 1 Allergies and Anaphylactic shock, Anaphylaxis
 2 Arthritis and osteo-arthritis
 3 Bronchitis (Bronicles)
 4 Chikungunya virus
 5 Colds, flu
 6 Flu, Influenza, Virus
 7 constipation
 8 Alzheimer`s
 9 heart palpitations, arrythmia
 10 viruses and DNA
 11 warts
 12 knee injury, problems
 13 head lice
 14 prostate (see also DISEASE1.TXT)

\1 Allergies and Anaphylactic shock, Anaphylaxis

A severe life threatening allergic reaction to an insect sting from bees or wasps, or drugs like penicillin. The entry of allergen into the blood stream causes the release of massive amounts histamine and other chemicals that over-act on the body causing havoc. Symptoms occur rapidly as sweating, breathing problems, nausea, uneven heart rate. Seek medical care immediately.

First aid: The victim should be prone with feet high. Seek medical attention. Epinephrine, antihistimine, or corticosteroid drugs are usually administered as soon as possible.

Identify allergen and prevent further contact. Watch victim for worsening condition. Cold compress (if) over sting area. Large doses (3-7gms) of vitimin C:

Adverse reaction of the body immune system against foreign substances, as drugs or common harmless foods. The risk of incorrect self diags is the unnecessary restriction of ones diet which may have adverse nutritional consequences. The problem is aggravated by unreliable commercial methods of diags.

Abstract: Primary care physicians can effectively treat patients with allergies. General practitioners and advanced practice nurses can identify common allergies with a careful medical history and skin prickttesting. A positive test result will indicate allergens which should be avoided. Household allergens, such as dust mites and pet dander, can be removed or reduced to control symptoms. Avoidance is an important component of allergy treatment. Antihistamine or corticosteroid nasal sprays or drops may be required for some patients. Specialist referral may be required in more difficult cases.

In parallel with the known increases in atopy (confirmed by a positive response in skin prick testing to one or more common allergens) and allergy there has been a marked increase in the proportion of general practitioner consultations for asthma, hay fever, and eczema. A greater awareness of the importance of allergy should lead to better diagnosis and management of allergy. This is essential for perennial allergic asthma in children and adults, in whom environmental control and allergen avoidance measures directed against house dust mites are of proved value in reducing asthma symptoms and bronchial hyper-responsiveness. It seems likely that these factors also reduce the need for drug treatment.

Rhinitis symptoms commonly have an allergic aetiology and may be seasonal or perennial. They may be responsible for severe impairment of quality of life. Rhinitis symptoms are frequently trivialised and misdiagnosed by both patients and doctors as "the permanent cold." This is unfortunate as avoidance measures combined with either topical corticosteroids or antihistamines, or both, are extremely effective in controlling symptoms with minimal side effects. Recent surveys have suggested that up to 80% of people with asthma also have rhinitis; treating rhinitis in such people has been shown to reduce asthma symptoms and bronchial hyper-responsiveness.

Role of the Practice Nurse. The practice nurse has a major (and now established) role in the routine care of asthmatic patients in general practice. It seems logical that this role of the specially trained nurse could be extended, with the support of the general practitioner, to include the recognition and treatment of the allergic component of asthma and also rhinitis.

The extent of the nurse's role depends on many factors, including skills, training, and knowledge. The knowledge base and skills of the doctor and the circumstances of the practice will similarly have an impact. Inquiry about allergic triggers in asthma should be routine in any asthma clinic.

An important question is whether this role should be extended to include more detailed inquiry and use of a simple range of skin prick tests. This issue is particu-larly important in Britain, which, in contrast to Europe and the United States, has few specialist allergy clinics in the NHS. By spending dedicated time with patients, or by enabling the doctor to spend more time with them, the trained nurse has an immense contribution to make to the task of improving management of asthma and allergy.

Allergy Diag in Gen Practice. Accurate allergy diagnosis may be limited by the availability of consultation time. None the less, time taken early on in obtaining a full history may well save time later. Patients should be allowed to explain their symptoms in their own time. At the end of the consultation it is often helpful to ask the patient, "what is your main problem?"

Skin Prick Testing IDs IgE sensitivity to common allergens, allows diags (or exclusion) of atopy, and provides helpful objective information that should be interpreted in the context of the clinical history of symptoms (or lack of symptoms) on exposure to relevant allergens in the indoor and outdoor environment or workplace. Although skin prick testing with aeroallergens is a simple and safe proc, it requires training in technique and, more important, in interpretation of the results. Measurement of serum allergen specific IgE, an alternative to skin tests, is done in most district hospitals.

Whether skin prick testing should be performed routinely in general practice in Britain remains a matter of debate. A pilot study evaluated skin prick testing in children and adults in 320 patients in 16 general practices in Britain. The study involved two days' training in allergy, combined with instruction in skin prick testing with four common allergens (and pos and neg controls). The participating nurses found that the tech-niques were simple, relatively easy to incorporate into their routine assessment of new referrals to the asthma clinic, and acceptable to both adults and children. The nurses also found the techniques acceptable. The proc undoubtedly increased the nurses' awareness of the role of allergy in patients' asthma, although further studies should look at specific outcome measures. An important finding was the value of negative results of skin prick tests, which excluded atopy in these patients and enabled the investigators to advise patients against inappro-priate allergen avoidance measures. A further important advantage was the visual illustration provided by pos results of skin tests, which could be used to reinforce the need for allergen avoidance.

Important practical considerations include the avoidance of use of antihistamines before skin prick testing. In general, when there is concordance between the clinical history and skin prick testing, management is straight forward. For exam, an asthmatic patient who has symptoms on exposure to cats or dust and in whom there is an objective confirmation (from skin prick testing) should receive appropriate advice on avoidance. Similarly, a negative history together with negative results of skin prick testing exclude the need for allergen avoidance. When results are discordant (pos hist with neg results, or vice versa) they may indicate the need for referral to a specialist. Skin prick tests with common aeroallergens are safe and may be performed by the practice nurse. However, in view of the theoretical risk (albeit remote) associated with giving allergens, injectable adrenaline should be avail. Skin prick testing in general practice may be restricted to the four common allergens (house dust mite, cat, dog, grass) and controls (histamine and allergen diluent). Patch testing for suspected contact allergy is complex and should be done by a specialist dermatologist.

Mgmnt of Allergy in Gen Practice. If an allergen has been identified as contributing to or causing disease then consideration should be given to the need for measures for avoiding that allergen. These measures should be regarded as complementary to drug treatment. This should not detract from time given to advising patients on the need to take prophylactic drugs regularly - for example, regular inhaled corticosteroids for asthma. In practice, total avoidance, especially of aeroallergens, may be very difficult, so the aim is to reduce overall exposure as much as possible.

Avoidance measures for house dust mites should focus mainly on the bedroom. Room should be ventilated regularly; mattresses, pillows, and duvets should be encased in mite proof allergen covers (which may be left in place for up to six mths) with the usual bed covers for mattress, pillows, and duvet put on over the top. Patients should be advised to launder bedding every 1-2 wks at 60 deg C. Vacuum cleaners with an adequate filter to remove house dust mite allergen and prevent dissem-ination through the vacuum exhaust have been recommended by the British Allergy Foundation. Removal of the bedroom carpet (where poss) is important. Soft toys should be reduced to a min and be washable; they may be placed regularly in a freezer to kill the mites. Even when these measures are applied, improvement may take 3-6 mths.

When pet allergy is diagnosed, the offending animal (and if possible all furry animals) should be excluded from the home. Psychosocial considerations may mean that the best that can be achieved is confining the animal outside or in the kitchen, with a recommendation not to replace an animal. Again, advice to remove the bedroom carpet should be given. Some studies have shown that washing a cat weekly (cat allergens are present on the fur and are extremely water soluble) may reduce allergen load when combined with removal of the bedroom carpet. Even if the pet is removed, vigorous cleaning for 3-6 mths afterwards is needed to min pet allergen concentrations in the home.

It is unlikely that patients with summer hay fever will be able to avoid pollens. The best aim should be control of symptoms with topical corticosteroids and antihist-amines so that the patient may lead as normal a life as possible. Patients with severe hay fever, however, should keep windows shut (cars and buildings); wear glasses or sunglasses; avoid grassy spaces, especially in the evening, when pollen counts are highest; fit a pollen filter to the car; and consider a holiday by the sea or abroad at peak times.

The practice nurse routinely provides individualised written instructions for asthmatic patients -- about drug treatment, need for peak flow monitoring, inhaler technique, etc. He or she may also advise on allergen avoidance and environmental control measures. The nurse may also advise patients with rhinitis how to use nasal sprays: blow the nose; tilt head so the chin is resting on the chest; hold the spray bottle upright and place nozzle just inside one nostril; apply one or two sprays as prescribed; repeat with the other nostril.

Occasionally corticosteroid nasal drops may be required, particularly for rhinosinusitis. These should be taken in the "head upside down position," best achieved by lying on your back on a bed, tilting your head right over the edge of the bed, applying drops to both nostrils and waiting for two minutes before getting up.

A Medic Alert bracelet or necklace (with an inscription that alerts other doctors to the possible cause of any future reaction) is very valuable for people at risk of anaphylaxis -- for example, in response to penicillin, stinging insects, foods, or latex -- and for patients with asthma who have sensitivity to aspirin. The practice nurse may teach patients how to use syringes of injectable adrenaline (epinephrine) -- usually this will follow recommendation by an allergy specialist.

General practitioners can obtain a list of NHS allergy clinics from the British Society for Allergy and Clinical Immunology.

The Way Forward. Many primary care practices already benefit from clinics devoted to the management of asthma, one of the common diseases frequently associated with allergy. Taking an allergy history with or without skin prick tests may enhance the effectiveness of asthma care. Skin testing with a limited range of reagents in gen prac is both practicable and desirable. The recognition of the importance of rhinitis and role of allergy in rhinitis and eczema will also enhance the management of atopic patients in gen prac. Food allergy and occupational allergy should be considered, if such allergies are present, the patient should be referred to a specialist. The logical person to deliver allergen avoidance advice is the practice nurse, supported by the primary care doctor, and, where necessary, the local allergy service, whether provided by an NHS based specialist allergist or an organ-based specialist with training in allergy. The allergist may also effectively evaluate the role of allergy in patients presenting with non-specific symptoms -for example, the so-called multiple chemical sensitivity syndrome.

Allergy History in General Practice. Symptoms: past and present; frequency and severity; seasonal or perennial; provoking factors Impact on lifestyle: absence from work or school; leisure time; sleep Nature of occupation and hobbies. Treatment: past & present; compliance; efficacy; side effects Allergens in the home. Asthma, eczema, rhinitis, or drug or food allergy: past and present. Family history of allergic disease. Main problem?

Skin Prick Testing: Practice Points. Always check that the patient is not taking antihistamines before performing skin prick tests. Always include positive (histamine) and negative (allergen diluent) control tests In a positive result the weal is (arbitrarily) >/= 2 mm greater than that for the negative control Skin prick tests should be performed on the flexor aspect of the forearm with a sterile lancet. The procedure should not be painful or draw blood Oral corticosteroids do not significantly inhibit allergen skin prick tests. Dermato-graphism may confound results (although it is evident as a positive response at the negative control site) Skin prick tests should not be performed if the patient has severe eczema Measurement of allergen specific IgE concentrations (radioallergosorbent test (RAST)) is an alternative if skin prick tests cannot be performed.

When to Refer Patients for Specialist Allergy Advice For investigation and management of anaphylaxis If the diagnosis of allergy is in doubt - for exam, discordance between the clinical history and the results of skin prick testing or the radioallergosorbent test If food allergy is suspected (for assessment and expert dietetic input) If occupational allergy is suspected In cases of urticaria in which an allergic aetiology is suspected For consideration for immunotherapy (in cases of severe hay fever, allergy to venom from stinging insects) To exclude allergy as a cause of non-specific illness

Allergy in General Practice By Sue Cross, Sallie Buck, Jane Hubbard. British Med Journal. May 23 1998; 316(7144)

Sue Cross is director of training at the National Asthma and Respiratory TrainingCCentre, Warwick, and chairwoman of the Nurse Practitioner Association; Sallie Buck and Jane Hubbard are practice nurses in Exeter and Kingston on Thames respectively, and both are regional trainers for the National Asthma and Respiratory Training Centre, Warwick.

A Note of Caution on Bee Sting Allergies By ERIC NAGOURNEY 7/10/01. Anyone wtth a history of bee sting allergies shouldn't put too much faith in a skin test that shows the danger has gone away, researchers have found.

Writing in a recent issue of The Journal of Allergy and Clinical Immunology, scientists from Johns Hopkins said the skin tests used by allergists to detect bee sting allergies were only 90 percent reliable. In the rest of the cases, people who have been given clean bills of health may actually be vulnerable to life-threatening reactions if stung.

Better testing methods are urgently needed, the researchers wrote. In the meantime, they said, skin tests should be repeated when the results are negative for people with histories of allergic reactions to stings. More elaborate tests should be performed and patients warned that they may still be at risk.

For the study, scientists gave skin tests to 307 people who had had allergic reactions to bee stings. Ninety-nine of the people (32%) tested negative  that is, their skin did not react to the bee venom. But blood tests suggested that 56 of those who had tested negative on skin tests were still, in fact, allergic. And of 51 people with negative tests who agreed to let themselves be stung, 11 had significant allergic reactions.

All About Allergy histamine - a chemical present in cells throughout the body that is released during an allergic reaction.

What is allergy? Allergy is a the body's reaction caused when the immune system mistakenly identifies a normally harmless substance as damaging to the body.

Normally, the human body defends itself against harmful substances such as viruses or bacteria, but sometimes the defenses aggressively attack usually innocuous substances such as dust, mold, or pollen.

The immune system generates large amounts of the antibodies called immunoglobin E (IgE), a complex chemical weapon, to attack and destroy the supposed enemy. Each IgE antibody specifically targets a particular allergen -- the substance that causes the allergy. In this disease-fighting process, inflammatory chemicals like histamines, cytokines, and leukotrienes are released or produced, and some unpleasant (and, in extreme cases, life-threatening) symptoms may be experienced by an allergy-prone person.

What are allergic reactions? An allergic reaction may occur anywhere in the body, in the skin, eyes, lining of the stomach, nose, sinuses, throat, and lungs -- places where immune system cells are located to fight off invaders that are inhaled, swallowed, or come in contact with the skin.

Reactions may result in: rhinitis - nasal stuffiness, sneezing, nasal itching, nasal discharge, itching in ears or roof of mouth allergic conjunctivitis - red, itchy, watery eyes atopic dermatitis - red, itchy, dry skin urticaria - hives or itchy welts contact dermatitis - itchy rash asthma (airway problems such as shortness of breath, coughing, wheezing) What causes allergic reactions? Although hundreds of ordinary substances could trigger allergic reactions, the most common triggers -- called allergens -- are

pollens molds household dust, dust mites and their waste animal protein (dander, urine, oil from skin) industrial chemicals foods medicines feathers insect stings cockroaches and their waste Who is affected by allergy? Allergies can affect anyone, regardless of age, gender, race, or socioeconomic status. Generally, allergies are more common in children, however, a first-time occurrence can happen at any age, or recur after many years of remission.

There is a tendency for allergies to occur in families, although the exact genetic factors that cause it are not yet understood. In susceptible people, factors such as hormones, stress, smoke, perfume, or other environmental irritants may also play a role. Often, the symptoms of allergies develop gradually over a period of time.

Allergy sufferers may become so accustomed to chronic symptoms such as sneezing, nasal congestion, or wheezing, that they do not consider their symptoms oo be unusual. Yet, with the help of an allergist, these symptoms can usually be prevented or controlled and quality of life greatly improved.

How is allergy diagnosed? In addition to performing a clinical examination and taking a medical history, a physician may also use:

skin test The skin test is a method of measuring the patient's level of IgE antibodies to specific allergens. Using diluted solutions of specific allergens, the physician either injects the patient with the solutions, or applies them to a small scratch or puncture. Reaction appears as a small red area on the skin. A reaction to the skin test does not always mean that the patient is allergic to the allergen that caused the reaction. blood test The blood test is used to measure the patient's level of IgE antibodies to specific allergens. One common blood test is called RAST (radioallergosorbent test).

How is allergy treated? Specific treatment for allergy will be determined by your physician(s) based on: overall health and medical history. Extent of the disease. Your tolerance for specific meds, procedures, or therapies. Expectations for the course of the disease. Your opinion or preference.

Modern Med: . Anna who? by Dr Iain Corness, PM 10/02.

The difficult sounding name of Anaphylaxis is just a fancy word for the most severe form of allergic reaction you can have. Those people who have experienced this will attest to just how frightening it can be. And they have good reason to be frightened - it is classed as a medical emergency as people can die from this reaction. It is also much more common than you would imagine. The quoted figures from America are that Anaphylaxis occurs at an annual rate of 30 per 100,000.

