Online Medicine Resource

MALE INFERTILITY TREATMENT OPTIONS

2010-04-16T12:26:00.000+05:30

The introduction of Intracytoplasmic Sperm Injection (ICSI) over the past five years has revolutionised the management of male infertility.

Intracytoplasmic sperm injection (ICSI) is an in vitro fertilization procedure in which a single sperm is injected directly into an egg; this procedure is most commonly used to overcome male infertility problems.

The procedure is done under a microscope using micromanipulation devices (micromanipulators, microinjectors and micropipettes). A holding pipette (on picture on left) stablizes the mature oocyte. from the opposite site a thin, hollow needle is pierced into the inner part of the oocyte, the oolemma. it is loaded with a single sperm that will be released into the oocyte. The pictured oocyte has an extruded polar body at about 12 o'clock indicating its maturity. After the procedure, the oocyte will be placed into cell culture and checked on the following day for signs of fertilization.

In natural fertilisation sperm compete and when the first sperm enters the egg cell, the egg cell blocks the entry of any other sperm. Concern has been raised that in ICSI this sperm selection process is bypassed and the sperm is selected by the embryologist without undergoing any specific testing. However, in mid 2006 the FDA cleared a device that allows embryologists to select mature sperm for ICSI based on sperm binding to hyaluronan, the main constituent of the gel layer (cumulus oophorus) surrounding the oocyte. The device provides microscopic droplets of hyaluronan hydrogel attached to the culture dish. The embryologist places the prepared sperm on the microdot, selects and captures sperm that bind to the dot. Basic research on the maturation of sperm shows that hyaluronan-binding sperm are more mature and show fewer DNA strand breaks and significantly lower levels of aneuploidy than the sperm population from which they were selected.

There is some suggestion that birth defects are increased with the use of IVF in general, and ICSI specifically. It is hoped that use of new device (PICSI) will lower the apparently elevated level of birth defects associated with ICSI.

Medical conditions - Causes of Male Infertility

2010-04-16T12:21:00.002+05:30

There are various medical conditions that can cause infertility which include:

Diabetes
Pituitary gland disease
Hypothalamus disorder
Multiple sclerosis
Chlamydia
Prostatitis
Cushing’s syndrome
Hypogonadism
Mumps

There are two types of diabetes – Type 1 and Type 2 which are both to do with abnormally high levels in sugar in the bloodstream. Type 1 starts in childhood and is where the body is unable to produce any insulin.

Type 2 affects mainly older people and is where the body is unable to produce enough insulin. It is also known as ‘insulin-dependant’ diabetes.

How does this relate to infertility? A body of research has shown that there is a link between diabetes and male infertility. It appears to be the case that sperm produced by a man with diabetes are more damaged than those from a non-diabetic.

These damaged sperm are unable to fertilise an egg which leads to problems with conceiving.

Further studies are needed in order to determine the extent of the problem but it does seem to suggest that this will be a major cause of male infertility in the future.

Pituitary gland disease is classed as a hormonal problem and one of the many causes of male infertility. If it fails to send the correct signals to activate the testes then testosterone levels will drop which affects sperm production.

The hypothalamus is responsible for testosterone production but problems with this can reduce testosterone levels which directly impacts upon fertility levels.

Multiple sclerosis is a condition which affects myelin – the protective coating on nerve fibres which enable messages to be transmitted from the brain to the rest of the body. This myelin becomes damaged which then affects these messages.

In respect of male fertility, the layer of myelin on the nerves which control sexual response become damaged which disrupts this response, leading to problems with erection and ejaculation.

Chlamydia is a sexually transmitted disease (STD) which has come to our attention in recent years. It is most prevalent in young people and is a major area of concern for experts as it can have long term effects. And one of these effects is infertility.

It affects the quantity, shape and movement of sperm which damages male fertility.

Prostatitis is inflammation of the prostate gland which can cause permanent infertility if left untreated. Symptoms of this include painful ejaculation and urination.

Cushing’s syndrome is a hormonal disorder which is caused by excessive levels of cortisol in the body. Cortisol is produced by the adrenal glands and is responsible for a variety of functions which include: regulating blood pressure and the immune system, controlling blood sugar levels and an appropriate response to stress (‘fight or flight’).

But too much cortisol causes a whole range of problems which include:

Muscle weakness
Obesity
Water retention (around the ankles)
Reduced libido (and reduced fertility)
High blood pressure
Aches and pains
Excess thirst
Mood swings

Reduced libido (or lack of a sex drive) is likely to affect your sexual performance and ability to conceive.

Hypogonadism is a condition which can occur as a result of an injury or disease to the pituitary glands, hypothalamus or testicles. It can decrease the levels of the hormone gonadotrophin which in turn, lowers testosterone levels.

Lowered testosterone levels inhibit sperm production and may cause erectile dysfunction.

Mumps is a common childhood illness which usually causes no long term effects but, complications do happen. It is especially problematic for adult men as it can infect the testicles, causing orchitis which may cause sterility.

Around 20 to 30% cases of men with mumps experience orchitis. Symptoms of this include tenderness, swelling and a fever and it tends to occur a week after the outbreak of the disease.

Other general medical conditions which cause infertility include kidney disease, cancer, high blood pressure, stroke and coronary heart disease.

Failure to ejaculate - Causes of Male Infertility

2010-04-16T12:21:00.001+05:30

Ejaculation problems include a failure to ejaculate, sperm retention or a flushing of sperm into the bladder instead (known as retrograde ejaculation).

Problems with ejaculation can be caused by the following:

Disease such as multiple sclerosis or diabetes
Paralysis (spinal cord injury)
Damage occurred during surgery
Psychological issues
Certain medications such as high blood pressure medication

Other ejaculation problems include premature ejaculation and delayed ejaculation. Premature ejaculation is the condition in which the man ejaculates too quickly during sexual intercourse. This is much more common than delayed ejaculation in which ejaculation doesn’t happen straight away even though you have a normal erection.

Prescription medicines - Causes of Male Infertility

2010-04-16T12:18:00.000+05:30

A prescription medicine is designed to treat a particular complaint but many of them have side effects which can affect fertility. The use and indeed the overuse of these have been found to cause infertility.

What doesn’t help matters is when the medicine prescribed for a condition then causes another set of symptoms which impact upon fertility levels.

Problems to be aware of include:

Erectile dysfunction
Low sperm count
Hormone imbalance

If you are trying to conceive but require prescription medicines then discuss your concerns with your GP. He or she can recommend an alternative and the best way of changing from your current medication to a less risky one.

This also applies to over the counter medicines. These may seem fairly innocuous but they can have side effects, and one of these may be infertility. We tend to buy these assuming that they will cure whatever condition we have but they may not be the best option.

If you are thinking of doing this then check with your GP first before purchasing over the counter medicines from your local chemist or pharmacy.

At the end of the day you want to ensure that your reproductive system is in the best shape it can be when planning a family. So ensure that your lifestyle poses no or minimal risk to your fertility.

Another issue is that of cancer treatment: if you have been receiving radiation therapy or chemotherapy then this does affect fertility. In some cases it causes short term infertility but in others it can lead to long term infertility problems.

Cancer drugs can affect the quality and quantity of sperm produced as well as problems with ejaculation.

Speak to your GP or fertility specialist about this if you have to undergo chemotherapy or radiation therapy. He or she may advise you to store your sperm in a sperm bank prior to your cancer treatment which will help to preserve them.

Environmental issues (exposure to toxins etc) - Causes of Male Infertility

2010-04-16T12:17:00.001+05:30

These refer to potential hazards at work, in the home and during leisure.

If you work with hazardous chemicals such as pesticides, solvents and fuels then consider that these have been linked to fertility issues so discuss this further with your employer. If you are bothered by this then see if your employer will allow you to change jobs or move to another department whilst undergoing fertility tests.

If this is not possible then ensure that you follow guidelines prescribed by your health and safety department, wear protective clothing if necessary and shower afterwards to remove any potentially damaging chemicals.

Other factors which can affect your fertility include a lack of activity and overheated environments. If you are inactive at work and tend to sit down for long periods of time then what happens is that your core temperature rises which overheats the testes and so reduces sperm count.

If you have a job which requires you to sit down for long periods of time then try to take short breaks. And wear loose fitting underwear such as boxer shorts which allows the testes to remain cool and the sperm healthy.

Another work related aspect is if your job requires you to do any heavy lifting or carrying. There is a risk of injuring your back or an abdominal strain (hernia) which may affect your fertility. If you do have to lift anything then take extra care whilst doing so or see if you can change duties in the meantime.

This equally applies to any manual work you may do around the home.

As regards leisure: certain sports especially contact sports such as rugby have a high risk of injury, for example to the groin area. Other equally risky sports include heavy weightlifting and endurance cycling. It may be a good idea to ease off on these or change to something less rigorous whilst trying to conceive.

Lifestyle issues - Causes of Male Infertility

2010-04-16T12:16:00.001+05:30

These include diet, smoking, alcohol consumption and even the type of pants you wear!

Smoking lowers sperm count as well as affecting sperm quality so both the quality and quality of your sperm are affected. In fact, this sperm count can be 13 to 17% lower in men who smoke as compared to non-smoking males.

It can also damage the blood vessels within the penis which decreases blood flow and causes ineffective erections.

These are all good reasons to give up smoking if you and your partner are trying to conceive.

Visit our female infertility section to learn more about the effects of smoking on your partner.

Another aspect is alcohol: alcohol consumption can affect fertility in both men and women. Even a moderate amount of alcohol can have quite a drastic effect. With men it can reduce the size of the testicles, lower sperm count, decrease the quality of the sperm (more poor quality sperm), decrease libido and even cause impotence.

You may enjoy a few drinks after work or at the weekend when socialising but you need to look at your intake if you are trying to conceive. It is better to limit this to the occasional drink rather than on a regular basis.

This equally applies to your partner as drinking can also affect the woman’s fertility.

Your diet plays more of a part in fertility than you think. A healthy diet, rich in antioxidants, especially vitamins C and E are particularly crucial for fertility. They can boost sperm production, ensuring that these sperm are of a superior quality and likely to fertilise an egg.

Conversely, a diet which is lacking in certain vitamins and minerals, for example, zinc, can reduce the volume of semen produced by the male. A certain amount of semen is required for fertilisation and a diet which is deficient in zinc will affect this.

If you feel that you are lacking in zinc then introduce the following zinc rich foods into your diet:

Wheat germ
Seafood
Beef
Lamb

Other factors which can affect sperm count include: wearing tight underwear, riding a bicycle for a long period of time (the saddle puts pressure on the groin which can damage arteries and nerves) and drug use (cannabis, cocaine or steroids)

Vasectomy - Causes of Male Infertility

2010-04-16T12:14:00.000+05:30

A vasectomy is a surgical procedure in which the vas deferens (the tube which carries sperm) is cut and tied off to prevent sperm from accessing the ejaculatory semen.

This won’t affect your sex drive or the ability to ejaculate but your semen won’t contain any sperm. You will still produce sperm but these cannot escape via your penis and are naturally absorbed by your body.

As a result of this many men consider this to be a permanent state of affairs and usually choose to have this operation if they are not planning on starting a family. It is also known as male sterilisation.

The procedure can be reversed via a vasectomy reversal operation but this is not a guarantee of future fertility.

If you have undergone this procedure and want it reversed check with your GP as success rates depend on the length of time between the original procedure and the reversal.

Blockage in the ejaculatory duct - Causes of Male Infertility

2010-04-16T12:12:00.000+05:30

The ejaculatory duct is the part of the male reproductive system which enables sperm to travel from the epididymis to the ejaculatory fluid.

The ejaculatory duct consists of the epididymi and the vas deferens. The epididymi are two coiled tubes which store and transport sperm from the testes. This sperm then moves from the epididymi to the vas deferens, ready for ejaculation.

This is a straightforward process but in a small percentage of cases this duct becomes blocked which prevents the sperm from reaching your partner’s egg in order to fertilise it.

A blockage can be caused by a groin injury, congenital defect, vasectomy or a sexually transmitted disease (STD).

Surgery is required to remove the blockage and this generally has a high success rate.

Disease or trauma to the testicles - Causes of Male Infertility

2010-04-16T12:11:00.000+05:30

An injury or disease to the testicles can reduce their function and so impact upon fertility. For example, a blow received playing sport or as a result of a fight.

This can affect the blood supply to the testicles which damages the ability produce sperm.

Viral infections such as orchitis (painful swelling of the testicles) can also mean a failure to produce sperm.

Surgery can be carried out to treat any of these but it is not a guarantee of fertility.

Variococele - Causes of Male Infertility

2010-04-16T12:10:00.001+05:30

This is a medical condition which affects the blood vessels of the penis. These veins are designed to channel blood away from the penis and scrotum but if they become diseased then the ability to do so is affected.

These diseased veins look very similar to the varicose veins seen on the legs.

What happens is that these veins become enlarged and swollen which causes the blood to pool within them. This can then cause the temperature of the scrotum to rise which reduces the number of sperm in the testis.

If you develop variococele then it doesn’t automatically mean that you will become infertile but it does increase that risk.

Genetic disorders - Causes of Male Infertility

2010-04-16T12:06:00.000+05:30

These are uncommon but do occur in men who have low or no sperms. Some of these are not immediately obvious but there is concern over one particular type of gene which causes problems with the Y-chromosome. This can be passed down to male offspring as a result of an assisted fertility technique such as intracytoplasmic sperm injection (ICSI). And this can lead to infertility.

Another genetic disorder is Klinefelters syndrome which leads to an extra Y-chromosome in men. It is also known as ‘trisomy’ and is characterised as XYY rather than the usual male XY configuration.

It is easy to assume that men who have this extra chromosome will be extra fertile but unfortunately the opposite is true. They tend to have serious fertility problems and are often classed as being sterile.

Abnormal/low sperm count - Causes of Male Infertility

2010-04-16T12:04:00.001+05:30

Around 75% of cases of male infertility are due to a low or abnormal sperm count.

The medical term for low sperm count is oligospermia and this is now defined as 10 million/ml of semen although this figure used to be set at 40 million/ml. The reason for this is that if your female partner is young and healthy then a sperm count as low as 10 million/ml can still achieve conception.

Bear in mind that sperm counts do vary over time so a temporary low count is not uncommon. So, if you undergo a fertility test which reports a low sperm count then this may not be an accurate reading.

An abnormal sperm is one that it is abnormally shaped which makes it more difficult for that sperm to travel through the fallopian tube and fertilise an egg.

There are certain drugs such as anabolic steroids, sulfasalazine and chemotherapy medication which can cause a low sperm count.

Another factor is that of trauma or injury to the testicles. If you have sustained an injury to your testicles or have undergone surgery for testicular cancer then your sperm count will be affected.

Other aspects to take into account are sperm movement and shape. The shape and movement of a sperm can determine how likely it is to fertilise an egg. As you can guess a sperm which is oddly shaped or moves very slowly is unlikely to fertilise an egg.

The medical term for low quality sperm is dysspermia.

Ideally you need 60% normal sperm to guarantee fertility so quality can be more important than quantity.

MALE INFERTILITY

2010-04-16T12:03:00.001+05:30

Male infertility accounts for around 20 to 25% of infertility cases which is higher than many people think. It is easy to assume that infertility is a female problem, which is the traditional view, but it’s often the case that the man has the problem rather than the woman.

There are many reasons for male infertility which include the following:

Hormone disorders
Abnormal/low sperm count
Genetic disorders
Variococele
Disease or trauma to the testicles
Blockage in the ejaculatory duct
Vasectomy
Lifestyle issues
Environmental issues (exposure to toxins etc)
Prescription medicines
Failure to ejaculate
Medical conditions

There are a small percentage of cases in which there appears to be no obvious cause of infertility. These are known as ‘idiopathic’ cases.

Male infertility problems are often categorised into four areas: hormonal, structural, lifestyle and genetic. And many of these are related to each other. In other words, a genetic cause of infertility can also be related to a structural problem (e.g. damage to the male reproductive organs).

Hormone disorders

The reproductive endocrine system exists in a delicate state of balance which can easily be upset. The main hormones of this system are testosterone, follicle stimulating hormone (FSH) and luteinizing hormones (LH). These are responsible for male fertility.

Any problem in the central nervous system such as the adrenal glands or thyroid glands can minimise the production of LH and FSH which then impacts upon fertility. For example, a problem with the adrenal glands can cause low testosterone levels which also affect fertility.

LISTERIA

2010-04-16T12:01:00.002+05:30

What is listeriosis (Listeria infection)?

Listeriosis, a serious infection caused by eating food contaminated with the bacterium Listeria monocytogenes, is an important public health problem. The disease primarily affects pregnant women, newborns, and adults with weakened immune systems. It can be avoided by following a few simple recommendations.

What are the symptoms of listeriosis?

A person with listeriosis (listeria infection) has fever, muscle aches, and sometimes gastrintestinal symptoms such as nausea or diarrhoea. If infection spreads to the nervous system, symptoms such as headache, stiff neck, confusion, loss of balance, or convulsions can occur.

Infected pregnant women may experience only a mild, flu-like illness; however, infections during pregnancy can lead to miscarraige or stillbirth, premature delivery, or infection of the newborn.

How great is the risk for listeriosis?

In the United States, an estimated 2,500 persons become seriously ill with listeriosis each year. Of these, 500 die. At increased risk are:

Pregnant women - They are about 20 times more likely than other healthy adults to get listeriosis. About one-third of listeriosis cases happen during pregnancy.
Newborns - Newborns rather than the pregnant women themselves suffer the serious effects of infection in pregnancy.
Persons with weakened immune systems
Persons with cancer, diabetes, or kidney disease
Persons with AIDS - They are almost 300 times more likely to get listeriosis than people with normal immune systems.
Persons who take glucocorticosteroid medications
The elderly

Healthy adults and children occasionally get infected with Listeria, but they rarely become seriously ill.

How does Listeria get into food?

Listeria monocytogenes is found in soil and water. Vegetables can become contaminated from the soil or from manure used as fertilizer.
Animals can carry the bacterium without appearing ill and can contaminate foods of animal origin such as meats and dairy products. The bacterium has been found in a variety of raw foods, such as uncooked meats and vegetables, as well as in processed foods that become contaminated after processing, such as soft cheeses and cold cuts at the deli counter. Unpasteurized (raw) milk or foods made from unpasteurized milk may contain the bacterium.

Listeria is killed by pasteurization and cooking; however, in certain ready-to-eat foods such as hot dogs and deli meats, contamination may occur after cooking but before packaging.

How do you get listeriosis?

You get listeriosis by eating food contaminated with Listeria. Babies can be born with listeriosis if their mothers eat contaminated food during pregnancy. Although healthy persons may consume contaminated foods without becoming ill, those at increased risk for infection can probably get listeriosis after eating food contaminated with even a few bacteria. Persons at risk can prevent Listeria infection by avoiding certain high-risk foods and by handling food properly.

Can listeriosis be prevented?

The general guidelines recommended for the prevention of listeriosis are similar to those used to help prevent other foodborne illnesses, such as salmonellosis.

How can you reduce your risk for listeriosis?

General recommendations:

Thoroughly cook raw food from animal sources, such as beef, pork, or poultry.
Wash raw vegetables thoroughly before eating.
Keep uncooked meats separate from vegetables and from cooked foods and ready-to-eat foods.
Avoid unpasteurized (raw) milk or foods made from unpasteurized milk.
Wash hands, knives, and cutting boards after handling uncooked foods.
Consume perishable and ready-to-eat foods as soon as possible.

Recommendations for persons at high risk, such as pregnant women and persons with weakened immune systems, in addition to the recommendations listed above:

Do not eat hot dogs, luncheon meats, or deli meats, unless they are reheated until steaming hot.
Avoid getting fluid from hot dog packages on other foods, utensils, and food preparation surfaces, and wash hands after handling hot dogs, luncheon meats, and deli meats.
Do not eat soft cheeses such as feta, Brie, and Camembert, blue-veined cheeses, or Mexican-style cheeses such as queso blanco, queso fresco, and Panela, unless they have labels that clearly state they are made from pastuerized milk.
Do not eat refrigerated p�t�s or meat spreads. Canned or shelf-stable p�t�s and meat spreads may be eaten.
Do not eat refrigerated smoked seafood, unless it is contained in acooked dish, such as a casserole. Refrigerated smoked seafood, such as salmon, trout, whitefish, cod, tuna or mackerel, is most often labeled as "nova-style," "lox," "kippered," "smoked," or "jerky." The fish is found in the refrigerator section or sold at deli counters of grocery stores and delicatessens. Canned or shelf-stable smoked seafood may be eaten.

How do you know if you have listeriosis?

There is no routine screening test for susceptibility to listeriosis during pregnancy, as there is for rubella and some other congenital infections. If you have symptoms such as fever or stiff neck, consult your doctor. A blood or spinal fluid test (to cultivate the bacteria) will show if you have listeriosis. During pregnancy, a blood test is the most reliable way to find out if your symptoms are due to listeriosis.

What should you do if you've eaten a food recalled because of Listeria contamination?

The risk of an individual person developing Listeria infection after consumption of a contaminated product is very small. If you have eaten a contaminated product and do not have any symptoms, we do not recommend that you have any tests or treatment, even if you are in a high-risk group. However, if you are in a high-risk group, have eaten the contaminated product, and within 2 months become ill with fever or signs of serious illness, you should contact your physician and inform him or her about this exposure.

Can listeriosis be treated?

When infection occurs during pregnancy, antibiotics given promptly to the pregnant woman can often prevent infection of the foetus or newborn.

Babies with listeriosis receive the same antibiotics as adults, although a combination of antibiotics is often used until physicians are certain of the diagnosis. Even with prompt treatment, some infections result in death. This is particularly likely in the elderly and in persons with other serious medical problems.

IVF (IN VITRO FERTILISATION) AND GIFT (GAMETE INTRA FALLOPIAN TRANSFER)

2009-08-19T12:44:00.000+05:30

What is IVF?

In vitro fertilisation (IVF) is a technique in which egg cells are fertilised by sperm outside the woman's womb. IVF is a major treatment in infertility when other methods of achieving conception have failed.

The process involves hormonally controlling the ovulatory process, removing ova (eggs) from the woman's ovaries and letting sperm fertilise them in a fluid medium. The fertilised egg (zygote) is then transferred to the patient's uterus with the intent to establish a successful pregnancy.

What is GIFT?

Gamete intrafallopian transfer (GIFT) is an infertility treatment in which eggs are removed from a woman's ovaries, and placed in one of the fallopian tubes, along with the man's sperm. This allows fertilization to take place inside the woman's body.

It takes, on average, four to six weeks to complete a cycle of GIFT. First, the woman must take a fertility drug to stimulate egg production in the ovaries. The doctor will monitor the growth of the ovarian follicles, and once they are mature, the woman will be injected with Human chorionic gonadotropin (hCG). The eggs will be harvested approximately 36 hours later, mixed with the man's sperm, and placed back into the woman's Fallopian tubes using a laparoscope.

A woman must have at least one normal fallopian tube in order for GIFT to be suitable. It is used in instances where the fertility problem relates to sperm dysfunction, and where the couple has idiopathic (unknown cause) infertility. Some patients may prefer the procedure to IVF for ethical reasons, since the fertilization takes place inside the body.

As with most fertility procedures, success depends on the couple's age and the woman's egg quality. It is estimated that approximately 25-30% of GIFT cycles result in pregnancy, with a third of those being multiple pregnancies.

Many specialists in infertility would look at GIFT as a procedure that is outdated (2004) as pregnancy rates in IVF tend to be equal or better and do not require laparoscopy.

IVF Method

Ovarian stimulation

Treatment cycles are typically started on the third day of menstruation and consist of a regimen of fertility medications to stimulate the development of multiple follicles of the ovaries. In most patients injectable gonadotropins (usually FSH analogues) are used under close monitoring. Such monitoring frequently checks the oestradiol level and, by means of gynaecologic ultrasonography, follicular growth. Typically approximately 10 days of injections will be necessary. Endogenous ovulation is blocked by the use of GnRH agonists or GnRH antagonists.

Oocyte retrieval

When follicular maturation is judged to be adequate, human chorionic gonadotropin (β-hCG) is given. This agent, which acts as an analogue of luteinising hormone, would cause ovulation about 36 hours after injection, but a retrieval procedure takes place just prior to that, in order to recover the egg cells from the ovary. The eggs are retrieved from the patient using a transvaginal technique involving an ultrasound-guided needle piercing the vaginal wall to reach the ovaries. Through this needle follicles can be aspirated, and the follicular fluid is handed to the IVF laboratory to identify ova. The retrieval procedure takes about 20 minutes and is usually done under conscious sedation or general anaesthesia.

IVF laboratory

In the laboratory, the identified eggs are stripped of surrounding cells and prepared for fertilisation. In the meantime, semen is prepared for fertilisation by removing inactive cells and seminal fluid. The sperm and the egg are incubated together (at a ratio of about 75,000:1) in the culture media for about 18 hours. By that time fertilisation should have taken place and the fertilised egg would show two pronuclei. In situations where the sperm count is low a single sperm is injected directly into the egg using intracytoplasmic sperm injection (ICSI). The fertilised egg is passed to a special growth medium and left for about 48 hours until the egg has reached the 6-8 cell stage.

Laboratories have developed grading methods to judge oocyte and embryo quality. Typically, embryos that have reached the 6-8 cell stage are transferred three days after retrieval.

Embryo transfer

Embryos are graded by the embryologist based on the number of cells, evenness of growth and degree of fragmentation. The number to be transferred depends on the number available, the age of the woman and other health and diagnostic factors. In countries such as the UK, Australia and New Zealand, a maximum of two embryos are transferred except in unusual circumstances. This is to limit the number of multiple pregnancies. The embryos judged to be the "best" are transferred to the patient's uterus through a thin, plastic catheter, which goes through her vagina and cervix. Several embryos may be passed into the uterus to improve chances of implantation and pregnancy.

Post-transfer

The patient has to wait two weeks before she returns to the clinic for the pregnancy test. During this time she may receive progesterone—a hormone that keeps the uterus lining thickened and suitable for implantation. Many IVF programmes provide additional medications as part of their protocol.

