutershealth.com/atoz/html/Kaolin_Pectin.htm

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Ketoconazole http://www.reutershealth.com/atoz/html/Ketoconazole.htm

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Ketoprofen http://www.reutershealth.com/atoz/html/Ketoprofen.htm

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Ketorolac Tromethamine http://www.reutershealth.com/atoz/html/Ketorolac_Tromethamine.ht m

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Labetalol HCL http://www.reutershealth.com/atoz/html/Labetalol_HCL.htm

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Lactulose http://www.reutershealth.com/atoz/html/Lactulose.htm

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Lamivudine http://www.reutershealth.com/atoz/html/Lamivudine.htm

Researching Your Medications 203

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Lamivudine Zidovudine http://www.reutershealth.com/atoz/html/Lamivudine_Zidovudine.ht m

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Lamotrigine http://www.reutershealth.com/atoz/html/Lamotrigine.htm

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Lansoprazole http://www.reutershealth.com/atoz/html/Lansoprazole.htm

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Leucovorin Calcium http://www.reutershealth.com/atoz/html/Leucovorin_Calcium.htm

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Lopinavir Ritonavir http://www.reutershealth.com/atoz/html/Lopinavir_Ritonavir.htm

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Loracarbef http://www.reutershealth.com/atoz/html/Loracarbef.htm

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Lovastatin http://www.reutershealth.com/atoz/html/Lovastatin.htm

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Methenamine and Methenamine Salts http://www.reutershealth.com/atoz/html/Methenamine_and_Methena mine_Salts.htm

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Pantoprazole Sodium http://www.reutershealth.com/atoz/html/Pantoprazole_Sodium.htm

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Promethazine HCl http://www.reutershealth.com/atoz/html/Promethazine_HCl.htm

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Propafenone http://www.reutershealth.com/atoz/html/Propafenone.htm

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Propantheline Bromide http://www.reutershealth.com/atoz/html/Propantheline_Bromide.htm

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Propoxyphene http://www.reutershealth.com/atoz/html/Propoxyphene.htm

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Propranolol HCl http://www.reutershealth.com/atoz/html/Propranolol_HCl.htm

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Protriptyline HCl http://www.reutershealth.com/atoz/html/Protriptyline_HCl.htm

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Quazepam http://www.reutershealth.com/atoz/html/Quazepam.htm

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Quinapril HCl http://www.reutershealth.com/atoz/html/Quinapril_HCl.htm

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Quinidine http://www.reutershealth.com/atoz/html/Quinidine.htm

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Quinine Sulfate http://www.reutershealth.com/atoz/html/Quinine_Sulfate.htm

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Rizatriptan http://www.reutershealth.com/atoz/html/Rizatriptan.htm

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Rofecoxib http://www.reutershealth.com/atoz/html/Rofecoxib.htm

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Ropinirole Hydrochloride http://www.reutershealth.com/atoz/html/Ropinirole_Hydrochloride.h tm

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Rosiglitazone Maleate http://www.reutershealth.com/atoz/html/Rosiglitazone_Maleate.htm

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Salicylate Combination http://www.reutershealth.com/atoz/html/Salicylate_Combination.htm

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Salmeterol http://www.reutershealth.com/atoz/html/Salmeterol.htm

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Saquinavir Mesylate http://www.reutershealth.com/atoz/html/Saquinavir_Mesylate.htm

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Sargramostim http://www.reutershealth.com/atoz/html/Sargramostim.htm

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Selegiline HCl http://www.reutershealth.com/atoz/html/Selegiline_HCl.htm

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Senna http://www.reutershealth.com/atoz/html/Senna.htm

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Sertraline HCl http://www.reutershealth.com/atoz/html/Sertraline_HCl.htm

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Sibutramine Hydrochloride http://www.reutershealth.com/atoz/html/Sibutramine_Hydrochloride. htm

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Sildenafil http://www.reutershealth.com/atoz/html/Sildenafil.htm

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Simvastatin http://www.reutershealth.com/atoz/html/Simvastatin.htm

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Sirolimus http://www.reutershealth.com/atoz/html/Sirolimus.htm

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Sodium Bicarbonate http://www.reutershealth.com/atoz/html/Sodium_Bicarbonate.htm

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Sotalol HCl http://www.reutershealth.com/atoz/html/Sotalol_HCl.htm

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Sparfloxacin http://www.reutershealth.com/atoz/html/Sparfloxacin.htm

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Spironolactone http://www.reutershealth.com/atoz/html/Spironolactone.htm

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Sucralfate http://www.reutershealth.com/atoz/html/Sucralfate.htm

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Sufentanil Citrate http://www.reutershealth.com/atoz/html/Sufentanil_Citrate.htm

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Sulfasalazine http://www.reutershealth.com/atoz/html/Sulfasalazine.htm

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Sulfinpyrazone http://www.reutershealth.com/atoz/html/Sulfinpyrazone.htm

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Tamsulosin Hydrochloride http://www.reutershealth.com/atoz/html/Tamsulosin_Hydrochloride. htm

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Terbinafine http://www.reutershealth.com/atoz/html/Terbinafine.htm

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Valganciclovir http://www.reutershealth.com/atoz/html/Valganciclovir.htm Mosby’s GenRx

Mosby’s GenRx database (also available on CD-Rom and book format) covers 45,000 drug products including generics and international brands. It provides prescribing information, drug interactions, and patient information. Information can be obtained at the following hyperlink: http://www.genrx.com/Mosby/PhyGenRx/group.html.

Physicians Desk Reference The Physicians Desk Reference database (also available in CD-Rom and book format) is a full-text drug database. The database is searchable by brand name, generic name or by indication. It features multiple drug interactions

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reports. Information can be obtained at the following hyperlink: http://physician.pdr.net/physician/templates/en/acl/psuser_t.htm.

Other Web Sites A number of additional Web sites discuss drug information. As an example, you may like to look at www.drugs.com which reproduces the information in the Pharmacopeia as well as commercial information. You may also want to consider the Web site of the Medical Letter, Inc. which allows users to download articles on various drugs and therapeutics for a nominal fee: http://www.medletter.com/.

Contraindications and Interactions (Hidden Dangers) Some of the medications mentioned in the previous discussions can be problematic for patients with diarrhea--not because they are used in the treatment process, but because of contraindications, or side effects. Medications with contraindications are those that could react with drugs used to treat diarrhea or potentially create deleterious side effects in patients with diarrhea. You should ask your physician about any contraindications, especially as these might apply to other medications that you may be taking for common ailments. Drug-drug interactions occur when two or more drugs react with each other. This drug-drug interaction may cause you to experience an unexpected side effect. Drug interactions may make your medications less effective, cause unexpected side effects, or increase the action of a particular drug. Some drug interactions can even be harmful to you. Be sure to read the label every time you use a nonprescription or prescription drug, and take the time to learn about drug interactions. These precautions may be critical to your health. You can reduce the risk of potentially harmful drug interactions and side effects with a little bit of knowledge and common sense. Drug labels contain important information about ingredients, uses, warnings, and directions which you should take the time to read and understand. Labels also include warnings about possible drug interactions. Further, drug labels may change as new information becomes available. This is why it’s especially important to read the label every time you use a

Researching Your Medications 207

medication. When your doctor prescribes a new drug, discuss all over-thecounter and prescription medications, dietary supplements, vitamins, botanicals, minerals and herbals you take as well as the foods you eat. Ask your pharmacist for the package insert for each prescription drug you take. The package insert provides more information about potential drug interactions.

A Final Warning At some point, you may hear of alternative medications from friends, relatives, or in the news media. Advertisements may suggest that certain alternative drugs can produce positive results for patients with diarrhea. Exercise caution--some of these drugs may have fraudulent claims, and others may actually hurt you. The Food and Drug Administration (FDA) is the official U.S. agency charged with discovering which medications are likely to improve the health of patients with diarrhea. The FDA warns patients to watch out for44: ·

Secret formulas (real scientists share what they know)

·

Amazing breakthroughs or miracle cures (real breakthroughs don’t happen very often; when they do, real scientists do not call them amazing or miracles)

·

Quick, painless, or guaranteed cures

·

If it sounds too good to be true, it probably isn’t true.

If you have any questions about any kind of medical treatment, the FDA may have an office near you. Look for their number in the blue pages of the phone book. You can also contact the FDA through its toll-free number, 1888-INFO-FDA (1-888-463-6332), or on the World Wide Web at www.fda.gov.

General References In addition to the resources provided earlier in this chapter, the following general references describe medications (sorted alphabetically by title; hyperlinks provide rankings, information and reviews at Amazon.com):

This section has been adapted from http://www.fda.gov/opacom/lowlit/medfraud.html.

44

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· Drug Development: Molecular Targets for Gi Diseases by Timothy S. Gaginella (Editor), Antonio Guglietta (Editor); Hardcover - 288 pages (December 1999), Humana Press; ISBN: 0896035891; http://www.amazon.com/exec/obidos/ASIN/0896035891/icongroupinterna · Drug Therapy for Gastrointestinal and Liver Diseases by Michael J.G. Farthing, M.D. (Editor), Anne B. Ballinger (Editor); Hardcover - 346 pages, 1st edition (August 15, 2001), Martin Dunitz Ltd.; ISBN: 1853177334; http://www.amazon.com/exec/obidos/ASIN/1853177334/icongroupinterna · Immunopharmacology of the Gastrointestinal System (Handbook of Immunopharmacology) by John L. Wallace (Editor); Hardcover (October 1997), Academic Press; ISBN: 0127328602; http://www.amazon.com/exec/obidos/ASIN/0127328602/icongroupinterna · A Pharmacologic Approach to Gastrointestinal Disorders by James H. Lewis, M.D. (Editor); Hardcover – (February 1994), Lippincott, Williams & Wilkins; ISBN: 0683049704; http://www.amazon.com/exec/obidos/ASIN/0683049704/icongroupinterna

Vocabulary Builder The following vocabulary builder gives definitions of words used in this chapter that have not been defined in previous chapters: ACTH: Adrenocorticotropic hormone. [EU] Albuterol: A racemic mixture with a 1:1 ratio of the r-isomer, levalbuterol, and s-albuterol. It is a short-acting beta2-adrenergic agonist with its main clinical use in asthma. [NIH] Allopurinol: A xanthine oxidase inhibitor that decreases uric acid production. [NIH] Alprostadil: A potent vasodilator agent that increases peripheral blood flow. It inhibits platelet aggregation and has many other biological effects such as bronchodilation, mediation of inflammation, etc. [NIH] Aminophylline: A drug combination that contains THEOPHYLLINE and ethylenediamine. It is more soluble in water than theophylline but has similar pharmacologic actions. It's most common use is in bronchial asthma, but it has been investigated for several other applications. [NIH] Amiodarone: An antianginal and antiarrhythmic drug. It increases the duration of ventricular and atrial muscle action by inhibiting Na,K-activated myocardial adenosine triphosphatase. There is a resulting decrease in heart rate and in vascular resistance. [NIH] Amoxapine:

The N-demethylated derivative of the antipsychotic agent

Researching Your Medications 209

loxapine that works by blocking the reuptake of norepinephrine, serotonin, or both. It also blocks dopamine receptors. [NIH] Amoxicillin: A broad-spectrum semisynthetic antibiotic similar to ampicillin except that its resistance to gastric acid permits higher serum levels with oral administration. [NIH] Amphetamine: A powerful central nervous system stimulant and sympathomimetic. Amphetamine has multiple mechanisms of action including blocking uptake of adrenergics and dopamine, stimulation of release of monamines, and inhibiting monoamine oxidase. Amphetamine is also a drug of abuse and a psychotomimetic. The l- and the d,l-forms are included here. The l-form has less central nervous system activity but stronger cardiovascular effects. The d-form is dextroamphetamine. [NIH] Amphotericin B: Macrolide antifungal antibiotic produced by Streptomyces nodosus obtained from soil of the Orinoco river region of Venezuela. [NIH] Ampicillin: Semi-synthetic derivative of penicillin that functions as an orally active broad-spectrum antibiotic. [NIH] Amyl Nitrite: A vasodilator that is administered by inhalation. It is also used recreationally due to its supposed ability to induce euphoria and act as an aphrodisiac. [NIH] Analgesic: An agent that alleviates pain without causing loss of consciousness. [EU] Aqueous: Watery; prepared with water. [EU] Atenolol: A cardioselective beta-adrenergic blocker possessing properties and potency similar to propranolol, but without a negative inotropic effect. [NIH]

Cetirizine: A potent second-generation histamine H1 antagonist that is effective in the treatment of allergic rhinitis, chronic urticaria, and polleninduced asthma. Unlike many traditional antihistamines, it does not cause drowsiness or anticholinergic side effects. [NIH] Chloroquine: The prototypical antimalarial agent with a mechanism that is not well understood. It has also been used to treat rheumatoid arthritis, systemic lupus erythematosus, and in the systemic therapy of amebic liver abscesses. [NIH] Cimetidine: A histamine congener, it competitively inhibits histamine binding to H2 receptors. Cimetidine has a range of pharmacological actions. It inhibits gastric acid secretion, as well as pepsin and gastrin output. It also blocks the activity of cytochrome P-450. [NIH] Clonazepam: An anticonvulsant used for several types of seizures, including myotonic or atonic seizures, photosensitive epilepsy, and absence seizures, although tolerance may develop. It is seldom effective in

210 Diarrhea

generalized tonic-clonic or partial seizures. The mechanism of action appears to involve the enhancement of GABA receptor responses. [NIH] Clorazepate Dipotassium: A water-soluble benzodiazepine derivative effective in the treatment of anxiety. It has also muscle relaxant and anticonvulsant actions. [NIH] Colestipol: Highly crosslinked and insoluble basic anion exchange resin used as anticholesteremic. It may also may reduce triglyceride levels. [NIH] Didanosine: A dideoxynucleoside compound in which the 3'-hydroxy group on the sugar moiety has been replaced by a hydrogen. This modification prevents the formation of phosphodiester linkages which are needed for the completion of nucleic acid chains. Didanosine is a potent inhibitor of HIV replication, acting as a chain-terminator of viral DNA by binding to reverse transcriptase; ddI is then metabolized to dideoxyadenosine triphosphate, its putative active metabolite. [NIH] Doxycycline: A synthetic tetracycline derivative with a range of antimicrobial activity and mode of action similar to that of tetracycline, but more effective against many species. Animal studies suggest that it may cause less tooth staining than other tetracyclines. [NIH] Enoxacin: An orally administered broad-spectrum fluoroquinolone antibacterial agent active against most gram-negative and gram-positive bacteria. Its clinical efficacy has been confirmed in a variety of systemic infections and particularly in urinary tract infections. The drug is well tolerated by adults, but should not be used in children and pregnant women. [NIH]

Erythromycin: A bacteriostatic antibiotic substance produced by Streptomyces erythreus. Erythromycin A is considered its major active component. In sensitive organisms, it inhibits protein synthesis by binding to 50S ribosomal subunits. This binding process inhibits peptidyl transferase activity and interferes with translocation of amino acids during translation and assembly of proteins. [NIH] Erythropoietin: Glycoprotein hormone, secreted chiefly by the kidney in the adult and the liver in the fetus, that acts on erythroid stem cells of the bone marrow to stimulate proliferation and differentiation. [NIH] Estradiol: The most potent mammalian estrogenic hormone. It is produced in the ovary, placenta, testis, and possibly the adrenal cortex. [NIH] Ethacrynic Acid: A compound that inhibits symport of sodium, potassium, and chloride primarily in the ascending limb of Henle, but also in the proximal and distal tubules. This pharmacological action results in excretion of these ions, increased urinary output, and reduction in extracelluar fluid. This compound has been classified as a loop or high ceiling diuretic. [NIH] Etodolac: A nonsteroidal anti-inflammatory agent with potent analgesic and

Researching Your Medications 211

antiarthritic properties. It has been shown to be effective in the treatment of osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, and in the alleviation of postoperative pain. [NIH] Famotidine: A competitive histamine H2-receptor antagonist. Its main pharmacodynamic effect is the inhibition of gastric secretion. [NIH] Felodipine: A dihydropyridine calcium antagonist with positive inotropic effects. It lowers blood pressure by reducing peripheral vascular resistance through a highly selective action on smooth muscle in arteriolar resistance vessels. [NIH] Fluconazole: Triazole antifungal agent that is used to treat oropharyngeal candidiasis and cryptococcal meningitis in AIDS. [NIH] Flucytosine: A fluorinated cytosine analog that is used as an antifungal agent. [NIH] Flurbiprofen: An anti-inflammatory analgesic and antipyretic of the phenylalkynoic acid series. It has been shown to reduce bone resorption in periodontal disease by inhibiting carbonic anhydrase. [NIH] Furosemide: A sulfamyl saluretic and diuretic. It has a fast onset and short duration of action and is used in edema and chronic renal insufficiency. [NIH] Ganciclovir: Acyclovir analog that is a potent inhibitor of the Herpesvirus family including cytomegalovirus. Ganciclovir is used to treat complications from AIDS-associated cytomegalovirus infections. [NIH] Gemfibrozil: A lipid-regulating agent that lowers elevated serum lipids primarily by decreasing serum triglycerides with a variable reduction in total cholesterol. These decreases occur primarily in the VLDL fraction and less frequently in the LDL fraction. Gemfibrozil increases HDL subfractions HDL2 and HDL3 as well as apolipoproteins A-I and A-II. Its mechanism of action has not been definitely established. [NIH] Glipizide: An oral hypoglycemic agent which is rapidly absorbed and completely metabolized. [NIH] Glyburide: An antidiabetic sulfonylurea derivative with actions similar to those of chlorpropamide. [NIH] Glycopyrrolate: A muscarinic antagonist used as an antispasmodic, in some disorders of the gastrointestinal tract, and to reduce salivation with some anesthetics. [NIH] Gold Sodium Thiomalate: A variable mixture of the mono- and disodium salts of gold thiomalic acid used mainly for its anti-inflammatory action in the treatment of rheumatoid arthritis. It is most effective in active progressive rheumatoid arthritis and of little or no value in the presence of extensive deformities or in the treatment of other forms of arthritis. [NIH]

212 Diarrhea

Griseofulvin: An antifungal antibiotic. Griseofulvin may be given by mouth in the treatment of tinea infections. [NIH] Hydroxyurea: An antineoplastic agent that inhibits DNA synthesis through the inhibition of ribonucleoside diphosphate reductase. [NIH] Ibuprofen: A nonsteroidal anti-inflammatory agent with analgesic properties used in the therapy of rheumatism and arthritis. [NIH] Indapamide: A sulfamyl diuretic with about 16x the effect of furosemide. It has also been shown to be an effective antihypertensive agent in the clinic. [NIH]

Insulin: A protein hormone secreted by beta cells of the pancreas. Insulin plays a major role in the regulation of glucose metabolism, generally promoting the cellular utilization of glucose. It is also an important regulator of protein and lipid metabolism. Insulin is used as a drug to control insulindependent diabetes mellitus. [NIH] Iodine: A nonmetallic element of the halogen group that is represented by the atomic symbol I, atomic number 53, and atomic weight of 126.90. It is a nutritionally essential element, especially important in thyroid hormone synthesis. In solution, it has anti-infective properties and is used topically. [NIH]

Isosorbide Dinitrate: A vasodilator used in the treatment of angina. Its actions are similar to nitroglycerin but with a slower onset of action. [NIH] Isotretinoin: A topical dermatologic agent that is used in the treatment of acne vulgaris and several other skin diseases. The drug has teratogenic and other adverse effects. [NIH] Itraconazole: An antifungal agent that has been used in the treatment of histoplasmosis, blastomycosis, cryptococcal meningitis, and aspergillosis. [NIH]

Ketoconazole: Broad spectrum antifungal agent used for long periods at high doses, especially in immunosuppressed patients. [NIH] Ketoprofen: An ibuprofen-type anti-inflammatory analgesic and antipyretic. It is used in the treatment of rheumatoid arthritis and osteoarthritis. [NIH] Ketorolac Tromethamine: A pyrrolizine carboxylic acid derivative structurally related to indomethacin. It is a non-steroidal anti-inflammatory agent used for analgesia for postoperative pain and inhibits cyclooxygenase activity. [NIH] Lamivudine: A reverse transcriptase inhibitor and zalcitabine analog in which a sulfur atom replaces the 3' carbon of the pentose ring. It is used to treat HIV disease. [NIH] Misoprostol: A synthetic analog of natural prostaglandin E1. It produces a

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dose-related inhibition of gastric acid and pepsin secretion, and enhances mucosal resistance to injury. It is an effective anti-ulcer agent and also has oxytocic properties. [NIH] Propafenone: An antiarrhythmia agent that is particularly effective in ventricular arrhythmias. It also has weak beta-blocking activity. The drug is generally well tolerated. [NIH] Propoxyphene: A narcotic analgesic structurally related to METHADONE. Only the dextro-isomer has an analgesic effect; the levo-isomer appears to exert an antitussive effect. [NIH] Quinidine: An optical isomer of quinine, extracted from the bark of the Cinchona tree and similar plant species. This alkaloid dampens the excitability of cardiac and skeletal muscles by blocking sodium and potassium currents across cellular membranes. It prolongs cellular action potential, and decreases automaticity. Quinidine also blocks muscarinic and alpha-adrenergic neurotransmission. [NIH] Scopolamine: An alkaloid from Solanaceae, especially Datura metel L. and Scopola carniolica. Scopolamine and its quaternary derivatives act as antimuscarinics like atropine, but may have more central nervous system effects. Among the many uses are as an anesthetic premedication, in urinary incontinence, in motion sickness, as an antispasmodic, and as a mydriatic and cycloplegic. [NIH] Sirolimus: A macrolide compound obtained from Streptomyces hygroscopicus that acts by selectively blocking the transcriptional activation of cytokines thereby inhibiting cytokine production. It is bioactive only when bound to immunophilins. Sirolimus is a potent immunosuppressant and possesses both antifungal and antineoplastic properties. [NIH] Sodium Bicarbonate: A white, crystalline powder that is commonly used as a pH buffering agent, an electrolyte replenisher, systemic alkalizer and in topical cleansing solutions. [NIH] Sorbitol: A polyhydric alcohol with about half the sweetness of sucrose. Sorbitol occurs naturally and is also produced synthetically from glucose. It was formerly used as a diuretic and may still be used as a laxative and in irrigating solutions for some surgical procedures. It is also used in many manufacturing processes, as a pharmaceutical aid, and in several research applications. [NIH] Sucralfate: A basic aluminum complex of sulfated sucrose. It is advocated in the therapy of peptic, duodenal, and prepyloric ulcers, gastritis, reflux esophagitis, and other gastrointestinal irritations. It acts primarily at the ulcer site, where it has cytoprotective, pepsinostatic, antacid, and bile acidbinding properties. The drug is only slightly absorbed by the digestive mucosa, which explains the absence of systemic effects and toxicity. [NIH]

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Sulbactam: A beta-lactamase inhibitor with very weak antibacterial action. The compound prevents antibiotic destruction of beta-lactam antibiotics by inhibiting beta-lactamases, thus extending their spectrum activity. Combinations of sulbactam with beta-lactam antibiotics have been used successfully for the therapy of infections caused by organisms resistant to the antibiotic alone. [NIH] Sulfinpyrazone: A uricosuric drug that is used to reduce the serum urate levels in gout therapy. It lacks anti-inflammatory, analgesic, and diuretic properties. [NIH] Transdermal: Entering through the dermis, or skin, as in administration of a drug applied to the skin in ointment or patch form. [EU] Triamterene: A pteridine that is used as a mild diuretic. [NIH]

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APPENDIX B. RESEARCHING ALTERNATIVE MEDICINE Overview Complementary and alternative medicine (CAM) is one of the most contentious aspects of modern medical practice. You may have heard of these treatments on the radio or on television. Maybe you have seen articles written about these treatments in magazines, newspapers, or books. Perhaps your friends or doctor have mentioned alternatives. In this chapter, we will begin by giving you a broad perspective on complementary and alternative therapies. Next, we will introduce you to official information sources on CAM relating to diarrhea. Finally, at the conclusion of this chapter, we will provide a list of readings on diarrhea from various authors. We will begin, however, with the National Center for Complementary and Alternative Medicine’s (NCCAM) overview of complementary and alternative medicine.

What Is CAM?45 Complementary and alternative medicine (CAM) covers a broad range of healing philosophies, approaches, and therapies. Generally, it is defined as those treatments and healthcare practices which are not taught in medical schools, used in hospitals, or reimbursed by medical insurance companies. Many CAM therapies are termed “holistic,” which generally means that the healthcare practitioner considers the whole person, including physical, mental, emotional, and spiritual health. Some of these therapies are also known as “preventive,” which means that the practitioner educates and 45

Adapted from the NCCAM: http://nccam.nih.gov/nccam/fcp/faq/index.html#what-is.

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treats the person to prevent health problems from arising, rather than treating symptoms after problems have occurred. People use CAM treatments and therapies in a variety of ways. Therapies are used alone (often referred to as alternative), in combination with other alternative therapies, or in addition to conventional treatment (sometimes referred to as complementary). Complementary and alternative medicine, or “integrative medicine,” includes a broad range of healing philosophies, approaches, and therapies. Some approaches are consistent with physiological principles of Western medicine, while others constitute healing systems with non-Western origins. While some therapies are far outside the realm of accepted Western medical theory and practice, others are becoming established in mainstream medicine. Complementary and alternative therapies are used in an effort to prevent illness, reduce stress, prevent or reduce side effects and symptoms, or control or cure disease. Some commonly used methods of complementary or alternative therapy include mind/body control interventions such as visualization and relaxation, manual healing including acupressure and massage, homeopathy, vitamins or herbal products, and acupuncture.

What Are the Domains of Alternative Medicine?46 The list of CAM practices changes continually. The reason being is that these new practices and therapies are often proved to be safe and effective, and therefore become generally accepted as “mainstream” healthcare practices. Today, CAM practices may be grouped within five major domains: (1) alternative medical systems, (2) mind-body interventions, (3) biologicallybased treatments, (4) manipulative and body-based methods, and (5) energy therapies. The individual systems and treatments comprising these categories are too numerous to list in this sourcebook. Thus, only limited examples are provided within each. Alternative Medical Systems Alternative medical systems involve complete systems of theory and practice that have evolved independent of, and often prior to, conventional biomedical approaches. Many are traditional systems of medicine that are

46

Adapted from the NCCAM: http://nccam.nih.gov/nccam/fcp/classify/index.html.

