Pharmacy and Medicine

FACTS SHEET – INFLUENZA A (H1N1)

• What is influenza – A(H1N1)

Influenza – A (H1N1) (earlier know as swine flu) is a new influenza virus causing illness in people. First detected in Mexico in April, 2009, it has spread to many countries in the World. Swine flu is basically a misnomer. This was originally referred to as “swine flu” because laboratory testing showed that many of the genes in this new virus were very similar to those found in pigs in North America. Further on, it has been found that this new virus has gene segments from the swine, avian and human flu virus genes. The scientists calls this a ‘quadruple reassortant” virus and hence this new (novel) virus is christened “influenza-A (H1N1) virus.”

• Influenza A(H1N1) outbreak

It is causing an epidemic among humans in Mexico and it has spread to Argentina, Australia, Austria, Belgium, Brazil, Canada, Chile, China, Colombia, Costa Rica, Cuba, Denmark, Ecuador, El Salvador, Finland, France, Germany, Guatemala, India, Ireland, Israel, Italy, Japan, Republic of Korea, Malaysia, Netherlands, New Zealand, Norway, Panama, Peru, Poland, Portugal, Spain, Sweden, Switzerland, Thailand, Turkey, UK and USA.

• Are there human/infections with influenza – A (H1N1) in India?
  

One passenger who traveled to India from USA has tested positive for Influenza A [H1N1]. There is no further spread from him. Do not panic!

• Is it safe to take pork items?

Pigs have nothing to do with this disease. Pork products are absolutely safe if properly cooked. There is no need to cull pigs. Do not panic if some pigs die in the community due to natural disease.

• Is this flu virus contagious?

Influenza A (H1N1) virus is contagious and spreading from human to human.

• What are the signs and symptoms of influenza-A (H1N1) in people?

The symptoms of swine flu in people are similar to the symptoms of regular seasonal flu and include fever, cough, sore throat, body aches, headache, chills and fatigue. Some people have reported diarrhea and vomiting associated with influenza-A (H1N1)

• How does influenza-A (H1N1) spread?

Flu viruses are spread mainly from person to person through droplets created while coughing or sneezing by a person infected with the influenza-A (H1N1).

• How can someone with the flu infect someone else?

Infected person may be able to infect others beginning one day before symptoms develop and up to seven or more days after becoming sick.

• How to keep away from getting the flu?

First and most important: Follow simple steps as cough etiquettes (covering mouth & nose with handkerchief or tissue paper while coughing), stay at least an arm’s length from persons coughing or sneezing, avoid gathering and wash your hands frequently. Try to stay in good general health. Get plenty of sleep, be physically active, manage your stress, drink plenty of fluids and eat nutritious food.

• Are there medicines to treat this flu?

Yes. Necessary medicines in sufficient quantity are available. The Government has in the designated hospitals stored medicines if required. It is strongly advisable not to take medicines of your own, as it will lower your immunity.

• What can I do to protect myself from getting sick?

(a) Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.

(b) Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol-based hand cleaners are also effective.

(c) Avoid touching your eyes, nose or mouth. Germs spread this way.

(d) Try to avoid close contact with people having respiratory illness.

(e) If one gets sick with influenza, one must stay at home, away from work or school and limit contact with others to keep from infecting them. However, if one is having any respiratory distress, one should report to a nearby hospital.

• What steps Government of India taking to prevent outbreak of this flu in India?

(1) The strategy is basically to detect early cases among the passengers coming from the affected countries either by air, road or ship.

(2) The Government has launched a massive mass media campaign to inform and educate people on dos and do nots.

(3) Sharing information with public through media.

APPEAL

People who have traveled from the affected countries in the past ten days and show symptoms of influenza A (H1N1) like fever, cough, sore throat and difficulty in breathing should immediately contact the telephone number given below or the nearby Government Hospital.

Assembly:

1:The Heart- The pumping Station Of Our Body which helps to purify our blood & pumps it through whole body.










2:This is one of the major Reason for the Heart Attack.

