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By J. Vatras. Southern Virginia University.

Some patients report superimposed paroxysms of stabbing ice pick-like pain in the periorbital region that lasts for a few seconds and occur once or several times in rapid succession proven 4 mg aristocort. Over 50 percent of sufferers report that alcohol is a potent precipitant of cluster headaches during a cluster bout; this sensitivity to alcohol ceases when the cluster ends discount aristocort 40mg with mastercard. The frequency of attacks depends upon the type of cluster: Episodic cluster headaches are most common purchase 40mg aristocort visa, occurring in about 80 to 90 percent of patients suffering from this disorder. They are characterized by one to three attacks of periorbital pain per day over a six to twelve week period, followed by an average pain free interval of six months to one year. Chronic cluster headaches are characterized by the absence of sustained periods of remission. Attacks of pain tend to recur at the same hour each day for the duration of a single cluster; attacks occur between 9 pm and 9 am in up to 80 percent. University of South Alabama, Department of Family Medicine June 30, 2008 152 Management: Abortive therapy — Abortive therapy of cluster headaches can be difficult because of the short duration of each episode. Nevertheless, a number of medications have proven effective Oxygen — Acute cluster headaches can be aborted by inhalation of 100 percent oxygen in the majority of patients. Octreotide —appears to be effective and well tolerated in the treatment of acute cluster headaches. Prophylaxis — Prophylactic therapy should be started as soon as possible at the onset of a cluster episode. Verapamil was found to be effective for prophylaxis but there is a four to six week delay before the headaches remit. Prednisone is highly effective for prophylaxis, but should not be used chronically due to side effects. Lithium appears to be particularly effective for the chronic form of cluster headaches. Ergotamine, Cyproheptadine, and Indomethacin have also been shown to be effective. Prophylactic medications can be tapered after the expected duration of the cluster has passed. Strength of Recommendations Key clinical recommendation Label The first-line treatments for acute cluster headache are oxygen or sumatriptan, or a A combination of the two. Less well-studied alternatives for acute treatment include intranasal dihydroergotamine, B intranasal lidocaine, and intranasal capsaicin. Verapamil, in a dosage of 360 to 480 mg daily, can effectively reduce the number of attacks A during a cluster headache period. Less well-studied alternatives for prophylaxis include prednisone and antiepileptic drugs; B they should only be considered if verapamil is not tolerated or not effective. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, opinion, or case series. Surgical Therapy: Patients with chronic cluster headaches that do not respond to medications may be considered for surgical therapy aimed at the trigeminal nerve. A case series found that 15 of 17 patients who underwent complete or partial section of the trigeminal nerve had complete or near- complete relief of symptoms. University of South Alabama, Department of Family Medicine June 30, 2008 153 Diagnosis and Treatment of Headache Algorithm Diagnosis algorithm • Evaluate type of headache • Take a detailed history and assess functional impairment • Rule out causes for concern • Consider secondary headaches • Refer to specialist Migraine Treatment Tension-type Headache Cluster Headache • Categorize and select treatment based on severity • Establish diagnosis • Establish diagnosis and functional impairment • Acute treatment • Acute treatment • Patient education and • Prophylactic treatment • Prophylactic treatment lifestyle modifications • Patient education and • Patient education and lifestyle modifications lifestyle modifications Resources for Patients: http://www. Obtain adequate information to develop a working diagnosis in an efficient manner 9. Arrange for definitive care of identified specific causes of throat pain at time of presentation or with appropriate follow-up 10. General approach to history: The history for pharyngitis is primarily to establish risk of the symptom being caused by a life threatening condition and to determine whether the patient has streptococcal pharyngitis. This is done initially by observing the patient for signs of toxicity, and listening to the quality of the patient’s voice. Following this, the time course of the illness and associated symptoms will give important clues as to whether this is infectious due to bacterial causes, infectious due to viral causes, inflammatory, or related to another disease process (such as Gastroesophageal Reflux Disease) Vocal Quality - Location – Where does your throat hurt? If a life threatening infection is suspected, further testing in a hospital setting might include direct visualization (epiglottis, peritonsilar abscess, palatal cellulitis, diptheria), diagnostic imaging (abscess). Patients over 15: A number of diseases and conditions can cause symptoms of pharyngitis. In patients with persistent symptoms, consider immunologic testing for connective tissue diseases. In patients with persistent symptoms and exposure to tobacco and/or alcohol referral for direct visualization might be warranted, particularly of the symptoms are associated with voice changes, weight loss, or other worrisome signs. If a life threatening infection is suspected, further testing in a hospital setting might include direct visualization (epiglottis, peritonsilar abscess, palatal cellulitis, diptheria), diagnostic imaging (abscess). Topical anesthetics such as Chlorasceptic spray help patient to tolerate symptoms until infection resolves and assist with maintaining hydration. Ingestion of fluid that is not at room temperature (either warmer or colder) is often easier for the patient. Cure rates with oral regimes dosed anywhere from every 12 to every 6 hours have been found to be equivalent. Alternative antibiotics for use with those patients who reprt allergies or have treatment failures are found in the appendix. Ingestion of fluid that is not at room temperature (either warmer or colder) is often easier for the patient.