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practiced by individual cultures throughout the world, including a number of venerable Asian approaches. Traditional oriental medicine emphasizes the balance or disturbances of qi (pronounced chi) or vital energy in health and disease, respectively. Traditional oriental medicine consists of a group of techniques and methods including acupuncture, herbal medicine, oriental massage, and qi gong (a form of energy therapy). Acupuncture involves stimulating specific anatomic points in the body for therapeutic purposes, usually by puncturing the skin with a thin needle. Ayurveda is India’s traditional system of medicine. Ayurvedic medicine (meaning “science of life”) is a comprehensive system of medicine that places equal emphasis on body, mind, and spirit. Ayurveda strives to restore the innate harmony of the individual. Some of the primary Ayurvedic treatments include diet, exercise, meditation, herbs, massage, exposure to sunlight, and controlled breathing. Other traditional healing systems have been developed by the world’s indigenous populations. These populations include Native American, Aboriginal, African, Middle Eastern, Tibetan, and Central and South American cultures. Homeopathy and naturopathy are also examples of complete alternative medicine systems. Homeopathic medicine is an unconventional Western system that is based on the principle that “like cures like,” i.e., that the same substance that in large doses produces the symptoms of an illness, in very minute doses cures it. Homeopathic health practitioners believe that the more dilute the remedy, the greater its potency. Therefore, they use small doses of specially prepared plant extracts and minerals to stimulate the body’s defense mechanisms and healing processes in order to treat illness. Naturopathic medicine is based on the theory that disease is a manifestation of alterations in the processes by which the body naturally heals itself and emphasizes health restoration rather than disease treatment. Naturopathic physicians employ an array of healing practices, including the following: diet and clinical nutrition, homeopathy, acupuncture, herbal medicine, hydrotherapy (the use of water in a range of temperatures and methods of applications), spinal and soft-tissue manipulation, physical therapies (such as those involving electrical currents, ultrasound, and light), therapeutic counseling, and pharmacology.

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Mind-Body Interventions Mind-body interventions employ a variety of techniques designed to facilitate the mind’s capacity to affect bodily function and symptoms. Only a select group of mind-body interventions having well-documented theoretical foundations are considered CAM. For example, patient education and cognitive-behavioral approaches are now considered “mainstream.” On the other hand, complementary and alternative medicine includes meditation, certain uses of hypnosis, dance, music, and art therapy, as well as prayer and mental healing.

Biological-Based Therapies This category of CAM includes natural and biological-based practices, interventions, and products, many of which overlap with conventional medicine’s use of dietary supplements. This category includes herbal, special dietary, orthomolecular, and individual biological therapies. Herbal therapy employs an individual herb or a mixture of herbs for healing purposes. An herb is a plant or plant part that produces and contains chemical substances that act upon the body. Special diet therapies, such as those proposed by Drs. Atkins, Ornish, Pritikin, and Weil, are believed to prevent and/or control illness as well as promote health. Orthomolecular therapies aim to treat disease with varying concentrations of chemicals such as magnesium, melatonin, and mega-doses of vitamins. Biological therapies include, for example, the use of laetrile and shark cartilage to treat cancer and the use of bee pollen to treat autoimmune and inflammatory diseases.

Manipulative and Body-Based Methods This category includes methods that are based on manipulation and/or movement of the body. For example, chiropractors focus on the relationship between structure and function, primarily pertaining to the spine, and how that relationship affects the preservation and restoration of health. Chiropractors use manipulative therapy as an integral treatment tool. In contrast, osteopaths place particular emphasis on the musculoskeletal system and practice osteopathic manipulation. Osteopaths believe that all of the body’s systems work together and that disturbances in one system may have an impact upon function elsewhere in the body. Massage therapists manipulate the soft tissues of the body to normalize those tissues.

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Energy Therapies Energy therapies focus on energy fields originating within the body (biofields) or those from other sources (electromagnetic fields). Biofield therapies are intended to affect energy fields (the existence of which is not yet experimentally proven) that surround and penetrate the human body. Some forms of energy therapy manipulate biofields by applying pressure and/or manipulating the body by placing the hands in or through these fields. Examples include Qi gong, Reiki and Therapeutic Touch. Qi gong is a component of traditional oriental medicine that combines movement, meditation, and regulation of breathing to enhance the flow of vital energy (qi) in the body, improve blood circulation, and enhance immune function. Reiki, the Japanese word representing Universal Life Energy, is based on the belief that, by channeling spiritual energy through the practitioner, the spirit is healed and, in turn, heals the physical body. Therapeutic Touch is derived from the ancient technique of “laying-on of hands.” It is based on the premises that the therapist’s healing force affects the patient’s recovery and that healing is promoted when the body’s energies are in balance. By passing their hands over the patient, these healers identify energy imbalances. Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields to treat illnesses or manage pain. These therapies are often used to treat asthma, cancer, and migraine headaches. Types of electromagnetic fields which are manipulated in these therapies include pulsed fields, magnetic fields, and alternating current or direct current fields.

Can Alternatives Affect My Treatment? A critical issue in pursuing complementary alternatives mentioned thus far is the risk that these might have undesirable interactions with your medical treatment. It becomes all the more important to speak with your doctor who can offer advice on the use of alternatives. Official sources confirm this view. Though written for women, we find that the National Women’s Health Information Center’s advice on pursuing alternative medicine is appropriate for patients of both genders and all ages.47

47

Adapted from http://www.4woman.gov/faq/alternative.htm.

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Is It Okay to Want Both Traditional and Alternative or Complementary Medicine? Should you wish to explore non-traditional types of treatment, be sure to discuss all issues concerning treatments and therapies with your healthcare provider, whether a physician or practitioner of complementary and alternative medicine. Competent healthcare management requires knowledge of both conventional and alternative therapies you are taking for the practitioner to have a complete picture of your treatment plan. The decision to use complementary and alternative treatments is an important one. Consider before selecting an alternative therapy, the safety and effectiveness of the therapy or treatment, the expertise and qualifications of the healthcare practitioner, and the quality of delivery. These topics should be considered when selecting any practitioner or therapy.

Finding CAM References on Diarrhea Having read the previous discussion, you may be wondering which complementary or alternative treatments might be appropriate for diarrhea. For the remainder of this chapter, we will direct you to a number of official sources which can assist you in researching studies and publications. Some of these articles are rather technical, so some patience may be required.

The Combined Health Information Database For a targeted search, The Combined Health Information Database is a bibliographic database produced by health-related agencies of the Federal Government (mostly from the National Institutes of Health). This database is updated four times a year at the end of January, April, July, and October. Check the titles, summaries, and availability of CAM-related information by using the “Simple Search” option at the following Web site: http://chid.nih.gov/simple/simple.html. In the drop box at the top, select “Complementary and Alternative Medicine.” Then type “diarrhea” (or synonyms) in the second search box. We recommend that you select 100 “documents per page” and to check the “whole records” options. The following was extracted using this technique:

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Homeopathic Treatment of Acute Childhood Diarrhea: Results from a Clinical Trial in Nepal Source: Journal of Alternative and Complementary Medicine: Research on Paradigm, Practice and Policy. 6(2): 131-139. April 2000. Summary: This journal article presents the results from a clinical trial of homeopathic medicine for the treatment of diarrhea in children. The sample consisted of 126 children, aged 6 months to 5 years, who presented at a private, charitable health clinic in Kathmandu, Nepal, with a history of diarrhea for no more than 5 days. Patients who had used standard antidiarrheal medication within the previous 48 hours and those with severe diarrhea requiring hospitalization were excluded. The children were randomly assigned to individualized treatment with 1 of 19 homeopathic remedies or to placebo, with instructions to take one dose after each unformed stool for up to 5 days. Parents recorded daily stools on a diary card, and health workers made home visits to monitor the children. The main outcome measures were the duration of diarrhea and average number of stools per day. Of the 126 children enrolled, 116 completed the trial. The mean number of stools per day over the 5-day treatment period was 3.2 for the treatment group and 4.5 for the placebo group. The probability that a child would still have diarrhea at day 5 was 42.1 percent in the homeopathy group and 60.5 percent in the placebo group. The most commonly used remedies, used in 77 percent of cases, were Podophyllum, Sulphur, and Arsenicum. The article has 1 figure, 4 tables, and 30 references.

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Treatment of Senile Diabetic Diarrhea With Traditional Chinese Drugs Source: Journal of Traditional Chinese Medicine. 19(4): 264-267. 1999. Summary: This journal article describes the use of traditional Chinese drugs to treat senile diabetic diarrhea. Seventy-five patients with senile type II diabetes complicated by diarrhea were assigned to treatment (n=40) and control (n=35) groups. The treatment group received Jiang Tang Zhi Xie Fang (a hypoglycemic and antidiarrheal decoction made from nine herbs) for 1 month. Xiaoke (diabetic) pills were added for patients with blood sugar levels higher than 12 mmol/l. Patients in the control group received glybenzcyclamide to control blood sugar and Li Zhu Chang Le (a preparation of Bacillus bifidus) to treat the diarrhea. Patients were followed for 6 months, and outcomes were classified according to predefined criteria. In the treatment group, 28 patients were classified as clinically cured (70.0 percent), 11 remarkably improved (27.5 percent), and 1 failed (2.5 percent). In the control group, 23 patients were clinically cured (65.7 percent), 10 remarkably improved (28.6 percent), and 2 failed. The total effective rate was 97.5 percent in the treatment

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group and 94.3 percent in the control group. The authors conclude that Jiang Tang Zhi Xie Fang appears to be a safe and effective treatment for type II diabetic diarrhea.. ·

Herbs To Improve Digestion: Herbal Remedies for Stomach Pain, Constipation, Ulcers, Colitis and Other Gastrointestinal Problems Source: New Canaan, CT: Keats Publishing, Inc. 1996. 90 p. Contact: Available from Keats Publishing, Inc., division of NTC/Contemporary. 203 Kitchawan Road, South Salem, NY 10590. 914533-1175, FAX: 914-533-0035. PRICE: $4.95. ISBN: 087983742X. Summary: This book describes the use of herbs to improve digestion, including herbal remedies for stomach pain, constipation, ulcers, colitis, and other gastrointestinal problems. It provides an overview of the digestive system, including the digestive process and the role of bacteria. It discusses juicing, food sensitivities, digestive enzymes, and the role of exercise in improving digestion. It contains descriptions of frequently occurring digestive disorders such as colic, constipation, Crohn's disease, diarrhea, diverticulitis, flatulence, gastritis, heartburn, hemorrhoids, indigestion, irritable bowel syndrome, and ulcers. It provides suggestions on using herbs to treat these problems, and describes 12 steps to better digestion. This book contains a resource list and an index.

National Center for Complementary and Alternative Medicine The National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health (http://nccam.nih.gov) has created a link to the National Library of Medicine’s databases to allow patients to search for articles that specifically relate to diarrhea and complementary medicine. To search the database, go to the following Web site: www.nlm.nih.gov/nccam/camonpubmed.html. Select “CAM on PubMed.” Enter “diarrhea” (or synonyms) into the search box. Click “Go.” The following references provide information on particular aspects of complementary and alternative medicine (CAM) that are related to diarrhea: ·

Acute diarrhea: a practical review. Author(s): Aranda-Michel J, Giannella RA. Source: The American Journal of Medicine. 1999 June; 106(6): 670-6. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10378626&dopt=Abstract

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Anti-diarrheal effect of water extract of Evodiae fructus in mice. Author(s): Yu LL, Liao JF, Chen CF. Source: Journal of Ethnopharmacology. 2000 November; 73(1-2): 39-45. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11025137&dopt=Abstract

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Clinical therapeutic effect of drug-separated moxibustion on chronic diarrhea and its immunologic mechanisms. Author(s): Wu H, Chen H, Hua X, Shi Z, Zhang L, Chen J. Source: J Tradit Chin Med. 1997 December; 17(4): 253-8. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10437206&dopt=Abstract

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Control of irinotecan-induced diarrhea by octreotide after loperamide failure. Author(s): Barbounis V, Koumakis G, Vassilomanolakis M, Demiri M, Efremidis AP. Source: Supportive Care in Cancer : Official Journal of the Multinational Association of Supportive Care in Cancer. 2001 June; 9(4): 258-60. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11430421&dopt=Abstract

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Dental injuries due to African traditional therapies for diarrhea. Author(s): Graham EA, Domoto PK, Lynch H, Egbert MA. Source: The Western Journal of Medicine. 2000 August; 173(2): 135-7. Review. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10924443&dopt=Abstract

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Diarrhea in HIV-infected individuals: a review. Author(s): Bowers JM, Dols CL, Barreuther CJ. Source: Aids Patient Care and Stds. 1996 February; 10(1): 25-31. Review. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11361655&dopt=Abstract

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Diarrhea. Author(s): Hu J.

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Source: J Tradit Chin Med. 2002 March; 22(1): 78-80. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11977529&dopt=Abstract ·

Diarrhea: new treatment option from Shaman. Author(s): James JS. Source: Aids Treat News. 1999 August 6; (No 324): 1-2. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11366574&dopt=Abstract

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Dietary fiber fraction of germinated barley foodstuff attenuated mucosal damage and diarrhea, and accelerated the repair of the colonic mucosa in an experimental colitis. Author(s): Kanauchi O, Iwanaga T, Andoh A, Araki Y, Nakamura T, Mitsuyama K, Suzuki A, Hibi T, Bamba T. Source: Journal of Gastroenterology and Hepatology. 2001 February; 16(2): 160-8. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11207896&dopt=Abstract

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Effects of Keishi-ka-shakuyaku-to (Gui-Zhi-Jia-Shao-Yao-Tang) on diarrhea and small intestinal movement. Author(s): Saitoh K, Kase Y, Ishige A, Komatsu Y, Sasaki H, Shibahara N. Source: Biol Pharm Bull. 1999 January; 22(1): 87-9. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=9989669&dopt=Abstract

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Glutamine for irinotecan diarrhea. Author(s): Savarese D, Al-Zoubi A, Boucher J. Source: Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology. 2000 January; 18(2): 450-1. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10637264&dopt=Abstract

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Homeopathic treatment of acute childhood diarrhea: results from a clinical trial in Nepal. Author(s): Jacobs J, Jimenez LM, Malthouse S, Chapman E, Crothers D, Masuk M, Jonas WB.

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Source: Journal of Alternative and Complementary Medicine (New York, N.Y.). 2000 April; 6(2): 131-9. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10784270&dopt=Abstract ·

Inhibition of thromboxane A(2)-induced Cl(-) secretion by antidiarrhea drug loperamide in isolated rat colon. Author(s): Suzuki T, Sakai H, Ikari A, Takeguchi N. Source: The Journal of Pharmacology and Experimental Therapeutics. 2000 October; 295(1): 233-8. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10991984&dopt=Abstract

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INR elevation associated with diarrhea in a patient receiving warfarin. Author(s): Smith JK, Aljazairi A, Fuller SH. Source: The Annals of Pharmacotherapy. 1999 March; 33(3): 301-4. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10200853&dopt=Abstract

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Intestinal alkalization as a possible preventive mechanism in irinotecan (CPT-11)-induced diarrhea. Author(s): Ikegami T, Ha L, Arimori K, Latham P, Kobayashi K, Ceryak S, Matsuzaki Y, Bouscarel B. Source: Cancer Research. 2002 January 1; 62(1): 179-87. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11782376&dopt=Abstract

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Lack of oncogenicity of wood creosote, the principal active ingredient of Seirogan, an herbal antidiarrheal medication, in Sprague-Dawley rats. Author(s): Kuge T, Shibata T, Willett MS, Turck P, Traul KA. Source: International Journal of Toxicology. 2001 September-October; 20(5): 297-305. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11766127&dopt=Abstract

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Lactobacillus therapy for acute infectious diarrhea in children: a metaanalysis. Author(s): Van Niel CW, Feudtner C, Garrison MM, Christakis DA.

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Source: Pediatrics. 2002 April; 109(4): 678-84. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11927715&dopt=Abstract ·

Life-threatening Clostridium difficile-associated diarrhea induced by paclitaxel-carboplatin combination chemotherapy. Author(s): Yamazawa K, Kanno H, Seki K, Kuzuta T, Matsui H, Sekiya S. Source: Acta Obstetricia Et Gynecologica Scandinavica. 2001 August; 80(8): 768-9. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11531624&dopt=Abstract

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Management of protease inhibitor-associated diarrhea. Author(s): Sherman DS, Fish DN. Source: Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America. 2000 June; 30(6): 908-14. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10854364&dopt=Abstract

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Managing nausea, vomiting, and diarrhea. Author(s): Highleyman L. Source: Beta. 2002 Spring; 15(2): 29-39. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=12064304&dopt=Abstract

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Modified irinotecan hydrochloride (CPT-11) administration schedule improves induction of delayed-onset diarrhea in rats. Author(s): Kurita A, Kado S, Kaneda N, Onoue M, Hashimoto S, Yokokura T. Source: Cancer Chemotherapy and Pharmacology. 2000; 46(3): 211-20. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11021738&dopt=Abstract

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Modified starch enhances absorption and accelerates recovery in experimental diarrhea in rats. Author(s): Wingertzahn MA, Teichberg S, Wapnir RA. Source: Pediatric Research. 1999 March; 45(3): 397-402. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10088661&dopt=Abstract

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Modulation of irinotecan-induced diarrhea by cotreatment with neomycin in cancer patients.

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Author(s): Kehrer DF, Sparreboom A, Verweij J, de Bruijn P, Nierop CA, van de Schraaf J, Ruijgrok EJ, de Jonge MJ. Source: Clinical Cancer Research : an Official Journal of the American Association for Cancer Research. 2001 May; 7(5): 1136-41. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11350876&dopt=Abstract ·

Patterns of health seeking behavior during episodes of childhood diarrhea: a study of Tzotzil-speaking Mayans in the highlands of Chiapas, Mexico. Author(s): Granich R, Cantwell MF, Long K, Maldonado Y, Parsonnet J. Source: Social Science & Medicine (1982). 1999 February; 48(4): 489-95. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10075174&dopt=Abstract

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Prevention of diarrhea and pneumonia by zinc supplementation in children in developing countries: pooled analysis of randomized controlled trials. Zinc Investigators' Collaborative Group. Author(s): Bhutta ZA, Black RE, Brown KH, Gardner JM, Gore S, Hidayat A, Khatun F, Martorell R, Ninh NX, Penny ME, Rosado JL, Roy SK, Ruel M, Sazawal S, Shankar A. Source: The Journal of Pediatrics. 1999 December; 135(6): 689-97. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10586170&dopt=Abstract

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Prevention of irinotecan (CPT-11)-induced diarrhea by oral alkalization combined with control of defecation in cancer patients. Author(s): Takeda Y, Kobayashi K, Akiyama Y, Soma T, Handa S, Kudoh S, Kudo K. Source: International Journal of Cancer. Journal International Du Cancer. 2001 April 15; 92(2): 269-75. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11291056&dopt=Abstract

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Randomized clinical trial of soy formula with and without added fiber in antibiotic-induced diarrhea. Author(s): Burks AW, Vanderhoof JA, Mehra S, Ostrom KM, Baggs G. Source: The Journal of Pediatrics. 2001 October; 139(4): 578-82. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11598607&dopt=Abstract

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Randomized comparison of prophylactic antidiarrheal treatment versus no prophylactic antidiarrheal treatment in patients receiving CPT-11 (irinotecan) for advanced 5-FU-resistant colorectal cancer: an open-label multicenter phase II study. Author(s): Ychou M, Douillard JY, Rougier P, Adenis A, Mousseau M, Dufour P, Wendling JL, Burki F, Mignard D, Marty M. Source: American Journal of Clinical Oncology : the Official Publication of the American Radium Society. 2000 April; 23(2): 143-8. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10776974&dopt=Abstract

·

Randomized, community-based trial of the effect of zinc supplementation, with and without other micronutrients, on the duration of persistent childhood diarrhea in Lima, Peru. Author(s): Penny ME, Peerson JM, Marin RM, Duran A, Lanata CF, Lonnerdal B, Black RE, Brown KH. Source: The Journal of Pediatrics. 1999 August; 135(2 Pt 1): 208-17. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10431116&dopt=Abstract

·

Severe CPT-11-induced diarrhea in presence of FK-506 following liver transplantation for hepatocellular carcinoma. Author(s): Gornet JM, Lokiec F, Duclos-Vallee JC, Azoulay D, Goldwasser F. Source: Anticancer Res. 2001 November-December; 21(6A): 4203-6. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11911319&dopt=Abstract

·

Substantial activity of budesonide in patients with irinotecan (CPT-11) and 5-fluorouracil induced diarrhea and failure of loperamide treatment. Author(s): Lenfers BH, Loeffler TM, Droege CM, Hausamen TU. Source: Annals of Oncology : Official Journal of the European Society for Medical Oncology / Esmo. 1999 October; 10(10): 1251-3. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10586346&dopt=Abstract

·

Substantial reduction in severe diarrheal morbidity by daily zinc supplementation in young north Indian children. Author(s): Bhandari N, Bahl R, Taneja S, Strand T, Molbak K, Ulvik RJ, Sommerfelt H, Bhan MK.

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Source: Pediatrics. 2002 June; 109(6): E86. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=12042580&dopt=Abstract ·

Testing control of radiation-induced diarrhea with a psyllium bulking agent: a pilot study. Author(s): Murphy J, Stacey D, Crook J, Thompson B, Panetta D. Source: Can Oncol Nurs J. 2000 Summer; 10(3): 96-100. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11894282&dopt=Abstract

·

Thalidomide and irinotecan-associated diarrhea. Author(s): Tchekmedyian NS. Source: American Journal of Clinical Oncology : the Official Publication of the American Radium Society. 2002 June; 25(3): 324. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=12040298&dopt=Abstract

·

The beneficial effects of weekly low-dose vitamin A supplementation on acute lower respiratory infections and diarrhea in Ecuadorian children. Author(s): Sempertegui F, Estrella B, Camaniero V, Betancourt V, Izurieta R, Ortiz W, Fiallo E, Troya S, Rodriguez A, Griffiths JK. Source: Pediatrics. 1999 July; 104(1): E1. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10390287&dopt=Abstract

·

The impact of infant feeding patterns on infection and diarrheal disease due to enterotoxigenic Escherichia coli. Author(s): Long K, Vasquez-Garibay E, Mathewson J, de la Cabada J, DuPont H. Source: Salud Publica Mex. 1999 July-August; 41(4): 263-70. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10624137&dopt=Abstract

·

Therapeutic response to octreotide in patients with refractory CPT-11 induced diarrhea. Author(s): Pro B, Lozano R, Ajani JA.

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Source: Investigational New Drugs. 2001; 19(4): 341-3. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11561696&dopt=Abstract ·

Treatment of chronic idiopathic large-bowel diarrhea in dogs with a highly digestible diet and soluble fiber: a retrospective review of 37 cases. Author(s): Leib MS. Source: J Vet Intern Med. 2000 January-February; 14(1): 27-32. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10668813&dopt=Abstract

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Treatment of gastric ulcers and diarrhea with the Amazonian herbal medicine sangre de grado. Author(s): Miller MJ, MacNaughton WK, Zhang XJ, Thompson JH, Charbonnet RM, Bobrowski P, Lao J, Trentacosti AM, Sandoval M. Source: American Journal of Physiology. Gastrointestinal and Liver Physiology. 2000 July; 279(1): G192-200. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10898763&dopt=Abstract

·

Treatment of senile diabetic diarrhea with traditional Chinese drugs. Author(s): Weng J. Source: J Tradit Chin Med. 1999 December; 19(4): 264-7. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10921129&dopt=Abstract

·

Untractable diarrhea due to late onset celiac disease of the adult following pancreatoduodenectomy. Author(s): Boggi U, Bellini R, Rossetti E, Pietrabissa A, Mosca F. Source: Hepatogastroenterology. 2001 July-August; 48(40): 1030-2. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11490792&dopt=Abstract

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Use of a chinese herbal medicine for treatment of hiv-associated pathogen-negative diarrhea. Author(s): Cohen MR, Mitchell TF, Bacchetti P, Child C, Crawford S, Gaeddert A, Abrams DI.