Vomiting (known medically as emesis and informally as throwing up and a number of other terms) is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose. Undesired vomiting may result from many causes, ranging from gastritis or poisoning to brain tumors, or elevated intracranial pressure. The feeling that one is about to vomit is called nausea. It usually precedes, but does not always lead to vomiting. Antiemetics are sometimes necessary to suppress nausea and vomiting, and, in severe cases where dehydration develops, intravenous fluid may need to be administered to replace fluid volume.
Vomiting is different from regurgitation, although the two terms are often used interchangeably. Regurgitation is the return of undigested food back up the esophagus to the mouth, without the force and displeasure associated with vomiting. The causes of vomiting and regurgitation are generally different.
Receptors on the floor of the fourth ventricle of the brain represent a chemoreceptor trigger zone, known as the area postrema, stimulation of which can lead to vomiting. The area postrema is a circumventricular organ and as such lies outside the blood-brain barrier; it can therefore be stimulated by blood-borne drugs that can stimulate vomiting or inhibit it.

There are various sources of input to the vomiting center:
* The chemoreceptor trigger zone at the base of the fourth ventricle has numerous dopamine D2 receptors, serotonin 5-HT3 receptors, opioid receptors, acetylcholine receptors, and receptors for substance P. Stimulation of different receptors are involved in different pathways leading to emesis, in the final common pathway substance P appears to be involved.[1]
* The vestibular system which sends information to the brain via cranial nerve VIII (vestibulocochlear nerve). It plays a major role in motion sickness and is rich in muscarinic receptors and histamine H1 receptors.
* Cranial nerve X (vagus nerve), which is activated when the pharynx is irritated, leading to a gag reflex.
* Vagal and enteric nervous system inputs that transmit information regarding the state of the gastrointestinal system. Irritation of the GI mucosa by chemotherapy, radiation, distention, or acute infectious gastroenteritis activates the 5-HT3 receptors of these inputs.
* The CNS mediates vomiting arising from psychiatric disorders and stress from higher brain centers.

Act:
The vomiting act encompasses three types of outputs initiated by the chemoreceptor trigger zone: Motor, parasympathetic nervous system (PNS), and sympathetic nervous system (SNS). They are as follows:
* Increased salivation to protect the enamel of teeth from stomach acids (excessive vomiting leads to dental erosion). This is part of the PNS output.
* A deep breath is taken to avoid aspiration of vomit.
* Retroperistalsis, starting from the middle of the small intestine, sweeping up the contents of the digestive tract into the stomach, through the relaxed pyloric sphincter.
* A lowering of intrathoracic pressure (by inspiration against a closed glottis), coupled with an increase in abdominal pressure as the abdominal muscles contract, propels stomach contents into the esophagus as the lower esophageal sphincter relaxes. The stomach itself does not contract in the process of vomiting except for at the angular notch, nor is there any retroperistalsis in the esophagus.
* Vomiting is ordinarily preceded by retching.
* Vomiting also initiates an SNS response causing both sweating and increased heart rate.
The neurotransmitters that regulate vomiting are poorly understood, but inhibitors of dopamine, histamine, and serotonin are all used to suppress vomiting, suggesting that these play a role in the initiation or maintenance of a vomiting cycle. Vasopressin and neurokinin may also participate.

Phases:
The vomiting act has two phases. In the retching phase, the abdominal muscles undergo a few rounds of coordinated contractions together with the diaphragm and the muscles used in respiratory inspiration. For this reason, an individual may confuse this phase with an episode of violent hiccups. In this retching phase nothing has yet been expelled. In the next phase, also termed the expulsive phase, intense pressure is formed in the stomach brought about by enormous shifts in both the diaphragm and the abdomen. These shifts are, in essence, vigorous contractions of these muscles that last for extended periods of time - much longer than a normal period of muscular contraction. The pressure is then suddenly released when the upper esophageal sphincter relaxes resulting in the expulsion of gastric contents. For people not in the habit of exercising the abdominal muscles, they may be painful for the next few days. The relief of pressure and the release of endorphins into the bloodstream after the expulsion causes the vomiter to feel better.