The causes are multiple and include food allergy, penicillin, cephalosporin and sulfur drugs, intravenous contrast medium (used in some special X-Rays), aspirin and non-steroidal anti-inflammatory drugs, walnuts, cashews and pistachios and insect stings. The commonest food allergy is peanuts and again going to the American figures, peanuts cause 30,000 documented cases of Anaphylaxis every year and 200 deaths within that figure. (And you never imagined that those nuts on the bar were killers, did you?)

The symptoms include a very sudden and severe breathing problem (bronchospasm - the basis of asthma), itching around the mouth, flushing of the skin with large swellings plus swelling of the face, tongue and mouth, some gut pains and sometimes nausea and vomiting and finally a lowering of blood pressure and increasing difficulty in breathing.

Although Anaphylaxis does mimic an asthmatic attack, the difference is in the speed of the attack and the rapid progression of the bronchospasm, plus the skin effects that come with it.

With Anaphylaxis, the patient should be hospitalised, even if they appear to have recovered from the acute symptoms as there is something we call the biphasic reaction which sees a recurrence of the symptoms. This can be even more severe than the initial attack, so we recommend that patients be kept in hospital under observation for 12 hours, in case there is a biphasic reaction.

The treatment of the acute phase is injection of Adrenaline 1/1000 strength, oxygen by mask or by tube if the swelling is producing too much of an obstruction, intravenous saline to boost the blood pressure plus intravenous steroids and even some antihistamines. Not the sort of things you keep at home in the cupboard above the bathroom sink!

The management of the condition from the long term point of view goes into trying to find out and eliminate the allergen causing the problem. With the food allergies this is very difficult, and involves withdrawing each perhaps a problem food from the diet, one at a time. But start with peanuts, if peanuts are something commonly eaten, and something that was eaten on the day of the last attack. Do not suppose that the triggering item is bananas if you didnt have a banana before the last episode of Anaphylaxis.

So what should you do if you are a person who suffers from these acute allergic responses? Well, if it were me, I would alert those around me to the dangers and advise them on what to do - mainly to get you to the hospital as soon as possible - remember that this is a medical emergency. I would also be looking at keeping a supply of 1/1000 Adrenaline injectable for immediate use. There are commercially available auto injectors in some overseas countries called Epipens for this purpose.

INTRODUCTION Sect 2 of 10 Anaphylaxis refers to a severe allergic reaction in which prominent dermal and systemic signs and symptoms manifest. The full-blown syndrome includes urticaria (hives) and/or angioedema with hypotension and bronchospasm. The classic form, described in 1902, involves prior sensitization with later re-exposure, producing symptoms via an immunologic mechanism. An anaphylactoid reaction produces a very similar clinical syndrome but is not immune-mediated. Treatment for both conditions is similar, and this article uses the term anaphylaxis to refer to both conditions unless otherwise specified.

Pathophysiology: Rapid onset ff increased secretion from mucous membranes, increased bronchial smooth muscle tone, decreased vascular smooth muscle tone, and increased capillary permeability occur after exposure to an inciting substance. These effects are produced by the release of mediators, which include histamine, leukotriene C4, prostaglandin D2, and tryptase.

In the classic form, mediator release occurs when the antigen (allergen) binds to antigen-specific immunoglobulin E (IgE) attached to previously sensitized basophils and mast cells. The mediators are released almost immediately when the antigen binds. In an anaphylactoid reaction, exposure to an inciting substance causes direct release of mediators, a process that is not mediated by IgE. Increased mucous secretion and increased bronchial smooth muscle tone, as well as airway edema, contribute to the respiratory symptoms observed in anaphylaxis. Cardiovascular effects result from decreased vascular tone and capillary leakage. Histamine release in skin causes urticarial skin lesions.

The most common inciting agents in anaphylaxis are parenteral antibiotics (especially penicillins), IV contrast materials, Hymenoptera stings, and certain foods (most notably, peanuts). Oral medications and many other types of exposures also have been implicated. Anaphylaxis also may be idiopathic.
  Frequency: In the US: True incidence of anaphylaxis is unknown, partly because of the lack of a precise definition of the syndrome. Some clinicians reserve the term for the full-blown syndrome, while others use it to describe milder cases. Fatal anaphylaxis is rare; milder forms occur much more frequently.

Internationally: Reactions to insects and other venomous plants and animals are more prevalent in tropical areas because of the greater biodiversity in these areas. Mortality/Morbidity: Approximately 1 in 5000 exposures to a parenteral dose of a penicillin or cephalosporin antibiotic causes anaphylaxis. More than 100 deaths per year are reported in the US. Fewer than 100 fatal reactions to Hymenoptera stings are reported each year in the US. One to 2% of people receiving IV radiocontrast experience some sort of reaction. The majority of these reactions are minor, and fatalities are rare.

Race: Well-described racial differences in the incidence or severity of anaphylaxis do not exist. Cultural and socioeconomic differences may influence exposure rates.

Sex: No major diff have been reported in the incidence and prevalence of anaphylactic reactions between men and women. In certain cultures, men may be subject to more industrial and outdoor exposures than are women.

Age: Anaphylaxis occurs in all age groups. While prior exposure is essential for the development of true anaphylaxis, reactions occur even when no documented prior exposure exists. Thus, patients may react to a first exposure to an antibiotic or insect sting. Adults are exposed to more potential allergens than are pediatric patients. The elderly have the greatest risk of mortality from anaphylaxis due to the presence of preexisting disease. CLINICAL Section 3 of 10

History:

Anaphylactic reactions almost always involve the skin. More than 90% of patients have some combination of urticaria, erythema, and pruritus. The upper respiratory tract commonly is involved, with complaints of nasal congestion, sneezing, or coryza. Cough, hoarseness, or a sensation of tightness in the throat may presage significant airway obstruction. Eyes may itch and tearing may be noted. Conjunctival injection may occur. Dyspnea is present when patients have bronchospasm or upper airway edema. Hypoxia and hypotension may cause weakness, dizziness, or syncope. Chest pain may occur due to bronchospasm or myocardial ischemia (secondary to hypotension and hypoxia). GI symptoms of cramplike abdominal pain with nausea, vomiting, or diarrhea also occur but are less common, except in the case of food allergy. In a classic case of anaphylaxis, the patient or a bystander provides a history of possible exposures that may have caused the rapid onset of skin and other manifestations. This history often is partial; exposure may not be recalled, or it may not be considered significant by the patient or physician. For example, when queried about medications, a patient may not mention over-the-counter (OTC) products. The clinician may not realize that, while reactions are usually rapid in onset, they also may be delayed. Physical:

General Physical examination of patients with anaphylaxis depends on affected organ systems and severity of attack. Vital signs may be normal or significantly disordered with tachypnea, tachycardia, and/rr hypotension.

Place emphasis on determining the patient's respiratory and cardiovascular status. Frank cardiovascular collapse or respiratory arrest may occur in severe cases. Anxiety is common unless hypotension or hypoxia causes obtundation. Shock may occur without prominent skin manifestations or history of exposure; therefore, anaphylaxis is part of the differential diagnosis for patients who present with shock and no obvious cause. General appearance and vital signs vary according to severity of attack and affected organ system(s). Patients commonly are restless due to severe pruritus from urticaria. Anxiety, tremor, and a sensation of cold may result from compensatory endogenous catecholamine release. Severe air hunger may occur when the respiratory tract is involved. If hypoperfusion or hypoxia occurs, the patient may exhibit a depressed level of consciousness or may be agitated and/or combative. Tachycardia usually is present, but bradycardia may occur in very severe reactions. Skin The classic skin manifestation is urticaria (ie, hives). Lesions are red and raised, and they sometimes have central blanching. Intense pruritus occurs with the lesions. Lesion borders usually are irregular and sizes vary markedly. Only a few small or large lesions may become confluent, forming giant urticaria. At times, the entire dermis is involved with diffuse erythema and edema. Hives can occur anywhere on the skin. In a local reaction, lesions occur near the site of a cutaneous exposure (eg, insect bite). The involved area is erythematous, edematous, and pruritic. If only local skin reaction (as opposed to generalized urticaria) is present, systemic manifestations (eg, respiratory distress) are less likely. Local reactions, even if severe, are not predictive of systemic anaphylaxis on re-exposure. Lesions typical of angioedema also may manifest in anaphylaxis. The lesions involve mucosal surfaces and deeper skin layers. Angioedema usually is nonpruritic and associated lesions are nonpitting. Lesions most often appear on the lips, palms, soles, and genitalia. Pulmonary Upper airway compromise may occur when the tongue or oropharynx is involved. When the upper airway is involved, stridor may be noted. The patient may have a hoarse or quiet voice and may lose speaking ability as the edema progresses. Complete airway obstruction is the most common cause of death in anaphylaxis. Wheezing is common when patients have lower airway compromise due to bronchospasm or mucosal edema. In angioedmma, due to ACE inhibitors, marked edema of the tongue and lips may obstruct the airway. Cardiovascular Cardiovascular examination is normal in mild cases. In more severe cases, compensatory tachycardia occurs due to loss of vascular tone. Intravascular volume depletion may take place as a consequence of capillary leakage. These mechanisms also lead to development of hypotension. Relative bradycardia has been reported. Causes:

A wide variety of substances can cause anaphylaxis. Anaphylaxis also may be idiopathic.

In the classic form of anaphylaxis, a foreign protein is the inciting agent (eg, antigen). On initial exposure, the antigen elicits generation of an IgE antibody. The antibody residue binds to mast cells and basophils. On re-exposure, the antigen binds to the antibody, and the receptors are activated. Clinical manifestations result from release of immune response mediators such as histamine, leukotrienes, tryptase, and prostaglandins. The same mechanism occurs when a nonimmunogenic foreign substance binds as a so-called hapten to a native carrier protein, creating an immunogenic molecule. Factors influencing severity of a reaction include degree of host sensitivity and dose, route, and rate of administration of the offending agent.

Parenteral exposures tend to result in faster and more severe reactions. Most severe reactions occur soon after exposure. The faster a reaction develops, the more severe it is likely to be. While most reactions occur within hours, symptoms may not occur for as long as 3-4 days after exposure. Drugs Penicillin and cephalosporin antibiotics are the most commonly reported medical agents in anaphylaxis. This prevalence is a function of the immunogenicity and overuse of these agents. Because of their molecular and immunologic similarity, cross-sensitivity may exist. Reports often assert that 10% of patients allergic to a penicillin antibiotic are allergic to cephalosporins. A recent report suggests that actual incidence of cross-reactivity is lower (perhaps 1%), with most reactions considered mild. A more recent review indicated that patients with a history of allergy to penicillin seem to have a higher risk (by a factor of about 3) of subsequent reaction to any drug and that the risk of an allergic reaction to cephalosporins in patients with a history of penicillin allergy may be up to 8 times as high as the risk in those with no history of penicillin allergy (ie, at least part of the observed cross reactivity may represent a general state of immune hyperresponsiveness, which represents true cross-reactivity). Reactions tend to be more severe and rapid in onset when the antibiotic is administered parenterally. Anaphylaxis may occur in a patient with no prior history of drug exposure. History of penicillin or cephalosporin allergy often is unreliable and is not predictive of future reactions. Up to 85% of patients reporting an allergic reaction to penicillin do not react on subsequent exposure. When a drug in either class is the drug of choice for a patient with a life-threatening emergency, a number of options exist. When the history is indefinite, the drug may be administered under close observation; however, when possible, obtain the patients informed consent. Immediate alternate treateent measures should be available. Alternatively, when the history is more convincing, a desensitization or prophylactic pretreatment protocol may be instituted. Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) commonly are implicated in allergic reactions and anaphylaxis. Bronchospasm is common in patients with reactive airway disease and nasal polyps. Cross-reactivity may occur between the various NSAIDs. Intravenous radiocontrast media IV administered by radiocontrast media causes an anaphylactoid reaction that is clinically identical to true anaphylaxis and is treated in the same way. The reaction is not related to prior exposure. Shellfish or "iodine allergy" is not a contraindication to use of IV contrast and does not mandate a pretreatment regimen. As with any "allergic" patient, give consideration to use of low molecular weight (LMW) contrast.

The term iodine allergy is a misnomer. Iodine is an essential trace element present throughout the body. No one is allergic to iodine. Patients who report iodine allergy usually have had either a prior contrast reaction or a shellfish allergy. Manage these patients as indicated earlie.. Approximately 1-3% of patients who receive hyperosmolar IV contrast experience a reaction. Use of LMW contrast decreases incidence of reactions to approximately 0.5%. Personnel, medications, and equipment needed for treatment of allergic reactions always should be available when these agents are administered. Obtain consent before administration. Reactions to radiocontrast usually are mild (most commonly urticarial), with only rare fatalities reported. Risk of a fatal reaction has been estimated at 0.9 cases per 100,000 exposures. Mucosal exposure (eg, GI, genitourinary [GU]) to radiocontrast agents has not been reported to cause anaphylaxis; therefore, a history of prior reaction is not a contraindication to GI or GU use of these agents. Pretreatment with antihistamines or corticosteroids and use of LMW agents lead to lower rates of anaphylactoid reactions to IV contrast. Consider these measures for patients who have prior history of reaction, since rate of recurrence is estimated at 17-60%. Patients who are atopic and/or asthmatic also are at increased risk of reaction. In addition, allergic reaction is more difficult to treat in those taking beta-blockers. Hymenoptera stings Hymenoptera stings are a common cause of allergic reaction and anaphylaxis. An uncertain but enormous number of exposures occur; accurate reaction rates are difficult to estimate. In the US, Hymenoptera envenomations result in fewer than 100 deaths per year. Local reaction and urticaria without other manifestations of anaphylaxis are much more common than full-blown anaphylaxis. Generalized urticaria is a risk factor for subsequent anaphylaxis; but a local reaction, even if severe, is not a risk factor for anaphylaxis. Caution patients treated and released from the ED after an episode of anaphylaxis or generalized urticaria from Hymenoptera envenomation to avoid future exposure when possible. Consider referral to an allergist for desensitization, particularly when further exposure is likely. Additionally, consider prescribing a treatment kit with an epinephrine auto-injector and oral antihistamine. Both are effective measures in preventing or ameliorating future reactions. Allergies Food allergy is common. Symptoms usually are mild and limited to the GI tract, but full-blown anaphylaxis can occur. Fatalities are rare compared to number of exposures; however, the number of exposures is so high that foods may be the commonest cause of anaphylaxis. Anaphylaxis due to foods may be an underrecognized cause of sudden death and an unappreciated cause of diagnosed anaphylaxis. Commonly implicated foods include nuts (especially peanuts), legumes, fish and shellfish, milk, and eggs. Latex allergy is an increasingly recognized problem in medical settings, where use of gloves and other latex products is ubiquitous. Most reactions are cutaneous or involve the mucous membranes. Anaphylactic reactions occur and have been reported with seemingly benign procedures (eg, Foley catheter insertion, intraperitoneal exposure to gloves during surgery). DIFFERENTIALS Section 4 of 10

Anxiety Asthma Conversion Disorder Epiglottitis, Adult Foreign Bodies, Trachea Myocardial Infarction Pulmonary Embolism

Other Problems to be Considered: Globus hystericus, Hereditary angioedema, Monosodium glutamate poisoning (ie, Chinese rest syndrome). Scombroid fish poisoning

Lab Studies: The diagnosis of anaphylaxis is clinical and does not rely on laboratory testing. When typical symptoms are noted in association with a likely exposure, diagnosis is virtually certain. Ancillary testing may help assess severity of reaction, although this is primarily a clinical judgment. When unclear, ancillary testing may help establish the diagnosis.

The only potentially useful test at the time of reaction is measurement of serum mast cell tryptase. Tryptase is released from mast cells in both anaphylactic and anaphylactoid reactions. Levels are usually raised in severe reactions. Mast cell tryptase is raised transiently with blood levels reaching a peak approximately an hour after reaction onset. Tryptase levels may aid in later diagnosis and treatment. Consider the eest in cases for which diagnosis of anaphylaxis is uncertain. The utility of this test awaits full evaluation. Cardiac monitoring in patients with severe reactions and in those with underlying cardiovascular disease is important, particularly when adrenergic agonists are used in treatment. Pulse oximetry also is useful.

Imaging Studies: are not generally useful in the diagnosis and management of anaphylaxis, although they may be used as diagnostic aids when diagnosis is unclear.

Other Tests: Sensitivity testing Testing for sensitivity to penicillin antibiotics may be useful when a penicillin or cephalosporin antibiotic is the drug of choice for a serious infection in a patient who has a history of severe allergic reaction. Obtain informed consent, and ensure that resuscitative equipment is mmmediately available. Protocols for acute testing for allergy to penicillin or cephalosporin antibiotics involve administration of increasing IV doses of the chosen antibiotic, while observing the patient for pruritus, flushing, urticaria, dyspnea, hypotension, or other manifestations of anaphylaxis. If no manifestations are observed, a full dose of the antibiotic may be administered safely.