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Source: Integr. Med. 2000 March 21; 2(2): 79-84. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10882880&dopt=Abstract ·

Vitamin A supplementation in acute diarrhea. Author(s): Yurdakok K, Ozmert E, Yalcin SS, Laleli Y. Source: Journal of Pediatric Gastroenterology and Nutrition. 2000 September; 31(3): 234-7. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10997364&dopt=Abstract

·

Vitamin A supplementation of South African children with severe diarrhea: optimum timing for improving biochemical and clinical recovery and subsequent vitamin A status. Author(s): Rollins NC, Filteau SM, Elson I, Tomkins AM. Source: The Pediatric Infectious Disease Journal. 2000 April; 19(4): 284-9. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10783015&dopt=Abstract

·

Zinc supplementation in malnourished children with persistent diarrhea in Pakistan. Author(s): Bhutta ZA, Nizami SQ, Isani Z. Source: Pediatrics. 1999 April; 103(4): E42. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10103334&dopt=Abstract

Additional Web Resources A number of additional Web sites offer encyclopedic information covering CAM and related topics. The following is a representative sample: ·

Alternative Medicine Foundation, Inc.: http://www.herbmed.org/

·

AOL: http://search.aol.com/cat.adp?id=169&layer=&from=subcats

·

Chinese Medicine: http://www.newcenturynutrition.com/

·

drkoop.comÒ: http://www.drkoop.com/InteractiveMedicine/IndexC.html

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Family Village: http://www.familyvillage.wisc.edu/med_altn.htm

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Google: http://directory.google.com/Top/Health/Alternative/

·

Healthnotes: http://www.thedacare.org/healthnotes/

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·

Open Directory Project: http://dmoz.org/Health/Alternative/

·

TPN.com: http://www.tnp.com/

·

Yahoo.com: http://dir.yahoo.com/Health/Alternative_Medicine/

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WebMDÒHealth: http://my.webmd.com/drugs_and_herbs

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WellNet: http://www.wellnet.ca/herbsa-c.htm

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WholeHealthMD.com: http://www.wholehealthmd.com/reflib/0,1529,,00.html

General References A good place to find general background information on CAM is the National Library of Medicine. It has prepared within the MEDLINEplus system an information topic page dedicated to complementary and alternative medicine. To access this page, go to the MEDLINEplus site at: www.nlm.nih.gov/medlineplus/alternativemedicine.html. This Web site provides a general overview of various topics and can lead to a number of general sources. The following additional references describe, in broad terms, alternative and complementary medicine (sorted alphabetically by title; hyperlinks provide rankings, information, and reviews at Amazon.com): ·

Gastrointestinal Disorders and Nutrition by Tonia Reinhard; Paperback - 192 pages (January 24, 2002), McGraw-Hill Professional Publishing; ISBN: 0737303611; http://www.amazon.com/exec/obidos/ASIN/0737303611/icongroupinter na

·

Healthy Digestion the Natural Way: Preventing and Healing Heartburn, Constipation, Gas, Diarrhea, Inflammatory Bowel and Gallbladder Diseases, Ulcers, Irritable Bowel Syndrome, and More by D. Lindsey Berkson, et al; Paperback - 256 pages, 1st edition (February 2000), John Wiley & Sons; ISBN: 0471349623; http://www.amazon.com/exec/obidos/ASIN/0471349623/icongroupinter na

·

No More Heartburn: Stop the Pain in 30 Days--Naturally!: The Safe, Effective Way to Prevent and Heal Chronic Gastrointestinal Disorders by Sherry A. Rogers, M.D.; Paperback - 320 pages (February 2000), Kensington Publishing Corp.; ISBN: 1575665107; http://www.amazon.com/exec/obidos/ASIN/1575665107/icongroupinter na

Researching Alternative Medicine 233

For additional information on complementary and alternative medicine, ask your doctor or write to: National Institutes of Health National Center for Complementary and Alternative Medicine Clearinghouse P. O. Box 8218 Silver Spring, MD 20907-8218

Researching Nutrition 235

APPENDIX C. RESEARCHING NUTRITION Overview Since the time of Hippocrates, doctors have understood the importance of diet and nutrition to patients’ health and well-being. Since then, they have accumulated an impressive archive of studies and knowledge dedicated to this subject. Based on their experience, doctors and healthcare providers may recommend particular dietary supplements to patients with diarrhea. Any dietary recommendation is based on a patient’s age, body mass, gender, lifestyle, eating habits, food preferences, and health condition. It is therefore likely that different patients with diarrhea may be given different recommendations. Some recommendations may be directly related to diarrhea, while others may be more related to the patient’s general health. These recommendations, themselves, may differ from what official sources recommend for the average person. In this chapter we will begin by briefly reviewing the essentials of diet and nutrition that will broadly frame more detailed discussions of diarrhea. We will then show you how to find studies dedicated specifically to nutrition and diarrhea.

Food and Nutrition: General Principles What Are Essential Foods? Food is generally viewed by official sources as consisting of six basic elements: (1) fluids, (2) carbohydrates, (3) protein, (4) fats, (5) vitamins, and (6) minerals. Consuming a combination of these elements is considered to be a healthy diet:

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·

Fluids are essential to human life as 80-percent of the body is composed of water. Water is lost via urination, sweating, diarrhea, vomiting, diuretics (drugs that increase urination), caffeine, and physical exertion.

·

Carbohydrates are the main source for human energy (thermoregulation) and the bulk of typical diets. They are mostly classified as being either simple or complex. Simple carbohydrates include sugars which are often consumed in the form of cookies, candies, or cakes. Complex carbohydrates consist of starches and dietary fibers. Starches are consumed in the form of pastas, breads, potatoes, rice, and other foods. Soluble fibers can be eaten in the form of certain vegetables, fruits, oats, and legumes. Insoluble fibers include brown rice, whole grains, certain fruits, wheat bran and legumes.

·

Proteins are eaten to build and repair human tissues. Some foods that are high in protein are also high in fat and calories. Food sources for protein include nuts, meat, fish, cheese, and other dairy products.

·

Fats are consumed for both energy and the absorption of certain vitamins. There are many types of fats, with many general publications recommending the intake of unsaturated fats or those low in cholesterol.

Vitamins and minerals are fundamental to human health, growth, and, in some cases, disease prevention. Most are consumed in your diet (exceptions being vitamins K and D which are produced by intestinal bacteria and sunlight on the skin, respectively). Each vitamin and mineral plays a different role in health. The following outlines essential vitamins: ·

Vitamin A is important to the health of your eyes, hair, bones, and skin; sources of vitamin A include foods such as eggs, carrots, and cantaloupe.

·

Vitamin B1, also known as thiamine, is important for your nervous system and energy production; food sources for thiamine include meat, peas, fortified cereals, bread, and whole grains.

·

Vitamin B2, also known as riboflavin, is important for your nervous system and muscles, but is also involved in the release of proteins from nutrients; food sources for riboflavin include dairy products, leafy vegetables, meat, and eggs.

·

Vitamin B3, also known as niacin, is important for healthy skin and helps the body use energy; food sources for niacin include peas, peanuts, fish, and whole grains

·

Vitamin B6, also known as pyridoxine, is important for the regulation of cells in the nervous system and is vital for blood formation; food sources for pyridoxine include bananas, whole grains, meat, and fish.

Researching Nutrition 237

·

Vitamin B12 is vital for a healthy nervous system and for the growth of red blood cells in bone marrow; food sources for vitamin B12 include yeast, milk, fish, eggs, and meat.

·

Vitamin C allows the body’s immune system to fight various diseases, strengthens body tissue, and improves the body’s use of iron; food sources for vitamin C include a wide variety of fruits and vegetables.

·

Vitamin D helps the body absorb calcium which strengthens bones and teeth; food sources for vitamin D include oily fish and dairy products.

·

Vitamin E can help protect certain organs and tissues from various degenerative diseases; food sources for vitamin E include margarine, vegetables, eggs, and fish.

·

Vitamin K is essential for bone formation and blood clotting; common food sources for vitamin K include leafy green vegetables.

·

Folic Acid maintains healthy cells and blood and, when taken by a pregnant woman, can prevent her fetus from developing neural tube defects; food sources for folic acid include nuts, fortified breads, leafy green vegetables, and whole grains.

It should be noted that one can overdose on certain vitamins which become toxic if consumed in excess (e.g. vitamin A, D, E and K). Like vitamins, minerals are chemicals that are required by the body to remain in good health. Because the human body does not manufacture these chemicals internally, we obtain them from food and other dietary sources. The more important minerals include: ·

Calcium is needed for healthy bones, teeth, and muscles, but also helps the nervous system function; food sources for calcium include dry beans, peas, eggs, and dairy products.

·

Chromium is helpful in regulating sugar levels in blood; food sources for chromium include egg yolks, raw sugar, cheese, nuts, beets, whole grains, and meat.

·

Fluoride is used by the body to help prevent tooth decay and to reinforce bone strength; sources of fluoride include drinking water and certain brands of toothpaste.

·

Iodine helps regulate the body’s use of energy by synthesizing into the hormone thyroxine; food sources include leafy green vegetables, nuts, egg yolks, and red meat.

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·

Iron helps maintain muscles and the formation of red blood cells and certain proteins; food sources for iron include meat, dairy products, eggs, and leafy green vegetables.

·

Magnesium is important for the production of DNA, as well as for healthy teeth, bones, muscles, and nerves; food sources for magnesium include dried fruit, dark green vegetables, nuts, and seafood.

·

Phosphorous is used by the body to work with calcium to form bones and teeth; food sources for phosphorous include eggs, meat, cereals, and dairy products.

·

Selenium primarily helps maintain normal heart and liver functions; food sources for selenium include wholegrain cereals, fish, meat, and dairy products.

·

Zinc helps wounds heal, the formation of sperm, and encourage rapid growth and energy; food sources include dried beans, shellfish, eggs, and nuts.

The United States government periodically publishes recommended diets and consumption levels of the various elements of food. Again, your doctor may encourage deviations from the average official recommendation based on your specific condition. To learn more about basic dietary guidelines, visit the Web site: http://www.health.gov/dietaryguidelines/. Based on these guidelines, many foods are required to list the nutrition levels on the food’s packaging. Labeling Requirements are listed at the following site maintained by the Food and Drug Administration: http://www.cfsan.fda.gov/~dms/labcons.html. When interpreting these requirements, the government recommends that consumers become familiar with the following abbreviations before reading FDA literature:48 ·

DVs (Daily Values): A new dietary reference term that will appear on the food label. It is made up of two sets of references, DRVs and RDIs.

·

DRVs (Daily Reference Values): A set of dietary references that applies to fat, saturated fat, cholesterol, carbohydrate, protein, fiber, sodium, and potassium.

·

RDIs (Reference Daily Intakes): A set of dietary references based on the Recommended Dietary Allowances for essential vitamins and minerals and, in selected groups, protein. The name “RDI” replaces the term “U.S. RDA.”

48

Adapted from the FDA: http://www.fda.gov/fdac/special/foodlabel/dvs.html.

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·

RDAs (Recommended Dietary Allowances): A set of estimated nutrient allowances established by the National Academy of Sciences. It is updated periodically to reflect current scientific knowledge. What Are Dietary Supplements?49

Dietary supplements are widely available through many commercial sources, including health food stores, grocery stores, pharmacies, and by mail. Dietary supplements are provided in many forms including tablets, capsules, powders, gel-tabs, extracts, and liquids. Historically in the United States, the most prevalent type of dietary supplement was a multivitamin/mineral tablet or capsule that was available in pharmacies, either by prescription or “over the counter.” Supplements containing strictly herbal preparations were less widely available. Currently in the United States, a wide array of supplement products are available, including vitamin, mineral, other nutrients, and botanical supplements as well as ingredients and extracts of animal and plant origin. The Office of Dietary Supplements (ODS) of the National Institutes of Health is the official agency of the United States which has the expressed goal of acquiring “new knowledge to help prevent, detect, diagnose, and treat disease and disability, from the rarest genetic disorder to the common cold.”50 According to the ODS, dietary supplements can have an important impact on the prevention and management of disease and on the maintenance of health.51 The ODS notes that considerable research on the effects of dietary supplements has been conducted in Asia and Europe where the use of plant products, in particular, has a long tradition. However, the overwhelming majority of supplements have not been studied scientifically. To explore the role of dietary supplements in the improvement of health care, the ODS plans, organizes, and supports conferences, workshops, and symposia on scientific topics related to dietary supplements. The ODS often This discussion has been adapted from the NIH: http://ods.od.nih.gov/whatare/whatare.html. 50 Contact: The Office of Dietary Supplements, National Institutes of Health, Building 31, Room 1B29, 31 Center Drive, MSC 2086, Bethesda, Maryland 20892-2086, Tel: (301) 435-2920, Fax: (301) 480-1845, E-mail: [email protected]. 51 Adapted from http://ods.od.nih.gov/about/about.html. The Dietary Supplement Health and Education Act defines dietary supplements as “a product (other than tobacco) intended to supplement the diet that bears or contains one or more of the following dietary ingredients: a vitamin, mineral, amino acid, herb or other botanical; or a dietary substance for use to supplement the diet by increasing the total dietary intake; or a concentrate, metabolite, constituent, extract, or combination of any ingredient described above; and intended for ingestion in the form of a capsule, powder, softgel, or gelcap, and not represented as a conventional food or as a sole item of a meal or the diet.” 49

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works in conjunction with other NIH Institutes and Centers, other government agencies, professional organizations, and public advocacy groups. To learn more about official information on dietary supplements, visit the ODS site at http://ods.od.nih.gov/whatare/whatare.html. Or contact: The Office of Dietary Supplements National Institutes of Health Building 31, Room 1B29 31 Center Drive, MSC 2086 Bethesda, Maryland 20892-2086 Tel: (301) 435-2920 Fax: (301) 480-1845 E-mail: [email protected]

Finding Studies on Diarrhea The NIH maintains an office dedicated to patient nutrition and diet. The National Institutes of Health’s Office of Dietary Supplements (ODS) offers a searchable bibliographic database called the IBIDS (International Bibliographic Information on Dietary Supplements). The IBIDS contains over 460,000 scientific citations and summaries about dietary supplements and nutrition as well as references to published international, scientific literature on dietary supplements such as vitamins, minerals, and botanicals.52 IBIDS is available to the public free of charge through the ODS Internet page: http://ods.od.nih.gov/databases/ibids.html. After entering the search area, you have three choices: (1) IBIDS Consumer Database, (2) Full IBIDS Database, or (3) Peer Reviewed Citations Only. We recommend that you start with the Consumer Database. While you may not find references for the topics that are of most interest to you, check back periodically as this database is frequently updated. More studies can be found by searching the Full IBIDS Database. Healthcare professionals and researchers generally use the third option, which lists peer-reviewed citations. In all cases, we suggest that you take advantage of the “Advanced Search” option that allows you to retrieve up to 100 fully explained Adapted from http://ods.od.nih.gov. IBIDS is produced by the Office of Dietary Supplements (ODS) at the National Institutes of Health to assist the public, healthcare providers, educators, and researchers in locating credible, scientific information on dietary supplements. IBIDS was developed and will be maintained through an interagency partnership with the Food and Nutrition Information Center of the National Agricultural Library, U.S. Department of Agriculture.

52

Researching Nutrition 241

references in a comprehensive format. Type “diarrhea” (or synonyms) into the search box. To narrow the search, you can also select the “Title” field. The following is a typical result when searching for recently indexed consumer information on diarrhea: ·

Antibiotic-associated diarrhea. It can be serious. Source: Anonymous Mayo-Clin-Health-Lett. 1999 July; 17(7): 6 0741-6245

·

Cholesterol absorption and cholesterol and bile acid synthesis in two brothers with IDDM and diarrhea. Author(s): Second Department of Medicine, University of Helsinki, Finland. Source: Gylling, H Miettinen, T A Diabetes-Care. 1994 November; 17(11): 1345-7 0149-5992

·

Cola drinks for rehydration--not recommended for diarrhea. Source: Nutr-M-D. Van Nuys, Calif. : The Journal. January 1987. volume 13 (1) page 5. charts. 0732-0167

·

Diarrhea and malabsorption associated with the acquired immunodeficiency syndrome (AIDS). Source: Nutrition-reviews (USA). (August 1985). volume 43(8) page 235237. immunological diseases digestive disorders diarrhoea digestive system diseases men 0029-6643

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Diarrhea complicating enteral feeding after liver transplantation. Author(s): Department of Medicine, University of Illinois, Chicago 60612. Source: Benya, R Damle, P Mobarhan, S Nutr-Revolume 1990 March; 48(3): 148-52 0029-6643

·

Diarrhea induced by enteral feeding. Author(s): Loyola University Medical Center, Loyola University, Maywood, IL, USA. Source: Mobarhan, S DeMeo, M Nutr-Revolume 1995 March; 53(3): 67-70 0029-6643

·

Effect of acute diarrheal disease on infants' dietary intake. Source: Anonymous Nutr-Revolume 1991 July; 49(7): 211-3 0029-6643

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Feeding during diarrhea. Source: Nutrition-reviews (USA). (March 1986). volume 44(3) page 102. therapeutic diets diarrhoea children nutritional requirements rehydration 0029-6643

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Infant formulas designed for treatment of protracted diarrhea. Source: Anonymous Nutr-Revolume 1988 November; 46(11): 376-9 00296643

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Looking at dietary effects on weight loss and diarrhea in HIV seropositive patients: a pilot project. Source: Cheung, N Nutr-Health. 1995; 10(3): 201-2 0260-1060

·

Nutritional therapy for infants with diarrhea. Author(s): Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030. Source: Lifschitz, C H Shulman, R J Nutr-Revolume 1990 September; 48(9): 329-38 0029-6643

·

Oral rehydration solution therapy in the management of children with rotavirus diarrhea. Author(s): College of Veterinary Medicine, University of MissouriColumbia 65212, USA. Source: Nappert, G Barrios, J M Zello, G A Naylor, J M Nutr-Revolume 2000 March; 58(3 Pt 1): 80-7 0029-6643

· The best way to treat your child's diarrhea. Source: Tufts-Univ-Diet-Nutr-Lett. New York, N.Y. : The Letter. April 1990. volume 8 (2) page 7-8.

Federal Resources on Nutrition In addition to the IBIDS, the United States Department of Health and Human Services (HHS) and the United States Department of Agriculture (USDA) provide many sources of information on general nutrition and health. Recommended resources include: ·

healthfinder®, HHS’s gateway to health information, including diet and nutrition: http://www.healthfinder.gov/scripts/SearchContext.asp?topic=238&pag e=0

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The United States Department of Agriculture’s Web site dedicated to nutrition information: www.nutrition.gov

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The Food and Drug Administration’s Web site for federal food safety information: www.foodsafety.gov

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The National Action Plan on Overweight and Obesity sponsored by the United States Surgeon General: http://www.surgeongeneral.gov/topics/obesity/

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The Center for Food Safety and Applied Nutrition has an Internet site sponsored by the Food and Drug Administration and the Department of Health and Human Services: http://vm.cfsan.fda.gov/

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·

Center for Nutrition Policy and Promotion sponsored by the United States Department of Agriculture: http://www.usda.gov/cnpp/

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Food and Nutrition Information Center, National Agricultural Library sponsored by the United States Department of Agriculture: http://www.nal.usda.gov/fnic/

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Food and Nutrition Service sponsored by the United States Department of Agriculture: http://www.fns.usda.gov/fns/

Additional Web Resources A number of additional Web sites offer encyclopedic information covering food and nutrition. The following is a representative sample: ·

AOL: http://search.aol.com/cat.adp?id=174&layer=&from=subcats

·

Family Village: http://www.familyvillage.wisc.edu/med_nutrition.html

·

Google: http://directory.google.com/Top/Health/Nutrition/

·

Healthnotes: http://www.thedacare.org/healthnotes/

·

Open Directory Project: http://dmoz.org/Health/Nutrition/

·

Yahoo.com: http://dir.yahoo.com/Health/Nutrition/

·

WebMDÒHealth: http://my.webmd.com/nutrition

·

WholeHealthMD.com: http://www.wholehealthmd.com/reflib/0,1529,,00.html

Vocabulary Builder The following vocabulary builder defines words used in the references in this chapter that have not been defined in previous chapters: Overdose: 1. to administer an excessive dose. 2. an excessive dose. [EU] Riboflavin: Nutritional factor found in milk, eggs, malted barley, liver, kidney, heart, and leafy vegetables. The richest natural source is yeast. It occurs in the free form only in the retina of the eye, in whey, and in urine; its principal forms in tissues and cells are as FMN and FAD. [NIH] Thermoregulation: Heat regulation. [EU] Thyroxine: An amino acid of the thyroid gland which exerts a stimulating effect on thyroid metabolism. [NIH]

Finding Medical Libraries 245

APPENDIX D. FINDING MEDICAL LIBRARIES Overview At a medical library you can find medical texts and reference books, consumer health publications, specialty newspapers and magazines, as well as medical journals. In this Appendix, we show you how to quickly find a medical library in your area.

Preparation Before going to the library, highlight the references mentioned in this sourcebook that you find interesting. Focus on those items that are not available via the Internet, and ask the reference librarian for help with your search. He or she may know of additional resources that could be helpful to you. Most importantly, your local public library and medical libraries have Interlibrary Loan programs with the National Library of Medicine (NLM), one of the largest medical collections in the world. According to the NLM, most of the literature in the general and historical collections of the National Library of Medicine is available on interlibrary loan to any library. NLM’s interlibrary loan services are only available to libraries. If you would like to access NLM medical literature, then visit a library in your area that can request the publications for you.53

53

Adapted from the NLM: http://www.nlm.nih.gov/psd/cas/interlibrary.html.

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Finding a Local Medical Library The quickest method to locate medical libraries is to use the Internet-based directory published by the National Network of Libraries of Medicine (NN/LM). This network includes 4626 members and affiliates that provide many services to librarians, health professionals, and the public. To find a library in your area, simply visit http://nnlm.gov/members/adv.html or call 1-800-338-7657.

Medical Libraries Open to the Public In addition to the NN/LM, the National Library of Medicine (NLM) lists a number of libraries that are generally open to the public and have reference facilities. The following is the NLM’s list plus hyperlinks to each library Web site. These Web pages can provide information on hours of operation and other restrictions. The list below is a small sample of libraries recommended by the National Library of Medicine (sorted alphabetically by name of the U.S. state or Canadian province where the library is located):54 ·

Alabama: Health InfoNet of Jefferson County (Jefferson County Library Cooperative, Lister Hill Library of the Health Sciences), http://www.uab.edu/infonet/

·

Alabama: Richard M. Scrushy Library (American Sports Medicine Institute), http://www.asmi.org/LIBRARY.HTM

·

Arizona: Samaritan Regional Medical Center: The Learning Center (Samaritan Health System, Phoenix, Arizona), http://www.samaritan.edu/library/bannerlibs.htm

·

California: Kris Kelly Health Information Center (St. Joseph Health System), http://www.humboldt1.com/~kkhic/index.html

·

California: Community Health Library of Los Gatos (Community Health Library of Los Gatos), http://www.healthlib.org/orgresources.html

·

California: Consumer Health Program and Services (CHIPS) (County of Los Angeles Public Library, Los Angeles County Harbor-UCLA Medical Center Library) - Carson, CA, http://www.colapublib.org/services/chips.html

·

California: Gateway Health Library (Sutter Gould Medical Foundation)

·

California: Health Library (Stanford University Medical Center), http://www-med.stanford.edu/healthlibrary/

54

Abstracted from http://www.nlm.nih.gov/medlineplus/libraries.html.

Finding Medical Libraries 247

·

California: Patient Education Resource Center - Health Information and Resources (University of California, San Francisco), http://sfghdean.ucsf.edu/barnett/PERC/default.asp

·

California: Redwood Health Library (Petaluma Health Care District), http://www.phcd.org/rdwdlib.html

·

California: San José PlaneTree Health Library, http://planetreesanjose.org/

·

California: Sutter Resource Library (Sutter Hospitals Foundation), http://go.sutterhealth.org/comm/resc-library/sac-resources.html

·

California: University of California, Davis. Health Sciences Libraries

·

California: ValleyCare Health Library & Ryan Comer Cancer Resource Center (ValleyCare Health System), http://www.valleycare.com/library.html

·

California: Washington Community Health Resource Library (Washington Community Health Resource Library), http://www.healthlibrary.org/

·

Colorado: William V. Gervasini Memorial Library (Exempla Healthcare), http://www.exempla.org/conslib.htm

·

Connecticut: Hartford Hospital Health Science Libraries (Hartford Hospital), http://www.harthosp.org/library/

·

Connecticut: Healthnet: Connecticut Consumer Health Information Center (University of Connecticut Health Center, Lyman Maynard Stowe Library), http://library.uchc.edu/departm/hnet/

·

Connecticut: Waterbury Hospital Health Center Library (Waterbury Hospital), http://www.waterburyhospital.com/library/consumer.shtml

·

Delaware: Consumer Health Library (Christiana Care Health System, Eugene du Pont Preventive Medicine & Rehabilitation Institute), http://www.christianacare.org/health_guide/health_guide_pmri_health _info.cfm

·

Delaware: Lewis B. Flinn Library (Delaware Academy of Medicine), http://www.delamed.org/chls.html

·

Georgia: Family Resource Library (Medical College of Georgia), http://cmc.mcg.edu/kids_families/fam_resources/fam_res_lib/frl.htm

·

Georgia: Health Resource Center (Medical Center of Central Georgia), http://www.mccg.org/hrc/hrchome.asp

·

Hawaii: Hawaii Medical Library: Consumer Health Information Service (Hawaii Medical Library), http://hml.org/CHIS/

248 Diarrhea

·

Idaho: DeArmond Consumer Health Library (Kootenai Medical Center), http://www.nicon.org/DeArmond/index.htm

·

Illinois: Health Learning Center of Northwestern Memorial Hospital (Northwestern Memorial Hospital, Health Learning Center), http://www.nmh.org/health_info/hlc.html

·

Illinois: Medical Library (OSF Saint Francis Medical Center), http://www.osfsaintfrancis.org/general/library/

·

Kentucky: Medical Library - Services for Patients, Families, Students & the Public (Central Baptist Hospital), http://www.centralbap.com/education/community/library.htm

·

Kentucky: University of Kentucky - Health Information Library (University of Kentucky, Chandler Medical Center, Health Information Library), http://www.mc.uky.edu/PatientEd/

·

Louisiana: Alton Ochsner Medical Foundation Library (Alton Ochsner Medical Foundation), http://www.ochsner.org/library/

·

Louisiana: Louisiana State University Health Sciences Center Medical Library-Shreveport, http://lib-sh.lsuhsc.edu/

·

Maine: Franklin Memorial Hospital Medical Library (Franklin Memorial Hospital), http://www.fchn.org/fmh/lib.htm

·

Maine: Gerrish-True Health Sciences Library (Central Maine Medical Center), http://www.cmmc.org/library/library.html

·

Maine: Hadley Parrot Health Science Library (Eastern Maine Healthcare), http://www.emh.org/hll/hpl/guide.htm

·

Maine: Maine Medical Center Library (Maine Medical Center), http://www.mmc.org/library/

·

Maine: Parkview Hospital, http://www.parkviewhospital.org/communit.htm#Library

·

Maine: Southern Maine Medical Center Health Sciences Library (Southern Maine Medical Center), http://www.smmc.org/services/service.php3?choice=10

·

Maine: Stephens Memorial Hospital Health Information Library (Western Maine Health), http://www.wmhcc.com/hil_frame.html

·

Manitoba, Canada: Consumer & Patient Health Information Service (University of Manitoba Libraries), http://www.umanitoba.ca/libraries/units/health/reference/chis.html

·

Manitoba, Canada: J.W. Crane Memorial Library (Deer Lodge Centre), http://www.deerlodge.mb.ca/library/libraryservices.shtml

Finding Medical Libraries 249

·

Maryland: Health Information Center at the Wheaton Regional Library (Montgomery County, Md., Dept. of Public Libraries, Wheaton Regional Library), http://www.mont.lib.md.us/healthinfo/hic.asp

·

Massachusetts: Baystate Medical Center Library (Baystate Health System), http://www.baystatehealth.com/1024/

