Jeffrey A Brinker, M.D.
- Professor of Medicine
- Joint Appointment in Radiology and Radiological Science
The limbal or bulbar form is less characteristic and frequently seen in black races discount 2mg alkeran mastercard. The striking lesion is at the limbus where a wall of gelatinous thickening appears (Fig generic alkeran 2mg fast delivery. Giant Papillary Conjunctivitis Pathology Smears of conjunctiva show the A giant papillary reaction in the conjunctiva presence of eosinophilic granules in great occurs in contact lens (hydrophilic lenses) numbers alkeran 2 mg visa. Histopathology of vernal conjunctivitis wearers, patients with ocular prosthesis and reveals: (i) excessive epithelial hyperplasia, (ii) patients in whom corneal sutures, particularly of extensive infiltration by eosinophils, plasma cells, keratoplasty, are not removed. The papillae are lymphocytes and monocytes in the adenoid layer, polygonal and resemble cobblestones as in vernal and (iii) spectacular increase in the fibrous layer conjunctivitis. Diclofenac sodium or discontinuation of lens or prosthesis wear and ketorolac tromethamine 0. To avoid corticosteroid-related complito endogenous microbial proteins which in most cations, intermittent (pulse) therapy is indicated. Soluble corticosteroid drops are used 2-4 hourly Phlyctenulosis may occur secondary to staphyfor 5-7 days and then rapidly tapered. The disease is common in native to topical steroid therapy is an injection of malnourished and debilitated children between triamcinolone acetonide (40 mg per ml) injected in 5 and 12 years of age. The disease in a pure Pathology the histopathology of a phlycten shows form does not give many symptoms except mild a characteristic subepithelial mononuclear discomfort and irritation with reflex lacrimation. When secondary infection supervenes, mucopurulent discharge become prominent additional polymorphonuclear cells appear and symptoms. The characteristic lesion of the conjunctivitis is a phlycten or phlyctens (blebs). Single or multiple, Differential diagnosis Besides phlycten, a nodule small, round white or gray nodules raised above at the limbus may be seen in episcleritis, inflamed the surface are found at or near the limbus pinguecula, filtering bleb following glaucoma (Fig. The presence of phlycten on the surgery, suture cyst, dermoid and foreign body palpebral conjunctiva is a rarity. The bigger phlyctenular conjunctivitis, inflamed pinguecula phlycten appears as a pustule (Fig. Both vascular and cellular reactions occur around the Treatment the treatment of phlyctenular conjuncphlycten. Corneal phlycten often causes tonsils and adenoids should be properly treated pain and photophobia. A pannus is seen around and attempts should be made to desensitize the a raised gray phlycten. The phlycten ulcerates patient against tubercular or Staphylococcal and forms a triangular fascicular ulcer with allergens. Site Usually at Away from Away from limbus limbus and limbus and usually usually nasally temporally 4. Shape Small raised round Flat and Relatively bigger flat nodule triangular round nodule 5. Complications Keratitis and May lead to Rarely scleritis nodular pterygium degeneration formation Hot compresses and irrigation with saline papillary hypertrophy or a chronic follicular reduce mucopurulent discharge. Follicles are most predominantly antibiotic and corticosteroid eye drop several times seen on the inferior tarsal conjunctiva and fornix. The latter can lead to contraction of fornices (pseudopemdisappears within a week. Atropine, miotics, conjunctiva include concretions, pinguecula and antiviral agents, aminoglycosides, epinephrine pterygium. Prostaglandin analogue Concretions and brimonidine may also cause toxic conjuncConcretions or lithiasis are small, hard, elevated tivitis. They Clinical features the characteristic toxic reaction never undergo calcareous degeneration, therefore, in the conjunctiva occurs either in the form of a the term is a misnomer. Concretions are caused by 136 Textbook of Ophthalmology accumulation of inspissated mucus and degenewind blown areas of Australia, Middle-East, rated epithelial cells in the loops of Henle. Foreign body Pathologic changes in the conjunctiva are sensation is the main symptom and occasionally a basically the same as those in the pinguecula, but corneal abrasion may develop. Removal of concreproliferative inflammatory reaction is quite tions with a sharp needle after topical anesthesia prominent. Pinguecula Clinical features Pterygium seldom gives any Pinguecula is a degeneration of the bulbar symptom but its progression may cause conjunctiva characterized by the presence of a astigmatism and its extension in the pupillary yellowish triangular spot near the limbus, the apex area of the cornea may cause serious visual of the triangle being towards the canthus. The condition is found blunt apex, head, (ii) a few infiltrates in front of the in elderly people, especially in those living in apex, cap, (iii) a limbal part, neck, and (iv) a bulbar dusty and windy climate. The name pinguecula portion extending between the limbus and the is derived from pinguis meaning fat. If deposition of iron in the corneal epithelium pinguecula causes cosmetic disfigurement it has anterior to the head of the pterygium. It is characterized by a triangular encroachment of the conjunctiva onto the cornea usually on the nasal side. Excision of pterygium is generally Features Pterygium Pseudopterygium recommended. An autoconjuncin adults in children tival graft or amniotic membrane transplantation 2. Status Progressive Almost always or stationary stationary aseptic scleral necrosis and sclerokeratitis in some 6.
