Aches and Pains, Everyday Moulds & Facemasks


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Dr Libby Radcliffe talks about the aches & pains suffered by aspergillosis patients, the different causes and what can be done to reduce them. Professor Malcolm Richardson talks about the types of moulds we all come across every day and the damage they can cause in the wrong places. Dr Graham Atherton talks about the correct specification for facemasks used to reduce the inhalation of mould spores when carrying out routine daily tasks & hobbies.

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Aches and Pains, Everyday Moulds & Facemasks

  2. 2. Programme 1pm Light lunch, Tea Coffee 1.30pm Dr Libby Ratcliffe ‘Aches & Pains’ 2pm Graham Atherton ‘Submitting your side effects’ 2.20pm Break: Social time, chat to staff 2.40pm Malcolm Richardson ‘Everyday Moulds’ 3pm Debbie Kennedy ‘Why we do drug levels’ 3.15pm Meet the Team: Questions & Answers 3.30pm Close
  3. 3. Aches & painsL. Ratcliffe16.11.2012
  4. 4.  Aches and pains Survival manual
  5. 5. Aches & pains & Aspergillus The Aspergillus diseases Other chronic diseases  Arthritis  Diabetes  bronchiectasis  Autoimmune diseases  Other infections  “chronic fatigue” Acute illneses  Viral infections … Medications Other contributing factors  alcohol
  6. 6. Muscle aches Injury or trauma including strains and sprains Overuse- using muscles too much, too often, too soon Tension or stress Drugs Diseases Electrolyte imbalance
  7. 7. Aspergillus & symptoms Fatigue Malaise Chest pain Fever, chills Headache Muscle aches
  8. 8. Aches & pains & medication Antifungal medication Other medication  Statins  Steroids  Antihypertensives  antibiotics Interactions
  9. 9. Itraconazole Adverse reactions  N=189patients (Tucker et al, 1990)  1984-89  Itra related AE 39%  Nausea/vomiting 10%  Fatigue 1%  Clinical trials of systemic fungal infections  N=602 patients  Fatigue 3%  Malaise 1%  Post marketing experience  Myalgia, arthralgia  SPC  9% AE → 15% AE if prolonged usage
  10. 10. Voriconazole CPC (summary of product characteristic) Database >2000 patients  1655 patients in therapeutic trials  Heterogeneous populations  Very common ≥1/10  Common ≥1/102 - <1/10  Uncommon ≥ 1/102 -<1/103  Rare ≥ 1/102 -<1/104  Very rare >1/104 Back pain- common Arthritis- uncommon
  11. 11. Wermers et al. Clin Infect Dis 2011:52:1
  12. 12. Posaconazole CPC >2400 patients and healthy volunteers  Clinical trials and post-marketing experience Most common:  Nausea, vomiting, diarrhoea, pyrexia, increased billirubin Common:  common Uncommon:  Back pain  Breast pain  Pains  Malaise
  13. 13. Other medication Statins Biphosphonates ACE inhibitors Linazolid, metronidazole long term
  14. 14. How to deal with it all?
  15. 15. Side EffectsWhat are they?Why do they happen?Why is this subject important for antifungal drugs inparticular?
  16. 16. What are side effects?In medicine, a side effect is an effect, whethertherapeutic or adverse, that is secondary to the oneintended; although the term is predominantlyemployed to describe adverse effects, it can also applyto beneficial, but unintended, consequences of the useof a drug.
  17. 17. When do they happen?Some are predictable – we know if we suppress our immune system to enable an organ transplant we are also making ourselves more vulnerable to infectionSome less predictable – who could have predicted voriconazole would make many people sensitive to light?
  18. 18. Are side effect always bad?Occasionally, drugs are prescribed or proceduresperformed specifically for their side effects; in thatcase, said side effect ceases to be a side effect, and isnow an intended effect.For instance, X-rays were historically (and arecurrently) used as an imaging technique; the discoveryof their oncolytic capability led to their employ inradiotherapy (ablation of malignant tumours).
  19. 19. Examples of therapeutic side-effects Bevacizumab (Avastin) has been used against wet age-related macular degeneration, as well as macular edema from diseases such as diabetic retinopathy and central retinal vein occlusion.[1] Bupropion, an anti-depressant sold as Wellbutrin, is also used as a smoking cessation aid; this indication was later approved, and the name of the smoking cessation product is Zyban. In Ontario, Canada, smoking cessation drugs are not covered by provincial drug plans; elsewhere, Zyban is priced higher than Wellbutrin, despite being the same drug. Therefore, some physicians prescribe Wellbutrin for both indications. Carbamazepine is an approved treatment for manic depression and convulsions, but has side effects useful in treating attention-deficit hyperactivity disorder (ADHD), schizophrenia, phantom limb syndrome, paroxysmal extreme pain disorder, neuromyotonia, and post-traumatic stress disorder.[4] Dexamethasone and Betamethasone in premature labor, to enhance pulmonary maturation of the fetus.[5] Doxepin has been used to treat Angiodema and severe allergic reactions due to its strong antihistamine properties.[6] Gabapentin, approved for treatment of seizures and postherpetic neuralgia in adults, has side-effects which are useful in treating bipolar disorder, essential tremor, hot flashes, migraine prophylaxis, neuropathic pain syndromes, phantom limb syndrome, and restless leg syndrome.[7] Magnesium sulfate in obstetrics for premature labor and preeclampsia.[5] The SSRI medication sertraline is approved as an anti-depressant, but delays conjugal climax in men, and thus may be supplied to those in which climax is premature.[9]