·

Massachusetts: Boston University Medical Center Alumni Medical Library (Boston University Medical Center), http://medlibwww.bu.edu/library/lib.html

·

Massachusetts: Lowell General Hospital Health Sciences Library (Lowell General Hospital), http://www.lowellgeneral.org/library/HomePageLinks/WWW.htm

·

Massachusetts: Paul E. Woodard Health Sciences Library (New England Baptist Hospital), http://www.nebh.org/health_lib.asp

·

Massachusetts: St. Luke’s Hospital Health Sciences Library (St. Luke’s Hospital), http://www.southcoast.org/library/

·

Massachusetts: Treadwell Library Consumer Health Reference Center (Massachusetts General Hospital), http://www.mgh.harvard.edu/library/chrcindex.html

·

Massachusetts: UMass HealthNet (University of Massachusetts Medical School), http://healthnet.umassmed.edu/

·

Michigan: Botsford General Hospital Library - Consumer Health (Botsford General Hospital, Library & Internet Services), http://www.botsfordlibrary.org/consumer.htm

·

Michigan: Helen DeRoy Medical Library (Providence Hospital and Medical Centers), http://www.providence-hospital.org/library/

·

Michigan: Marquette General Hospital - Consumer Health Library (Marquette General Hospital, Health Information Center), http://www.mgh.org/center.html

·

Michigan: Patient Education Resouce Center - University of Michigan Cancer Center (University of Michigan Comprehensive Cancer Center), http://www.cancer.med.umich.edu/learn/leares.htm

·

Michigan: Sladen Library & Center for Health Information Resources Consumer Health Information, http://www.sladen.hfhs.org/library/consumer/index.html

·

Montana: Center for Health Information (St. Patrick Hospital and Health Sciences Center), http://www.saintpatrick.org/chi/librarydetail.php3?ID=41

250 Diarrhea

·

National: Consumer Health Library Directory (Medical Library Association, Consumer and Patient Health Information Section), http://caphis.mlanet.org/directory/index.html

·

National: National Network of Libraries of Medicine (National Library of Medicine) - provides library services for health professionals in the United States who do not have access to a medical library, http://nnlm.gov/

·

National: NN/LM List of Libraries Serving the Public (National Network of Libraries of Medicine), http://nnlm.gov/members/

·

Nevada: Health Science Library, West Charleston Library (Las Vegas Clark County Library District), http://www.lvccld.org/special_collections/medical/index.htm

·

New Hampshire: Dartmouth Biomedical Libraries (Dartmouth College Library), http://www.dartmouth.edu/~biomed/resources.htmld/conshealth.htmld /

·

New Jersey: Consumer Health Library (Rahway Hospital), http://www.rahwayhospital.com/library.htm

·

New Jersey: Dr. Walter Phillips Health Sciences Library (Englewood Hospital and Medical Center), http://www.englewoodhospital.com/links/index.htm

·

New Jersey: Meland Foundation (Englewood Hospital and Medical Center), http://www.geocities.com/ResearchTriangle/9360/

·

New York: Choices in Health Information (New York Public Library) NLM Consumer Pilot Project participant, http://www.nypl.org/branch/health/links.html

·

New York: Health Information Center (Upstate Medical University, State University of New York), http://www.upstate.edu/library/hic/

·

New York: Health Sciences Library (Long Island Jewish Medical Center), http://www.lij.edu/library/library.html

·

New York: ViaHealth Medical Library (Rochester General Hospital), http://www.nyam.org/library/

·

Ohio: Consumer Health Library (Akron General Medical Center, Medical & Consumer Health Library), http://www.akrongeneral.org/hwlibrary.htm

·

Oklahoma: Saint Francis Health System Patient/Family Resource Center (Saint Francis Health System), http://www.sfhtulsa.com/patientfamilycenter/default.asp

Finding Medical Libraries 251

·

Oregon: Planetree Health Resource Center (Mid-Columbia Medical Center), http://www.mcmc.net/phrc/

·

Pennsylvania: Community Health Information Library (Milton S. Hershey Medical Center), http://www.hmc.psu.edu/commhealth/

·

Pennsylvania: Community Health Resource Library (Geisinger Medical Center), http://www.geisinger.edu/education/commlib.shtml

·

Pennsylvania: HealthInfo Library (Moses Taylor Hospital), http://www.mth.org/healthwellness.html

·

Pennsylvania: Hopwood Library (University of Pittsburgh, Health Sciences Library System), http://www.hsls.pitt.edu/chi/hhrcinfo.html

·

Pennsylvania: Koop Community Health Information Center (College of Physicians of Philadelphia), http://www.collphyphil.org/kooppg1.shtml

·

Pennsylvania: Learning Resources Center - Medical Library (Susquehanna Health System), http://www.shscares.org/services/lrc/index.asp

·

Pennsylvania: Medical Library (UPMC Health System), http://www.upmc.edu/passavant/library.htm

·

Quebec, Canada: Medical Library (Montreal General Hospital), http://ww2.mcgill.ca/mghlib/

·

South Dakota: Rapid City Regional Hospital - Health Information Center (Rapid City Regional Hospital, Health Information Center), http://www.rcrh.org/education/LibraryResourcesConsumers.htm

·

Texas: Houston HealthWays (Houston Academy of Medicine-Texas Medical Center Library), http://hhw.library.tmc.edu/

·

Texas: Matustik Family Resource Center (Cook Children’s Health Care System), http://www.cookchildrens.com/Matustik_Library.html

·

Washington: Community Health Library (Kittitas Valley Community Hospital), http://www.kvch.com/

·

Washington: Southwest Washington Medical Center Library (Southwest Washington Medical Center), http://www.swmedctr.com/Home/

NIH Consensus Statement on Travelers’ Diarrhea 253

APPENDIX

E. NIH CONSENSUS TRAVELERS’ DIARRHEA

STATEMENT

ON

Overview NIH Consensus Development Conferences are convened to evaluate available scientific information and resolve safety and efficacy issues related to biomedical technology. The resultant NIH Consensus Statements are intended to advance understanding of the technology or issue in question and to be useful to health professionals and the public.55 Each NIH consensus statement is the product of an independent, non-Federal panel of experts and is based on the panel’s assessment of medical knowledge available at the time the statement was written. Therefore, a consensus statement provides a “snapshot in time” of the state of knowledge of the conference topic. The NIH makes the following caveat: “When reading or downloading NIH consensus statements, keep in mind that new knowledge is inevitably accumulating through medical research. Nevertheless, each NIH consensus statement is retained on this website in its original form as a record of the NIH Consensus Development Program.”56 The following concensus statement was posted on the NIH site and not indicated as “out of date” in March 2002. It was originally published, however, in January 1985.57

55 This paragraph is adapted from the NIH: http://odp.od.nih.gov/consensus/cons/cons.htm. 56 Adapted from the NIH: http://odp.od.nih.gov/consensus/cons/consdate.htm. 57 Travelers’ Diarrhea. NIH Consensus Statement Online, 1985 Jan 28-30 [cited 2002 February 19]; 5(8):1-19: http://consensus.nih.gov/cons/048/048_statement.htm.

254 Diarrhea

What Is Travelers’ Diarrhea? Diarrhea is by far the most frequent health problem of travelers to developing countries. Of the estimated 300 million international travelers who will cross the world’s frontiers this year, at least 16 million persons from industrialized countries, including more than 8 million U.S. residents, will travel to developing countries. Approximately one-third of these travelers to developing countries will get diarrhea. The economic impact of travelers’ diarrhea (TD) is substantial, because fear of sickness is one of the major deterrents to tourism. International tourists worldwide spend over $100 billion annually, and the economies of many nations depend on this travel. For educational, recreational, political, and financial reasons, this international exchange should be fostered. The incidence of TD varies markedly by destination and may depend in part on the number of dietary indiscretions made by the traveler and on the style of travel. TD is caused by a variety of infectious agents, and the spectrum of clinical illness varies considerably. However, this illness in travelers is usually not severe; high fever, vomiting, or bloody stools occur only in a minority of cases. Dietary prudence and hygienic measures are safe and simple preventive techniques, but they do not eliminate entirely the risk of diarrhea. Prophylactic measures such as antidiarrheal drugs and oral antimicrobial agents have been used. TD is treated with a variety of regimens, including oral electrolyte solutions, antidiarrheal compounds, and antimicrobial drugs, prescribed either singly or in combination. There continues to be a debate concerning whether the risk of antimicrobial agents is worth the benefit; whether early therapy of ill travelers is preferable to daily prophylaxis of all travelers; whether all currently employed treatment strategies are useful; and whether given groups of travelers, such as vacationers, students, or business travelers, should be selectively advised to follow special regimens. To resolve some of these questions, the NIH Office of Medical Applications of Research and the National Institute of Allergy and Infectious Diseases convened a Consensus Development Conference on Travelers’ Diarrhea on January 28-30, 1985. After 1 1/2 days of expert presentation of the available data, a consensus panel of epidemiologists, biostatisticians, microbiologists, pediatricians, internists, infectious diseases specialists, travel experts, and lay representatives considered the evidence and agreed on answers to the following questions:

NIH Consensus Statement on Travelers’ Diarrhea 255

·

What is the epidemiology of travelers’ diarrhea, and why is it important?

·

What causes travelers’ diarrhea?

·

What prevention measures are effective for travelers’ diarrhea?

·

What treatment measures are effective for travelers’ diarrhea?

·

What should be the direction of future research?

Epidemiology of Travelers’ Diarrhea Travelers’ diarrhea is a syndrome characterized by a twofold or greater increase in the frequency of unformed bowel movements. Commonly associated symptoms include abdominal cramps, nausea, bloating, urgency, fever, and malaise. Episodes of TD usually begin abruptly, occur during travel or soon after returning home, and are generally self-limited. Within this context, travelers at risk are defined as individuals from industrialized countries visiting for a period of up to 1 month a region or country where there is an increased risk of developing diarrhea. The public health and medical importance of TD is related to the large numbers of travelers who place themselves at risk each year. Furthermore, TD is but a mild reflection of the severe underlying problem of diarrhea among children in the tropics. The most important determinant of risk is the destination of the traveler. Attack rates in the range of 20 to 50 percent are commonly reported, but recent data are available from relatively few countries. The best available estimates of country-specific attack rates have been reported for Swiss travelers. Examples of high-risk destinations include most of the developing countries of Latin America, Africa, the Middle East, and Asia. Intermediate risk destinations include most of the Southern European countries and a few Caribbean islands. Low risk destinations include Canada, Northern Europe, Australia, New Zealand, the United States, and a number of the Caribbean islands. TD is slightly more common in young adults than in older people. The reasons for this difference are unclear, but may include a lack of acquired immunity, more adventurous travel styles, and different eating habits. Attack rates are similar in men and women. The most common onset of TD is usually within the first week, but onset may occur at any time during the visit, and even after returning home. TD is acquired through ingestion of fecally contaminated food and/or water. Both cooked and uncooked foods may be implicated if improperly handled.

256 Diarrhea

Especially risky foods include raw vegetables, raw meat, and raw seafood. Tap water ice, unpasteurized milk and dairy products, and unpeeled fruits are associated with increased risk of TD; bottled carbonated beverages (especially flavored beverages), beer, wine, hot coffee or tea, or water boiled or appropriately treated with iodine or chlorine are safe. The eating place appears to be an important variable, with private homes, restaurants, and street vendors listed in order of increasing risk. TD typically results in four to five loose or watery stools per day. The median duration of diarrhea is 3 to 4 days. Ten percent of the cases persist longer than 1 week, approximately 2 percent longer than 1 month, and less than 1 percent longer than 3 months. Persistent diarrhea is thus quite uncommon and may differ considerably from acute TD with respect to etiology and risk factors. Travelers may experience more than one attack of TD during a single trip. Approximately 15 percent experience vomiting, and 2 to 10 percent may have diarrhea accompanied by fever or bloody stools, or both. Rarely is TD life-threatening. In an extensive survey of several hundred thousand Swiss travelers, no deaths could be attributed to TD.

What Causes Travelers’ Diarrhea? Infectious agents are the primary cause of TD. This statement is based on investigations designed to isolate known infectious organisms from diarrheal stools of tourists and on studies that demonstrated the efficacy of antibacterial agents. In addition, induced disease in volunteers has confirmed the causal role of the putative bacterial and viral agents in producing TD. All travelers from industrialized countries going to developing countries quickly develop a rapid, dramatic change in their intestinal flora. These new organisms often include the potential enteric pathogens. Those who develop diarrhea have ingested an inoculum of virulent organisms sufficiently large to overcome individual defense mechanisms, resulting in symptoms.

Enteric Bacterial Pathogens Enterotoxigenic Escherichia coli (ETEC) are the most common causative agents of TD in all countries where surveys have been conducted. The discovery and understanding of the mechanisms of action of cholera enterotoxin led to investigations that demonstrated enterotoxins in E. coli

NIH Consensus Statement on Travelers’ Diarrhea 257

and other bacteria. These organisms adhere in the small intestine, where they multiply and produce an enterotoxin (either heat stable or heat labile) that causes fluid secretion and diarrhea. Identification of the ETEC is a difficult task, requiring sophisticated techniques that remain somewhat insensitive. Other E. coli have different virulence traits. These have been termed enteroadherent, enteroinvasive, and enteropathogenic E. coli. No systematic search for these other E. coli has been conducted in patients with TD. Limited data suggest that they are a minor cause of TD. Salmonella gastroenteritis is a well-known disease that occurs throughout the world. In the industrialized nations, this large group of organisms is the most common cause of outbreaks of food-associated diarrhea. In the developing countries, the proportion of cases of TD caused by salmonellae varies but is not high. Salmonellae also can cause dysentery characterized by bloody mucus-containing small-volume stools. Shigellae are well known as the cause of bacillary dysentery. They cause TD in about 5 to 15 percent of travelers in a few countries. Few of the infected travelers had dysentery, but most had watery diarrhea. Campylobacter jejuni is a common cause of diarrhea throughout the world. Recent, limited data have shown that C. jejuni is responsible for a small percentage of the reported cases of TD, some with bloody diarrhea. Additional studies are needed to determine how frequently it causes TD. Vibrio parahaemolyticus is associated with the ingestion of raw or poorly cooked seafood and has caused TD in Japanese people traveling in Asia. How frequently it causes disease in other areas of the world is unknown. Other potential bacterial pathogens, including Aeromonas hydrophila, Yersinia enterocolitica, Pleisiomonas shigelloides, Vibrio cholerae (non-01), and Vibrio fluvialis, are known to cause diarrhea in children and adults. In Thailand, Aeromonas and Pleisiomonas have been isolated from stools of Peace Corps volunteers who had TD. A better appreciation of the importance of each of these bacteria as causative agents of TD requires a more intensive search for them, using appropriate selective isolation media or rapid diagnostic techniques.

258 Diarrhea

Viral Enteric Pathogens--Rotavirus and Norwalk-Like Virus Along with the newly acquired bacterial flora, many viruses also are acquired. In six studies, for example, 0 to 36 percent of diarrheal illnesses (median 22 percent) were associated with rotaviruses in the stools. However, a comparable number of asymptomatic travelers also had rotaviruses, and up to 50 percent of symptomatic rotavirus infections were associated with nonviral pathogens. Ten to 15 percent of travelers develop a serologic conversion to Norwalk-like viruses. The roles of adenoviruses, astroviruses, coronaviruses, enteroviruses, or other viral agents in causing TD are even less clear. Although viruses are commonly acquired by travelers, they do not appear to be frequent causes of TD in adults.

Parasitic Enteric Pathogens The few studies that have included an examination for parasites reveal that 0 to 9 percent have Giardia lamblia or Entamoeba histolytica. Cryptosporidium has recently been recognized in sporadic cases of TD. Dientamoeba fragilis, Isospora belli, Balantidium coli, or Strongyloides stercoralis may cause occasional cases of TD. While not major causes of acute TD, these parasites should be sought in persisting, unexplained cases.

Unknown Causes No data have been presented to support noninfectious causes of TD such as changes in diet, jet lag, altitude, and fatigue. Current evidence indicates that in all but a few instances (e.g., drug-induced or preexisting gastrointestinal disorders) an infectious agent or agents cause diarrhea in tourists. Even with the application of the best current methods for detecting bacteria, viruses, and parasites, in various studies 20 to 50 percent remain without recognized etiologies. The unrecognized causes may be attributed to: ·

Recognized pathogens that were not uniformly sought in every study (such as Campylobacter, Aeromonas, Yersinia, Pleisiomonas, Vibrios, viruses, and parasites like sp;Cryptosporidium).

·

Unrecognized pathogens.

·

Known bacterial pathogens that were not detected. Our best methods for detecting enterotoxigenic E. coli and Shigella, for example, are insensitive and miss 30 to 40 percent of cases in outbreak or volunteer studies.

NIH Consensus Statement on Travelers’ Diarrhea 259

Effective Prevention Measures for Travelers’ Diarrhea There are four possible approaches to prevention of TD. They include instruction regarding food and beverage preparation, immunization, use of nonantimicrobial medications, and prophylactic antimicrobial drugs. Data indicate that meticulous attention to food and beverage preparation, as mentioned above, can decrease the likelihood of developing TD. Most travelers, however, encounter great difficulty in observing the requisite dietary restrictions. No available vaccines and none that are expected to be available in the next 5 years are effective against TD. Several nonantimicrobial agents have been advocated for prevention of TD. Available controlled studies indicate that prophylactic use of difenoxine, the active metabolite of diphenoxylate (Lomotil), actually increases the incidence of TD, in addition to producing other undesirable side effects. No antiperistaltic agents (e.g., Lomotil and Imodium) are effective in preventing TD. No data support the prophylactic use of activated charcoal. Bismuth subsalicylate, taken in liquid form as the active ingredient of PeptoBismol (2 oz four times daily), has decreased the incidence of diarrhea by 60 percent in one study. Available data are not extensive enough to exclude a risk to the traveler from the use of such large doses of bismuth subsalicylate over a period of several weeks. In patients already taking salicylates for arthritis, large concurrent doses of bismuth subsalicylate can produce toxic serum concentrations of salicylate. On the basis of its modest potential benefit achieved with large doses, together with its uncertain risks, bismuth subsalicylate is not recommended for prophylaxis of TD. Controlled data are available on the prophylactic value of several antimicrobial drugs. Entero-vioform and related halogenated hydroxyquinoline derivatives (e.g., clioquinol, iodoquinol, Mexaform, Intestopan, and others) are not helpful in preventing TD, may have serious neurological side effects, and should never be used for prophylaxis of TD. Carefully controlled studies have indicated that two agents, doxycycline and trimethoprim/sulfamethoxazole (TMP/SMX), when taken prophylactically, are consistently effective in reducing the incidence of TD by 50 to 86 percent in various areas of the developing world. One study shows that trimethoprim alone is also effective.

260 Diarrhea

The benefits of widespread prophylactic use of doxycycline or TMP/SMX or TMP alone in several million travelers must be weighed against the potential drawbacks. The known risks include allergic and other side effects (such as common skin rashes, photosensitivity of the skin, blood disorders, StevensJohnson syndrome, and staining of the teeth in children) as well as other infections that may be induced by antimicrobial therapy (such as antibioticassociated colitis, Candida vaginitis, and possibly salmonella enteritis). Because of the uncertain risk of widespread administration of these antimicrobial agents, their prophylactic use is not recommended. Nor is there any basis for recommending their use prophylactically for special groups of travelers. For example, the physician should not recommend an agent for prophylactic use by a business traveler and deny such use by a honeymoon couple. Furthermore, there is no documented evidence that there are any groups of disease entities that are worsened sufficiently by an episode of TD to risk the rare undesirable side effects of prophylactic antimicrobial drugs. The selective pressure of prophylactic use of antimicrobial agents on the genetic pool of antimicrobial resistance is of concern, but may be insignificant in light of the widespread use of over-the-counter antimicrobial agents in many developing countries. The increasing frequency of resistance to multiple antimicrobial agents (including both doxycycline and TMP/SMX) will limit the effectiveness of these agents in many areas. Available data support only the instruction of travelers in regard to sensible dietary practices as a prophylactic measure. On the basis of apparent risk/benefit ratios, prophylactic antimicrobial agents are not recommended for travelers. This recommendation is justified by the excellent results of early treatment of TD as outlined below. By avoiding prophylactic antimicrobial agents, only those people traveling to high-risk areas who develop moderate to severe TD (less than 30 percent of travelers at risk) will be exposed to the side effects of antimicrobial agents, and the exposure will be restricted to 3 days or fewer in those individuals. Some travelers may wish to consult with their physician and may elect to use prophylactic antimicrobial agents for travel under special circumstances, once the risks and benefits are clearly understood.

Effective Treatment Measures for Travelers’ Diarrhea The individuals with TD have two major complaints for which they desire relief--abdominal cramps and diarrhea. Many agents have been proposed to

NIH Consensus Statement on Travelers’ Diarrhea 261

control these symptoms, but few have been demonstrated to be effective by rigorous clinical trials.

Nonspecific Agents A variety of “adsorbents” have been used in the treatment of diarrhea. For example, activated charcoal has been found ineffective in the treatment of diarrhea. Kaolin and pectin have been widely used for diarrhea. The combination appears to give the stools more consistency but has not been shown to decrease cramps and frequency of stools nor to shorten the course of infectious diarrhea. Lactobacillus preparations and yogurt have also been advocated, but no evidence supports these treatments for TD. Bismuth subsalicylate preparation (1 oz every 30 minutes for eight doses) decreased the rate of stooling by one-half in a study of travelers with diarrhea when compared with a placebo group. However, there was no difference between the two groups in stool output in the first four hours of the study. There is concern about taking, without supervision, large amounts of bismuth and salicylate, especially in individuals who may be intolerant to salicylates, who have renal insufficiency, or who take salicylates for other reasons.

Antimotility Agents Antimotility agents are widely used in the treatment of diarrhea of all types. Natural opiates (paregoric, deodorized tincture of opium, and codeine) have long been used to control diarrhea and cramps. Synthetic agents, diphenoxylate and loperamide, come in convenient dosage forms and provide prompt symptomatic but temporary relief. However, they should not be used in patients with high fever or with blood in the stool. These drugs should be discontinued if symptoms persist beyond 48 hours. Diphenoxylate and loperamide should not be used in children under the age of 2.

Oral Fluids Most individuals with TD do not develop serious dehydration. Fluid and electrolyte balance can be maintained by potable fruit juices, caffeine-free

262 Diarrhea

soft drinks, and salted crackers. The individual with TD should avoid alcohol and caffeine-containing beverages. Dairy products aggravate diarrhea in some people and should be avoided. Individuals with severe dehydration may require special fluid and electrolyte replacement in the form of oral replacement solutions such as those recommended by the World Health Organization.

Antimicrobial Treatment Travelers who develop diarrhea with three or more loose stools in an 8-hour period, especially if associated with nausea, vomiting, abdominal cramps, fever, or blood in the stools, may benefit from antimicrobial treatment. A typical 3- to 5-day illness can be shortened to 1 to 1 1/2 days by effective antimicrobial agents. Those best studied to date are TMP/SMX, 160 mg TMP and 800 mg SMX, or TMP alone, 200 mg taken twice daily. Preliminary evidence suggests that doxycycline taken 100 mg twice daily is also effective. Three days of treatment is recommended, although 2 days or fewer may be sufficient. Nausea and vomiting without diarrhea should not be treated with antimicrobial drugs.

Precautions in Children and Pregnant Women Although children do not make up a large proportion of travelers to highrisk areas, some children do accompany their families. Teenagers should follow the advice given to adults, with possible adjustment of doses of medication. Physicians should be aware of the risks of tetracyclines to children under 12 years. There is a paucity of data available about usage of antidiarrheal drugs in children. Drugs should be prescribed with caution for pregnant women and nursing mothers.

Summary Recommendation for Treatment TD is usually a mild, self-limited disorder, with complete recovery even in the absence of therapy; hence, therapy should be considered optional. ·

Fluids should be taken as described above.

·

If rapid relief of symptoms is desired after one or two unformed stools accompanied by cramps, nausea, or malaise, diphenoxylate or loperamide may be taken. An alternative is to start bismuth subsalicylate (1 oz every 30 minutes for eight doses). Although this regimen decreases

NIH Consensus Statement on Travelers’ Diarrhea 263

the number of stools and increases their consistency, the beneficial activity of bismuth subsalicylate is somewhat slower than that of antimotility drugs. ·

If it is important to shorten the course or decrease the severity of moderate to severe TD, antimicrobial agents may be taken. After 3 or more loose stools with symptoms, consideration can be given to a short course of TMP/SMX or TMP alone or doxycycline.

·

A small percentage of travelers have persisting diarrhea with serious fluid loss, fever, and blood or mucus in the stools. This suggests that a more serious illness is involved, and such individuals should seek medical attention.

In conclusion, travelers to areas of high risk should obtain an antimotility drug or bismuth subsalicylate for milder forms of TD, and an antimicrobial agent (TMP/SMX or TMP alone or doxycycline) for more severe TD. Advice concerning side effects of these drugs and various aspects of hygiene and dietary precautions should be obtained. By obtaining the proper drugs in advance, the beleaguered traveler might avoid buying over-the-counter drugs abroad with potentially dangerous ingredients.

What Should Be the Direction of Future Research? Although much has been learned about TD over the past 25 years, there is considerable need for additional research on this important syndrome. Epidemiology ·

Epidemiologic data are needed from well-designed surveys and prospective studies, especially among travelers to countries and regions not previously examined. These investigations should be expanded to include young and elderly travelers, for whom few data exist.

·

Case-control studies should be designed to identify independent risk factors and specific etiologic agents. Such studies should apply all available microbiologic techniques to determine systematically the risk of TD attributable to specific microorganisms in various countries. Etiology

·

The development of rapid diagnostic techniques (e.g., hybridization techniques and use of monoclonal antibodies) would facilitate all clinical and epidemiologic research.

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·

Additional information should be sought regarding the pathogenesis of TD, which should lead to more specific therapeutic interventions.

·

There is a need for careful monitoring of increasing resistance to antimicrobial drugs, especially among the enterotoxigenic E. coli, in different intermediate and high-risk destinations.