- Symmetrical thalamic calcifications
- Marshall syndrome
- Matthew Wood syndrome
- Acne rosacea
- Chromosome 1, trisomy 1q42 qter
- Angiomatosis systemic cystic seip syndrome
- Interstitial pneumonia
- Dysphonia, chronic spasmodic
Unrefreshing sleep* At least one of the following manifestations is also required: 1 generic alkeran 2 mg fast delivery. The diagnosis of systemic intolerance disease (myalgic encephalomyelitis/chronic fatigue syndrome) should be questioned if patients do not have these symptoms at least half of the time with moderate purchase alkeran 2mg visa, substantial cheap 2mg alkeran with visa, or severe intensity. Other Poxviruses That Infect 72 Humans: Parapoxviruses (Including Orf Virus), Molluscum Contagiosum, and Yatapoxviruses Brett W. Complications include aseptic meningitis, transverse myelitis, and sacral radiculopathy. Suppression of Oral acyclovir, 400 mg bid (I) recurrent genital Valacyclovir, 500 mg daily (I) or Consider for patients with frequent (>6 herpes 1000 mg daily (I) or 250-500 mg bid (I) episodes) or severe recurrences, in prevents symptomatic reactivation. Given the brief period of viral replication and rapid evolution of lesions, patients should be given drugs for self-administration when prodromal symptoms occur. These topical preparations should be applied to the lesions once daily for 5 consecutive days. It is a two-dose series with the frst administered at 12 to 15 months of age and the second between 4 and 6 years. Recent evidence points to great genomic variability during replication in a single patient. Genomic analysis using high-throughput deep sequencing in congenitally infected infants reveals extensive genomic variability and diversity. Chronic hepatitis B is also more likely in high-risk patient groups such as injection drug users, men who have sex with men, and human immunodefciency virus–infected individuals. Human Parvoviruses, 84 Including Parvovirus B19V and Human Bocaparvoviruses Kevin E. By age 15, 50% of children in America and Europe will have been infected and have IgG. The virus has been isolated in 11 states, primarily within the Rocky Mountain region, as well as southwestern Canada. Louis Encephalitis, 90 Tick-Borne Encephalitis, Kyasanur Forest Disease, Alkhurma Hemorrhagic Fever, Zika) Stephen J. Severe disease is infrequent (~2% to 4% of apparent cases) but potentially fatal. Nonsevere disease (outpatient) accounts for much of dengue’s global socioeconomic impact. She was the author for this and other chapters for previous editions of this book. Multiple outbreaks have been detected subsequently in Bangladesh and India, including cases that have involved human-to-human transmission. Clinical manifestations of Hendra virus infection range from a self-limited infuenza-like syndrome to a fatal respiratory illness or encephalitis. They cause epidemic acute respiratory disease characterized by fever, cough, and systemic symptoms. In addition to infecting humans, infuenza A viruses infect a wide variety of animals, particularly migratory waterfowl. New infuenza A virus subtypes sporadically emerge in humans to cause widespread disease, or pandemics. They undergo constant antigenic evolution, referred to as antigenic drif or shif that allows them to reinfect individuals who have had previous infections. Terapy is most efective when used early in the course of illness (see Table 102-1). Food and Drug Administration-approved prescribing information for 2013-2014 infuenza vaccines for the most complete and updated information, including (but not limited to) indications, contraindications, and precautions. Specifc guidance regarding site and needle length for intramuscular administration may be found in the Advisory Committee on Immunization Practices General Recommendations on Immunization. California Encephalitis, Hantavirus 103 Pulmonary Syndrome, and Bunyavirus Hemorrhagic Fevers Dennis A. Ribavirin treatment has been studied only in some bunyavirus infections, and data from in vitro and in vivo models hold promise. Limiting the duration of breast-feeding to less than 6 months may be attempted in lowincome countries. The name of the disease (polios, “gray”; myelos, “marrow” or “spinal cord”), now commonly shortened to polio, is descriptive of the pathologic lesions that involve neurons in the gray matter, especially in the anterior horns of the spinal cord. They remain endemic in three countries (Afghanistan, Nigeria, and Pakistan) and have recently been reintroduced in several sub-Saharan African and Eastern Mediterranean