The diagnosis of alien dysmetria discount aristocort 4 mg free shipping, myoclonus of the upper extremities with movements buy aristocort 4mg with amex, hand syndrome was considered generic aristocort 40mg fast delivery. Occupational therapy was provided to the patient, in were increased but symmetrical. Discussion: Alien Hand with no changes on encephalic parenchyma, namely on basal gan- syndrome is a rare motor function disturbance that occurs follow- glia. Discussion: Cardiac arrest is the most common cause of involvement, commonly in the form of impaired consciousness. Material and Methods: A very sensitive Purkinje cell loss could contribute to neurologic 60-year-old female patient, with previous history of depression dysfunction, including posthypoxic myoclonus and ataxia. To the and hypertension, who developed, a neurological state of de- best of our knowledge, there have not been any reports concerning creased consciousness, ataxic gait, ophtalmoplegia and arrefexic cardiac arrest due to heat stroke. Heat stroke is characterized by faccid tetraparesis, days after an abdominal surgery for abscess hyperpyrexia, hot dry skin and central nervous system disturbance. The association of cardiac arrest and heat stroke with intravenous immunoglobulins, and improved consciousness is not described in the literature. It was only 16 weeks after the onset of cannot be fully cured, their functionality and quality of life can be symptoms, that she was admitted to a rehabilitation center. Kim4 mechanism, often triggered by previous infection, is the proposed 1National Rehabilitation Center, Seoul, 2Hanyang University, cause. Treatment comprises intravenous immunoglobulins and/or Seoul, 3Dankook University, Yong-in, 4National Rehabilitation plasmapheresis. Early, inten- sive, multimodal rehabilitation is determinant for the fnal func- Introduction/Background: Upper extremity functional defcits af- tional outcomes. Early referral for rehabilita- tried for upper extremity rehabilitation, however, hand rehabilita- tion is ideal, but it depends on a speedy diagnostic process. The change of those variables were compared between cial nerve, and leads to facial palsy, otalgia, and skin lesions of the the two groups using the linear mixed model. In addition, symptoms such as glove group showed the improvement of writing of Jebsen-Taylor dizziness and hearing loss may develop following involvement of hand function test (p=0. Changes of the Fugl-Meyer describing simultaneous involvement of the glossopharyngeal and assessment and other measurements did not differ between two vagus nerves. Material and glove system is a feasible rehabilitation tool for enhancing upper Methods: A 63-yr-old male patient, with a past medical history extremity, especially hand function in patients with stroke. Detailed physical examination revealed erythe- A Rare Mix for Rehabilitation: Bickerstaff Syndrome matous vesicles on the left auricle, gag refex was hyporefexic, Overlapped by Miller-Fisher Syndrome and Guillain- and laryngeal elevation was decreased when swallowing saliva. Acyclovir (800 mg/day) was administered intravenously for 1Centro Hospitalar de São João, Porto, 2Centro de Medicina de 21 days, and prednisolone (22. The characteristics of a lesion, licluding its volume, otalgia, hoarseness, and dizziness developed along with dyspha- have been suggested to infuence stroke recovery, but equivocal gia. Although the mechanism about descending involvement of evidence supports this precept. We To evaluate the relationship lower cranial nerves is uncertain, several hypotheses have been between volume of middle cerebral artery ischemic lesion and proposed. First, invasion of cranial nerves may have been due to postural control ability in the chronic phase of stroke. Patient who had hemorrhagic nerves are supplied by the ascending pharyngeal artery. The facial, or multiple stroke lesions, any neurologic condition(beyond the maxillary and mandibular nerves of the trigeminal nerve are sup- stroke) that impaired function of affected leg, previous history of plied by the middle meningeal artery. Lesion volume was obtained from of polyneuropathy occurring after vasculitis due to viral infection. A)) to determine the effect of computer-based The Relationship between Motivation and Functional work on postural balance. Static balance control was measured by equilibrium score and dynamic balance control was measured by Outcome in an Inpatient Rehabilitation Setting rhythmic weight shift test. Results: Data were collected 1 1 1 related to patient`s lesion volume (mean volume=14 cm3 or 4. The p value for Introduction:Apathy is a disturbance of motivation, emotion or in- the