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U. Grubuz. Western States Chiropractic College.

She had decreased perception of light touch sensation over the left leg and flank buy propranolol cheap. Over the same area buy 80mg propranolol otc, sensory testing using a pin produced a heightened order generic propranolol pills, unpleasant sensation purchase propranolol 40mg. On tests of coordination, she had slowness and clumsiness with the left arm, giving a tendency to overshoot the target. Gait was mildly unstable, with a stiff, awkward tendency to circumduct the left leg. What is the differential diagnosis of the patient’s presenting symptoms: left leg weakness and numbness? History of present illness: One year before presentation, the patient gradually became aware of clumsiness and difficulty while dancing. Attributing the problem to her busy schedule, she decided to take a two-month vacation in the south of France. She found herself progressively unable to climb hills, ascend stairs, or rise from a seated position due to leg weakness. Over two weeks before admission, she developed difficulty reaching and lifting objects. There was no weakness referable to the bulbar musculature, but she complained of shortness of breath. There was no muscle pain or aching, back pain, sensory symptoms, or bladder or bowel impairment. She returned to New York, and took a taxi directly from the airport to the Emergency Room at Columbia University Medical Center. She did not experience systemic symptoms, such as anorexia, weight loss, joint pains, neck pain, rashes, night sweats, myoglobinuria or other medical symptoms. Past medical history: Hypertension, treated using propranolol Family history: Her parents died in their eighties of unknown cause. The cranial nerve exam was normal, including visual system, eye movements, facial strength, sensation, hearing, and lower cranial nerves. She had moderately severe weakness of neck flexion and proximal arm extension; wrist and finger extensors were slightly weak. She had moderately severe proximal leg weakness, and was unable to arise from a low chair without assistance. Her deep tendon reflexes were diffusely hypoactive and the planter responses were flexor. Course in hospital: The patient was treated with intravenous corticosteroids, an antacid, a H2-blocker, and her anti-hypertensive agent. She was discharged on prednisone 50 mg daily, and over two months gained weight and developed glucose intolerance. The steroid was slowly tapered and another immunosuppressive agent, azathioprine [Imuran] 50 mg twice daily, was added. This regimen, in combination with light physical therapy, produced a gradual return to normal strength. One year after discharge from hospital, she was seen socially in her high heels by her neurologist at a hospital fund raising gala. Based on the history and exam, what is the localization of this patient’s progressive weakness? How can myelopathy, radiculopathy, neuropathy, myopathy, and neuromuscular junction disorders be distinguished clinically, and by using electrodiagnostic studies? V eterinary R adiation F acility S urvey 2001 z Externalbeam • 42 sites :academ ic40% , private 60% • O rth ovoltage (3),linac(18),C obalt60 (12) z 2790 dogs and 1081 cats z N o 1 disease:M astC ellTum or z Th ree m ach ines inM assach usetts S im ilarity and difference z S im ilarity z Difference • B iology ofdisease • C om binationth erapy • R esponse • P rotocol • S ide effects • C ost • A nesth esia • N o com plain! Th ere is a significantassociationbetweenth erm aldose groupand tim e to localfailure after controlling fortotaldurationofh eating,tum or volum e and tum orgrade (h az ard ratio oflow vs. Durationofh eating and tum or volum e values used inth e estim ationof survivalfuctions were m edianvalues forth e respective groupand overall,respectively. H tm in=totaldurationofh eattreatm ent; m ediandurationofh eating inth e th erm al dose groupwas used inth e plot. K aplan-M eiersurvival distributionfunction estim ates oftim e to local failure fordogs inth e h igh th erm aldose group. Totalh eating duration was divided into th irds for th e analysis (n=21 dogs each curve). Th e longest h eating durationis associated with sh orter durationoftum orcontrol. P retargeted im m unoscintigraph y S elected