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Thus blood pressure medication micardis buy plavix overnight, until quality evidence is available heart attack exo xoxo purchase plavix 75 mg on-line, the choice of surgical procedure for symptomatic spinal stenosis is to be decided by the surgeon and patient arteria carotida generic plavix 75mg. One moderate quality study compared laminoplasty with skip laminectomy and found no differences prehypertension 2016 buy plavix 75 mg otc. These procedures are effective for treatment of the lumbar spine (see Low Back Disorders Guideline). These procedures are invasive, have adverse effects, but may be less invasive than fusion and thus are recommended for select patients (see Fusion below). In Cochrane Library we found and reviewed 13 articles and considered 2 for inclusion. Of the 26 articles considered for inclusion, 14 randomized trials and 11 systematic studies met the inclusion criteria. Data spondylosis, C least 12 months follow Japanese Orthopedic open-door and French-door suggest overall French disc herniation, up. However, quality studies document fusion is not a reliable indicator for resolution of pain. These methodological issues impair the ability to draw robust evidence-based conclusions. However, some surgeons perform cervical fusion for cases of axial cervical pain without radicular pain, and there are no quality studies identified to support surgery for those patients. Recommendation: Cervical Discectomy with Fusion for Chronic Radiculopathy Cervical discectomy with fusion is recommended for patients with chronic radiculopathy due to ongoing nerve root compression who continue to have significant pain and functional limitation after at least 6 months of time and appropriate non-operative treatment. The decision to use an anterior or posterior approach and what technique to achieve a fusion (which procedure) to use should be left to the surgeon. Recommendation: Decompression Surgery for Spinal Stenosis/Myelopathy Decompression with fusion is recommended for treatment of patients with symptomatic spinal stenosis that is intractable to non-operative management. The decision to use an anterior or posterior approach and what technique to achieve a fusion should be left to the surgeon. Recommendation: Fusion for Degenerative Spondylolisthesis Fusion is recommended for treatment of degenerative spondylolisthesis. Recommendation: Spinal Fusion with Simultaneous Discectomy Spinal fusion is recommended as an option at the time of discectomy if a patient is having a simultaneous discectomy on the same disc. Recommendation: Pulsed Electromagnetic Field Stimulation for Cervical Spine Fusion Patients Pulsed electromagnetic field stimulation for cervical spine fusion is not recommended as a routine treatment for these patients, including patients with multiple spine fusion levels or in smokers. Recommendation: Autologous Platelet Gel for Cervical Spine Fusion Patients Autologous platelet gel for cervical spine fusion is not recommended. There are no quality studies of cervical or thoracic spondylolisthesis which are believed to be relatively uncommon, although there are a few in the lumbar spine. Cervical fusion has been proposed as treatment for spondylolisthesis, disc herniation, spinal stenosis, and chronic non-specific cervical pain (also referred to as degenerative disc disease, discogenic cervical pain, micro instability, black disc disease, and cervical spondylosis). The available quality studies suggest cervical fusion for radiculopathy results in improvements in arm pain more than cervical pain, because nerve root decompression is done at the time of fusion (see evidence table), thus fusion appears to be an option, although discectomy appears to be equally effective. Chronic cervical pain patients can be extremely difficult to manage, particularly when the pain is severe, narcotic and other drug issues are present, adherence to exercise regimens is weak, psychosocial stressors are present, and coping skills are poor. Fusion is often viewed as one of the last resort options for treatment of these individuals. Similarly, patients often come to view these surgical procedures as potential cures. However, there are no quality studies documenting improved results with fusion compared with other treatments including non-operative treatments for these patients. Pulsed electromagnetic field stimulation has been used to increase radiological fusion rates in high risk patients, particularly including fusion of multiple levels or in smokers (who are more likely to have non unions than are non-smokers). Cervical fusion is among the more invasive of the commonly performed spine surgeries. However, for a select few chronic radicular pain patients, particularly those who have recurrence after discectomy, it may be recommended. In Cochrane Library, we found and reviewed 37 articles, and considered 0 for inclusion. Of the 98 articles considered for inclusion, 80 randomized trials and 18 systematic studies met the inclusion criteria. Surgery superior to precluding assessment years preferences and collar at 14-16 weeks (p <0. At 12 co-intervention Foundation, and flexibility, isometric neck months, no difference between procedures. Eur Spine J after treatment