regression coeffcient of lesion volume was 0. Conclusion: There are no signifcant relation- athy has been reported to interfere with efforts at rehabilitation and ship in lesion volume and postural control ability in the chronic complicate further both assessment and treatment. Other factors may account for variance in postural to assess whether, and to what extent, lack of motivation relates to control ability after stroke. Twenty two had orthopedic problems and Traumatic Spinal Cord Injury Patients 8 had right- hemispheric stroke. The apathetic patients tended to the effect of electrical stimulation in extensor spasticity of lower be older (mean age 82. Apathy had a statistically signifcant im- Design: Hospital-based randomized study. Intervention: Study group discharge did not differ signifcantly in the patients with or without (n=18) received electrical stimulation and standard physiotherapy apathy. Conclusion: Results showed stimulation in study group were 60 Hz with 5 second on and 2 that apathy appeared to have a signifcant negative impact on over- second off, intensity ranging from 1 to 10 mA with suboptimal mo- all functional outcome. It does seem to interfere in improving or tor contraction with treatment duration of 20 minutes per session, worsening the patients’ clinical condition.

Rheumatoid nodule (one or several nodules) When respiratory symptoms are accompanied by radi- Vascular malformation ographic abnormalities discount aristocort 15 mg with amex, diseases of the pulmonary Bronchogenic cyst Localized opacification (infiltrate) parenchyma or the pleura are usually present aristocort 15mg amex. Either dif- Pneumonia (bacterial 15 mg aristocort with visa, atypical, mycobacterial, fuse or localized parenchymal lung disease is generally or fungal infection) visualized well on the radiograph, and both air and liquid Neoplasm in the pleural space (pneumothorax and pleural effusion, Radiation pneumonitis respectively) are usually readily detected by radiography. Bronchiolitis obliterans with organizing pneumonia Radiographic findings in the absence of respiratory Bronchocentric granulomatosis symptoms often indicate localized disease affecting the Pulmonary infarction airways or the pulmonary parenchyma. One or more Diffuse interstitial disease Idiopathic pulmonary fibrosis nodules or masses may suggest intrathoracic malignancy, Pulmonary fibrosis with systemic rheumatic disease but they may also be the manifestation of a current or Sarcoidosis previous infectious process. Multiple nodules affecting Drug-induced lung disease only one lobe suggest an infectious cause rather than Pneumoconiosis malignancy because metastatic disease would not have a Hypersensitivity pneumonitis predilection for only one discrete area of the lung. Infection (pneumocystis, viral pneumonia) Patients with diffuse parenchymal lung disease on radi- Langerhans cell histiocytosis Diffuse alveolar disease ographic examination may be free of symptoms, as is Cardiogenic pulmonary edema sometimes the case in those with pulmonary sarcoidosis. The Sensory Afferents experience derives from interactions among multiple physiological, psychological, social, and environmental Chemoreceptors in the carotid bodies and medulla are factors, and may induce secondary physiological and activated by hypoxemia, acute hypercapnia, and acidemia. J-receptors, which are sensitive to interstitial Respiratory sensations are the consequence of interac- edema, and pulmonary vascular receptors, which are tions between the efferent, or outgoing, motor output activated by acute changes in pulmonary artery pressure, from the brain to the ventilatory muscles (feed-forward) appear to contribute to air hunger. Hyperinflation is and the afferent, or incoming, sensory input from recep- associated with the sensation of an inability to get a tors throughout the body (feedback), as well as the inte- deep breath or of an unsatisfying breath. It is unclear if grative processing of this information that we infer must this sensation arises from receptors in the lungs or chest be occurring in the brain (Fig. Motor Efferents Integration: Efferent-Reafferent Mismatch Disorders of the ventilatory pump are associated with increased work of breathing or a sense of an increased A discrepancy or mismatch between the feed-forward effort to breathe. Afferents also project to the areas of the breath restriction) brain responsible for control of ventilation. The motor cortex, Heavy breathing, Deconditioning responding to input from the control centers, sends neural rapid breathing, messages to the ventilatory muscles and a corollary dis- breathing more charge to the sensory cortex (feed-forward with