im ages ofone study anim alsh owing righ tlateral(toprow)and dorsal(bottom row)views at1 h ourfor99m Tc- cM O R F alone,99m Tc-IgG alone and IgG -M O R F followed at3 days with 99m Tc- IgG -M O R F cM O R F. R egions of associationwillbe refined,using a sm aller num berofindividuals from oth erbreeds. In addition to the increase in ocular size also comes a much larger and stronger orbicularis oculi muscle. Questions not only relating to the chief complaint and recent history, but also to previous ocular problems with this animal and relatives as well as any current or past problems with animals stabled in the same environment. The Ophthalmic Examination Examination Environment  The examination environment is important and can greatly influence the examination results. In an environment that is too distractive and bright, a complete careful examination can not be done; especially in an animal that is unruly. Introductory Examination Process  Initially a cursory physical examination and gross examination of the head and ocular region prior to any sedation or local anesthesia is advisable. First and foremost one should determine if the animal is sighted  The menace response is acceptable, but even prior to that, note how the animal is reacting to its surroundings. For example, how the animal behaves while being unloaded from a trailer, or while turned out in the paddock. Watch carefully as the animal is being led on a lead and how it reacts to other animals and its environment. First and foremost one should determine if the animal is sighted  An obstacle course would be ideal yet in my experience it is not always practical. First and foremost one should determine if the animal is sighted  The history with these animals will commonly include frequent trauma and difficulty navigating at night or in dim light. Vision Testing The menace response is a learned response which will not generally be present in foals less than two weeks of age. A hand or finger(s) thrust is made toward the eye, avoiding setting up stimulating air currents, or touching tactile hairs (vibrissae). Therefore, the seventh cranial nerve and orbicularis oculi muscle must also be intact along with visual pathways up to and including the cortex. When performing this test the examiner should stand on one side of the animal to assure that his hand motion is not in the visual field of the contralateral eye. The strength of the blink response can be amplified by actually touching the periocular region on the first one or two thrusts and then stopping short of this on the next two or three. Some animals need to be reminded, if you will, that the thrusted finger may touch them. Vision Testing  Throwing cotton balls, wads of cotton or a glove in the air can be helpful in visual assessment but it is not always reliable. Vision Testing  The end point with this method would be head motion and /or reflex blink, which can be subtle. The examiner needs to be assured that the object thrown is large enough to be seen, that the object does not make a noise, set up stimulating air currents, nor is thrown into the visual field of the opposite eye. A few repeated responses are necessary to avoid interpreting a coincidental blink or head motion with a positive sign. Vision Testing  Throwing Cotton Balls Gross Evaluation  Symmetry  Ocular discharge  Normal Position of the Upper Eyelid Cilia  Ptosis  Blepharospasm  Photophobia  Surface Topography  Pupillary symmetry Symmetry  Evaluate symmetry of the head and facial expression. Ocular discharge  Ocular discharge if present should be characterized as serous, mucoid, purulent, hemorrhagic, seromucoid, mucopurulent, or serosanguinous. Normal Position of the Upper Eyelid Cilia  The position of the upper eyelid cilia normally should be directed nearly perpendicular to the corneal surface. Blepharospasms  Blepharospasm (forced blinking) is usually a sign of ocular pain and commonly is also associated with an ocular discharge. Photophobia Ocular pain that results in blepharospasm can stem from superficial sites (eg: cornea) or deep intraocular ones (eg: uvea-ciliary spasm). Surface Topography  Surface topography of the periorbital and ocular structures such as eyelid creases and folds, as well as the supraorbital fossal depression may be accentuated or lost.