·

There is a particular need to assess the frequency, risk factors, and microbiology of persistent diarrhea following travel. Better approaches to diagnosis in these patients are needed.

Prevention and Treatment ·

Newer approaches to vaccine development should be applied to the causal microorganisms of TD.

·

Randomized prospective studies or carefully controlled observational studies should be conducted to determine the true efficacy of dietary restrictions.

·

All agents effective in prevention and treatment of TD should be investigated in larger populations traveling to as-yet-unstudied destinations. Such populations should include children and elderly travelers.

·

Large-scale drug surveillance studies are required to identify important but uncommon toxicities or side effects of various drugs.

·

Minimal effective doses and duration for preventing and treating TD remain to be determined for general therapeutic agents.

·

The active agents and mode of action of bismuth subsalicylate remain to be elucidated, and the tablet form of the drug requires further evaluation.

·

A better understanding of the neurohumoral control of intestinal secretion and its potential interaction with microbial enterotoxins may help in the design of more rational therapeutic strategies for TD. Further study of antisecretory and absorption-enhancing agents may improve pharmacologic therapy and enhance the efficacy and acceptability of oral replacement solutions. Improved understanding of the components of motility that will enhance but not impede absorption may help in the design of rational antimotility therapy.

NIH Consensus Statement on Travelers’ Diarrhea 265

Conclusion Diarrhea is the major health problem in travelers to developing countries. Travel to high-risk areas in Latin America, Africa, the Middle East, and Asia is associated with diarrhea rates of 20 to 50 percent. The syndrome is caused by an infection acquired by ingesting fecally contaminated food or beverages. Escherichia coli, a common species of enteric bacteria, is the leading pathogen, although a host of other bacteria, viruses, and protozoa have been implicated in some cases. Prudent dietary and hygienic practices should be followed, and they will prevent some, but not all, diarrhea. Antimicrobial agents are not recommended for prevention of TD. Such widespread usage in millions of travelers would cause many side effects, including some severe ones, while preventing a disease that has had no reported mortality. Instead of universal antimicrobial prophylaxis, a more sensible approach is rapid institution of effective treatment that can shorten the disease to 30 hours or less in most people. For mild diarrhea, an antimotility drug such as diphenoxylate or loperamide could be taken. Alternatively, bismuth subsalicylate, which works somewhat slower, can be used. For more severe diarrhea, an antimicrobial drug may be used for treatment, and trimethoprim/sulfamethoxazole, trimethoprim alone, and doxycycline are among the choices. These drugs could be carried by the traveler for use in the event of illness. Oral rehydration should be instituted when necessary. The millions of Americans who travel annually to developing countries and their physicians must be warned of the potential risks of prophylactic antimicrobial drugs, with the attendant side effects in otherwise healthy individuals, and should be informed of the alternative method of prompt, effective treatment for diarrhea.

Vocabulary Builder Antibacterial: A substance that destroys bacteria or suppresses their growth or reproduction. [EU] Balantidium: A genus of protozoa parasitic in the digestive tract of vertebrate or invertebrate hosts. Asexual multiplication is accomplished by transverse binary fission. Its organisms are ovoidal in shape and have a ciliated covering over the entire body. [NIH] Causal: Pertaining to a cause; directed against a cause. [EU] Chlorine: A greenish-yellow, diatomic gas that is a member of the halogen

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family of elements. It has the atomic symbol Cl, atomic number 17, and atomic weight 70.906. It is a powerful irritant that can cause fatal pulmonary edema. Chlorine is used in manufacturing, as a reagent in synthetic chemistry, for water purification, and in the production of chlorinated lime, which is used in fabric bleaching. [NIH] Clioquinol: A potentially neurotoxic 8-hydroxyquinoline derivative long used as a topical anti-infective, intestinal antiamebic, and vaginal trichomonacide. The oral preparation has been shown to cause subacute myelo-optic neuropathy and has been banned worldwide. [NIH] Dientamoeba: A genus of minute protozoa that are characterized by the preponderance of binucleate over uninucleate forms, the presence of several distinct granules in the karyosome, and the lack of a cystic stage. It is parasitic in the large intestine of humans and certain monkeys. [NIH] Dysentery: Any of various disorders marked by inflammation of the intestines, especially of the colon, and attended by pain in the abdomen, tenesmus, and frequent stools containing blood and mucus. Causes include chemical irritants, bacteria, protozoa, or parasitic worms. [EU] Hygienic: Pertaining to hygiene, or conducive to health. [EU] Iodoquinol: One of the halogenated 8-quinolinols widely used as an intestinal antiseptic, especially as an antiamebic agent. It is also used topically in other infections and may cause CNS and eye damage. It is known by very many similar trade names world-wide. [NIH] Isospora: A genus of protozoan parasites found in the intestines of birds, amphibians, reptiles, and mammals, including man. The oocysts produce two sporocysts, each with four sporozoites. Many species are parasitic in wild and domestic animals. [NIH] Labile: 1. gliding; moving from point to point over the surface; unstable; fluctuating. 2. chemically unstable. [EU] Malaise: A vague feeling of bodily discomfort. [EU] Photosensitivity: An abnormal cutaneous response involving the interaction between photosensitizing substances and sunlight or filtered or artificial light at wavelengths of 280-400 mm. There are two main types : photoallergy and photoxicity. [EU] Prophylaxis: The prevention of disease; preventive treatment. [EU] Strongyloides: A genus of parasitic nematodes widely distributed as intestinal parasites of mammals. [NIH] Tenesmus: Straining, especially ineffectual and painful straining at stool or in urination. [EU] Tetracycline:

An

antibiotic

originally

produced

by

Streptomyces

NIH Consensus Statement on Travelers’ Diarrhea 267

viridifaciens, but used mostly in synthetic form. It is an inhibitor of aminoacyl-tRNA binding during protein synthesis. [NIH] Vaginitis: Inflammation of the vagina characterized by pain and a purulent discharge. [NIH]

Online Glossaries 269

ONLINE GLOSSARIES The Internet provides access to a number of free-to-use medical dictionaries and glossaries. The National Library of Medicine has compiled the following list of online dictionaries: ·

ADAM Medical Encyclopedia (A.D.A.M., Inc.), comprehensive medical reference: http://www.nlm.nih.gov/medlineplus/encyclopedia.html

·

MedicineNet.com Medical Dictionary (MedicineNet, Inc.): http://www.medterms.com/Script/Main/hp.asp

·

Merriam-Webster Medical Dictionary (Inteli-Health, Inc.): http://www.intelihealth.com/IH/

·

Multilingual Glossary of Technical and Popular Medical Terms in Eight European Languages (European Commission) - Danish, Dutch, English, French, German, Italian, Portuguese, and Spanish: http://allserv.rug.ac.be/~rvdstich/eugloss/welcome.html

·

On-line Medical Dictionary (CancerWEB): http://www.graylab.ac.uk/omd/

·

Technology Glossary (National Library of Medicine) - Health Care Technology: http://www.nlm.nih.gov/nichsr/ta101/ta10108.htm

·

Terms and Definitions (Office of Rare Diseases): http://rarediseases.info.nih.gov/ord/glossary_a-e.html

Beyond these, MEDLINEplus contains a very user-friendly encyclopedia covering every aspect of medicine (licensed from A.D.A.M., Inc.). The ADAM Medical Encyclopedia Web site address is http://www.nlm.nih.gov/medlineplus/encyclopedia.html. ADAM is also available on commercial Web sites such as drkoop.com (http://www.drkoop.com/) and Web MD (http://my.webmd.com/adam/asset/adam_disease_articles/a_to_z/a). Topics of interest can be researched by using keywords before continuing elsewhere, as these basic definitions and concepts will be useful in more advanced areas of research. You may choose to print various pages specifically relating to diarrhea and keep them on file. The NIH, in particular, suggests that patients with diarrhea visit the following Web sites in the ADAM Medical Encyclopedia: ·

Basic Guidelines for Diarrhea

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Bacterial gastroenteritis Web site: http://www.nlm.nih.gov/medlineplus/ency/article/000254.htm Campylobacter enteritis Web site: http://www.nlm.nih.gov/medlineplus/ency/article/000224.htm Diarrhea Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003126.htm Traveler's diarrhea diet Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002433.htm ·

Signs & Symptoms for Diarrhea Abdominal cramps Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003120.htm Abdominal pain Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003120.htm Blood in stools Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003130.htm Blood in the stool Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003130.htm Confusion Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003205.htm Diarrhea Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003126.htm

Online Glossaries 271

Dry skin Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003250.htm Fever Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003090.htm Gastrointestinal bleeding Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003133.htm Loose stool Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003126.htm Loss of appetite Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003121.htm Nausea Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003117.htm Pain while passing stool Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003131.htm Rapid heart rate Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003077.htm Skin turgor Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003281.htm Stools - floating Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003128.htm

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Stools, bloody Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003130.htm Stress Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003211.htm Tenesmus Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003131.htm Vomiting Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003117.htm Weakness Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003174.htm ·

Diagnostics and Tests for Diarrhea BUN Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003474.htm Chem-20 Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003468.htm Creatinine Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003475.htm Fecal smear Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003755.htm IgA Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003544.htm

Online Glossaries 273

Stool culture Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003758.htm Stool gram stain Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003757.htm Urine specific gravity Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003587.htm ·

Nutrition for Diarrhea Bulk Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002470.htm Coffee Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002445.htm Fats Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002468.htm Fiber Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002470.htm Protein Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002467.htm Yogurt Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002463.htm

·

Background Topics for Diarrhea

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Acute Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002215.htm Chemotherapy Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002324.htm Electrolyte Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002350.htm Electrolytes Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002350.htm Enterotoxin Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002352.htm Gastrectomy Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002945.htm Incidence Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002387.htm Intravenous Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002383.htm Physical examination Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002274.htm Radiation therapy Web site: http://www.nlm.nih.gov/medlineplus/ency/article/001918.htm

Online Glossaries 275

Systemic Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002294.htm Toxins Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002331.htm

Online Dictionary Directories The following are additional online directories compiled by the National Library of Medicine, including a number of specialized medical dictionaries and glossaries: ·

Medical Dictionaries: Medical & Biological (World Health Organization): http://www.who.int/hlt/virtuallibrary/English/diction.htm#Medical

·

MEL-Michigan Electronic Library List of Online Health and Medical Dictionaries (Michigan Electronic Library): http://mel.lib.mi.us/health/health-dictionaries.html

·

Patient Education: Glossaries (DMOZ Open Directory Project): http://dmoz.org/Health/Education/Patient_Education/Glossaries/

·

Web of Online Dictionaries (Bucknell University): http://www.yourdictionary.com/diction5.html#medicine

Glossary 277

DIARRHEA GLOSSARY The following is a complete glossary of terms used in this sourcebook. The definitions are derived from official public sources including the National Institutes of Health [NIH] and the European Union [EU]. After this glossary, we list a number of additional hardbound and electronic glossaries and dictionaries that you may wish to consult. Abdomen: That portion of the body that lies between the thorax and the pelvis. [NIH] Absenteeism: Chronic absence from work or other duty. [NIH] Acetaminophen: Analgesic antipyretic derivative of acetanilide. It has weak anti-inflammatory properties and is used as a common analgesic, but may cause liver, blood cell, and kidney damage. [NIH] Achlorhydria: A lack of hydrochloric acid in gastric juice despite stimulation of gastric secretion. [NIH] Acidosis: Too much acid in the body. For a person with diabetes, this can lead to diabetic ketoacidosis. [NIH] ACTH: Adrenocorticotropic hormone. [EU] Adenine: A purine base and a fundamental unit of adenine nucleotides. [NIH] Adenosine: A nucleoside that is composed of adenine and d-ribose. Adenosine or adenosine derivatives play many important biological roles in addition to being components of DNA and RNA. Adenosine itself is a neurotransmitter. [NIH] Adjuvant: A substance which aids another, such as an auxiliary remedy; in immunology, nonspecific stimulator (e.g., BCG vaccine) of the immune response. [EU] Adolescence: The period of life beginning with the appearance of secondary sex characteristics and terminating with the cessation of somatic growth. The years usually referred to as adolescence lie between 13 and 18 years of age. [NIH]

Aeromonas: A genus of gram-negative, facultatively anaerobic, rod-shaped bacteria that occurs singly, in pairs, or in short chains. Its organisms are found in fresh water and sewage and are pathogenic to humans, frogs, and fish. [NIH] Albuterol: A racemic mixture with a 1:1 ratio of the r-isomer, levalbuterol, and s-albuterol. It is a short-acting beta2-adrenergic agonist with its main clinical use in asthma. [NIH]

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Alimentary: Pertaining to food or nutritive material, or to the organs of digestion. [EU] Alkaloid: One of a large group of nitrogenous basis substances found in plants. They are usually very bitter and many are pharmacologically active. Examples are atropine, caffeine, coniine, morphine, nicotine, quinine, strychnine. The term is also applied to synthetic substances (artificial a's) which have structures similar to plant alkaloids, such as procaine. [EU] Allopurinol: A xanthine oxidase inhibitor that decreases uric acid production. [NIH] Alprostadil: A potent vasodilator agent that increases peripheral blood flow. It inhibits platelet aggregation and has many other biological effects such as bronchodilation, mediation of inflammation, etc. [NIH] Aluminum: A metallic element that has the atomic number 13, atomic symbol Al, and atomic weight 26.98. [NIH] Aminophylline: A drug combination that contains theophylline and ethylenediamine. It is more soluble in water than theophylline but has similar pharmacologic actions. It's most common use is in bronchial asthma, but it has been investigated for several other applications. [NIH] Amiodarone: An antianginal and antiarrhythmic drug. It increases the duration of ventricular and atrial muscle action by inhibiting Na,K-activated myocardial adenosine triphosphatase. There is a resulting decrease in heart rate and in vascular resistance. [NIH] Amitriptyline: Tricyclic antidepressant with anticholinergic and sedative properties. It appears to prevent the re-uptake of norepinephrine and serotonin at nerve terminals, thus potentiating the action of these neurotransmitters. Amitriptyline also appears to antaganize cholinergic and alpha-1 adrenergic responses to bioactive amines. [NIH] Amoxapine: The N-demethylated derivative of the antipsychotic agent loxapine that works by blocking the reuptake of norepinephrine, serotonin, or both. It also blocks dopamine receptors. [NIH] Amoxicillin: A broad-spectrum semisynthetic antibiotic similar to ampicillin except that its resistance to gastric acid permits higher serum levels with oral administration. [NIH] Amphetamine: A powerful central nervous system stimulant and sympathomimetic. Amphetamine has multiple mechanisms of action including blocking uptake of adrenergics and dopamine, stimulation of release of monamines, and inhibiting monoamine oxidase. Amphetamine is also a drug of abuse and a psychotomimetic. The l- and the d,l-forms are included here. The l-form has less central nervous system activity but stronger cardiovascular effects. The d-form is dextroamphetamine. [NIH]

Glossary 279

Amphotericin B: Macrolide antifungal antibiotic produced by Streptomyces nodosus obtained from soil of the Orinoco river region of Venezuela. [NIH] Ampicillin: Semi-synthetic derivative of penicillin that functions as an orally active broad-spectrum antibiotic. [NIH] Amyl Nitrite: A vasodilator that is administered by inhalation. It is also used recreationally due to its supposed ability to induce euphoria and act as an aphrodisiac. [NIH] Analgesic: An agent that alleviates pain without causing loss of consciousness. [EU] Anaphylactic: Pertaining to anaphylaxis. [EU] Anastomosis: An opening created by surgical, traumatic or pathological means between two normally separate spaces or organs. [EU] Anemia: A reduction in the number of circulating erythrocytes or in the quantity of hemoglobin. [NIH] Anomalies: Birth defects; abnormalities. [NIH] Anorectal: Pertaining to the anus and rectum or to the junction region between the two. [EU] Anorexia: Lack or loss of the appetite for food. [EU] Anthropology: The science devoted to the comparative study of man. [NIH] Anthropometry: The technique that deals with the measurement of the size, weight, and proportions of the human or other primate body. [NIH] Antibacterial: A substance that destroys bacteria or suppresses their growth or reproduction. [EU] Antibiotic: A chemical substance produced by a microorganism which has the capacity, in dilute solutions, to inhibit the growth of or to kill other microorganisms. Antibiotics that are sufficiently nontoxic to the host are used as chemotherapeutic agents in the treatment of infectious diseases of man, animals and plants. [EU] Antibodies: Proteins that the body makes to protect itself from foreign substances. In diabetes, the body sometimes makes antibodies to work against pork or beef insulins because they are not exactly the same as human insulin or because they have impurities. The antibodies can keep the insulin from working well and may even cause the person with diabetes to have an allergic or bad reaction to the beef or pork insulins. [NIH] Antibody: An immunoglobulin molecule that has a specific amino acid sequence by virtue of which it interacts only with the antigen that induced its synthesis in cells of the lymphoid series (especially plasma cells), or with antigen closely related to it. Antibodies are classified according to their ode of action as agglutinins, bacteriolysins, haemolysins, opsonins, precipitins,

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etc. [EU] Anticholinergic: An agent that blocks the parasympathetic nerves. Called also parasympatholytic. [EU] Antidepressant: An agent that stimulates the mood of a depressed patient, including tricyclic antidepressants and monoamine oxidase inhibitors. [EU] Antiemetic: An agent that prevents or alleviates nausea and vomiting. Also antinauseant. [EU] Antigens: Substances that cause an immune response in the body. The body "sees" the antigens as harmful or foreign. To fight them, the body produces antibodies, which attack and try to eliminate the antigens. [NIH] Antihistamine: A drug that counteracts the action of histamine. The antihistamines are of two types. The conventional ones, as those used in allergies, block the H1 histamine receptors, whereas the others block the H2 receptors. Called also antihistaminic. [EU] Antimicrobial: Killing microorganisms, or suppressing their multiplication or growth. [EU] Antispasmodic: An agent that relieves spasm. [EU] Antiviral: Destroying viruses or suppressing their replication. [EU] Anus: The distal or terminal orifice of the alimentary canal. [EU] Anxiety: The unpleasant emotional state consisting of psychophysiological responses to anticipation of unreal or imagined danger, ostensibly resulting from unrecognized intrapsychic conflict. Physiological concomitants include increased heart rate, altered respiration rate, sweating, trembling, weakness, and fatigue; psychological concomitants include feelings of impending danger, powerlessness, apprehension, and tension. [EU] Apnea: A transient absence of spontaneous respiration. [NIH] Appendicitis: Acute inflammation of the vermiform appendix. [NIH] Aqueous: Watery; prepared with water. [EU] Aromatic: Having a spicy odour. [EU] Ascariasis: Infection by nematodes of the genus ASCARIS. Ingestion of infective eggs causes diarrhea and pneumonitis. Its distribution is more prevalent in areas of poor sanitation and where human feces are used for fertilizer. [NIH] Ascites: Effusion and accumulation of serous fluid in the abdominal cavity; called also abdominal or peritoneal dropsy, hydroperitonia, and hydrops abdominis. [EU] Aspiration: The act of inhaling. [EU] Assay: Determination of the amount of a particular constituent of a mixture,

Glossary 281

or of the biological or pharmacological potency of a drug. [EU] Astringent: Causing contraction, usually locally after topical application. [EU] Asymptomatic: No symptoms; no clear sign of disease present. [NIH] Atenolol: A cardioselective beta-adrenergic blocker possessing properties and potency similar to propranolol, but without a negative inotropic effect. [NIH]

Atrophy: A wasting away; a diminution in the size of a cell, tissue, organ, or part. [EU] Atropine: A toxic alkaloid, originally from Atropa belladonna, but found in other plants, mainly Solanaceae. [NIH] Auscultation: The act of listening for sounds within the body, chiefly for ascertaining the condition of the lungs, heart, pleura, abdomen and other organs, and for the detection of pregnancy. [EU] Azithromycin: A semi-synthetic macrolide antibiotic structurally related to erythromycin. It has been used in the treatment of Mycobacterium avium intracellulare infections, toxoplasmosis, and cryptosporidiosis. [NIH] Bacillus: A genus of bacteria of the family Bacillaceae, including large aerobic or facultatively anaerobic, spore-forming, rod-shaped cells, the great majority of which are gram-positive and motile. The genus is separated into 48 species, of which three are pathogenic, or potentially pathogenic, and the remainder are saprophytic soil forms. Many organisms historically called Bacillus are now classified in other genera. [EU] Bacteroides: A genus of gram-negative, anaerobic, rod-shaped bacteria. Its organisms are normal inhabitants of the oral, respiratory, intestinal, and urogenital cavities of humans, animals, and insects. Some species may be pathogenic. [NIH] Balantidium: A genus of protozoa parasitic in the digestive tract of vertebrate or invertebrate hosts. Asexual multiplication is accomplished by transverse binary fission. Its organisms are ovoidal in shape and have a ciliated covering over the entire body. [NIH] Barium: An element of the alkaline earth group of metals. It has an atomic symbol Ba, atomic number 56, and atomic weight 138. All of its acid-soluble salts are poisonous. [NIH] Benign: Not malignant; not recurrent; favourable for recovery. [EU] Berberine: An alkaloid from Hydrastis canadensis L., Berberidaceae. It is also found in many other plants. It is relatively toxic parenterally, but has been used orally for various parasitic and fungal infections and as antidiarrheal. [NIH] Bezoars: Concretions of swallowed hair, fruit or vegetable fibers, or similar substances found in the alimentary canal. [NIH]

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Bifidobacterium: A rod-shaped, gram-positive, non-acid-fast, non-sporeforming, non-motile bacterium that is a genus of the family actinomycetaceae. It inhabits the intestines and feces of humans as well as the human vagina. [NIH] Bile: An emulsifying agent produced in the liver and secreted into the duodenum. Its composition includes bile acids and salts, cholesterol, and electrolytes. It aids digestion of fats in the duodenum. [NIH] Biliary: Pertaining to the bile, to the bile ducts, or to the gallbladder. [EU] Biochemical: Relating to biochemistry; characterized by, produced by, or involving chemical reactions in living organisms. [EU] Biopsy: The removal and examination, usually microscopic, of tissue from the living body, performed to establish precise diagnosis. [EU] Biotinylation: Incorporation of biotinyl groups into molecules. [NIH] Bismuth: A metallic element that has the atomic symbol Bi, atomic number 83 and atomic weight 208.98. [NIH] Blindness: The inability to see or the loss or absence of perception of visual stimuli. This condition may be the result of eye diseases; optic nerve diseases; optic chiasm diseases; or brain diseases affecting the visual pathways or occipital lobe. [NIH] Blister: Visible accumulations of fluid within or beneath the epidermis. [NIH] Budesonide: A glucocorticoid used in the management of asthma, the treatment of various skin disorders, and allergic rhinitis. [NIH] Cachexia: A profound and marked state of constitutional disorder; general ill health and malnutrition. [EU] Camptothecin: An alkaloid isolated from the stem wood of the Chinese tree, Camptotheca acuminata. This compound selectively inhibits the nuclear enzyme DNA topoisomerase. Several semisynthetic analogs of camptothecin have demonstrated antitumor activity. [NIH] Campylobacter: A genus of bacteria found in the reproductive organs, intestinal tract, and oral cavity of animals and man. Some species are pathogenic. [NIH] Capsules: Hard or soft soluble containers used for the oral administration of medicine. [NIH] Carbohydrate: An aldehyde or ketone derivative of a polyhydric alcohol, particularly of the pentahydric and hexahydric alcohols. They are so named because the hydrogen and oxygen are usually in the proportion to form water, (CH2O)n. The most important carbohydrates are the starches, sugars, celluloses, and gums. They are classified into mono-, di-, tri-, poly- and heterosaccharides. [EU]

Glossary 283

Carboplatin: An organoplatinum compound that possesses antineoplastic activity. [NIH] Carcinoma: A malignant new growth made up of epithelial cells tending to infiltrate the surrounding tissues and give rise to metastases. [EU] Catheter: A tubular, flexible, surgical instrument for withdrawing fluids from (or introducing fluids into) a cavity of the body, especially one for introduction into the bladder through the urethra for the withdraw of urine. [EU]

Causal: Pertaining to a cause; directed against a cause. [EU] Caustic: An escharotic or corrosive agent. Called also cauterant. [EU] Cervical: Pertaining to the neck, or to the neck of any organ or structure. [EU] Cetirizine: A potent second-generation histamine H1 antagonist that is effective in the treatment of allergic rhinitis, chronic urticaria, and polleninduced asthma. Unlike many traditional antihistamines, it does not cause drowsiness or anticholinergic side effects. [NIH] Character: In current usage, approximately equivalent to personality. The sum of the relatively fixed personality traits and habitual modes of response of an individual. [NIH] Chemotherapeutics: Noun plural but singular or plural in constructions : chemotherapy. [EU] Chemotherapy: The treatment of disease by means of chemicals that have a specific toxic effect upon the disease - producing microorganisms or that selectively destroy cancerous tissue. [EU] Chimera: An individual that contains cell populations derived from different zygotes. [NIH] Chlorine: A greenish-yellow, diatomic gas that is a member of the halogen family of elements. It has the atomic symbol Cl, atomic number 17, and atomic weight 70.906. It is a powerful irritant that can cause fatal pulmonary edema. Chlorine is used in manufacturing, as a reagent in synthetic chemistry, for water purification, and in the production of chlorinated lime, which is used in fabric bleaching. [NIH] Chloroquine: The prototypical antimalarial agent with a mechanism that is not well understood. It has also been used to treat rheumatoid arthritis, systemic lupus erythematosus, and in the systemic therapy of amebic liver abscesses. [NIH] Cholangitis: Inflammation of a bile duct. [EU] Cholera: An acute diarrheal disease endemic in India and Southeast Asia whose causative agent is vibrio cholerae. This condition can lead to severe dehydration in a matter of hours unless quickly treated. [NIH]