Success rates

Chance of a successful pregnancy is approximately 15% for each IVF cycle, although selected clinics are now able to claim rates up to 50% per cycle. There are many factors that determine success rates including the age of the patient, the quality of the eggs and sperm, the duration of the infertility, the health of the uterus, and the medical expertise. It is a common practice for IVF programmes to boost the pregnancy rate by placing multiple embryos during embryo transfer. A flip side of this practice is a higher risk of multiple pregnancy, itself associated with obstetric complications.

IVF programmes generally publish their pregnancy rates. However, comparisons between clinics are difficult as many variables determine outcome. Furthermore, these statistics depend strongly on the type of patients selected.

There are many reasons why pregnancy may not occur following IVF and embryo transfer, including

The timing of ovulation may be misjudged, or ovulation may not be able to be predicted or may not occur
Attempts to obtain eggs that develop during the monitored cycle may be unsuccessful
The eggs obtained may be abnormal or may have been damaged during the retrieval process
A semen specimen may not be able to be provided
Fertilization of eggs to form embryos may not occur
Cleavage or cell division of the fertilised eggs may not take place
The embryo may not develop normally
Implantation may not occur
Equipment failure, infection and/or human error or other unforeseen and uncontrollable factors, which may result in the loss of or damage to the eggs, the semen sample and/or the embryos.

Potential Complications

The major complication of IVF is the risk of multiple births. This is directly related to the practice of transferring multiple embryos at embryo transfer. Multiple births are related to increased risk of pregnancy loss, obstetrical complications, prematurity, and neonatal morbidity with the potential for long term damage. Strict limits on the number of embryos that may be transferred have been enacted in some countries (e.g., England) to reduce the risk of high-order multiples (triplets or more), but are not universally followed or accepted. Spontaneous splitting of embryos in the womb after transfer does occur, but is rare (<1%)>

Another risk of ovarian stimulation is the development of ovarian hyperstimulation syndrome.

INFERTILITY What is infertility?

2009-08-19T12:36:00.000+05:30

Most experts define infertility as not being able to get pregnant after at least one year of trying. Women who are able to get pregnant but then have repeat miscarriages are also said to be infertile.

Pregnancy is the result of a complex chain of events. In order to get pregnant:

A woman must release an egg from one of her ovaries (ovulation).
The egg must go through a fallopian tube toward the uterus (womb).
A man's sperm must join with (fertilize) the egg along the way.
The fertilized egg must attach to the inside of the uterus (implantation).

Infertility can result from problems that interfere with any of these steps.

Is infertility a common problem?

About 1 in 10 women have difficulty getting pregnant or carrying a baby to term.

Is infertility just a woman's problem?

No, infertility is not always a woman's problem. In only about one-third of cases is infertility due to the woman (female factors). In another one third of cases, infertility is due to the man (male factors). The remaining cases are caused by a mixture of male and female factors or by unknown factors.

What causes infertility in men?

Infertility in men is most often caused by:

problems making sperm -- producing too few sperm or none at all
problems with the sperm's ability to reach the egg and fertilize it -- abnormal sperm shape or structure prevent it from moving correctly

Sometimes a man is born with the problems that affect his sperm. Other times problems start later in life due to illness or injury. For example, cystic fibrosis often causes infertility in men.

What increases a man's risk of infertility?

The number and quality of a man's sperm can be affected by his overall health and lifestyle. Some things that may reduce sperm number and/or quality include:

alcohol
drugs
environmental toxins, including pesticides and lead
smoking cigarettes
health problems
medicines
radiation treatment and chemotherapy for cancer
age

What causes infertility in women?

Problems with ovulation account for most cases of infertility in women. Without ovulation, there are no eggs to be fertilized. Some signs that a woman is not ovulating normally include irregular or absent menstrual periods.

Less common causes of fertility problems in women include:

blocked fallopian tubes due to pelvic inflammatory disease, endometriosis, or surgery for an ectopic pregnancy
physical problems with the uterus
uterine fibroids

What things increase a woman's risk of infertility?

Many things can affect a woman's ability to have a baby. These include:

age
stress
poor diet
athletic training
being overweight or underweight
tobacco smoking
alcohol
sexually transmitted diseases (STDs)
health problems that cause hormonal changes

How does age affect a woman's ability to have children?

More and more women are waiting until their 30s and 40s to have children. Actually, about 20 percent of women in the United States now have their first child after age 35. So age is an increasingly common cause of fertility problems. About one third of couples in which the woman is over 35 have fertility problems.

Aging decreases a woman's chances of having a baby in the following ways:

The ability of a woman's ovaries to release eggs ready for fertilization declines with age.
The health of a woman's eggs declines with age.
As a woman ages she is more likely to have health problems that can interfere with fertility.
As a women ages, her risk of having a miscarriage increases.

How long should women try to get pregnant before calling their doctors?

Most healthy women under the age of 30 shouldn't worry about infertility unless they've been trying to get pregnant for at least a year. At this point, women should talk to their doctors about a fertility evaluation. Men should also talk to their doctors if this much time has passed.

In some cases, women should talk to their doctors sooner. Women in their 30s who've been trying to get pregnant for six months should speak to their doctors as soon as possible. A woman's chances of having a baby decrease rapidly every year after the age of 30. So getting a complete and timely fertility evaluation is especially important.

Some health issues also increase the risk of fertility problems. So women with the following issues should speak to their doctors as soon as possible:

irregular periods or no menstrual periods
very painful periods
endometriosis
pelvic inflammatory disease
more than one miscarriage

No matter how old you are, it's always a good idea to talk to a doctor before you start trying to get pregnant. Doctors can help you prepare your body for a healthy baby. They can also answer questions on fertility and give tips on conceiving.

How will doctors find out if a woman and her partner have fertility problems?

Sometimes doctors can find the cause of a couple's infertility by doing a complete fertility evaluation. This process usually begins with physical exams and health and sexual histories. If there are no obvious problems, like poorly timed intercourse or absence of ovulation, tests will be needed.

Finding the cause of infertility is often a long, complex and emotional process. It can take months for you and your doctor to complete all the needed exams and tests. So don't be alarmed if the problem is not found right away.

For a man, doctors usually begin by testing his semen. They look at the number, shape, and movement of the sperm. Sometimes doctors also suggest testing the level of a man's hormones.

For a woman, the first step in testing is to find out if she is ovulating each month. There are several ways to do this. A woman can track her ovulation at home by:

recording changes in her morning body temperature (basal body temperature) for several months
recording the texture of her cervical mucus for several months
using a home ovulation test kit (available at drug or grocery stores)

Doctors can also check if a woman is ovulating by doing blood tests and an ultrasound of the ovaries. If the woman is ovulating normally, more tests are needed.

Some common tests of fertility in women include:

Hysterosalpingography: In this test, doctors use x-rays to check for physical problems of the uterus and fallopian tubes. They start by injecting a special dye through the vagina into the uterus. This dye shows up on the x-ray. This allows the doctor to see if the dye moves normally through the uterus into the fallopian tubes. With these x-rays doctors can find blockages that may be causing infertility. Blockages can prevent the egg from moving from the fallopian tube to the uterus. Blockages can also keep the sperm from reaching the egg.
Laparoscopy: During this surgery doctors use a tool called a laparoscope to see inside the abdomen. The doctor makes a small cut in the lower abdomen and inserts the laparoscope. Using the laparoscope, doctors check the ovaries, fallopian tubes, and uterus for disease and physical problems. Doctors can usually find scarring and endometriosis by laparoscopy.

How do doctors treat infertility?

Infertility can be treated with medicine, surgery, artificial insemination or assisted reproductive technology. Many times these treatments are combined. About two-thirds of couples who are treated for infertility are able to have a baby. In most cases infertility is treated with drugs or surgery.

Doctors recommend specific treatments for infertility based on:

test results
how long the couple has been trying to get pregnant
the age of both the man and woman
the overall health of the partners
preference of the partners

Doctors often treat infertility in men in the following ways:

Sexual problems: If the man is impotent or has problems with premature ejaculation, doctors can help him address these issues. Behavioral therapy and/or medicines can be used in these cases.
Too few sperm: If the man produces too few sperm, sometimes surgery can correct this problem. In other cases, doctors can surgically remove sperm from the male reproductive tract. Antibiotics can also be used to clear up infections affecting sperm count.

Various fertility medicines are often used to treat women with ovulation problems. It is important to talk with your doctor about the pros and cons of these medicines. You should understand the risks, benefits, and side effects.

Doctors also use surgery to treat some causes of infertility. Problems with a woman's ovaries, fallopian tubes, or uterus can sometimes be corrected with surgery.

Intrauterine insemination (IUI) is another type of treatment for infertility.IUI is known by most people as artificial insemination. In this procedure, the woman is injected with specially prepared sperm. Sometimes the woman is also treated with medicines that stimulate ovulation before IUI.

IUI is often used to treat:

mild male factor infertility
women who have problems with their cervical mucus
couples with unexplained infertility

What medicines are used to treat infertility in women?

Some common medicines used to treat infertility in women include:

Clomiphene citrate (Clomid): This medicine causes ovulation by acting on the pituitary gland. It is often used in women who have Polycystic Ovarian Syndrome (PCOS) or other problems with ovulation. This medicine is taken by mouth.
Human menopausal gonadotropin or hMG (Repronex, Pergonal): This medicine is often used for women who don't ovulate due to problems with their pituitary gland. hMG acts directly on the ovaries to stimulate ovulation. It is an injected medicine.
Follicle-stimulating hormone or FSH (Gonal-F, Follistim): FSH works much like hMG. It causes the ovaries to begin the process of ovulation. These medicines are usually injected.
Gonadotropin-releasing hormone (Gn-RH) analog: These medicines are often used for women who don't ovulate regularly each month. Women who ovulate before the egg is ready can also use these medicines. Gn-RH analogs act on the pituitary gland to change when the body ovulates. These medicines are usually injected or given with a nasal spray.
Metformin (Glucophage): Doctors use this medicine for women who have insulin resistance and/or Polycystic Ovarian Syndrome (PCOS). This drug helps lower the high levels of male hormones in women with these conditions. This helps the body to ovulate. Sometimes clomiphene citrate or FSH is combined with metformin. This medicine is usually taken by mouth.
Bromocriptine (Parlodel): This medicine is used for women with ovulation problems due to high levels of prolactin. Prolactin is a hormone that causes milk production.

Many fertility drugs increase a woman's chance of having twins, triplets or other multiples. Women who are pregnant with multiple foetuses have more problems during pregnancy. Multiple foetuses have a high risk of being born too early (prematurely). Premature babies are at a higher risk of health and developmental problems.

What is assisted reproductive technology (ART)?

Assisted reproductive technology (ART) is a term that describes several different methods used to help infertile couples. ART involves removing eggs from a woman's body, mixing them with sperm in the laboratory and putting the embryos back into a woman's body.

How often is assisted reproductive technology (ART) successful?

Success rates vary and depend on many factors. Some things that affect the success rate of ART include:

age of the partners
reason for infertility
clinic
type of ART
if the egg is fresh or frozen
if the embryo is fresh or frozen

The US Centers for Disease Prevention (CDC) collects success rates on ART for some fertility clinics. According to the 2003 CDC report on ART, the average percentage of ART cycles that led to a healthy baby were as follows:

37.3% in women under the age of 35
30.2% in women aged 35-37
20.2% in women aged 37-40
11.0% in women aged 41-42

ART can be expensive and time-consuming. But it has allowed many couples to have children that otherwise would not have been conceived. The most common complication of ART is multiple foetuses. But this is a problem that can be prevented or minimized in several different ways.

What are the different types of assisted reproductive technology (ART)?

Common methods of ART include:

In vitro fertilization (IVF) means fertilization outside of the body. IVF is the most effective ART. It is often used when a woman's fallopian tubes are blocked or when a man produces too few sperm. Doctors treat the woman with a drug that causes the ovaries to produce multiple eggs. Once mature, the eggs are removed from the woman. They are put in a dish in the lab along with the man's sperm for fertilization. After 3 to 5 days, healthy embryos are implanted in the woman's uterus.
Zygote intrafallopian transfer (ZIFT) or Tubal Embryo Transfer is similar to IVF. Fertilization occurs in the laboratory. Then the very young embryo is transferred to the fallopian tube instead of the uterus.
Gamete intrafallopian transfer (GIFT) involves transferring eggs and sperm into the woman's fallopian tube. So fertilization occurs in the woman's body. Few practices offer GIFT as an option.
Intracytoplasmic sperm injection (ICSI) is often used for couples in which there are serious problems with the sperm. Sometimes it is also used for older couples or for those with failed IVF attempts. In ICSI, a single sperm is injected into a mature egg. Then the embryo is transferred to the uterus or fallopian tube.

ART procedures sometimes involve the use of donor eggs (eggs from another woman), donor sperm, or previously frozen embryos. Donor eggs are sometimes used for women who can not produce eggs. Also, donor eggs or donor sperm is sometimes used when the woman or man has a genetic disease that can be passed on to the baby.

FOLIC ACID is Pregnancy

2009-08-19T12:35:00.001+05:30

What is folic acid?

Folic acid is a B vitamin. Folic acid helps the body make healthy new cells.

Why should women take folic acid?

All women need folic acid. When a woman has enough folic acid before and during pregnancy, it can help prevent major birth defects of her baby's brain or spine.

Be sure to get enough folic acid every day. Start before you are pregnant. Folic acid is needed during the first few weeks, often before a woman knows she is pregnant. And half of all pregnancies in the U.S. are not planned. That is why it's so important to start taking folic acid each day, even when you are not planning to get pregnant.

Folic acid might also have other benefits for men and women of any age. Some studies show that folic acid might help prevent heart disease, stroke, some cancers, and possibly Alzheimer's disease.

How can women get folic acid?

All women should aim to get at least 400 micrograms (400 mcg) of folic acid each day. There are a few easy ways she can do this.

Take a daily vitamin that has folic acid in it. Most multivitamins sold in the U.S. have enough. Check the label on the vitamin to be sure. It should say �400 mcg� or �100%� next to folic acid. Some labels might use the word �folate� for folic acid. Or you can take a vitamin pill that only has folic acid in it. You can find both of these types at your local grocery, drug store, or discount store.

Another way to get enough folic acid is to eat a serving of breakfast cereal that contains 100% of the daily value (DV) for folic acid each day. Check the label on the box to be sure it has enough.

Eat a healthy diet that contains lots of fruits and vegetables and other foods that have folic acid (or folate) in them or added to them. Foods that contain folic acid (or folate) include broccoli, asparagus, bananas, oranges, peas, nuts, bread, cereal, and flour.

How much folic acid should you take?

Read the descriptions below to see how much folic acid you should take. Check off the one that applies to you.

	You are able to get pregnant. Take 400 mcg of folic acid every day.
	You are pregnant. Take 600mcg of folic acid every day.
	You are breastfeeding. Take 500mcg of folic acid every day.
	You had a baby with spina bifida or anencephaly and want to get pregnant again. Talk with your doctor, and ask for a prescription for a higher dose of folic acid. You should take 4,000 micrograms (4,000 mcg) starting at least one to three months before getting pregnant and during the first 3 months of pregnancy. That's 10 times the normal amount! But don't try to get the larger amount by taking more than one multivitamin or prenatal vitamin a day. You could get too much of another vitamin that could harm you or your baby.
	You had a baby with spina bifida or anencephaly. You are not planning to have another baby. Take 400 mcg of folic acid every day.

What is Ectopic Pregnancy

2009-08-19T12:34:00.001+05:30

An ectopic pregnancy is one in which the fertilized ovum is implanted in any tissue other than the uterine wall. Most ectopic pregnancies occur in the Fallopian tube (so-called tubal pregnancies), but implantation can also occur in the cervix, ovaries, and abdomen.

An Overview of ectopic pregnancy

In a normal pregnancy, the fertilized egg enters the uterus and settles into the uterine lining where it has plenty of room to divide and grow. About 1% of pregnancies are in an ectopic location with implantation not occurring inside of the womb, and of these 98% occur in the Fallopian tubes.

In a typical ectopic pregnancy, the embryo does not reach the uterus, but instead adheres to the lining of the Fallopian tube. The implanted embryo burrows actively into the tubal lining. Most commonly this invades vessels and will cause bleeding. This bleeding expels the implantation out of the tubal end as a tubal abortion. Some women thinking they are having a miscarriage are actually having a tubal abortion. There is no inflammation of the tube in ectopic pregnancy. The pain is caused by prostaglandins released at the implantation site, and by free blood in the peritoneal cavity, which is locally irritant. Sometimes the bleeding might be heavy enough to threaten the health or life of the woman. Usually this degree of bleeding is due to delay in diagnosis, but sometimes, especially if the implantation is in the proximal tube (just before it enters the uterus), it may invade into Sampson's artery, causing heavy bleeding earlier than usual.

If left untreated, about half of ectopic pregnancies will resolve without treatment. These are the tubal abortions. The advent of methotrexate treatment for ectopic pregnancy has reduced the need for surgery; however, surgical intervention is still required in cases where the Fallopian tube has ruptured or is in danger of doing so. This intervention may be laparoscopic or through a larger incision, known as a laparotomy.

What causes an ectopic pregnancy

The cause of ectopic pregnancy is unknown. After fertilization of the oocyte in the peritoneal cavity, the egg takes about nine days to migrate down the tube to the uterine cavity at which time it implants. Wherever the embryo finds itself at that time, it will begin to implant.

There are some speculative specific causes or associations. Smoking, advanced maternal age and prior tubal damage of any origin are well shown risk factors for ectopic pregnancy.

Cilial damage and tube occlusion

Hair-like cilia located on the internal surface of the Fallopian tubes carry the fertilized egg to the uterus. Damage to the cilia or blockage of the Fallopian tubes is likely to lead to an ectopic pregnancy. Women with pelvic inflammatory disease (PID) have a high occurrence of ectopic pregnancy. This results from the build-up of scar tissue in the Fallopian tubes, causing damage to cilia. If however both tubes were occluded by PID, pregnancy would not occur and this would be protective against ectopic pregnancy. Tubal surgery for damaged tubes might remove this protection and increase the risk of ectopic pregnancy. Tubal ligation can predispose to ectopic pregnancy. Seventy percent of pregnancies after tubal cautery are ectopic, while 70% of pregnancies after tubal clips are intrauterine. Reversal of tubal sterilization carries a risk for ectopic pregnancy. This is higher if more destructive methods of tubal ligation (tubal cautery, partial removal of the tubes) have been used than less destructive methods (tubal clipping). A history of ectopic pregnancy increases the risk of future occurrences to about 10%. This risk is not reduced by removing the affected tube, even if the other tube appears normal.

Excessive oestrogen and progesterone

There has been speculation about the role of hormones in the genesis of ectopic pregnancy. No proven association has been established. High levels of oestrogen and progesterone are thought possibly to increase the risk of ectopic pregnancy because these hormones slow the movement of the fertilized egg through the Fallopian tube. However, advancing age is a risk factor for ectopic pregnancy, although this is a period of declining hormone levels.

Role of intrauterine devices (IUD)

The use of intrauterine devices (IUDs) was thought at one time to increase the risk of ectopic pregnancy. However the older model copper based IUDs were only effective in preventing intrauterine pregnancies, not tubal pregnancies. As the IUD is effective in reducing pregnacy overall, the relative risk only of ectopic is increased. The old copper-based IUDs reduced the overall pregnancy rate so effectively that even the gross ectopic rates were reduced. Nonetheless any pregnancy conceived with an IUD in situ must be investigated to exclude possible ectopic pregnancy.

The newer hormone-based (levonorgestrel) IUS creates such a profound suppression of the endometrium that overall pregnancy rate is lower even than that of male or female sterilization. There are some data available for ectopic pregnancy with the IUS, but the relative risk is extremely low, around 0.01%.

Association with infertility

Infertility treatments are highly variable and specific to individual patients. IVF is used for patients with damaged tubes which are an inherent risk factor for ectopic. Ectopic pregnancies have been seen with In Vitro Fertilization, but is uncommon and quickly diagnosed by the early ultrasounds that these intensively surveyed patients undergo.

Other

Patients are at higher risk for ectopic pregnancy with advancing age. Also, it has been noted that smoking is associated with ectopic risk. Vaginal douching is thought by some to increase ectopic pregnancies. Women exposed to diethylstilbestrol (DES) in utero (aka "DES Daughters") also have an elevated risk of ectopic pregnancy, up to 3 times the risk of unexposed women.

What are the symptoms of an ectopic pregnancy

Early symptoms are either absent or subtle. Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of 5 to 8 weeks. Later presentations are more common in communities deprived of modern diagnostic ability.

The early signs are:

Pain and discomfort, usually mild. A corpus luteum on the ovary in a normal pregnancy may give very similar symptoms.

Vaginal bleeding, usually mild. An ectopic pregnancy is usually a failing pregnancy and falling levels of progesterone from the corpus luteum on the ovary cause withdrawal bleeding. This can be indistinguishable from an early miscarraige or the 'implantation bleed' of a normal early pregnancy.

Patients with a late ectopic pregnancy typically have pain and bleeding. This bleeding will be both vaginal and internal and has two discrete pathophysiologic mechanisms.

External bleeding is due to the falling progesterone levels.

Internal bleeding is due to hemorrhage from the affected tube.

The differential diagnosis at this point is between miscarriage, ectopic pregnancy, and early normal pregnancy. The presence of a positive pregnancy test virtually rules out pelvic infection as it is rare indeed to find pregnancy with an active Pelvic Inflammatory Disease (PID). The most common misdiagnosis assigned to early ectopic pregnancy is PID.

More severe internal bleeding may cause:

Lower back, abdominal, or pelvic pain.
Shoulder pain. This is caused by free blood tracking up the abdominal cavity, and is an ominous sign.
There may be cramping or even tenderness on one side of the pelvis.
The pain is of recent onset, meaning it must be differentiated from cyclical pelvic pain, and is often getting worse.

Ectopic pregnancy is noted that it can mimic symptoms of other diseases such as appendicitis, other gastrointestinal disorder, problems of the urinary system, as well as pelvic inflammatory disease and other gynaecologic problems.

How is an ectopic pregnancy diagnosed ?

An ectopic pregnancy has to be suspected in any woman with lower abdominal pain and/or unusual bleeding who is or might be sexually active and whose pregnancy test is positive. And abnormal rise in blood hCG levels may also indicate an ectopic pregnancy. The threshold of discrimination of intrauterine pregnancy today is around 3000 IU/ml of Human Chorionic Gonadotropin (HCG). A high resolution, vaginal ultrasound scan showing no intrauterine pregnancy is presumptive evidence that an ectopic pregnancy is present if the threshold of discrimination for HCG has been reached. An empty uterus with levels lower than 3000IU/ml may be evidence of an ectopic pregnancy, but may also be consistent with an intrauterine pregnancy which is simply too small to be seen on ultrasound. If there is uncertainty it might be necessary to wait a few days and repeat the bloodwork and ultrasound.

An ultrasound showing a gestational sac with foetal heart is clear evidence of ectopic pregnancy.

Free fluid which is non echogenic is a normal finding in the late menstrual cycle and early normal pregnacy. This is a transudate and is not presumptive evidence of bleeding. Echogenic free fluid suggests the presence of blood clot and is suggestive of free blood in the peritoneum.

A laparoscopy or laparotomy can also be performed to visually confirm an ectopic pregnancy. Often if a tubal abortion has occurred, or a tubal rupture has occurred, it is hard actually to find the pregnancy tissue. Laparoscopy in very early ectopic pregnancy may rarely show a normal looking Fallopian tube.

Nontubal ectopic pregnancy

2% of ectopic pregnancies occur in the ovary, cervix, or are intraabdominal. Transvaginal ultrasound examination is usually able to detect a cervical pregnancy. An ovarian pregnancy is differentiated from a tubal pregnancy by the Spiegelberg criteria.

While a foetus of ectopic pregnancy is typically not viable, very rarely, an abdominal pregnancy has been salvaged. In such a situation the placenta sits on the intraabdominal organs or the peritoneum and has found sufficient blood supply. In this author's experience this is invariably bowel or mesentery, but other sites, such as the renal (kidney), liver or hepatic (liver) artery or even aorta have been described. Support to near viability has occasionally been described, but even in third world countries, the diagnosis is most commonly made at 16 to 20 weeks gestation. Such a foetus would have to be delivered by laparotomy. Maternal morbidity and mortality from extrauterine pregnancy is high as attempts to remove the placenta from the organs to which it is attached usually lead to uncontrollable bleeding from the attachment site. If the organ to which the placenta is attached is removable, such as a section of bowel, then the placenta should be removed together with that organ. This is such a rare occurrence that true data are unavailable and reliance must be made on anecdotal reports. However, the vast majority of abdominal pregnancies require intervention well before fetal viability because the risk of hemorrhage.

Treatment of ectopic pregnancy

Nonsurgical treatment

Early treatment of an ectopic pregnancy with the drug methotrexate has proven to be a viable alternative to surgical treatment since 1993. If administered early in the pregnancy, methotrexate can disrupt the growth of the developing embryo causing the cessation of pregnancy.

Surgical treatment

If haemorrhaging has already occurred, surgical intervention may be necessary if there is evidence of ongoing blood loss. However, as already stated, about half of ectopics result in tubal abortion and are self limiting. The option to go to surgery is thus often a difficult decision to make in an obviously stable patient with minimal evidence of blood clot on ultrasound.

Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise the affected Fallopian and remove only the pregnancy (salpingostomy) or remove the affected tube with the pregnancy (salpingectomy).

Chances of future pregnancy after an ectopic pregnancy

The chance of future pregnancy depends on the status of the tube(s) that are left behind, but is decreased. The chance of recurrent ectopic pregnancy is about 10% and is independent of whether the affected tube was repaired (salpingostomy) or removed (salpingectomy). Successful pregnancy rates vary widely between different centres, and appear to be operator dependent. Pregnancy rates with successful methotrexate treatment compare favourably with the highest reported pregnancy rates. Often, patients may have to resort to IVF to achieve a successful pregnancy. The use of IVF does not preclude further ectopic pregnancies, but the likelihood is reduced.

Complications with ectopic pregnancy

The most common complication is rupture with internal bleeding that leads to shock. Death from rupture is rare. Infertility occurs in 10 - 15% of women who have had an ectopic pregnancy.

Down's Syndrome Explained

2009-08-19T12:33:00.000+05:30

What is Down's Syndrome?

Down's syndrome is set of mental and physical symptoms that result from having an extra copy of Chromosome 21.