countries. Vaccination of older children and adults may be warranted, including patients with chronic hepatitis B and C (see Table 110-1). However, the illness is not sufciently distinctive in individual cases to permit a clinical diagnosis to be made on clinical grounds alone. Enzyme immunoassays are also available, but they are generally of low sensitivity, although high specifcity. Intravenous immune globulin has been used in immunosuppressed patients, but its efcacy is not established. Quinolones, especially moxifoxacin, are active against all of the genital mycoplasmas. Other manifestations include headache, myalgias, nausea, vomiting, and abdominal pain. Fluorescent in situ hybridization can identify organisms in tissue, although standard histopathologic stains are negative. Evolutionary models of the emergence of methicillin-resistant Staphylococcus aureus. Finding coagulase-negative staphylococci at high numbers or repetitively in situations clinically consistent with infection is indicative of a true infection.
In addition buy 2mg alkeran fast delivery, there is the additional risk of vascular occlusion progressing back along the arterial branches corresponding to order cheap alkeran online the adjacent segments or contralateral hepatic lobule 2 mg alkeran with visa. Surgical excision At the present time the accepted procedure is tumour resection or enucleation,99 as it is not necessary to include any resection margin of healthy liver tissue to avoid tumour recurrence. The margin between hepatic haemangiomas and healthy hepatic tissue is minimal, with no infiltration or satellite nodules which would justify the inclusion of a healthy margin of tissue covering the resected tumour to ensure greater safety. Anatomical resections (segmentectomies, lobectomies and extended lobectomies) 3,111,112 are only indicated in exceptional cases of unilobular multiple hepatic haemangiomas, or those confined to several segments in which multiple tumourectomy would leave areas of the hepatic parenchyma poorly vascularized with the danger of biliary leaks, increasing postoperative morbidity and hindering the process of liver regeneration. Perhaps the best example is the Kasabach-Merritt syndrome,45,46 provided that there are no multiple cerebral haemangiomas which are generally incompatible with survival. In our experience in 625 hepatic transplants undertaken between April 1986 and September 1998, we have seen two cases, although in the case of an adult patient the histopathological diagnosis was a haemangioendothelioma, whereas in the case of a baby girl with Kasabach-Merritt syndrome, the patient was a 39day-old neonate weighing 2. While still in the incubator, she underwent surgery on the twenty-first day after birth because of a patent ductus. The liver was removed and replaced by total graft in a premature baby, after a 24-week pregnancy, at 2. Nevertheless, the indication for hepatic transplantation in the Kasabach-Merritt syndrome is dubious, as haemangiomas tend to disappear or lead to thrombosis and resolution, as happens in cutaneous haemangiomas. For this reason, it is only indicated in particularly acute situations in order to save the patient’s life. The existence of a giant haemangioma, in this syndrome could in exceptional circumstances indicate a liver transplantation. Biopsy by excision in these cases is advisable but not compulsory, especially given the complications this produces. In cavernous haemangiomas located on the left hepatic lobule, the most commonly accepted incision is an upper midline extended inferiorly to improve access. These tumours are large in diameter and impossible to resect through a smaller incision (Figs 10. Between 10 and 20 years ago, Japanese surgeons were keen on the use of thoracolaparotomy during transplantation of hepatomas, however this incision has now fallen into disuse, and is only used in exceptional cases (Fig. In spite of the advance of laparoscopy over the last few years, this technique is not indicated in the surgical treatment of giant haemangiomas due to risk of rupture, and consequent haemorrhage. Similarly, laparoscopic examination and biopsy by excision, along with direct laparoscopic ultrasound, do not offer any therapeutic benefit to these patients. In the future the possibility of undertaking laparoscopic arterial ligation, sclerotherapy and/or cryotherapy may arise. Vascular control the reduction in size which occurs following arterial ligation can be dramatic, and is maximized by extending this ligature to involve the trunk