respect to the instructions sent to the muscles). An alternative approach is to inquire larly important when there is a mechanical derangement about the activities a patient can do (i. Anxiety Acute anxiety may increase the severity of dyspnea either Affective Dimension by altering the interpretation of sensory data or by leading For a sensation to be reported as a symptom, it must be to patterns of breathing that heighten physiologic abnor- perceived as unpleasant and interpreted as abnormal. In patients with expira- are still in the early stages of learning the best ways to tory flow limitation, for example, the increased respiratory assess the affective dimension of dyspnea. Some therapies rate that accompanies acute anxiety leads to hyperinfla- for dyspnea, such as pulmonary rehabilitation, may reduce tion, increased work of breathing, a sense of an increased breathing discomfort, partly by altering this dimension. Alterations in As with pain, dyspnea assessment begins with a determi- the respiratory system can be considered in the context nation of the quality of the discomfort (Table 2-1). Similarly, alterations in the cardiovas- Sensory Intensity cular system can be grouped into three categories: con- A modified Borg scale or visual analogue scale can be used ditions associated with high, normal, and low cardiac to measure dyspnea at rest, immediately after exercise, or output (Fig. When confronted with a pathophysiologic categories that explain the vast majority of patient with shortness of breath of unclear cause, it is useful cases. Stimulation of pul- associated with obesity is probably caused by multiple monary receptors, as occurs in those with acute bron- mechanisms, including high cardiac output and impaired chospasm, interstitial edema, and pulmonary embolism, ventilatory pump function. High alti- Normal Cardiac Output tude, high progesterone states such as pregnancy, and drugs Cardiovascular deconditioning is characterized by early such as aspirin stimulate the controller and may cause dys- development of anaerobic metabolism and stimulation pnea even when the respiratory system is normal. Diastolic dys- function—caused by hypertension, aortic stenosis, or Ventilatory Pump hypertrophic cardiomyopathy—is an increasingly frequent Disorders of the airways (e. Conditions Low Cardiac Output that stiffen the chest wall, such as kyphoscoliosis, or that Diseases of the myocardium resulting from coronary weaken the ventilatory muscles, such as myasthenia artery disease and nonischemic cardiomyopathies result gravis or Guillain-Barré syndrome, are also associated in a greater left ventricular end-diastolic volume and an with an increased effort to breathe. Large pleural effu- elevation of the left ventricular end-diastolic as well as sions may contribute to dyspnea, both by increasing the pulmonary capillary pressures. Pulmonary receptors are work of breathing and by stimulating pulmonary recep- stimulated by the elevated vascular pressures and resul- tors if associated atelectasis is present. Gas Exchanger Pneumonia, pulmonary edema, and aspiration all inter- fere with gas exchange. In these cases, relief of hypoxemia typically In obtaining a history, the patient should be asked to has only a small impact on the intensity of dyspnea. Orthopnea is a common indicator of congestive heart High Cardiac Output failure, mechanical impairment of the diaphragm asso- Mild to moderate anemia is associated with breathing ciated with obesity, or asthma triggered by esophageal discomfort during exercise. Left-to-right intracardiac 10 History Quality of sensation, timing, positional disposition Persistent vs. Nocturnal dyspnea suggests congestive heart accessory muscles of ventilation; and the tripod posi- failure or asthma. Whereas acute, intermittent episodes tion, characterized by sitting with one’s hands braced of dyspnea are more likely to reflect episodes of on the knees) is indicative of disorders of the venti- myocardial ischemia, bronchospasm, or pulmonary latory pump, most commonly increased airway resis- embolism, chronic persistent dyspnea is typical of tance or stiff lungs and chest wall. Risk factors for the vital signs, an accurate assessment of the respira- occupational lung disease and for coronary artery dis- tory rate should be obtained and examination for a ease should be solicited. Exami- The physical examination should begin during the nation of the chest should focus on symmetry of interview of the patient. A patient’s inability to speak movement, percussion (dullness indicative of pleural in full sentences before stopping to get a deep breath effusion, hyperresonance a sign of emphysema), and suggests a condition