Normally, a fertilized egg has 23 pairs of chromosomes. In most people with Down syndrome, there is an extra copy of Chromosome 21 (also called trisomy 21 because there are three copies of this chromosome instead of two), which changes the body's and brain's normal development.

What are the signs and symptoms of Down syndrome?

Even though people with Down syndrome may have some physical and mental features in common, symptoms of Down syndrome can range from mild to severe. Usually, mental development and physical development are slower in people with Down syndrome than in those without the condition.

Mental retardation is a disability that causes limits on intellectual abilities and adaptive behaviors (conceptual, social, and practical skills people use to function in everyday lives). Most people with Down syndrome have IQs that fall in the mild to moderate range of mental retardation. They may have delayed language development and slow motor development.

Some common physical signs of Down syndrome include:

Flat face with an upward slant to the eye, short neck, and abnormally shaped ears
Deep crease in the palm of the hand
White spots on the iris of the eye
Poor muscle tone, loose ligaments
Small hands and feet

There are a variety of other health conditions that are often seen in people who have Down syndrome, including:

Congenital heart disease
Hearing problems
Intestinal problems, such as blocked small bowel or oesophagus
Celiac disease
Eye problems, such as cataracts
Thyroid dysfunctions
Skeletal problems
Dementia�similar to Alzheimer's

What is the treatment for Down syndrome?

Down syndrome is not a condition that can be cured. However, early intervention can help many people with Down syndrome live productive lives well into adulthood.

Children with Down syndrome can often benefit from speech therapy, occupational therapy, and exercises for gross and fine motor skills. They might also be helped by special education and attention at school. Many children can integrate well into regular classes at school.

Who is at risk for Down syndrome?

The chance of having a baby with Down syndrome increases as a woman gets older�from about 1 in 1,250 for a woman who gets pregnant at age 25, to about 1 in 100 for a woman who gets pregnant at age 40. But, most babies with Down syndrome are born to women under age 35 because more younger women have babies.

Because the chances of having a baby with Down syndrome increase with the age of the mother, many health care providers recommend that women over age 35 have prenatal testing for the condition. Testing the baby before it is born to see if he or she is likely to have Down syndrome allows parents and families to prepare for the baby's special needs.

Parents who have already have a baby with Down syndrome or who have abnormalities in their own chromosome 21 are also at higher risk for having a baby with Down Syndrome.

Once the baby is born, a blood test can confirm whether the baby has Down syndrome.

Donor Insemination Explained

2009-08-18T16:23:00.000+05:30

What is donor insemination?

Donor insemination is where semen from a donor is artificially inseminated into a woman who wishes to conceive (ie. have a baby) but does not have a fertile male partner.

Artificial insemination is when sperm is placed into the uterus or cervix of a female by using artificial means.

Artificial insemination

In humans artificial insemination is usually part of an infertility treatment; either the woman's partner's sperm (artificial insemination by husband, AIH) or donor sperm (artificial insemination by donor) can be used.

The woman's menstrual cycle is closely observed, using ovulation kits, ultrasounds or blood tests. When an ovum is released, semen from a donor is inserted into her body. Just as with in vitro fertilization, the male donor is recommended not to ejaculate for a few days before the procedure. This is to ensure a higher sperm count. After the donation the sperm must immediately be �washed� in a laboratory. The process of �washing� the sperm increases the chances of fertilization and removes any chemicals in the semen that may cause discomfort for the woman. A chemical is added to the sperm that will separate the most active sperm in the sample. If the procedure is successful, she conceives and bears to term a baby as normal, making her both the genetic and gestational mother.

Of course, there are various gradations of treatment, and more technical procedures are sometimes needed. For example, semen can be injected directly into a woman's uterus to improve the chance of conception in a process called intrauterine insemination.

Artificial insemination has become a significant issue in recent years, particularly in debates revolving around surrogate parenting. Legal issues have arisen in cases where the gestational (and possibly genetic) mother decides to keep the child. Likewise, there have been debates over the rights of sperm donors.

Chorionic Villus Sampling (CVS) Details

2009-08-18T16:21:00.002+05:30

In chorionic villus sampling (CVS), the doctor collects a small piece of tissue from the placenta using a needle passed through the mother’s vagina and cervix. The placenta has the same genetic makeup as the baby.

Most healthy women do not need all the tests. Ultrasound examinations during pregnancy are routine, although they are not always required and rarely influence treatment decisions. Amniocentesis and CVS are recommended only when a risk of genetic problems exists because of family history or something detected during an ultrasound. Amniocentesis and CVS carry a slight risk of harming the baby and mother, or ending the pregnancy in miscarriage, so those risks should be weighed carefully against the potential benefits of learning about the baby’s condition. .

Amniocentesis, the removal and analysis of a small sample of foetal cells from the amniotic fluid, is widely available and involves a lower risk of miscarriage than chorionic villus sampling. However, amniocentesis cannot be done until the 14th to 18th week of pregnancy.

Chorionic villus sampling, conducted at 9 to 11 weeks of pregnancy, involves extracting a tiny amount of chorionic villi, tissue extensions that will eventually develop into a placenta. The villi can be obtained through the pregnant woman's abdomen or cervix. This type of sampling carries a 1-2% risk of miscarriage.

A third diagnostic method, percutaneous umbilical blood sampling or PUBS, is the most accurate method in detecting Down's syndrome and can be used to confirm the results of CVS or amniocentesis. However, PUBS cannot be performed until later in the pregnancy, during the 18th to 22nd weeks, and carries the greatest risk of miscarriage. Extra care should be taken in this time and if need be contact your doctor at once.

Birth Defects Explained

2009-08-18T16:21:00.001+05:30

What are birth defects?

Birth defects are structural or functional abnormalities present at birth that cause physical or mental disability. Some may be fatal.

Researchers have identified thousands of different birth defects. Currently, birth defects are the leading cause of death for infants during the first year of life.

What causes birth defects?

Birth defects have a variety of causes, such as:

Genetic problems caused when one or more genes doesn't work properly or part of a gene is missing

Problems with chromosomes, such as having an extra chromosome or missing part of a chromosome

Environmental factors that a woman is exposed to during pregnancy, such as rubella or German measles while pregnant, or using drugs or alcohol during pregnancy

What are the different types of birth defects?

There are two main types of birth defects: structural and functional/developmental.

Structural birth defects are related to a problem with body parts. Some physical problems include cleft lip or cleft palate, heart defects, such as missing or misshaped valves, and abnormal limbs, such as a club foot. They also include neural tube defects, such as spina bifida, problems that are related to the growth and development of the brain and spinal cord.

Functional birth defects are related to a problem with how a body part or body system works. These problems often lead to developmental disabilities and can include things such as:

Nervous system or brain problems - such as learning disabilities, mental retardation, behavioral disorders, speech or language difficulties, convulsions, and movement trouble. Some examples of birth defects that affect the nervous system include Autism, Down syndrome, Prader-Willi syndrome, and Fragile X syndrome.

Sensory problems - such as blindness, cataracts and other visual problems, and varying degrees of hearing loss including deafness

Metabolic disorders - involve a body process or chemical pathway or reaction, such as conditions that limit the body's ability to get rid of waste materials or harmful chemicals. Two common metabolic disorders are phenylketonuria (PKU) and hypothryroidsim.

Degenerative disorders--are conditions that might not be obvious at birth, but cause one or more aspects of health to steadily get worse. For example, X-linked adrenoleukodystrophy (X-ALD), which was the focus of the movie Lorenzo's Oil, Rett syndrome, muscular dystrophy, and lysosomal disorders are examples of degenerative disorders.

In some cases, birth defects are caused by a combination of factors. Some recognized patterns of birth defects affect many parts or processes in the body, leading to both structural and functional problems.

Amniocentesis

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In amniocentesis, the doctor inserts a needle through the mother’s skin into the amniotic sac to collect about an ounce of amniotic fluid. The fluid contains genetic material from the baby that can be analyzed for signs of defects.

Most healthy women do not need all the tests. Ultrasound examinations during pregnancy are routine, although they are not always required and rarely influence treatment decisions. Amniocentesis and Chorionic Villus Sampling (CVS) are recommended only when a risk of genetic problems exists because of family history or something detected during an ultrasound. Amniocentesis and CVS carry a slight risk of harming the baby and mother, or ending the pregnancy in miscarriage, so those risks should be weighed carefully against the potential benefits of learning about the baby’s condition.

PREGNANCY & BIRTH

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This section looks at issues relating to pregnancy, labour and child birth.

AMNIOCENTISIS

Pregnant women over 35 should consider whether to have an amniocentisis to test for foetal abnormalities. This article details the procedure, the risks and benefits.

BIRTH DEFECTS

Birth defects are abnormalities present at birth that cause physical or mental disability. This article looks at causes and types of birth defect.

CHORIONIC VILLUS SAMPLING (CVS)
CVS is a test on the placenta to check for possible genetic abnormalities in the foetus. This article looks at how the test is performed and the risks of the procedure.

DONOR INSEMINATION
Donor insemination offers the hope of a pregnancy for some infertile couples. This article outlines the procedure and the legal issues related to it.

DOWN'S SYNDROME

This article outlines the age-related risk of having a baby with Down's syndrome, and the features of this genetic condition.

ECTOPIC PREGNANCY

This is a potentially life-threatening condition of early pregnancy and all women should be aware of the symptoms. Modern treatment aims to preserve future fertility.

FOLIC ACID

Folic acid has been shown to reduce the incidence of spina bifida when taken before conception and in early pregnancy. This article profiles the supplement.

GLOSSARY OF TERMS USED IN ASSISTED REPRODUCTIVE TECHNOLOGY
This article explains the technical terms and jargon used during infertility treatment, and is a helpful guide for those undergoing or considering treatment.

INFERTILITY

Infertility is experienced by an estimated 10 percent of couples. This article looks at some of the causes and when to seek expert help.

IVF (IN VITRO FERTILISATION) AND GIFT (GAMETE INTRA FALLOPIAN TRANSFER)
IVF and GIFT offer hope of a genetic child to many infertile couples. This article outlines how the procedures are carried out, and their success rates.

LISTERIA

This is a food-borne illness which is dangerous for pregnant women and those with weak immune systems. This article profiles the illness and how to minimise your risk of getting it.

MALE INFERTILITY

This article discusses the latest technology in treatment options for male infertility, including the Intracytoplasmic Sperm Injection and donor insemination.

MALE INFERTILITY TREATMENT OPTIONS
The development of Intracytoplasmic Sperm Injections (ICSI) has offered hope of a genetic child to infertile men. This article outlines this treatment and other options for infertile men.

MEDICATION IN PREGNANCY

This article provides a useful overview of the issues about medication use during pregnancy.

MISCARRIAGE

A miscarriage is a distressing event for many couples. This article looks at why they occur and the theories behind recurrent miscarriage.

PAIN RELIEF IN LABOUR
This article provides a broad overview of the different methods of pain relief that can be used during child birth.

POST NATAL DEPRESSION
An estimated 10 percent of new mothers get post natal depression. This article outlines the theories behind the disorder and what can be done to help.

PRE-ECLAMPSIA

Pre-eclampsia is a condition related to increased blood pressure and protein in the mother's urine. This article looks at the risks related to the condition.

PREGNANCY OVERVIEW

A normal pregnancy can still involve some undesirable symptoms like nausea and back pain. This article offers an overview of a healthy pregnancy.

RUBELLA

German measles is normally a mild illness but is serious in pregnant women because of the risks of birth defects. This article provides an overview of the illness.

SLAPPED CHEEK DISEASE (FIFTH DISEASE)
Slapped cheek disease is a mild illness among children but can be serious in pregnancy. This article looks at the symptoms and what can be done to help.

TOXOPLASMOSIS

Toxoplasmosis is an infection carried by cats that can be dangerous in pregnancy. This article looks at the risks of infection.

ULTRASOUND SCANNING

Ultrasound scanning is a common diagnostic technique. It is often used during pregnancy and to diagnose medical problems. This article outlines how the scan is performed and what preparation is required.

VASECTOMY REVERSAL

A small percentage of men will seek a vasectomy reversal. This article discusses the operation and the success rates.

How much does cosmetic surgery cost?

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Cosmetic surgery is cheaper than it used to be and has become affordable for a great many people.

However, prices vary according to the procedure. The more complicated and extensive the procedure the more expensive it is likely to be. Many sites do not list prices on their site as they state that each procedure, surgeon and hospital is different and will, of course, charge different prices.

One of the most common questions when it comes to cosmetic surgery is, what is the price? how much does it cost? why are some clinics cheaper than others?

The overall cost of any cosmetic surgery procedure ultimately depends on a number of different factors including but not limited to:

The experience of the surgeon
The Location of the Clinic
The aftercare package that you get
The type of procedure you are having
The type or quality of materials being used (eg implant type)
The number of days in hospital required

To get an idea of the cost of your cosmetic surgery it is better to arrange a free, no-obligation consultation with a surgeon in which you will be given a quote. This exact quote should include surgeon’s fees, anaesthetist’s fees, clinic/hospital care and aftercare. This means you will know exactly what you are paying for.

As a rough guide though, you are looking at paying £3,500 to £5,000 for breast augmentation; £3,000 to £4,000 for rhinoplasty and £2,800 to £3,500 for blepharoplasty. And I am saying it again a Rough guide, as prices may vary is different countries as well as for doctors fees and hospital fees!

In respect of paying for your surgery you have several options. You can either pay for it yourself or you can take out a loan to cover the cost. The loan can either be a personal loan from your local bank or building society or obtained through a finance scheme.

Many cosmetic surgery providers will operate a finance scheme which enables you to take out a loan to cover the cost of your treatment. Another option is a specialist medical loans provider.

If you have private health insurance then note that cosmetic surgery usually appears on their list of ‘exclusions’. They will only pay out for treatment which is considered a ‘medical necessity’.

What are the risks of cosmetic surgery?

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All forms of surgery are risky and cosmetic surgery is no exception. There are, what might be termed ‘general’ risks: these are risks which apply to all types of surgery and include blood clots, infection, bleeding and scarring. Anaesthesia can also be risky although advances in medical technology mean that this is very rare. However there can be complications in a small minority of cases.

Every patient is an individual. They will all react differently to the treatment. Scarring is an issue and whilst every effort is made to minimise them they do still occur. This is more of a problem with ethnic minorities who, because of their darker skins are prone to thicker, raised scars or ‘keloid’ scars.

If you are in less than perfect health then there will be increased risks during surgery. If you have a history of heart disease or are overweight then you are at a greater risk of complications from a general anaesthetic. These complications can take the form of a stroke due to raised blood pressure or an abnormal heart rhythm. However, these are still rare.

Unfortunately, there have been several cases in the media, of people who have died after cosmetic surgery. These are likely to have occurred as a result of surgery performed by unlicensed surgeons or surgeons who do not specialise in cosmetic surgery.

Another risk linked to this is that it is a fast growing market and a lucrative one as well. It can prove tempting to unscrupulous or ‘greedy’ practitioners who see this specialism as an easy way of making money. And there is no shortage of people who want cosmetic procedures.

What are the benefits of cosmetic surgery?

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The benefits are an improved appearance and greater self-confidence. As long as you are realistic about the results of the procedure then you will be satisfied with your surgery.

Basically, you are looking at physical and psychological benefits. It depends on the procedure but in physical terms, you may be looking at a slimmer and more toned physique. Mentally, your self-esteem will be higher and you will generally, feel better about yourself.

What are the complications of cosmetic surgery?

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Cosmetic surgery is similar to any other type of surgery in that it comes with a very small amount of risk. It has the same risks that all surgery has which include infection, bleeding and scarring. There are also risks involved with anaesthesia.

Anaesthesia is safe but in a few rare cases there can be complications. If a patient is overweight, suffering from heart disease, high blood pressure or some other chronic disease then this can cause problems. If you have an allergy or have experienced problems with surgery before then it is very important that you mention this before your procedure.

Another risk and one that has been reported in the media is where surgery has been undertaken by an inexperienced or unlicensed surgeon. If this happens then the results can be life threatening. This is why it is important to find a good, reputable surgeon.

What will recovery from Cosmetic surgery involve?

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If you have had a general anaesthetic then you will have been taking to a high dependency unit after your surgery. Once the medical staff are satisfied with your progress then you will be returned to your room.

Once there, a nurse will perform some additional checks which include blood pressure, and will check the surgical wound as well.

You will be encouraged to get up and move around as much as you can as this helps to prevent blood clots. You may have some small tubes inserted into the surgical wound which are used to drain off any excess fluids. These will be removed in a day or so.

You will experience some soreness and bruising after your procedure but you will be given medication to control the pain. This is entirely normal and will ease after a short period of time. If you have had facial surgery then you can use Cosmetic Camouflage make up to disguise the signs of bruising.

Everyone is different when it comes to recovery. Generally, you will be advised to rest and take things easy after your surgery. If you have had stitches then you will be asked to return to the clinic/hospital for removal of these unless they are the dissolvable type.

You may have to take a week or more off work. In that time, take it easy and ask someone to help you with normal everyday tasks during that time. Don’t overdo it. In that time you may have to wear loose fitting clothing which doesn’t rub against the surgical wound but again, this depends on the type of surgery you have had. This is particularly relevant for those patients who have had a breast lift or obesity surgery.

As regards physical activities such as sport; if you play sport then, depending on your surgery, you may have to wait for 6 weeks or more before resuming that activity. It all depends on the type of cosmetic procedure that you have had.

You will have a follow up consultation after your surgery. This depends on the type of procedure you have had but it can vary from one week to three months. You will be able to contact your surgeon and his/her team at any time following your surgery. You will be given these contact details at the clinic or hospital.

Cosmetic surgery is usually successful but if you experience any of the following symptoms then contact your surgeon immediately:

Heavy bleeding
Intense pain
Shortness of breath or a rapid heartbeat
Infection

What will happen on the day of cosmetic surgery?

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If you are being admitted as an in-patient then you will have to complete an admission form. This is a standard procedure and will not take very long.

You will be settled into your room and a nurse will perform some pre-surgery checks. These include blood pressure as well as taki9ng blood and urine samples.

You will also be given a pair of compression stockings to wear. Being inactive carries a small risk of DVT or Deep Vein Thrombosis and wearing these can help to prevent this. You may also be given an injection of a blood thinning drug called Heparin. After your procedure you will be encouraged to move around as much as you can to prevent any build up of blood clots in the legs.

Your surgeon will visit you before your surgery to check that everything is okay and that you are satisfied with what will happen. If you have any questions then feel free to ask them. Make sure you fully understand what this cosmetic procedure will entail.

How do I prepare for cosmetic surgery?

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Your surgeon may advise you to follow a pre-surgery regime beforehand. This could include stopping smoking – if you are a smoker as this slows down the healing process and following a diet and exercise plan.

You may have to take time off work so make sure you arrange that with your employer.

If you are taking any medication, such as nutritional supplements, then you may have to stop taking these before surgery. There is the risk of them reacting with the anaesthetic and any drugs used during or after the surgery.

It is a good idea to stop taking these at least two weeks before your cosmetic procedure.

If you are having a general anaesthetic then you will have been advised beforehand about eating and drinking before surgery. In general, the advice is to have your last meal or drink 6 hours before your surgery. If you are taking any medications prescribed by your GP then still take them as normal which includes the day of your procedure. However, check with your surgeon beforehand.

You should have been given a list of instructions of what to do before your cosmetic procedure. Make sure you stick to these even if they seem a bit trivial as there is usually a very good reason why you should do so. It is better to discuss these with your surgeon rather than ignoring any of them as it could impact upon your treatment.

I want to go ahead with Cosmetic Surgery what do I do next?

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If you have read through everything, understand what the surgery will involve and have found a reputable surgeon then you are nearly ready to make a decision.

Remember: you can change your mind at any time.

Make sure that you are happy with everything your surgeon has told you and that you have been as equally honest with him/her.
If you are going into hospital for treatment then talk with the surgeon and his/her team or other health care professionals.

It is a good idea to discuss your cosmetic treatment with your GP. He/she will give you an objective opinion and can advise you where necessary.

If your surgeon is satisfied with your reasons for cosmetic surgery and that you are realistic about what can be achieved then surgery can be arranged.

Your surgeon will recommend that you give yourself a couple of weeks before making that final decision. This is, in effect, a ‘cooling off’ period in which you will take time to think things through and weight up the pros and cons of surgery. If you change your mind at this point then that is fine.

If you decide to go ahead with surgery then you will be given an agreement form to sign. This is, in effect, a consent form. It will contain details of the cosmetic procedure as well as the cost. These costs should be broken down so you can see what it covers. For example, does it cover the cost of aftercare and any further surgery if required?

Read the form carefully to see if there is a section regarding cancellation charges. If you change your mind after you have signed this form then you could be subject to a financial penalty. Check to see if this is included in the form.

Your surgeon or clinic will keep a record of your treatment which will include photographs taken ‘before’ and ‘after’ your cosmetic procedure. Make sure you are happy for your surgeon to show these to other patients. Your surgeon should ask for your permission to do this or to show any part of your records to other patients.

Can I go abroad for cosmetic surgery?

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It is tempting to go abroad for cosmetic treatment as many clinics are cheaper than the UK. There is also the opportunity to stay for a period of time and treat it is a ‘holiday’. The thought of having treatment and then recuperating in an exotic location is very hard to resist!

You can opt to go abroad but think carefully before you do so.

There are risks with this option. As with any service there are unlicensed clinics and unscrupulous surgeons. What you need to consider is if something goes wrong with your procedure, can it be put right or will you have to find a UK based surgeon?

Can you afford to fly back out to the country where you had the surgery if something goes wrong afterwards?

Aftercare is a very important part of the cosmetic surgery process: if you have the surgery here in the UK then you are not far away from your surgeon or clinic. However, this becomes a problem if you have had this treatment abroad.

A sad fact of this is that many UK surgeons are seeing cases of ‘botched’ surgery or post-surgery complications. In effect they have to pick up the pieces. They are seeing people who have had surgery performed by unqualified or inexperienced surgeons. People who have been tempted by what looks like a great deal only for it to turn out to be a nightmare!

It may appear to be cheaper but you might find that you have to pay out for any extras such as aftercare. And some clinics may not provide this at all. Add in the cost of the flight and any optional extras and that great deal might turn out to be more expensive than you think.

Whether you go abroad or stay in the UK, go by your ‘gut feelings’. If the clinic or surgeon doesn’t seem right or suitable for you then go somewhere else.

Can I have cosmetic surgery on the NHS?

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In general, cosmetic surgery is not available on the NHS. However, there may be circumstances in which the NHS will pay although this is usually when combined with reconstructive plastic surgery.

If you require surgery to rebuild or repair a part of your body that has been damaged by an injury or illness then the NHS will pay for this. This is seen as ‘medically essential’.

However, cosmetic surgery is seen as ‘elective’: that means it is something the patient has chosen to have as opposed to being necessary. And, because it is concerned with physical appearance is often treated as a ‘frivolous’ concern.

If you can demonstrate a genuine ‘need’ then you may be able to have cosmetic surgery on the NHS; if not, then you will have to find a private clinic or hospital.

If you have private medical insurance then be aware that most insurers will not pay out for cosmetic surgery.

What questions should I ask my surgeon at the consultation?

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The aim is to be as thoroughly informed as possible. When looking for a cosmetic surgeon, ensure that he/she is professionally qualified to carry out this type of surgery. Apply the following criteria to your surgeon:

Is a member of BAAPS/BAPRAS
Is listed on the GMC’s Specialist Register for Plastic Surgery
Had held or is currently holding an NHS consultant position
Is an FRCS (Plast)

Ask to see ‘before’ and ‘after’ photographs: your surgeon should have photographs taken of pre-surgery and post-surgery patients. Make sure that your surgeon is experienced in the cosmetic procedure you wish to have. Check with him/her as to how many years they have performed this procedure and their success rates.

Your initial consultation should be between you and the surgeon: some clinics will set up a meeting between you and a ‘patient advisor’ or nurse. You want to talk to the person who is performing the actual surgery so ask to see the cosmetic surgeon.

Ask as many questions as you need to and ask the same question more than once until you are satisfied with the answers. Most surgeons are more than happy to answer patient’s questions. If your surgeon is reluctant or evasive then go somewhere else.

If the clinic or surgeon offers to treat other parts of the body or does ‘special deals’ then find another clinic/surgeon. This also applies if you feel that you are being pressured into making a decision. You want to have as much information as you need before making a decision. And, take your time before making that decision.

Here is a list of questions to ask your surgeon:

What can I expect from this surgery?
What type of anaesthetic is used?
What are the benefits of this procedure?
What are the risks of this surgery?
How long will the recovery take?
How long will I have to take off work?
If something goes wrong who do I contact?
What aftercare is available if something does go wrong?
Can I see you after the procedure?
How much scarring will there be?
How long do I have to wait before the stitches are removed or dissolve?
Can I expect much pain and bruising afterwards?
Will the procedure need to be repeated and when?
How much will it cost? Does that include any extras?
If I change my mind will I have to pay the full cost of the treatment?

You will probably think of more questions to ask but these are few of the most common ones asked by patients.

Your cosmetic surgeon has a duty of care and responsibility to you: but you also have to be honest at the consultation. If you have an underlying medical complaint or have experienced problems with surgery before then tell your surgeon. It is important to be as frank and as honest as you can. If you don’t then there is the risk of something going wrong which your surgeon didn’t know about beforehand.

If you have an allergy or allergies or are taking any medication then it is vital that you mention this.

Your surgeon should also mention about the risks associated with surgery in general. Surgery is safe but in a tiny minority of cases complications can occur. It is important that you are aware of these and take them into account when making your decision.

Where do I find a cosmetic surgeon?

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This is a very important decision to make. There are many surgeons out there who perform cosmetic surgery but not all of them are qualified to do so. At the end of the day you are literally putting your life in this person’s hands so you want to be sure that he/she is suitably qualified.

A good way to start is to take to your GP. He/she will offer a non-judgemental opinion about cosmetic surgery and will help and advise you. Your GP may be able to recommend a surgeon or a cosmetic surgery clinic/hospital.

The Medic8 directory of Cosmetic Surgeons may be a good place to start your reserach, read the clinic profile, read about the surgeon's experience and

Try respected organisations such as BAAPS, the GMC or The British Association of Cosmetic Surgeons. These organisations will have lists of UK based surgeons.