Passing between these bony expansions are the intertrochanteric line on the anterior femur and the larger intertrochanteric crest on the posterior femur buy propranolol 80 mg fast delivery. On the posterior shaft of the femur is the gluteal tuberosity proximally and the linea aspera in the mid-shaft region order cheap propranolol. The expanded distal end consists of three articulating surfaces: the medial and lateral condyles propranolol 80 mg mastercard, and the patellar surface purchase propranolol toronto. It articulates with the patellar surface on the anterior side of the distal femur, thereby protecting the muscle tendon from rubbing against the femur. The interosseous border of each bone is the attachment site for the interosseous membrane of the leg, the connective tissue sheet that unites the tibia and fibula. The proximal tibia consists of the expanded medial and lateral condyles, which articulate with the medial and lateral condyles of the femur to form the knee joint. On the anterior side of the proximal tibia is the tibial tuberosity, which is continuous inferiorly with the anterior border of the tibia. The head of the fibula forms the proximal end and articulates with the underside of the lateral condyle of the tibia. The talus articulates superiorly with the distal tibia, the medial malleolus of the tibia, and the lateral malleolus of the fibula to form the ankle joint. Anterior to the talus is the navicular bone, and anterior to this are the medial, intermediate, and lateral cuneiform bones. The apical ectodermal ridge, located at the end of the limb bud, stimulates growth and elongation of the limb. During the sixth week, the distal end of the limb bud becomes paddle-shaped, and selective cell death separates the developing fingers and toes. At the same time, mesenchyme within the limb bud begins to differentiate into hyaline cartilage, forming models for future bones. During the seventh week, the upper limbs rotate laterally and the lower limbs rotate medially, bringing the limbs into their final positions. Endochondral ossification, the process that converts the hyaline cartilage model into bone, begins in most appendicular bones by the twelfth fetal week. This begins as a primary ossification center in the diaphysis, followed by the later appearance of one or more secondary ossifications centers in the regions of the epiphyses. Disappearance of the epiphyseal plate is followed by fusion of the bony components to form a single, adult bone. The clavicle develops via intramembranous ossification, in which mesenchyme is converted directly into bone tissue. Ossification within the clavicle begins during the fifth week of development and continues until 25 years of age. The prosthetic knee components must be properly if a fracture of the distal radius involves the joint surface of aligned to function properly. Which tarsal three arches of the hand, and what is the importance of bones are in the proximal, intermediate, and distal groups? What is a bunion and what type would surgery be required and how would the fracture be of shoe is most likely to cause this to develop? What is the large opening in the bony pelvis, development do these events occur: (a) first appearance of located between the ischium and pubic regions, and what the upper limb bud (limb ridge); (b) the flattening of the two parts of the pubis contribute to the formation of this distal limb to form the handplate or footplate; and (c) the opening? Discuss two possible injuries of the pectoral girdle that may occur following a strong blow to the shoulder or a hard 40. Your friend runs out of gas and you have to help body weight is passed in a posterior direction and one-half push his car. Describe that convey the forces passing from your hand, through the arrangement of the tarsal and metatarsal bones that are your upper limb and your pectoral girdle, and to your axial involved in both the posterior and anterior distribution of skeleton. At these joints, the articulating surfaces of the adjacent bones can move smoothly against each other. Conversely, joints that provide the most movement 356 Chapter 9 | Joints between bones are the least stable. Understanding the relationship between joint structure and function will help to explain why particular types of joints are found in certain areas of the body. The articulating surfaces of bones at stable types of joints, with little or no mobility, are strongly united to each other. For example, most of the joints of the skull are held together by fibrous connective tissue and do not allow for movement between the adjacent bones. Similarly, other joints united by fibrous connective tissue allow for very little movement, which provides stability and weight-bearing support for the body. For example, the tibia and fibula of the leg are tightly united to give stability to the body when standing. At other joints, the bones are held together by cartilage, which permits limited movements between the bones. Thus, the joints of the vertebral column only allow for small movements between adjacent vertebrae, but when added together, these movements provide the flexibility that allows your body to twist, or bend to the front, back, or side. In contrast, at joints that allow for wide ranges of motion, the articulating surfaces of the bones are not directly