that leads to stimulation of the auscultation (wheezes, rales, rhonchi, prolonged controller or an impairment of the ventilatory pump expiratory phase, diminished breath sounds, which with reduced vital capacity. Evidence for increased are clues to disorders of the airways, and interstitial work of breathing (supraclavicular retractions; use of edema or fibrosis). The cardiac examination should focus on signs of elevated right heart pressures (jugu- the respiratory system is probably the cause of the 11 lar venous distention, edema, accentuated pulmonic problem. Alternatively, if the heart rate is above 85% component to the second heart sound), left ventricu- of the predicted maximum, anaerobic threshold lar dysfunction (S3 and S4 gallops), and valvular dis- occurs early, the blood pressure becomes excessively ease (murmurs). The first goal is to correct the underlying problem Patients with exertional dyspnea should be asked to responsible for the symptom. A should be administered if the resting O2 saturation is “picture” of the patient while symptomatic may be 90% or below or if the patient’s saturation decreases to worth thousands of dollars in laboratory tests. Studies of anxiolytics and antidepres- indicates obstructive lung disease; low lung volumes sants have not demonstrated consistent benefit.

Richard N aristocort 10mg for sale, Porath D cheap aristocort 10 mg mastercard, Radspieler A purchase aristocort 15 mg otc, Schwager J (2005) Mol Nutr Food Res 49:431 156. Okawara M, Katsuki H, Kurimoto E, Shibata H, Kume T, Akaike A (2007) Biochem Pharmacol 73:550 163. Ono K, Hasegawa K, Naiki H, Yamada M (2004) J Neurosci Res 75:742 Chapter 3 Research into Isofavonoid Phyto-oestrogens in Plant Cell Cultures M. The physiological and pharmacological properties of isofavones are discussed in the Introduc- tion. The accumulation of phyto-oestrogens by plant cell and tissue cultures is reviewed. A special emphasis is put on the infuence of basic experimental me- dia and physiological factors on the production of isofavonoids in in vitro cul- tures. The potential role of the transformation process as well as the techniques (including infection with bacteria and particle bombardment) and the various technological procedures (elicitation, feeding experiments) in isofavone bio- synthesis is discussed. Moreover, this chapter deals with the in vitro cultures of legume plants oriented for selective accumulation of phyto-oestrogens. Strictly controlled conditions and constant access to stable biological material made it possible to conduct basic research into plant physiology on a much larger scale than before, leading to the expla- nation of numerous biochemical processes that constitute primary and second- ary tissue metabolism [3, 4]. It was also proved that plant biomasses cultivated in vitro are capable of biosynthesis of secondary metabolites typical for intact plants, or that they may serve as sources of entirely new substances not identi- fed in nature [3–10]. In effect, a path was opened for intensive biotechnological research into the potential use of in vitro cultures to produce highly valuable secondary metabolites, including compounds for which medical applications could be found [10–13]. Statistical research indicated that even in developed countries, where the broadly understood chemical synthesis is the basis for the pharmaceutical in- dustry as such, still as much as 25 % of all medicines are compounds of natural origin. Steady degradation of the environment, slow growth of plants, com- mon problems with low concentrations of active substances in the cultivated plants are only some of the factors that make it diffcult to obtain biologically active substances from natural sources. With the aforementioned obstacles and the need to cultivate tropical species in a temperate climate, in vitro cultures came to be seen as an alternative method for producing secondary metabolites with particularly valuable therapeutic properties [3, 14]. Among the numerous secondary metabolites, it is isofavonoids, together with alkaloids and terpenoids, that are natural compounds most commonly re- searched under in vitro conditions [9, 10, 15]. The reason for this may be seen in their multidirectional biological activity [16, 17]. Isofavones, being recognised phytoalexins and phytoanticipins, play a key role in the defence mechanisms in plants of Fabaceae family. That is why plant biomasses obtained from various species of legume plants became model systems for testing the defence response of plants to broadly defned environmental stresses [18, 19]. Isofavones are, in addition, secondary metabolites with broad health-promoting activity. In