of the portal vein entering the tumour. Enlargements of these two segments can be seen, giving the appearance of a complete liver. The subphrenic space can be seen after removal of the large haemangioma localized in the right lobe of the liver. Ligation of a main branch of the hepatic artery (right or left), and of the portal vein is essential in most cases of giant haemangioma that require anatomical resection. For this reason, control must be prehepatic using a vascular clamp or vessel loop which permits arterial and venous blood flow to re-establish itself after tumour enucleation14 (Fig. The fastest and easiest method of preventing afferent blood flow is complete vascular occlusion of the liver at the hepatoduodenal ligament. Vascular occlusion is achieved at the level of the hepatoduodenal ligament and supra and infrahepatic vena cava. Similarly, ex vivo procedures of bench resection,119 which occasionally play a role in the resection of malignant hepatic tumours, offer no advantage while they do give rise to a number of possible complications. Similarly, the whole of the tumour must be removed, with no residual tumour capsule. The segmental branches of the intrahepatic biliary tree should be preserved and small vessels displaced by tumour growth may be ligated and divided by suture-ligature stitches. Accidental ligature of larger intrahepatic vascular structures must be avoided as these could give rise to biliary fistulae. Unrecognized small biliary leaks are the most frequent cause of perihepatic infection, giving rise to subphrenic abscesses. Nevertheless, in attempting to simplify the procedure we prefer to use clips to dissect through liver tissue. Maintaining the integrity of the biliary tree For several years cholangiography after tumour excision had been the rule for many surgeons to ensure the absence of biliary fistulae. Nevertheless, this procedure usually involves a cholecystectomy which is unnecessary, particularly when the bile duct is far from the tumour. Less frequently this is undertaken by transhepatic puncture, afterwards compressing the parenchyma in order to force the passage of contrast into the bile duct, or by direct puncture of the common hepatic or bile duct. Nevertheless, identification of a biliary fistula on the raw liver surface—even if this is small in diameter—may be done by wiping with a surgical gauze. By moving this slowly away from the liver surface a small stain of bile can be seen which indicates its exact location. Assisting biliary drainage with a T-tube is not indicated for any type of liver resection, considering the fact that this increases the morbidity of the procedure. Surgical Management of hepatobiliary and pancreatic disorders 296 the raw surface is fulgurated by argon beam coagulation, thus removing any microscopic capsular remains which could have been left behind. This is because reabsorbable polyglycolic acid is sensitive to the high temperatures of fulguration.
Vitamin supplementation reduces the progression of atherosclerosis in hyperhomocysteinemic renal-transplant recipients order 2mg alkeran with mastercard. Changes in serum folate concentrations following voluntary food fortification in Australia purchase alkeran with a visa. The efficacy of folic acid and folinic acid in reducing methotrexate gastrointestinal toxicity in rheumatoid arthritis: A metaanalysis of randomized controlled trials buy alkeran us. The relationship between serum folate, vitamin B12, and homocysteine levels in major depressive disorder and the timing of improvement with fluoxetine. Oral 5-methyltetrahydrofolic acid in senile organic mental disorders with depression: results of a double-blind multicentre study. Folate is associated with the natural history of high-risk human papillomaviruses. Interaction among folate, riboflavin, genotype, and cancer, with reference to colorectal and cervical cancer. Homocysteine and B vitamins relate to brain volume and white-matter changes in geriatric patients with psychiatric disorders. Association between plasma homocysteine concentrations and extracranial carotid-artery stenosis. The impact of plasma folate levels of mothers and newborns on intrauterine growth retardation and birth weight. Effects of extended systemic and topical folate supplementation on gingivitis of pregnancy. Dietary folate and the risk of depression in Finnish middle-aged men: A prospective followup study. Low dietary folate intake is associated with and excess incidence of acute coronary events. Use of periconceptional folic acid supplements