there was no weakness and sensory statistical difference between loss can be expected to groups in muscle strength. The months after surgery, while surgery group had greater slow improvement with Second report of improvement compared to conservative treatments Persson 1997 physiotherapy and cervical and recurrent symptoms in Spine J. Subjective discectomy and herniation, but no data least 6 weeks; age titanium cage (n = 41). Iliac result in excellent pain Suggests no difference crest grafts used (N = relief immediately in outcomes. Odom fusion is a promising Excellent/Good at 6/12 months: therapeutic option in 72. Radiologically No mention of assessed fusion status at 12 sponsorship or month follow up: 81%, 74%. Smith 36 scores, Oswestry Disability disc height or segmental collapse, although no segmental Robinson approach scores between groups (p = lordosis during cervical clinically significant instability. ProOsteon 200 locking plates (Stratec Study results mixed, and hydroxyapatite Medical) all patients. Novus ring (n = 11) in cessation of enrollment due effectiveness could be block older (58 vs. Study enrollments Surgery individualized, have clinical meaning and in this study and stopped prematurely due generally including lucency disappeared at 12 autologous bone graft. Follow-up at 4, global assessments for all Trabecular Metal than with Conclusions on efficacy degenerative disc 12, and 24 months. Kyphosis more cervical spine surgery plating results in no 1998 correlate 1-level Robinson method. No has a number of unique suggest no clinical conservative plates that were differences in bone density (p = advantages over traditional differences in outcomes. No randomized is therefore a logical conclusion outcomes in single-level on levels of disease, No mention of that the plate design does not fusions but statistical raises questions about sponsorship or have any effect on the clinical trends indicated that those conclusions. At when the indication criteria sponsorship or 3 months, patients had returned are fulfilled. At 12 months, fusion rate at 6 months earlier fusion but did not patients (Smith 4 hours a day for 3 86.

Also heart attack craig yopp generic plavix 75mg fast delivery, the subjective feeling of having slept better may also be related to the significant (p= hypertension nursing interventions 75mg plavix amex. It can also be speculated that being connected to the portable sleep monitoring equipment may have had some effect on participants sleep patterns artery dorsalis pedis order plavix 75mg mastercard. For example blood pressure medication no erectile dysfunction cheap 75mg plavix with visa, the discomfort associated with walking around connected to the equipment may have resulted in some participants retiring to bed earlier than they would normally do. It may have also been a factor affecting participants to remain in bed or spend shorter time out of bed in case of an awakening during the night. Since diminished subjective sleep quality is one of the most frequent health complaints in the elderly (Prinz, 1995), the significant improvement in most aspects of subjective sleep status in the yoga group is an important finding despite the discrepancy seen between the subjective and corresponding objective sleep quality measures. This may be partially explained by the 249 potentially addictive characteristics of these medications (Longo & Johnson, 2000). Perhaps a longer intervention period may be needed to reduce dependency on these medications. The lack of significant change in sleepiness and daytime dysfunction measures may possibly be related to persistent consumption of sedatives/hypnotics and relaxants, as regular use of these medications has been shown to be associated with daytime drowsiness (Nowell et al. The present study has demonstrated that yoga results in 250 significant improvements (p<. Additional studies are required to further examine the psycho-physiological mechanisms involved in the strong association between anxiety, stress, depression and insomnia and how yoga affects those mechanisms. This will enable developing more effective yoga interventions for these conditions. The acceptability of yoga is evidenced by the rapid and wide-ranging response to the recruitment advertising campaign and the low dropout rate, while the safety is indicated by the lack of adverse events. However, compliance in general and home practice compliance in particular was below recommended level. Overall, only 10 percent of participants achieved a practice compliance level equal or above the recommended level of three daily practice units. The results of the daily logs revealed that for the present study compliance level did not vary much over the 12 weeks intervention period with most participants maintaining a constant individual compliance level and changes in compliance being related to transient events. Overall, study findings revealed that achieving an adequate practice compliance level was essential for effective application of the yoga protocol, especially for improving insomnia status. It seems that at least 25 minutes of daily practice is required to achieve these benefits. Yoga practice, as applied in the present study, appears to be a safe, easy to implement, and well