ad- dition to the anti-infammatory, antifungal and anti-free-radical activities that are typical for the whole group of biofavonoids, they also have features typical for compounds that inhibit oestrogen β receptors in mammals [16, 17, 20–22]. For this reason, among other applications, they are commonly recommended for the treatment of menopause symptoms [21, 23]. Moreover, some consider- ation is given to the possible using isofavones in the prevention and treatment of neoplasms related to the distortion of hormonal balance in the body [16, 17, 22, 24, 25]. Predominantly limited to soy-bean products, the natural sources of isofavones do not permit mass production of substantial amounts of these compounds, not only for the pharmaceutical industry, but also for the compre- hensive pharmacological and toxicological research of the isolated substances Chapter 3 Research into Isofavonoid Phyto-oestrogens in Plant Cell Cultures 57 [26]. Therefore, in recent years, only very few reports dealing with biotechno- logical research indicated the possibility of using in vitro cultures of certain species of the Fabaceae family for large-scale production of phyto-oestrogens [27, 28]. Irrespective of the main goal of a research project, the biosynthesis and metabolism of isofavonoids is stimulated in in vitro cultures by using both traditional as well as more advanced biotechnological strategies [15, 26]. Such procedures as the modifcation of the basic composition of the experimental medium, with a focus on growth regulators [29–33] and the regulation of the growth conditions by controlled lighting and temperature, should be mentioned [30, 34, 35]. The natural enzymatic potential of the investigated biomass is also used to induce broadly understood bioconversion with the use of direct and indirect precursors, in order to obtain the fnal product [36–38]. Based on the fact that isofavones belong to a class of substances that play an active role in defence processes [18, 19], the biosynthesis and metabolism of these compounds in plant cells is regulated using a wide range of biotic and abiotic elicitors [39–43]. Sample tests of isofavone accumulation in various types of in vitro cultures (callus, suspension, roots and shoots) provide prelimi- nary insight into the production potential of the particular types of cultures [27, 28, 31–33, 44]. The metabolism of isofavones was also investigated using transgenic biomasses (suspensions, hairy roots, regenerated organs) obtained through genetic transformation with wild or pre-designed strains of bacteria [31, 45–47], or particle bombardment [48, 49]. The following discussion, based on current literature reports, presents the impact of the particular growth strategies on the biosynthesis and metabolism of isofavones in in vitro plant cultures. These modifcations involve both qualitative and quantitative changes in the macro- and microelements, sources of carbon and growth regulators respon- sible for the particular hormonal balance in the growth system [2, 5, 8, 9, 51]. The composition of these media, especially in terms of growth regulators, was selected to support the micropropagation of the investigated species or to ensure maximum growth of the biomasses [44, 52–56]. For instance, in callus and suspension cultures of the most frequently inves- tigated species of the Fabaceae family, such as Glycine max, Cicer arietinum, Phaseolus vulgaris, Lupinus albus and Medicago sativa, the growth regulators 58 M. Luczkiewicz of choice were most often kinetin and 2,4-dichlorophenoxyacetic acid (2,4-D) [27, 28, 37–39, 41, 42]. It should be noted here that the effect of the particular growth regulators on shoot initiation and elongation was variable and each time was species specifc [44, 55–63]. Only few reported experiments involving in vitro cultures of Fabaceae plants were directly focussed on the infuence of the basic composition of the experi- mental media on the accumulation of isofavones in the plant material [30–34, 55, 64, 65]. The other experiments showed that a signifcant increase in the concentra- tion of the discussed compounds in the biomasses can be achieved by reduc- ing the level of mineral salts in the growth media [64–66]. A reduction of am- monia salts and nitrites in the growth media caused Phaseolus vulgaris shoot cultures to synthesise several times more phaseolin and kievetone than control biomasses [34]. The process was accompanied by a generally increased expres- sion of genes related to the phenylpropanoid pathway and inhibition of cul- ture growth. Similarly, increased nitrogen content in the medium resulted in the concentration of phytoalexins in bean shoots being reduced by even 9 % [34].