united to each other. Instead, these surfaces are enclosed within a space filled with lubricating fluid, which allows the bones to move smoothly against each other. These joints provide greater mobility, but since the bones are free to move in relation to each other, the joint is less stable. Most of the joints between the bones of the appendicular skeleton are this freely moveable type of joint. These joints allow the muscles of the body to pull on a bone and thereby produce movement of that body region. Your ability to kick a soccer ball, pick up a fork, and dance the tango depend on mobility at these types of joints. Structural classifications of joints take into account whether the adjacent bones are strongly anchored to each other by fibrous connective tissue or cartilage, or whether the adjacent bones articulate with each other within a fluid-filled space called a joint cavity. Functional classifications describe the degree of movement available between the bones, ranging from immobile, to slightly mobile, to freely moveable joints. The amount of movement available at a particular joint of the body is related to the functional requirements for that joint. Thus immobile or slightly moveable joints serve to protect internal organs, give stability to the body, and allow for limited body movement. Structural Classification of Joints The structural classification of joints is based on whether the articulating surfaces of the adjacent bones are directly connected by fibrous connective tissue or cartilage, or whether the articulating surfaces contact each other within a fluid- filled joint cavity. At a synovial joint, the articulating surfaces of the bones are not directly connected, but instead come into contact with each other within a joint cavity that is filled with a lubricating fluid. Functional Classification of Joints The functional classification of joints is determined by the amount of mobility found between the adjacent bones. Joints are thus functionally classified as a synarthrosis or immobile joint, an amphiarthrosis or slightly moveable joint, or as a diarthrosis, which is a freely moveable joint (arthroun = “to fasten by a joint”). Depending on their location, fibrous joints may be functionally classified as a synarthrosis (immobile joint) or an amphiarthrosis (slightly mobile joint). Cartilaginous joints are also functionally classified as either a synarthrosis or an amphiarthrosis joint. Examples include sutures, the fibrous joints between the bones of the skull that surround and protect the brain (Figure 9. An example of this type of joint is the cartilaginous joint that unites the bodies of adjacent vertebrae. Filling the gap between the vertebrae is a thick pad of fibrocartilage called an intervertebral disc (Figure 9. Each intervertebral disc strongly unites the vertebrae but still allows for a limited amount of movement between them. However, the small movements available between adjacent vertebrae can sum together along the length of the vertebral column to provide for large ranges of body movements. This is a cartilaginous joint in which the pubic regions of the right and left hip bones are strongly anchored to each other by fibrocartilage. The strength of the pubic symphysis is important in conferring weight-bearing stability to the pelvis. Each disc allows for limited movement between the vertebrae and thus functionally forms an amphiarthrosis type of joint. Intervertebral discs are made of fibrocartilage and thereby structurally form a symphysis type of cartilaginous joint. These types of joints include all synovial joints of the body, which provide the majority of body movements.

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Numerous examples of individuals born with a clubfoot who went on to successful careers include Dudley Moore (comedian and actor) order generic propranolol on line, Damon Wayans (comedian and actor) order propranolol 40mg with visa, Troy Aikman (three-time Super Bowl-winning 340 Chapter 8 | The Appendicular Skeleton quarterback) cheap propranolol 80mg fast delivery, Kristi Yamaguchi (Olympic gold medalist in figure skating) buy generic propranolol online, Mia Hamm (two-time Olympic gold medalist in soccer), and Charles Woodson (Heisman trophy and Super Bowl winner). The clavicle is an anterior bone whose sternal end articulates with the manubrium of the sternum at the sternoclavicular joint. The acromial end of the clavicle articulates with the acromion of the scapula at the acromioclavicular joint. This end is also anchored to the coracoid process of the scapula by the coracoclavicular ligament, which provides indirect support for the acromioclavicular joint. The clavicle supports the scapula, transmits the weight and forces from the upper limb to the body trunk, and protects the underlying nerves and blood vessels. It mediates the attachment of the upper limb to the clavicle, This OpenStax book is available for free at http://cnx. Posteriorly, the spine separates the supraspinous and infraspinous fossae, and then extends laterally as the acromion. The proximal humerus consists of the head, which articulates with the scapula at the glenohumeral joint, the greater and lesser tubercles separated by the intertubercular (bicipital) groove, and the anatomical and surgical necks. The distal humerus is flattened, forming