National Recreation and Park Association"s Certified Park and Recreation Professional Test - NRPA CPRP Exam Secrets Study Guide

National Recreation and Park Association’s Certified Park and Recreation Professional Test – NRPA CPRP Exam Secrets Study Guide

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What Are Sinkholes and Where Do They Occur?

What Are Sinkholes and Where Do They Occur?

What Are Sinkholes and Where Do They Occur?

USA.gov sent this bulletin at 03/11/2013 12:10 PM EDT If you heard recent news reports about a devastating sinkhole in Florida, you may be wondering how this type of event occurs. 

According to the U.S. Geological Survey (USGS), sinkholes are most common in karst terrain, or regions where the rock below the land surface is soluble. When water from rainfall moves down through the soil, the rock begins to dissolve, creating spaces and caverns underground. If the underground spaces get too big, a sudden collapse occurs.

A

bout 20% of the United States is susceptible to sinkhole events, but the most damage tends to occur in Florida, Texas, Alabama, Missouri, Kentucky, Tennessee, and Pennsylvania.

Detailed geologic mapping, which defines areas of soluble rock at the surface and subsurface, can help educate land planners and policy makers about sinkhole risk.

If you know that you live in an area underlain by soluble rock, check your property for holes in the ground or cracks in your structure’s foundation.

Learn more about the science of sinkholes from the U.S. Geological Survey.

Airway microbiota and bronchial hyperresponsiveness in patients with suboptimally controlled asthma

Airway microbiota and bronchial hyperresponsiveness in patients with suboptimally controlled asthma
Yvonne J. Huang, MD

Affiliations
Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, Calif
, Craig E. Nelson, PhD
AffiliationsMarine Science Institute, University of California, Santa Barbara, Calif
, Eoin L. Brodie, PhD
AffiliationsEarth Sciences Division, Lawrence Berkeley National Laboratory, Berkeley, Calif
, Todd Z. DeSantis, MS
AffiliationsEarth Sciences Division, Lawrence Berkeley National Laboratory, Berkeley, Calif
, Marshall S. Baek, BS
AffiliationsDepartment of Anesthesia and Perioperative Care, University of California, San Francisco, Calif
, Jane Liu, MS
AffiliationsDivision of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, Calif
, Tanja Woyke, PhD
AffiliationsUS Department of Energy, Joint Genome Institute, Walnut Creek, Calif
, Martin Allgaier, PhD
AffiliationsDepartment of Anesthesia and Perioperative Care, University of California, San Francisco, Calif
, Jim Bristow, MD
AffiliationsUS Department of Energy, Joint Genome Institute, Walnut Creek, Calif
, Jeanine P. Wiener-Kronish, MD
AffiliationsDepartment of Anesthesia and Perioperative Care, University of California, San Francisco, Calif
, E. Rand Sutherland, MD, MPH
AffiliationsDivision of Pulmonary and Critical Care Medicine, Department of Medicine, National Jewish Health, Denver, Colo
, Tonya S. King, PhD
AffiliationsDivision of Biostatistics, Department of Public Health Sciences, Pennsylvania State University, Hershey, Pa
, Nikolina Icitovic, MAS
AffiliationsDivision of Biostatistics, Department of Public Health Sciences, Pennsylvania State University, Hershey, Pa
, Richard J. Martin, MD
AffiliationsDivision of Pulmonary and Critical Care Medicine, Department of Medicine, National Jewish Health, Denver, Colo
, William J. Calhoun, MD
AffiliationsDivision of Allergy, Pulmonary, Immunology, Critical Care and Sleep, Department of Internal Medicine, University of Texas Medical Branch at Galveston, Galveston, Tex
, Mario Castro, MD
AffiliationsDivision of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St Louis, Mo
, Loren C. Denlinger, MD, PhD
AffiliationsDivision of Pulmonary and Critical Care Medicine, Department of Medicine, University of Wisconsin Schools of Medicine and Public Health, Madison, Wis
, Emily DiMango, MD
AffiliationsDivision of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
, Monica Kraft, MD
AffiliationsDivision of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University, Durham, NC
, Stephen P. Peters, MD, PhD
AffiliationsSection on Pulmonary, Critical Care, Allergy and Immunological Diseases, Department of Internal Medicine, Wake Forest University Health Sciences, Winston-Salem, NC
, Stephen I. Wasserman, MD
AffiliationsAllergy and Immunology Section, Department of Medicine, University of California San Diego, San Diego, Calif
, Michael E. Wechsler, MD
AffiliationsDivision of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Mass
, Homer A. Boushey, MD
AffiliationsDivision of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, Calif
, Susan V. Lynch, PhD
AffiliationsDivision of Gastroenterology, Department of Medicine, University of California, San Francisco, CalifReprint requests: Susan V. Lynch, PhD, Colitis and Crohn’s Disease Center, Division of Gastroenterology, Department of Medicine, Box 0538, University of California, San Francisco, CA 94143.
, National Heart, Lung, and Blood Institute’s Asthma Clinical Research Network