in Victoria and New South Wales, Australia. Methylenetetrahydrofolate reductase and transcobalamin genetic polymorphisms in human spontaneous abortion: biological and clinical implications. Folate 485 © 2007 Elsevier Australia Garlic Historical note Garlic has been used as both a food and a medicine since antiquity. Legend has it that garlic was used in ancient Egypt to increase workers’ resistance to infection and later used externally to prevent wound infection. Sanskrit records document the use of garlic approximately 5000 years ago and the Chinese have been using it for over 3000 years. Louis Pasteur was one of the first scientists to confirm that garlic had antimicrobial properties. Traditionally, garlic has been used as a warming and blood cleansing herb to prevent and treat colds and flu, coughs, menstrual pain and expel worms and other parasites. Of the numerous constituents present, it is the alliin component and resultant degradation products, such as allicin and ajoene, that produce much of the herb’s pharmacological activity. These are formed when garlic is crushed or chewed and Garlic 486 alliin is exposed to the enzyme alliinase. Additionally, antithrombotic activity has been identified under clinical conditions (Ali & Thomson 1995). The compounds containing an allyl-disulfide or allyl-sulfhydryl group are most likely responsible for the inhibition of cholesterol synthesis by garlic and that this inhibition is likely to be mediated at sterol 4-alpha-methyl oxidase (Singh & Porter 2006). Allicin is believed to be chiefly responsible for garlic’s antimicrobial activity. More specifically, it has been found to exert antibacterial activity against a wide range of Gram-negative and Gram-positive bacteria, including multidrug-resistant enterotoxicogenic strains of Escherichia coli, Staphylococcus aureus, Mycobacterium tuberculosis, Proteus spp. Ajoene is another important antimicrobial constituent, with greater antiviral activity than allicin, according to one in vitro test (Weber et al 1992). Helicobacter pylori infection Several in vitro and in vivo tests have shown that garlic has activity against H. Two studies found that a combination of garlic and omeprazole produced synergistic effects against H. Diallyl disulfide, one of the most studied oilsoluble organosulfur compounds in garlic, has demonstrated antineoplastic activity against both hormone-dependent and hormone-independent breast cancer cell lines (Nakagawa et al 2001). It also inhibits the proliferation of human tumour cell lines for colon, lung and skin cancer (Sundaram & Milner 1996). Garlic derivatives inhibit proliferation of human prostate cancer cell lines and human breast cancer cell lines (Pinto & Rivlin 2001). In vitro results also show ajoene induces apoptosis in human leukaemic cells (Dirsch et al 2002), whereas allicin, but not its precursor alliin, inhibits proliferation of human mammary, endometrial, and colon cancer cells (Hirsch et al 2000). Notable among these is a depression in nitrosamine formation and a reduction in carcinogen bioactivation (Milner 2001). Some of the organosulfur compounds may also aid detoxification by enhancing glutathione S© 2007 Elsevier Australia transferases, thereby reducing carcinogen loads (Bianchini & Vainio 2001). Suppression of proliferation associated with a depression in cell cycle progression and the induction of apoptosis has also been observed (Knowles & Milner 2001). More specifically, garlic significantly decreased aortic tissue cholesterol as determined biochemically, fatty streak formation and the size of atherosclerotic plaque, compared with controls in an animal model (Campbell et al 2001). Similar results have been obtained using ultrasound techniques in a randomised, double-blind, placebo-controlled clinical trial, involving 152 people (Koscielny et al 1999). Not only did high-dose garlic powder significantly reduce arteriosclerotic plaque volume, it also induced a slight regression in plaque spread within the 4-year test period. Results from several recently published animal studies further confirm antiatherogenic effects and have investigated the mechanisms responsible (Durak et al 2002, Ferri et al 2003, Kwon et al 2003). One in-vivo study found that garlic activated antioxidant systems and decreased peroxidation in aortic tissue (Durak et al 2002) whereas ajoene inhibited smooth muscle cell proliferation in another (Ferri et al 2003). However, a more recent study using a higher dose of 3 g/day over 26 weeks found no effects (Ali & Thomson 1995).