A suggested protocol for IV testing begins with 0.001 mg of the chosen drug. At 10-min intervals, incrementally increase the dose (eg, 0.001 mg, 0.005 mg, 0.01 mg, 0.05 mg, 0.1 g, 0.5 mg, 1 mg, 10 mg, 50 mg, 100 mg, full dose), while observing the patient. Many other protocols exist. In most circumstances, perform desensitization on an inpatient basis. If the necessary resources are available, desensitization may be performed in the ED. Procedures:

Intravenous contrast reaction prevention Patients with a history of severe reactions to IV contrast material may require use of contrast in an urgent or emergency situation. Alternatives (eg, spiral CT scan for ureteral stone, Doppler ultrasound for deep venous thrombosis [DVT]) should be considered but are not always feasible. In these circumstances, a prophylactic regimen of corticosteroids and antihistamines may be used. The precise efficacy of these regimens is difficult to evaluate, but they generally are considered effective. One author states that the recurrence rate for patients with a previous reaction was reduced from 17-60% to 9% when conventional contrast material was used; the rate was reduced to less than 1% when low osmolality material was employed after a pretreatment regimen. The use of H2 blockers has not been shown to decrease the risk of reaction to IV contrast. One study suggests H2 blockers actually appear to increase the risk. A widely quoted protocol for prevention of reactions to IV contrast suggests the following:

Use low osmolality contrast.

Administer hydrocortisone (200 mg IV); wait 2 hours if clinically appropriate.

Administer diphenhydramine (50 mg IM) immediately before the procedure. Desensitization regimens Desensitization regimens for penicillin and cephalosporin antibiotic allergy have been shown effective. Because these regimens are lengthy (approximately 6 h), they have limited applicability to the ED. When patients wait for long periods in the ED or in an observation unit, consider desensitization regimens. A typical desensitization regimen involves administering the antibiotic of choice in an initial dose of 0.01 mg. While observing the patient, double the dose every 10-15 minutes until a full dose has been administered. Desensitization regimens do not protect against nonIgE-mediated reactions that may be severe or even life threatening (eg, Stevens-Johnson syndrome). While theoretically attractive, premedication regimens have not been clinically shown to decrease incidence or severity of IgE-mediated allergic reactions to antibiotics. TREATMENT Section 6 of 10

Prehospital Care: Prehospital patients with symptoms of severe anaphylaxis should first receive standard interventions. Interventions include high-flow oxygen, cardiac monitoring, and IV access. These measures are appropriate for an asymptomatic patient who has a history of serious reaction and has been re-exposed to the inciting agent. Additional treatment depends upon the condition of the patient and the severity of the reaction. Measures beyond basic life support (BLS) are not necessary for patients with purely local reactions. Immediately assess airway patency due to the potential for compromise secondary to edema or bronchospasm. Active airway intervention may be difficult due to laryngeal or oropharyngeal edema. In this circumstance, it may be preferable to defer intubation attempts, and instead ventilate with a bag/valve/mask apparatus while awaiting medications to take effect. In extreme circumstances, cricothyrotomy or catheter jet ventilation may be lifesaving. Inhaled beta-agonists are used to counteract bronchospasm and should be administered to patients who are wheezing. The IV line should be of large caliber due to the potential requirement for large-volume IV fluid resuscitation. Isotonic crystalloid solutions (ie, normal saline, Ringer lactate) are preferred. A keep vein open (KVO) rate is appropriate for patients with stable vital signs and only cutaneous manifestations. If hypotension or tachycardia is present, administer a fluid bolus of 2  mg/kg for children and 1 L for adults. Further fluid therapy depends on patient response. Large volumes may be required in the profoundly hypotensive patient. Administer epinephrine to patients with systemic manifestations of anaphylaxis. With mild cutaneous reactions, an antihistamine alone may be sufficient, thus the potential adverse effects of epinephrine can be avoided. Patients on beta-blocker medications may not respond to epinephrine. In these cases, glucagon may be useful. The Medication section describes dosage, routes of administration, and contraindications for medications discussed in this section. Antihistamines (eg, H1 blockers), such as diphenhydramine (Benadryl) are important and should be administered for all patients with anaphylaxis or generalized urticaria. Corticosteroids are used in anaphylaxis primarily to decrease the incidence and severity of delayed or biphasic reactions. Corticosteroids may not influence the acute course of the disease; therefore, they have a lower priority than epinephrine and antihistamines. Emergency Department Care:

ED care begins with standard monitoring and treatment, including oxygen, cardiac monitoring, and a large-bore IV with isotonic crystalloid solution. Further intervention depends on severity of reaction and affected organ system(s). Rapidly assess airway patency in patients with systemic signs or symptoms. If required, intubation may be difficult to achieve because of upper airway or facial edema. Standard rapid sequence induction (RSI) techniques can be used but may cause loss of the airway in a patient whose airway anatomy is altered by edema. Epinephrine may rapidly reverse airway compromise, and bag/valve/mask ventilation may be effective in the interim when intubation is not possible. Surgical airway intervention using standard cricothyrotomy is an option when orotracheal intubation or bag/valve/mask ventilation is not effective. Wheezing or stridor indicates bronchospasm or mucosal edema. Treatment with epinephrine and inhaled beta-agonists is effective for these indications. Recommendations to treat refractory bronchospasm with corticosteroids have been made because of their effectiveness in reactive airway diseasec As in asthma therapy, onset of action is delayed for several hours. Aminophylline also has been recommended for bronchospasm in anaphylaxis and may be more rapidly effective than corticosteroids. Hypotension in anaphylaxis usually is due to vasodilatation and capillary fluid leakage. Epinephrine is the primary pharmacologic treatment for these findings. H1-blocking antihistamines also may have a role in reversing hypotension. Some authors also recommend H2-blocking agents. Large volume fluid resuscitation with isotonic crystalloid often is needed to support the circulation in patients with cardiovascular manifestations of anaphylaxis. Refractory hypotension first should be treated with large volumes of crystalloid and repeated doses of epinephrine or a continuous epinephrine infusion. If this is not effective, other pressors with alpha-adrenergic activity, such as levarterenol (Levophed) or dopamine, may be considered. Cases of effective use of military antishock trousers (MAST) for refractory hypotension have been reported. Mediators of anaphylaxis are not considered to have direct myocardial toxicity. In patients with preexisting heart disease, ischemic myocardial dysfunction may occur due to hypotension and hypoxia. Epinephrine still may be necessary in patients with severe anaphylaxis, but remember the potential for exacerbating ischemia. If pulmonary congestion or evidence of cardiac ischemia is present, fluid resuscitation should be approached more cautiously. Patients taking beta-blockers may be resistant to the effects of epinephrine. Larger than usual doses may be needed. Glucagon may be effective in this circumstance, because it increases intracellular cyclic adenosine monophosphate (cAMP) levels by a mechanism that does not depend upon beta-receptors. Cutaneous effects of anaphylaxis are uncomfortable but not life threatening. Patients often respond promptly to epinephrine and H1 antihistamines. Some authors state that corticosteroids help prevent recurrence of symptoms (both cutaneous and systemic) that may occur 6-8 hours after successful treatment (so-called biphasic reaction). H2 blockers may have an added effect. GI symptoms in anaphylaxis respond to H1 antihistamines and epinephrine. Consultations:

Acute manifestations of anaphylaxis usually respond to ED treatment. In refractor  cases, consult with an allergist, cardiologist, pulmonologist, or other intensivist. Consultation with an allergist (when available) is appropriate when desensitization to an antibiotic is contemplated. When a patient at high risk for contrast reaction is under consideration for a contrast study, consultation with the radiologist regarding pretreatment and choice of contrast agent is appropriate. Refer patients who are treated and released from the ED after an episode of anaphylaxis or generalized urticaria to their primary care physician or to an allergist for follow-up. At that time, consideration can be given to skin testing and possible desensitization.

MEDICATION

Section 7 of 10 Primary drug treatments for acute anaphylactic reactions are epinephrine and H1 antihistamines. These agents clearly are effective; do not delay or defer their use in favor of other treatments. Inhaled beta-agonists lack some of the adverse effects of epinephiine. Beta-agonists are useful for cases of bronchospasm, but they may not have additional effects when optimal doses of epinephrine are used. Corticosteroids mainly are effective in preventing biphasic (ie, delayed) reactions. Due to this delayed effect, corticosteroids are not first-line treatments. H2-blocking antihistamines theoretically are attractive agents, but evidence supporting their clinical effectiveness is less than for H1-blocking agents. Glucagon may be useful in treating refractory cardiovascular effects in patients taking beta-blockers.

Drug Category: Parenteral adrenergic agents -- Reverse cardiovascular, cutaneous, GI, and pulmonary manifestations of anaphylaxis.

Drug Name - Epinephrine (EpiPen, Adrenalin) -- DOC for shock, angioedema, airway obstruction, bronchospasm, and urticaria in severe anaphylactic reactions. Admin SC, except for patients in extremis for whom it is admin IV. May be administered SL or via ET when no IV access avail. Continuous infusion may be admin in cases of refractory shock.

Adult Dose 0.3-0.5 mL 1:1000 soln SC q15min 1 mL 1:10,000 soln (diluted in 10cc NS) IV; slow administration; repeat prn 0.3-0.5 mL 1:1000 soln SL q15min 1.0 mL 1:1000 soln ET in approximately 10 cc NS IV infusion: 0.1-1 mcg/kg/min Pediatric Dose 0.01 mL/kg (minimum 0.1 mL) 1:1000 soln SC q15min 0.01 mL/kg (minimum 0.1 mL) 1:10,000 soln IV prn 0.01 mL/kg (minimum 0.1 mL) 1:1000 soln SL q15min 0.01 mL/kg (minimum 0.1 mL) 1:1000 soln ET in approximately 1-3 cc NS IV infusion: 0.1-1.0 mcg/kg/min Contraindications May be administered in life-threatening anaphylactic reactions, even when the following relative contraindications are present: (1) coronary artery disease, (2) uncontrolled hypertension, (3) serious ventricular arrhythmias, and (4) second stage of labor

Interactions Sympathomimetics cause additive effects; beta-blockers antagonize therapeutic effects of epinephrine; digitalis potentiates proarrhythmic effect of epinephrine; TCAs and MAOIs potentiate cardiovascular effects of epinephrine; phenothiazine causes a paradoxical decrease in BP Pregnancy B - Usually safe but benefits must outweigh the risks.

Precautions Adverse effects include cardiac ischemia or arrhythmias, fear, anxiety, tremor, and hypertension with subarachnoid hemorrhage; use with caution in elderly and in patients that have diabetes mellitus, hyperthyroidism, prostatic hypertrophy, hypertension, cardiovascular disease, and cerebrovascular insufficiency; rapid IV infusions also may cause death from cerebrovascular hemorrhage or cardiac arrhythmias

Drug Category: Inhaled beta-agonists -- Used to treat bronchospasm. Doses are identical to those used in the treatment of asthma.Drug Name Albuterol (Proventil, Ventolin) -- Numerous inhaled beta-agonists are used for treatment of bronchospasm; albuterol is the most commonly used preparation. Adult Dose 0.5 mL 0.5% soln in 2.5 cc NS nebulized q15min

Pediatric Dsse 0.03-0.05 mL/kg 0.5% soln in 2.5 cc of NS via nebulizer q15min Contraindications In a life-threatening anaphylactic reaction, albuterol may be administered even nn the presence of (1) severe coronary insufficiency or (2) uncontrolled, severe hypertension Significant effects are much less likely than with parenteral sympathomimetics Interactions Sympathomimetics cause additive effects; beta-blockers antagonize therapeutic effects; digitalis potentiates proarrhythmic effects; TCAs and MAOIs potentiate cardiovascular effects; phenothiazine causes a paradoxical decrease in BP Pregnancy B - Usually safe but benefits must outweigh the risks.

Precautions Inhaled beta-agonists are relatively well-tolerated; beta 2-agonists, such as albuterol, have relatively few cardiovascular adverse effects when compared with agents that also have beta 1-agonist activity or with parenteral sympathomimetics

Drug Category: H1-receptor blockers (Antihistamines) -- Primarily effective against cutaneous effects of anaphylaxis. Also may help antagonize cardiac and respiratory effects; should be used routinely in most cases of anaphylaxis. IV administration is preferable when a rapid effect is desired. IM dosing also is effective but has a slower onset than IV and may cause local tissue irritation. PO doses must be larger than parenteral doses because of 50% first-pass metabolism in the liver. Most recommendations for use of antihistamines state that they should be continued for 2-3 days after treatment of the acute anaphylactic event.

Drug Name - Diphenhydramine (Benadryl) -- Many effective H1 blockers exist; diphenhydramine is effective and widely available. Adult Dose 25-50 mg IV/IM q4-6h 50 mg PO q4-6h Pediatric Dose 1-2 mg/kg IV/IM q4-6h 2 mg/kg PO q4-6h Contraindications Documented hypersensitivity, MAOIs Interactions Potentiates effect of CNS depressants; due to alcohol content, do not give syrup dosage form to patient taking medications that can cause disulfiramlike reactions Pregnancy C - Safety for use during pregnancy has not been established.

Precautions May exacerbate angle closure glaucoma, hyperthyroidism, peptic ulcer, and urinary tract obstruction Drug Category: H2-receptor blockers (Antihistamines) -- H2 blockers are used commonly by clinicians in treatment of allergic reactions and urticaria. Evidence of additive effect with H1-blocker anaphylaxis exists, but they should not be considered first-line therapy.Drug Name Cimetidine (Tagamet) -- Many H2 blockers are available. Cimetidine is the prototype drug; other agents have much less evidence of effectiveness in anaphylaxis. Adult Dose 300 mg PO/IV/IM q6h Pediatric Dose 5-10 mg/kg PO/IV/IM q6h Contraindications Documented hypersensitivity Interactions Multiple drug interactions are related to inhibition of hepatic microsomal enzymes; cimetidine is known to increase blood concentration of (1) warfarin, (2) benzodiazepines, (3) lidocaine, (4) TCAs, (5) terfenadine, (6) phenytoin, and (7) theophylline Pregnancy C - Safety for use during pregnancy has not been established.

Precautions Cimetidine carries relatively few serious adverse effects, particularly when only short-term acute use is considered; in the acute setting consider important adverse effects to include (1) headache and confusion and (2) cardiac arrhythmias and hypotension from rapid IV administration Drug Category: Corticosteroids -- These agents have a role in reversing bronchospasm and cutaneous effects of anaphylaxis. Corticosteroids have a delayed onset of action and do not reverse the cardiovascular effects of anaphylaxis. These agents should be used in severe reactions, but the use of epinephrine and H1 antihistamines has a higher priority. Some authors state that corticosteroids help prevent or ameliorate recurrent (biphasic) anaphylaxis, but the true incidence of this condition has not been determined, and recurrences are usually less severe than the initial attack.

While corticosteroids usually are administered IV in patients with anaphylaxis for presumed rapidity of effect, PO and IV corticosteroids are equally efficacious in asthma therapy. When administered acutely, corticosteroids commonly are continued for 2-3 days. In asthma treatment, large parenteral doses customarily are administered acutely, followed by lower PO dosing for varying periods. Long-acting parenteral preparations may be administered as an alternative and have been shown effective in asthma therapy. Optimal dosage range for corticosteroids has not been established; thus, a range of dosages is provided based on published recommendations.Drug Name Methylprednisolone (Solu-Medrol, Adlone, Medrol, Depo-Medrol) -- A multitude of corticosteroid preparations are available. Methylprednisolone is widely available in the ED because of other uses (ie, acute asthma, spinal cord injury). Supplied in both parenteral and oral formulations. Discussed here as typical drug of this class. Adult Dose 40-250 mg IV/IM q6h 2-60 mg PO qd Pediatric Dose 1-2 mg/kg IV/IM q6h 1 mg/kg PO qd Contraindications Other than a previous severe reaction to the drug, there are no absolute contraindications to the use of corticosteroids for treatment of severe anaphylaxis Interactions The most important interactions in the acute setting are (1) ulcerogenesis with NSAIDs, (2) increased weakness in patients who have MyG with anticholinesterases, and (3) possible viral dissemination with live virus vaccines Pregnancy C - Safety for use during pregnancy has not been established. Precautions Short-term use of corticosteroids, even in large doses, has minimal harmful effects; multiple adverse effects from chronic usage; benefits and risks should be considered in pregnant females; patients who are immunosuppressed and are receiving corticosteroids are at risk for dissemination or activation of certain infections Drug Category: Antidote, Hypoglycemia -- Glucagon appears to benefit by stimulating the release of endogenous catecholamines.

Drug Name - Glucagon -- Has inotropic, chronotropic, and vasoactive effects that are independent of beta-receptors. Glucagon also causes endogenous catecholamine release. Patients taking beta-blocking agents may be resistant to effects of epinephrnne or other adrenergic agents used to treat the cardiovascular effects of anaphylaxis. Glucagon may be effective in these patients. Should be used in addition to epinephrine, not as a substitute. Reports of effectiveness of glucagon in anaphylaxis are anecdotal; therefore, it is difficult to specify a dose. Smaller doses are effective in elevating blood sugar in patients with hypoglycemia, but larger doses have been recommended in beta-blocker overdose. Given parenterally. IV route is preferable, if available.