Content:
Gastric secretions and likewise vomit are highly acidic. Recent food intake will be reflected in the gastric vomit. Irrespective of the content, vomit tends to be malodorous.
The content of the vomitus (vomit) may be of medical interest. Fresh blood in the vomit is termed hematemesis ("blood vomiting"). Altered blood bears resemblance to coffee grounds (as the iron in the blood is oxidized) and, when this matter is identified, the term "coffee ground vomiting" is used. Bile can enter the vomit during subsequent heaves due to duodenal contraction if the vomiting is severe. Fecal vomiting is often a consequence of intestinal obstruction or a gastrocolic fistula and is treated as a warning sign of this potentially serious problem ("signum mali ominis"); such vomiting is sometimes called "miserere."
If the vomiting reflex continues for an extended period with no appreciable vomitus, the condition is known as non-productive emesis or dry heaves, which can be painful and debilitating.

Complications:
1.Aspiration of vomit:
Vomiting can be dangerous if the gastric content gets into the respiratory tract. Under normal circumstances the gag reflex and coughing will prevent this from occurring, however these protective reflexes are compromised in persons under the influences of certain substances such as alcohol or anesthesia. The individual may choke and asphyxiate or suffer an aspiration pneumonia.
2.Dehydration and electrolyte imbalance:
Prolonged and excessive vomiting will deplete the body of water (dehydration) and may alter the electrolyte status. Gastric vomiting leads to the loss of acid (protons) and chlorine directly. Combined with the resulting alkaline tide, this leads to hypochloremic metabolic alkalosis (low chloride levels together with high HCO3 and CO2 and increased blood pH) and often hypokalemia (potassium depletion). The hypokalemia is an indirect result of the kidney compensating for the loss of acid. With the loss of intake of food the individual may eventually become cachectic. A less frequent occurrence results from a vomiting of intestinal contents, including bile acids and HCO3- which can lead to metabolic acidosis.
3.Mallory-Weiss tear:
Repeated or profuse vomiting may cause erosions to the esophagus or small tears in the esophageal mucosa (Mallory-Weiss tear). This may become apparent if fresh red blood is mixed with vomit after several episodes.
4.Recuurent Vomiting:
Recurrent vomiting, such as observed in bulimia nervosa, may lead to destruction of the tooth enamel due to the acidity of the vomit. Digestive enzymes can also have a negative effect on oral health, by degrading the tissue of the gums.

Causes:
Vomiting may be due to a large number of causes, and protracted vomiting has a long differential diagnosis.
1.Digestive tract:
* Gastritis (inflammation of the gastric wall, usually by viruses)
* Gastroenteritis
* Pyloric stenosis (in babies, this typically causes a very forceful "projectile vomiting" and is an indication for urgent surgery)
* Bowel obstruction
* Overeating
* Acute abdomen and/or peritonitis
* Ileus
* Cholecystitis, pancreatitis, appendicitis, hepatitis
* Food poisoning
* In children, it can be caused by an allergic reaction to cow's milk proteins (Milk allergy or lactose intolerance)
2.Sensory system:
* Movement: motion sickness (which is caused by overstimulation of the labyrinthine canals of the ear)
* Ménière's disease
3.Causes in the brain:
* Concussion
* Cerebral hemorrhage
* Migraine
* Brain tumors, which can cause the chemoreceptors to malfunction
* Benign intracranial hypertension and hydrocephalus
4.Metabolic disturbances (these may irritate both the stomach and the parts of the brain that coordinate vomiting)
* Hypercalcemia (high calcium levels)
* Uremia (urea accumulation, usually due to renal failure)
* Adrenal insufficiency
* Hypoglycemia
* Hyperglycemia
5.Pregnancy
* Hyperemesis, Morning sickness
6.Drug reaction (vomiting may occur as an acute somatic response to)
* alcohol (being sick while being drunk or being sick the next morning, suffering from the after-effects, i.e., the hangover).
* opioids
* selective serotonin reuptake inhibitors
* many chemotherapy drugs
* some entheogens (such as peyote or ayahuasca)