It is a good idea to do some background research beforehand. Read up as much as you can on the type of cosmetic procedure you are interested in. It is also a good idea to talk to others who have undergone this type of surgery. They may also be able to recommend a cosmetic surgeon.

It is worthwhile preparing a series of questions beforehand and discussing these with several surgeons. It is important that you like your surgeon: after all you are placing your trust in him/her as well as entering into a professional relationship. It is important that you feel that your surgeon is someone you can ‘get on with’ and is friendly and approachable.

As with anything in life it is a good idea to draw up a shortlist. Visit each surgeon on that list and compare their services and prices. Bear in mind though that cheapest doesn’t always mean the best! So be careful and make your decision with a clear mind.

Are there any reasons why I shouldn’t have surgery?

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If your overall health is poor or if you are a heavy smoker then you are unlikely to be suitable for surgery. A surgeon will be reluctant to operate if you are unrealistic in your expectations or have a ‘fragile’ mental state.

Pregnancy will rule you out for surgery. If you are taking any medication then check to see if this will exclude you from having surgery. Your suitability for a cosmetic procedure will be discussed between you and your surgeon.

Who should consider cosmetic surgery?

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Anyone can be considered for cosmetic surgery although there are age limits – both upper and lower. However, it does depend on the procedure. Many surgeons will recommend an upper age limit of 50 although it is not uncommon to hear about patients in the 60’s and 70’s undergoing cosmetic surgery.

In regard to the minimum age for surgery, you do hear of teenagers opting for surgery: although health professionals would prefer that surgery is not performed on under 18’s.

It is important to bear in mind that cosmetic surgery is not the answer to any deep psychological problems. It can improve your appearance but not any serious long-term issues.

Ideally, you should be in good health, preferably a non-smoker and a realistic set of expectations. That last item is very important: it is so easy to get carried away with images of celebrities and models.

Many people ask to look like their favourite film star, model or celebrity without realising that these pictures are often airbrushed or altered in some other way. What they are seeing is often an unrealistic look. Plus many of these models are the exception rather than the norm. Most ‘ordinary’ women do not look like that and it is difficult if not impossible to achieve that look. And whilst cosmetic surgery can achieve great results it cannot perform miracles!

The main things to ask yourself are why do you want surgery, are you doing this for yourself or someone else, are you looking to change your appearance or your life and will it improve your employment/promotion prospects.

If you are looking to change an aspect of your appearance then cosmetic surgery can help but tends to work best when combined with other lifestyle changes such as a healthy diet and exercise.

What are the most popular types of cosmetic surgery for women?

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Breast enhancement or ‘augmentation’ is still the most popular cosmetic procedure for women. It is more commonly known as a ‘boob job’ and basically involves increasing the size of the breasts.

Women have traditionally been judged on their bodies and facial appearance and this is still a factor today. The rise of celebrity culture and the emphasis of youth and looks have helped to create a culture of physical perfection.

According to BAAPS (source: annual audit 2008), 91% of cosmetic surgery procedures were chosen by women. The most popular procedures chosen by women are:

Breast Augmentation
Blepharoplasty
Rhytidectomy
Abdominoplasty
Breast Reduction

Other popular procedures for women include breast reduction, liposuction and body lifts. Women are also very keen on anti-ageing treatments such as fat injections, gels and chemical peels.

What are the most popular types of cosmetic surgery for men?

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Cosmetic surgery is increasing in popularity with men. Even though more women than men choose to have surgery, the numbers of men opting for some form of cosmetic procedure has increased over the last few years.

This may be because women are seen to be much more concerned with their appearance than men. And society places much more pressure on women to look good. Traditionally, women have been judged on physical appearance whereas men have not.

However, this trend has started to change especially with the rise of celebrity culture. Men as well as women are much more concerned with how they look, dress and feel. This has become more of an issue with the current economic climate. Plus we in the West place a high premium of physical attractiveness, body image and self-confidence.

Men are now experiencing these cultural pressures. They are turning to cosmetic surgery as a way of boosting their confidence and desirability in an increasingly competitive world.

The British Association of Aesthetic Plastic Surgeons (BAAPS) reports that many more men are choosing to have cosmetic surgery. The top 5 most popular cosmetic procedures are:

Rhinoplasty
Blepharoplasty
Otoplasty
Liposuction
Male breast reduction surgery

Other equally popular procedures include facelifts or ‘rhytidectomy’, abdominoplasty or ‘tummy tuck’ and ‘brow lifts’.

Men are also turning to non-surgical cosmetic treatments such as chemical peels, dermal fillers and wrinkle relaxation.

COSMETIC SURGERY TREATMENTS

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This Section will Include:

BREAST SURGERY
Breast Enlargement Surgery
Breast implants - A Guide
Breast Lift Surgery
Breast Asymmetry Surgery
Breast Reduction Surgery
Breast Capsulectomy Surgery
Breast Implant removal Surgery
Breast implant replacement
Capsular Contracture
Nipple reduction surgery
Inverted Nipple surgery
FACIAL SURGERY
Facelift
Mini Facelift
Rhinoplasty - Nose Reshaping
Revision Rhinoplasty
Eyelid Lift surgery
Neck lift surgery
Brow Lift / Forehead Lift
Cheek Implant Surgery
Chin Augmentation - Implants
Chin Reduction Surgery
Canthoplasty
Ear Correction Surgery
Septoplasty
FAT REMOVAL
Liposuction
Liposelection
Arm Lift Surgery
Body Lift Surgery
Male breast reduction
Buttock Lift surgery
Buccal fat removal
Feather Lift Surgery
Extended abdominoplasty
Tummy Tuck
Mini Tummy Tuck
Partial abdominoplasty
Thigh Lift Surgery
NON SURGICAL
Botox
Aphrodite Gold
Collagen Lip Injection
Fat Injections
Hydrafill
Juvederm
Laser Skin Resurfacing
Microdermabrasion
Myobloc
Obagi Skin Peel
Restylane
Sculptra
Thermage
Wrinkle treatments
MISCELLANEOUS
Laser Hair Removal
Scar Revision
Thread Vein removal
Penis Enlargement Surgery
Vaginoplasty - vaginal tightening
Labioplasty
Varicose Vein Surgery
TOP 10 COSMETIC SURGERY PROCEDURES

Cosmetic Surgery

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Cosmetic surgery is now more popular that ever with reality TV shows such as extreme makeover increasing public awareness about cosmetic surgery and plastic surgery procedures. Although in the past cosmetic surgery was only availble to the rich and famous, it is now becoming popular amongst the general public.

The Medic8 guide to cosmetic surgery aims to provide a comprehensive non-biased overview of cosmetic and plastic surgery procedures, the benefits, the risks involved and what you could expect from the cosmetic surgery procedure that you are intrested in.

What is Cosmetic Surgery?

Cosmetic surgery involves having a surgical procedure carried out by a plastic/cosmetic surgeon to improve the "look" of a particular part of your body. Cosmetic surgery can not only improve physical appearance but it can also have emotional and psychological effects. Procedures such as breast enlargement or a facelift could have a great influence on an individual's self esteem and confidence levels.

Cosmetic Surgery has its risks

As with any surgical procedures there are risks involved and it is important that before undergoing any cosmetic surgery procedures that you are fully aware of all the potential risks and potential side effects and discuss these with your surgeon.

Your Questions answered in our Cosmetic Surgery Guide

In this Guide to cosmetic surgery we have tried to cover all your questions and the links below give an overview of the most common cosmetic surgery questions asked by patients that are considering going under the knife. If you would like to learn more indepth information about individual cosmetic surgery procedures then take a look at Cosmetic Surgery Treatments.

VENOUS LEG ULCERS

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Venous ulcers are wounds that are thought to occur due to improper functioning of valves in the veins, usually of the legs. They are the major cause of chronic wounds.

Pathophysiology

The exact aetiology of venous ulcers is not certain, but they are thought to arise when venous valves that exist to prevent backflow of blood do not function properly, causing the pressure in veins to increase. The body needs the pressure gradient between arteries and veins in order for the heart to pump blood forward through arteries and into veins. When venous hypertension exists, arteries no longer have significantly higher pressure than veins, blood is not pumped as effectively into or out of the area and it pools.

Venous hypertension may also stretch veins and allow blood proteins to leak into the extravascular space, isolating extracellular matrix (ECM) molecules and growth factors, preventing them from helping to heal the wound. Leakage of fibrinogen from veins as well as deficiencies in fibrinolysis may also cause fibrin to build up around the vessels, preventing oxygen and nutrients from reaching cells. Venous insufficiency may also cause white blood cells (leukocytes) to accumulate in small blood vessels, releasing inflammatory factors and reactive oxygen species (ROS, free radicals) and further contributing to chronic wound formation. Buildup of white blood cells in small blood vessels may also plug the vessels, further contributing to ischaemia. This blockage of blood vessels by leukocytes may be responsible for the "no reflow phenomenon," in which ischaemic tissue is never fully reperfused. Allowing blood to flow back into the limb, for example by elevating it, is necessary but also contributes to reperfusion injury . Other comorbidities may also be the root cause of venous ulcers.

Treatment

Venous ulcers are costly to treat, and there is a significant chance that they will recur after healing; one study found that up to 48% of venous ulcers had recurred by the fifth year after healing.

Non-elastic, ambulatory, below knee (BK) compression aggressively counters the impact of reflux on venous pump failure. Compression therapy is used for venous leg ulcers and can decrease blood vessel diameter and pressure, which increases their effectiveness, preventing blood from flowing backwards. Compression is also used to increase release of inflammatory cytokines, lower the amount of fluid leaking from capillaries and therefore prevent swelling, and prevent clotting by decreasing activation of thrombin and increasing that of plasmin. Compression is applied using elastic bandages or boots specificially designed for the purpose.

Artificial skin, made of collagen and cultured skin cells, is also used to cover venous ulcers and excrete growth factors to help them heal.

URINARY INCONTINENCE IN WOMEN

2009-08-08T04:10:00.001+05:30

What is urinary incontinence?

Urinary incontinence is when urine leaks out before you can get to a bathroom. If you have urinary incontinence, you're not alone. Millions of women have this problem.

What causes urinary incontinence?

There are many reasons why a woman may leak urine. Sometimes it's caused by an illness, in which case bladder control returns when the illness goes away. For example, bladder infections and infections in the vagina can cause incontinence for a short time. Being unable to have a bowel movement or taking certain medicines also may make it hard to control your bladder.

Sometimes incontinence is an ongoing problem, in which case the cause might be:

the bladder cannot empty completely
weakening of the muscles that help to hold or release urine
a blocked urinary passage
damage to the nerves that control the bladder

Sometimes, diseases such as arthritis make it hard to get to the bathroom in time and can make it even harder to control urine leakage.

How common is urinary incontinence?

More than 13 million Americans � male and female, young and old � have incontinence. Women are more likely to leak urine than men.

Older women have more bladder control problems than younger women. But loss of bladder control does not have to happen as you age. If you're leaking urine, talk to your doctor about it. Your doctor can help you.

Does having a baby cause urinary incontinence?

Yes. It can, but don't panic. If you lose bladder control after having a baby, the problem often goes away by itself. Your muscles may just need time to recover.

Being pregnant also can cause leakage due to:

pressure of the pregnancy on the bladder and pelvic muscles
vaginal delivery
episiotomy (the cut in the muscle that makes it easier for the baby to come out)
damage to bladder control nerves

If you still have bladder problems six weeks after having your baby, talk to your doctor. Without treatment, lost bladder control can become a long-term problem. Leaking can also result from some medical conditions, including neurologic injury, birth defects, strokes, multiple sclerosis, and physical problems associated with aging.

Sometimes bladder control problems show up years after you've had your baby. Some women do not have problems until later, often in their 40's.

Unborn babies push down on the bladder, urethra (tube that you urinate from) and pelvic muscles.

Does menopause affect urinary incontinence?

Yes. Some women have bladder control problems after they stop having periods (called menopause or change of life). After your periods end, your body stops making the female hormone estrogen. Some experts think this loss of estrogen weakens the vaginal tissue.

If you're leaking urine, talk to your doctor about it. Your doctor can help you.

Are there different types of urinary incontinence?

Yes.

Stress incontinence � leakage happens with coughing, sneezing, exercising, laughing, lifting heavy things, and other movements that put pressure on the bladder. It is the most common type of incontinence. It can be treated and sometimes cured.
Urge incontinence � this is sometimes called "overactive bladder." Leakage usually happens after a strong, sudden urge to urinate. The sudden urge may occur when you don't expect it, such as during sleep, after drinking water, or when you hear running water or touch it.
Functional incontinence � leaking because you can't get to a toilet in time. People with this type of incontinence may have problems thinking, moving, or speaking that keep them from reaching a toilet. For example, a person with Alzheimer's disease may not plan a trip to the bathroom in time to urinate. A person in a wheelchair may be unable to get to a toilet in time.
Overflow incontinence � leaking urine because the bladder doesn't empty completely. Overflow incontinence is less common in women.
Mixed incontinence � two or more types of incontinence together, most often stress and urge incontinence.
Transient incontinence � leaking urine for a short time due to an illness such as a bladder infection. Leaking stops when the illness is treated.

How do I talk to my doctor about urinary incontinence?

Most people don't want to talk to their doctor about such a personal topic. But keep in mind that urinary incontinence is a common medical problem. Millions of women have the same problem, so your doctor has probably heard many stories like yours.

Even if you feel shy, it is up to you to take the first step. Some doctors don't treat bladder control problems, so they may not think to ask about it. Others might expect you to bring up the subject. If your doctor doesn't treat bladder problems, ask for help finding a doctor who does.

Here are some questions to ask your doctor:

Could what I eat or drink cause bladder problems?
Could my medicines (prescription or over-the-counter) cause bladder problems?
Could other medical conditions cause loss of bladder control?
What are the treatments to regain bladder control? Which one is best for me?
What can I do about the odor and rash caused by urine?

It may help to write down when you leak urine. Be sure to note what you were doing at the time, for example, sneezing, coughing, laughing, or sleeping. Take this log with you when you visit your doctor.

How do I find out if I have urinary incontinence?

The first step is to see your doctor. If your doctor doesn't treat bladder problems, ask for help finding someone who does.

Your doctor will ask you about your symptoms and take a medical history. Your doctor will ask you:

how often you empty your bladder
how and when you leak urine
how much urine you leak

Your doctor will do a physical exam to look for signs of health problems that can cause incontinence. Your doctor also will do a test to figure out how well your bladder works and how much it can hold. For this test, you will drink water and urinate into a measuring pan, after which your doctor will measure any urine still in the bladder. Your doctor also may order one or more of the following other tests:

Stress test � while you cough or bear down, the doctor watches for loss of urine.
Urinalysis � you give a urine sample, which is tested for signs of infection and other causes of incontinence.
Blood test � you give a blood sample, which is sent to a lab where it is tested for signs of other causes of incontinence.
Ultrasound � sound waves are used to take a picture of the kidneys, bladder, and urethra. Your doctor will look to see if there are any problems in these areas that could cause incontinence.
Cystoscopy � a thin tube with a tiny camera is placed in the urethra to view the inside of the urethra and bladder.
Urodynamics � a thin tube is placed into your bladder and your bladder is filled with water. Your doctor measures the pressure in the bladder.

Your doctor may ask you to write down when you empty your bladder and how much urine you produce for a day or a week.

Is there anything I can do to prevent urinary incontinence?

Yes. Exercising your pelvic floor muscles regularly can help prevent bladder problems. These exercises are called Kegels.

How to do Kegel exercises:

It may be easier to begin practicing these exercises while lying down.
Squeeze the muscles in your genital area as if you were trying to stop the flow of urine or trying to stop from passing gas. Try not to squeeze the muscles in your belly or legs at the same time.
Relax. Squeeze the muscles again and hold for 3 seconds. Then relax for 3 seconds. Do this 8 more times. Work up to 5 sets of 10.
When your muscles get stronger, do your exercises sitting or standing. You can do these exercises any time, while sitting at your desk, in the car, waiting in line, doing the dishes, etc.

Be patient. It may take 3 to 6 weeks before you see results.

If you're not sure you're doing Kegel exercises right, ask your doctor or nurse to check you while you try to do them. If you aren't squeezing the right muscles, your doctor or nurse can teach you the right way to do the exercises. A pelvic floor physical therapist may be available in your area to help teach you how to strengthen these muscles or help you with other treatments.

How is urinary incontinence treated?

There are many ways to treat incontinence. Your doctor will work with you to find the best treatment for you.

Treatments include:

Pelvic Muscle Exercises (Kegel exercises) � easy exercises to make your pelvic muscles stronger. Doing these exercises every day can help reduce or cure stress leakage.

Electrical Stimulation � electrodes are placed in the vagina or rectum for a short time to stimulate nearby muscles and make them stronger. This treatment can reduce both stress incontinence and urge incontinence.
Biofeedback � biofeedback helps you learn how your body works. A therapist puts an electrical patch over your bladder and urethral muscles. A wire connected to the patch is linked to a TV screen. You and your therapist watch the screen to see when these muscles contract, so you can learn to control these muscles. Biofeedback can be used with pelvic muscle exercises and electrical stimulation to help control stress incontinence and urge incontinence.
Timed Voiding or Bladder Retraining � there are two ways you can train your bladder to hold urine better. In timed voiding, you urinate at set times instead of waiting for a strong urge. To do bladder retraining, you slowly increase the time between your scheduled voiding times to train your bladder to hold urine better. These treatments can reduce urge incontinence and overflow incontinence. A doctor can tell you if these may help you.
Weight Loss � extra weight puts more pressure on your bladder and nearby muscles, which can cause bladder control problems. If you're overweight, work with your doctor to plan a diet and exercise program that works for you.
Dietary Changes � certain foods and drinks can cause incontinence, such as caffeine (found in coffee, some sodas, and chocolate), tea, and alcohol. Limiting these foods and drinks can reduce incontinence.
Medications � medications can reduce some types of leakage. Talk to your doctor to see if medication is right for you.
Pessary � a pessary is a small device that fits in your vagina and helps hold it up. A pessary can help reduce leakage. Your doctor or nurse will decide which type and size of pessary is right for you and will check the pessary regularly.
Implants � your doctor may suggest injecting a material into the space around the urethra with a needle. This material thickens the area around the urethra so you can control your urine flow better.
Surgery � surgery can fix problems such as blocked areas. It can also support the bladder or the urethra to prevent loss of urine. A surgeon can also put a small device in the body that acts on nerves to control bladder activity.
Urethral Inserts � a urethral insert is a thin tube that you place inside the urethra that blocks urine from coming out. You take the tube out when you need to urinate and then put it back in until you need to urinate again.
External Urethral Barrier � this device is a small foam or gel disposable pad that you place over the opening of the urethra. The pad seals itself against your body, keeping you from leaking. When you go to the bathroom you take it off. After urinating you place a new pad over the urethra.
Catheters � if nothing else helps, the doctor may suggest catheters, thin tubes placed in the bladder by a doctor or by you. A catheter drains the bladder for you, sometimes into an attached bag.

TINNITUS

2009-08-08T04:09:00.000+05:30

Tinnitus is a symptom associated with many forms of hearing loss. It can also be a symptom of other health problems.

Tinnitus can be so severe that it interferes with daily activities. People with severe cases of tinnitus may find it difficult to hear, work, or even sleep.

What causes tinnitus?

Hearing loss. Doctors and scientists have discovered that people with different kinds of hearing loss also have tinnitus.

Loud noise. Too much exposure to loud noise can cause noise-induced hearing loss and tinnitus.

Medicine. More than 200 medicines can cause tinnitus. If you have tinnitus and you take medicine, ask your doctor or pharmacist whether your medicine could be involved.

Other health problems. Allergies, tumours, and problems in the heart and blood vessels, jaws, and neck can cause tinnitus.

What should I do if I have tinnitus?

The most important thing you can do is to go see your doctor. Your doctor can try to determine what is causing your tinnitus. He or she can check to see if it is related to blood pressure, kidney function, diet, or allergies. Your doctor can also determine whether your tinnitus is related to any medicine you are taking.

To learn more about what is causing your tinnitus, your doctor may refer you to an otolaryngologist, an ear, nose, and throat doctor. He or she will examine your ears and your hearing to try to find out why you have tinnitus. Another hearing professional, an audiologist, can measure your hearing. If you need a hearing aid, an audiologist can fit you with one that meets your needs.

How will hearing experts treat my tinnitus?

Although there is no cure for tinnitus, scientists and doctors have discovered several treatments that may give you some relief. Not every treatment works for everyone, so you may need to try several to find the ones that help.

Treatments can include:

Hearing aids. Many people with tinnitus also have a hearing loss. Wearing a hearing aid makes it easier for some people to hear the sounds they need to hear by making them louder. The better you hear other people talking or the music you like, the less you notice your tinnitus.

Maskers. Maskers are small electronic devices that use sound to make tinnitus less noticeable. Maskers do not make tinnitus go away, but they make the ringing or roaring seem softer. For some people, maskers hide their tinnitus so well that they can barely hear it.

Some people sleep better when they use maskers. Listening to static at a low volume on the radio or using bedside maskers can help. These are devices you can put by your bed instead of behind your ear. They can help you ignore your tinnitus and fall asleep.

Medicine or drug therapy. Some medicines may ease tinnitus. If your doctor prescribes medicine to treat your tinnitus, he or she can tell you whether the medicine has any side effects.

Tinnitus retraining therapy. This treatment uses a combination of counselling and maskers. Otolaryngologists and audiologists help you learn how to deal with your tinnitus better. You may also use maskers to make your tinnitus less noticeable. After a while, some people learn how to avoid thinking about their tinnitus. It takes time for this treatment to work, but it can be very helpful.

Counselling. People with tinnitus may become depressed. Talking with a counsellor or people in tinnitus support groups may be helpful.

Relaxing. Learning how to relax is very helpful if the noise in your ears frustrates you. Stress makes tinnitus seem worse. By relaxing, you have a chance to rest and better deal with the sound.

What can I do to help myself?

Think about things that will help you cope. Many people find listening to music very helpful. Focusing on music might help you forget about your tinnitus for a while. It can also help mask the sound. Other people like to listen to recorded nature sounds, like ocean waves, the wind, or even crickets.

Avoid anything that can make your tinnitus worse. This includes smoking, alcohol, and loud noise. If you are a construction worker, an airport worker, or a hunter, or if you are regularly exposed to loud noise at home or at work, wear ear plugs or special earmuffs to protect your hearing and keep your tinnitus from getting worse.

If it is hard for you to hear over your tinnitus, ask your friends and family to face you when they talk so you can see their faces. Seeing their expressions may help you understand them better. Ask people to speak louder, but not shout. Also, tell them they do not have to talk slowly, just more clearly.

SECONDARY PREVENTION AFTER A HEART ATTACK

2009-08-08T04:06:00.000+05:30

The risk of a recurrent myocardial infarction (MI, heart attack) decreases with strict blood pressure management and lifestyle changes, chiefly smoking cessation, regular exercise, a sensible diet for patients with heart disease, and limitation of alcohol intake.

Patients are usually commenced on several long-term medications post-MI, with the aim of preventing secondary cardiovascular events such as further myocardial infarctions, congestive heart failure or cerebrovascular accident (CVA). Unless contraindicated, such medications may include:

Antiplatelet drug therapy such as aspirin and/or clopidogrel should be continued to reduce the risk of plaque rupture and recurrent myocardial infarction. Aspirin is first-line, owing to its low cost and comparable efficacy, with clopidogrel reserved for patients intolerant of aspirin. The combination of clopidogrel and apirin may further reduce risk of cardiovascular events, however the risk of hemorrhage is increased.

Beta blocker therapy such as metoprolol or carvedilol should be commenced. These have been particularly beneficial in high-risk patients such as those with left ventricular dysfunction and/or continuing cardiac ischaemia. β-Blockers decrease mortality and morbidity. They also improve symptoms of cardiac ischemia in NSTEMI.

ACE inhibitor therapy should be commenced 24-48 hours post-MI in haemodynamically-stable patients, particularly in patients with a history of MI, diabetes mellitus, hypertension, anterior location of infarct (as assessed by ECG), and/or evidence of left ventricular dysfunction. ACE inhibitors reduce mortality, the development of heart failure, and decrease ventricular remodelling post-MI.

Statin therapy has been shown to reduce mortality and morbidity post-MI. The effects of statins may be more than their LDL lowering effects. The general consensus is that statins have plaque stabilization and multiple other ("pleiotropic") effects that may prevent myocardial infarction in addition to their effects on blood lipids.

The aldosterone antagonist agent eplerenone has been shown to further reduce risk of cardiovascular death post-MI in patients with heart failure and left ventricular dysfunction, when used in conjunction with standard therapies above.

Omega-3 fatty acids, commonly found in fish, have been shown to reduce mortality post-MI. While the mechanism by which these fatty acids decrease mortality is unknown, it has been postulated that the survival benefit is due to electrical stabilization and the prevention of ventricular fibrillation. However, further studies in a high-risk subset have not shown a clear-cut decrease in potentially fatal arrhythmias due to omega-3 fatty acids.

RESTLESS LEGS SYNDROME

2009-08-08T04:00:00.000+05:30

What Is Restless Legs Syndrome?

Restless legs syndrome (RLS) is a sensory disorder causing an almost irresistible urge to move the legs. The urge to move is usually due to unpleasant feelings in the legs that occur when at rest. People with RLS use words such as creeping, crawling, tingling, or burning to describe these feelings. Moving the legs eases the feelings, but only for a while. The unpleasant feelings may also occur in the arms.

Effects of RLS

RLS can make it hard to fall asleep and stay asleep. People with RLS often don't get enough sleep and may feel tired and sleepy during the day. This can make it difficult to:

Concentrate, making it harder to learn and remember things
Work
Carry out other usual daily activities
Take part in family and social activities

Not getting enough sleep can also make you feel depressed or have mood swings.