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Dioscorides described celery as an effective remedy for ‘heated stomach’ and breast lumps and used it as a diuretic for urinary retention and dropsy alkeran 2 mg without a prescription. The major constituents of celery seed oil include pinene and D-limonene (Saleh et al 1985) purchase alkeran 2mg without prescription. Celery also contains flavonoids generic 2mg alkeran amex, such as apigenin, luteolin and isoquercitrin, and phenolic acids and alkaloids (Fisher & Painter 1996). Several constituents show anti-inflammatory activity, such as apigenin, eugenol, ferulic acid, luteolin and bergapton (Duke 2003). Studies in rats suggest that some celery seed extracts are highly effective in suppressing experimental arthritis without exhibiting any gastrotoxicity (Whitehouse et al 1999). Celery consumption has been linked to a reduced risk of developing colon cancer (Slattery et al 2000) and stomach cancer (Haenszel et al 1976). Celery extracts have also been found to have significant activity as a mosquito repellent (Tuetun et al 2004, 2005). A small uncontrolled trial of 15 patients with chronic arthritis found that treatment with celery seed extract significantly reduced pain symptoms after 3 weeks (Bone 2003). Although it is not certain that the herb has antibacterial activity against microorganisms implicated in urinary tract infection, it is used for its diuretic effect. The British Herbal Pharmacopoeia gives the specific indication of celery for rheumatoid arthritis and depression (Fisher & Painter 1996). Oriental medicine uses the seeds to treat headaches and as a digestive aid and emmenagogue. Topical exposure to celery may cause contact dermatitis angiooedema and urticaria (Kauppinen et al 1980). Photodermatitis has been recorded with occupational exposure (Seligman et al 1987) and celery has been suggested to cause ocular phototoxicity (Fraunfelder 2004). It is used to treat osteoarthritis and demonstrates anti-inflammatory activity in experimental models. Celery is likely to be safe when used in quantities commonly used in foods; however, there is the possibility for allergy and contact sensitivity. The effect of celery and parsley juices on pharmacodynamic activity of drugs involving cytochrome P450 in their metabolism. Celery allergens in patients with positive double-blind placebo-controlled food challenge. Chemoprevention of benzo[a]pyrene-induced forestomach cancer in mice by natural phthalides from celery seed oil. Celery 202 © 2007 Elsevier Australia Chamomile Historical note Chamomiles have been used as medicines since antiquity and traditionally grouped in botanical texts under the same general heading. The Anglo-Saxons used chamomile, presumably the Roman chamomile, as one of their nine sacred herbs. Culpeper lists numerous ailments for which chamomile was used, such as jaundice, fevers, kidney stones, colic, retention of urine and inflammation of the bowel (Culpeper 1995). It was also widely used to treat common conditions in children including colic in infants, teething pains and fever (Grieve 1976). It is used in the treatment of gout and to reduce the severity of sciatic pain, either taken internally or applied as a poultice externally (Culpeper 1995). Today, chamomile tea is one of the most popular herbal teas in Australia and New Zealand, and extracts are also used in cosmetics, as bath preparations, in hair dye for blonde hair, shampoos, mouthwashes and preparations to prevent sunburn (Foster & Leung 1996). Chamomile 203 © 2007 Elsevier Australia Clinical note — the difference between German and Roman chamomile. Chamomilla recutita is widely distributed in waste lands and in the neglected fields of Europe, particularly in Croatia and Hungary. Many plants are referred to as chamomile or have the word ‘chamomile’ as part of their common name. Of the large number of species of chamomile growing in Europe, North Africa and the temperate region of Asia, five grow wild in the United Kingdom and Europe. It has similar uses to the German chamomile, such as an aromatic bitter for digestive conditions, antispasmodic agent, mild sedative, and topically for its anti-inflammatory and mild analgesic properties. This is derived from matricin, also known as proazulene or prochamazulene, a precursor of chamazulene. Chamazulene (1–15%), farnesene, alpha-bisabolol and bisabolol oxides A and B (up to 50% of the essential oil; proportions vary depending on the chemotype), bisabolone oxide, chamazulene (from matricin on distillation), matricin, chamaviolin, spathulenol and cisand trans-enyne dicyclo ethers (spiroether, polyacetylenes). Chamomile 204 © 2007 Elsevier Australia German chamomile has four chemotypes (variations of the plant product according to chemical composition). These relate to slight variations in the bisabolol oxide content of the essential oil (Gasic et al 1986). Chemotypes, which contain highest levels of alpha-bisabolol (known as C and D chemotypes), should be sourced when an essential oil is required for antiphlogistic or spasmolytic properties. Chamomile extract showed anti-inflammatory effects when applied topically in animal models of inflammation (Al-Hindawi et al 1989, Plevova 1999, Shipochliev et al 1981). In a comparative trial, hydro-alcoholic extracts of chamomile produced antiinflammatory actions when applied topically in the croton ear test in the mouse. The hydro-alcoholic extract reduced oedema in a dose-dependent manner and was equivalent in effectiveness to benzydamine at twice the usual clinical dose, but hydrocortisone was found to be the most effective treatment (Tubaro et al 1984). Another comparative study investigated the anti-inflammatory effects of an extract prepared from dried flowers, an extract based on fresh flowers, and the volatile oil, in croton oil-induced dermatitis of mouse ear. The activity of fresh chamomile equalled the activity of the reference drug (benzydamine). The anti-inflammatory activity of the herb appears to be due to several different constituents, chiefly apigenin, matricin, chamazulene and alpha-bisabolol, although others may also exist.