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Cholesterol: The principal sterol of all higher animals, distributed in body tissues, especially the brain and spinal cord, and in animal fats and oils. [NIH] Chronic: Persisting over a long period of time. [EU] Cimetidine: A histamine congener, it competitively inhibits histamine binding to H2 receptors. Cimetidine has a range of pharmacological actions. It inhibits gastric acid secretion, as well as pepsin and gastrin output. It also blocks the activity of cytochrome P-450. [NIH] Ciprofloxacin: A carboxyfluoroquinoline antimicrobial agent that is effective against a wide range of microorganisms. It has been successfully and safely used in the treatment of resistant respiratory, skin, bone, joint, gastrointestinal, urinary, and genital infections. [NIH] Cirrhosis: Liver disease characterized pathologically by loss of the normal microscopic lobular architecture, with fibrosis and nodular regeneration. The term is sometimes used to refer to chronic interstitial inflammation of any organ. [EU] Cisplatin: An inorganic and water-soluble platinum complex. After undergoing hydrolysis, it reacts with DNA to produce both intra and interstrand crosslinks. These crosslinks appear to impair replication and transcription of DNA. The cytotoxicity of cisplatin correlates with cellular arrest in the G2 phase of the cell cycle. [NIH] Clarithromycin: A semisynthetic macrolide antibiotic derived from erythromycin that is active against a variety of microorganisms. It can inhibit protein synthesis in bacteria by reversibly binding to the 50S ribosomal subunits. This inhibits the translocation of aminoacyl transfer-RNA and prevents peptide chain elongation. [NIH] Clioquinol: A potentially neurotoxic 8-hydroxyquinoline derivative long used as a topical anti-infective, intestinal antiamebic, and vaginal trichomonacide. The oral preparation has been shown to cause subacute myelo-optic neuropathy and has been banned worldwide. [NIH] Clonazepam: An anticonvulsant used for several types of seizures, including myotonic or atonic seizures, photosensitive epilepsy, and absence seizures, although tolerance may develop. It is seldom effective in generalized tonic-clonic or partial seizures. The mechanism of action appears to involve the enhancement of GABA receptor responses. [NIH] Clorazepate Dipotassium: A water-soluble benzodiazepine derivative effective in the treatment of anxiety. It has also muscle relaxant and anticonvulsant actions. [NIH] Clostridium: A genus of motile or nonmotile gram-positive bacteria of the family bacillaceae. Many species have been identified with some being pathogenic. They occur in water, soil, and in the intestinal tract of humans

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and lower animals. [NIH] Clotrimazole: An imidazole derivative with a broad spectrum of antimycotic activity. It inhibits biosynthesis of the sterol ergostol, an important component of fungal cell membranes. Its action leads to increased membrane permeability and apparent disruption of enzyme systems bound to the membrane. [NIH] Coagulation: 1. the process of clot formation. 2. in colloid chemistry, the solidification of a sol into a gelatinous mass; an alteration of a disperse phase or of a dissolved solid which causes the separation of the system into a liquid phase and an insoluble mass called the clot or curd. Coagulation is usually irreversible. 3. in surgery, the disruption of tissue by physical means to form an amorphous residuum, as in electrocoagulation and photocoagulation. [EU] Codeine: An opioid analgesic related to MORPHINE but with less potent analgesic properties and mild sedative effects. It also acts centrally to suppress cough. [NIH] Colestipol: Highly crosslinked and insoluble basic anion exchange resin used as anticholesteremic. It may also may reduce triglyceride levels. [NIH] Colic: Paroxysms of pain. This condition usually occurs in the abdominal region but may occur in other body regions as well. [NIH] Colitis: Inflammation of the colon. [EU] Collagen: The protein substance of the white fibres (collagenous fibres) of skin, tendon, bone, cartilage, and all other connective tissue; composed of molecules of tropocollagen (q.v.), it is converted into gelatin by boiling. collagenous pertaining to collagen; forming or producing collagen. [EU] Colonoscopy: Endoscopic examination, therapy or surgery of the luminal surface of the colon. [NIH] Colorectal: Pertaining to or affecting the colon and rectum. [EU] Condoms: A sheath that is worn over the penis during sexual behavior in order to prevent pregnancy or spread of sexually transmitted disease. [NIH] Confusion: Disturbed orientation in regard to time, place, or person, sometimes accompanied by disordered consciousness. [EU] Conjugated: Acting or operating as if joined; simultaneous. [EU] Constipation: Infrequent or difficult evacuation of the faeces. [EU] Contamination: The soiling or pollution by inferior material, as by the introduction of organisms into a wound, or sewage into a stream. [EU] Coronavirus: A genus of the family coronaviridae which causes respiratory or gastrointestinal disease in a variety of vertebrates. [NIH] Cryosurgery: The use of freezing as a special surgical technique to destroy or excise tissue. [NIH]

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Cryptosporidiosis: Parasitic intestinal infection with severe diarrhea caused by a protozoan, cryptosporidium. It occurs in both animals and humans. [NIH] Cryptosporidium: A genus of coccidian parasites of the family cryptosporidiidae, found in the intestinal epithelium of many vertebrates including humans. [NIH] Cutaneous: Pertaining to the skin; dermal; dermic. [EU] Cyclic: Pertaining to or occurring in a cycle or cycles; the term is applied to chemical compounds that contain a ring of atoms in the nucleus. [EU] Cyclophosphamide: Precursor of an alkylating nitrogen mustard antineoplastic and immunosuppressive agent that must be activated in the liver to form the active aldophosphamide. It is used in the treatment of lymphomas, leukemias, etc. Its side effect, alopecia, has been made use of in defleecing sheep. Cyclophosphamide may also cause sterility, birth defects, mutations, and cancer. [NIH] Cyclospora: A genus of coccidian parasites in the family eimeriidae. Cyclospora cayetanensis is pathogenic in humans, probably transmitted via the fecal-oral route, and causes nausea and diarrhea. [NIH] Cytokines: Non-antibody proteins secreted by inflammatory leukocytes and some non-leukocytic cells, that act as intercellular mediators. They differ from classical hormones in that they are produced by a number of tissue or cell types rather than by specialized glands. They generally act locally in a paracrine or autocrine rather than endocrine manner. [NIH] Cytomegalovirus: A genus of the family herpesviridae, subfamily betaherpesvirinae, infecting the salivary glands, liver, spleen, lungs, eyes, and other organs, in which they produce characteristically enlarged cells with intranuclear inclusions. Infection with Cytomegalovirus is also seen as an opportunistic infection in AIDS. [NIH] Defecation: The normal process of elimination of fecal material from the rectum. [NIH] Degenerative: Undergoing degeneration : tending to degenerate; having the character of or involving degeneration; causing or tending to cause degeneration. [EU] Dehydration: The condition that results from excessive loss of body water. Called also anhydration, deaquation and hypohydration. [EU] Dementia: An acquired organic mental disorder with loss of intellectual abilities of sufficient severity to interfere with social or occupational functioning. The dysfunction is multifaceted and involves memory, behavior, personality, judgment, attention, spatial relations, language, abstract thought, and other executive functions. The intellectual decline is usually progressive, and initially spares the level of consciousness. [NIH]

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Dentures: An appliance used as an artificial or prosthetic replacement for missing teeth and adjacent tissues. It does not include crowns, dental abutments, nor tooth, artificial. [NIH] Dermatitis: Inflammation of the skin. [EU] Desipramine: A tricyclic dibenzazepine compound that potentiates neurotransmission. Desipramine selectively blocks reuptake of norepinephrine from the neural synapse, and also appears to impair serotonin transport. This compound also possesses minor anticholingeric activity, through its affinity to muscarinic receptors. [NIH] Diarrhea: Passage of excessively liquid or excessively frequent stools. [NIH] Diarrhoea: Abnormal frequency and liquidity of faecal discharges. [EU] Didanosine: A dideoxynucleoside compound in which the 3'-hydroxy group on the sugar moiety has been replaced by a hydrogen. This modification prevents the formation of phosphodiester linkages which are needed for the completion of nucleic acid chains. Didanosine is a potent inhibitor of HIV replication, acting as a chain-terminator of viral DNA by binding to reverse transcriptase; ddI is then metabolized to dideoxyadenosine triphosphate, its putative active metabolite. [NIH] Dientamoeba: A genus of minute protozoa that are characterized by the preponderance of binucleate over uninucleate forms, the presence of several distinct granules in the karyosome, and the lack of a cystic stage. It is parasitic in the large intestine of humans and certain monkeys. [NIH] Dietetics: The study and regulation of the diet. [NIH] Digestion: The process of breakdown of food for metabolism and use by the body. [NIH] Diphenoxylate: A meperidine congener used as an antidiarrheal, usually in combination with atropine. At high doses, it acts like morphine. Its unesterified metabolite difenoxin has similar properties and is used similarly. It has little or no analgesic activity. [NIH] Diverticulitis: Inflammation of a diverticulum, especially inflammation related to colonic diverticula, which may undergo perforation with abscess formation. Sometimes called left-sided or L-sides appendicitis. [EU] Diverticulum: A pathological condition manifested as a pouch or sac opening from a tubular or sacular organ. [NIH] Doxycycline: A synthetic tetracycline derivative with a range of antimicrobial activity and mode of action similar to that of tetracycline, but more effective against many species. Animal studies suggest that it may cause less tooth staining than other tetracyclines. [NIH] Duodenum: The first or proximal portion of the small intestine, extending

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from the pylorus to the jejunum; so called because it is about 12 fingerbreadths in length. [EU] Dysentery: Any of various disorders marked by inflammation of the intestines, especially of the colon, and attended by pain in the abdomen, tenesmus, and frequent stools containing blood and mucus. Causes include chemical irritants, bacteria, protozoa, or parasitic worms. [EU] Dyspepsia: Impairment of the power of function of digestion; usually applied to epigastric discomfort following meals. [EU] Dysphagia: Difficulty in swallowing. [EU] Edema: Excessive amount of watery fluid accumulated in the intercellular spaces, most commonly present in subcutaneous tissue. [NIH] Electrolyte: A substance that dissociates into ions when fused or in solution, and thus becomes capable of conducting electricity; an ionic solute. [EU] Electrophysiological: Pertaining to electrophysiology, that is a branch of physiology that is concerned with the electric phenomena associated with living bodies and involved in their functional activity. [EU] Encopresis: Incontinence of feces not due to organic defect or illness. [NIH] Endemic: Present or usually prevalent in a population or geographical area at all times; said of a disease or agent. Called also endemial. [EU] Endocrinology: A subspecialty of internal medicine concerned with the metabolism, physiology, and disorders of the endocrine system. [NIH] Endogenous: Developing or originating within the organisms or arising from causes within the organism. [EU] Endoscopy: Visual inspection of any cavity of the body by means of an endoscope. [EU] Enema: A clyster or injection; a liquid injected or to be injected into the rectum. [EU] Enoxacin: An orally administered broad-spectrum fluoroquinolone antibacterial agent active against most gram-negative and gram-positive bacteria. Its clinical efficacy has been confirmed in a variety of systemic infections and particularly in urinary tract infections. The drug is well tolerated by adults, but should not be used in children and pregnant women. [NIH]

Entamoeba: A genus of ameboid protozoa characterized by the presence of beaded chromatin on the inner surface of the nuclear membrane. Its organisms are parasitic in invertebrates and vertebrates, including humans. [NIH]

Enterocolitis: Inflammation involving both the small intestine and the colon; see also enteritis. [EU]

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Enterocytozoon: A genus of parasitic protozoa in the family Enterocytozoonidae, which infects humans. Enterocytozoon bieneusi has been found in the intestines of patients with AIDS. [NIH] Enterotoxins: Substances that are toxic to the intestinal tract causing vomiting, diarrhea, etc.; most common enterotoxins are produced by bacteria. [NIH] Enzyme: A protein molecule that catalyses chemical reactions of other substances without itself being destroyed or altered upon completion of the reactions. Enzymes are classified according to the recommendations of the Nomenclature Committee of the International Union of Biochemistry. Each enzyme is assigned a recommended name and an Enzyme Commission (EC) number. They are divided into six main groups; oxidoreductases, transferases, hydrolases, lyases, isomerases, and ligases. [EU] Eosinophilia: The formation and accumulation of an abnormally large number of eosinophils in the blood. [EU] Epidemic: Occurring suddenly in numbers clearly in excess of normal expectancy; said especially of infectious diseases but applied also to any disease, injury, or other health-related event occurring in such outbreaks. [EU] Epigastric: Pertaining to the epigastrium. [EU] Erythromycin: A bacteriostatic antibiotic substance produced by Streptomyces erythreus. Erythromycin A is considered its major active component. In sensitive organisms, it inhibits protein synthesis by binding to 50S ribosomal subunits. This binding process inhibits peptidyl transferase activity and interferes with translocation of amino acids during translation and assembly of proteins. [NIH] Erythropoietin: Glycoprotein hormone, secreted chiefly by the kidney in the adult and the liver in the fetus, that acts on erythroid stem cells of the bone marrow to stimulate proliferation and differentiation. [NIH] Escherichia: A genus of gram-negative, facultatively anaerobic, rod-shaped bacteria whose organisms occur in the lower part of the intestine of warmblooded animals. The species are either nonpathogenic or opportunistic pathogens. [NIH] Esophagitis: Inflammation, acute or chronic, of the esophagus caused by bacteria, chemicals, or trauma. [NIH] Estradiol: The most potent mammalian estrogenic hormone. It is produced in the ovary, placenta, testis, and possibly the adrenal cortex. [NIH] Ethacrynic Acid: A compound that inhibits symport of sodium, potassium, and chloride primarily in the ascending limb of Henle, but also in the proximal and distal tubules. This pharmacological action results in excretion of these ions, increased urinary output, and reduction in extracelluar fluid.

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This compound has been classified as a loop or high ceiling diuretic. [NIH] Ethnopharmacology: The study of the actions and properties of drugs, usually derived from medicinal plants, indigenous to a population or ethnic group. [NIH] Etodolac: A nonsteroidal anti-inflammatory agent with potent analgesic and antiarthritic properties. It has been shown to be effective in the treatment of osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, and in the alleviation of postoperative pain. [NIH] Etoposide: A semisynthetic derivative of podophyllotoxin that exhibits antitumor activity. Etoposide inhibits DNA synthesis by forming a complex with topoisomerase II and DNA. This complex induces breaks in double stranded DNA and prevents repair by topoisomerase II binding. Accumulated breaks in DNA prevent entry into the mitotic phase of cell division, and lead to cell death. Etoposide acts primarily in the G2 and S phases of the cell cycle. [NIH] Evacuation: An emptying, as of the bowels. [EU] Exogenous: Developed or originating outside the organism, as exogenous disease. [EU] Famotidine: A competitive histamine H2-receptor antagonist. Its main pharmacodynamic effect is the inhibition of gastric secretion. [NIH] Fatigue: The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. [NIH] Fats: One of the three main classes of foods and a source of energy in the body. Fats help the body use some vitamins and keep the skin healthy. They also serve as energy stores for the body. In food, there are two types of fats: saturated and unsaturated. [NIH] Feces: The excrement discharged from the intestines, consisting of bacteria, cells exfoliated from the intestines, secretions, chiefly of the liver, and a small amount of food residue. [EU] Felodipine: A dihydropyridine calcium antagonist with positive inotropic effects. It lowers blood pressure by reducing peripheral vascular resistance through a highly selective action on smooth muscle in arteriolar resistance vessels. [NIH] Fermentation: An enzyme-induced chemical change in organic compounds that takes place in the absence of oxygen. The change usually results in the production of ethanol or lactic acid, and the production of energy. [NIH] Fibrosis: The formation of fibrous tissue; fibroid or fibrous degeneration [EU] Filtration: The passage of a liquid through a filter, accomplished by gravity,

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pressure, or vacuum (suction). [EU] Fissure: Any cleft or groove, normal or otherwise; especially a deep fold in the cerebral cortex which involves the entire thickness of the brain wall. [EU] Flatulence: The presence of excessive amounts of air or gases in the stomach or intestine, leading to distention of the organs. [EU] Flaviviridae: A family of RNA viruses, some formerly classified under Togoviridae, many of which cause disease in humans and domestic animals. The three genera are flavivirus, pestivirus, and hepatitis c-like viruses. [NIH] Flavivirus: A genus of flaviviridae, also known as Group B arbovirus, containing several subgroups and species. Most are arboviruses transmitted by mosquitoes or ticks. The type species is yellow fever virus. [NIH] Fleas: Parasitic, blood-sucking, wingless insects comprising the order Siphonaptera. [NIH] Fluconazole: Triazole antifungal agent that is used to treat oropharyngeal candidiasis and cryptococcal meningitis in AIDS. [NIH] Flucytosine: A fluorinated cytosine analog that is used as an antifungal agent. [NIH] Fluorouracil: A pyrimidine analog that acts as an antineoplastic antimetabolite and also has immunosuppressant. It interferes with DNA synthesis by blocking the thymidylate synthetase conversion of deoxyuridylic acid to thymidylic acid. [NIH] Flurbiprofen: An anti-inflammatory analgesic and antipyretic of the phenylalkynoic acid series. It has been shown to reduce bone resorption in periodontal disease by inhibiting carbonic anhydrase. [NIH] Flushing: A transient reddening of the face that may be due to fever, certain drugs, exertion, stress, or a disease process. [NIH] Fructose: A type of sugar found in many fruits and vegetables and in honey. Fructose is used to sweeten some diet foods. It is considered a nutritive sweetener because it has calories. [NIH] Furosemide: A sulfamyl saluretic and diuretic. It has a fast onset and short duration of action and is used in edema and chronic renal insufficiency. [NIH] Ganciclovir: Acyclovir analog that is a potent inhibitor of the Herpesvirus family including cytomegalovirus. Ganciclovir is used to treat complications from AIDS-associated cytomegalovirus infections. [NIH] Gastritis: Inflammation of the stomach. [EU] Gastroduodenal: Pertaining to or communicating with the stomach and duodenum, as a gastroduodenal fistula. [EU] Gastrostomy: Creation of an artificial external opening into the stomach for nutritional support or gastrointestinal compression. [NIH]

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Gemfibrozil: A lipid-regulating agent that lowers elevated serum lipids primarily by decreasing serum triglycerides with a variable reduction in total cholesterol. These decreases occur primarily in the VLDL fraction and less frequently in the LDL fraction. Gemfibrozil increases HDL subfractions HDL2 and HDL3 as well as apolipoproteins A-I and A-II. Its mechanism of action has not been definitely established. [NIH] Genotype: The genetic constitution of the individual; the characterization of the genes. [NIH] Giardia: A genus of flagellate intestinal protozoa parasitic in various vertebrates, including humans. Characteristics include the presence of four pairs of flagella arising from a complicated system of axonemes and cysts that are ellipsoidal to ovoidal in shape. [NIH] Glipizide: An oral hypoglycemic agent which is rapidly absorbed and completely metabolized. [NIH] Glucose: D-glucose, a monosaccharide (hexose), C6H12O6, also known as dextrose (q.v.), found in certain foodstuffs, especially fruits, and in the normal blood of all animals. It is the end product of carbohydrate metabolism and is the chief source of energy for living organisms, its utilization being controlled by insulin. Excess glucose is converted to glycogen and stored in the liver and muscles for use as needed and, beyond that, is converted to fat and stored as adipose tissue. Glucose appears in the urine in diabetes mellitus. [EU] Glutamine: A non-essential amino acid present abundantly throught the body and is involved in many metabolic processes. It is synthesized from glutamic acid and ammonia. It is the principal carrier of nitrogen in the body and is an important energy source for many cells. [NIH] Gluten: The protein of wheat and other grains which gives to the dough its tough elastic character. [EU] Glyburide: An antidiabetic sulfonylurea derivative with actions similar to those of chlorpropamide. [NIH] Glycopyrrolate: A muscarinic antagonist used as an antispasmodic, in some disorders of the gastrointestinal tract, and to reduce salivation with some anesthetics. [NIH] Gold Sodium Thiomalate: A variable mixture of the mono- and disodium salts of gold thiomalic acid used mainly for its anti-inflammatory action in the treatment of rheumatoid arthritis. It is most effective in active progressive rheumatoid arthritis and of little or no value in the presence of extensive deformities or in the treatment of other forms of arthritis. [NIH] Griseofulvin: An antifungal antibiotic. Griseofulvin may be given by mouth in the treatment of tinea infections. [NIH]

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Groin: The external junctural region between the lower part of the abdomen and the thigh. [NIH] Heartburn: Substernal pain or burning sensation, usually associated with regurgitation of gastric juice into the esophagus. [NIH] Hematemesis: Vomiting of blood. [NIH] Hematology: A subspecialty of internal medicine concerned with morphology, physiology, and pathology of the blood and blood-forming tissues. [NIH] Hemorrhage: Bleeding or escape of blood from a vessel. [NIH] Hemorrhoids: Varicosities of the hemorrhoidal venous plexuses. [NIH] Hepatic: Pertaining to the liver. [EU] Hepatitis: Inflammation of the liver. [EU] Hepatobiliary: Pertaining to the liver and the bile or the biliary ducts. [EU] Hepatocellular: Pertaining to or affecting liver cells. [EU] Hepatomegaly: Enlargement of the liver. [EU] Heredity: 1. the genetic transmission of a particular quality or trait from parent to offspring. 2. the genetic constitution of an individual. [EU] Hernia: (he protrusion of a loop or knuckle of an organ or tissue through an abnormal opening. [EU] Herpes: Any inflammatory skin disease caused by a herpesvirus and characterized by the formation of clusters of small vesicles. When used alone, the term may refer to herpes simplex or to herpes zoster. [EU] Hiccup: A spasm of the diaphragm that causes a sudden inhalation followed by rapid closure of the glottis which produces a sound. [NIH] Hoarseness: An unnaturally deep or rough quality of voice. [NIH] Homeostasis: A tendency to stability in the normal body states (internal environment) of the organism. It is achieved by a system of control mechanisms activated by negative feedback; e.g. a high level of carbon dioxide in extracellular fluid triggers increased pulmonary ventilation, which in turn causes a decrease in carbon dioxide concentration. [EU] Homogeneous: Consisting of or composed of similar elements or ingredients; of a uniform quality throughout. [EU] Hybridization: The genetic process of crossbreeding to produce a hybrid. Hybrid nucleic acids can be formed by nucleic acid hybridization of DNA and RNA molecules. Protein Hybridization allows for hybrid proteins to be formed from polypeptide chains. [NIH] Hydroxyurea: An antineoplastic agent that inhibits DNA synthesis through the inhibition of ribonucleoside diphosphate reductase. [NIH]

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Hygienic: Pertaining to hygiene, or conducive to health. [EU] Hyperbilirubinemia: Pathologic process consisting of an abnormal increase in the amount of bilirubin in the circulating blood, which may result in jaundice. [NIH] Hyperplasia: The abnormal multiplication or increase in the number of normal cells in normal arrangement in a tissue. [EU] Hypersensitivity: A state of altered reactivity in which the body reacts with an exaggerated immune response to a foreign substance. Hypersensitivity reactions are classified as immediate or delayed, types I and IV, respectively, in the Gell and Coombs classification (q.v.) of immune responses. [EU] Hypertension: Persistently high arterial blood pressure. Various criteria for its threshold have been suggested, ranging from 140 mm. Hg systolic and 90 mm. Hg diastolic to as high as 200 mm. Hg systolic and 110 mm. Hg diastolic. Hypertension may have no known cause (essential or idiopathic h.) or be associated with other primary diseases (secondary h.). [EU] Hypertrophy: Nutrition) the enlargement or overgrowth of an organ or part due to an increase in size of its constituent cells. [EU] Ibuprofen: A nonsteroidal anti-inflammatory agent with analgesic properties used in the therapy of rheumatism and arthritis. [NIH] Idiopathic: Of the nature of an idiopathy; self-originated; of unknown causation. [EU] Ileitis: Inflammation of the ileum. [EU] Ileostomy: Surgical creation of an external opening into the ileum for fecal diversion or drainage. Loop or tube procedures are most often employed. [NIH]

Ileus: Obstruction of the intestines. [EU] Immunity: The condition of being immune; the protection against infectious disease conferred either by the immune response generated by immunization or previous infection or by other nonimmunologic factors (innate i.). [EU] Immunization: The induction of immunity. [EU] Immunoassay: Immunochemical assay or detection of a substance by serologic or immunologic methods. Usually the substance being studied serves as antigen both in antibody production and in measurement of antibody by the test substance. [NIH] Immunocompetence: The ability of lymphoid cells to mount a humoral or cellular immune response when challenged by antigen. [NIH] Incontinence: Inability to control excretory functions, as defecation (faecal i.) or urination (urinary i.). [EU]

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Incubation: The development of an infectious disease from the entrance of the pathogen to the appearance of clinical symptoms. [EU] Indapamide: A sulfamyl diuretic with about 16x the effect of furosemide. It has also been shown to be an effective antihypertensive agent in the clinic. [NIH]

Indinavir: A potent and specific HIV protease inhibitor that appears to have good oral bioavailability. [NIH] Induction: The act or process of inducing or causing to occur, especially the production of a specific morphogenetic effect in the developing embryo through the influence of evocators or organizers, or the production of anaesthesia or unconsciousness by use of appropriate agents. [EU] Infantile: Pertaining to an infant or to infancy. [EU] Inflammation: A pathological process characterized by injury or destruction of tissues caused by a variety of cytologic and chemical reactions. It is usually manifested by typical signs of pain, heat, redness, swelling, and loss of function. [NIH] Infusion: The therapeutic introduction of a fluid other than blood, as saline solution, solution, into a vein. [EU] Ingestion: The act of taking food, medicines, etc., into the body, by mouth. [EU]

Insulin: A protein hormone secreted by beta cells of the pancreas. Insulin plays a major role in the regulation of glucose metabolism, generally promoting the cellular utilization of glucose. It is also an important regulator of protein and lipid metabolism. Insulin is used as a drug to control insulindependent diabetes mellitus. [NIH] Intermittent: Occurring at separated intervals; having periods of cessation of activity. [EU] Intestines: The section of the alimentary canal from the stomach to the anus. It includes the large intestine and small intestine. [NIH] Intubation: The insertion of a tube into a body canal or hollow organ, as into the trachea or stomach. [EU] Iodine: A nonmetallic element of the halogen group that is represented by the atomic symbol I, atomic number 53, and atomic weight of 126.90. It is a nutritionally essential element, especially important in thyroid hormone synthesis. In solution, it has anti-infective properties and is used topically. [NIH]

Iodoquinol: One of the halogenated 8-quinolinols widely used as an intestinal antiseptic, especially as an antiamebic agent. It is also used topically in other infections and may cause CNS and eye damage. It is known by very many similar trade names world-wide. [NIH]