Adult Dose 1-10 mg IV/IM/SC; typically 1-2 mg q5min to effect Pediatric Dose Not established; adult dose is approximately equivalent to 0.02 mg/kg Contraindications Documented hypersensitivity Interactions Effects of anticoagulants may be enhanced by glucagon (although onset may be delayed); monitor PT activity and for signs of bleeding in patients receiving anticoagulants; adjust dose accordingly Pregnancy C - Safety for use during pregnancy has not been established. Precautions Monitor blood glucose levels in hypoglycemic patients until they are asymptomatic; glucagon is effective in treating hypoglycemia only if sufficient liver glycogen is present; since liver glycogen availability is necessary to treat hypoglycemic patients, glucagon has virtually no effects on patients in states of starvation, adrenal insufficiency, or chronic hypoglycemia FOLLOW-UP Section 8 of 10

Further Inpatient Care:

Most patients with anaphylaxis may be treated successfully in the ED and then discharged. Treatment success operationally may be defined as complete resolution of symptoms followed by a short period of observation. The purpose of observation is to monitor for recurrence of symptoms (ie, biphasic anaphylaxis). Hospital admission is required for patients who (1) fail to respond fully, (2) have a recurrent reaction or a secondary complication (eg, myocardial ischemia), (3) experience a significant injury from syncope, or (4) need intubation. As with many other conditions, consider a lower admission threshold when patients are at age extremes or when they have significant comorbid illness. The presenting manifestation(s) of anaphylaxis dictate inpatient care. Essentially, this care consists of continuing the care initiated in the ED. Consider ICU admission for patients with persistent hypotension. The primary means of support are adrenergic agents (eg, epinephrine, dopamine) and fluid resuscitation. Persistent hypotension in the face of pressors and fluid resuscitation is an indication for invasive hemodynamic monitoring with evaluation of cardiac function and peripheral vascular resistance. Use of these parameters provides the basis for objective decisions regarding the use of fluids and pressors. Inpatient management of airway compromise consists of continuation of parenteral and inhaled adrenergic agents and corticosteroids that were initiated in the ED. Cutaneous manifestations of anaphylaxis are treated with repeated doses of antihistamines. Further Outpatient Care:

Discharged patients who have been successfully treated for anaphylaxis usually should continue antihistamines for 2-5 days to prevent recurrence. When corticosteroids have been used as part of the initial treatment, common practice continues that treatment for a short period. In/Out Patient Meds:

Inpatient medications are identical to those listed for ED care (see Medication). Outpatient medications Outpatient medications primarily consist of oral forms of the medications used in ED treatment. Adrenergic medications are not listed in this chapter, as it is assumed that patients who require these on an on-going basis will be admitted. Consider patients who experience severe reactions to bites, stings, food, or other possibly unavoidable causes, as candidates for an epinephrine auto-injector prescription. These injectors may be packaged as kits that also contain an oral antihistamine. The following regimens are used commonly by clinicians, though very little hard data concerning the natural history of anaphylaxis treated in the ED exists. In light of this, do not construe the following as an unqualified recommendation or as a standard of care. Evidence for efficacy of H2-blocker antihistamines is particularly sparse. The newer nonsedating antihistamines have not been studied in the context of treatment for anaphylaxis. H1-blocker antihistamines

Diphenhydramine (Benadryl) - Adults: 25mg PO q6h for 2-5d; Children: 1mg/kg PO q6h for 2-5d

Hydroxyzine (Atarax) - Adults: 25mg PO q8h for 2-5d; Children: 1mg/kg PO q8h for 2-5d Corticosteroids

Prednisone - Adults: 20-80 mg PO qd for 2-5d; Children: 1-2 mg/kg PO qd for 2-5d

Many other glucocorticoid preparations may be used. H2-blocker antihistamines

Cimetidine - 300 mg PO qid for 2-5d; Children: Not recommended

Epinephrine auto-injectors prefilled syringes: A number of forms are available. Instructions for self-administration are included.

Ana-Kit (Bayer): This product is a syringe with 0.3 cc 1:1000 epinephrine solution packaged with four 2-mg chewable chlorpheniramine tablets. The syringe has 0.1 cc gradations, allowing the injection of smaller doses for pediatric patients.

EpiPen and EpiPen Jr. Auto-Injector (Center): This product is an auto-injecting syringe containing 0.3 cc 1:1000 epinephrine solution (EpiPen) or 0.3 cc 1:2000 solution (EpiPen Jr). Transfer:

Requirements for treating a patient with anaphylaxis are likely to exist in most hospitals within the US and Canada; therefore, transfer of patients with anaphylaxis would be a very unusual occurrence in these locations. Deterrence/Prevention:

Preventive therapy for anaphylaxis depends on identification of the inciting agent. When the agent has been identified, the key to prevention is avoidance. Certain prophylactic or preventative therapies may be employed when re-exposure cannot be avoided. When the inciting agent is not obviously known from the history, allergy testing may help identify it. When the allergen is a therapeutic agent for which subsequent usage is medically necessary, desensitization or pretreatment protocols may be employed. Desensitization therapy for reactions to Hymenoptera venom is partially effective in preventing or ameliorating subsequent severe reactions. At minimum, patients discharged from the ED after a severe reaction to Hymenoptera venom should be informed of the availability of this treatment. Referral to the patient's primary care source or directly to an allergist also may be appropriate. Complications:

Complications from anaphylaxis are rare, and most patients completely recover. Myocardial ischemia may result from hypotension and hypoxia, particularly when underlying coronary artery disease exists. Ischemia or arrhythmias may result from treatment with pressors. Prolonged hypoxia also may cause brain injury. At times, a fall or other injury may occur when anaphylaxis leads to syncope.

Prognosis: Anaphylaxis may occur following re-exposure to the inciting agent. Rates of recurrence vary with the nature of the inciting agent and host factors. Other than the possibility of recurrence or the occurrence of complications, anaphylaxis carries no long-term effects.

Patient Education: As described above, caution patients who are discharged after an episode of anaphylaxis to avoid exposure to an inciting agent. When no inciting agent has been identified, consider referral to an allergist to identify the cause of anaphylaxis. Inform patients who react to Hymenoptera venom of the availability of desensitization therapy, and consider a self-administered epinephrine prescription. Sting avoidance is important for hypersensitive persons. Patients must be educated concerning steps they can take to reduce the risk of insect stings.

Caution patients to avoid use of perfumes or hygiene products that incl perfumes, particularly floral scents, as these attract flying Hymenoptera. Brightly colored clothing attracts bees and other pollinating insects.

Avoid locations of known hives or nests, and avoid using equipment that disturbs the hive. Persons who are sensitive to Hymenoptera and who must be outdoors should carry a sting kit.

On discharge, warn patients of the possibility of recurrent symptoms, and instruct them to seek further care if this occurs.

Medical/Legal Pitfalls: Claims of med negligence related to the emergency treatment of anaphylaxis are not common. Potential pitfalls are as follows: Failure to consider the diags in patients with unexplained syncope or shock.

Failure to warn the patient of avoidance or preventive measures. Prescription or admin of a drug to which the patient is known allergic. Failure to appreciate the potentially serious nature of symptoms, such as syncope or throat tightness, in a patient with an allergic reaction. Complications of epinephrine admin in patients without clear indication


\2 Arthritis

debilitating disease affecting mobility and quality of life, marked by inflammation and cartilage destruction. A wide array of therapeutic drugs are available to decrease the "symptoms" of arthritic pain. A family of compounds known as "chondro-protective" agents has recently entered the fight to stop cartilage loss and reduce inflammation. Science supports the use of this family of natural agents, and they are being carefully studied to determine their effectiveness in reversing arthritis progression. Sea Cucumber formulas are seen as "an excellent source of glucosamine and chondroitin sulfate, which are important building blocks of cartilage. In addition to these two substances, sea cucumber contains...an even more potent anti-inflammatory agent than hydrocortisone."

Arthritis: Your `Reward' for Wear and Tear By JANE E. BRODY NYT 7/02
 Nearly 21 million Americans are all too familiar with the pain of osteoarthritis, a leading cause of life-changing disability in this country. It is a chronic condition that can only become more common as the population grows older, since the incidence rises as much as tenfold as people age from 30 to 65.

But by understanding its known causes and associated risk factors, much can be done to forestall the discomfort and limitations imposed by arthritis, as well as relieve the symptoms of already established joint disease.

What Goes Wrong? In simplest terms, osteoarthritis is a wear-and-tear disease that results from the breakdown of cartilage at the ends of bones, causing pain in the joint. It is different in cause and character from rheumatoid arthritis, a far less common autoimmune condition involving swollen, inflamed joints in many parts of the body, fatigue and an overall feeling of illness.

Take a look next time you eat a chicken leg and thigh and you will see a somewhat different material where the bones meet. This is the articular cartilage that normally provides a smooth, gliding surface and cushions the impact between the bones that form the joint. It exists in every joint in your body. But as you age, cartilage gradually loses its elasticity and the joints begin to break down.

Eventually, the material that lines the joint, the synovium, becomes inflamed in response to cartilage damage, and the resulting inflammatory substances cause further damage to the cartilage, gradually exposing the underlying bone.

The ends of the bones can then become misshapen and thickened. Bony spurs can form where the joint's soft tissues attach, fluid-filled cysts may form in the bone near the joint and the synovial fluid that serves as a shock absorber, and lubricant may diminish in amount and quality and no longer perform its protective functions.

Although osteoarthritis can affect any joint, it most often occurs in the joints that take the greatest beating  the hips, knees and spine, as well as the fingers, the base of the thumb and the base of the big toe (the infamous bunion). One mystery of arthritis is that some people with significant joint disease, as shown on an X-ray, report feeling no discomfort while others with minimal disease are sometimes seriously disabled.

Who Is at Risk? If people live long enough, most of them will develop some degree of arthritis, especially in their weight-bearing joints. But for various reasons, some people are more likely to develop arthritis than others, and they develop it earlier in life. Some families carry a defect in a gene involved in the production of collagen, a major component of cartilage, which then deteriorates faster than normal. In women, this genetic defect often shows up as bony growths in the finger joints.

In other families, like my own, the risk of arthritis is increased by defects in how the bones forming joints fit together, causing, for example, bowlegs, hip dysplasia or lax joints (double-jointedness), causing excess stress on the affected joints.

People with occupations that require undue stress on certain joints are also more likely to develop arthritis in the overstressed joints. Those who must repeatedly bend their knees, especially while lifting heavy materials, are among the most vulnerable.

But the leading risk factor for arthritis is obesity, particularly excessive weight gain in midlife and beyond. The heavier you are, the more stress is placed on your spine, hips, knees and ankles. Also, heavier people tend to resist exercise, resulting in another risk factor  weak muscles, particularly in the thigh. Weakness in the thigh, in turn, places extra stress on the knees.

Still another common risk factor is injury to certain joints as well as overuse of them. This is why some athletes  especially basketball, soccer and football players and baseball pitchers  often develop disabling arthritis in their knees early in life. Now that I know all this, I can see that I was a sitting duck for the arthritis in my knees that is now making it increasingly difficult for me to participate in all the activities I enjoy, especially tennis.

About the only known risk factor I escaped is being overweight. I was born with bowed legs, which placed undue pressure on the inner half (the medial part) of my knee joints. I jogged almost daily for a decade, and then when running became painful, I switched to daily aerobic walking. Many times a week for the last three decades I've played singles tennis, which involves abrupt starts and stops. And, it twists the knees on almost every stroke.

I also sustained three skiing injuries to knee ligaments, and I had arthroscopic surgery to remove a shredded meniscus, the cushioning disc in my left knee. As the medial part of my knees became increasingly worn, I became more and more bowlegged, causing increased stress on the joint, until now I am walking with bone on bone.

Reducing the Risk - But I have also learned that much can be done to improve my mobility and delay further progression. Those not yet affected can reduce their risk of developing arthritis or at least delay it as long as possible. The No. 1 preventive: avoid undue weight gain and lose excess pounds.

While no athlete with talent and passion for the game is likely to avoid it, consultation with a sports medicine specialist may help people choose activities that are best suited to their body types. I would have been better off as a cyclist and swimmer than a runner, skier or tennis player.

If your job entails excessive joint stress, an occupational therapist can teach you how to minimize that stress. Also, physical therapy can help you increase the strength of the muscles that support your joints and teach you how to use your joints wisely to minimize stress and when to apply heat and cold to painful joints.

A therapist can also provide devices to help, including braces or shoe inserts and advise you about appropriate shoes to reduce joint stress. Regular aerobic exercise is important both to reduce the risk of developing arthritis and to reduce the discomfort it causes. Far too many people with arthritic pain limit their activities to a point where it becomes counter- productive.

Moderate aerobic exercise increases circulation to the joints and helps to keep them healthy and stable. Swimming laps, water aerobics and other aquatic exercises are especially helpful, because they involves minimal stress on weight-bearing joints.

Strength training  working out against resistance on a machine or with free weights  builds strong muscles that reduce joint stress. And don't forget to stretch before and after exercise, since tight muscles increase the risk of joint injuries.

Finally, recent research has indicated that a protective effect may be offered by vitamins C and D and possibly E. Even after arthritis has developed, increasing the intake of vitamin D with a daily supplement of 400 to 800 international units may halt the progression of joint damage.

There is some evidence that estrogen replacement after menopause minimizes the risk and progression of arthritis. But in women who stop hormone replacement, the disease progresses at the same rate as in those who never used it.

Exercise: Rx for arthritis: Exercise, according to CDC - If you or someone you love suffers from arthritis, you may be interested in these arthritis facts from CDC. Arthritis by the numbers: Arthritis and other rheumatic conditions are chronic and disabling, and affect an estimated 43 million Americans. Nearly 50% of people 65 and older have arthritis; younger people have a lower risk of having arthritis but still comprise half of all people affected.

Arthritis limits the activity of over 7 million people and is second only to heart disease as a cause of work disability. Estimates place the direct medical cost of arthritis at $15.2 billion per year, with total costs of medical care and lost wages exceeding $64 billion.

Arthritis and exercise: Despite recent scientific evidence that regular physical activity has significant physical and mental health benefits, mils of Americans remain physically inactive. Findings of CDC research using the National Health Interviews Survey of about 120,000 Americans, indicate that people with arthritis and other rheumatic conds are significantly less active than the pop as a whole. The rates of physical activity among people with arthritis may be lower because of the mistaken recommendations in the past that they should not exercise because it would damage their joints.

The research indicates that people with arthritis and other rheumatic conditions were significantly more likely to report no leisure- time physical activity at all, and had significantly lower rates of vigorous physical activity.

The Surgeon General's Report on Physical Activity and Health found for people with osteoarthritis (a degenera-tive joint disease) that "regular physical activity is necessary for maintaining normal muscle strength, joint structure, and joint function  and was not associated with joint damage or development of osteoarthritis and may be beneficial for many people with arthritis." Other studies have found that people with arthritis have experienced improvement in muscle function and other important health benefits from exercise training.

This was true even for older adults with arthritis. (Osteoarthritis patients should avoid high-impact exercises such as running that may put excessive strain on joints, however). People with arthritis should see their doctor or physical or occupational therapist prior to increasing their level of physical activity. Clearly, if you have arthritis, you are not alone  about one in six Americans has some form of the disease. Just as clearly, exercise can play an important role in your arthritis control plan. Its never to late to start an exercise program. Why not talk with your doctor and make a resolution to increase your exercise?

You may think that exercise and arthritis do not go hand in hand. If so, you would be mistaken. It was thought for many years that if you had arthritis you should not exercise because it would damage your joints. Now, however, research has shown that exercise is an essential tool in managing your arthritis.

Regular, moderate exercise offers a whole host of benefits to people with arthritis. Mainly, exercise reduces joint pain and stiffness, builds strong muscle around the joints, and increases flexibility and endurance. But it also helps promote overall health and fitness by giving you more energy, helping you sleep better, controlling your weight, decreasing depression, and giving you more self-esteem. Furthermore, exercise can help stave off other health problems such as osteoporosis and heart disease.

Starting an exercise program can seem like a daunting proposition. The important thing to remember is to start slow and make it fun. It is always good to start with flexibilty exercises, which are basically stretching exercises that will improve your range of motion and help you perform daily activities. Once you feel comfortable you can move on to weight training and endurance exercises such as bicycling. You may be reluctant to exercise because you are in such pain. If this is the case you may want to start with a water exercise program. In the water your body's buoyancy reduces stress on your hips, knees, and spine.

An exercise program can include anything from walking around the block, taking a yoga class, or playing a round of golf. In this section we've attempted to give you all the information you will need on how to start exercising and the proper way to incorporate exercise into the management of your arthritis.

Whatever exercise program you decide on you should always consult with your doctor before starting out. Two other types of health professionals that can help you develop an exercise program that fits your specific needs are a physical or occupational therapist. A physical therapist can show you the proper techniques and precautions when performing certain types of exercise. An occupational therapist can show you how to perform daily activities without putting additional stress on your joints and can provide you with splints or assistive devices that can make working out more comfortable.