RLS can range from mild to severe, based on:

How much discomfort you have in your legs and arms
Whether you feel the need to move around
How much relief you get from moving around
How much sleep disturbance you have
How tired or sleepy you are during the day
How often you have symptoms
How severe your symptoms are on most days
How well you carry out daily activities
How angry, depressed, sad, anxious, or irritable you feel

Types of RLS

There are two types of RLS:

Primary RLS is the most common type of RLS. It is also called idiopathic RLS. �Primary� means the cause is not known. Primary RLS, once it starts, usually becomes a lifelong condition. Over time, symptoms tend to get worse and occur more often, especially if they began in childhood or early in adult life. In milder cases, there may be long periods of time with no symptoms, or symptoms may last only for a limited time.
Secondary RLS is RLS that is caused by another disease or condition or, sometimes, from taking certain medicines. Symptoms usually go away when the disease or condition improves, or if the medicine is stopped.

Periodic Limb Movement Disorder

Most people with RLS also have a condition called periodic limb movement disorder (PLMD). PLMD is a condition in which a person's legs twitch or jerk uncontrollably about every 10 to 60 seconds. This usually happens during sleep. These movements cause repeated awakenings that disturb or reduce sleep. PLMD usually affects the legs but can also affect the arms.

Outlook

RLS can be unpleasant and uncomfortable. However, there are some simple self-care approaches and lifestyle changes that can help in mild cases. RLS symptoms often improve with medical treatment. Research is ongoing to better understand the causes of RLS and to develop better treatments.

What Causes Restless Legs Syndrome?

Primary RLS

In most cases of restless legs syndrome (RLS), no cause can be found. When no cause can be found, the condition is called primary RLS. It is known, however, that primary RLS tends to run in families. People whose parents have RLS are more likely to develop the disorder. This suggests that there may be a genetic link that increases the chance of getting RLS.

Secondary RLS

Secondary RLS is RLS that is caused by another disease or condition, or as a side effect of certain medications. Some of the diseases and conditions that can cause RLS are:

Iron deficiency (with or without anaemia)
Kidney failure
Diabetes
Parkinson's disease
Damage to the nerves in the hands or feet (peripheral neuropathy) (pe-RIF-e-ral noo-ROP-a-the)
Rheumatoid arthritis (ROO-ma-toyd ar-THRI-tis)
Pregnancy

RLS is common in pregnant women. It usually occurs during the last 3 months of pregnancy and usually improves or disappears within a few weeks after delivery. However, some women may continue to have symptoms after giving birth or may develop RLS again later in life.

Some of the types of medicines that can cause RLS are:

Antiseizure medicines
Antinausea medicines
Antidepressants
Some cold and allergy medicines

RLS symptoms usually go away when the medicine is stopped.

Certain substances can trigger RLS symptoms or make them worse. These substances include:

Caffeine
Alcohol
Tobacco

Who Is At Risk for Restless Legs Syndrome?

Restless legs syndrome (RLS) may affect as many as 12 million people in the United States.

Gender

RLS affects both men and women. The disorder occurs more often in women than in men.

Age

The number of cases of RLS rises with age. Many people with RLS are diagnosed in middle age. But in up to two out of every five cases, the symptoms of RLS begin before age 20. People who develop RLS early in life usually have a family history of the disorder.

Race/Ethnic Group

RLS can affect people of any race or ethnic group. The disorder is more common in persons of northern European descent.

Pregnancy

RLS is common in pregnant women. It usually occurs during the last 3 months of pregnancy and usually improves or disappears within a few weeks after delivery.

What Are the Signs and Symptoms of Restless Legs Syndrome?

Restless legs syndrome (RLS) has several major signs and symptoms:

An almost irresistible urge to move the legs or arms when sitting or lying down
An unpleasant feeling in the legs
Difficulty falling asleep or staying asleep because of the unpleasant feelings in the legs or arms
Daytime sleepiness, which results from a lack of restful sleep due to the repeated limb movements

Urge To Move

RLS gets its name from the urge to move the legs when sitting or lying down. This urge is due to unpleasant feelings in the legs that are relieved by movement. Typical movements are:

Pacing and walking
Jiggling the legs
Stretching and flexing
Tossing and turning
Rubbing the legs

Unpleasant Feelings

The urge to move the legs usually is due to unpleasant feelings in the legs. People with RLS describe these feelings as:

Creeping
Crawling
Pulling
Itching
Tingling
Burning
Aching
Painful
Hard to describe

Children may describe RLS symptoms differently than adults.

The unpleasant feelings in RLS usually occur in the lower leg (calf). But the feelings can occur at any place between the thigh and the ankle and also in the arm. The feelings are worse:

When lying down or sitting for a long period of time
During the evening or night, more so than during the day

The unpleasant feelings also:

Make it hard to fall asleep or stay asleep
Are not as bad or go away when you move

Duration and Severity

RLS symptoms tend to get worse over time. They may begin in childhood and develop slowly over several years. People with early symptoms are more likely to have other family members with RLS than people who develop RLS later in life.

Symptoms tend to worsen faster when RLS occurs later in life. RLS that occurs later in life is also more likely to result from an underlying condition or illness than RLS that occurs early in life.

People with mild symptoms may only notice them when they are still or awake for a long time, such as on a long airplane trip.

How Is Restless Legs Syndrome Diagnosed?

The way that you describe your symptoms is very important in diagnosing restless legs syndrome (RLS). Your doctor will:

Take a complete medical history
Do a complete physical examination
Order other tests

The diagnosis of RLS usually requires the following four conditions be present:

An urge to move the legs due to an unpleasant feeling in the legs.
The urge to move the legs, or the unpleasant feelings in the legs, begins or gets worse when you are at rest or not moving around frequently.
The urge to move the legs, or the unpleasant feelings in the legs, is partly or completely relieved by movement (such as walking or stretching) for as long as the movement continues.
The urge to move the legs, or the unpleasant feelings in the legs, is worse in the evening and at night, or only occurs in the evening or at night.

Medical History

Your doctor will take a medical history and ask questions such as:

Can you describe your symptoms?
When did your symptoms first begin?
When during the day or night do the symptoms usually occur?
When are your symptoms worse?
Do symptoms interfere with your sleep?

Your doctor will also ask about your sleep habits, such as:

The time you go to bed and get up
Your routine before going to bed
Noise, light, and interruptions in the room where you sleep
Whether you snore

Your doctor will ask about how you feel during the day, including whether:

You are tired and sleepy when you wake up and during the day.
You have trouble concentrating.
You doze off or have difficulty staying awake doing routine tasks, especially driving.

Your doctor will ask questions to find out if your symptoms are a result of a possible underlying condition. Questions might include:

Do members of your family have similar symptoms?
What medicines (over-the-counter and prescription) do you take?
Do you snore loudly and frequently?
Do you gasp for air during sleep?
Do you use caffeine, tobacco, or alcohol?

Physical Exam

A physical exam is done to:

Identify any underlying condition that may cause RLS
Rule out other disorders

Your doctor also will pay special attention to:

The nerves in your spinal cord (especially) and legs and arms
The blood flow in your legs and arms

Other Tests

There is no test currently available to diagnose RLS.

However, blood tests can be used to look for underlying conditions that can cause RLS. These tests check for:

Low iron stores or iron deficiency
Diabetes
Kidney disease
Other vitamin and mineral deficiencies

How Is Restless Legs Syndrome Treated?

The goals of treatment for restless legs syndrome (RLS) are to:

Relieve symptoms
Increase the amount and quality of sleep
Treat or correct any underlying condition that may cause RLS

Types of treatment include:

Lifestyle changes and other nondrug treatments
Medicines

Lifestyle Changes and Other Non-drug Treatments

Lifestyle changes can improve and relieve symptoms of RLS. Lifestyle changes may be the only treatment needed for mild RLS. Some lifestyle changes that may help include:

Avoid things that can make symptoms of RLS worse:
- Tobacco
- Alcohol
- Caffeine�Chocolate, coffee, tea, and some soft drinks contain caffeine. Although it may seem to help overcome daytime sleepiness, caffeine usually only delays or masks RLS symptoms, and often makes them worse.
- Some medicines�Some types of over-the-counter and prescription medicines can also make RLS symptoms worse. These include:
  - Antidepressants (most of them)
  - Antinausea medicines
  - Antipsychotic medicines
  - Antihistamines
Adopt good sleep habits:
- Keep your bedroom or sleep area cool, quiet, comfortable, and free of unnecessary light.
- Use your bedroom for sleeping, not for watching TV or using computers or cell phones.
- Go to bed every night at the same time and wake up at the same time every morning. Some people with RLS find it helpful to go to bed later in the evening and get up later in the morning. The important thing is to get enough sleep so that you feel rested when you wake up.
Follow a programme of moderate exercise

Other activities that also may help relieve symptoms include:

Walking or stretching
Taking a hot or cold bath
Massaging the leg or arm
Using heat or ice packs

Medicines

Medicines can help relieve some symptoms of RLS. Doctors prescribe medicines to treat RLS in people:

With clearly defined symptoms
Whose symptoms cannot be controlled by lifestyle and nondrug treatments

No single medicine is helpful in all persons with RLS. It may take several changes in medicines and dosages to find the best approach. Sometimes, a medicine will work for a while and then stop working.

Some medicines may not be safe for pregnant women.

Always talk with your doctor before taking any medicines, even over-the-counter medicines.

Specific medicines

Medicines used to treat Parkinson's disease also are used to treat RLS. Even though these medicines help reduce RLS symptoms, RLS is not a form of Parkinson's disease. The medicines help reduce the amount of motion in the legs. They include:

Levodopa (le-vo-DO-pa)
- Is best used to treat mild cases of RLS
- Is short-acting
- Works for a while but does not work long term in most people
Dopamine agonists (pergolide (PER-go-lid), pramipexole (prah-mih-PEX-ohl), and ropinirole (roh-PIN-ih-roll))
- Are used to treat moderate and severe cases of RLS
- Are used to treat mild cases of RLS if levodopa stops working
- Are long-acting

The U.S. Food and Drug Administration recently approved ropinirole to treat moderate to severe RLS.

Other medicines may be used to treat RLS, including:

Strong pain-relieving medicines (narcotics).
- Used most often when symptoms are severe
- May be used in people who don't respond to dopamine agonists
Sedatives (benzodiazepines (BEN-so-di-AZ-e-pens)).
- Help with falling asleep
- May cause daytime sleepiness
- Are not recommended for people with sleep apnea and for older persons
Medicines used to treat epilepsy (anticonvulsants: gabapentin (gab-ah-PEN-tin), carbamazepine (kar-bam-AZ-e-pen), and valproate (val-PROH-ate)). These types of medicines are:
- Considered when dopamine agonists fail
- Most effective in persons with daytime and evening symptoms, as well as sleep-onset symptoms, and in those who describe the unpleasant feelings in the legs as painful.
Iron supplements, if iron deficiency appears to be contributing to RLS. Iron supplements should only be used if recommended by a doctor.

Living With Restless Legs Syndrome

Restless legs syndrome (RLS) is often a lifelong condition. The symptoms may come and go frequently or disappear completely for long periods of time. They may get worse over time. Lifestyle changes and medicines can help control and relieve the symptoms of RLS. For severe symptoms, ongoing medicines may be needed. Talk with your doctor about lifestyle changes and medicines that might help your symptoms. New treatments are being developed as research continues.

RLS that occurs during pregnancy usually improves or disappears within a few weeks after delivery.

Key Points

Restless legs syndrome (RLS) is a sensory disorder causing an almost irresistible urge to move the legs. The urge to move the legs is usually due to unpleasant feelings in the legs that occur when at rest. Movement eases the feelings but only for a while.
Symptoms of RLS can range from mild to severe. Symptoms tend to get worse over time. They sometimes begin during childhood.
People with RLS may describe the unpleasant feelings in their legs as creeping, crawling, tingling, burning, or painful. Often, the feelings are hard to describe.
Many people with RLS also have periodic limb movement disorder. This is a condition in which a person's legs twitch or jerk uncontrollably every 10 to 60 seconds. This usually happens during sleep.
RLS can make it difficult to fall asleep and stay asleep. People with RLS often don't get enough sleep and may feel tired and sleepy during the day.
There are two types of RLS: primary and secondary.
- In primary RLS the cause is not known. However, it tends to run in families.
- Secondary RLS is RLS that is caused by another disease or condition or, sometimes, by taking certain medicines.
- RLS is common in pregnant women. It usually occurs during the last 3 months of pregnancy and usually improves or disappears within a few weeks after delivery.
Lifestyle changes can improve and relieve symptoms of RLS. Lifestyle changes may be the only treatment needed for mild symptoms of RLS.
Medicines can help to treat more severe symptoms of RLS. No single medicine is helpful in all persons with RLS. It may take several changes in medicines and dosages to find the best approach.

QUININE SULPHATE

2009-08-08T03:57:00.000+05:30

Use: Night cramps, Malaria

This medicine is mainly indicated for reducing the occurrence of nocturnal leg cramps. It is also used to treat falciparum malaria.

Cautions:

- atrial fibrillation
- heart block/conduction defects
- pregnancy
- G6P deficiency

Contra-indications:

- haemoglobinuria
- myasthenia gravis
- optic neuritis

Side effects:

- cinchonism (tinnitus, headache, nausea, diarrhoea, blurred vision, deafness, vertigo)
- hypersensitivity
- blood disorders
- kidney failure
- hypoglycaemia
- heart arrythmias

Quinine is very toxic in overdose, overdose of any medicine is lethal and in such a case dial your local doctor or hospital for assistanceas soon as possible.

POSTHERPETIC NEURALGIA (SHINGLES)

2009-08-08T03:55:00.000+05:30

What is postherpetic neuralgia?

Postherpetic neuralgia is a nerve pain (neuralgia) that persists after a shingles rash has cleared.

Shingles (herpes zoster) is an outbreak of rash or blisters on the skin that is caused by the same virus that causes chicken pox - the varicella-zoster virus.

The first sign of shingles is often burning or tingling pain, or sometimes numbness, in or under the skin. You may also feel ill with fever, chills, headache, or upset stomach.

After several days, a rash of small fluid-filled blisters, reminiscent of chickenpox, appears on reddened skin.

The pain associated with shingles can be intense and is often described as "unrelenting."

Anyone who has had chickenpox is at risk for shingles. Scientists think that in the original battle with varicella-zoster, some of the virus particles leave the skin blisters and move into the nervous system. When the varicella-zoster virus reactivates, the virus moves back down the long nerve fibers that extend from the sensory cell bodies to the skin and cause the characteristic blisters of shingles .

Is there any treatment?

The severity and duration of an attack of shingles can be significantly reduced by immediate treatment with antiviral drugs, which include acyclovir, valcyclovir, or famcyclovir.

Antiviral drugs may also help stave off the painful after-effects of shingles known as postherpetic neuralgia.

Other treatments for postherpetic neuralgia include steroids, antidepressants, anticonvulsants, and topical agents.

What is the prognosis?

For most people, the lesions heal, the pain subsides within 3 to 5 weeks, and the blisters leave no scars.

However, shingles is a serious threat in immunosuppressed individuals � for example, those with HIV infection or who are receiving cancer treatments that can weaken their immune systems. People who receive organ transplants are also vulnerable to shingles because they are given drugs that suppress the immune system.

POLYMYALGIA RHEUMATICA

2009-08-08T03:49:00.001+05:30

What Are Polymyalgia Rheumatica and Giant Cell Arteritis?

Polymyalgia rheumatica is a rheumatic disorder that is associated with moderate to severe muscle pain and stiffness in the neck, shoulder, and hip area. Stiffness is most noticeable in the morning.

This disorder may develop rapidly--in some patients, overnight. In other people, polymyalgia rheumatica develops more gradually.

The cause of polymyalgia rheumatica is not known; however, possibilities include immune system abnormalities and genetic factors. The fact that polymyalgia rheumatica is rare in people under the age of 50 suggests it may be linked to the aging process.

Polymyalgia rheumatica may go away without treatment in 1 to several years. With treatment, the symptoms of polymyalgia rheumatica are quickly controlled, but relapse if treatment is stopped too early.

Giant cell arteritis, also known as temporal arteritis and cranial arteritis, is a disorder that results in swelling of arteries in the head (most often the temporal arteries, which are located on the temples on each side of the head), neck, and arms. This swelling causes the arteries to narrow, reducing blood flow. Early treatment is critical for good prognosis.

How Are Polymyalgia Rheumatica and Giant Cell Arteritis Related?

It is unclear how or why polymyalgia rheumatica and giant cell arteritis are related, but an estimated 15 percent of people in the United States with polymyalgia rheumatica also develop giant cell arteritis. Patients can develop giant cell arteritis either at the same time as polymyalgia rheumatica or after the polymyalgia symptoms disappear. About half of the people affected by giant cell arteritis also have polymyalgia rheumatica.

When a person is diagnosed with polymyalgia rheumatica, the doctor also should look for symptoms of giant cell arteritis because of the risk of blindness. With proper treatment, the disease is not threatening. Untreated, however, giant cell arteritis can lead to serious complications including permanent vision loss and stroke. Patients must learn to recognise the signs of giant cell arteritis, because they can develop even after the symptoms of polymyalgia rheumatica disappear. Patients should report any symptoms to the doctor immediately.

Who Is at Risk?

White women over the age of 50 are most at risk of developing polymyalgia rheumatica and giant cell arteritis. Women are twice as likely as men to develop the conditions. Both conditions almost exclusively affect people over the age of 50. The average age at onset is 70 years. Polymyalgia rheumatica and giant cell arteritis are quite common. In the United States, it is estimated that 700 per 100,000 people in the general population over 50 years of age develop polymyalgia rheumatica. An estimated 200 per 100,000 people over the age of 50 develop giant cell arteritis.

What Are the Symptoms?

The primary symptoms of polymyalgia rheumatica are moderate to severe stiffness and muscle pain near the neck, shoulders, or hips. The stiffness is more severe upon waking or after a period of inactivity, and typically lasts longer than 30 minutes. People with this condition also may have flu-like symptoms, including fever, weakness, and weight loss.

Early symptoms of giant cell arteritis also may resemble the flu. People are likely to experience headaches, pain in the temples, and blurred or double vision. Pain may also affect the jaw and tongue.

How Are Polymyalgia Rheumatica and Giant Cell Arteritis Diagnosed?

No single test is available to definitively diagnose polymyalgia rheumatica. To diagnose the condition, a physician considers the patient's medical history, including symptoms that the patient reports, and results of laboratory tests that can rule out other possible diagnoses.

The most typical laboratory finding in people with polymyalgia rheumatica is an elevated erythrocyte sedimentation rate, commonly referred to as the sed rate. This test measures how quickly red blood cells fall to the bottom of a test tube of unclotted blood. Rapidly descending cells (an elevated sed rate) indicate inflammation in the body. While the sed rate measurement is a helpful diagnostic tool, it alone does not confirm polymyalgia rheumatica. An abnormal result indicates only that tissue is inflamed, which also is a symptom of many forms of arthritis and/ or other rheumatic diseases. Before making a diagnosis of polymyalgia rheumatica, the doctor may perform additional tests to rule out other conditions, including rheumatoid arthritis, because symptoms of polymyalgia rheumatica and rheumatoid arthritis can be similar.

The doctor may recommend a test for rheumatoid factor (RF). RF is an antibody sometimes found in the blood. (An antibody is a special protein made by the immune system.) People with rheumatoid arthritis are likely to have RF in their blood, but most people with polymyalgia rheumatica do not. If the diagnosis still is unclear, a physician may conduct additional tests to rule out other disorders.

Doctors and patients both need to be aware of the risk of giant cell arteritis in people with polymyalgia rheumatica and should be on the lookout for symptoms of the disorder. Severe headaches, jaw pain, and vision problems are typical symptoms of giant cell arteritis. In addition, physical examination may reveal an abnormal temporal artery: tender to the touch, inflamed, and with reduced pulse. Because of the possibility of permanent blindness, a temporal artery biopsy is recommended if there is any suspicion of giant cell arteritis.

In a person with giant cell arteritis, the biopsy will show abnormal cells in the artery walls. Some patients showing symptoms of giant cell arteritis will have negative biopsy results. In such cases the doctor may suggest a second biopsy.

What Are the Treatments?

Polymyalgia rheumatica usually disappears without treatment in 1 to several years. With treatment, however, symptoms disappear quickly, usually in 24 to 48 hours. If there is no improvement, the doctor is likely to consider other possible diagnoses.

The treatment of choice is corticosteroid medication, usually prednisone. Polymyalgia rheumatica responds to a low daily dose of prednisone. The dose is increased as needed until symptoms disappear. Once symptoms disappear, the doctor may gradually reduce the dosage to determine the lowest amount needed to alleviate symptoms. The amount of time that treatment is needed is different for each patient. Most patients can discontinue medication after 6 months to 2 years. If symptoms recur, prednisone treatment is required again.

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen also may be used to treat polymyalgia rheumatica. The medication must be taken daily, and long-term use may cause stomach irritation. For most patients, NSAIDs alone are not enough to relieve symptoms.

Giant cell arteritis carries a small but definite risk of blindness. The blindness is permanent once it happens. A high dose of prednisone is needed to prevent blindness and should be started as soon as possible, perhaps even before the diagnosis is confirmed with a temporal artery biopsy. When treated, symptoms quickly disappear. Typically, people with giant cell arteritis must continue taking a high dose of prednisone for 1 month. Once symptoms disappear and the sed rate is normal and there is no longer a risk of blindness, the doctor can begin to gradually reduce the dose. When treated properly, giant cell arteritis rarely recurs.

People taking low doses of prednisone rarely experience side effects. Side effects are more common among people taking higher doses. But all patients should be aware of potential effects, which include:

fluid retention and weight gain
rounding of the face
delayed wound healing
bruising easily
diabetes
myopathy (muscle wasting)
glaucoma
increased blood pressure
decreased calcium absorption in the bones, which can lead to osteoporosis
irritation of the stomach

People taking corticosteroids may have some side effects or none at all. A patient should report any side effects to the doctor. When the medication is stopped, the side effects disappear. Because prednisone and other corticosteroid drugs change the body's natural production of corticosteroid hormones, the patient should not stop taking the medication unless instructed by the doctor. The patient and doctor must work together to gradually reduce the medication.

What Is the Outlook?

Most people with polymyalgia rheumatica and giant cell arteritis lead productive, active lives. The duration of drug treatment differs by patient. Once treatment is discontinued, polymyalgia may recur; but once again, symptoms respond rapidly to prednisone. When properly treated, giant cell arteritis rarely recurs.

PNEUMONIA

2009-08-08T03:47:00.000+05:30

Pneumonia is an illness of the lungs and respiratory system in which the alveoli (microscopic air-filled sacs of the lung responsible for absorbing oxygen from the atmosphere) become inflamed and flooded with fluid.

Pneumonia can result from a variety of causes, including infection with bacteria, viruses, fungi, or parasites. Pneumonia may also occur from chemical or physical injury to the lungs, or indirectly due to another medical illness, such as lung cancer or alcohol abuse.

Typical symptoms associated with pneumonia include cough, chest pain, fever, and difficulty in breathing. Diagnostic tools include x-rays and examination of the sputum. Treatment depends on the cause of pneumonia; bacterial pneumonia is treated with antibiotics.

Pneumonia is a common illness which occurs in all age groups, and is a leading cause of death among the elderly and people who are chronically ill. Vaccines to prevent certain types of pneumonia are available. The prognosis for an individual depends on the type of pneumonia, the appropriate treatment, any complications, and the person's underlying health.

Symptoms

People with infectious pneumonia often have a cough that produces greenish or yellow sputum and a high fever that may be accompanied by shaking chills. Shortness of breath is also common, as is pleuritic chest pain, a sharp or stabbing pain, either felt or worse during deep breaths or coughs. People with pneumonia may cough up blood, experience headaches, or develop sweaty and clammy skin. Other symptoms may include loss of appetite, fatigue, blueness of the skin, nausea, vomiting, mood swings, and joint pains or muscle aches. Less common forms of pneumonia can cause a variety of other symptoms. For instance, pneumonia caused by Legionella may cause abdominal pain and diarrhoea, while pneumonia caused by tuberculosis or Pneumocystis may cause only weight loss and night sweats. In elderly people the manifestations of pneumonia may not be typical. Instead, they may develop new or worsening confusion or may experience unsteadiness leading to falls. Infants with pneumonia may have many of the symptoms above, but in many cases, they are simply sleepy or have decreased appetite.

Diagnosis

To diagnose pneumonia, health care providers rely on a patient's symptoms and findings from physical examination. Information from a chest X-ray, blood tests, and sputum cultures may also be helpful. The chest X-ray is typically used for diagnosis in hospitals and some clinics with X-ray facilities. However, in a community setting (general practice), pneumonia is usually diagnosed based on symptoms and physical examination alone. Diagnosing pneumonia can be difficult in some people, especially those who have other illnesses. Occasionally a chest CT scan or other tests may be needed to distinguish pneumonia from other illnesses.

Physical examination

Individuals with symptoms of pneumonia need medical evaluation. Physical examination by a health care provider may reveal fever or sometimes low body temperature, an increased respiratory rate, low blood pressure, a fast heart rate, or a low oxygen saturation, which is the amount of oxygen in the blood as indicated by either pulse oximetry or blood gas analysis. People who are struggling to breathe, confused, or who have cyanosis (blue-tinged skin) require immediate attention.

Listening to the lungs with a stethoscope (auscultation) can reveal several things. A lack of normal breath sounds, the presence of crackling sounds (rales), or increased loudness of whispered speech (whispered pectoriloquy) can identify areas of the lung that are stiff and full of fluid, called "consolidation." The examiner may also feel the way the chest expands (palpation) and tap the chest wall (percussion) to further localize consolidation. The examiner may also palpate for increased vibration of the chest when speaking (tactile vocal fremitus).

Chest X-rays, sputum cultures and other tests

An important test for detecting pneumonia in unclear situations is a chest x-ray. Chest x-rays can reveal areas of opacity (seen as white) which represent consolidation. Pneumonia is not always seen on x-rays, either because the disease is only in its initial stages, or because it involves a part of the lung not easily seen by x-ray. In some cases, chest CT (computed tomography) can reveal pneumonia that is not seen on chest x-ray. X-rays can be misleading, because other problems, like lung scarring and congestive heart failure, can mimic pneumonia on x-ray. Chest x-rays are also used to evaluate for complications of pneumonia.

If an individual is not getting better with antibiotics, or if the health care provider has concerns about the diagnosis, a culture of the person's sputum may be requested. Sputum cultures generally take at least two to three days, so they are mainly used to confirm that the infection is sensitive to an antibiotic that has already been started. A blood sample may similarly be cultured to look for infection in the blood (blood culture). Any bacteria identified are then tested to see which antibiotics will be most effective.