a lateral supracondylar ridge that terminates at the small lateral epicondyle. The articulating surfaces of the distal humerus consist of the trochlea medially and the capitulum laterally. Depressions on the humerus that accommodate the forearm bones during bending (flexing) and straightening (extending) of the elbow include the coronoid fossa, the radial fossa, and the olecranon fossa. The elbow joint is formed by the articulation between the trochlea of the humerus and the trochlear notch of the ulna, plus the articulation between the capitulum of the humerus and the head of the radius. The proximal radioulnar joint is the articulation between the head of the radius and the radial notch of the ulna. The proximal ulna also has the olecranon process, forming an expanded posterior region, and the coronoid process and ulnar tuberosity on its anterior aspect. On the proximal radius, the narrowed region below the head is the neck; distal to this is the radial tuberosity. The shaft portions of both the ulna and radius have an interosseous border, whereas the distal ends of each bone have a pointed styloid process. The proximal row contains (from lateral to medial) the scaphoid, lunate, triquetrum, and pisiform bones. The distal row of carpal bones contains (from medial to lateral) the hamate, capitate, trapezoid, and trapezium bones (“So Long To Pinky, Here Comes The Thumb”). The thumb contains a proximal and a distal phalanx, whereas the remaining digits each contain proximal, middle, and distal phalanges. The hip bone articulates posteriorly at the sacroiliac joint with the sacrum, which is part of the axial skeleton. The right and left hip bones converge anteriorly and articulate with each other at the pubic symphysis. The primary function of the pelvis is to support the upper body and transfer body weight to the lower limbs. Located at either end of the iliac crest are the anterior superior and posterior superior iliac spines. The medial surface of the upper ilium forms the iliac fossa, with the arcuate line marking the inferior limit of this area. The posterior margin of the ischium has the shallow lesser sciatic notch and the ischial spine, which separates the greater and lesser sciatic notches. The pubis is joined to the ilium by the superior pubic ramus, the superior surface of which forms the pectineal line. The pubic arch is formed by the pubic symphysis, the bodies of the adjacent pubic bones, and the two inferior pubic rami. The sacrum is also joined to the hip bone by the sacrospinous ligament, which attaches to the ischial spine, and the sacrotuberous ligament, which attaches to the ischial tuberosity. The sacrospinous and sacrotuberous ligaments contribute to the formation of the greater and lesser sciatic foramina. The broad space of the upper pelvis is the greater pelvis, and the narrow, inferior space is the lesser pelvis. Compared to the male, the female pelvis is wider to accommodate childbirth, has a larger subpubic angle, and a broader greater sciatic notch. These are the thigh, located between the hip and knee joints; the leg, located between the knee and ankle joints; and distal to the ankle, the foot. These are the femur, patella, tibia, fibula, seven tarsal bones, five metatarsal bones, and 14 phalanges. Most diarthrotic joints are found in the appendicular skeleton and thus give the limbs a wide range of motion. These joints are divided into three categories, based on the number of axes of motion provided by each. An axis in anatomy is described as the movements in reference to the three anatomical planes: transverse, frontal, and sagittal. Thus, diarthroses are classified as uniaxial (for movement in one plane), biaxial (for movement in two planes), or multiaxial joints (for movement in all three anatomical planes). The joint allows for movement along one axis to produce bending or straightening of the finger, and movement along a second axis, which allows for spreading of the fingers away from each other and bringing them together. A joint that allows for the several directions of movement is called a multiaxial joint (polyaxial or triaxial joint). They allow the upper or lower limb to move in an anterior- posterior direction and a medial-lateral direction. This third movement results in rotation of the limb so that its anterior surface is moved either toward or away from the midline of the body. At a syndesmosis joint, the bones are more widely separated but are held together by a narrow band of fibrous connective tissue called a ligament or a wide sheet of connective tissue called an interosseous membrane. This type of fibrous joint is found between the shaft regions of the long bones in the forearm and in the leg. Lastly, a gomphosis is the narrow fibrous joint between the roots of a tooth and the bony socket in the jaw into which the tooth fits. Suture All the bones of the skull, except for the mandible, are joined to each other by a fibrous joint called a suture. The fibrous connective tissue found at a suture (“to bind or sew”) strongly unites the adjacent skull bones and thus helps to protect the brain and form the face. In adults, the skull bones are closely opposed and fibrous connective tissue fills the narrow gap between the bones. The suture is frequently convoluted, forming a tight union that prevents most movement between the