Illness:
* Norwalk virus

Miscellaneous:
* Self-induced
o Eating disorders (anorexia nervosa or bulimia nervosa)
o To eliminate an ingested poison (some poisons should not be vomited as they may be more toxic when inhaled or aspirated; it is better to ask for help before inducing vomiting)
o Some people who are engaged in binge drinking will induce vomiting in order to make room in their stomachs for further alcohol consumption.
* After surgery (postoperative nausea and vomiting)
* Disagreeable sights, smells or thoughts (such as decayed matter, others' vomit, thinking of vomiting), etc.
* Extreme pain, such as intense headache or myocardial infarction (heart attack)
* Violent emotions
* Cyclic vomiting syndrome (a poorly-understood condition with attacks of vomiting)
* High doses of ionizing radiation will sometimes trigger a vomit reflex in the victim
* Violent fits of coughing, hiccups, or asthma
* Nervousness
* Performing physical activity (such as swimming) shortly after a meal.
* Being struck hard in the stomach.
* Overexertion (doing too much strenuous exercise can lead to vomiting shortly afterwards).
* Rumination syndrome, an underdiagnosed and poorly understood disorder that causes sufferers to regurgitate food shortly after ingestion.

Unusual types:
Fecal vomiting is a kind of emesis in which half-digested matter is expelled from the intestines into the stomach, by spasmodic contractions of the gastric muscles, and then subsequently forcefully expelled from the stomach up into the esophagus and out through the mouth and sometimes nasal passages. Though it is not actual fecal matter that is expelled, it smells similar. Alternative medical terms for fecal vomiting are copremesis and stercoraceous vomiting.[2] This form of aspiration usually leads to a severe aspiration pneumonia, secondary to the massive number of bacteria present in the fecal matter.[citation needed] This form of pneumonia is often severe enough to be fatal.

An antiemetic is a drug that is effective against vomiting and nausea. Anti-emetics are typically used to treat motion sickness and the side effects of opioid analgesics, general anaesthetics and chemotherapy directed against cancer.

Types of Antiemetics:

Antiemetics include:

* 5-HT3 receptor antagonists - these block serotonin receptors in the central nervous system and gastrointestinal tract. As such, they can be used to treat post-operative and cytotoxic drug nausea & vomiting.
o Dolasetron (Anzemet) Dolasetron can be administered in tablet form or in an injection. Tablets are administered one hour before chemotherapy or surgery. Injection is administered 30 minutes before certain chemotherapy or surgery.
o Granisetron (Kytril, Sancuso) Granisetron can be administered in tablet (Kytril), oral solution (Kytril), or in a single transdermal patch to the upper arm (SANCUSO). Tablet and Oral solution (Kytril) should be administered twice daily up to one hour before chemotherapy with 12 hours between doses. Granisetron in patch form (SANCUSO) should be applied to the upper arm a minimum of 24 to 48 hours before the chemotherapy regimen begins. One patch can be worn for up to 7 days depending on the chemotherapy regimen.
o Ondansetron (Zofran) Ondansetron is administered in an oral tablet form 30 minutes before chemotherapy. Further doses may be taken 1-2 days after chemotherapy completion.
o Tropisetron (Navoban) Tropisetron can be administered in oral capsules or in injection form. It is given as a single for 6 days after the first day of chemotherapy.
o Palonosetron (Aloxi) Palonosetron can be administered in an injection form 30 minutes before chemotherapy regimen begins or immediately before surgery. It can also be administered in oral capsule form one hour prior to the start of chemotherapy.
o Mirtazapine (Remeron)
* Dopamine antagonists act in the brain and are used to treat nausea and vomiting associated with neoplastic disease, radiation sickness, opioids, cytotoxic drugs and general anaesthetics.
o Domperidone
o Droperidol, haloperidol, chlorpromazine, promethazine, prochlorperazine. Some of these drugs are limited in their usefullness by their extra-pyramidal and sedative side-effects.
o Metoclopramide (Reglan) also acts on the GI tract as a pro-kinetic, and is thus useful in gastrointestinal disease; however, it is poor in cytotoxic or post-op vomiting.
o Alizapride
* Antihistamines (H1 histamine receptor antagonists), effective in many conditions, including motion sickness and severe morning sickness in pregnancy.
o Cyclizine
o Diphenhydramine (Benadryl)
o Dimenhydrinate (Gravol, Dramamine)
o Meclizine (Bonine, Antivert)
o Promethazine (Pentazine, Phenergan, Promacot)
o Hydroxyzine
* Cannabinoids are used in patients with cachexia, cytotoxic nausea, and vomiting, or who are unresponsive to other agents.
o Cannabis (Marijuana). Most patients prefer smoked or vaporized cannabis over pharmaceutical versions because they do not contain all 66 cannabinoids that are in cannabis, many of which have medicinal applications. Medical marijuana is also much less expensive than related pharmaceuticals. CBD is a main cannabinoid not in Marinol or Cesamet.
o Dronabinol (Marinol). Ninety percent of sales are for cancer and AIDS patients. The other 10% of its sales thought to be for pain, Multiple Sclerosis and also for Alzheimer's disease.
o Nabilone (Cesamet). Put back on the market in late 2006. In the US, it is a Schedule II substance unlike Marinol which is Schedule III and cannabis which is Schedule I.
o Sativex is an oral spray containing THC and CBD. It is currently legal in Canada and a few countries in Europe but not in the U.S.
* Benzodiazepines
o Midazolam given at the onset of anesthesia has been shown in recent trials to be as effective as ondansetron, a 5-HT3 antagonist in the prevention of post-operative nausea and vomiting. Further studies need to be undertaken.
o Lorazepam said to be very good as an adjunct treatment for nausea along with first line medications such as Compazine or Zofran.
* Anticholinergics
o Hyoscine (also known as scopolamine)
* Steroids
o Dexamethasone given in low dose at the onset of a general anaesthetic for surgery is an effective anti-emetic. The specific mechanism of action is not fully understood.
* NK1 receptor antagonist
o Aprepitant (Emend) Commercially available NK1 Receptor antagonist
o Casopitant Investigational NK1 receptor antagonist
* Other
o Trimethobenzamide; thought to work on the CTZ
o Ginger
o Emetrol also claimed to be an effective antiemetic.
o Propofol given intravenously. It has been used in an acute care setting in hospital as a rescue therapy for emesis.
o Peppermint claimed to help nausea or stomach pain when added into a tea or peppermint candies.
o Muscimol purported as such [1]
o Ajwain purported to be antiemetic. It is a popular spice in India, Ethiopia and Eritrea.
o Zolpidem has also been reported to be a newer antiemetic that is being used more and more for patients that have been unresponsive to other first-line typical antiemetic. Its mechanism of action when used as an antiemetic (Zolpidem's first-most prescribed on-label use is for the treatment of insomnia; some cancer patients receiving chemotherapy medication, as well as Zolpidem (which at the time was only being used by the patents to help their cancer-related insomnia; and noticed the potentially powerful antiemetic properties of the medicine, which was reported to their doctors). Clinicians have not found a direct link between specific types of nausea and Zolpidem other than various patient reports that appear to show a possible, and potentially powerful and new secondary-use of the medication (off-label at this point). More formal trials will need to be concluded before any detailed results can be analyzed. In the meantime, physicians do seem to be using Zolpidem on a growing basis; usually as a second- or third-line drug after a patient has tried the more prominent antiemetics such as Zofran. Lastly, judging from the fairly small number of actual published reports from physicians using this medication (Probably due to the fact that either a patient's insurance refused to off-label coverage and/or that physicians are less-likely overall to present or publicly generate major "breakthrough" news when they only have treated/access to a small and typically quite limited number of patients. At this time it seems that the main trials and individual, case-by-case usage of this medication for nausea, have been centered in both the United Kingdom and the United States. Also to note, it is not understood, or well-enough studied at this point to say that Zolpidem is a virtually "unknown" antiemetic, but when patients have severe nausea reactions to any number of root causes; ongoing daily treatment with Zolpidem seems to be a worthy medication to explore with the patient.