A complete blood count may show a high white blood cell count, indicating the presence of an infection or inflammation. In some people with immune system problems, the white blood cell count may appear deceptively normal. Blood tests may be used to evaluate kidney function (important when prescribing certain antibiotics) or to look for low blood sodium. Low blood sodium in pneumonia is thought to be due to extra anti-diuretic hormone produced when the lungs are diseased (SIADH). Specific blood serology tests for other bacteria (Mycoplasma, Legionella and Chlamydophila) and a urine test for Legionella antigen are available. Respiratory secretions can also be tested for the presence of viruses such as influenza, respiratory syncytial virus, and adenovirus.

Pathophysiology

The symptoms of infectious pneumonia are caused by the invasion of the lungs by microorganisms and by the immune system's response to the infection. Although over one hundred strains of microorganism can cause pneumonia, only a few of them are responsible for most cases. The most common causes of pneumonia are viruses and bacteria. Less common causes of infectious pneumonia include fungi and parasites.

Viruses

Viruses must invade cells in order to reproduce. Typically, a virus reaches the lungs when airborne droplets are inhaled through the mouth and nose. Once in the lungs, the virus invades the cells lining the airways and alveoli. This invasion often leads to cell death, either when the virus directly kills the cells, or through a type of cell self-destruction called apoptosis. When the immune system responds to the viral infection, even more lung damage occurs. White blood cells, mainly lymphocytes, activate a variety of chemical cytokines which allow fluid to leak into the alveoli. This combination of cell destruction and fluid-filled alveoli interrupts the normal transportation of oxygen into the bloodstream.

In addition to damaging the lungs, many viruses affect other organs and thus can disrupt many different body functions. Viruses also can make the body more susceptible to bacterial infections; for this reason, bacterial pneumonia often complicates viral pneumonia.

Viral pneumonia is commonly caused by viruses such as influenza virus, respiratory syncytial virus (RSV), adenovirus, and metapneumovirus. Herpes simplex virus is a rare cause of pneumonia except in newborns. People with immune system problems are also at risk for pneumonia caused by cytomegalovirus (CMV).

Bacteria

Bacteria typically enter the lung when airborne droplets are inhaled, but they can also reach the lung through the bloodstream when there is an infection in another part of the body. Many bacteria live in parts of the upper respiratory tract, such as the nose, mouth and sinuses, and can easily be inhaled into the alveoli. Once inside the alveoli, bacteria may invade the spaces between cells and between alveoli through connecting pores. This invasion triggers the immune system to send neutrophils, which are a type of defensive white blood cell, to the lungs. The neutrophils engulf and kill the offending organisms, and they also release cytokines, causing a general activation of the immune system. This leads to the fever, chills, and fatigue common in bacterial and fungal pneumonia. The neutrophils, bacteria, and fluid from surrounding blood vessels fill the alveoli and interrupt normal oxygen transportation.

Bacteria often travel from an infected lung into the bloodstream, causing serious or even fatal illness such as septic shock, with low blood pressure and damage to multiple parts of the body including the brain, kidneys, and heart. Bacteria can also travel to the area between the lungs and the chest wall (the pleural cavity) causing a complication called an empyema.

The most common causes of bacterial pneumonia are Streptococcus pneumoniae, Gram-negative bacteria and "atypical" bacteria. The terms "Gram-positive" and "Gram-negative" refer to the bacteria's color (purple or red, respectively) when stained using a process called the Gram stain. The term "atypical" is used because atypical bacteria commonly affect healthier people, cause generally less severe pneumonia, and respond to different antibiotics than other bacteria.

The types of Gram-positive bacteria that cause pneumonia can be found in the nose or mouth of many healthy people. Streptococcus pneumoniae, often called "pneumococcus", is the most common bacterial cause of pneumonia in all age groups except newborn infants. Another important Gram-positive cause of pneumonia is Staphylococcus aureus. Gram-negative bacteria cause pneumonia less frequently than gram-positive bacteria. Some of the gram-negative bacteria that cause pneumonia include Haemophilus influenzae, Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosa and Moraxella catarrhalis. These bacteria often live in the stomach or intestines and may enter the lungs if vomit is inhaled. "Atypical" bacteria which cause pneumonia include Chlamydophila pneumoniae, Mycoplasma pneumoniae, and Legionella pneumophila.

Fungi

Fungal pneumonia is uncommon, but it may occur in individuals with immune system problems due to AIDS, immunosuppresive drugs, or other medical problems. The pathophysiology of pneumonia caused by fungi is similar to that of bacterial pneumonia. Fungal pneumonia is most often caused by Histoplasma capsulatum, Cryptococcus neoformans, Pneumocystis jiroveci, and Coccidioides immitis. Histoplasmosis is most common in the Mississippi River basin, and coccidioidomycosis is most common in the southwestern United States.

Parasites

A variety of parasites can affect the lungs. These parasites typically enter the body through the skin or by being swallowed. Once inside the body, they travel to the lungs, usually through the blood. There, as in other types of pneumonia, a combination of cellular destruction and immune response causes disruption of oxygen transportation. One type of white blood cell, the eosinophil, responds vigorously to parasite infection. Eosinophils in the lungs can lead to eosinophilic pneumonia, thus complicating the underlying parasitic pneumonia. The most common parasites causing pneumonia are Toxoplasma gondii, Strongyloides stercoralis, and Ascariasis.

Types of pneumonia

Pneumonias can be classified in several different ways. Pathologists classified them according to the anatomic changes that were found in the lungs during autopsies. As more became known about the microorganisms causing pneumonia, a microbiologic classification arose, and with the advent of x-rays, a radiological classification was developed. Another important classification system used for pneumonia is the combined clinical classification, which combines many factors, including age, risk factors for certain microorganisms, the presence of underlying lung disease and underlying systemic disease, and whether he or she has recently been hospitalized.

Early classification schemes

Initial descriptions of pneumonia focused on the anatomic or pathologic appearance of the lung, either by direct inspection at autopsy or by its appearance under a microscope. A lobar pneumonia is an infection that only involves a single lobe, or section, of a lung. Lobar pneumonia is often due to Streptococcus pneumoniae. Multilobar pneumonia involves more than one lobe, and it often is a more severe illness than lobar pneumonia. Interstitial pneumonia involves the areas in between the alveoli, and it may be called "interstitial pneumonitis." Interstitial pneumonia is more likely to be caused by viruses or by atypical bacteria.

The discovery of x-rays made it possible to determine the anatomic type of pneumonia without direct examination of the lungs at autopsy and led to the development of a radiological classification. Early investigators distinguished between typical lobar pneumonia and atypical (e.g. Chlamydophila) or viral pneumonia using the location, distribution, and appearance of the opacities they saw on chest x-rays. Certain x-ray findings can be used to help predict the course of illness, although it is not possible to clearly determine the microbiologic cause of a pneumonia based on x-rays alone.

With the advent of modern microbiology, classification based upon the causative microorganism became possible. Determining which microorganism is causing an individual's pneumonia is an important step in deciding treatment type and length. Sputum cultures, blood cultures, tests on respiratory secretions, and specific blood tests are used to determine the microbiologic classification. Because such laboratory testing typically takes several days, microbiologic classification is usually not possible at the time of initial diagnosis.

Combined clinical classification

Traditionally, clinicians have classified pneumonia by clinical characteristics, dividing them into "acute" (less than three weeks duration) and "chronic" pneumonias. This is useful because chronic pneumonias tend to be either non-infectious, or mycobacterial, fungal, or mixed bacterial infections caused by airway obstruction. Acute pneumonias are further divided into the classic bacterial bronchopneumonias (such as Streptococcus pneumoniae), the atypical pneumonias (such as the interstitial pneumonitis of Mycoplasma pneumoniae or Chlamydia pneumoniae), and the aspiration pneumonia syndromes.

The combined clinical classification, now the most commonly used classification scheme, attempts to identify a person's risk factors when he or she first comes to medical attention. The advantage of this classification scheme over previous systems is that it can help guide the selection of appropriate initial treatments even before the microbiologic cause of the pneumonia is known. There are two broad categories of pneumonia in this scheme: Community-acquired pneumonia and hospital-acquired pneumonia.

Community-acquired pneumonia

Community-acquired pneumonia (CAP) is infectious pneumonia in a person who has not recently been hospitalized. CAP is the most common type of pneumonia. The most common causes of CAP differ depending on a person's age, but they include Streptococcus pneumoniae, viruses, the atypical bacteria, and Haemophilus influenzae. Overall, Streptococcus pneumoniae is the most common cause of community-acquired pneumonia worldwide. Gram-negative bacteria cause CAP in certain at-risk populations. CAP is the fourth most common cause of death in the United Kingdom and the sixth in the United States. An outdated term, walking pneumonia, has been used to describe a type of community-acquired pneumonia of less severity (hence the fact that the patient can continue to "walk" rather than require hospitalization). Walking pneumonia is usually caused by a virus or by atypical bacteria.

Hospital-acquired pneumonia

Hospital-acquired pneumonia, also called nosocomial pneumonia, is pneumonia acquired during or after hospitalization for another illness or procedure with onset at least 72 hrs after admission. The causes, microbiology, treatment and prognosis are different from those of community-acquired pneumonia. Up to 5% of patients admitted to a hospital for other causes subsequently develop pneumonia. Hospitalized patients may have many risk factors for pneumonia, including mechanical ventilation, prolonged malnutrition, underlying heart and lung diseases, decreased amounts of stomach acid, and immune disturbances. Additionally, the microorganisms a person is exposed to in a hospital are often different from those at home . Hospital-acquired microorganisms may include resistant bacteria such as MRSA, Pseudomonas, Enterobacter, and Serratia. Because individuals with hospital-acquired pneumonia usually have underlying illnesses and are exposed to more dangerous bacteria, it tends to be more deadly than community-acquired pneumonia. Ventilator-associated pneumonia (VAP) is a subset of hospital-acquired pneumonia. VAP is pneumonia which occurs after at least 48 hours of intubation and mechanical ventilation.

Other types of pneumonia

Severe acute respiratory syndrome (SARS)

SARS is a highly contagious and deadly type of pneumonia which first occurred in 2002 after initial outbreaks in China. SARS is caused by the SARS coronavirus, a previously unknown pathogen. New cases of SARS have not been seen since June 2003.

Bronchiolitis obliterans organizing pneumonia (BOOP)

BOOP is caused by inflammation of the small airways of the lungs. It is also known as cryptogenic organizing pneumonitis (COP).

Eosinophilic pneumonia

Eosinophilic pneumonia is invasion of the lung by eosinophils, a particular kind of white blood cell. Eosinophilic pneumonia often occurs in response to infection with a parasite or after exposure to certain types of environmental factors.

Chemical pneumonia

Chemical pneumonia (usually called chemical pneumonitis) is caused by chemical toxins such as pesticides, which may enter the body by inhalation or by skin contact. When the toxic substance is an oil, the pneumonia may be called lipoid pneumonia.

Aspiration pneumonia

Aspiration pneumonia (or aspiration pneumonitis) is caused by aspirating foreign objects which are usually oral or gastric contents, either while eating, or after reflux or vomiting which results in bronchopneumonia[3]. The resulting lung inflammation is not an infection but can contribute to one, since the material aspirated may contain anaerobic bacteria or other unusual causes of pneumonia. Aspiration is a leading cause of death among hospital and nursing home patients, since they often cannot adequately protect their airways and may have otherwise impaired defenses.

Treatment

Most cases of pneumonia can be treated without hospitalization. Typically, oral antibiotics, rest, fluids, and home care are sufficient for complete resolution. However, people with pneumonia who are having trouble breathing, people with other medical problems, and the elderly may need more advanced treatment. If the symptoms get worse, the pneumonia does not improve with home treatment, or complications occur, the person will often have to be hospitalized.

Antibiotics are used to treat bacterial pneumonia. In contrast, antibiotics are not useful for viral pneumonia, although they sometimes are used to treat or prevent bacterial infections that can occur in lungs damaged by a viral pneumonia. The antibiotic choice depends on the nature of the pneumonia, the most common microorganisms causing pneumonia in the local geographic area, and the immune status and underlying health of the individual. Treatment for pneumonia should ideally be based on the causative microorganism and its known antibiotic sensitivity. However, a specific cause for pneumonia is identified in only 50% of people, even after extensive evaluation. Because treatment should generally not be delayed in any person with a serious pneumonia, empiric treatment is usually started well before laboratory reports are available. In the United Kingdom, amoxicillin is the antibiotic selected for most patients with community-acquired pneumonia, sometimes with added clarithromycin; patients allergic to penicillins are given erythromycin instead of amoxicillin. In North America, where the "atypical" forms of community-acquired pneumonia are becoming more common, azithromycin, clarithromycin, and the fluoroquinolones have displaced amoxicillin as first-line treatment. The duration of treatment has traditionally been seven to ten days, but there is increasing evidence that shorter courses (as short as three days) are sufficient.

Antibiotics for hospital-acquired pneumonia include vancomycin, third- and fourth-generation cephalosporins, carbapenems, fluoroquinolones, and aminoglycosides. These antibiotics are usually given intravenously. Multiple antibiotics may be administered in combination in an attempt to treat all of the possible causative microorganisms. Antibiotic choices vary from hospital to hospital because of regional differences in the most likely microorganisms, and because of differences in the microorganisms' abilities to resist various antibiotic treatments.

People who have difficulty breathing due to pneumonia may require extra oxygen. Extremely sick individuals may require intensive care treatment, often including intubation and artificial ventilation.

Viral pneumonia caused by influenza A may be treated with rimantadine or amantadine, while viral pneumonia caused by influenza A or B may be treated with oseltamivir or zanamivir. These treatments are beneficial only if they are started within 48 hours of the onset of symptoms. Many strains of H5N1 influenza A, also known as avian influenza or "bird flu," have shown resistance to rimantadine and amantadine. There are no known effective treatments for viral pneumonias caused by the SARS coronavirus, adenovirus, hantavirus, or parainfluenza virus.

Complications

Sometimes pneumonia can lead to additional medical problems called complications. Complications are more frequently associated with bacterial pneumonia than with viral pneumonia. The most important complications include:

Respiratory and circulatory failure

Because pneumonia affects the lungs, often people with pneumonia have difficulty breathing, and it may not be possible for them to breathe well enough to stay alive without support. Non-invasive breathing assistance may be helpful, such as with a bilevel positive airway pressure machine. In other cases, placement of an endotracheal tube (breathing tube) may be necessary, and a ventilator may be used to help the person breathe.

Pneumonia can also cause respiratory failure by triggering acute respiratory distress syndrome (ARDS), which results from a combination of infection and inflammatory response. The lungs quickly fill with fluid and become very stiff. This stiffness, combined with severe difficulties extracting oxygen due to the alveolar fluid, create a need for mechanical ventilation.

Sepsis and septic shock are potential complications of pneumonia. Sepsis occurs when microorganisms enter the bloodstream and the immune system responds by secreting cytokines. Sepsis most often occurs with bacterial pneumonia; Streptococcus pneumoniae is the most common cause. Individuals with sepsis or septic shock need hospitalization in an intensive care unit. They often require intravenous fluids and medications to help keep their blood pressure from dropping too low. Sepsis can cause liver, kidney, and heart damage, among other problems, and it often causes death.

Pleural effusion, empyema and abscess

Occasionally, microorganisms infecting the lung will cause fluid (a pleural effusion) to build up in the space that surrounds the lung (the pleural cavity). If the microorganisms themselves are present in the pleural cavity, the fluid collection is called an empyema. When pleural fluid is present in a person with pneumonia, the fluid can often be collected with a needle (thoracentesis) and examined. Depending on the results of this examination, complete drainage of the fluid may be necessary, often requiring a chest tube. In severe cases of empyema, surgery may be needed. If the fluid is not drained, the infection may persist, because antibiotics do not penetrate well into the pleural cavity.

Rarely, bacteria in the lung will form a pocket of infected fluid called an abscess. Lung abscesses can usually be seen with a chest x-ray or chest CT scan. Abscesses typically occur in aspiration pneumonia and often contain several types of bacteria. Antibiotics are usually adequate to treat a lung abscess, but sometimes the abscess must be drained by a surgeon or radiologist.

Prognosis and mortality

With treatment, most types of bacterial pneumonia can be cured within one to two weeks. Viral pneumonia may last longer, and mycoplasmal pneumonia may take four to six weeks to resolve completely. The eventual outcome of an episode of pneumonia depends on how ill the person is when he or she is first diagnosed. One way to predict outcome is to use the Pneumonia Severity Score or CURB-65 score, which takes into account the severity of symptoms, any underlying diseases, and age. This score can be helpful in deciding whether or not to hospitalize the person.

In the United States, about one of every twenty people with pneumococcal pneumonia will die. In cases where the pneumonia progresses to blood poisoning (bacteremia), one of every five will die. The death rate (or mortality) also depends on the underlying cause of the pneumonia. Pneumonia caused by Mycoplasma, for instance, is associated with little mortality. However, about half of the people who develop methicillin-resistant Staphylococcus aureus (MRSA) pneumonia while on a ventilator will die. In regions of the world without advanced health care systems, pneumonia is even deadlier. Limited access to clinics and hospitals, limited access to x-rays, limited antibiotic choices, and inability to treat underlying conditions inevitably leads to higher rates of death from pneumonia.

PNEUMOCOCCAL INFECTION AND VACCINATION

2009-08-08T03:44:00.000+05:30

Streptococcus pneumoniae, also known as pneumococcus, is a bacterium that is often found in the noses and throats of healthy persons and is spread person-to-person through close contact. Pneumococcus is a common cause of mild illnesses, such as sinus and ear infections, but also causes life-threatening infections such as pneumonia, meningitis, and infections of the bloodstream. Many strains are resistant to antibiotics.

Occurrence

Risk for pneumococcal disease is highest in young children, the elderly, and persons of any age who have chronic medical conditions such as heart disease, lung disease, or diabetes, or conditions that suppress the immune system, such as HIV. Smokers and those in close contact with small children are also at higher risk. Pneumococcal disease is more common in winter months and when respiratory viruses such as influenza are circulating. Outbreaks of pneumococcal disease are not common but can occur in child care centers, nursing homes, or other institutions. In the United States, most deaths from pneumococcal disease occur in older adults, although in developing countries many children die of pneumococcal pneumonia.

Risk to Travellers

Pneumococcal disease occurs worldwide. Crowded settings or situations with close, prolonged contact with young children may increase the risk of contracting pneumococcal disease while travelling.

Clinical Presentation

Fever and malaise are typical symptoms for all forms of pneumococcal disease and may be the only symptoms in young children with blood infections.

Patients with pneumonia usually have cough, often with purulent or blood-tinged sputum, and may have shaking chills, shortness of breath, or pleuritic chest pain. Fever and sputum production may be absent in elderly persons with pneumococcal pneumonia.

Patients with pneumococcal meningitis have headache, photophobia, stiff or painful neck, vomiting, lethargy, or decreased consciousness.

Persons with pneumococcal ear infections typically have pain in the infected ear and can have purulent drainage (pus) following perforation of the ear drum.

Sinus infections cause pain over the sinuses or in the teeth.

Prevention Vaccines

Two vaccines are available to prevent pneumococcal disease; the pneumococcal conjugate vaccine (PCV) (Prevnar, Wyeth Vaccines) and the pneumococcal polysaccharide vaccine (PPV) (Pneumovax, Merck). Both vaccines provide protection by inducing antibodies to specific types of pneumococcal capsule; 90 different types of pneumococcal capsule have been identified. The conjugate vaccine protects against the 7 serotypes most common in young children in the United States; the polysaccharide vaccine includes 23 types. Both vaccines are effective at preventing invasive disease; the severe form of pneumococcal disease in which the organism is found in blood, spinal fluid, or other typically sterile bodily fluids. The conjugate vaccine, licensed for use in young children, also prevents some pneumonia and ear infections.

Pneumococcal conjugate vaccine

The pneumococcal conjugate vaccine is part of the routine infant immunisation schedule. Health-care visits to receive travel-related vaccines provide a good opportunity to make sure that all routine vaccines are up to date. The pneumococcal conjugate vaccine is recommended for all children <2>

Sickle cell haemoglobinopathies,
functional or anatomical asplenia,
received or will receive a cochlear implant,
HIV infection,
chronic disease, including chronic cardiac and pulmonary disease (excluding asthma), diabetes mellitus, or cerebrospinal fluid leak; and
immunocompromising conditions, including a) haematologic or other disseminated malignancies; b) chronic renal failure or nephrotic syndrome; c) ongoing immunosuppressive therapy; and d) solid organ transplant.

Pneumococcal conjugate vaccine also should be considered for healthy children 2-4 years of age, especially those 24-35 months old, those attending group child care, and those of African-American, Alaskan Native or Native American descent.

Pneumococcal polysaccharide vaccine

The pneumococcal polysaccharide vaccine is part of the routine adult immunisation schedule, but many adults who should have received the vaccine have not. In 2003, only 62% of adults 65 years of age had received the vaccine.

Pneumococcal polysaccharide vaccine (Pneumovax) is recommended for all adults 65 years of age and for persons 2-64 years of age with certain chronic illnesses or immunocompromising conditions, including:

chronic cardiovascular disease (e.g., congestive heart failure or cardiomyopathies)
chronic pulmonary disease (e.g., chronic obstructive pulmonary disease or emphysema, but not asthma)
diabetes mellitus
alcoholism
chronic liver disease (cirrhosis)
cerebrospinal fluid leaks
functional or anatomic asplenia
cochlear implant (or those planning to receive a cochlear implant)
HIV infection
multiple myeloma
immunocompromising conditions, including a) haematologic or other generalised malignancies; b) chronic renal failure or nephrotic syndrome; c) ongoing immunosuppressive therapy; and d) bone marrow or solid organ transplant.

Recommended regimens for use of pneumococcal conjugate vaccine in children <5>

Age at examination (months)		Vaccination history	Recommended regimen1
2-6		0 doses	3 doses 2 months apart, 4th dose at age 12-15 months
		1 dose	2 doses 2 months apart, 4th dose at age 12-15 months
		2 doses	1 dose 2 months after the most recent dose, 4th dose at age 12-15 months
7-11		0 doses	2 doses 2 months apart, 3rd dose at 12-15 months
7-11		1 or 2 doses before age 7 months	1 dose at 7-11 months, with another dose at 12-15 months (2 months later)
12-23		0 doses	2 doses 2 months apart
		1 dose before age 12 months	2 doses 2 months apart
		1 dose at 12 months	1 dose 2 months after the most recent dose
		2 or 3 doses before age 12 months	1 dose 2 months after the most recent dose
24-59	Healthy children	Any incomplete schedule	Consider 1 dose 2 months after the most recent dose2
	High risk	Any incomplete schedule of <3>	1 dose 2 months after the most recent dose and another dose 2 months later
	High risk	Any incomplete schedule of 3 doses	1 dose 2 months after the most recent dose

1For children vaccinated at <1 src="http://www.medic8.com/images/gte.gif" id="spc-gte" alt="greater than or equal to" align="bottom" width="14" height="11">12 months should be at least 8 weeks apart.
2Providers should consider administering a single dose to unvaccinated, healthy children 24-59 months old, with priority to children 24-35 months old, children who attend group day care centers, children of African-American descent, and children of Alaskan Native or Native American descent not otherwise identified as high risk.

The polysaccharide vaccine should also be given to those 2-64 years of age who are living in settings in which the risk for invasive pneumococcal disease or its complications is increased, such as certain Native American communities (e.g., Alaskan Natives and certain American Indian populations) and residents of nursing homes and other long-term care facilities.

A single dose of pneumococcal polysaccharide vaccine should be given at age 65 years or at the time a high-risk condition is recognised. Children 2-4 years of age with indications for pneumococcal polysaccharide vaccine should receive polysaccharide vaccine at least 2 months after receiving doses of conjugate vaccine. Persons with an indication for polysaccharide vaccine but with unknown vaccination history should receive one dose. A second dose of vaccine should be used for the following groups:

persons 65 years of age who received the vaccine at least 5 years before and were <65>
persons with sickle cell disease, asplenia, renal disease, haematologic or generalised malignancy, or other immunocompromising condition.

For children <10 src="http://www.medic8.com/images/gte.gif" id="spc-gte" alt="greater than or equal to" align="bottom" width="14" height="11">3 years after the first dose; for older persons, revaccination may be given after 5 years. Because of limited data on the safety of multiple doses and on the duration of protection provided by polysaccharide vaccine, recommendations are for a single revaccination 3-5 years after the initial dose. These recommendations have been misinterpreted as suggesting revaccination every 5 years.

Safety/Side Effects

Mild local reactions such as redness, swelling, or tenderness occur in 10%-23% of infants after receipt of conjugate vaccine. Larger areas of redness or swelling or limitations in arm movement may occur in 1%-9%. For pneumococcal polysaccharide vaccine, mild, local side effects occur in approximately half of vaccine recipients and are more common after revaccination. Local reactions usually resolve by 48 hours after vaccination. More severe local reactions are rare. After conjugate vaccine, low-grade fever can occur in up to 24% of children and fever >102.2�F may occur in up to 2.5%. Systemic symptoms, including myalgias and fever, are rare after polysaccharide vaccine.

Precautions and contraindications

Conjugate vaccine is contraindicated for children known to have a hypersensitivity to any component of the vaccine. Health-care providers may delay vaccination of children with moderate or severe illness until the child has recovered, although minor illnesses, such as mild upper-respiratory tract infection with or without low-grade fever, are not contraindications. Revaccination with pneumococcal polysaccharide vaccine is contraindicated for persons who had a severe reaction (e.g., anaphylactic reaction or localized arthus-type reaction) to the initial dose. Data are limited on the safety of pneumococcal polysaccharide vaccine during the first trimester of pregnancy.

Additional Preventive Measures

Persons who smoke cigarettes can reduce their risk of pneumococcal disease by stopping smoking. In addition, improving control of chronic conditions that are predisposing factors for pneumococcal disease, such as diabetes and HIV, may reduce risk. Chemoprophylaxis is not routinely recommended. Daily penicillin prophylaxis for children with sickle-cell haemoglobinopathy is recommended beginning before 4 months of age. How long to continue prophylaxis is somewhat controversial. However, children with sickle-cell anaemia who had taken prophylactic penicillin for prolonged intervals but who had not had a severe pneumococcal infection or a splenectomy have stopped prophylactic penicillin therapy at 5 years of age without increased incidence of pneumococcal bacteremia or meningitis. Penicillin prophylaxis is also used for asplenic persons.