accepted non-drug intervention for the elderly in a western urban cultural setting. Specifically, improvements were seen in subjective measures of sleep latency, sleep duration, self assessed sleep quality, fatigue and vitality. Specifically, improvements were seen in levels of depression, anxiety, stress, tension and anger. Improvements were also seen in vitality and daily function in physical, emotional and social roles. While yoga was readily accepted by an elderly population, maintaining practice levels at a minimum of 25 minutes per day appears to be crucial for improving sleep quality and quality of life in this population. Factors that may increase participation include providing materials to support home practice, maintaining a yoga class component with one or two weekly classes to introduce, revise and reinforce the exercises prescribed for home practice, as well as providing a choice of exercises that can be graded according to different abilities. The present study has shown that yoga can be applied effectively to improve sleep and life quality in elderly presenting with complaints of insomnia. Examine if short and medium duration yoga programs can result in long term persistence of self home-based practice 2. Examine long term effects of short and medium duration yoga programs on sleep quality and quality of life Yoga encompasses a diversity of practices and techniques. Examine various physical and meditative yoga techniques to determine most effective for improving sleep quality. Future studies may benefit from making use of additional audio-visual aids such as video recordings of yoga sessions as well as software for personal computers with a menu system and links to detailed instructions, supporting material, detailed daily sleep and practice logs and questionnaires. Future studies may also benefit from making use of the internet to allow study participants to communicate with their yoga teachers and participate in online yoga classes. This would allow future studies to increase the number of classes and offer daily classes at convenient times. Applying such measures, may allow increasing the sample size and improving home practice compliance level. Introduction of online research systems may also be used for long term observation and follow up of practice outcomes and compliance levels. Future research in the area of geriatric insomnia would benefit from making use of such tools both as screening and diagnostic tools. The measures could easily be taken in participants home environments, during meditation and relaxation sessions and even during gentle exercise. Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. Correlation of subjective and objective sleep measurements at different stages of the treatment of depression Psychiatry Research, 120(2), 179 190. The impact and prevalence of chronic insomnia and other sleep disturbances associated with chronic illness. Characteristics of insomnia in the United States: Results of the 1991 National Sleep Foundation survey. Impaired Autonomic Balance During Slow Wave Sleep in Obstructive Sleep Apnea Patients Origin or Result Fluctuations in autonomic nervous activity during sleep displayed by power spectrum analysis of heart rate variability. Electrocardiogram Based Evaluation of Children with Sleep Related Upper Airway Obstruction. Complementary and Alternative Medicine Use among Adults and Children: United States, 2007. Validation of the Insomnia Severity Index as an outeome measure for insomnia research. Obstructive Sleep Apnea Syndrome: Pathogenesis of Neuropsychological Deficits J Clin Exp Neuropsychol. Full-scale and short-form of the Profile of Mood States: a factor analytic comparison. Sleep problems as a risk factor for falls in a sample of community-dwelling adults aged 64-99 years. Sleep disturbance and psychiatric disorders: A longitudinal epidemiological study of young adults. Sudarshan Kriya yogic breathing in the treatment of stress, anxiety, and depression: part I-neurophysiologic model. Sudarshan Kriya Yogic breathing in the treatment of stress, anxiety, and depression. Obstructive Sleep Apnea Syndrome in Morbid Obesity* Effects of Intragastric Balloon. Efficacy of Abbreviated Progressive Muscle Relaxation Training: A Quantitative Review of Behavioral Medicine Research. Relationships between mindfulness practice and levels of mindfulness, medical and psychological symptoms and well-being in a mindfulness-based stress reduction program. Accurate derivation of heart rate variability signal for detection of sleep disordered breathing in children. Sleep quality, depression state, and health status of older adults after silver yoga exercises: cluster randomized trial. Physical fitness of older adults in senior activity centres after 24-week silver yoga exercises. Effects of yoga on sleep quality and depression in elders in assisted living facilities. Intent-to-treat versus on treatment analysis: how to interpret the results of a clinical trial Paper presented at the First Natl Conference on Human Retroviruses and Related Infections 1993. Mindfulness-based stress reduction for stress management in healthy people: a review and meta-analysis. A systematic review of neurobiological and clinical features of mindfulness meditations.