bones. In newborns and infants, the areas of connective tissue between the bones are much wider, especially in those areas on the top and sides of the skull that will become the sagittal, coronal, squamous, and lambdoid sutures. During birth, the fontanelles provide flexibility to the skull, allowing the bones to push closer together or to overlap slightly, thus aiding movement of the infant’s head through the birth canal. After birth, these expanded regions of connective tissue allow for rapid growth of the skull and enlargement of the brain. The fontanelles greatly decrease in width during the first year after birth as the skull bones enlarge. When the connective tissue between the adjacent bones is reduced to a narrow layer, these fibrous joints are now called sutures. At some sutures, the connective tissue will ossify and be converted into bone, causing the adjacent bones to fuse to each other. At the time of birth, the frontal and maxillary bones consist of right and left halves joined together by sutures, which disappear by the eighth year as the halves fuse together to form a single bone. Late in life, the sagittal, coronal, and lambdoid sutures of the skull will begin to ossify and fuse, causing the suture line to gradually disappear. Syndesmosis A syndesmosis (“fastened with a band”) is a type of fibrous joint in which two parallel bones are united to each other by fibrous connective tissue. The gap between the bones may be narrow, with the bones joined by ligaments, or the gap may be wide and filled in by a broad sheet of connective tissue called an interosseous membrane. In the forearm, the wide gap between the shaft portions of the radius and ulna bones are strongly united by an interosseous membrane (see Figure 9. Similarly, in the leg, the shafts of the tibia and fibula are also united by an interosseous membrane. In addition, at the distal tibiofibular joint, the articulating surfaces of the bones lack cartilage and the narrow gap between the bones is anchored by fibrous connective tissue and ligaments on both the anterior and posterior aspects of the joint.

Oral selective antihistamine also was well represented (by at least three of five drugs [60 percent]) in comparisons to nasal antihistamine discount 40mg propranolol free shipping, oral decongestant (alone and in combination) discount propranolol 40 mg overnight delivery, and oral leukotriene receptor antagonist (montelukast) cheap 40 mg propranolol with visa. In contrast cheap propranolol 80mg online, for the comparisons of combination intranasal corticosteroid and nasal antihistamine to each component, only one of eight intranasal corticosteroids (fluticasone propionate; 12. Fluticasone propionate was the most studied intranasal corticosteroid and appeared in every comparison involving intranasal corticosteroids. The intranasal corticosteroid ciclesonide was not studied in any identified trial. No trials of nasal anticholinergic (ipratropium) or nasal decongestant were identified. Conclusions based on comparisons of pharmacologic classes that were poorly represented are limited to the specific drugs studied. How well such conclusions generalize to other drugs in the same class is uncertain. For the remaining eight comparisons, we were unable to compare short-term to longer-term use. For assessing nasal and eye symptom severity, most trials used a 4-point interval rating scale, from 0 for no symptoms to 3 for severe symptoms that interfere with one’s daily activity. When pooling results for meta-analyses, differences in scales were accommodated by use of standardized rather than non-standardized mean differences. Most trials could not be pooled due to a lack of reported variance for group-level treatment effects. Nocturnal symptoms are scored on a 7-point Likert scale from 0 (not 67 troubled) to 6 (extremely troubled). Each question is scored on a scale from 0 (not troubled) to 6 (extremely troubled). Most trials calculated mean change from baseline symptom scores by subtracting mean baseline scores from symptom scores averaged across the entire treatment duration. However, some used endpoint values rather than mean values for this calculation, and others performed no calculation, comparing endpoint values rather than change from baseline values. A third approach was to calculate change from baseline 37 using mean scores during an interval of the treatment duration, for example, the mean of scores during the third and fourth week of treatment compared with baseline. Finally, some reported only relative results, for example, the percent reduction from baseline scores. When pooling results for meta-analysis, differences in efficacy calculations were accommodated by reporting 48 mean differences rather than standardized mean differences. When meta-analysis was not possible, comparisons of treatment effects were approximated. The degree to which different methods of results reporting impacted the magnitude or statistical significance of observed treatment effects is uncertain. As above, when the result of statistical testing was reported, it became the main parameter for comparison of efficacy across trials. Additionally, 14, 6, and 11 trials used active, intermediate, and passive surveillance, respectively. Headache, sedation and nosebleeds were the most commonly reported events across the treatment