Acupuncture for the Relief of Arthritis Pain - Acupuncture, one of the oldest medical procedures in the world, started in China more than 2,000 years ago. Widely practiced in Asia and Europe, acupuncture for pain relief is increasingly popular with people in the United States. But how much do we really know about the effectiveness of acupuncture for the relief of arthritis pain? Here's a look at the Western science behind Chinese needle therapy.

How acupuncture for arthritis pain works - Traditional Chinese medicine is based on the belief that an essential life force called qi ("chee") flows through the body along channels called meridians. These meridians are like rivers that irrigate the body and nourish its tissues. Any obstruction along one of the meridians is like a dam that blocks the vital energy flow, creating pain and disease.

The insertion of hair-thin needles into specific points along the meridians is thought to help unblock the clogged energy channels. There are more than 2,000 such points on the body. Some practitioners use heat, pressure, friction, suction, or electrical impulses along with or instead of the usual needles, but the goal is always the same: to stimulate these points.

If meridians exist, Western scientists have found it hard to locate them. They don't correspond to the pathways of the nervous or circulatory system. That's not to say that acupuncture doesn't work. There have been numerous studies of the therapy's effectiveness, but many have been limited by poor design or small size. When it comes to arthritis pain relief, a 1997 consensus statement from the National Institutes of Health listed several conditions, including osteoarthritis, for which acupuncture "may be useful" when combined with standard medical care.

What to expect during an acupuncture session - The first acupuncture session may last about an hour and a half, with follow-up sessions taking about 30 minutes to an hour. Generally, 3 to 15 needles are put in place and left there for several minutes. Getting stuck with needles may sound more like torture than therapy. Yet most people say there's a slight stinging sensation as the needles enter, and no pain at all after that. Acupuncture needles are very thin and solid with a smooth point, not hollow with cutting edges like hypodermic needles. So, having them inserted may not be as uncomfortable as getting a shot or having blood drawn. The number of sessions needed varies. For a complex, long-standing problem such as arthritis, one or two treatments a week for several months is not uncommon. The cost generally runs $30 to $100 per session or more. In some cases, insurance may cover acupuncture for arthritis pain relief. You may wish to check with your insurance carrier prior to scheduling any acupuncture appointment.

Most people do not experience side effects from acupuncture therapy. However, some side effects such as bleeding or infection can occur and may be minimized through the use of disposable needles. Some people who have never experienced acupuncture may feel dizzy after their first acupuncture treatment. As with any complimentary therapy, you should consult your doctor if you're considering acupuncture for the relief of arthritis pain. He or she may choose to recommend it as part of your regular medical treatment. Your doctor may also refer you to a qualified practitioner.

When choosing an acupuncturist, you should ask about experience and credentials. The American Academy of Medical Acupuncture offers a referral service listing more than 1,500 physicians with specialized training in acupuncture. You can find the referral service on their web site at www.medicalacupuncture.org When considering a non-physician acupuncturist, you should look for one who is licensed and/or certified. The National Certification Commission for Acupuncture and Oriental Medicine certifies practitioners who have passed written and practical exams and who have significant formal schooling or professional experience.

What is arthroscopy? In the past, many orthopaedic injuries required complicated operations with large incisions, long hospital stays and extensive physical therapy. But with the development of arthroscopy, many joint injuries can be precisely evaluated and treated with minimal surgical intervention.

The arthroscope is a fiber optic instrument narrower than a pen which can be put into a joint through small incisions (portals) less than 5 millimeters in length. A camera is attached to the arthroscope and the image is viewed on a television monitor. Small instruments ranging from 3-5 millimeters in size may be inserted through additional portals. These instruments allow the surgeon to feel the various joint structures, diagnose the injury and then repair, reconstruct or remove the damaged structure.

The minimally invasive nature of arthroscopy has quickened the rehabilitation of numerous sports injuries. As our experience grows with the arthroscope, more and more can be done. Today many procedures are done entirely or in combination with the arthroscope. However, some sports injuries are still best treated with standard surgery.

What happens during an arthroscopy? Two small stab wounds are made on either side of the front of the knee. One is for the telescope, the other is either for an examining probe, or the instrument used to perform arthroscopic surgery. In a patient under 60 years of age with no other medical problems, it is usually a day-case procedure. In most cases, no splints or crutches are required and driving and work can be resumed a few days later.

Treatment of upper and lower extremity injuries including arthroscopy of the knee, ankle, shoulder, elbow, and carpal tunnel. Injuries of these areas include: ACL and meniscal injuries, rotator cuff disorders, carpal tunnel syndrome, joint replacement and cartilage grafting.

Arthroscopy of the Foot and Ankle - Technology and unique instrumentation have led to the development of surgical techniques for the diagnosis and repair of joint disorders. Knee arthroscopy was developed in the late 1960's. Small joint arthroscopy was developed in the early 1 980's by orthopaedic and podiatric surgeons and adapted to foot and ankle joints.

Your podiatric surgeon may identify a potential problem with a foot or ankle joint after examining the lower extremity. Arthroscopic surgery may be recommended to confirm a diagnosis or perform a surgical procedure within a joint using an arthroscopic instrument. For example, needle-like probes enter the joint through a small opening of the skin. The podiatric surgeon introduces a tiny camera to inspect the joint. The podiatric surgeon may also insert surgical instruments through another small incision to perform additional procedures within the joint.

Unlike traditional joint surgery that requires large incisions to expose the joint, arthroscopy uses small openings to examine the joint. By eliminating the need for large incisions, arthroscopy reduces the risk of infection and swelling. Podiatric surgeons may perform arthroscopic surgery in hospitals, outpatient surgery centers and in their offices. Arthroscopy is often a "same day" procedure allowing the patient to return home after surgery. Your podiatric surgeon will discuss all aspects of surgery with you.

Arthroscopy allows your podiatric surgeon to look directly into your ankle and reach a more accurate diagnosis. Additional benefits of arthroscopy include a shortened postoperative course and rapid recovery.

Study Suggests Carbohydrates Are Attacked in Arthritis By KENNETH CHANG NYT 8/02. Scientists may have discovered an important, unexpected clue in the long, elusive search for the cause of rheumatoid arthritis. Rheumatoid arthritis, a disease without cure that afflicts more than two million people in the United States, is thought to be caused by out-of-control immune cells that mistakenly attack cartilage and joints. But scientists have been unsure exactly what in the cartilage and joints the immune cells are attacking.

In such autoimmune diseases, the body's defense system typically turns against itself by homing in on and destroying one of the body's proteins. Some scientists have proposed that rheumatoid arthritis attacks collagen, a fibrous protein in cartilage, bone and connective tissues, but the evidence has been ambiguous. The new research suggests that the target of destruction is not a protein, but carbohydrates.

"There has to be some sort of attraction," said Dr. Julia Y. Wang, a professor of medicine at Harvard Medical School and Brigham and Women's Hospital in Boston. "Our study for the first time identifies a direct link between carbohydrates in our tissues, the immune system and rheumatoid arthritis." Dr Wang and Dr. Michael H. Roehrl of Harvard believe the target is a type of carbohydrate known as glycosaminoglycans, a major component of cartilage, joint fluids, connective tissue and skin.

If true, the findings could lead to drugs that reduce or disarm the rampaging cells. Dr. Wang presented the findings yesterday at the national meeting of the American Chemical Society in Boston. Other scientists will have to repeat the experiments before the theory gains acceptance. "I think this is of considerable interest and potentially very important," said Dr. John H. Klippel, medical director of the Arthritis Foundation. "It opens a new way of thinking about this disease. We don't think of the immune system as responding to complex carbohydrates."

In the experiments, Dr. Wang and Dr. Roehrl injected glycosaminoglycans into mice, inducing arthritis-like swelling and inflammation around the animals' joints. "The bones start to erode," Dr. Wang said. The mice also developed lesions in their tendons and skin, also symptoms of rheumatoid arthritis. The researchers developed a test to find immune cells that bind to glycosaminoglycans. The test revealed high concentrations of the cells not only in and around the mice's rheumatoid lesions, but also in bone marrow.

Dr. Wang said she believed that the body produces the carbohydrate-binding cells in bone marrow as a normal matter of course to control the level of glycosaminoglycans in the blood. When the level of the carbohydrate soars for some reason, she said, the immune system appears to respond by churning out more immune cells and some of the excess miss their intended targets in the blood and bind to glycosaminoglycans in the joints instead, to disastrous effect.

Tests on joint tissue from nine human arthritis patients showed the immune cells in people suffering from rheumatoid arthritis, but not other forms of arthritis, which are not autoimmune diseases. Dr Wang said she did not know why the carbohydrate levels might become elevated. Rheumatoid arthritis accounts for about 2.1 mil of the 42 mil cases of arthritis in the US and strikes fairly young in life, usually middle age, but sometimes as early as the 20's and 30's. About 3/4 of patients are women. Currently, some drugs alleviate the disease's painful swelling, but there is no cure.

OSTEO-ARTHRITIS

Non-inflammatory Arthritis Osteoarthritis (OA) is the commonest form of joint disease. It is generally considered to be due to "wear and tear" of the joints leading to damage of the joint surfaces which gives pain on movement.

There are many factors influencing its development, including a family history of OA and previous damage to the joint through injury or surgery. OA is very common in older age groups, but can affect younger people too.

Symptoms and Treatment - Symptoms in OA tend to get worse with activity, so that the end of the day is the worst time (in contrast to inflammatory arthritis). There may be hard, bony swelling of the joints, and a gritty feeling (or even noise) when the joint is moved (this is called crepitus).

Treatment is aimed mainly at symptom relief. Again, simple pain killers and anti-inflammatory drugs are used, and physiotherapy is also valuable in helping to strengthen muscle groups which stabilise and protect the affected joint. When weight-bearing joints such as hips, knees and ankles are involved it is important for overweight patients to loose weight, as this puts extra strain on these joints.

OA, or degenerative joint disease, is one of the oldest and most common types of arthritis. It is characterized by the breakdown of the joint's cartilage. Cartilage is the part of the joint that cushions the ends of bones. Cartilage breakdown causes bones to rub against each other, causing pain and loss of movement.

Most commonly affecting middle-aged and older people, OA can range from very mild to very severe. It affects hands and weight-bearing joints such as knees, hips, feet and the back.

What Causes It? There are many factors that can cause OA. Although age is a risk factor, research has shown that OA is not an inevitable part of aging. Obesity may lead to osteoarthritis of the knees. In addition, people with joint injuries due to sports , work-related activity or accidents may be at increased risk of developing OA.

Genetics has a role in the development of OA, particularly in the hands. Some people may be born with defective cartilage or with slight defects in the way that joints fit together. As a person ages, these defects may cause early cartilage breakdown in the joint. In the process of cartilage breakdown, there may be some inflammation, with enzymes released and more cartilage damage.

How Is It Diagnosed? Physicians make a diagnosis of OA based on a physical exam and history of symptoms. X-rays are used to confirm diagnosis. Most people over 60 reflect the disease on X-ray, and about one-third have actual symptoms.

Treatment Options

Treatment of osteoarthritis focuses on decreasing pain and improving joint movement, and may include:

Exercises to keep joints flexible and improve muscle strength Many different medications are used to control pain, including corticosteroids and NSAIDs. Glucocorticoids injected into joints that are inflamed and not responsive to NSAIDS. For mild pain without inflammation, acetaminophen may be used. Heat/cold therapy for temporary pain relief Joint protection to prevent strain or stress on painful joints Surgery (sometimes) to relieve chronic pain in damaged joints Weight control to prevent extra stress on weight-bearing joints

Who Is At Risk? Osteoarthritis affects an estimated 20.7 million Americans, mostly after age 45. Women are more commonly affected than men.

Other Info - OA is responsible for more than 7 million physician visits per year Eighty percent of people with OA report some form of limitation in movement or activities Knee OA can be as disabling as any cardiovascular disease except stroke As many as half the people who have OA do not know what type of arthritis they have and cannot make informed decisions about their care because treatment options vary among the more that 100 forms of arthritis Musculoskeletal conditions such as OA cost t he U.S. economy nearly $65 billion per year in direct expenses and lost wages and production

OA is a broad term used to refer to more than 100 conditions that can cause pain in the body's joints. OA is the most common form of arthritis - occurring in most adults over 60 yrs of age.

OA is also refered to as "degenerative joint disease". It is generally believed to be caused by the wear and tear that joints are subjected to over time. Some chemical and genetic factors may also play a part in the development of the disease. Risk facto rs such as being overweight, poor posture, congenital joint or bone deformities and injury to a joint may hasten the development of osteoarthritis in people under 60 years of age. Severe osteoarthritis affects three times as many women as men.

The weight bearing joints of the body are the ones most likely to be affected by osteoarthritis. These include the neck, hips, knees and lower back. The symptoms of osteoarthritis are pain, stiffness and swelling of the affected joints. In some cases cre aking or crackling sounds can be heard when the affected joint is moved.

In osteoarthritis, the cartilage (smooth, tough tissue) that covers the ends of the bones becomes irritated and inflammed. The cartilage then becomes soft and wears unevenly. Eventually, the cartilage becomes rough and pieces of it will break off and move around within the joint. If enough damage is done to the layer of cartilage, the bone underneath will be left unprotected and outgrowths of new bone (called osteophytes) will form. These new growths of bone often cause pain and reduced movement in the joint. Thickening of the ends of the bone may occur.

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\3 Bronchitis (Bronicles)

Bronchitis - is an inflammation of the bronchial tubes, or bronchi (the air passages that extend from the wind pipe into the lungs). The inflammation may be caused by a virus, bacteria, smoking or the inhalation of chemical pollutants or dust. When the cells of the bronchial lining tissue are irritated beyond a certain point, the tiny hairs (cilia) within them, which normally trap and eliminate pollutants, stop functioning. Consequently, the air passages become clogged by debris and irritation increases. In response, a heavy secretion of mucus develops, which causes the characteristic cough of bronchitis.

ACUTE BRONCHITIS - Brief bouts of acute bronchitis often evolve from a severe cold. This disorder may also follow or accompany the flu, or it may begin without having had an infection. Acute bronchitis usually lasts about 10 days. Severe cases may also cause general malaise and chest pain.

Seeking prompt treatment is advisable to prevent serious complications. If, for example, the inflammation extends downward to the ends of the bronchial tree and into the small bronchi (bronchioles) and then into the air sacs, bronchopneumonia results. The most effective way to deal with acute bronchitis consists of the following regimen: Avoid fatigue by getting proper rest, stay indoors when the weather is cold and windy and drink large amounts of fluid to help keep the chest mucus liquified. Congestive mucus should be coughed up, so avoid the use of cough suppressants. A doctor may recommend an expectorant to help loosen the mucus. Older people should consult a doctor about whether to take antibiotics to eliminate the risk of serious bacterial infection due to lowered resistance. A doctor should also be consulted when sputum (the mucus mixed with saliva) produced by the coughing is greenish-yellow and thick rather than gray and watery, or when fever rises and chest pains become severe.

CHRONIC BRONCHITIS - Chronic bronchitis is defined as excessive mucus secretion in the bronchi and a chronic or recurrent mucus-producing cough that lasts three or more months and recurs year after year. In diagnosing chronic bronchitis, it is important to rule out heart disease, lung infections, cancer and other disorders that may produce bronchitis-like symptoms. Chronic bronchitis may result from a series of attacks of acute bronchitis, or it may evolve gradually because of heavy smoking or the inhalation of air contaminated with other pollutants in the environment.

It develops slowly over many years and can be fatal. Most often in smokers. When the so-called smoker's cough is constant rather than occasional, the likelihood exists that the mucus-producing layer of the bronchial lining has thickened, narrowing the airways to the point where breathing becomes increasingly difficult. With the immobilization of the cilia that sweep the air clean of foreign irritants, the bronchial ways become more vulnerable to more infection and the spread of tissue damage.

There is no doubt that cigarette smoking is the chief cause of chronic bronchitis, and recent studies indicate that smoking marijuana causes similar damage. Unless some other factor can be isolated as the irritant that causes the symptoms, the first step in dealing with chronic bronchitis is to stop smoking. To alleviate symptoms, a doc may prescribe a combination of meds that will both open up obstructed bronchial airways and thin obstructive mucus so that it can be coughed up more easily. A steam vaporizer near the bed can also be helpful in easing chest congestion at night.

EARLY DETECTION OF TISSUE DAMAGE - Gradual and progressive damage of bronchial tissue cannot be detected by chest x-rays. However, screening tests have been developed recently for measuring the early changes in respiratory function that eventually lead to chronic bronchitis and other respiratory disorders. Evaluation of these tests has shown that a high incidence of disease of the smaller airways is present in young people who have smoked for one to five years. Although completely free of obvious symptoms, these individuals are highly likely candidates for future respiratory diseases.