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Ischemia: Deficiency of blood in a part, due to functional constriction or actual obstruction of a blood vessel. [EU] Islam: A monotheistic religion promulgated by the Prophet Mohammed with Allah as the deity. [NIH] Isosorbide Dinitrate: A vasodilator used in the treatment of angina. Its actions are similar to nitroglycerin but with a slower onset of action. [NIH] Isospora: A genus of protozoan parasites found in the intestines of birds, amphibians, reptiles, and mammals, including man. The oocysts produce two sporocysts, each with four sporozoites. Many species are parasitic in wild and domestic animals. [NIH] Isotretinoin: A topical dermatologic agent that is used in the treatment of acne vulgaris and several other skin diseases. The drug has teratogenic and other adverse effects. [NIH] Itraconazole: An antifungal agent that has been used in the treatment of histoplasmosis, blastomycosis, cryptococcal meningitis, and aspergillosis. [NIH]

Jaundice: A clinical manifestation of hyperbilirubinemia, consisting of deposition of bile pigments in the skin, resulting in a yellowish staining of the skin and mucous membranes. [NIH] Jejunum: That portion of the small intestine which extends from the duodenum to the ileum; called also intestinum jejunum. [EU] Ketoconazole: Broad spectrum antifungal agent used for long periods at high doses, especially in immunosuppressed patients. [NIH] Ketoprofen: An ibuprofen-type anti-inflammatory analgesic and antipyretic. It is used in the treatment of rheumatoid arthritis and osteoarthritis. [NIH] Ketorolac Tromethamine: A pyrrolizine carboxylic acid derivative structurally related to indomethacin. It is a non-steroidal anti-inflammatory agent used for analgesia for postoperative pain and inhibits cyclooxygenase activity. [NIH] Labile: 1. gliding; moving from point to point over the surface; unstable; fluctuating. 2. chemically unstable. [EU] Lamivudine: A reverse transcriptase inhibitor and zalcitabine analog in which a sulfur atom replaces the 3' carbon of the pentose ring. It is used to treat HIV disease. [NIH] Lesion: Any pathological or traumatic discontinuity of tissue or loss of function of a part. [EU] Leucovorin: The active metabolite of folic acid. Leucovorin is used principally as its calcium salt as an antidote to folic acid antagonists which block the conversion of folic acid to folinic acid. [NIH]

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Leukapheresis: The preparation of leukocyte concentrates with the return of red cells and leukocyte-poor plasma to the donor. [NIH] Lipid: Any of a heterogeneous group of flats and fatlike substances characterized by being water-insoluble and being extractable by nonpolar (or fat) solvents such as alcohol, ether, chloroform, benzene, etc. All contain as a major constituent aliphatic hydrocarbons. The lipids, which are easily stored in the body, serve as a source of fuel, are an important constituent of cell structure, and serve other biological functions. Lipids may be considered to include fatty acids, neutral fats, waxes, and steroids. Compound lipids comprise the glycolipids, lipoproteins, and phospholipids. [EU] Lipoxygenase: An enzyme of the oxidoreductase class that catalyzes reactions between linoleate and other fatty acids and oxygen to form hydroperoxy-fatty acid derivatives. Related enzymes in this class include the arachidonate lipoxygenases, arachidonate 5-lipoxygenase, arachidonate 12lipoxygenase, and arachidonate 15-lipoxygenase. EC 1.13.11.12. [NIH] Lumen: The cavity or channel within a tube or tubular organ. [EU] Lymphoma: Any neoplastic disorder of the lymphoid tissue, the term lymphoma often is used alone to denote malignant lymphoma. [EU] Malabsorption: Impaired intestinal absorption of nutrients. [EU] Malaise: A vague feeling of bodily discomfort. [EU] Malformation: A morphologic defect resulting from an intrinsically abnormal developmental process. [EU] Malignant: Tending to become progressively worse and to result in death. Having the properties of anaplasia, invasion, and metastasis; said of tumours. [EU] Mannitol: A diuretic and renal diagnostic aid related to sorbitol. It has little significant energy value as it is largely eliminated from the body before any metabolism can take place. It can be used to treat oliguria associated with kidney failure or other manifestations of inadequate renal function and has been used for determination of glomerular filtration rate. Mannitol is also commonly used as a research tool in cell biological studies, usually to control osmolarity. [NIH] Mastocytosis: A group of diseases resulting from proliferation of mast cells. [NIH]

Mediator: An object or substance by which something is mediated, such as (1) a structure of the nervous system that transmits impulses eliciting a specific response; (2) a chemical substance (transmitter substance) that induces activity in an excitable tissue, such as nerve or muscle; or (3) a substance released from cells as the result of the interaction of antigen with antibody or by the action of antigen with a sensitized lymphocyte. [EU]

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Megacolon: An abnormally large or dilated colon; the condition may be congenital or acquired, acute or chronic. [EU] Melena: 1. the passage of dark, pitchy, and grumous stools stained with blood pigments or with altered blood. 2. black vomit. [EU] Membrane: A thin layer of tissue which covers a surface, lines a cavity or divides a space or organ. [EU] Mentors: Senior professionals who provide guidance, direction and support to those persons desirous of improvement in academic positions, administrative positions or other career development situations. [NIH] Mesenteric: Pertaining to the mesentery : a membranous fold attaching various organs to the body wall. [EU] Metastasis: 1. the transfer of disease from one organ or part to another not directly connected with it. It may be due either to the transfer of pathogenic microorganisms (e.g., tubercle bacilli) or to transfer of cells, as in malignant tumours. The capacity to metastasize is a characteristic of all malignant tumours. 2. Pl. metastases. A growth of pathogenic microorganisms or of abnormal cells distant from the site primarily involved by the morbid process. [EU] Methotrexate: An antineoplastic antimetabolite with immunosuppressant properties. It is an inhibitor of dihydrofolate reductase and prevents the formation of tetrahydrofolate, necessary for synthesis of thymidylate, an essential component of DNA. [NIH] Microbiology: The study of microorganisms such as fungi, bacteria, algae, archaea, and viruses. [NIH] Microgram: A unit of mass (weight) of the metric system, being onemillionth of a gram (10-6 gm.) or one one-thousandth of a milligram (10-3 mg.). [EU] Micronutrients: Essential dietary elements or organic compounds that are required in only small quantities for normal physiologic processes to occur. [NIH]

Microorganism: A microscopic organism; those of medical interest include bacteria, viruses, fungi and protozoa. [EU] Misoprostol: A synthetic analog of natural prostaglandin E1. It produces a dose-related inhibition of gastric acid and pepsin secretion, and enhances mucosal resistance to injury. It is an effective anti-ulcer agent and also has oxytocic properties. [NIH] Mitomycin: An antineoplastic antibiotic produced by Streptomyces caespitosus. It acts as a bi- or trifunctional alkylating agent causing crosslinking of DNA and inhibition of DNA synthesis. [NIH] Mitosis: A method of indirect cell division by means of which the two

Glossary 299

daughter nuclei normally receive identical complements of the number of chromosomes of the somatic cells of the species. [NIH] Mobilization: The process of making a fixed part or stored substance mobile, as by separating a part from surrounding structures to make it accessible for an operative procedure or by causing release into the circulation for body use of a substance stored in the body. [EU] Modulator: A specific inductor that brings out characteristics peculiar to a definite region. [EU] Molecular: Of, pertaining to, or composed of molecules : a very small mass of matter. [EU] Monotherapy: A therapy which uses only one drug. [EU] Motility: The ability to move spontaneously. [EU] Mucus: The free slime of the mucous membranes, composed of secretion of the glands, along with various inorganic salts, desquamated cells, and leucocytes. [EU] Mycobacterium: An organism of the genus Mycobacterium. [EU] Nausea: An unpleasant sensation, vaguely referred to the epigastrium and abdomen, and often culminating in vomiting. [EU] Nelfinavir: A potent HIV protease inhibitor. It is used in combination with other antiviral drugs in the treatment of HIV in both adults and children. [NIH]

Neomycin: Antibiotic complex produced by Streptomyces fradiae. It is composed of neomycins A, B, and C. It acts by inhibiting translation during protein synthesis. [NIH] Neonatal: Pertaining to the first four weeks after birth. [EU] Neoplasms: New abnormal growth of tissue. Malignant neoplasms show a greater degree of anaplasia and have the properties of invasion and metastasis, compared to benign neoplasms. [NIH] Neoplastic: Pertaining to or like a neoplasm (= any new and abnormal growth); pertaining to neoplasia (= the formation of a neoplasm). [EU] Neural: 1. pertaining to a nerve or to the nerves. 2. situated in the region of the spinal axis, as the neutral arch. [EU] Neuromuscular: Pertaining to muscles and nerves. [EU] Neuropathy: A general term denoting functional disturbances and/or pathological changes in the peripheral nervous system. The etiology may be known e.g. arsenical n., diabetic n., ischemic n., traumatic n.) or unknown. Encephalopathy and myelopathy are corresponding terms relating to involvement of the brain and spinal cord, respectively. The term is also used to designate noninflammatory lesions in the peripheral nervous system, in

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contrast to inflammatory lesions (neuritis). [EU] Neutralization: An act or process of neutralizing. [EU] Nicotine: Nicotine is highly toxic alkaloid. It is the prototypical agonist at nicotinic cholinergic receptors where it dramatically stimulates neurons and ultimately blocks synaptic transmission. Nicotine is also important medically because of its presence in tobacco smoke. [NIH] Nitrogen: An element with the atomic symbol N, atomic number 7, and atomic weight 14. Nitrogen exists as a diatomic gas and makes up about 78% of the earth's atmosphere by volume. It is a constituent of proteins and nucleic acids and found in all living cells. [NIH] Nosocomial: Pertaining to or originating in the hospital, said of an infection not present or incubating prior to admittance to the hospital, but generally occurring 72 hours after admittance; the term is usually used to refer to patient disease, but hospital personnel may also acquire nosocomial infection. [EU] Nurseries: Facilities which provide care for infants. [NIH] Occult: Obscure; concealed from observation, difficult to understand. [EU] Octreotide: A potent, long-acting somatostatin octapeptide analog which has a wide range of physiological actions. It inhibits growth hormone secretion, is effective in the treatment of hormone-secreting tumors from various organs, and has beneficial effects in the management of many pathological states including diabetes mellitus, orthostatic hypertension, hyperinsulinism, hypergastrinemia, and small bowel fistula. [NIH] Oligosaccharides: Carbohydrates consisting of between two and ten monosaccharides connected by either an alpha- or beta-glycosidic link. They are found throughout nature in both the free and bound form. [NIH] Oocytes: Female germ cells in stages between the prophase of the first maturation division and the completion of the second maturation division. [NIH]

Opiate: A remedy containing or derived from opium; also any drug that induces sleep. [EU] Oral: Pertaining to the mouth, taken through or applied in the mouth, as an oral medication or an oral thermometer. [EU] Osmotic: Pertaining to or of the nature of osmosis (= the passage of pure solvent from a solution of lesser to one of greater solute concentration when the two solutions are separated by a membrane which selectively prevents the passage of solute molecules, but is permeable to the solvent). [EU] Osteoporosis: Reduction in the amount of bone mass, leading to fractures after minimal trauma. [EU] Overdose: 1. to administer an excessive dose. 2. an excessive dose. [EU]

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Paclitaxel: Antineoplastic agent isolated from the bark of the Pacific yew tree, Taxus brevifolia. Paclitaxel stabilizes microtubules in their polymerized form and thus mimics the action of the proto-oncogene proteins C-MOS. [NIH] Palpation: Application of fingers with light pressure to the surface of the body to determine consistence of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. [NIH] Pancreas: An organ behind the lower part of the stomach that is about the size of a hand. It makes insulin so that the body can use glucose (sugar) for energy. It also makes enzymes that help the body digest food. Spread all over the pancreas are areas called the islets of Langerhans. The cells in these areas each have a special purpose. The alpha cells make glucagon, which raises the level of glucose in the blood; the beta cells make insulin; the delta cells make somatostatin. There are also the PP cells and the D1 cells, about which little is known. [NIH] Pancreatitis: Inflammation (pain, tenderness) of the pancreas; it can make the pancreas stop working. It is caused by drinking too much alcohol, by disease in the gallbladder, or by a virus. [NIH] Pancrelipase: A preparation of hog pancreatic enzymes standardized for lipase content. [NIH] Parasitic: Pertaining to, of the nature of, or caused by a parasite. [EU] Parenteral: Not through the alimentary canal but rather by injection through some other route, as subcutaneous, intramuscular, intraorbital, intracapsular, intraspinal, intrasternal, intravenous, etc. [EU] Paromomycin: An oligosaccharide antibiotic produced by various Streptomyces. [NIH] Pathologic: 1. indicative of or caused by a morbid condition. 2. pertaining to pathology (= branch of medicine that treats the essential nature of the disease, especially the structural and functional changes in tissues and organs of the body caused by the disease). [EU] Pediatrics: A medical specialty concerned with maintaining health and providing medical care to children from birth to adolescence. [NIH] Peptic: Pertaining to pepsin or to digestion; related to the action of gastric juices. [EU] Perforation: 1. the act of boring or piercing through a part. 2. a hole made through a part or substance. [EU] Perfusion: 1. the act of pouring over or through, especially the passage of a fluid through the vessels of a specific organ. 2. a liquid poured over or through an organ or tissue. [EU] Perianal: Located around the anus. [EU]

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Pharmacist: A person trained to prepare and distribute medicines and to give information about them. [NIH] Pharmacokinetics: The action of drugs in the body over a period of time, including the processes of absorption, distribution, localization in tissues, biotransformation, and excretion. [EU] Phosphorylation: The introduction of a phosphoryl group into a compound through the formation of an ester bond between the compound and a phosphorus moiety. [NIH] Photosensitivity: An abnormal cutaneous response involving the interaction between photosensitizing substances and sunlight or filtered or artificial light at wavelengths of 280-400 mm. There are two main types : photoallergy and photoxicity. [EU] Physiologic: Normal; not pathologic; characteristic of or conforming to the normal functioning or state of the body or a tissue or organ; physiological. [EU]

Placenta: A highly vascular fetal organ through which the fetus absorbs oxygen and other nutrients and excretes carbon dioxide and other wastes. It begins to form about the eighth day of gestation when the blastocyst adheres to the decidua. [NIH] Pneumonia: Inflammation of the lungs with consolidation. [EU] Podophyllum: A genus of poisonous American herbs, family Berberidaceae. The roots yield podophyllotoxins and other pharmacologically important agents. The plant was formerly used as a cholagogue and cathartic. It is different from the European mandrake, mandragora. [NIH] Poisoning: A condition or physical state produced by the ingestion, injection or inhalation of, or exposure to a deleterious agent. [NIH] Polypeptide: A peptide which on hydrolysis yields more than two amino acids; called tripeptides, tetrapeptides, etc. according to the number of amino acids contained. [EU] Postoperative: Occurring after a surgical operation. [EU] Potassium: An element that is in the alkali group of metals. It has an atomic symbol K, atomic number 19, and atomic weight 39.10. It is the chief cation in the intracellular fluid of muscle and other cells. Potassium ion is a strong electrolyte and it plays a significant role in the regulation of fluid volume and maintenance of the water-electrolyte balance. [NIH] Preclinical: Before a disease becomes clinically recognizable. [EU] Prednisone: A synthetic anti-inflammatory glucocorticoid derived from cortisone. It is biologically inert and converted to prednisolone in the liver. [NIH]

Premenstrual: Occurring before menstruation. [EU]

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Preoperative: Preceding an operation. [EU] Prevalence: The number of people in a given group or population who are reported to have a disease. [NIH] Proctitis: Inflammation of the rectum. [EU] Progressive: Advancing; going forward; going from bad to worse; increasing in scope or severity. [EU] Propafenone: An antiarrhythmia agent that is particularly effective in ventricular arrhythmias. It also has weak beta-blocking activity. The drug is generally well tolerated. [NIH] Prophylaxis: The prevention of disease; preventive treatment. [EU] Propoxyphene: A narcotic analgesic structurally related to methadone. Only the dextro-isomer has an analgesic effect; the levo-isomer appears to exert an antitussive effect. [NIH] Prostate: A gland in males that surrounds the neck of the bladder and the urethra. It secretes a substance that liquifies coagulated semen. It is situated in the pelvic cavity behind the lower part of the pubic symphysis, above the deep layer of the triangular ligament, and rests upon the rectum. [NIH] Protease: Proteinase (= any enzyme that catalyses the splitting of interior peptide bonds in a protein). [EU] Proteins: Polymers of amino acids linked by peptide bonds. The specific sequence of amino acids determines the shape and function of the protein. [NIH]

Protozoan: 1. any individual of the protozoa; protozoon. 2. of or pertaining to the protozoa; protozoal. [EU] Proxy: A person authorized to decide or act for another person, for example, a person having durable power of attorney. [NIH] Psychiatric: Pertaining to or within the purview of psychiatry. [EU] Psychology: The science dealing with the study of mental processes and behavior in man and animals. [NIH] Psychotherapy: A generic term for the treatment of mental illness or emotional disturbances primarily by verbal or nonverbal communication. [NIH]

Psychotropic: Exerting an effect upon the mind; capable of modifying mental activity; usually applied to drugs that effect the mental state. [EU] Pulse: The rhythmical expansion and contraction of an artery produced by waves of pressure caused by the ejection of blood from the left ventricle of the heart as it contracts. [NIH] Purpura: Purplish or brownish red discoloration, easily visible through the epidermis, caused by hemorrhage into the tissues. [NIH]

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Quinidine: An optical isomer of quinine, extracted from the bark of the Cinchona tree and similar plant species. This alkaloid dampens the excitability of cardiac and skeletal muscles by blocking sodium and potassium currents across cellular membranes. It prolongs cellular action potential, and decreases automaticity. Quinidine also blocks muscarinic and alpha-adrenergic neurotransmission. [NIH] Radiology: A specialty concerned with the use of x-ray and other forms of radiant energy in the diagnosis and treatment of disease. [NIH] Radium: Radium. A radioactive element of the alkaline earth series of metals. It has the atomic symbol Ra, atomic number 88, and atomic weight 226. Radium is the product of the disintegration of uranium and is present in pitchblende and all ores containing uranium. It is used clinically as a source of beta and gamma-rays in radiotherapy, particularly brachytherapy. [NIH] Reagent: A substance employed to produce a chemical reaction so as to detect, measure, produce, etc., other substances. [EU] Receptor: 1. a molecular structure within a cell or on the surface characterized by (1) selective binding of a specific substance and (2) a specific physiologic effect that accompanies the binding, e.g., cell-surface receptors for peptide hormones, neurotransmitters, antigens, complement fragments, and immunoglobulins and cytoplasmic receptors for steroid hormones. 2. a sensory nerve terminal that responds to stimuli of various kinds. [EU] Recombinant: 1. a cell or an individual with a new combination of genes not found together in either parent; usually applied to linked genes. [EU] Recurrence: The return of a sign, symptom, or disease after a remission. [NIH] Reflux: A backward or return flow. [EU] Refractory: Not readily yielding to treatment. [EU] Rehydration: The restoration of water or of fluid content to a body or to substance which has become dehydrated. [EU] Reinfection: A second infection by the same pathogenic agent, or a second infection of an organ such as the kidney by a different pathogenic agent. [EU] Relaxant: 1. lessening or reducing tension. 2. an agent that lessens tension. [EU]

Remission: A diminution or abatement of the symptoms of a disease; also the period during which such diminution occurs. [EU] Resection: Excision of a portion or all of an organ or other structure. [EU] Respiratory: Pertaining to respiration. [EU] Riboflavin: Nutritional factor found in milk, eggs, malted barley, liver, kidney, heart, and leafy vegetables. The richest natural source is yeast. It

Glossary 305

occurs in the free form only in the retina of the eye, in whey, and in urine; its principal forms in tissues and cells are as FMN and FAD. [NIH] Rifabutin: A broad-spectrum antibiotic that is being used as prophylaxis against disseminated Mycobacterium avium complex infection in HIVpositive patients. [NIH] Ritonavir: An HIV protease inhibitor that works by interfering with the reproductive cycle of HIV. [NIH] Rotavirus: A genus of reoviridae, causing acute gastroenteritis in birds and mammals, including humans. Transmission is horizontal and by environmental contamination. [NIH] Ruminants: A suborder of the order artiodactyla whose members have the distinguishing feature of a four-chambered stomach. Horns or antlers are usually present, at least in males. [NIH] Saccharomyces: A genus of ascomycetous fungi Saccharomycetaceae, order saccharomycetales. [NIH]

of the

family

Saline: Salty; of the nature of a salt; containing a salt or salts. [EU] Saliva: The clear, viscous fluid secreted by the salivary glands and mucous glands of the mouth. It contains mucins, water, organic salts, and ptylin. [NIH] Salmonella: A genus of gram-negative, facultatively anaerobic, rod-shaped bacteria that utilizes citrate as a sole carbon source. It is pathogenic for humans, causing enteric fevers, gastroenteritis, and bacteremia. Food poisoning is the most common clinical manifestation. Organisms within this genus are separated on the basis of antigenic characteristics, sugar fermentation patterns, and bacteriophage susceptibility. [NIH] Saquinavir: An HIV protease inhibitor which acts as an analog of an HIV protease cleavage site. It is a highly specific inhibitor of HIV-1 and HIV-2 proteases. [NIH] Sarcoidosis: An idiopathic systemic inflammatory granulomatous disorder comprised of epithelioid and multinucleated giant cells with little necrosis. It usually invades the lungs with fibrosis and may also involve lymph nodes, skin, liver, spleen, eyes, phalangeal bones, and parotid glands. [NIH] Sarcoma: A tumour made up of a substance like the embryonic connective tissue; tissue composed of closely packed cells embedded in a fibrillar or homogeneous substance. Sarcomas are often highly malignant. [EU] Scopolamine: An alkaloid from Solanaceae, especially Datura metel L. and Scopola carniolica. Scopolamine and its quaternary derivatives act as antimuscarinics like atropine, but may have more central nervous system effects. Among the many uses are as an anesthetic premedication, in urinary incontinence, in motion sickness, as an antispasmodic, and as a mydriatic and cycloplegic. [NIH]

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Secretion: 1. the process of elaborating a specific product as a result of the activity of a gland; this activity may range from separating a specific substance of the blood to the elaboration of a new chemical substance. 2. any substance produced by secretion. [EU] Sedentary: 1. sitting habitually; of inactive habits. 2. pertaining to a sitting posture. [EU] Seizures: Clinical or subclinical disturbances of cortical function due to a sudden, abnormal, excessive, and disorganized discharge of brain cells. Clinical manifestations include abnormal motor, sensory and psychic phenomena. Recurrent seizures are usually referred to as epilepsy or "seizure disorder." [NIH] Selenium: An element with the atomic symbol Se, atomic number 34, and atomic weight 78.96. It is an essential micronutrient for mammals and other animals but is toxic in large amounts. Selenium protects intracellular structures against oxidative damage. It is an essential component of glutathione peroxidase. [NIH] Senna: Preparations of Cassia senna L. and C. angustifolia of the Leguminosae. They contain sennosides, which are anthraquinone type cathartics and are used in many different preparations as laxatives. [NIH] Serine: A non-essential amino acid occurring in natural form as the Lisomer. It is synthesized from glycine or threonine. It is involved in the biosynthesis of purines, pyrimidines, and other amino acids. [NIH] Serum: The clear portion of any body fluid; the clear fluid moistening serous membranes. 2. blood serum; the clear liquid that separates from blood on clotting. 3. immune serum; blood serum from an immunized animal used for passive immunization; an antiserum; antitoxin, or antivenin. [EU] Sigmoidoscopy: Endoscopic examination, therapy or surgery of the sigmoid flexure. [NIH] Sirolimus: A macrolide compound obtained from Streptomyces hygroscopicus that acts by selectively blocking the transcriptional activation of cytokines thereby inhibiting cytokine production. It is bioactive only when bound to immunophilins. Sirolimus is a potent immunosuppressant and possesses both antifungal and antineoplastic properties. [NIH] Sodium Bicarbonate: A white, crystalline powder that is commonly used as a pH buffering agent, an electrolyte replenisher, systemic alkalizer and in topical cleansing solutions. [NIH] Somatostatin: A polypeptide hormone produced in the hypothalamus, and other tissues and organs. It inhibits the release of human growth hormone, and also modulates important physiological functions of the kidney, pancreas, and gastrointestinal tract. Somatostatin receptors are widely

Glossary 307

expressed throughout the body. Somatostatin also acts as a neurotransmitter in the central and peripheral nervous systems. [NIH] Sorbitol: A polyhydric alcohol with about half the sweetness of sucrose. Sorbitol occurs naturally and is also produced synthetically from glucose. It was formerly used as a diuretic and may still be used as a laxative and in irrigating solutions for some surgical procedures. It is also used in many manufacturing processes, as a pharmaceutical aid, and in several research applications. [NIH] Species: A taxonomic category subordinate to a genus (or subgenus) and superior to a subspecies or variety, composed of individuals possessing common characters distinguishing them from other categories of individuals of the same taxonomic level. In taxonomic nomenclature, species are designated by the genus name followed by a Latin or Latinized adjective or noun. [EU] Spectrum: A charted band of wavelengths of electromagnetic vibrations obtained by refraction and diffraction. By extension, a measurable range of activity, such as the range of bacteria affected by an antibiotic (antibacterial s.) or the complete range of manifestations of a disease. [EU] Sphincter: A ringlike band of muscle fibres that constricts a passage or closes a natural orifice; called also musculus sphincter. [EU] Spiramycin: A macrolide antibiotic produced by Streptomyces ambofaciens. The drug is effective against gram-positive aerobic pathogens, N. gonorrhoeae, and staphylococci. It is used to treat infections caused by bacteria and Toxoplasma gondii. [NIH] Spirometry: Measurement of volume of air inhaled or exhaled by the lung. [NIH]

Sporadic: Neither endemic nor epidemic; occurring occasionally in a random or isolated manner. [EU] Staphylococcus: A genus of gram-positive, facultatively anaerobic, coccoid bacteria. Its organisms occur singly, in pairs, and in tetrads and characteristically divide in more than one plane to form irregular clusters. Natural populations of Staphylococcus are membranes of warm-blooded animals. Some species are opportunistic pathogens of humans and animals. [NIH]