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Mechanism: A channel forms between the lacerated vein and artery immediately post venepuncture heart attack 5 fragger purchase cheap plavix on-line, or in the healing process hypertension treatment guidelines 2014 plavix 75mg with amex. The affected area may be warm arrhythmia frequency discount plavix 75 mg amex, and the distal part of the arm may be cool if significant shunting of blood is present 5 plavix 75mg without a prescription. Compartment syndrome Definition: Increased intracompartment pressure leading to muscle and soft tissue necrosis. Mechanism: Blood may accumulate in the frontal deep areas of the forearm, closing small blood vessels and resulting in muscle and nerve tissue necrosis. Signs and symptoms: Painful arm, particularly on movement; swelling, paresthesias and partial paralysis. Brachial artery pseudoaneurysm Definition: Collection of blood outside an artery, contained by adventitia or the surrounding tissues alone. Mechanism: After a traumatic arterial puncture, blood may leak out of the artery and accumulate in the surrounding space. Signs and symptoms: Usually several of the following: discomfort, weakness, anxiety, light-headedness/dizziness, nausea, chills, sweating, vomiting, pallor, hyperventilation, rapid or a slow pulse. Reactions may occur before phlebotomy (rare), during phlebotomy or immediately after phlebotomy, when the donor stands up, in the refreshment area, or after the donor has left the collection site. Mechanism: Infusion of citrate anticoagulant during apheresis causes a fall in ionised calcium levels, leading to neuromuscular hyperactivity. If untreated, symptoms may progress to tetany and severe cardiac arrhythmias, including cardiac arrest. Operator error with mix up of saline and citrate bags may occur with some apheresis equipment, and lead to rapid citrate infusion. Symptoms and signs: Numbness or tingling of lips, feelings of vibrations, numbness or tingling in the fingers, metallic taste, chills, shivering, light-headedness, feeling of tightness, muscle twitching, rapid or slow pulse, shortness of breath. Symptoms may progress to carpopedal spasms and vomiting, and in severe reactions, to generalised muscle contractions (tetany), shock, irregular pulse and cardiac arrest. Mechanism: There may be malfunctioning valves, kinks or obstruction of the tubing, incorrect installation of equipment, or other equipment failures affecting the extracorporeal circuit. Mechanism: Air may enter into the lines due to incomplete priming of lines, as a result of a machine malfunction or defective collection kits or through incorrect manipulation by staff. Air may pass to the arterial circulation through an atrial septal defect, and reduce blood flow to the brain. Cough, dyspnea, apprehension, sweating, chest pain, confusion, tachycardia, hypotension, nausea and vomiting. Optional category: Infiltration Definition: Intravenous solute (saline solution) enters the extravascular tissues during volume replacement (generally only applicable to double red cell procedures). Mechanism: the needle is no longer positioned in the intravascular space, so fluids enter the surrounding tissues. Allergic reactions Allergy (local) Definition: Red or irritated skin at the venipuncture site. Mechanism: Reaction caused by allergens or irritants in solutions used for disinfection of the arm (such as iodine or chlorhexidine) or in manufacture of the collection set. Irritation may also occur due to application of the adhesive bandage (bandage adhesive dermatitis). An allergic reaction to latex that may be in supplies such as gloves may also occur. Signs and symptoms: Itching and redness at the venepuncture site, the bandage site, or the entire skin disinfection area. In a true allergic reaction, there may be a raised rash or hives in these areas that may expand to cover a larger area of the arm. Generalised allergic reaction (anaphylactic reaction) Definition: Anaphylactic type reactions usually starting soon after the procedure is begun and may progress rapidly to cardiac arrest. Mechanism: Extremely rare reactions, attributed to donor sensitivity to ethylene oxide gas used to sterilize