HELP FROM THE DOC - For the heavy smoker suffering from chronic bronchitis, self-treatment is not recommended. Use of OTC medicated inhalers and cough meds, unless specifically recommended by a doc, can produce undesirable results. Also, there is no conclusive evidence that massive doses of vit-C are effective in preventing bronchitis. If smoking is at the root of the problem and you have difficulty stopping, ask the doc for guidance. There are numerous stop-smoking pgms, ranging from peersupport grps to those involving hypnosis and behavior-modification techniques.

For patients who do not respond to dietary and other lifestyle changes, including a reduction of stress, medications may be prescribed. These may include an anticholinergic agent to reduce the intestinal overactivity, a mild tranquilizer or a sedative.

SUMMING UP - Bronchitis--an inflammation of the bronchial tubes--may be caused by smoking, air pollution and viral or bacterial infections. Complications of a cold or flu may lead to acute bronchitis, which can be treated with bed rest and by drinking plenty of fluids and staying indoors in damp, cold weather. Suffering from a series of acute bronchitis attacks, smoking heavily or inhaling contaminated air for prolonged periods may result in chronic bronchitis. Since chronic bronchitis can be life-threatening, it should receive professional medical attention, no matter what its underlying cause.

Modern Medicine: A bad attack of the Bronickles!
 by Dr Iain Corness, Consultant

There has been a literal epidemic of Bronchitis in the last couple of weeks. The hosp has been full of coughers, in my office three people have been off and a friend's children both ended up in hosp barking madly. Even myself, the bionic plane jumping man, was not immune and after a week am still coughing so badly that the domestic African Grey parrot now sounds definitely consumptive.

So what exactly is Bronchitis? Well, the first thing to understand is that Bronchitis is not a disease, it is a descriptive term. Remembering that anything ending in -itis means inflammation/infection, this means that Bronchitis is a condition affecting your bronchi which are your breathing tubes, leading into the lungs. (They start off large and become smaller as they split and dive deep into the lung tissue and when they become very small they are called bronchioles, (Bronchiolitis)

Now you can see why Bronchitis in different people does not necessarily have the same 'cause'. Generally it is bacterial, and there are many that can infect the bronchi, but it may also be caused by viruses and even irritative chemicals. So if you got over your Bronchitis in a week, don't scoff at someone who is still struggling three weeks later - it was from a different cause.

The symptoms of Bronchitis are mainly deep seated cough-ing, productive of sputum (that ugly glob you spit into the basin). Thick tenacious mucous is very difficult to bring up, and if you smoke, it becomes even harder. Smoking reduces your resistance to bugs, lowers the body's ability to expel the mucous and lengthens recovery time. If the infection does not remain in the bronchi, but gets out into the lung tissue, you are reaching Broncho-pneumonia, even more potentially serious as your respiratory capacity becomes increasingly smaller.

So how do you tell if the infection is just in the tubes, or spreading into the tissue? Very easily - see the doc, who with his stethoscope can listen and determine whether it is happening. Sorry, but you cannot do this on your own, unless, of course, you have your own stethoscope and have undertaken 6 years of intensive med training!

Cure is not all that difficult. An appropriate antibiotic in the case of a bacterial infection will work very quickly, but choosing the correct antibiotic is not a case of Give me a strip of 10 of the pink and green capsules. Clinical suspicion plays a part, experience too, and if necessary, sputum culture and antibiotic sensitivity is needed to optimise the choice. If the cough lasts more than a couple of days - get advice!


\4 Chikungunya virus

Caused by an alpha virus and transmitted by the aedes aegypti mosquito. Characterized by sudden onset, chills and fever, headache, nausea, vomiting, muscle and joint pain, arthralgia and rash. The illness usually lasts 3-7 days. In contrast to dengue fever, chikungunya is noted by a shorter febrile episode, by persistent arthralgia in some cases and usually non-fatal. Responds to aspirin and Ibuprofin, the virus does not cause hemorrhagic fever. Common in Asia, SE Asia, Africa.

The word "chikungunya" is Swahili for "that which bends up," in ref to the stooped posture of patients afflicted with the severe joint pain associated with this disease. The disease was first recognized in epidemic form in East Africa in 1952-53. The etiologic agent, chikungunya virus, is arthropod-borne and has been placed in the family Togaviridae , genus Alphavirus. Human infections are acquired by the bite of infected A.aegypti mosqui-toes, and epidemics are sustained by human-mosquito-human transmission. The epidemic cycle is thus similar to those of dengue and urban yellow fever. Chikungunya virus has been isolated from humans and mosquitoes in eastern, southern, western, and central Africa and in SE Asia, where it has been responsible for illnesses in hundreds to thousands of individuals. The virus has been implicated as the cause of epidemics in Asian countries including Thailand, the Philippines, Cambodia, Vietnam, India, Myanmar (Burma) and Sri Lanka.

ALPHA VIRUSES are known to give rise to a spectrum of disease in humans, ranging from silent asymptomatic infections to undifferentiated febrile illness to devastating encephalitis. The following alphaviruses have been associated primarily with fever and polyarthritis.

Chikungunya virus - CHIK is responsible for extensive Aedes aegypti transmitted urban disease in cities in Africa and major epidemics in Asia. The crippling arthralgia and frequent arthritis that accompany the fever and other systemic symptoms are clinically distinct. Several other toga viruses of the alphavirus genus (Ross River, O'nyong-nyong, etc) have been assoc with a similar syndrome.

CHIK virus is transmitted in the savannahs and forests of tropical Africa by Aedes mosquitoes of the subgenera Stegomyia and Diceromyia. Aedes aegypti is an important vector in urban epidemics in both Africa and Asia. CHIK activity in Asia has been documented since its isolation in BKK in 1958. Other countries which have reported CHIK activity include Cambodia, Vietnam, Myanmar, Sri Lanka, India, Indonesia, and the Philippines.

Clinical Features - CHIK is an acute infection of abrupt onset, heralded by fever and severe arthralgia, followed by other constitutional symptoms and rash, and lasting for a period of 1-7 days. The incubation period is usually 2-3 days, with a range of 1-12 days. Fever rises abruptly, often reaching 39 to 40 degrees centigrade and accompanied by intermittent shaking chills. This acute phase lasts 2-3 days. The temperature may remit for 1-2 days, resulting in a "saddle-back" fever curve.

The arthralgias are polyarticular, migratory, and predominantly affect the small joints of the hands, wrists, ankles and feet, with lesser involvement of larger joints. Pain on movement is worse in the morning, improved by mild exercise, and exacerbated by strenous exercise. Swelling may occur, but fluid accumulation is uncommon. Patients with milder articular manifestations are usually symptom-free within a few weeks, but more severe cases require months to resolve entirely.

Generalized myalgia, as well as back and shoulder pain, is common. Cutaneous manifestations are typical with many patients presenting with a flush over the face and trunk. This is usually followed by a rash generally described as maculopapular. The trunks and limbs are commonly invol-ved, but face, palms and soles may also show lesions. Pruritis or irritation may accompany the eruption.

During the acute disease, most patients will have headache, but it is not usually severe. Photophobia and retroorbital pain also occur but not severe. Conjunctival injection is present in some cases. Some patients will complain of sore throat and have pharyngitis on exam. CHIK infection has a somewhat different picture in younger patients.

Arthralgia and arthritis occur but are less prominent and last a shorter time. Rash may be less frequent; but in infants and younger children, prominent flushing and early appearance of maculopapular or urticarial eruption may be a useful indicator. In Asia, several virus isolations have been made from severely ill children diagnosed as having haemorrhagic fever, similar to DHF.

Treatment - Supportive care with rest is indicated during the acute joint symptoms. Movement and mild exercise tend to improve stiffness and morning arthralgia, but heavy exercise may exacerbate rheumatic symptoms. In unresolved arthritis refractory to aspirin and nonsteroidal antiinflammatory drugs, chloroquine phosphate (250 mg/day) has given promising results.

Diagnosis - The definitive diagnosis can only be made by laboratory means, but CHIK should be suspected when epidemic disease occurs with the characteristic triad of fever, rash and rheumatic manifestations. Virus isolation is readily accomplished by inoculation of mosquito cell culture, mosquito, mammalian cell culture or suckling mice. Viremia will be present in most patients during the first 48 hours of disease and may be detected as late as day 4 in some patients.

Virus-specific IgM antibodies are readily detected by capture ELISA in patients recovering from CHIK infection and they persist in excess of 6 months. Haemagglutination inhibition (HI) antibodies appear with the cessation of viremia. All patients will be positive by day 5 to 7 of illness. Neutralization antibodies parallel HI antibodies.

Chikungunya IgM serology test is avail at Univ Malaya. Ross River Virus (Epidemic Polyarthritis). Striking epidemics of rash and fever were noted in rural Australia as early as 1928. Both endemic and epidemic transmissions in Australia pose major public health problems. Although never fatal, the discomfort and loss of productivity from joint symptoms persist for weeks and occasionally even years. The isolation of Ross River virus from mosquitoes and its serologic association with epidemic polyarthritis led to better understanding of the disease.

RRV is endemic and epidemic in tropical and temperate regions of Australia. Large epidemics have been reported from Northern Territory, Queensland, Victoria, South Australia and New South Wales. Aedes mosquitoes such as Aedes vigilax and Aedes camptorhynchites, Culex annulirostris and Mansonia uniformis have been implicated as vectors.

Clinical Features - In Australian cases, the incubation period has been estimated to be 10-11 days. Onset is relatively sudden and the first symptom is usually joint pain. Rash occurs in the majority of patients, usually coincident with, or 1-2 days after, initial symptoms but in some cases rash preceded joint pains by 11 days and followed them as much as 15 days. The eruption is usually macular, papular, or both and occasionally is accompanied by vesiculation of the papules or petechiae.

The eruption is typically most prominent on the trunk and limbs and may involve the palms, soles, and face. In a minority of patients it is itchy, and it fades within a few days. Constitutional symptoms such as fatigue and lethargy occur in only half the patients. Body temp is normal, or in half the patients modestly elevated for 1-3 days. Myalgia, headache, anorexia, and nausea are common.

Three-fourths of patients have joint manifestations and are incapacitated for considerable periods of time. The severity of the pain interferes with sleeping, walking or grasping everyday objects. Involvement of multiple joints, often asymmetrical and usually migratory, occurs. Wrists, ankles, metacarpophalangeal, interphalangeal, and knee joints are most common, although toes, shoulders, and elbows are also targets.

Joints of the spine, hip and jaws are least often affected. Arthralgias are worse in the mornings or after immobilization; modest exercise may improve them. About one-third of patients will have true arthritis. Periarticular swelling and tenosynovitis are also common. 10-30% of patients will have paresthesias and/or pain in the palms and soles.

Most patients will be unable to work or perform house work; but in 4 weeks, half will be able to resume normal activities, albeit with residual arthralgia. About 10% will still be limited by joint symptoms at 3 months. Occasional patients will continue to have signs and symptoms of articular disease for 1-3 years.

Treatment and Prevention - Aspirin and, if no relief obtained, nonsteroidal antiinflammatory drugs should be used for relief of joint pains. Because eventual complete recovery is always assured, steroids should not be used. A prototype inactivated vaccine has been produced in Australia

\5 Colds, flu

The term common cold reflects the feeling of chilliness on exposure to cold that is part of the onset of symptoms. The feeling was originally believed to have a cause-and-effect relationship with the disease, but this is now known to be incorrect. More than 200 years ago, Benjamin Franklin pointed out that colds are caught from other people, not from exposure to a cold environment.

The common cold is an acute, communicable viral disease characterized by nasal stuffiness, sneezing, runny nose, throat irritation, and, sometimes, fever. There are more than 100 agents that cause the illness, including parainfluenza, influenza, and respiratory syncytial viruses, as well as reoviruses. Rhinoviruses, however, are the most frequent cause of the common cold.

The common cold is an illness that occurs seasonally. Young children can contract between three and eight colds a year, usually coming into contact with the infectious agents in day-care centres or preschools. All available evidence indicates that cold weather, chilled wet feet, and drafts do not cause or increase the susceptibility of people to colds. The usual duration of the illness is about five to seven days, but lingering cough and postnasal discharge may persist for two weeks or more.

Diagnosis of a cold is usually made by medical history alone, although it is possible to take a culture for viruses. There is no effective antiviral agent available for the common cold. Therapy consists of treating the symptomsrelieving aches, fever, and nasal obstruction. One of the greatest medical controversies in the 1970s concerned the efficacy of vitamin C in the prevention or treatment of the common cold. In two carefully controlled studies, administration of ascorbic acid (vitamin C) failed to prevent or decrease the symptoms of the common cold.

The common cold Once a virus becomes established on the respiratory surface of the nose, its activities irritate the nose's cells, which respond by pouring out streams of clear fluid. This fluid acts to dilute the virus and clear it from the nose. The sensory organs in the nose are stung by the inflammatory reaction, thereby setting up sneezing, a second method of expelling the virus. If the virus penetrates more deeply into the upper respiratory tract, coughing is added to the infected person's symptoms in a further effort to get rid of the virus. Symptoms abate as the host's defenses increase, the clear fluid often changing to a thick fluid that is full of the debris of dead cells. The common cold is the expression of an open fight between a rhinovirus and the host's defenses. It takes place in a restricted field, the nasal epithelium (covering layer), but it has, in miniature, all of the characteristics of the wider encounters between human beings and viruses that mark some of the more serious infectious diseases.

Influenza There are three families of influenza viruses, called the A, B, and C viruses. The A viruses cause the great influenza epidemics, and the B viruses cause smaller localized outbreaks; the C viruses are not important causes of disease in human beings.

The A viruses are not a stable family group; in fact, their most constant characteristic is change. The first virus in the family was isolated and identified in 1933 and was termed simply influenza virus A or, sometimes, A0. The virus kept changing but was still recognizable as virus A0 until 1946, by which time its character had changed so much that its designation was changed to A1. This A1 virus recurred for 11 years, continuously changing but still obviously an A1 virus. In 1957 another major change took place, and the A2 virus appeared; it was first detected in China and so was called the A2 Asian influenza virus. The A2 Asian strain continued to appear, changing slightly year by year, until 1968, when a different strain was isolated in Hong Kong. Although it iiffered considerably from the 1957 strain, it still had most of the A2 characteristics. It was therefore called not A3 but A2 Hong Kong 1968.

These changes, or mutations, occur in the antigenic structure of the virus. An antigen is that part of a microorganism that gives it its own specific character and that enables it to be identified from a crowd of otherwise similar microorganisms. The antigens of a germ, also closely connected with its infectivity, stimulate specific antibodies in the body of the infected host. These antibodies protect the host for some time against reinfection, and the microorganism finds it difficult to spread rapidly. When, however, a microorganism undergoes a major change in its antigenic composition, the antibodies provoked by the older antigens give no protection against the new, and the population is wide open to attack by what is, in the antigenic sense, a completely new microorganism. This has two important consequences. The new virus can sweep unhindered through unprotected hosts, and vaccines that gave protection against the old infection are useless against the new one. This happened in 1957 and 1968, when the new Asian and Hong Kong influenza virus strains swept across the globe, causing pandemics of the disease. The symptoms of influenza are always primarily respiratory in character. Some affected people have little more than a severe common cold, while others suffer an overwhelming general infection. The reaction depends upon where the virus strikes and how much resistance it meets. Reactions of the respiratory lining cells are the same as in the common cold, but location can make a major difference. Whereas fluid poured into the nose is an inconvenience to the host, fluid poured into the air cells of the lungs can be disastrous. In fatal cases there is no inflammatory reaction, as in pneumonia; instead, the lungs fill with fluid and death occurs before such a reaction can take place. Influenza is a rapidly disabling illness, but the worst symptoms are usually over in a week unless complications set in. These are usually not caused by the influenza virus itself but by such microorganisms as pneumococci, staphylococci, and Haemophilus influenzae.

A cold is a viral infection that starts in the upper respiratory tract, sometimes spreads to the lower structures, and may contribute secondary infections in the eyes or middle ears. The main differences between the common cold and other respiratory infections are the absence of fever and the relative mildness of the symptoms.

About 200 different strains of virus are capable of producing colds. Frequently two or more different viruses can be isolated during a single episode. The cold is spread by person-to-person contact. People can carry the virus and communicate it without themselves experiencing any of the symptoms. Incubation is shortusually one to four days. The viruses start spreading from an infected person before the symptoms appear, and the spread reaches its peak during the symptomatic phase.

The incidence of colds peaks during the autumn, and minor epidemics commonly occur throughout the winter. The reason for this incidence is unknown; it may not stem mainly from stresses imposed by chilly weather but rather result from the greater amount of time spent indoors, which increases the likelihood of close contact with those persons carrying cold viruses.

Pathologic changes occurring in the mucous membrane that lines the nose, the nasal sinuses, the nasopharynx, and other upper respiratory passages may include tissue swelling, congestion of blood, and oozing of fluids. During the acute phase of the disease, the respiratory secretions are altered by increase in serum proteins. Parts of cells may also be found in the fluids. Tissue repair is rapid and seems complete, although a relationship might exist between colds and more serious respiratory conditions.