Stimulant: 1. producing stimulation; especially producing stimulation by causing tension on muscle fibre through the nervous tissue. 2. an agent or remedy that produces stimulation. [EU] Stomach: An organ of digestion situated in the left upper quadrant of the abdomen between the termination of the esophagus and the beginning of the duodenum. [NIH] Streptococcus: A genus of gram-positive, coccoid bacteria whose organisms

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occur in pairs or chains. No endospores are produced. Many species exist as commensals or parasites on man or animals with some being highly pathogenic. A few species are saprophytes and occur in the natural environment. [NIH] Strongyloides: A genus of parasitic nematodes widely distributed as intestinal parasites of mammals. [NIH] Sucralfate: A basic aluminum complex of sulfated sucrose. It is advocated in the therapy of peptic, duodenal, and prepyloric ulcers, gastritis, reflux esophagitis, and other gastrointestinal irritations. It acts primarily at the ulcer site, where it has cytoprotective, pepsinostatic, antacid, and bile acidbinding properties. The drug is only slightly absorbed by the digestive mucosa, which explains the absence of systemic effects and toxicity. [NIH] Sulbactam: A beta-lactamase inhibitor with very weak antibacterial action. The compound prevents antibiotic destruction of beta-lactam antibiotics by inhibiting beta-lactamases, thus extending their spectrum activity. Combinations of sulbactam with beta-lactam antibiotics have been used successfully for the therapy of infections caused by organisms resistant to the antibiotic alone. [NIH] Sulfinpyrazone: A uricosuric drug that is used to reduce the serum urate levels in gout therapy. It lacks anti-inflammatory, analgesic, and diuretic properties. [NIH] Sweat: The fluid excreted by the sweat glands. It consists of water containing sodium chloride, phosphate, urea, ammonia, and other waste products. [NIH] Symptomatic: 1. pertaining to or of the nature of a symptom. 2. indicative (of a particular disease or disorder). 3. exhibiting the symptoms of a particular disease but having a different cause. 4. directed at the allying of symptoms, as symptomatic treatment. [EU] Systemic: Pertaining to or affecting the body as a whole. [EU] Tenesmus: Straining, especially ineffectual and painful straining at stool or in urination. [EU] Tetracycline: An antibiotic originally produced by Streptomyces viridifaciens, but used mostly in synthetic form. It is an inhibitor of aminoacyl-tRNA binding during protein synthesis. [NIH] Thermoregulation: Heat regulation. [EU] Thrombocytopenia: Decrease in the number of blood platelets. [EU] Thyroxine: An amino acid of the thyroid gland which exerts a stimulating effect on thyroid metabolism. [NIH] Tomography: The recording of internal body images at a predetermined

Glossary 309

plane by means of the tomograph; called also body section roentgenography. [EU]

Topical: Pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied. [EU] Toxicity: The quality of being poisonous, especially the degree of virulence of a toxic microbe or of a poison. [EU] Toxicology: The science concerned with the detection, chemical composition, and pharmacologic action of toxic substances or poisons and the treatment and prevention of toxic manifestations. [NIH] Toxin: A poison; frequently used to refer specifically to a protein produced by some higher plants, certain animals, and pathogenic bacteria, which is highly toxic for other living organisms. Such substances are differentiated from the simple chemical poisons and the vegetable alkaloids by their high molecular weight and antigenicity. [EU] Transdermal: Entering through the dermis, or skin, as in administration of a drug applied to the skin in ointment or patch form. [EU] Transfusion: The introduction of whole blood or blood component directly into the blood stream. [EU] Transplantation: The grafting of tissues taken from the patient's own body or from another. [EU] Triamterene: A pteridine that is used as a mild diuretic. [NIH] Tricyclic: Containing three fused rings or closed chains in the molecular structure. [EU] Trimebutine: Proposed spasmolytic with possible local anesthetic action used in gastrointestinal disorders. [NIH] Tryptophan: An essential amino acid that is necessary for normal growth in infants and for nitrogen balance in adults. It is a precursor serotonin and niacin. [NIH] Tuberculosis: Any of the infectious diseases of man and other animals caused by species of mycobacterium. [NIH] Ulceration: 1. the formation or development of an ulcer. 2. an ulcer. [EU] Urinalysis: Examination of urine by chemical, physical, or microscopic means. Routine urinalysis usually includes performing chemical screening tests, determining specific gravity, observing any unusual color or odor, screening for bacteriuria, and examining the sediment microscopically. [NIH] Urology: A surgical specialty concerned with the study, diagnosis, and treatment of diseases of the urinary tract in both sexes and the genital tract in the male. It includes the specialty of andrology which addresses both male

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genital diseases and male infertility. [NIH] Vaccination: The introduction of vaccine into the body for the purpose of inducing immunity. Coined originally to apply to the injection of smallpox vaccine, the term has come to mean any immunizing procedure in which vaccine is injected. [EU] Vaccine: A suspension of attenuated or killed microorganisms (bacteria, viruses, or rickettsiae), administered for the prevention, amelioration or treatment of infectious diseases. [EU] Vaginal: 1. of the nature of a sheath; ensheathing. 2. pertaining to the vagina. 3. pertaining to the tunica vaginalis testis. [EU] Vaginitis: Inflammation of the vagina characterized by pain and a purulent discharge. [NIH] Vancomycin: Antibacterial obtained from Streptomyces orientalis. It is a glycopeptide related to ristocetin that inhibits bacterial cell wall assembly and is toxic to kidneys and the inner ear. [NIH] Vascular: Pertaining to blood vessels or indicative of a copious blood supply. [EU] Vibrio: A genus of vibrionaceae, made up of short, slightly curved, motile, gram-negative rods. Various species produce cholera and other gastrointestinal disorders as well as abortion in sheep and cattle. [NIH] Virion: The infective system of a virus, composed of the viral genome, a protein core, and a protein coat called a capsid, which may be naked or enclosed in a lipoprotein envelope called the peplos. [NIH] Virulence: The degree of pathogenicity within a group or species of microorganisms or viruses as indicated by case fatality rates and/or the ability of the organism to invade the tissues of the host. [NIH] Viruses: Minute infectious agents whose genomes are composed of DNA or RNA, but not both. They are characterized by a lack of independent metabolism and the inability to replicate outside living host cells. [NIH] Visceral: , from viscus a viscus) pertaining to a viscus. [EU] Warfarin: An anticoagulant that acts by inhibiting the synthesis of vitamin K-dependent coagulation factors. Warfarin is indicated for the prophylaxis and/or treatment of venous thrombosis and its extension, pulmonary embolism, and atrial fibrillation with embolization. It is also used as an adjunct in the prophylaxis of systemic embolism after myocardial infarction. Warfarin is also used as a rodenticide. [NIH] Withdrawal: 1. a pathological retreat from interpersonal contact and social involvement, as may occur in schizophrenia, depression, or schizoid avoidant and schizotypal personality disorders. 2. (DSM III-R) a substance-

Glossary 311

specific organic brain syndrome that follows the cessation of use or reduction in intake of a psychoactive substance that had been regularly used to induce a state of intoxication. [EU] Xenopus: An aquatic genus of the family, Pipidae, occurring in Africa and distinguished by having black horny claws on three inner hind toes. [NIH] Yersinia: A genus of gram-negative, facultatively anaerobic rod- to coccobacillus-shaped bacteria that occurs in a broad spectrum of habitats. [NIH]

General Dictionaries and Glossaries While the above glossary is essentially complete, the dictionaries listed here cover virtually all aspects of medicine, from basic words and phrases to more advanced terms (sorted alphabetically by title; hyperlinks provide rankings, information and reviews at Amazon.com): ·

Dictionary of Medical Acronymns & Abbreviations by Stanley Jablonski (Editor), Paperback, 4th edition (2001), Lippincott Williams & Wilkins Publishers, ISBN: 1560534605, http://www.amazon.com/exec/obidos/ASIN/1560534605/icongroupinterna

·

Dictionary of Medical Terms : For the Nonmedical Person (Dictionary of Medical Terms for the Nonmedical Person, Ed 4) by Mikel A. Rothenberg, M.D, et al, Paperback - 544 pages, 4th edition (2000), Barrons Educational Series, ISBN: 0764112015, http://www.amazon.com/exec/obidos/ASIN/0764112015/icongroupinterna

·

A Dictionary of the History of Medicine by A. Sebastian, CD-Rom edition (2001), CRC Press-Parthenon Publishers, ISBN: 185070368X, http://www.amazon.com/exec/obidos/ASIN/185070368X/icongroupinterna

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Dorland’s Illustrated Medical Dictionary (Standard Version) by Dorland, et al, Hardcover - 2088 pages, 29th edition (2000), W B Saunders Co, ISBN: 0721662544, http://www.amazon.com/exec/obidos/ASIN/0721662544/icongroupinterna

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Dorland’s Electronic Medical Dictionary by Dorland, et al, Software, 29th Book & CD-Rom edition (2000), Harcourt Health Sciences, ISBN: 0721694934, http://www.amazon.com/exec/obidos/ASIN/0721694934/icongroupinterna

·

Dorland’s Pocket Medical Dictionary (Dorland’s Pocket Medical Dictionary, 26th Ed) Hardcover - 912 pages, 26th edition (2001), W B Saunders Co, ISBN: 0721682812, http://www.amazon.com/exec/obidos/ASIN/0721682812/icongroupinterna /103-4193558-7304618

312 Diarrhea

·

Melloni’s Illustrated Medical Dictionary (Melloni’s Illustrated Medical Dictionary, 4th Ed) by Melloni, Hardcover, 4th edition (2001), CRC PressParthenon Publishers, ISBN: 85070094X, http://www.amazon.com/exec/obidos/ASIN/85070094X/icongroupinterna

·

Stedman’s Electronic Medical Dictionary Version 5.0 (CD-ROM for Windows and Macintosh, Individual) by Stedmans, CD-ROM edition (2000), Lippincott Williams & Wilkins Publishers, ISBN: 0781726328, http://www.amazon.com/exec/obidos/ASIN/0781726328/icongroupinterna

·

Stedman’s Medical Dictionary by Thomas Lathrop Stedman, Hardcover 2098 pages, 27th edition (2000), Lippincott, Williams & Wilkins, ISBN: 068340007X, http://www.amazon.com/exec/obidos/ASIN/068340007X/icongroupinterna

·

Tabers Cyclopedic Medical Dictionary (Thumb Index) by Donald Venes (Editor), et al, Hardcover - 2439 pages, 19th edition (2001), F A Davis Co, ISBN: 0803606540, http://www.amazon.com/exec/obidos/ASIN/0803606540/icongroupinterna

Index 313

INDEX A Abdomen ......13, 14, 17, 28, 29, 122, 158, 160, 174, 266, 281, 288, 293, 299, 307 Abdominal.......12, 20, 22, 24, 32, 62, 120, 121, 123, 136, 148, 150, 156, 158, 255, 261, 262, 280, 285 Achlorhydria...........................................65 Acidosis .................................99, 100, 108 Adenine ...............................111, 114, 277 Adenosine............111, 114, 208, 277, 278 Adolescence ..........28, 121, 136, 277, 301 Adverse ...............................156, 212, 296 Albuterol ......................................208, 277 Algorithms..............................75, 122, 140 Alimentary....... 28, 86, 96, 136, 138, 280, 281, 295, 301 Alkaloid .......102, 114, 138, 174, 213, 281, 282, 300, 304, 305 Aluminum.......................61, 155, 213, 308 Analgesic ......25, 174, 210, 211, 212, 213, 214, 277, 285, 287, 290, 291, 294, 296, 303, 308 Anemia ..................................70, 120, 171 Anomalies ....................................121, 124 Anorectal .................................22, 32, 122 Antibacterial..29, 210, 214, 256, 288, 307, 308 Antibiotic .....29, 45, 52, 54, 106, 116, 151, 174, 175, 209, 210, 212, 214, 227, 260, 266, 278, 279, 281, 284, 289, 292, 298, 301, 305, 307, 308 Antibodies...... 71, 86, 96, 103, 264, 279, 280 Antibody......72, 87, 89, 96, 112, 138, 286, 294, 297 Anticholinergic .....136, 141, 209, 278, 283 Antidepressant.............................136, 278 Antigens.............86, 93, 98, 103, 280, 304 Antimicrobial .......160, 210, 254, 259, 260, 262, 263, 264, 265, 284, 287 Antispasmodic .............211, 213, 292, 305 Antiviral ..........................................90, 299 Anus ........................25, 60, 145, 279, 301 Anxiety...................................21, 210, 284 Appendicitis .........121, 122, 124, 137, 287 Aromatic ........................................99, 107 Ascites .................................121, 140, 142 Aspiration...............................................20 Assay...............................68, 89, 112, 294 Asymptomatic ..............................100, 258 Atrophy ........................................102, 170

Atropine....... 114, 174, 213, 278, 287, 305 Auscultation ........................................ 158 B Benign................................... 54, 122, 299 Bezoars............................................... 121 Bile ..... 12, 25, 28, 64, 145, 213, 241, 282, 283, 293, 296, 308 Biliary ..... 22, 28, 32, 120, 122, 123, 142, 293 Biochemical................... 75, 101, 111, 231 Biopsy ............................................. 60, 98 Biotinylation................................... 75, 104 Bismuth ..... 62, 155, 259, 261, 263, 264, 265 Budesonide ......................................... 228 C Cachexia ....................................... 22, 102 Camptothecin...................... 105, 114, 282 Capsules ..................................... 106, 239 Carbohydrate . 64, 89, 123, 142, 145, 238, 292 Carboplatin.................................. 105, 226 Carcinoma........................................... 228 Cardiac................................ 140, 213, 304 Causal......................................... 256, 264 Caustic ................................................ 121 Character ...................... 39, 145, 286, 292 Chemotherapeutics............................. 105 Chemotherapy . 44, 46, 60, 106, 114, 226, 283 Chlorine............................................... 256 Cholangitis .......................................... 142 Cholera .... 62, 76, 94, 103, 112, 130, 145, 256, 310 Cholesterol.. 134, 211, 236, 238, 241, 292 Cirrhosis...................................... 123, 140 Cisplatin .............................. 105, 114, 284 Clioquinol ............................................ 259 Clotrimazole .................................. 70, 107 Coagulation................................... 94, 310 Codeine............................................... 261 Colic ............................................ 124, 222 Colitis ...... 4, 33, 62, 109, 121, 122, 132, 141, 148, 149, 150, 222, 224, 260 Collagen.................................. 62, 87, 285 Colorectal........................ 44, 46, 120, 228 Conjugated............................................ 64 Constipation ... 20, 22, 24, 32, 60, 61, 120, 121, 122, 123, 125, 134, 140, 148, 150, 155, 156, 157, 222 Contamination............................... 29, 305

314 Diarrhea

Coronavirus .........................................108 Cryptosporidiosis .....................45, 52, 281 Cryptosporidium ..................................108 Cutaneous ...................................266, 302 Cyclic .............................................76, 112 Cyclophosphamide ..............................105 Cytokines ...............................70, 213, 306 Cytomegalovirus............11, 102, 211, 291 D Defecation .............28, 105, 156, 227, 294 Degenerative .......................................237 Dehydration ..... 11, 13, 14, 15, 17, 21, 61, 76, 87, 98, 99, 100, 108, 130, 262, 283 Diarrhoea.....................................130, 241 Digestion.......20, 29, 62, 85, 91, 123, 137, 222, 278, 288, 301, 307 Diphenoxylate..............259, 261, 263, 265 Diverticulitis .................................122, 222 Diverticulum.................................136, 287 Doxycycline .........259, 260, 262, 263, 265 Duodenum ....... 25, 27, 90, 121, 123, 282, 291, 296 Dysentery ............................................257 Dyspepsia............................120, 121, 156 Dysphagia......................................60, 120 E Edema .........................211, 266, 283, 291 Electrolyte...15, 28, 65, 68, 101, 123, 125, 133, 213, 254, 262, 302, 306 Electrophysiological...............................68 Encopresis...........................................121 Endemic...............65, 71, 87, 93, 283, 307 Endogenous ..........................................69 Endoscopy...................................141, 158 Enterotoxins...........88, 125, 256, 264, 289 Enzyme.......27, 66, 87, 92, 112, 114, 115, 174, 282, 285, 289, 290, 297, 303 Eosinophilia ...........................................62 Epidemic........................................93, 307 Epigastric ...............................60, 137, 288 Esophagitis ..................121, 140, 213, 308 Etoposide.............................................105 Evacuation.....................................26, 285 Exogenous.......................66, 88, 109, 290 F Fatigue...................................25, 258, 280 Fats.....25, 66, 88, 90, 136, 235, 236, 282, 284, 290, 297 Feces .......86, 98, 114, 137, 280, 282, 288 Fermentation ...................29, 97, 110, 305 Fibrosis .....66, 68, 75, 101, 121, 122, 124, 136, 160, 284, 305 Filtration.........................................90, 297 Flatulence ............................120, 122, 222 Flavivirus .............................................103 Fluorouracil......................44, 47, 105, 228

Fructose .............................................. 110 Furosemide ................................. 212, 295 G Gastritis......................... 65, 213, 222, 308 Gastroduodenal ..... 22, 27, 32, 121, 122, 291 Glucose.... 39, 76, 89, 101, 212, 213, 292, 295, 301, 307 Glutamine.............................................. 70 Gluten ................................................... 62 Goats ............................................ 99, 108 H Heartburn ...... 20, 120, 121, 156, 157, 222 Hematemesis ........................................ 60 Hematology........................................... 10 Hemorrhage .................. 92, 121, 122, 303 Hemorrhoids ....................................... 222 Hepatic........................................ 120, 123 Hepatitis ...... 11, 80, 103, 120, 121, 123, 124, 134, 140, 142 Hepatobiliary ................................. 22, 141 Hepatocellular ..................................... 228 Heredity............................................... 124 Hernia ................................................. 121 Herpes .................................... 11, 28, 293 Homeostasis ................................. 69, 123 Homogeneous ...................... 54, 104, 305 Hybridization ............................... 103, 264 Hydrogen ...................... 26, 210, 282, 287 Hygienic ...................................... 254, 265 Hyperbilirubinemia ........................ 28, 296 Hypertension......................... 54, 123, 300 I Idiopathic...... 64, 133, 137, 160, 230, 294, 305 Ileostomy............................................. 125 Immunity . 71, 97, 115, 116, 255, 294, 310 Immunization . 39, 54, 103, 130, 134, 259, 294, 306 Immunoassay ............................. 112, 113 Immunocompetence ....................... 66, 74 Incontinence .... 22, 32, 62, 122, 123, 140, 141, 148, 158, 213, 305 Induction ................. 72, 97, 115, 226, 294 Inflammation 62, 136, 156, 208, 266, 278, 280, 284, 287, 288 Infusion ............................................... 105 Ingestion ....... 92, 121, 239, 255, 257, 302 Insulin...... 39, 86, 89, 212, 279, 292, 295, 301 Intestines...... 12, 15, 20, 88, 89, 114, 266, 282, 288, 289, 290, 294, 296 Intubation .............................................. 65 Iodine .................................................. 256 Iodoquinol ........................................... 259 Ischemia.............................................. 150

Index 315

J Jaundice ......................................121, 123 Jejunum ...................64, 90, 137, 288, 296 L Labile ...................................................257 Leucovorin .......................................44, 47 Lipid .............................211, 212, 292, 295 Lumen..................................................111 Lymphoma...................................160, 297 M Malabsorption ...20, 60, 62, 64, 66, 72, 98, 102, 121, 123, 125, 132, 170, 241 Malaise ........................................255, 263 Malignant ....... 53, 54, 87, 122, 160, 281, 283, 297, 298, 305 Mannitol .................................................74 Melena ...................................................60 Membrane ....27, 69, 75, 87, 91, 125, 285, 288, 300 Mentors..................................................76 Mesenteric ...........................................123 Metastasis .....................54, 137, 297, 299 Methotrexate........................................105 Microbiology ........................................264 Micronutrients ..........................62, 70, 228 Microorganism ...............................25, 279 Mitomycin ............................................105 Mitosis .................................................102 Mobilization............................................68 Molecular ......10, 69, 70, 92, 94, 138, 164, 168, 169, 304, 309 Motility .................121, 123, 125, 140, 264 N Nausea .....12, 20, 87, 120, 121, 134, 136, 157, 226, 255, 262, 263, 280, 286 Nelfinavir................................................67 Neomycin.............................................226 Neonatal ..............................100, 122, 123 Neoplasms.......................53, 62, 121, 299 Neoplastic ............................123, 160, 297 Neural ..................................136, 237, 287 Neuromuscular ....................................140 Neuropathy ............................61, 266, 284 Neutralization.........................................72 Nicotine........................................114, 278 Nitrogen .......................................114, 286 Nosocomial..............................67, 91, 300 Nurseries .............................................100 O Occult ............................................62, 120 Octreotide ............................141, 223, 229 Oligosaccharides .........................109, 110 Oocytes .................................................69 Oral ...16, 26, 28, 52, 86, 87, 98, 100, 101, 125, 132, 158, 166, 174, 209, 211, 227,

254, 262, 264, 266, 278, 281, 282, 284, 286, 292, 295, 300 Osmotic......................... 62, 140, 142, 145 Overdose ............................................ 237 P Paclitaxel............................................. 226 Palpation ............................. 158, 160, 301 Pancreas.. 39, 60, 91, 121, 122, 123, 146, 212, 295, 301, 306 Pancreatitis ........... 62, 121, 124, 140, 142 Pancrelipase ......................................... 66 Parasitic ...... 12, 16, 27, 62, 88, 114, 122, 123, 133, 143, 265, 266, 281, 287, 288, 289, 292, 296, 308 Parenteral ................................... 121, 124 Pathologic ............................... 60, 92, 302 Peptic .................... 60, 122, 140, 213, 308 Perforation .................................. 136, 287 Perfusion............................................... 64 Pharmacist .......................... 149, 184, 207 Phosphorylation .............................. 69, 75 Photosensitivity................................... 260 Physiologic.... 62, 73, 75, 90, 93, 298, 304 Placenta ................................ 96, 210, 289 Pneumonia............................ 97, 144, 227 Poisoning .......................... 4, 29, 124, 305 Polypeptide ......... 103, 115, 145, 293, 306 Postoperative .......... 4, 211, 212, 290, 296 Potassium ..... 15, 64, 210, 213, 238, 289, 304 Prednisone.......................................... 156 Prevalence ............................................ 74 Progressive ................. 174, 211, 286, 292 Prophylaxis .. 94, 175, 254, 259, 265, 305, 310 Protease. 90, 96, 174, 175, 226, 295, 299, 305 Proteins.. 72, 87, 115, 160, 210, 236, 238, 286, 289, 293, 300 Protozoan................ 53, 74, 266, 286, 296 R Reagent ...................................... 266, 283 Receptor ....... 68, 112, 210, 211, 284, 290 Recombinant......................................... 72 Recurrence ......................................... 110 Reflux... 60, 121, 122, 125, 140, 156, 213, 308 Refractory ........................................... 229 Rehydration....... 13, 15, 16, 76, 98, 125, 132, 144, 158, 166, 241, 242, 265 Relaxant...................................... 210, 284 Remission ..................................... 93, 304 Resection ............................................ 132 Respiratory... 86, 113, 114, 130, 131, 160, 229, 281, 284, 285 Riboflavin ............................................ 236

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Rotavirus ......11, 12, 71, 74, 97, 106, 108, 109, 152, 242, 258 Ruminants ...........................................112 S Saline...................................115, 155, 295 Saliva ...................................................112 Salmonella...................................108, 260 Secretion ....39, 54, 64, 65, 68, 69, 75, 80, 85, 90, 99, 101, 111, 142, 209, 211, 213, 225, 257, 264, 277, 284, 290, 298, 299, 300, 306 Seizures.........................29, 209, 284, 306 Selenium........................................74, 238 Senna ............................................29, 306 Serine ....................................................69 Sigmoidoscopy ..................15, 21, 24, 141 Somatostatin....39, 54, 142, 145, 300, 301 Sorbitol ..........................................90, 297 Spectrum ....10, 80, 87, 94, 125, 175, 209, 210, 212, 214, 254, 278, 279, 285, 288, 296, 305, 308, 311 Sphincter .....................................138, 307 Sporadic ................................77, 100, 258 Stimulant..............................155, 209, 278 Stomach ....... 12, 20, 27, 39, 88, 90, 116, 121, 123, 124, 137, 222, 291, 295, 301, 305 Sulbactam....................................214, 308 Surgical....... 26, 29, 52, 86, 92, 121, 122, 132, 213, 279, 283, 285, 302, 307, 309 Symptomatic..........93, 145, 258, 261, 308 Systemic ...60, 62, 94, 160, 209, 210, 213, 283, 288, 305, 306, 308, 310 T Tears .....................................................13 Tenesmus....................................266, 288 Tetracycline .................................210, 287

Thermoregulation................................ 236 Thrombocytopenia .............................. 105 Thyroxine ............................................ 237 Tomography........................................ 158 Toothache ............................................. 60 Topical ...... 114, 175, 212, 213, 266, 281, 284, 296, 306, 309 Toxicity........................................ 213, 308 Toxicology..................................... 10, 165 Toxin ............................... 67, 69, 111, 133 Transfusion ......................................... 148 Transplantation .... 61, 121, 123, 124, 228, 241 Tricyclic ......................... 86, 136, 280, 287 U Ulceration.............................................. 60 Urinalysis ...................................... 55, 309 Urology.................................................. 10 V Vaccination ........................................... 97 Vaccine .... 72, 77, 85, 103, 116, 152, 264, 277, 310 Vaginal ........................................ 266, 284 Vaginitis .............................................. 260 Vancomycin ........................................ 192 Vascular ...... 60, 62, 116, 123, 208, 211, 278, 290, 302 Viral...... 11, 12, 16, 61, 68, 72, 80, 96, 99, 103, 104, 108, 112, 113, 117, 120, 123, 133, 210, 256, 258, 287, 310 Virion................................................... 103 Virulence ... 72, 74, 77, 100, 138, 257, 309 Viruses ..... 11, 12, 16, 21, 25, 94, 96, 104, 107, 115, 116, 138, 258, 265, 280, 291, 298, 310 W Warfarin .............................................. 225

Index 317

318 Diarrhea

Index 319

320 Diarrhea