Treatment

Pneumococcal disease of all types is usually treated with antibiotics. Mild forms such as uncomplicated ear or sinus infections in healthy persons may resolve without treatment. More serious forms of pneumococcal disease, such as bloodstream infections and pneumonia, require antibiotics and often require hospitalization and intravenous antiobiotics. Pneumococcal meningitis always requires hospitalization and intravenous antibiotics. Because pneumococcal disease is endemic worldwide, care from a physician specializing in travel or tropical medicine is not required.

PARKINSON'S DISEASE

2009-08-06T06:16:00.000+05:30

What is Parkinson's Disease?

Parkinson's disease belongs to a group of conditions called motor system disorders, which are the result of the loss of dopamine-producing brain cells.

The four primary symptoms of Parkinson's disease are tremor, or trembling in hands, arms, legs, jaw, and face; rigidity, or stiffness of the limbs and trunk; bradykinesia, or slowness of movement; and postural instability, or impaired balance and coordination. As these symptoms become more pronounced, patients may have difficulty walking, talking, or completing other simple tasks.

Parkinson's disease usually affects people over the age of 50.

Early symptoms of Parkinson's disease are subtle and occur gradually. In some people the disease progresses more quickly than in others. As the disease progresses, the shaking, or tremor, which affects the majority of Parkinson's disease patients may begin to interfere with daily activities.

Other symptoms may include depression and other emotional changes; difficulty in swallowing, chewing, and speaking; urinary problems or constipation; skin problems; and sleep disruptions.

There are currently no blood or laboratory tests that have been proven to help in diagnosing sporadic Parkinson's disease. Therefore the diagnosis is based on medical history and a neurological examination. The disease can be difficult to diagnose accurately. Doctors may sometimes request brain scans or laboratory tests in order to rule out other diseases.

Is there any treatment?

At present, there is no cure for Parkinson's disease, but a variety of medications provide dramatic relief from the symptoms. Usually, patients are given levodopa combined with carbidopa. Carbidopa delays the conversion of levodopa into dopamine until it reaches the brain. Nerve cells can use levodopa to make dopamine and replenish the brain's dwindling supply. Although levodopa helps at least three-quarters of parkinsonian cases, not all symptoms respond equally to the drug. Bradykinesia and rigidity respond best, while tremor may be only marginally reduced. Problems with balance and other symptoms may not be alleviated at all.

Anticholinergics may help control tremor and rigidity.

Other drugs, such as bromocriptine, pergolide, pramipexole, and ropinirole, mimic the role of dopamine in the brain, causing the neurones to react as they would to dopamine. An antiviral drug, amantadine, also appears to reduce symptoms.

In some cases, surgery may be appropriate if the disease doesn't respond to drugs. A therapy called deep brain stimulation (DBS) has now been approved by the U.S. Food and Drug Administration. In DBS, electrodes are implanted into the brain and connected to a small electrical device called a pulse generator that can be externally programmed. DBS can reduce the need for levodopa and related drugs, which in turn decreases the involuntary movements called dyskinesias that are a common side effect of levodopa. It also helps to alleviate fluctuations of symptoms and to reduce tremors, slowness of movements, and gait problems. DBS requires careful programming of the stimulator device in order to work correctly.

What is the prognosis?

Parkinson's disease is both chronic, meaning it persists over a long period of time, and progressive, meaning its symptoms grow worse over time.

Although some people become severely disabled, others experience only minor motor disruptions. Tremor is the major symptom for some patients, while for others tremor is only a minor complaint and other symptoms are more troublesome.

No one can predict which symptoms will affect an individual patient, and the intensity of the symptoms also varies from person to person.

OSTEOPOROSIS

2009-08-06T06:14:00.001+05:30

What is Osteoporosis?

Osteoporosis is a condition that means your bones are weak, and you're more likely to break a bone. Since there are no symptoms, you might not know your bones are getting weaker until you break a bone!

A broken bone can really affect a woman's life. It can cause disability, pain, or loss of independence. It can make it harder to do daily activities without help, such as walking. This can make it hard to participate in social activities. It can also cause severe back pain and deformity.

What bones does osteoporosis affect?

Osteoporosis can happen to any of your bones, but is most common in the hip, wrist, and in your spine, also called your vertebrae. Vertebrae are important because these bones support your body to stand and sit upright.

What things cause me to have a higher chance of getting osteoporosis?

Things that can increase your chances of developing osteoporosis include:

being female
small, thin body (under 127 pounds)
family history of osteoporosis
being postmenopausal or of an advanced age
Caucasian or Asian race, but African American and Hispanic women are also at significant risk for developing the disease
abnormal absence of menstrual periods or having an eating disorder, such as anorexia nervosa or bulimia that can cause menstrual periods to stop before menopause, and loss of bone tissue from too much exercise
low testosterone levels in men
a diet low in dairy products or other sources of calcium and vitamin D
inactive lifestyle
long-term use of glucocorticoids (medicines prescribed for many diseases, including arthritis, asthma, and lupus) anti-seizure medications; gonadotropin releasing hormone for treatment of endometriosis; aluminum-containing antacids; certain cancer treatments; and excessive thyroid hormone
cigarette smoking and drinking too much alcohol

How can I find out if I have weak bones?

There are tests you can get to find out your bone strength, also called bone density. One test is a dual-energy x-ray absorptiometry (DEXA). A DEXA takes x-rays of your bones. There are also other types of bone strength tests too. Talk with your doctor or nurse about which type of test is best for you.

If you are age 65 and older, you should get a bone density test. If you are between ages 60 and 64, weigh less than 154 pounds, and don't take estrogen, get a bone density test. Don't wait until age 65. You have a higher chance for breaks.

How can I prevent weak bones?

The best way to prevent weak bones is easy?start by building strong ones.

No matter how old you are, it is never too late to start! Building strong bones during childhood and adolescence is the best defense against getting osteoporosis later. Building strong bones at a young age will lessen the effects of the natural bone loss that starts around age 30. As you get older, your bones don't make new bone quickly enough to keep up with the bone loss. And after menopause, bone loss increases more quickly. But there are steps you can take to stop your bones from becoming weak and brittle.

1. Get enough calcium each day.

Bones are made of calcium. The best way to prevent osteoporosis is to get enough calcium in your diet. You need enough calcium each day for strong bones throughout life. You can get it through foods and/or calcium pills, which you can get at the drug store. Talk with your doctor or nurse before taking calcium pills to see which kind is best for you.

Pregnant or nursing women need the same amount of calcium as other women of the same age.

Here are some foods to help you get the calcium you need. Check the food labels for more information.

2. Get enough vitamin D each day.

It is also important to get enough vitamin D, which helps your body take in calcium. You can get vitamin D through sunlight and foods like milk. You need 10-15 minutes of sunlight to the hands, arms, and face, two to three times a week to get enough vitamin D. The amount of time depends on how sensitive your skin is to light, use of sunscreen, skin color, and pollution. You can also get vitamin D by eating foods or in your vitamin pills.

White milk is a good source of vitamin D, most yoghurts are not.

3. Eat a healthy diet.

Other nutrients, like vitamin A, vitamin C, magnesium, and zinc, as well as protein, help build strong bones too. Milk provides many of these nutrients. But you can also get these nutrients by eating a healthy diet, including with foods that have these nutrients. Some examples are lean meat, fish, green leafy vegetables, and oranges.

4. Get moving.

Being active really helps your bones by:

slowing bone loss
improving muscle strength
helping your balance

Do weight-bearing physical activity, which is any activity in which your body works against gravity. There are so many things you can do: walk, dance, run, climb stairs, garden, do yoga or tai chi, jog, hike, play tennis, or lift weights?it all helps!

5. Don't smoke.

Smoking raises a woman's risk of getting osteoporosis. It damages your bones and lowers the amount of estrogen in your body. Estrogen is a hormone made by your body that can help slow bone loss.

6. Drink alcohol moderately.

If you drink, do not drink more than one alcoholic drink per day. Alcohol can make it harder for your body to use the calcuim you take in.

7. Make your home safe.

Reduce your chances of falling by making your home safer. For example, use a rubber bath mat in the shower or tub. Keep your floors free from clutter. Remove throw rugs that cause you to trip. Make sure you have grab bars in the bath or shower.

8. Think about taking medicines to prevent or treat bone loss.

Talk with your doctor or nurse about the risks and benefits of medicines for bone loss.

Dairy foods make me sick. How can I get enough calcium?

If you are lactose intolerant, it can be hard to get enough calcium. Lactose intolerance means the body is not able to easily digest foods that contain lactose, or the sugar that is found in dairy products like milk. Gas, bloating, stomach cramps, diarrhoea, and nausea are symptoms you might have. It can start at any age but often begins as we grow older.

Lactose-reduced and lactose-free products are sold in food stores. There's a great variety, including milk, cheese, and ice cream. Found at the grocery store or drug store, you also can take special pills or liquids before eating to help you digest dairy foods.

You can also eat foods that have calcium added (fortified), like some cereals and orange juice. Also think about taking calcium pills. But talk to your doctor or nurse first to see which one is best for you. Please note: If you have symptoms of lactose intolerance, see your doctor or nurse. These symptoms could also be from a different, or more serious, illness.

Do men get osteoporosis?

Before the 1990s, we used to think only women got osteoporosis. Now we know that men also have to worry about weak bones. In fact, one in four men over age 50 will suffer a fracture caused by osteoporosis. But women are still four times more likely than men to develop osteoporosis because of the loss of estrogen at menopause. Estrogen blocks or slows down bone loss.

What is pregnancy-associated osteoporosis?

Pregnancy-associated osteoporosis is believed to be a rare condition that is usually found in the third trimester of a woman's pregnancy or after giving birth. It usually occurs during a woman's first pregnancy, is temporary, and does not happen again. Women affected usually complain of back pain, have a loss of height, and have vertebral fractures.

As of 1996, there had been 80 cases of this condition reported. Researchers do not know if this condition occurs as a result of pregnancy or because of other health problems the woman had.

Things that may cause this condition, such as genetic factors or steroid use, are being studied. Even though there is stress on a pregnant woman's calcium supply, and calcium leaves her body more often because of frequent urination, other changes during pregnancy, like increases in estrogen and weight gain, may actually help bone density. There is much more to be learned about how a woman's bone density is affected by pregnancy.

Will I suffer bone loss during breastfeeding?

Although bone density can be lost during breastfeeding, this loss tends to be temporary. Several studies have shown that when women have bone loss during lactation, they recover full bone density within six months after weaning.

How is osteoporosis treated?

Lifestyle changes and medical treatment are part of a total program to prevent future fractures. A diet rich in calcium, daily exercise, and drug therapy are treatment options. Good posture and prevention of falls can lower your chances of being injured.

These drugs are approved for the treatment or prevention of osteoporosis:

Alendronate. This drug belongs to a class of drugs called biophosphonates and is approved for both prevention and treatment of osteoporosis. It is used to treat bone loss from the long-term use of osteoporosis-causing medications and is used for osteoporosis in men. In postmenopausal women, it has shown to be effective at reducing bone loss, increasing bone density in the spine and hip, and reducing the risk of spine and hip fractures.
Risedronate. Like Alendronate, this drug also is a biophosphonate and is approved for both prevention and treatment of osteoporosis, for bone loss from the long-term use of osteoporosis-causing medications, and for osteoporosis in men. It has been shown to slow bone loss, increase bone density, and reduce the risk of spine and non-spine fractures.
Calcitonin. Calcitonin is a naturally occurring hormone involved in calcium regulation and bone metabolism. Calcitonin can be injected or taken as a nasal spray. In women who are at least five years beyond menopause, it slows bone loss and increases spinal bone density. Women report that it also eases pain associated with bone fractures.
Raloxifene. This drug is a selective estrogen receptor modulator (SERM) that has many estrogen-like properties. It is approved for prevention and treatment of osteoporosis and can prevent bone loss at the spine, hip, and other areas of the body. Studies have shown that it can decrease the rate of vertebral fractures by 30-50%.
Estrogen therapy (ET), or Hormone Therapy (HT). These drugs, which have been used to treat the symptoms of menopause, also are used to prevent bone loss. But recent studies suggest that this might not be a good option for many women. The Food and Drug Administration (FDA) has made the following recommendations for taking ET and HT:
Take the lowest possible doses of ET or HT for the shortest period of time to manage symptoms of menopause.
Talk about using other osteoporosis medications instead.
Parathyroid Hormone or Teriparatide (Fort�o®). This form of parathyroid hormone is approved for the treatment of osteoporosis in postmenopausal women and men who are at high risk for a fracture. It helps new bone to form and increases bone density. It has been shown to reduce fractures in postmenopausal women in the spine, hip, foot, ribs, and wrist. In men, it can reduce fractures in the spine. A patient gives it to herself as a daily injection for up to 24 months.

OSTEOARTHRITIS

2009-08-06T06:13:00.000+05:30

What Is Osteoarthritis?

Osteoarthritis is the most common type of arthritis, especially among older people. Sometimes it is called degenerative joint disease or osteoarthrosis.

Osteoarthritis is a joint disease that mostly affects the cartilage. Cartilage is the slippery tissue that covers the ends of bones in a joint. Healthy cartilage allows bones to glide over one another. It also absorbs energy from the shock of physical movement. In osteoarthritis, the surface layer of cartilage breaks down and wears away. This allows bones under the cartilage to rub together, causing pain, swelling, and loss of motion of the joint. Over time, the joint may lose its normal shape. Also, bone spurs--small growths called osteophytes--may grow on the edges of the joint. Bits of bone or cartilage can break off and float inside the joint space. This causes more pain and damage.

People with osteoarthritis usually have joint pain and limited movement. Unlike some other forms of arthritis, osteoarthritis affects only joints and not internal organs. For example, rheumatoid arthritis--the second most common form of arthritis--affects other parts of the body besides the joints. It begins at a younger age than osteoarthritis, causes swelling and redness in joints, and may make people feel sick, tired, and (uncommonly) feverish.

Who Has Osteoarthritis?

Osteoarthritis is one of the most frequent causes of physical disability among adults. More than 20 million people in the United States have the disease. By 2030, 20 percent of Americans--about 70 million people--will have passed their 65th birthday and will be at risk for osteoarthritis. Some younger people get osteoarthritis from joint injuries, but osteoarthritis most often occurs in older people. In fact, more than half of the population age 65 or older would show x-ray evidence of osteoarthritis in at least one joint. Both men and women have the disease. Before age 45, more men than women have osteoarthritis, whereas after age 45, it is more common in women.

How Does Osteoarthritis Affect People?

Osteoarthritis affects each person differently. In some people, it progresses quickly; in others, the symptoms are more serious. Scientists do not know yet what causes the disease, but they suspect a combination of factors, including being overweight, the aging process, joint injury, and stresses on the joints from certain jobs and sports activities.

Osteoarthritis most often occurs at the ends of the fingers, thumbs, neck, lower back, knees, and hips.

Osteoarthritis hurts people in more than their joints: their finances and lifestyles also are affected.

Financial effects include

The cost of treatment
Wages lost because of disability.

Lifestyle effects include

Depression
Anxiety
Feelings of helplessness
Limitations on daily activities
Job limitations
Trouble participating in everyday personal and family joys and responsibilities.

Despite these challenges, most people with osteoarthritis can lead active and productive lives. They succeed by using osteoarthritis treatment strategies, such as the following:

Pain relief medications
Rest and exercise
Patient education and support programs
Learning self-care and having a "good-health attitude."

Osteoarthritis Basics: The Joint and Its Parts

Most joints--the place where two moving bones come together--are designed to allow smooth movement between the bones and to absorb shock from movements like walking or repetitive movements. The joint is made up of:

Cartilage: a hard but slippery coating on the end of each bone.
Joint capsule: a tough membrane sac that holds all the bones and other joint parts together.
Synovium (sin-O-vee-um): a thin membrane inside the joint capsule.
Synovial fluid: a fluid that lubricates the joint and keeps the cartilage smooth and healthy.
Ligaments, tendons, and muscles: tissues that keep the bones stable and allow the joint to bend and move. Ligaments are tough, cord-like tissues that connect one bone to another. Tendons are tough, fibrous cords that connect muscles to bones. Muscles are bundles of specialized cells that contract to produce movement when stimulated by nerves.

How Do You Know if You Have Osteoarthritis?

Usually, osteoarthritis comes on slowly. Early in the disease, joints may ache after physical work or exercise. Osteoarthritis can occur in any joint. Most often it occurs at the hands, knees, hips, or spine.

Hands: Osteoarthritis of the fingers is one type of osteoarthritis that seems to have some hereditary characteristics; that is, it runs in families. More women than men have it, and they develop it especially after menopause. In osteoarthritis, small, bony knobs appear on the end joints of the fingers. They are called Heberden's (HEB-err-denz) nodes. Similar knobs, called Bouchard's (boo-SHARDZ) nodes, can appear on the middle joints of the fingers. Fingers can become enlarged and gnarled, and they may ache or be stiff and numb. The base of the thumb joint also is commonly affected by osteoarthritis. Osteoarthritis of the hands can be helped by medications, splints, or heat treatment.

Knees: The knees are the body's primary weight-bearing joints. For this reason, they are among the joints most commonly affected by osteoarthritis. They may be stiff, swollen, and painful, making it hard to walk, climb, and get in and out of chairs and bathtubs. If not treated, osteoarthritis in the knees can lead to disability. Medications, weight loss, exercise, and walking aids can reduce pain and disability. In severe cases, knee replacement surgery may be helpful.

Hips: Osteoarthritis in the hip can cause pain, stiffness, and severe disability. People may feel the pain in their hips, or in their groin, inner thigh, buttocks, or knees. Walking aids, such as canes or walkers, can reduce stress on the hip. Osteoarthritis in the hip may limit moving and bending. This can make daily activities such as dressing and foot care a challenge. Walking aids, medication, and exercise can help relieve pain and improve motion. The doctor may recommend hip replacement if the pain is severe and not relieved by other methods.

Spine: Stiffness and pain in the neck or in the lower back can result from osteoarthritis of the spine. Weakness or numbness of the arms or legs also can result. Some people feel better when they sleep on a firm mattress or sit using back support pillows. Others find it helps to use heat treatments or to follow an exercise programme that strengthens the back and abdominal muscles. In severe cases, the doctor may suggest surgery to reduce pain and help restore function.

The Warning Signs of Osteoarthritis

Steady or intermittent pain in a joint
Stiffness in a joint after getting out of bed or sitting for a long time
Swelling or tenderness in one or more joints
A crunching feeling or the sound of bone rubbing on bone
Hot, red, or tender? Probably not osteoarthritis. Check with your doctor about other causes, such as rheumatoid arthritis.
Pain? Not always. In fact, only a third of people whose x rays show evidence of osteoarthritis report pain or other symptoms.

How Do Doctors Diagnose Osteoarthritis?

No single test can diagnose osteoarthritis. Most doctors use a combination of the following methods to diagnose the disease and rule out other conditions:

Clinical history: The doctor begins by asking the patient to describe the symptoms, and when and how the condition started. Good doctor-patient communication is important. The doctor can give a better assessment if the patient gives a good description of pain, stiffness, and joint function, and how they have changed over time. It also is important for the doctor to know how the condition affects the patient's work and daily life. Finally, the doctor also needs to know about other medical conditions and whether the patient is taking any medicines.

Physical examination: The doctor will check the patient's general health, including checking reflexes and muscle strength. Joints bothering the patient will be examined. The doctor will also observe the patient's ability to walk, bend, and carry out activities of daily living.

X rays: Doctors take x rays to see how much joint damage has been done. X rays of the affected joint can show such things as cartilage loss, bone damage, and bone spurs. But there often is a big difference between the severity of osteoarthritis as shown by the x ray and the degree of pain and disability felt by the patient. Also, x rays may not show early osteoarthritis damage, before much cartilage loss has taken place.

Other tests: The doctor may order blood tests to rule out other causes of symptoms. Another common test is called joint aspiration, which involves drawing fluid from the joint for examination.

It usually is not difficult to tell if a patient has osteoarthritis. It is more difficult to tell if the disease is causing the patient's symptoms. Osteoarthritis is so common--especially in older people--that symptoms seemingly caused by the disease actually may be due to other medical conditions. The doctor will try to find out what is causing the symptoms by ruling out other disorders and identifying conditions that may make the symptoms worse. The severity of symptoms in osteoarthritis is influenced greatly by the patient's attitude, anxiety, depression, and daily activity level.

How Is Osteoarthritis Treated?

Most successful treatment programs involve a combination of treatments tailored to the patient's needs, lifestyle, and health. Osteoarthritis treatment has four general goals:

Improve joint care through rest and exercise.
Maintain an acceptable body weight.
Control pain with medicine and other measures.
Achieve a healthy lifestyle.

Osteoarthritis treatment plans often include ways to manage pain and improve function. Such plans can involve exercise, rest and joint care, pain relief, weight control, medicines, surgery, and nontraditional treatment approaches.

Exercise: Research shows that exercise is one of the best treatments for osteoarthritis. Exercise can improve mood and outlook, decrease pain, increase flexibility, improve the heart and blood flow, maintain weight, and promote general physical fitness. Exercise is also inexpensive and, if done correctly, has few negative side effects. The amount and form of exercise will depend on which joints are involved, how stable the joints are, and whether a joint replacement has already been done.

Rest and joint care: Treatment plans include regularly scheduled rest. Patients must learn to recognise the body's signals, and know when to stop or slow down, which prevents pain caused by overexertion. Some patients find that relaxation techniques, stress reduction, and biofeedback help. Some use canes and splints to protect joints and take pressure off them. Splints or braces provide extra support for weakened joints. They also keep the joint in proper position during sleep or activity. Splints should be used only for limited periods because joints and muscles need to be exercised to prevent stiffness and weakness. An occupational therapist or a doctor can help the patient get a properly fitting splint.

Nondrug pain relief: People with osteoarthritis may find nondrug ways to relieve pain. Warm towels, hot packs, or a warm bath or shower to apply moist heat to the joint can relieve pain and stiffness. In some cases, cold packs (a bag of ice or frozen vegetables wrapped in a towel can relieve pain or numb the sore area. (Check with a doctor or physical therapist to find out if heat or cold is the best treatment.) Water therapy in a heated pool or whirlpool also may relieve pain and stiffness. For osteoarthritis in the knee, patients may wear insoles or cushioned shoes to redistribute weight and reduce joint stress.

Weight control: Osteoarthritis patients who are overweight or obese need to lose weight. Weight loss can reduce stress on weight-bearing joints and limit further injury. A dietitian can help patients develop healthy eating habits. A healthy diet and regular exercise help reduce weight.

Medicines: Doctors prescribe medicines to eliminate or reduce pain and to improve functioning. Doctors consider a number of factors when choosing medicines for their patients with osteoarthritis. Two important factors are the intensity of the pain and the potential side effects of the medicine. Patients must use medicines carefully and tell their doctors about any changes that occur.

The following types of medicines are commonly used in treating osteoarthritis:

Paracetamol (acetaminophen): Paracetamol (acetaminophen) is a pain reliever that does not reduce swelling. Paracetamol does not irritate the stomach and is less likely than nonsteroidal anti-inflammatory drugs (NSAIDs) to cause long-term side effects. Research has shown that paracetamol relieves pain as effectively as NSAIDs for many patients with osteoarthritis.

Warning: People with liver disease, people who drink alcohol heavily, and those taking blood-thinning medicines or NSAIDs should use paracetamol with caution.

NSAIDs (nonsteroidal anti-inflammatory drugs): Many NSAIDs are used to treat osteoarthritis. Patients can buy some over the counter (for example, aspirin, Advil, Motrin IB, Aleve, ketoprofen). Others require a prescription. All NSAIDs work similarly: they fight inflammation and relieve pain. However, each NSAID is a different chemical, and each has a slightly different effect on the body.
Side effects: NSAIDs can cause stomach irritation or, less often, they can affect kidney function. The longer a person uses NSAIDs, the more likely he or she is to have side effects, ranging from mild to serious. Many other drugs cannot be taken when a patient is being treated with NSAIDs because NSAIDs alter the way the body uses or eliminates these other drugs. Check with your health care provider or pharmacist before you take NSAIDs in addition to another medication. Also, NSAIDs sometimes are associated with serious gastrointestinal problems, including ulcers, bleeding, and perforation of the stomach or intestine. People over age 65 and those with any history of ulcers or gastrointestinal bleeding should use NSAIDs with caution.

COX-2 inhibitors: Several new NSAIDs from a class of drugs known as COX-2 inhibitors are now being used to treat osteoarthritis. These medicines reduce inflammation similarly to traditional NSAIDs, but they cause fewer gastrointestinal side effects. However, these medications occasionally are associated with harmful reactions ranging from mild to severe.
Other medications: Doctors may prescribe several other medicines for osteoarthritis, including the following:
Topical pain-relieving creams, rubs, and sprays (for example, capsaicin cream), which are applied directly to the skin.

Mild narcotic painkillers, which--although very effective--may be addictive and are not commonly used.

Corticosteroids, powerful anti-inflammatory hormones made naturally in the body or manmade for use as medicine. Corticosteroids may be injected into the affected joints to temporarily relieve pain. This is a short-term measure, generally not recommended for more than two or three treatments per year. Oral corticosteroids should not be used to treat osteoarthritis.

Hyaluronic acid, a medicine for joint injection, used to treat osteoarthritis of the knee. This substance is a normal component of the joint, involved in joint lubrication and nutrition.

Most medicines used to treat osteoarthritis have side effects, so it is important for people to learn about the medicines they take. Even nonprescription drugs should be checked. Several groups of patients are at high risk for side effects from NSAIDs, such as people with a history of peptic ulcers or digestive tract bleeding, people taking oral corticosteroids or anticoagulants (blood thinners), smokers, and people who consume alcohol. Some patients may be able to help reduce side effects by taking some medicines with food. Others should avoid stomach irritants such as alcohol, tobacco, and caffeine. Some patients try to protect their stomachs by taking other medicines that coat the stomach or block stomach acids. These measures help, but they are not always completely effective.