  20. 20. Why do they happen? Developing drugs is difficult and complicated. Drugs are designed to work against a specific illness. In doing this they often interfere with other body systems. It is difficult to make a drug that targets one part of the body without affecting others. Every new drug is developed to hopefully be better than existing drugs. The current drugs may not be perfect, but they are better than they have ever been. And drugs in development now will hopefully be better still Genetic variability, Age
  21. 21. Why aren’t side effects prevented?A lot of attention is given to minimising side effects in a newdrug – testing is extensiveBUT tests are generally carried out by giving humanvolunteers ONLY the drug being tested. These test results areused to provide the guidance to doctors and patientscontained in the pack leafletsIn the real world patients often do not take only one drug.Medicines often interact with each other. Result = side effectsthat were not predicted
  22. 22. How can we all help?We can report all of our side effects to those whose jobit is to monitor them. This is especially important fornew drugs and for side effects NOT already listed inpack leaflets.Your doctor/nurse are the main reporters – and stillare as they have a good idea of what are unusual sideeffectsSo tell them!
  23. 23. MHRA – Yellow Card
  24. 24. Yellow Card SchemeMRHA are encouraging everyone to enter side effects using their new website software will highlight new side effects and interacting relationships with other drugsYou will be directly helping with Research !!
  25. 25. Yellow Card - offlineThere will still be a way for people who cannot accessthe internet to report side effects – forms available atpharmacists and are downloadable to print out toofrom MHRA website.This is a UK scheme. US patients have their ownauthorityFDA Adverse Event Reporting System (FAERS)(formerly AERS)
  26. 26. Facemasks HEPA filter. There are three grades of HEPA filters namely N95, N99 and N100 and the numbers refer to the percent of particles 0.3micron in size that filter is capable of removing from air that passes through it. An N95 filter will therefore remove 95% of all particles 0.3 micron in size from air that passes through it. Fungal spores are 2-3 microns in size so an N95 filter will remove far more than 95% of fungal spores from the air, though some will still get through. This standard is generally thought to be the best combination of efficiency and cost for the average home user - such as a gardener. Industrial users (e.g. workers remediating mouldy homes or other premises) may be exposed to far more spores and may opt for the more efficient N99 or N100 filters at higher cost.
  27. 27. FacemasksUK - In the UK and Europe the standards referred to are FFP1 (not appropriate for this purpose), FFP2 and FFP3. FFP2 is equivalent to N95 and FFP3 offers higher protection. Masks generally cost £2-3 each and are intended for single use.More expensive masks are available which can be used more than once - see 3M for one possible supplier.
  28. 28. What else?Is there anything you would like to suggest as a subject? – remember it can be any part of the service and only has to be enough to fill 10-15minLeave suggestions (& criticisms) using forms provided – anonymously if you prefer.orEmail to 0161 291 5866 – leave message if no answer
  29. 29. Next MonthDecember 21stChristmas Quiz Teams of 4
  30. 30. Everyday mouldsMalcolm Richardson PhD, FSB, FRCPath, FInstSSEMycology Reference Centre, Manchester
  31. 31. Toxic mould – media darling?
  32. 32. Fungi and the nose
  33. 33. Public concern! ”Exorcising a mold monster” ”Attack on the killer mold” ”It’s everywhere. Tales about rampant toxic mold get plenty of attention, but science tells a less dramatic story” ”The mold rush”
  34. 34. Sick buildings
  35. 35. Sick buildings
  36. 36. Sick buildings
  37. 37. Patients live in mouldy houses:exposure to Aspergillus and more
  38. 38. Bjerkandera adusta
  39. 39. Allergic fungal cough (fungus-associated chronic cough) Chronic cough Presence of environmental fungi, particularly Basidiomycetes in sputum Positivity in bronchoprovacation and lymphocyte stimulation tests Good response to antifungal drugs
  40. 40. Natural disasters
  41. 41. 42 days LAMB Snell & Yavakoli 2007; 119: 448-449
  42. 42. Sporangiospores
  43. 43. Joplin 13 identified case-patients  Median age: 48 years (13-76)  2 diabetics (15%)  10 admittted to ICU (77%) Case-patients: mean of 4 wounds: foreign material recovered from wounds in 6 patients (46%) Systemic antifungals; all case-patients: amphotericin B 5 deaths (38%) Casepatients: all located in zone that sustained most severe damage51st ICAAC Chicago (2011)
  44. 44. Mouldy dishwashers 189 sampled Environmental samples: 37C 62% positive for fungi  Exophiala dermatitidis  Exophiala phaeomuriformis Risk factors:  High temeperature  High moisture  Alkaline pH
  45. 45. Dimorphic pathogens Histoplasma Blastomyces Coccidioides Paracoccidioides
  46. 46. A common grass and soil fungus:Exserohilum rostratum
  47. 47. Fungalmeningitis:32 deaths,>400 sickpatients
  48. 48. Thank You“The best chance we have of beating this illness is to work together” Living with it, Working with it, Treating it Fungal Infection Trust