* Non-pharmaceutical therapies with some evidence of efficacy include acupuncture and hypnosis. All drugs have potential side effects. It is important to try to reduce the baseline risk of nausea and vomiting, particularly with respect to surgery.

Controlling nausea and vomiting (anti-emetic therapy)
This information is about ways to help prevent or reduce nausea (feelings of sickness) and vomiting (being sick), which can sometimes be caused by cancer or its treatment. It covers the medicines that are commonly used, which are known as anti-sickness drugs (or anti-emetics), as well as containing other ideas to help you cope.
If you are having chemotherapy or radiotherapy treatment, this information should ideally be read with our general information about these treatments.

Causes:
The mechanisms by which a person feels sick or vomits are complicated. Within the body, nausea and vomiting are controlled by an area of the brain known as the vomiting centre. This area may be stimulated to cause nausea or vomiting by nerves within the gut (stomach) or by other parts of the brain. Psychological and emotional factors can also influence whether a person feels sick.

Some of the reasons why someone with cancer may experience nausea and vomiting are listed below.
Treatments:
* Chemotherapy Some types of chemotherapy can affect the part of the brain known as the vomiting centre and cause nausea and vomiting.
* Radiotherapy If radiotherapy is given to the brain, stomach, bowel, or close to the liver, it may lead to nausea and vomiting.
* Hormonal therapies Hormonal therapies may occasionally cause nausea.
* Morphine-based medicines These are used as painkillers. Some of these drugs can affect the vomiting centre.

Physical reasons:
* Changes in the body chemistry High levels of calcium in the blood, or raised pressure within the brain, can affect the vomiting centre.
* Damage to the liver If the liver is not working properly, waste products can build up in the blood, leading to nausea and vomiting.
* Blockage of the bowel This can be caused by some types of cancer, especially cancers that affect the pelvis or abdomen.

Emotional reasons:
* Anxiety Feeling anxious about the cancer or your treatment may cause nausea and vomiting.
* Anticipatory nausea Feelings of nausea, and sometimes vomiting, can occasionally be triggered by circumstances that remind you of previous episodes of nausea and vomiting. This can sometimes occur with chemotherapy.

How anti-emetic medicines work:
The type of anti-sickness treatment you receive will depend on the cause. Sometimes there is more than one cause of nausea and vomiting and more than one type of treatment may be needed. The drugs also work in different ways and are often used together to best effect.

Many different types of drugs are used to control nausea and vomiting. Some of these work on the brain by preventing the stimulation of the vomiting centre. Others work on the gut by speeding up the rate at which the stomach empties and so help to move food through the intestines more quickly. The most effective way of controlling nausea and vomiting is by treating the cause, if possible.


Ways Of Administration:
Anti-emetic drugs can be given in different ways.

* By mouth Some tablets can be swallowed with plenty of water, while others can be placed under the tongue (sublingually) to dissolve.

* Into a vein by drip Some anti-emetics can be diluted in a fluid and given through a small tube (cannula) inserted into the vein (intravenously).

* Into the muscle The drugs are given by injection into a muscle (intramuscular injection).

*Into the fatty tissue under the skin (subcutaneously) The drugs are either injected using a syringe or given slowly over several hours, using a pump attached to a small needle that is placed just under the skin.

* Suppositories These are put into the back passage (rectum), where they dissolve and are absorbed into the bloodstream through the lining of the gut.

* Skin patches Some anti-emetic drugs can be absorbed through the skin (transdermally) from a small patch that is changed every three days.

Some cancer treatments, including certain chemotherapy drugs, are known to cause nausea and vomiting. If you are taking these drugs, anti-emetic therapy will be given before the treatment has started. It may also be continued for a few days after the treatment has finished.

When someone feels sick or nauseated due to the cancer itself, it can take a while to control this distressing symptom. You will be given anti-emetics and, if possible, the cause of the sickness will be treated.

Whatever the cause of the sickness, the anti-emetics should be taken regularly so that the sickness does not have a chance to come back. If you have any nausea or vomiting which is new, becomes worse, or lasts more than a few days, let your doctor or nurse know.