Surgery: For many people, surgery helps relieve the pain and disability of osteoarthritis. Surgery may be performed to

Remove loose pieces of bone and cartilage from the joint if they are causing mechanical symptoms of buckling or locking
Resurface (smooth out) bones
Reposition bones
Replace joints.

Surgeons may replace affected joints with artificial joints called prostheses. These joints can be made from metal alloys, high-density plastic, and ceramic material. They can be joined to bone surfaces by special cements. Artificial joints can last 10 to 15 years or longer. About 10 percent of artificial joints may need revision. Surgeons choose the design and components of prostheses according to their patient's weight, sex, age, activity level, and other medical conditions.

The decision to use surgery depends on several things. Both the surgeon and the patient consider the patient's level of disability, the intensity of pain, the interference with the patient's lifestyle, the patient's age, and occupation. Currently, more than 80 percent of osteoarthritis surgery cases involve replacing the hip or knee joint. After surgery and rehabilitation, the patient usually feels less pain and swelling, and can move more easily.

Non-traditional Approaches: Among the alternative therapies used to treat osteoarthritis are the following:

Acupuncture: Some people have found pain relief using acupuncture (the use of fine needles inserted at specific points on the skin). Preliminary research shows that acupuncture may be a useful component in an osteoarthritis treatment plan for some patients.
Folk remedies: Some patients seek alternative therapies for their pain and disability. Some of these alternative therapies have included wearing copper bracelets, drinking herbal teas, and taking mud baths. While these practices are not harmful, some can be expensive. They also cause delays in seeking medical treatment. To date, no scientific research shows these approaches to be helpful in treating osteoarthritis.
Nutritional supplements: Nutrients such as glucosamine and chondroitin sulfate have been reported to improve the symptoms of people with osteoarthritis, as have certain vitamins. Additional studies are being carried out to further evaluate these claims.

OEDEMA

2009-08-06T06:09:00.000+05:30

Oedema is swelling of any organ or tissue due to accumulation of excess lymph fluid, without an increase of the number of cells in the affected tissue. Oedema can accumulate in almost any location in the body, but the most common sites are the feet and ankles.

Oedema is the increase of interstitial fluid in any organ. Generally, the amount of interstitial fluid is in the balance of homeostasis. Increased secretion of fluid into the interstitium or impaired removal of this fluid may cause oedema.

Generation of interstitial fluid is regulated by the Starling equation of tissue fluid which states that it depends on the balance of osmotic pressure and of hydrostatic pressure which act in opposite directions across the semipermeable capillary walls. Consequently, anything that increases oncotic pressure outside blood vessels (for example inflammation), or reduces oncotic pressure in the blood (states of low plasma osmolality, for example cirrhosis) will cause oedema. Increased hydrostatic pressure inside the blood vessel (for example in heart failure) will have the same effect. If the permeability of the capillary walls increases, more fluid will tend to escape out of the capillary, as can happen when there is inflammation.

Abnormal removal of interstitial fluid is caused by obstruction of the lymphatic system, for example due to pressure from a cancer or enlarged lymph nodes, destruction of lymph vessels by radiotherapy, or infiltration of the lymphatics by infection such as elephantiasis.

Peripheral oedema

Oedema without a modifier usually refers to peripheral or dependent oedema, the accumulation of fluid in the parts of the body that are most affected by gravity. In ambulatory people these are the legs, although in those who are bedbound the first manifestation may be sacral oedema. If severe enough, peripheral oedema may progress to involve the abdominal or even thoracic wall (this may be referred to as generalized oedema or anasarca). In particular oedema states (e.g. nephrotic syndrome, see below), periorbital oedema (around the eyes) may be present.

Some phenomena may distinguish different causes of peripheral oedema. Most peripheral oedema is pitting oedema - pressing down will lead to a shift in the interstitial fluid and the formation of a small pit that resolves over seconds. Non-pitting oedema may reflect lymphedema, a form of oedema that develops when the lymph vessels are obstructed.

Causes of peripheral oedema are:

high hydrostatic pressure of the veins, leading to poor reabsorption of fluid

o venous obstruction, e.g. deep vein thrombosis (typically one-sided)
o congestive heart failure
o varicose veins
o asymmetric compression of thigh and leg (e.g., knee pads, tight jeans)

low oncotic pressure

o cirrhosis
o malnutrition
o nephrotic syndrome (renal protein loss)
o epidemic dropsy

obstruction of lymph drainage

o infection
o cancer
o fibrosis after surgery
o filariasis

inflammation (active secretion of fluid into the interstitial space due to increased membrane permeability by inflammatory mediators):

o allergic conditions (e.g. angioedema)
o any other form of inflammation (tumour - or swelling - is one of the main characteristics of inflammation)

Organ-specific oedema

Oedema of specific organs (cerebral oedema, pulmonary oedema, macular oedema) may also occur, each with different specific causes to peripheral oedema, but all based on the same principles. Ascites is effectively oedema within the peritoneal cavity, as pleural effusions are effectively oedema in the pleural cavity. Causes of oedema which are generalised to the whole body can cause oedema in multiple organs and peripherally. For example, severe heart failure can cause peripheral oedema, pulmonary oedema, pleural effusions and ascites.

MYELODYSPLASTIC SYNDROME

2009-08-06T06:08:00.000+05:30

Myelodysplastic syndrome is the term used for a group of diseases in which the bone marrow does not make enough healthy blood cells.

There are several types of myelodysplastic syndrome.

Age and past treatment with chemotherapy or radiation therapy affect the risk of developing a myelodysplastic syndrome.

Possible signs of myelodysplastic syndrome include feeling tired and shortness of breath.

Tests that examine the blood and bone marrow are used to detect (find) and diagnose myelodysplastic syndromes.

Myelodysplastic syndromes are diagnosed based on certain changes in the blood cells and bone marrow.

Certain factors affect prognosis (chance of recovery) and treatment options.

MUSCLE CRAMPS

2009-08-06T06:06:00.001+05:30

Muscle cramps are unpleasant, often painful sensations caused by contraction or over shortening of the muscles.

Cramps can be caused by cold, electrolyte imbalance, and/or overexertion.

Advised to drink milk everyday and try to keep up your calcium intake, it may not be a lot but it will help.

MACULAR DEGENERATION

2009-08-06T06:03:00.000+05:30

What is age-related macular degeneration?

Age-related macular degeneration (AMD) is a disease that blurs the sharp, central vision you need for "straight-ahead" activities such as reading, sewing, and driving. AMD affects the macula, the part of the eye that allows you to see fine detail. AMD causes no pain.

In some cases, AMD advances so slowly that people notice little change in their vision. In others, the disease progresses faster and may lead to a loss of vision in both eyes. AMD is a leading cause of vision loss in Americans 60 years of age and older.

Where is the macula? The macula is located in the center of the retina, the light-sensitive tissue at the back of the eye. The retina instantly converts light, or an image, into electrical impulses. The retina then sends these impulses, or nerve signals, to the brain

Are there different forms of AMD?

AMD occurs in two forms: wet and dry

Wet Age-related macular degeneration (Wet AMD) occurs when abnormal blood vessels behind the retina start to grow under the macula. These new blood vessels tend to be very fragile and often leak blood and fluid. The blood and fluid raise the macula from its normal place at the back of the eye. Damage to the macula occurs rapidly.

With wet AMD, loss of central vision can occur quickly. Wet AMD is considered to be advanced AMD and is more severe than the dry form.

An early symptom of wet AMD is that straight lines appear wavy. If you notice this condition or other changes to your vision, contact your eye care professional at once. You need a comprehensive dilated eye exam.

Dry Age-related macular degeneration (Dry AMD) occurs when the light-sensitive cells in the macula slowly break down, gradually blurring central vision in the affected eye. As dry AMD gets worse, you may see a blurred spot in the center of your vision. Over time, as less of the macula functions, central vision in the affected eye can be lost gradually.

The most common symptom of dry AMD is slightly blurred vision. You may have difficulty recognising faces. You may need more light for reading and other tasks. Dry AMD generally affects both eyes, but vision can be lost in one eye while the other eye seems unaffected.

One of the most common early signs of dry AMD is drusen. Drusen are yellow deposits under the retina. They often are found in people over age 60. Your eye care professional can detect drusen during a comprehensive dilated eye exam.

Dry AMD has three stages, all of which may occur in one or both eyes:

Early AMD. People with early AMD have either several small drusen or a few medium-sized drusen. At this stage, there are no symptoms and no vision loss.
Intermediate AMD. People with intermediate AMD have either many medium-sized drusen or one or more large drusen. Some people see a blurred spot in the center of their vision. More light may be needed for reading and other tasks.
Advanced Dry AMD. In addition to drusen, people with advanced dry AMD have a breakdown of light-sensitive cells and supporting tissue in the central retinal area. This breakdown can cause a blurred spot in the center of your vision. Over time, the blurred spot may get bigger and darker, taking more of your central vision. You may have difficulty reading or recognising faces until they are very close to you.

If you have vision loss from dry AMD in one eye only, you may not notice any changes in your overall vision. With the other eye seeing clearly, you still can drive, read, and see fine details. You may notice changes in your vision only if AMD affects both eyes. If blurriness occurs in your vision, see an eye care professional for a comprehensive dilated eye exam

Do drusen cause vision loss in advanced dry AMD?

Drusen alone do not usually cause vision loss. In fact, scientists are unclear about the connection between drusen and AMD. They do know that an increase in the size or number of drusen raises a person's risk of developing either advanced dry AMD or wet AMD. These changes can cause serious vision loss.

The dry form has early and intermediate stages.

Does the wet form have similar stages?

No. The wet form is considered advanced AMD.

Can advanced AMD be either the dry form or the wet form?

Yes. Both the wet form and the advanced dry form are considered advanced AMD. Vision loss occurs with either form. In most cases, only advanced AMD can cause vision loss.

People who have advanced AMD in one eye are at especially high risk of developing advanced AMD in the other eye.

Which is more common--the dry form or the wet form?

The dry form is much more common. More than 85 percent of all people with intermediate and advanced AMD combined have the dry form.

However, if only advanced AMD is considered, about two-thirds of patients have the wet form. Because almost all vision loss comes from advanced AMD, the wet form leads to significantly more vision loss than the dry form.

Can the dry form turn into the wet form?

Yes. All people who have the wet form had the dry form first.

The dry form can advance and cause vision loss without turning into the wet form. The dry form also can suddenly turn into the wet form, even during early stage AMD. There is no way to tell if or when the dry form will turn into the wet form.

Who is at risk for AMD?

AMD can occur during middle age. The risk increases with aging. Other risk factors include:

Smoking.
Obesity. Research studies suggest a link between obesity and the progression of early and intermediate stage AMD to advanced AMD.
Race. Whites are much more likely to lose vision from AMD than African Americans.
Family history. People with a family history of AMD are at higher risk of getting the disease.
Gender. Women appear to be at greater risk than men.

How is AMD detected?

AMD is detected during a comprehensive eye exam that includes:

Visual acuity test. This eye chart test measures how well you see at various distances.
Dilated eye exam. Drops are placed in your eyes to widen, or dilate, the pupils. Your eye care professional uses a special magnifying lens to examine your retina and optic nerve for signs of AMD and other eye problems. After the exam, your close-up vision may remain blurred for several hours.
Tonometry. An instrument measures the pressure inside the eye. Numbing drops may be applied to your eye for this test.

Your eye care professional also may do other tests to learn more about the structure and health of your eye.

During an eye exam, you may be asked to look at an Amsler grid. The pattern of the grid resembles a checkerboard. You will cover one eye and stare at a black dot in the center of the grid. While staring at the dot, you may notice that the straight lines in the pattern appear wavy. You may notice that some of the lines are missing. These may be signs of AMD.

If your eye care professional believes you need treatment for wet AMD, he or she may suggest a fluorescein angiogram. In this test, a special dye is injected into your arm. Pictures are taken as the dye passes through the blood vessels in your retina. The test allows your eye care professional to identify any leaking blood vessels and recommend treatment.

How is dry AMD treated?

Once dry AMD reaches the advanced stage, no form of treatment can prevent vision loss. However, treatment can delay and possibly prevent intermediate AMD from progressing to the advanced stage, in which vision loss occurs. The National Eye Institute's Age-Related Eye Disease Study (AREDS) found that taking a specific high-dose formulation of antioxidants and zinc significantly reduces the risk of advanced AMD and its associated vision loss. Slowing AMD's progression from the intermediate stage to the advanced stage will save the vision of many people.

What is the dosage of the AREDS formulation?

The specific daily amounts of antioxidants and zinc used by the study researchers were 500 milligrams of vitamin C, 400 International Units of vitamin E, 15 milligrams of beta-carotene (often labeled as equivalent to 25,000 International Units of vitamin A), 80 milligrams of zinc as zinc oxide, and two milligrams of copper as cupric oxide. Copper was added to the AREDS formulation containing zinc to prevent copper deficiency anemia, a condition associated with high levels of zinc intake.

Who should take the AREDS formulation?

People who are at high risk for developing advanced AMD should consider taking the formulation. You are at high risk for developing advanced AMD if you have either:

1. Intermediate AMD in one or both eyes.

2. Advanced AMD (dry or wet) in one eye but not the other eye.

Your eye care professional can tell you if you have AMD, its stage, and your risk for developing the advanced form.

The AREDS formulation is not a cure for AMD. It will not restore vision already lost from the disease. However, it may delay the onset of advanced AMD. It may help people who are at high risk for developing advanced AMD keep their vision.

Can people with early stage AMD take the AREDS formulation to help prevent the disease from progressing to the intermediate stage?

There is no apparent need for those diagnosed with early stage AMD to take the AREDS formulation. The study did not find that the formulation provided a benefit to those with early stage AMD. If you have early stage AMD, a comprehensive dilated eye exam every year can help determine if the disease is progressing. If early stage AMD progresses to the intermediate stage, discuss taking the formulation with your doctor.

Can diet alone provide the same high levels of antioxidants and zinc as the AREDS formulation?

No. The high levels of vitamins and minerals are difficult to achieve from diet alone. However, previous studies have suggested that people who have diets rich in green leafy vegetables have a lower risk of developing AMD.

Can a daily multivitamin alone provide the same high levels of antioxidants and zinc as the AREDS formulation?

No. The formulation's levels of antioxidants and zinc are considerably higher than the amounts in any daily multivitamin.

If you are already taking daily multivitamins and your doctor suggests you take the high-dose AREDS formulation, be sure to review all your vitamin supplements with your doctor before you begin. Because multivitamins contain many important vitamins not found in the AREDS formulation, you may want to take a multivitamin along with the AREDS formulation. For example, people with osteoporosis need to be particularly concerned about taking vitamin D, which is not in the AREDS formulation.

How is wet AMD treated?

Wet AMD can be treated with laser surgery, photodynamic therapy, and injections into the eye. None of these treatments is a cure for wet AMD. Each treatment may slow the rate of vision decline or stop further vision loss, but the disease and loss of vision may progress despite treatment.

Laser surgery. This procedure uses a laser to destroy the fragile, leaky blood vessels. A high energy beam of light is aimed directly onto the new blood vessels and destroys them, preventing further loss of vision. However, laser treatment also may destroy some surrounding healthy tissue and some vision. Only a small percentage of people with wet AMD can be treated with laser surgery. Laser surgery is more effective if the leaky blood vessels have developed away from the fovea, the central part of the macula. Laser surgery is performed in a doctor's office or eye clinic.

The risk of new blood vessels developing after laser treatment is high. Repeated treatments may be necessary. In some cases, vision loss may progress despite repeated treatments.
Photodynamic therapy.A drug called verteporfin is injected into your arm. It travels throughout the body, including the new blood vessels in your eye. The drug tends to "stick" to the surface of new blood vessels. Next, a light is shined into your eye for about 90 seconds. The light activates the drug. The activated drug destroys the new blood vessels and leads to a slower rate of vision decline. Unlike laser surgery, this drug does not destroy surrounding healthy tissue. Because the drug is activated by light, you must avoid exposing your skin or eyes to direct sunlight or bright indoor light for five days after treatment. Photodynamic therapy is relatively painless. It takes about 20 minutes and can be performed in a doctor's office.

Photodynamic therapy slows the rate of vision loss. It does not stop vision loss or restore vision in eyes already damaged by advanced AMD. Treatment results often are temporary. You may need to be treated again.
Injections. Wet AMD can now be treated with a new drug that is injected into the eye (anti-VEGF therapy). Abnormally high levels of a specific growth factor occur in eyes with Wet AMD and promote the growth of abnormal new blood vessels. This drug treatment blocks the effects of the growth factor.

You will need multiple injections, usually given about six weeks apart. The eye is numbed before each injection. After the injection, you will remain in the doctor's office for a while and your eye will be monitored. As with photodynamic therapy, the main benefit for patients treated with the drug is to slow vision loss from AMD.

What can I do if I already have lost some vision from AMD?

If you have lost some sight from AMD, don't be afraid to use your eyes for reading, watching TV, and other routine activities. Normal use of your eyes will not cause further damage to your vision.

If you have lost some sight from AMD, ask your eye care professional about low vision services and devices that may help you make the most of your remaining vision. Ask for a referral to a specialist in low vision. Many community organisations and agencies offer information about low vision counselling, training, and other special services for people with visual impairments. A nearby school of medicine or optometry may provide low vision services.

What can I do to protect my vision?

Dry AMD - If you have dry AMD, you should have a comprehensive dilated eye exam at least once a year. Your eye care professional can monitor your condition and check for other eye diseases. Also, if you have intermediate AMD in one or both eyes, or advanced AMD in one eye only, your doctor may suggest that you take the AREDS formulation containing the high levels of antioxidants and zinc.

Because dry AMD can turn into wet AMD at any time, you should get an Amsler grid from your eye care professional. Use the grid every day to evaluate your vision for signs of wet AMD. This quick test works best for people who still have good central vision. Check each eye separately. Cover one eye and look at the grid. Then cover your other eye and look at the grid. If you detect any changes in the appearance of this grid or in your everyday vision while reading the newspaper or watching television, get a comprehensive dilated eye exam.

Wet AMD - If you have wet AMD and your doctor advises treatment, do not wait. After laser surgery or photodynamic therapy, you will need frequent eye exams to detect any recurrence of leaking blood vessels. Studies show that people who smoke have a greater risk of recurrence than those who don't. In addition, check your vision at home with the Amsler grid.

If you detect any changes, schedule an eye exam immediately.

Can my lifestyle make a difference?

Your lifestyle can play a role in reducing your risk of developing AMD.

Eat a healthy diet high in green leafy vegetables and fish.
Don't smoke.
Maintain normal blood pressure.
Watch your weight.
Exercise.

LEVODOPA

2009-08-06T06:00:00.000+05:30

Levodopa (INN) or L-DOPA (3,4-dihydroxy-L-phenylalanine) is an intermediate in dopamine biosynthesis. Clinically, levodopa is used in the management of Parkinson's disease. Biologically, it is a component in marine adhesives used by pelagic life.

Therapeutic use

Levodopa is used as a prodrug to increase dopamine levels for the treatment of Parkinson's disease, since it is able to cross the blood-brain barrier whereas dopamine itself cannot. Once levodopa has entered the central nervous system (CNS), it is metabolised to dopamine by aromatic-L-amino-acid decarboxylase. However, conversion to dopamine also occurs in the peripheral tissues, causing adverse effects and decreasing the available dopamine to the CNS, so it is standard practice to co-administer a peripheral DOPA decarboxylase inhibitor – carbidopa or benserazide – and often a catechol-O-methyl transferase (COMT) inhibitor.

Adverse effects

Possible adverse drug reactions include:

Hypotension, especially if the dosage is too high.

Arrhythmias, although these are uncommon.

Nausea, which is often helped by taking the drug with food, although protein interferes with drug absorption.

Gastrointestinal bleeding.

Disturbed respiration. This is not always harmful, and can actually benefit patients with upper airway obstruction.

Hair loss.

Confusion.

Extreme emotional states, particularly anxiety, but also excessive libido.

Vivid dreams and/or fragmented sleep.

Visual and possibly auditory hallucinations.

Effects on learning. There is some evidence that it improves working memory, while impairing other complex functions.

Sleepiness and sleep attacks.

a condition similar to amphetamine psychosis.

Although there are a number of adverse effects associated with levodopa, particularly psychiatric ones, it has fewer than other anti-Parkinson's drugs, including anticholinergics, selegiline, amantadine, and dopamine agonists.

More serious are the effects of chronic levodopa administration, which include:

End-of-dose deterioration of function.

On/off oscillations.

Freezing during movement.

Dose failure (drug resistance).

Dyskinesia at peak dose.

Clinicians will try to avoid these by limiting levodopa dosages as far as possible until absolutely necessary.

Biosynthesis

L-DOPA is produced from the amino acid tyrosine by the enzyme tyrosine hydroxylase. It is also the precursor molecule for the catecholamine neurotransmitters dopamine and norepinephrine (noradrenaline), and the hormone epinephrine (adrenaline). Dopamine is formed by the decarboxylation of L-DOPA.

The prefix L- references its property of levorotation (compared with dextrorotation or D-dopa).

History

In work that earned him a Nobel Prize, Swedish scientist Arvid Carlsson first showed in the 1950s that administering levodopa to animals with Parkinsonian symptoms would cause a reduction of the symptoms. The neurologist Oliver Sacks describes this treatment in human patients with encephalitis lethargica in his book Awakenings on which the movie of the same name is based.

The 2001 Nobel Prize in Chemistry was also related to L-DOPA: the Nobel Committee awarded one-fourth of the prize to William S. Knowles for his work on chirally catalysed hydrogenation reactions, the most noted example of which was uses for the synthesis of L-DOPA.

Adhesion

DOPA is a key molecule in the formation of marine adhesive proteins, such as those found in mussels. It is believed to be responsible for the water-resistance and rapid curing abilities of these proteins. DOPA may also be used to prevent surfaces from fouling by bonding antifouling polymers to a susceptible substrate.

Melanin Formation

Both levodopa and the related amino acid tyrosine are precursors to the biological pigment melanin. The enzyme tyrosinase catalyzes the oxidation of either substrate to the reactive intermediate dopaquinone, which reacts further, eventually leading to eumelanin oligomers.

JOINT REPLACEMENT SURGERY

2009-08-06T05:59:00.000+05:30

Joint replacement is one of the most common and successful operations in modern orthopaedic surgery. It consists of replacing painful, arthritic, worn or diseased parts of the joint with artificial surfaces shaped in such a way as to allow joint movement.

Arthroplasty is a common but loose term for joint replacement. Other types of surgery are also arthroplasties. Other common and valid synonyms are total joint replacement, total joint arthroplasty, joint resurfacing and artificial joint surgery.

Technique

Joint replacement is major surgery. The joint must be exposed and dislocated. The joint surface and some bone tissue is then removed from the bone ends and the prosthetic components implanted. They may be fixed by an interference fit with the expectation of bone-ingrowth or using PMMA "cement" as a grout to hold the metal components into the bone. The dislocation of the joint is reduced and the ligaments and muscles over the joint are repaired where possible.

Variations

There are many variations in the exact shape and design of the components and the technique and instruments needed to place them correctly. Although these design innovations are all driven by the impetus to improve results, most of the benefits are unproven. The results are already so good that very large, powerful studies are needed to demonstrate improvement from 95% success to anything better than that.

The main variations in technique are cemented vs cementless fixation; resurfacing or more radical removal of bone; and minimally invasive technique where the exposure is more limited.

Indications

Joint Replacement surgery is indicated when the symptoms, usually pain and loss of function, are disabling. As the risks of surgery are significant, the patient must understand them and prefer to take those risks rather than continue with the symptoms.

Contra-indications

Purulent discharge (infection) in the operative area is considered an absolute contra-indication because of the disastrous consequences of post-operative deep infection. Infection anywhere in the patient is a strong but relative contra-indication.

Poor health is a relative contra-indication as the patient must be strong enough to withstand the stresses of major surgery. Some feel that persistent immobility due to pain is a more serious threat to health even in patients with severe heart and lung disease.

Pre-operative work-up

Because of the major surgery a complete pre-anaesthetic work-up is required. In elderly patients this usually would include ECG, Chest Xray, urine tests, haematology and biochemistry blood tests. Cross match of blood is routine also as a high percentage of patients receive a blood transfusion. Pre-operative planning requires accurate Xrays of the affected joint. The implant design is selected and the size matched to the xray images (a process known as templating).

Post-operative rehabilitation

Early mobilisation of the patient is thought to be the key to reducing the chances of complications such as venous thromboembolism and Pneumonia. Modern practice is to mobilize patients as soon as possible and ambulate with walking aids when tolerated. Depending on the joint involved and the pre-op status of the patient the time of hospitalization varies from 1 day to 2 weeks with the average being 4-7 days in most regions.
Physiotherapy is used extensively to help patients recover function after joint replacement surgery. A graded exercise programme is needed. Initially the patients' muscles have not healed after the surgery; exercises for range of motion of the joints and ambulation should not be strenuous. Later when the muscle is healed the aim of exercise expands to include strengthening and recovery of function.

Timecourse of recovery

A few days hospitalization followed by several weeks of protected function, healing and rehabilitation. This may then be followed by several months of slow improvement in strength and endurance.

Risks and complications:

Medical risks

The stress of the operation may result in medical problems of varying incidence and severity.

Heart Attack
Stroke
Venous Thromboembolism
Pneumonia
Increased confusion
Urinary Tract Infection (UTI)

Intra-operative risks

Mal-position of the components

o Shortening
o Instability/dislocation
o Loss of range of motion

Fracture of the adjacent bone
Nerve damage
Damage to blood vessels

Immediate risks

Infection

o Superficial
o Deep

Dislocation

Medium-term risks

Dislocation
Persistent pain
Loss of range of motion
Weakness
Indolent infection

Long-term risks

Loosening of the components: the bond between the bone and the components or the cement may breakdown or fatigue. As a result the component moves inside the bone causing pain. Fragments of wear debris may cause an inflammatory reaction with bone absorption which can cause loosening. This phenomenon is known as osteolysis.
Wear of the bearing surfaces: polyethylene is thought to wear in weight bearing joints such as the hip at a rate of 0.3mm per year. This may be a problem in itself since the bearing surfaces are often less than 10 mm thick and may deform as they get thinner. It is also a problem because the wear debris may cause problems.