Cold symptoms vary from person to person, but in the individual the same symptoms tend to recur in succeeding bouts of infection. Manifestations may include sneezing, headaches, fatigue, chilling, sore throat, inflammation of the nose (rhinitis), and nasal discharge. There is usually no fever. The symptoms usually last for only a few days.

The nasal discharge is the first warning. The secretions become watery, clear, and excessive. Later, they thicken, increase in mucus and pus content, and may colour a yellow-green, with traces of blood. Coughing can be dry or produce amounts of mucus. Other, more serious diseases with similar general symptoms may be mistaken for a cold; some of these are tuberculosis, bronchitis, lung abscesses, and inflammation around the heart (pericarditis).

Treatment is, in most instances, directed toward allaying of symptoms, coupled with rest and adequate fluid intake. Occasionally antibiotics are given to prevent secondary infections.

Pneumonias Pneumonia is an inflammation of the lungs that can be caused by viruses, bacteria, fungi, mycoplasmas, rickettsias, Chlamydia, or parasites. It can also occur as a hypersensitivity, or allergic response, to agents such as mold, humidifiers, and animal excreta.

Viral pneumonias are primarily caused by respiratory syncytial, parainfluenza, and influenza viruses. Pneumonias with similar symptoms are also caused by mycoplasmas (the most common cause of pneumonia in young adults), two species of Chlamydia, and the rickettsial disease known as Q fever. Symptoms of these pneumonias include runny nose, decreased appetite, and low-grade fever, usually followed by respiratory congestion and cough. Diagnosis is established by physical examination and chest X-rays. Nonbacterial pneumonia is treated primarily with supportive care, while specific antimicrobial agents are used for mycoplasmas, Chlamydia, and rickettsias. In general, the prognosis is excellent.

Tuberculosis should always be considered a possibility in any patient with pneumonia, and skin testing is included in the initial examination of patients with lung problems. Fungal infections such as coccidioidomycosis and histoplasmosis should also be considered, particularly if the patient was recently exposed to excavations, backyard swimming pools, old sheds or barns, or dust storms. Other fungal and protozoan parasites (such as Pneumocystis carinii) are common in patients receiving immunosuppressive drugs or in patients with cancer or other chronic diseases.

Hypersensitivity pneumonias are a spectrum of disorders that arise from an allergic response to the inhalation of a variety of organic dusts. Interest in these disorders began in 1932 with the first description of farmer's lung, a disease caused by exposure to moldy hay. Since then, similar diseases have been seen following exposure to moldy sugarcane, room humidifiers, and air-conditioning ducts, all of which contain the fungus Actinomyces.

Other fungi found in barley, maple logs, and wood pulp may cause similar illnesses. In addition, people exposed to rats, gerbils, pigeons, parakeets, and doves may develop manifestations of hypersensitivity pneumonia. Initially, these patients experience fever with chills, cough, shortness of breath, headache, muscle pain, and malaise, all of which may subside in a day if there is no further exposure. A more insidious form of hypersensitivity pneumonia is associated with persistent malaise, fever, weight loss, and cough.

Diagnosis is established by medical history, physical examination, and specific laboratory tests. Treatment consists of removing the patient from the offending environment, bed rest, and supportive care. Bacterial pneumonia has been a frequent and serious human illness throughout recorded history. Examination of Egyptian mummies has revealed that some of them died of the illness. The disease was well known to the Greeks and Romans; the symptoms and treatment of bacterial pneumonia were described by Hippocrates (c. 460c. 377 BC).

Streptococcus pneumoniae is the leading bacterial cause of pneumonia. Staphylococcus aureus, Haemophilus influenzae, and Legionella pneumophila are other important causes. Patients with bacterial pneumonias typically suffer a sudden onset of high fever with chills, cough, chest pain, and difficulty in breathing. Diagnosis usually can be established by taking a culture of the organism from the patient's sputum and by chest X-ray examination. Treatment is with specific antibiotics and supportive care. In the United States the mortality rate of bacterial pneumonia is less than 1 percent, except in the elderly or in individuals with rapidly progressing, overwhelming disease.

When winter temps drop significantly below normal, staying warm and safe can become a challenge. Extremely cold temps often accompany a winter storm, so you may have to cope with power failures and icy roads. Although staying indoors as much as possible can help reduce the risk of car crashes and falls on the ice, you may also face indoor hazards. Many homes will be too cold -- either due to a power failure or because the heating system isn't adequate for the weather. When people must use space heaters and fireplaces to stay warm, the risk of household fires increases, as well as the risk of carbon monoxide poisoning.

Exposure to cold temps, whether indoors or outside, can cause other serious or life-threatening health problems. Infants and the elderly are particularly at risk, but anyone can be affected. To keep yourself and your family safe, you should know how to prevent cold-related health problems and what to do if a cold-weather health emergency arises.

The emergency procs outlined here are not a substitute for training in first aid. However, these proc will help you know when to seek medical care and what to do until help becomes available.

Plan Ahead > Prepare for extremely cold weather every winter. It's always a poss. There are steps you can take in advance for greater wintertime safety in your home and in your car.

Emergency supplies list: An alternate way to heat your home during a power failure: dry firewood for a fireplace or wood stove, or kerosene for a kerosene heater furnace fuel (coal, propane, or oil) electric space heater blankets, matches, multipurpose, dry-chemical fire extinguisher, first aid kit and instruction manual flashlight or battery-powered lantern, battery-powered radio, batt-powered clock or watch, extra batt. non-electric can opener. snow shovel, rock salt, special needs items (diapers, hearing aid batteries, etc.)

Prepare Your Home for Winter. Although periods of extreme cold cannot always be predicted far in advance, weather forecasts can sometimes provide you with several days' notice. Listen to weather forecasts regularly, and check your emergency supplies whenever a period of extreme cold is predicted.

If you plan to use a fireplace or wood stove for emergency heating, have your chimney or flue inspected each year. Ask your local fire department to recommend an inspector, or find one in the yellow pages of your telephone directory under "chimney cleaning."

Also, if you'll be using a fireplace, wood stove, or kerosene heater, install a smoke detector and a batt-operated carbon monoxide detector near the area to be heated. Test them mthly, and replace batts twice yearly.

Your ability to feel a change in temp decreases with age, and older people are more susceptible to health problems caused by cold. If you are more than 65 years old, place an easy-to-read thermometer in an indoor location where you will see it frequently, and check the temp of your home often during the winter months.

Insulate any water lines that run along exterior walls so your water supply will be less likely to freeze. To the extent possible, weatherproof your home by adding weather-stripping, insulation, insulated doors and storm windows, or thermal-pane windows.

Winter Survival Kit For Your HomeKeep several days' supply of these items: Food that needs no cooking or refrigeration, such as bread, crackers, cereal, canned foods, and dried fruits. Remember baby food and formula if you have young children. Water stored in clean containers or purchased, bottled water -- in case your water pipes freeze and rupture -- 5 gallons per person. Medicines that any family member may need.

If your area is prone to long periods of cold temperatures, or if your home is isolated, stock additional amounts of food, water, and medicine.

Prepare Your Car for Winter. You can avoid many dangerous winter travel problems by planning ahead. Have maintenance service on your vehicle as often as the manufacturer recommends. In addition, every fall:

Have the radiator system serviced, or check the antifreeze level yourself with an antifreeze tester. Add antifreeze, as needed. Replace windshield-wiper fluid with a wintertime mixture. Replace any worn tires, and check the air pressure in the tires.

During winter, keep the gas tank near full to help avoid ice in the tank and fuel lines.

Winter Survival Kit for Your CarEquip your car with these items: blankets first aid kit a can and waterproof matches (to melt snow for water) windshield scraper booster cables road maps compass tool kit paper towels bag of sand or cat litter(to pour on ice or snow for added traction) tire chains (in areas with heavy snow) collapsible shovel high-calorie canned or dried foods and a can opener flashlight and extra batteries canned compressed air with sealant (for emergency tire repair) brightly colored cloth

Indoor Safety. Heat Your Home Safely. If you plan to use a wood stove, fireplace, or space heater, be extremely careful. Follow the manufacturer's instructions as well as the advance home safety measures on page 4 and remember these safety tips: Store a multipurpose, dry chemical fire extinguisher near the area to be heated. Do not burn paper in a fireplace. Ensure adequate ventilation if you must use a kerosene heater. Use only the type of fuel your heater is designed to use -- don't substitute. If your heater has a damaged electrical cord or produces sparks, don't use it. Use fireplaces, wood stoves, and other combustion heaters only if they are properly vented to the outside and do not leak flue gas into the indoor air space. Do not place a space heater near things that may catch on fire, such as drapes, furniture, or bedding.

Light and Cook Safely. If there is a power failure: Use batt-powered flashlights or lanterns rather than candles, if poss. Never leave lit candles unattended. Never use a charcoal grill indoors -- the fumes are deadly. If you must use a small, portable gas camp stove indoors, be sure to: use adequate ventilation; and cook several feet away from drapes, furniture, or other things that can catch on fire.

Conserve Heat. You may need fresh air coming in for your heater or for emergency cooking arrangements. But if you don't need extra ventilation, keep as much heat as possible inside your home. Avoid unnecessary opening of doors or windows. Close off unneeded rooms, stuff towels or rags in cracks under doors, and close draperies or cover windows with blankets at night.

Monitor Temp. Infants less than one year old should never sleep in a cold room because (1) infants lose body heat more easily than adults; and (2) unlike adults, infants can't make enough body heat by shivering. Provide warm clothing and a blanket for infants and try to maintain a warm indoor temperature. If the temperature cannot be maintained, make temporary arrangements to stay elsewhere. In an emergency, you can keep an infant warm using your own body heat. If you must sleep, take precautions to prevent rolling on the baby. Pillows and other soft bedding can also present a risk of smothering; remove them from the area near the baby.

Older adults often make less body heat because of a slower metabolism and less physical activity. If you are more than 65 years of age, check the temperature in your home often during severely cold weather. Also, check on elderly friends and neighbors frequently to ensure that their homes are adequately heated.

Keep a Water Supply. Extreme cold can cause water pipes in your home to freeze and sometimes rupture. When very cold temperatures are expected:

Leave all water taps slightly open so they drip continuously. Keep the indoor temperature warm. Improve the circulation of heated air near pipes. For example, open kitchen cabinet doors beneath the kitchen sink.

If your pipes do freeze, do not thaw them with a torch. Instead, thaw them slowly by directing the warm air from an electric hair dryer onto the pipes.

If you cannot thaw your pipes, or the pipes are ruptured, use bottled water or get water from a neighbor's home. As an emergency measure -- if no other water is available -- snow can be melted for water. Bringing water to a rolling boil for one minute will kill most microorganisms or parasites that may be present, but won't remove chemical pollutants sometimes found in snow.

Eat and Drink Wisely. Eating well-balanced meals will help you stay warmer. Do not drink alcoholic beverages -- they cause your body to lose heat more rapidly. Instead, drink warm, sweet beverages such as hot chocolate or sweetened coffee or tea to help maintain your body temperature. If you have any dietary restrictions, ask your doctor.

Outdoor Safety. When the weather is extremely cold, and especially if there are high winds, try to stay indoors. Make any trips outside as brief as possible, and remember these tips to protect your health and safety.

Dress Warmly and Stay Dry Adults and children should wear: a hat a scarf or knit mask to cover face and mouth sleeves that are snug at the wrist mittens (they are warmer than gloves) water-resistant coat and shoes several layers of loose-fitting clothing

Be sure the outer layer of your clothing is tightly woven, preferably wind resistant, to reduce body-heat loss caused by wind. Wool, silk, or polypropylene inner layers of clothing will hold more body heat than cotton. Stay dry -- wet clothing chills the body rapidly. Excess perspiration will increase heat loss, so remove extra layers of clothing whenever you feel too warm. Also, avoid getting gasoline or alcohol on your skin while de-icing and fueling your car or using a snow blower. These materials in contact with the skin greatly increase heat loss from the body. Do not ignore shivering. It's an important first sign that the body is losing heat. Persistent shivering is a signal to return indoors.

Avoid Exertion Cold weather puts an extra strain on the heart. If you have heart disease or high blood pressure, follow your doctor's advice about shoveling snow or performing other hard work in the cold. Otherwise, if you have to do heavy outdoor chores, dress warmly and work slowly. Remember, your body is already working hard just to stay warm, so don't overdo it.

Understand Wind Chill As the speed of the wind increases, it can carry heat away from your body much more quickly. When there are high winds, serious weather-related health problems are more likely, even when temperatures are only cool.

Avoid Ice Walking on ice is extremely dangerous. Many cold-weather injuries result from falls on ice-covered sidewalks, steps, driveways, and porches. Keep your steps and walkways as free of ice as possible using rock salt or another chemical de-icing compound. Sand may also be used on walkways to reduce the risk of slipping.

Be Safe During Recreation If you are hiking, camping, or skiing during cold weather, avoid becoming overtired. Be prepared to take emergency shelter, and carry waterproof matches and paraffin fire starters with you. Carefully watch for signs of cold-weather health problems.

Be Cautious About Travel Listen for radio or television reports of travel advisories issued by the National Weather Service. Avoid traveling on ice-covered roads if at all possible. If you must travel by car, use tire chains. If you must travel, let someone know your destination and when you expect to arrive. Ask them to notify authorities if you are late. Check and restock the winter emergency supplies in your car before you leave. Never pour water on your windshield to remove ice or snow; shattering may occur. Don't rely on a car to provide sufficient heat; the car may break down. Always carry clothing appropriate for the winter conditions.

What to Do if You Get Stranded Staying in your vehicle when stranded is often the safest choice if winter storms create poor visibility or if roadways are ice covered. These steps will increase your safety when stranded:

Tie a brightly colored cloth to the antenna as a signal to rescuers. Move anything you need from the trunk into the passenger area. Wrap your entire body, including your head, in extra clothing, blankets, or newspapers. Stay awake. You will be less vulnerable to cold-related health problems. Run the motor (and heater) for about 10 minutes per hour, opening one window slightly to let in air. Make sure that snow is not blocking the exhaust pipe -- this will reduce the risk of carbon monoxide poisoning. As you sit, keep moving your arms and legs to improve your circulation and stay warmer. Do not eat unmelted snow because it will lower your body temp.

Cold-Weather Health Conditions Serious health problems can result from prolonged exposure to the cold. The most common cold-related problems are hypothermia and frostbite.

Hypothermia. When exposed to cold temperatures, your body begins to lose heat faster than it can be produced. Prolonged exposure to cold will eventually use up your body's stored energy. The result is hypothermia, or abnormally low body temperature. Body temperature that is too low affects the brain, making the victim unable to think clearly or move well. This makes hypothermia particularly dangerous because a person may not know it is happening and won't be able to do anything about it.

Hypothermia is most likely at very cold temperatures, but can occur even at cool temperatures (above 40F) if a person becomes chilled from rain, sweat, or submersion in cold water.

Victims of hypothermia are most often (1) elderly people with inadequate food, clothing, or heating; (2) babies sleeping in cold bedrooms; and (3) people who remain outdoors for long periods -- the homeless, hikers, hunters, etc.

Recognizing Hypothermia. Warnings signs of hypothermia:

Adults: shivering / exhaustion confusion / fumbling hands, memory loss / slurred speech drowsiness

Infants: bright red, cold skin very low energy

What to Do. If you notice any of these signs, take the person's temp. If it is below 95, the situation is an emergency -- get medical attention immediately.

If medical care is not available, begin warming the person, as follows: Get the victim into a warm room or shelter. If the victim has on any wet clothing, remove it. Warm the center of the body first -- chest, neck, head, and groin -- using an electric blanket, if available. Or use skin-to-skin contact under loose, dry layers of blankets, clothing, towels, or sheets. Warm beverages can help increase the body temperature, but do not give alcoholic beverages. Do not try to give beverages to an unconscious person. After body temperature has increased, keep the person dry and wrapped in a warm blanket, including the head and neck. Get medical attention as soon as poss.

A person with severe hypothermia may be unconscious and may not seem to have a pulse or to be breathing. In this case, handle the victim gently, and get emergency assistance immediately. Even if the victim appears dead, CPR should be provided. CPR should continue while the victim is being warmed, until the victim responds or medical aid becomes available. In some cases, hypothermia victims who appear to be dead can be successfully resuscitated.

Frostbite is an injury to the body that is caused by freezing. Frostbite causes a loss of feeling and color in affected areas. It most often affects the nose, ears, cheeks, chin, fingers, or toes. Frostbite can permanently damage the body, and severe cases can lead to amputation. The risk of frostbite is increased in people with reduced blood circulation and among people who are not dressed properly for extremely cold temperatures.

Recognizing Frostbite At the first signs of redness or pain in any skin area, get out of the cold or protect any exposed skin -- frostbite may be beginning. Any of the following signs may indicate frostbite: a white or grayish-yellow skin area skin that feels unusually firm or waxy numbness

A victim is often unaware of frostbite until someone else points it out because the frozen tissues are numb.