comparisons. Reporting of adverse events fell into one of three categories: (1) general statements such as, “All groups were similar in the percentage of patients with clinical and laboratory adverse 97 experiences;” (2) accounts only of adverse events that occurred with a frequency greater than zero; and (3) accounts of adverse events in each treatment group. Adverse event data from trials in the second category were uninformative because we could not distinguish between missing adverse event reports and adverse events that occurred with a frequency of zero in other treatment groups. In the third category, trials that reported events as a proportion of reports rather than a proportion of patients were not useful for comparative purposes; these data were abstracted to assess consistency of the body of evidence. Trials that reported efficacy results at multiple time points did not report adverse events by occurrence in time. For this reason, it was not possible to compare the emergence of adverse events across varying treatment exposures. In addition to the four main domains assessed (risk of bias, consistency, directness, and precision), the following additional domains were considered and deemed not relevant for the reasons listed: Dose-response association – Levels of exposure tended to be standard for each intervention. Publication bias – We found no indication that relevant empirical findings were unpublished. A Description of Included Studies, Key Points, and Synthesis and Strength of Evidence are presented for each treatment comparison. Description of Included Studies o For additional information, detailed abstraction tables are located in Appendix C. Synthesis and Strength of Evidence o This section is organized by type of outcome (nasal symptoms, eye symptoms, asthma symptoms, and quality of life). For each type of outcome, individual outcomes are presented usually in two paragraphs: The first summarizes the findings for that outcome. The second describes the overall rating of the strength of evidence for that outcome. For outcomes or comparisons that are more complex, more than two paragraphs may be required. If meta- analyses were conducted for three of the outcomes, these would follow the treatment effect summary table for nasal outcomes. Trial size ranged from 86 to 220 patients randomized to treatment groups of interest. Oral selective antihistamines studied were loratadine 81, 83 82 (two trials ) and cetirizine (one trial ); oral nonselective antihistamines were clemastine (two 81, 83 82 81, 83 82 trials ) and chlorpheniramine (one trial ). Quality of life at 2 weeks: Evidence was insufficient to support the use of one treatment over the other based on one trial 82 with high risk of bias. These results are based on trials of two of five oral selective antihistamines (40 percent) and two of eleven oral nonselective antihistamines (18 percent). Synthesis and Strength of Evidence Nasal symptom results discussed below are summarized in Table 13. This trial was rated fair quality, and reported a non-statistically significant treatment effect of 0. Because consistency of the observed effect cannot be assessed with a single trial and because the effect was imprecise, the evidence was insufficient to support the use of one treatment over the other. Quality of Life 82 Of three identified trials, one (N=86) reported quality of life outcomes. This trial was rated poor quality due to noncomparable groups at baseline and inappropriate analysis of results (unadjusted for baseline group differences). Risk of bias for this outcome was considered high based on both trial quality and the use of quality of life measures in an unblinded trial population. Consistency is unknown with a single trial, and the 40 treatment effect was imprecise. The evidence was therefore insufficient to support the use of one treatment over the other for this outcome. Trial size ranged from 30 to 360 patients randomized to treatment groups of interest. Oral selective antihistamines studied were cetirizine 85-87 88 84 (three trials ), loratadine (one trial ), and desloratadine (one trial ); nasal antihistamine was 86, 88 azelastine in all five trials. In three trials that reported information on race, the majority was white (69-81 percent). Three trials 85, 87 used a 4-point (0=no symptoms, 3=severe symptoms) rating scale for the assessment of four 84, 85, 87 nasal symptoms (congestion, rhinorrhea, sneezing, and itch). Of several outcomes reported by Gambardella (1993) , sufficient information was provided to abstract adverse events only. Quality of life at 2 weeks: Evidence was insufficient to support the use of one treatment 85, 87 over the other based on two trials with low risk of bias and consistent but imprecise results. These results are based on trials of three of five oral selective antihistamines (60 percent) and one of two nasal antihistamines (50 percent). Synthesis and Strength of Evidence Nasal symptom results discussed below are summarized in Table 16. As shown in these tables, only two trials provided variance estimates for reported outcomes. Nasal Symptoms 84-87 Four trials (N=1022) assessed congestion after 2 weeks of treatment and reported greater improvement with nasal antihistamine than with oral selective antihistamine.

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