Affiliations
Investigators of the Asthma Clinical Research Network are listed in Appendix E1 in this article’s Online Repository at www.jacionline.org.
Received 17 July 2010; received in revised form 8 October 2010; accepted 27 October 2010. published online 03 January 2011.

Background
Improvement in lung function after macrolide antibiotic therapy has been attributed to reduction in bronchial infection by specific bacteria. However, the airway might be populated by a more diverse microbiota, and clinical features of asthma might be associated with characteristics of the airway microbiota present.

Objective
We sought to determine whether relationships exist between the composition of the airway bacterial microbiota and clinical features of asthma using culture-independent tools capable of detecting the presence and relative abundance of most known bacteria.

Methods
In this pilot study bronchial epithelial brushings were collected from 65 adults with suboptimally controlled asthma participating in a multicenter study of the effects of clarithromycin on asthma control and 10 healthy control subjects. A combination of high-density 16S ribosomal RNA microarray and parallel clone library-sequencing analysis was used to profile the microbiota and examine relationships with clinical measurements.

Results
Compared with control subjects, 16S ribosomal RNA amplicon concentrations (a proxy for bacterial burden) and bacterial diversity were significantly higher among asthmatic patients. In multivariate analyses airway microbiota composition and diversity were significantly correlated with bronchial hyperresponsiveness. Specifically, the relative abundance of particular phylotypes, including members of the Comamonadaceae, Sphingomonadaceae, Oxalobacteraceae, and other bacterial families were highly correlated with the degree of bronchial hyperresponsiveness.

Conclusion: The composition of bronchial airway microbiota is associated with the degree of bronchial hyperresponsiveness among patients with suboptimally controlled asthma. These findings support the need for further functional studies to examine the potential contribution of members of the airway microbiota in asthma pathogenesis.

Airway microbiota and bronchial hyperresponsiveness in patients with suboptimally controlled asthma

ASMA
Actualidad Ultimas noticias – JANOes y agencias –
El asma podría estar relacionada con bacterias de las vías respiratorias
JANO.es y agencias · 21 Febrero 2011 11:32

Científicos de la Universidad de California en San Francisco han observado que las vías aéreas bronquiales de los pacientes asmáticos están infectadas por una colección más compleja y rica de microbios.

El asma podría tener una relación con la composición del grupo de bacterias que viven en los bronquios, un hallazgo que podría sugerir un nuevo tratamiento para esta común enfermedad inflamatoria, según un estudio de la Universidad de California en San Francisco, publicado en el Journal of Allergy and Clinical Immunology.

Utilizando nuevos métodos de detección, los investigadores han descubierto que la diversidad de microbios que habitan en el tracto respiratorio es mucho más grande de lo que se sospechaba, por lo que crean una comunidad microbiana compleja e interconectada que parece estar asociada al asma, similar a la que se ha encontrado en las enfermedades inflamatorias del intestino, la vaginitis, la periodontitis y, posiblemente, incluso en la obesidad.

En contra de la creencia popular, los científicos también vieron que las vías aéreas no son necesariamente ambientes totalmente estériles, incluso en personas sanas. Las vías aéreas de los asmáticos están infectadas por una colección más compleja y rica de bacterias. Estos descubrimientos podrían mejorar la comprensión de la biología del asma y potencialmente, llevar a terapias nuevas y mejoradas.