some collection kits. Signs and symptoms: Apprehension, anxiousness, flushing, swelling of eyes, lips or tongue, cyanosis, cough, wheezing, dyspnea, chest tightness, cramps, nausea, vomiting, diarrhoea, tachycardia, hypotension, and altered mentation. Only cases with definite, probable or possible imputability should be included in international reporting. Major cardiovascular events, including death, may occur in the hours after attending the collection centre for blood donation. This can occur without any relation to the donation (for deaths, this is described by the term actuarial deaths). Other complications Other systemic reactions or complications that do not fit into the above, such as chest pain that may have been investigated as angina, but was actually musculoskeletal, or transmission of infection to a donor through erroneous re-use of equipment. Grading of severity for donor reactions does not easily fit into grading systems used for adverse reactions in patients. The criteria for classification of a reaction as serious (severe) as derived from these systems are: Hospitalization: If it was attributable to the complication. The criterion of hospital admission is applicable if a donor is kept in hospital overnight. Intervention: To preclude permanent damage or impairment of a body function or to prevent death (life threatening) Symptoms: Causing significant disability or incapacity following a complication of blood donation and persisted for more than a year after the donation (Long term morbidity) Death: If it follows a complication of blood donation and the death was possibly, probably or definitely related to the donation. Types and definitions of reactions: Certain complications of donation are by their nature mild or severe. Local reactions Most local reactions (hematoma, arm pain syndromes) would not be considered severe. Severe consequences are separate reaction types: deep venous thrombosis, arteriovenous fistula, and compartment syndrome. This may be captured by the duration of symptoms (optional split in nerve pain category). Complications that are by their nature severe include generalised allergic (anaphylactic) reactions, and all major cardiovascular events. Grading of imputability the strength of relation between donation and complication is: Definite or certain: When there is conclusive evidence beyond reasonable doubt for the relation. Unlikely or doubtful: When the evidence is clearly in favor of attributing the complication to other causes. Excluded: When there is conclusive evidence beyond reasonable doubt that the complication can be attributed to causes other than the donation. Imputability should only be reported for cardiovascular events leading to hospitalization or death post-donation, and only cases with imputability of possible, probable or definite should be captured. Related to apheresis Citrate reactions Haemolysis Air embolism Infiltration D. Other serious complications Acute cardiac symptoms (other than myocardial infarction or cardiac arrest). Other For A-F, optional separate reporting of reactions classified as serious according to standard criteria (life-threatening or leading to hospitalisation, incapacity, chronic morbidity or death). First-time vs repeat donor Age group of donors (optional): 16-18, 19-22, 23-29, 30-69, 70 and over 4. Total donations (who proceeded to phlebotomy) by type of donation per calendar year a. First-time vs repeat donors Age group of donors (optional): 16-18, 19-22, 23-29, 30-69, 70 and over 3. Volume of bags for whole blood collection (may split whole blood denominator into two if very different sizes used, for example 250 ml vs. On site and when donors call back and question on record of donation (if possible, do not use information from routine requestioning of donors on record of donation for statistics for international comparisons) 6. For the frst time, we can in-vivo visualize not only the vitreo-retinal interface but also the cortical vitreous which is important at the time when more and more therapies are delivered via intra-vitreal injections. Multimodal All-in-One fundus imaging tool will bring the next level of diagnostic capability to you and your patients.