Durante los tres años que ha durado este proyecto piloto, los científicos recogieron muestras del revestimiento de las vías aéreas de 65 adultos con asma leve a moderado y de 10 sujetos sanos.

Después, utilizando una herramienta capaz de identificar cerca de 8.500 grupos distintos de bacterias en un único ensayo, desarrollaron los perfiles de los organismos presentes en cada muestra para buscar relaciones entre la comunidad de bacterias y las características clínicas de los pacientes con asma.

Descubrieron que las muestras de vías aéreas bronquiales de pacientes asmáticos contenían más bacterias que las muestras de pacientes sanos. Asimismo, encontraron una mayor diversidad de bacterias en los pacientes asmáticos con las vías aéreas más sensibles (una característica del asma).

Según el coautor de este estudio Homer Boushey, profesor de Medicina en la División de Cuidados Médicos Pulmonares y Críticos de la UCSF, “la gente piensa que el asma está causado por la inhalación de alérgenos, pero este estudio muestra que podría ser más complicado que eso, el asma podría conllevar la colonización de las vías aéreas por parte de múltiples bacterias”.

En los últimos años, los científicos habían comenzado a estudiar las comunidades de microorganismos de especies distintas (microbioma), que se encuentran tanto en individuos sanos como enfermos, para entender mejor su papel en una variedad de enfermedades. Pero la investigación en microbioma dentro de la enfermedad respiratoria es un terreno relativamente inexplorado.

Para Yvonne J. Huang, investigadora principal de este estudio, “conocemos bastante poco sobre la diversidad, complejidad y funciones colectivas de las bacterias que viven en el tracto respiratorio y de cómo pueden contribuir al desarrollo de enfermedades como el asma”.

Journal of Allergy and Clinical Immunology 2011;127:372-381
Airway microbiota and bronchial hyperresponsiveness in patients with suboptimally controlled asthma

Journal of Allergy and Clinical Immunology
Journal of Allergy and Clinical Immunology – Home

University of California, San Francisco
University of California, San Francisco | www.ucsf.edu.

Actualidad Ultimas noticias – JANOes y agencias – El asma podria estar relacionada con bacterias de las vias respiratorias – JANO.es – ELSEVIER

Now, It"s Your Turn: How You Can Take Medicine Safely

How You Can Take Medicine Safely | NIH MedlinePlus the Magazine

Now, It’s Your Turn: How You Can Take Medicine Safely

08/21/2013 04:59 PM EDT

Related MedlinePlus Page: Medication Errors

Summer 2013 Table of Contents

Your doctor has prescribed a medicine. The pharmacist has filled the prescription. Now it’s up to you to take the medicine safely. Here are some tips that can help:

• Make a list of all the medicines you take, including over-the-counter products and dietary supplements. Show it to all of your healthcare providers including physical therapists and dentists. Keep one copy in your medicine cabinet and one in your wallet or pocketbook. The list should include the: name of each medicine, doctor who prescribed it, reason it was prescribed, amount you take, and time(s) you take it.


• Read and save in one place all written information that comes with the medicine.


• Take your medicine in the exact amount and at the time your doctor prescribes.


• Call your doctor right away if you have any problems with your medicine or if you are worried that it might be doing more harm than good. Your doctor may be able to change your prescription to a different one that will work better for you.


• Use a memory aid to take your medicines on time. Some people use mealtime or bedtime as a reminder to take their medicine. Other people use charts, calendars, and weekly pill boxes. Find a system that works for you.


• Do not skip doses of medication or take half doses to save money. Talk with your doctor or pharmacist if you can’t afford the prescribed medicine. There may be less costly choices or special programs to help with the cost of certain drugs.


• Avoid mixing alcohol and medicine. Some medicines may not work correctly or may make you sick if taken with alcohol.


• Take your medicine until it’s finished or until your doctor says it’s okay to stop.


• Don’t take medicines prescribed for another person or give yours to someone else.


• Don’t take medicine in the dark. To avoid making a mistake, turn your light on before reaching for your pills.


• Check the expiration dates on your medicine bottles. Your pharmacist can probably tell you how to safely get rid of medicine you no longer need or that is out of date. The pharmacist might be able to dispose of it for you.