Symptom frequency and severity in patients with metastatic or locally recur In the care of cancer patients blood pressure 300 over 200 purchase plavix 75mg visa, cough may become very rent lung cancer: a prospective study using the Lung distressing in the terminal stage blood pressure chart monitor discount 75 mg plavix fast delivery. If the cough is productive arteria lingualis effective 75 mg plavix, it is helpful consecutive patients admitted to an acute hospice/ to position the patient so that expectoration is assisted heart attack move me stranger buy generic plavix 75mg line, palliative care unit. The concerns of pa tory tract infection, if the symptoms of cough and dysp tients under palliative care and a heart failure clinic are not noea are very distressing. The measurement of prescribed drugs which can cause dry mouth and re symptoms in children with cancer. A case-control study of derived humanized monoclonal antibody, a novel agent lung cancer among Czech women. Lung toxicity following chest properties in lung cancer: relationship with site of lesion. Oxford Text in lung cancer patients: a retrospective study of risk factors book of Palliative Medicine, 2nd edn. Symptom Management in smoking on the development of radiation-induced pneu Advanced Cancer, 2nd edn. Bronchiolitis obliter pulmonary aspergillosis in immunocompromised pa ans organizing pneumonia syndrome in breast-conserving tients. Health-related qual plasty for acute unilateral vocal fold paralysis following ity of life, symptom distress and sense of coherence in adult intrathoracic surgery. Self-perceived analysing symptom palliation in cancer clinical trials: a physical, psychologic, and general symptoms in survivors deceptively difcult exercise. Idiopathic alone for medically inoperable stage I non-small-cell lung pneumonia syndrome following myeloablative cancer: the Duke experience. Delayed pul tive study on quality of life before and after radical radio monary toxicity syndrome following high-dose therapy in non-small-cell lung cancer. Am J Respir Crit Care Med 1998; 157: 37 Medical Research Council Lung Cancer Working Party. Continuous hyperfractionated accelerated 50 Jassem J, Krzakowski M, Roszkowski K etal. Quality vanced non-small cell lung cancer: clinical outcomes and of life after palliative radiotherapy in non-small cell lung quality of life. Palliative treat advanced non-small cell lung cancer: changes in perform ment of advanced non small cell lung cancer with ance status and tumour-related symptoms. Textbook of radiotherapy course for locally advanced non-small cell Medical Oncology, 2nd edn. Assessment and management of levodropropizine and dihydrocodeine on nonproductive respiratory symptoms of malignant disease. High dose rate en syndrome in breast cancer patients undergoing high-dose dobronchial brachytherapy: results and complications in chemotherapy and autologous stem cell transplantation. Using anti diotherapy for malignant bronchial obstruction or recur muscarinic drugs in the management of death-rattle: evi rence. Widdicombe Introduction myelination, conduction velocity and sites of ter mination in the airways. The utility of each of these the cough reex is one of several defensive reexes that approaches for dening airway afferent nerve subtypes serve to protect the airways from the potentially dam is limited in large part by the lack of specicity of aging effects of inhaled particulate matter, aeroaller the various characteristics studied. Most airway afferent nerves found in any of pathways involved in the cough reex is derived from these species are described reasonably well as either studies in animals. Al specic) for these afferent nerve subtypes and that these though poorly described, afferent nerves innervating reexes are modulated by interventions that preferen other viscera as well as somatosensory nerves innervat tially alter the activity or actions of the afferent nerve ing the chest wall, diaphragm and abdominal muscula subtypes studied is further evidence for the utility of ture also likely play an integral role in regulating cough. The characteristics of the afferent nerve subtypes in Airway afferent nerve subtypes can be distinguished nervating the airways are described briey in Table based on their physicochemical sensitivity, adaptation 16. Neither subtype of mechanoreceptor re ings of afferent nerve activity in the vagus nerve of anaes sponds to capsaicin (Cap), but both re intensely when the thetized rats. Modied with per spond vigorously to intravenous injections of the vanilloid mission from [10]. Consis mans (see below), and full all of the accepted criteria tent with this latter assertion, experiments performed for mediating cough [1,4,13,24]. C-bres may synthesize C-bres of neuropeptides, abolishes cough in guinea neuropeptides that are subsequently transported to pigs induced by citric acid, but has no effect