• Make sure you store all medicines and supplements out of sight and out of reach of children. And don’t take your medicines in front of young children. They might try to copy you.

Find Out More

• 
  National Institute on Aging (NIA) Information Center
  1-800-222-2225 (toll-free) | 1-800-222-4225 (TTY/toll-free)
  www.nia.nih.gov/health
  www.nia.nih.gov/espanol
  

To sign up for regular email alerts about new publications and other information from the NIA, go to www.nia.nih.gov/health.

• 
  MedlinePlus: www.medlineplus.gov. Type in “medicines” in the Search box. Also, click on “Drugs & Supplements” to search for specific medicines.


• Visit www.nihseniorhealth.gov, a senior-friendly website from the NIA and the National Library of Medicine. This website has health and wellness information for older adults. Special features make it simple to use. For example, you can click on a button to have the text read out loud or to make the type larger.


• 
  Centers for Medicare and Medicaid Services
  7500 Security Boulevard
  Baltimore, MD
  21244–1850
  1–800–633–4227 (1–800–MEDICARE/toll-free) www.medicare.gov
  


• 
  Food and Drug Administration
  10903 New Hampshire Avenue
  Silver Spring, MD 20993
  1–888–463–6332 (toll-free)
  www.fda.gov
  


• 
  Partnership for Prescription Assistance
  1–888–477–2669 (toll-free)
  www.pparx.org
  

Asthma more common, severe among obese kids: study: MedlinePlus

Asthma more common, severe among obese kids: study: MedlinePlus

 

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Asthma more common, severe among obese kids: study

Friday, August 9, 2013

Related MedlinePlus Pages

• Asthma in Children


• Obesity in Children

By Genevra Pittman
NEW YORK (Reuters Health) – Overweight and obese children are more likely to be diagnosed with asthma, according to a new study – and when they do have the condition, it tends to be more severe than in normal weight youth.
Researchers found that heavier kids and teenagers with asthma had more emergency room visits for the condition and used more “rescue” medications.
“If parents are noticing that their overweight or obese child is having asthma-like symptoms, one thing to pay attention to, instead of just addressing the asthma, is to potentially address the child’s weight,” said Mary Helen Black, the study’s lead author from Kaiser Permanente Southern California’s department of research and evaluation.
For their study, she and her colleagues analyzed the electronic health records of 623,000 six- to 19-year-olds covered by Kaiser’s health plan in 2007 through 2011. None of those children initially had asthma.
Over an average of three years, just under 32,000 of them – about five percent – were diagnosed with the condition.
The researchers found that the more children weighed, the more likely they were to develop asthma. Compared to normal weight kids, those who were overweight but not obese were 16 percent more likely to be diagnosed with asthma, and the most obese were 37 percent more likely.
That was after taking into account children’s age, gender and race, the study team wrote this week in the American Journal of Epidemiology.
Among those who developed asthma, heavier kids and teens in the study also tended to have more complications than their slimmer peers.
In the year after their diagnosis, for example, 106 out of every 1,000 extremely obese youth went to the ER for asthma, compared to 87 of every 1,000 normal weight kids with asthma. And obese children were more likely to have an asthma “exacerbation” (that is, worsening of their condition) and to need “rescue” medicines, called short-acting beta agonists, when their usual medicines weren’t enough.
According to the Centers for Disease Control and Prevention, one in 11 U.S. children has asthma. In 2008, asthma caused 10.5 million missed school days.
Black said it’s possible the body-wide inflammation seen in obesity may affect asthma risk and severity. Or, she added, the link between obesity and asthma could be due to the direct effect of extra weight on the airways.
“Especially those (children) who are extremely obese definitely have a more restricted capacity for air exchange and things like that,” Black told Reuters Health.
“It’s a little more difficult for them mechanically to breathe.”
If that’s the case, Black said, “If an extremely obese child is able to get down into even the overweight range, they may have a much greater capacity for breathing normally.”
Dr. Peter Michelson, a pediatrician who has studied obesity and asthma at St. Louis Children’s Hospital, said a limitation of this and other studies is that it’s not clear whether asthma was diagnosed with lung function tests.
Without those measures, he said, it’s possible some kids were being treated for shortness of breath due to being obese and out of shape, and not true asthma.
“The results would be interesting, but I feel that it’s incomplete because the characterization of how severe the asthma is really needs pulmonary function (measurements),” Michelson, who wasn’t involved in the new research, told Reuters Health.
“We need more data specifically about lung function to characterize these patients more definitively and to see if asthma and obesity are as definitively linked as we think.”
“Having an actual quantitative measure of lung function would be ideal,” Black said.
But, she added, “I don’t think there’s gross misclassification going on here.”
Dr. Carlos Camargo, an epidemiologist from the Harvard School of Public Health in Boston who has also studied this topic, said the new report “confirms observations from several prior studies.”
Camargo told Reuters Health in an email that in order to learn how to improve asthma control in people with the condition, and to prevent asthma in the first place, the next step will be to conduct more reliable trials, in which people are randomly assigned to different therapies.
SOURCE: http://bit.ly/18gpxb5 American Journal of Epidemiology, online August 6, 2013.

Reuters Health

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Asthma in Children

Obesity in Children

AHRQ Innovations Exchange | Expert Commentary: National Academy and Affiliated State Chapters Support Pediatricians in Improving Asthma Care, Leading to Better Guideline Adherence and Disease Control, Fewer Acute Episodes

AHRQ Innovations Exchange | Expert Commentary: National Academy and Affiliated State Chapters Support Pediatricians in Improving Asthma Care, Leading to Better Guideline Adherence and Disease Control, Fewer Acute Episodes

Innovation Profile:

National Academy and Affiliated State Chapters Support Pediatricians in Improving Asthma Care, Leading to Better Guideline Adherence and Disease Control, Fewer Acute Episodes

 

Pediatric Asthma Is a Worthy Quality Improvement Target

By Paul V. Williams, MD
Northwest Asthma & Allergy Center

Efforts to improve pediatric asthma care are important, given the prevalence of the condition and its potential for causing adverse health outcomes. As a pediatric allergist, I’ve been involved in quality improvement in my own practice, though not specifically focused on adherence to asthma treatment guidelines. We can gain some insights into the challenges of quality improvement related to asthma care by considering two innovation profiles featured on the AHRQ Health Care Innovations Exchange. One profile—National Academy and Affiliated State Chapters Support Pediatricians in Improving Asthma Care, Leading to Better Guideline Adherence and Disease Control, Fewer Acute Episodes—describes a 1-year quality improvement project by the American Academy of Pediatrics (AAP) that helped 49 pediatric practices in 4 states to better adhere to established asthma care guidelines. The other profile—Mobile Clinic And In-Home Educator Generate Small, Short-Term Increases in Symptom-Free Days in Inner-City Preschool Children With Asthma But No Improvements in Other Key Outcomes—describes an attempt to use a mobile pediatric asthma clinic to improve asthma management among children enrolled in the Head Start program in Baltimore.

The pediatricians who organized the AAP initiative succeeded in what they tried to do, based on the impressive improvements in physician performance reported among the participating practices, with the percentage of patients receiving “optimal” care rising from 35 percent at baseline to 85 percent a year later. It appears that the practices—located in Alabama, Maine, Ohio, and Oregon—represent a reasonable cross-section of pediatric practices in the United States. It’s somewhat surprising that only 58 percent of the patients were considered to have well-controlled asthma at baseline, because you might expect that primary care pediatricians would tend to care for patients with relatively well-controlled, intermittent asthma. However, the practices may have tended to focus their quality improvement efforts on patients with a history of having less-than-optimal disease control.

After the intervention, 72 percent of the patients were classified as having well-controlled asthma, an outcome similar to results in other studies aimed at improving pediatric asthma care. As with other quality improvement studies, the key question is, what will happen to these patients over the long term? If the practices achieved lasting improvement in the asthma care process, the measured gains in physician performance could lead to long-term improvements in asthma control. In any case, if pediatricians in other settings can achieve even a fraction of the reported performance improvements, and demonstrate that the gains are sustainable, there’s a real potential for success. That’s why the AAP is continuing to support quality improvement initiatives that focus on asthma care.