on cough their central and peripheral nerve terminals evoked by mechanical probing of the airway mucosa in [9,37,39,40]. Finally, pharmacological bronchopulmonary C-bres has been exploited to de studies which take advantage of the somewhat unique scribe the distribution and peripheral nerve terminals expression of neurokinins by airway C-bres have of these unmyelinated airway afferent nerve endings. In anaesthetized animals, for exam distinction based both on sites of termination but also ple, C-bre stimulation has consistently failed to evoke on responsiveness to chemical and mechanical stimuli coughing, even though cough can be readily induced in [14]. Notably, pulmonary C-bres in dogs may be unre these animals by mechanically probing mucosal sites sponsive to histamine, whilst bronchial C-bres (in along the airways [6,24,25,47]. Consistent with readily activated by chemical stimuli such as capsaicin, this notion, general anaesthesia can also inhibit the bradykinin, citric acid, hypertonic saline and sulphur cough reex in human subjects [48]. Reex responses evoked by C-bre that anaesthesia prevents C-bre activation and C activation include increased airway parasympathetic bre-mediated reex effects entirely. C-bres are nerve activity and the chemoreex, characterized by readily activated in anaesthetized animals and apnoea (followed by rapid shallow breathing), brady can precipitate profound cardiorespiratory reexes cardia and hypotension [11,14,21,34]. Alternatively, general anaesthesia may inter subtypes are unique to the guinea-pig trachea, is un fere with the conscious perception of airway irritation known. Whether this is reective of their peculiarity to the teresting that capsaicin-evoked cough can be con guinea-pig or of the fact that myelinated, nociceptor sciously suppressed in human subjects [53]. Yet an like bres innervating the airways of other species have equally viable hypothesis is that C-bre stimulation been excluded from published analyses is also un alone is simply insufcient to evoke cough but depends known. Extracellular recording in the vagal [56] and Ho and colleagues [10] both described a sensory ganglia of guinea-pigs indicates that about half population of myelinated afferent nerves innervating of the tracheal afferent nerves responsive to both the airways of rats that were activated vigorously by bradykinin and capsaicin are small, myelinated, Ad lung deation yet adapted rapidly to sustained lung bres [9]. These afferent nerves, which were active nociceptors resemble the myelinated nociceptors de throughout the respiratory cycle, appeared to be physi scribed in somatic tissues [54]. The adaptation index (a measurement of af ferent responsiveness to sustained mechanical stimula Peripheral interactions tion) of these bres also differs considerably. In cats and dogs, for example, aggerated sensations of pain following cutaneous stim bradykinin and capsaicin evoke bronchospasm, ulation. Studies of central sensitization in the spinal bronchial vasodilatation and mucus secretion, but cord have revealed two features of the somatosensory these responses can be prevented entirely with atropine system that facilitate this hyperreexia. Unlike those seen in rats and guinea and mechanoreceptor nerve terminals appear to con pigs, therefore, parasympathetic reexes account for verge onto common integrative neurones in the spinal the end-organ effects mediated by airway C-bre cord. Secondly, this convergence allows for central am activation in the airways of dogs and cats [14,70,71]. In many systems, this synergy and resulting hy portance of the axon reex in humans, as there are few perreexia is precipitated by neurokinins released from substance P-containing nerve bres in human airways, the central terminals of somatosensory C-bres. This and there is no evidence that these nerves correspond to results in a long-lasting hyperexcitability of spinal inte the terminals of capsaicin-sensitive afferent C-bres grative neurones [35,78]. Although studies in vitro suggest that capsaicin Several lines of evidence suggest that a process can evoke contractions of the airway smooth muscle similar to central sensitization may play a role in airway and enhance mucus secretion in human tissue prepara defensive reexes. In addition, (and other species) has to be reconciled with data show anatomical and functional studies have shown consid ing that C-bre stimulants are extremely effective at erable convergence of vagal afferents in brainstem evoking cough. Acti Central interactions vation of C-bre afferent nerves in the lung evokes pro Our understanding of central integration of airway found increases in cholinergic tone in the airways by afferent bres is somewhat limited. In the absence of airway mechanoreceptor be obtained from studies in other systems, particularly activity, C-bres are ineffective at evoking reex re the somatosensory system.