Assuming that proper assessment of asthma severity and control has been accomplished, inadequate adherence to prescribed treatment is generally the main barrier to successful asthma management. We know that many patients who say that they are taking their medications actually haven’t filled or refilled their prescriptions, but their physicians often lack a good way to assess adherence. Even in practices like my own that use an electronic health record system, the infrastructure often is not yet in place to enable electronic communication with pharmacies.

The mobile pediatric asthma clinic that was used in the Baltimore program was introduced in 1995 in Los Angeles. The original Breathmobile program achieved some great successes by taking care to the patients. Back in the 1990s, though, it was probably easier to make a big difference in asthma care. After all, it was only in 1991 that the National Asthma Education and Prevention Program had distributed its initial guidelines on diagnosis and management of asthma, in response to the lack of standardization in asthma care. By 2005, when Baltimore’s Breathmobile program began serving children enrolled in Head Start, the level of asthma care may have been fairly good already. And given the low rates of family participation, we shouldn’t be surprised that the program had such a limited impact on patient outcomes.

Asthma diagnosis is difficult in preschool children, because young children have great variability in disease expression and are not developmentally able to undergo spirometry assessments. Also, we have relatively few data on treatment efficacy in preschool children and their symptoms often improve spontaneously. Although these factors can make it difficult to assess the value of early intervention, efforts to identify and treat high-risk populations are worth pursuing as we seek to address unmet needs for effective care among children with asthma.

About the Author:

Paul V. Williams, MD, is an allergy and asthma specialist at the Mount Vernon, WA, office of the Northwest Asthma & Allergy Center. He is a member of the Board of Directors of the Joint Council on Allergy, Asthma and Immunology, and represents the American Medical Association on the National Asthma Education and Prevention Panel.

Disclosure Statement: Dr. Williams has been involved in a variety of leadership roles with the American Academy of Pediatrics, which developed the asthma care quality improvement project described in the innovation profile about the AAP initiative.

 

Original publication: May 09, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: May 09, 2012.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Answers About Nocturnal Asthma - 5 Answers About Night Time Asthma

An asthma flare up any time of the day can be scary. But experiencing an attack at night leaves you far more vulnerable. Yet those who suffer with this condition often have this scary experience 2 to 3 times a week. And given that studies have shown that 30% of asthma fatalities occur at night, this is a condition that needs to be effectively managed. Here are 5 answers that will help.

What are the causes? No one really knows exactly what causes it, but there are a number of factors that those with the condition have in common. People who are overweight are more prone to the condition. Genetics also play a part in determining who will and will not have it.

There is also a natural decrease in some hormones at night which often allows more mucous production, and bronchial spasms. Add to this the natural drop and body temperature and these factors create conditions that are ripe for an attack.

Is there a cure? The medical community says there is no known cure, but that a combination of medication and lifestyle changes can make it a manageable condition.

What kinds of drugs are the most effective? Drugs for asthma are designed to work in different ways and are prescribed based on the severity of the condition. Bronchodilators are used to relax muscles and enlarge airways making it easier to breathe. This type of drug is used as a quick fix to relieve a flare up. Steroids are used to reduce inflammation in the airways.

Oral steroids affect the entire body while those that are inhaled have the greatest affect locally. Some types of steroids are able to reduce the body’s reaction to triggers and reduce the amount and severity of attacks over time. Your physician will make a decision about which of these will help you manage your asthma more effectively. And it is very likely that some combination will affect a solution that you can literally live with.

What types of irritants can trigger an attack? Night time in the bedroom can be a Pandora’s Box in terms of irritants. One of the most potent triggers is the protein in dust mite feces. And dust mite population is generally highest in the bedroom.

Because mites make their home in your mattress, pillows and linens, unless you cover your bedding with covers that keep them out, you are likely to have problems trying to get a good night’s sleep. Other common triggers include household dust, mold and mildew spores, and pet dander.

What should an effective management plan consist of? One of the most natural ways to start is by eating healthy and controlling your weight. Your physician will most probably design a plan that may include a rescue inhaler, and/or a time-released controller that will lessen your body’s reactions to triggers.

Cleaning up indoor air quality to make it virtually allergen free is also an effective way to control nocturnal asthma.