What to Do If you detect symptoms of frostbite, seek medical care. Because frostbite and hypothermia both result from exposure, first determine whether the victim also shows signs of hypothermia, as described previously. Hypothermia is a more serious medical condition and requires emergency medical assistance.

If (1) there is frostbite but no sign of hypothermia and (2) immediate medical care is not available, proceed as follows: Get into a warm room as soon as possible. Unless absolutely necessary, do not walk on frostbitten feet or toes -- this increases the damage. Immerse the affected area in warm -- not hot -- water (the temperature should be comfortable to the touch for unaffected parts of the body). Or, warm the affected area using body heat. For example, the heat of an armpit can be used to warm frostbitten fingers. Do not rub the frostbitten area with snow or massage it at all. This can cause more damage. Don't use a heating pad, heat lamp, or the heat of a stove, fireplace, or radiator for warming. Affected areas are numb and can be easily burned.

These procedures are not substitutes for proper medical care. Hypothermia is a medical emergency and frostbite should be evaluated by a health care provider. It is a good idea to take a first aid and emergency resuscitation (CPR) course to prepare for cold-weather health problems. Knowing what to do is an important part of protecting your health and the health of others.

One more cool tip... Taking preventive action is your best defense against having to deal with extreme cold-weather conditions. By preparing your home and car in advance for winter emergencies and by observing safety precautions during times of extremely cold weather, you can reduce the risk of weather-related health problems.


\6 Flu, Influenza, Virus

Asia HKG is the breeding ground and origin of flu viruses due to abundance and proximity of ducks, chickens, pigs, and fish near people. Thirty million died in Spanish Flu pandemic of 1918-1920. Other outbreaks: Asian flu 57, HKG flu 68 killed 46K. Easily transmitted by coughs and sneezes.

Runny nose, fever, chills, headache, sore throat.

PM: Annual innoculation in Oct. Season is Nov-Apr.

Amantadine, a drug. Annual innoculation is best in Oct. before the flu season in Dec-Mar. Rest, fluids, aspirin. If not better in 3 days, see doctor.

Deadliest flu season was 89/90 when 44,000 people croked.

Most prevalent strain is Sydney, H3N2 4/98. Harbin virus H3N2 infected 70% of people in NE China area during yrs 98/00. Others: Type A-H3N2 98/99, 30,000 people died.

A highly contagious infection of the respiratory tract caused by a myxovirus and transmitted by airborne droplet infection. It occurs in isolated cases, epidemics, and pandemics. Symptoms include sore throat, cough, fever, muscular pains, and weakness. The incubation period is brief (1-3 days), and the onset is usually sudden, with chills, fever, and malaise. Treatment is symptomatic and usually involves bed rest, acetaminophen, and drinking of fluids. Fever and constitutional symptoms distinguish influenza from the common cold. Complete recovery in from 3-10 days is the rule, but bacterial pneumonia may occur among high-risk patients, such as the elderly, the very young, and people who have chronic pulmonary disease.

Three main strains of flu virus have been recognized: types A, B, and C. New strains of the virus emerge at regular intervals and are named according to their geo-graphic origin. Asian flu is a type A influenza. Yearly vaccination with the currently prevalent strain of flu virus is recommended for elderly or debilitated persons and health care personnel. Treatment or prophylaxis in high-risk patients may be achieved with amantadine.

Centers for Disease Control and Prevention INFLUENZA Clinical Features of Influenza | The Influenza Viruses | Natural History of Human Influenza

Clinical Features of Influenza Influenza, commonly called "the flu," is caused by viruses that infect the respiratory tract. Compared with most other viral respiratory infections, such as the common cold, influenza infection often causes a more severe illness. Typical clinical features of influenza include fever (usually 100F to 103F in adults and often even higher in children) and respiratory symptoms, such as cough, sore throat, runny or stuffy nose, as well as headache, muscle aches, and often extreme fatigue. Although nausea, vomiting, and diarrhea can sometimes accompany influenza infection, especially in children, gastrointestinal symptoms are rarely prominent. The term "stomach flu" is a misnomer that is sometimes used to describe gastrointestinal illnesses caused by other microorganisms.

Most people who get the flu recover completely in 1 to 2 weeks, but some people develop serious and potentially life-threatening medical complications, such as pneumonia. In an average year, influenza is associated with about 20,000 deaths nationwide and many more hospitalizations. Flu-related complications can occur at any age; however, the elderly and people with chronic health problems are much more likely to develop serious complications after influenza infection than are younger, healthier people.

The Influenza Viruses Influenza viruses are divided into three types, designated A, B, and C. Influenza types A and B are responsible for epidemics of respiratory illness that occur almost every winter and are often associated with increased rates for hospitalization and death. Influenza type C differs from types A and B in some important ways. Type C infection usually causes either a very mild respiratory illness or no symptoms at all; it does not cause epidemics and does not have the severe public health impact that influenza types A and B do. Efforts to control the impact of influenza are aimed at types A and B, and the remainder of this discussion will be devoted only to these two types.

Influenza viruses continually change over time, usually by mutation. This constant changing enables the virus to evade the immune system of its host, so that people are susceptible to influenza virus infection throughout life. This process works as follows: a person infected with influenza virus develops antibody against that virus; as the virus changes, the "older" antibody no longer recognizes the "newer" virus, and reinfection can occur. The older antibody can, however, provide partial protection against reinfection. Currently, three different influenza strains circulate worldwide: two type A viruses and one type B. Type A viruses are divided into subtypes based on differences in two viral proteins called the hemagglutinin (H) and the neuraminidase (N). The current subtypes of influenza A are designated A(H1N1) and A(H3N2).

Influenza type A viruses undergo two kinds of changes. One is a series of mutations that occur over time and cause a gradual evolution of the virus. This is called antigenic "drift." The other kind of change is an abrupt change in the hemagglutinin and/or the neuraminidase proteins. This is called antigenic "shift." In this case, a new subtype of the virus suddenly emerges. Type A viruses undergo both kinds of changes; influenza type B viruses change only by the more gradual process of antigenic drift.

Natural History of Human Influenza Influenza A and B viruses continually undergo antigenic drift. This process accounts for most of the changes that occur in the viruses from one influenza season to another. Antigenic shift occurs only occasionally. When it does occur, large numbers of people, and sometimes the entire population, have no antibody protection against the virus. This may result in a worldwide epidemic, called a pandemic. During this century, pandemics occurred in 1918, 1957, and 1968, each of which resulted in large numbers of deaths, as noted below.

Mortality associated with pandemics:

1918-19 "Spanish flu" A(H1N1) -- Caused the highest known influenza-related mortality: approximately 500,000 deaths occurred in the United States, 20 million worldwide.

1957-58 "Asian flu" A(H2N2) -- 70,000 deaths in the United States. 1968-69 "Hong-Kong flu" A(H3N2) -- 34,000 deaths in the United States.

The emergence of the "Hong Kong flu" in 1968-69 marked the beginning of the type A(H3N2) era. When this virus first emerged, it was associated with lower mortality than that caused by the two previous pandemic viruses. Several possible reasons for this lower mortality have been hypothesized. First, only the hemagglutinin changed from the "Asian" strain [type A(H2N2)]; the neuraminidase (N2) stayed the same, and therefore existing antibody could be expected to offer some protection. A second possibility is suggested by evidence that a virus with a similar hemagglutinin may have circulated from the late 1890s to the early 1900s. If this were the case, people who were in their sixties and older in 1968 may have had some protection from antibody acquired in their youth.

There are still many things about influenza viruses that are not understood. Although the newly emerged type A(H3N2) virus caused only moderate mortality in 1968 compared with other pandemic viruses, this virus has continued to cause substantial mortality as it has continued to circulate and evolve. In the years since its emergence, type A(H3N2) epidemics have caused more than 400,000 deaths in the United States alone, and more than 90% of these deaths have occurred among elderly people. Of the influenza viruses currently in worldwide circulation, A(H3N2) still has the most severe overall impact.

The other influenza A subtype currently in circulation, type A(H1N1), also has an interesting history. After the devastating pandemic of 1918-19, this subtype continued to circulate and undergo antigenic drift. It periodically caused large epidemics, but never on the scale of the 1918-19 pandemic. When the "Asian" strain [(A(H2N2)] emerged in 1957, the A(H1N1) viruses disappeared (as did the A(H2N2) viruses when the "Hong Kong" virus emerged in 1968). In 1977, the A(H1N1) viruses reappeared and have cocirculated with A(H3N2) viruses ever since. However, the impact of A(H1N1) has been different during its most recent appearance. The virus that reappeared in 1977 was virtually identical to an A(H1N1) virus that circulated in 1950. Therefore, most people born before 1950 were immune, and epidemics caused by A(H1N1) viruses since 1977 have primarily affected younger people. The fact that the elderly appear to have natural protection against current A(H1N1) viruses probably explains the low mortality associated with recent epidemics in which this subtype was the predominant strain. However, as A(H1N1) viruses continue to evolve, they could begin to have a more severe impact on the elderly.

For information on influenza A(H5N1) or A(H9N2) in Hong Kong, please go back to the CDC Influenza Homepage.

\7 constipation

Many people believe that if they don't have a bowel movement everyday, they have constipation and need to take a laxative. If you are one of those people, you are probably wrong. If you usually feel bloated, swell up, or otherwise uncomfortable when you have bowel movements, or if you frequently have fewer than three bowel movements a week, you should see a doctor. Let the doctor decide if you are constipated, and if so, what to do about it.

Constipation is commonest in the elderly, and usually results from a lifetime of not eating enough fiber-rich foods such as fruit, fresh vegetables and high fiber breads and cereals. It also frequently occurs when a person's surroundings or food change, in which case it usually goes away on its own in a few days. If the symptoms last more than two to three weeks, you need to see a doctor because constipation can indicate other problems.

If necessary, the doctor will check to see if you have a pelvic or gallbladder disease, check for blood or parasites in your stool, and see if you have irritable bowel syndrome. For most people, however, an increase in fruits, vegetables, and cereals coupled with regular exercise and lots of water are the best way to treat and prevent constipation.

Summary:  BACKGROUND: Polyethylene glycol (PEG) 3350 is a non-absorbable, non-metabolised osmotic agent used in lavage solutions for gut cleansing. AIMS: To compare the efficacy of PEG and lactulose in chronic constipation.

METHODS: A total of 115 patients with chronic constipation entered a multicentre, randomised, comparative trial. They initially received two sachets containing either PEG (13 g/sachet) or lactulose (10 g/sachet) and were given an option to change the dose to one or three sachets/day, depending on response. RESULTS: Ninety nine patients completed the trial. After four weeks, patients in the PEG group (n=50) had a higher number of stools and a lower median daily score for straining at stool than patients in the lactulose group (n=49). Overall improvement was greater in the PEG group.

Clinical tolerance was similar in the two groups, but flatus was less frequently reported in the PEG group. The mean number of liquid stools was higher in the PEG group but the difference was significant only for the first two weeks. There were no serious adverse events and no significant change in laboratory tests in either group. At the end of the study, the number of sachets used by the patients was 1.6 (0.7)/day in the PEG group and 2.1 (0.7)/day in the lactulose group. Sixty one patients completed a further two months open study of one to three sachets PEG daily; there was no loss of efficacy and no serious toxicity. Conclusion: Low dose PEG 3350 was more effective than lactulose and better tolerated.

There is wide variability in what is considered normal patterns of bowel elimination. While some healthy people may have consistently soft or near runny stools, others may have consistently hard firm stools, but no difficulty in passing them.

When the stool is hard, infrequent, and requires significant effort to pass, the person has constipation. Constipation may cause discomfort with passage of stools, and passage of large, wide stools may tear the mucosal membrane of the anus, especially in children, causing bleeding and the possibility of an anal fissure.

Constipation can be caused by changes in diet, decrease in physical activity, lack of toilet facilities, behavior and psychological problems, dehydration, diseases of the bowel, neurological diseases, congenital diseases, medications, and many other causes.

Dehydration - The lack of adequate body fluids needed for the body to carry on normal functions at an optimal level. Dehydration can be caused by fluid loss (through vomiting, diarrhea or excessive urination), inadequate intake, or a combination of both. The most common cause of dehydration in infants and children is acute gastro-enteritis with its associated vomiting and diarrhea.

Dehydration is classified as mild, moderate, or severe based on the percentage of body weight lost during the acute illness. Depending on age, mild dehydration is seen with a loss of 3-5% of body weight. Moderate dehydration is seen with a 6-10% loss of body weight. Severe dehydra-tion, which is a life-threatening emergency, occurs when more than 9-15% of body weight is lost.

Constipation is the infrequent and difficulty in eliminating feces. Normal frequentcy is daily to three times a week. Longer than that, the shit hardens causing difficulty and pain. It is associated with small, hard, or drystools. Since bowel patterns differ among individuals, infrequ- ency alone does not necessarily imply constipation.

Main cause of constipation is diet; high in animal fats and/or sweets. Other causes: Dehydration, medication, iron, lack of execise, drugs, lifestyle. Other causes; not eenough fluids, laxative overuse, or enough fiber. A loss of muscle tone in the abdomen and pelvic area as a result of too little exercise may cause constipation. It can also be caused by certain disorders, diseases, and medications. Lack of exercise is a contributing factor.

Symptoms may include: Small bowel movements hard, dry bowel movements difficult bowel movements pain during bowelmovements. Do the following to ease your constipation: Do not delay bowel movements. Go shit whenever you feel you need to. Drink a lot of fluids. Increase the amount of fiber in your diet. Discuss with your doctor whether any of your medications may be causing constipation. Get a lot of exercise.

Tell your doctor if: You start having constipation after years of normal bowel movements. You have pain while shitting or for some time afterward. You see blood in your shit. You lose weight unexpectedly. How can I take care of myself? To help take care of yourself, follow these guidelines: Eat fresh vegetables and fruit daily.

Exercise regularly. For example, walk for 20 minutes every day. Drink prune juice or eat stewed fruits at breakfast. Drink plenty of fluids. Take a fiber product like Metamucil or Citrucel once or twice a day forseveral days if you are constipated. If the problem continues, check with your doctor, but generally you can take one to three doses of these products a day, regularly. Avoid using laxatives. Avoid using cathartics, which are products that will cause the runs. Cathartics irritate the lining of the intestines. If necessary, ask your doctor about giving yourself an enema.


\8 Alzheimer's

A common degenerative brain disease that impairs mental and emotional function in older adults, causing them to lose their memory and ability to care for themselves. Although there is extensive ongoing research, no cure has yet been found for Alzheimer's .

A brain disorder marked by a slowly deterioration of brain tissue and therefore, of brain function as well. This gradual decline in mental capacity affects memory and reasoning abilities in about 6% of people over the age of 65, in more than 10% of those between 75-85, and in about 20% of those over 85.

The disease is the most common form of dementia (a general term for mental decline, especially in memory and thought processes) among the elderly. It was first described early in the twentieth century by German neurologist Alois Alzheimer. The disease ca uses irreversible changes in nerve cells in certain vulnerable areas of the brain, including nerve cell loss, abnormal tangles within nerve cells, and deficiencies of several chemicals in the brain.

The disease starts slowly, usullly with forgetfulness and personality changes, but daily activities soon become impossible, leaving the patient bewildered and frustrated. Eventually, he or she loses control of mental and bodily functions and becomes comp letely dependent on others for all care. Most patients die within 5 to 10 years after diagnosis, often from infections such as pneumonia. Among American adults, Alzheimer's disease is the fourth leading cause of death.

No single cause of Alzheimer's disease has been found, but the following have been strongly associated with its development: genetic factors, such as inheriting an abnormal gene

neurochemical factors, such as a deficiency of several neurotransmitters (chemicals essential for transmitting nerve messages)

environmental factors, such as exposure to excess aluminum and manganese

viral factors, such as exposure to a slow-acting virus

immunological factors, such as a malfunction of the immune system whereby the body begins to attack its own tissues, producing antibodies to its own cells.

The only identified risk factors for Alzheimer's disease are advancing age and family history of dementia, Alzheimer's disease, or Down syndrome.

SIGNS AND SYMPTOMS of Alzheimer's disease vary with the stage of the disease, as outlined below:

Stage 1 forgetfulness poor insight problems finding the right word to say personality changes problems with calculations losing or misplacing things repeating questions or statements a minor degree of disorientation

Stage 2 worsening memory using words less and less appropriately loss of basic self-care skills further personality changes agitation inability to recognize distant family or friends difficulty communicating wandering off having delusions and hallucinations

Stage 3 total helplessness hostility complete loss of memory loss of bladder and bowel control total lack of comprehension loss of motor skills inability to communicate

DETECTION AND DIAGNOSIS Since some cases of mental decline in elderly people can be reversed once the cause is found, the doctor will screen the patient for many other problems, scch as heart disease, anemia, side effects of medications, and depression.  The doctor will take a detailed medical history, including a complete inventory of any prescription and over-the-counter drugs the patient is taking, and do a physical and a neurological examination, including a functional and mental status assessment te st. A variety of laboratory examinations will also help with the diagnosis, such as blood and urine tests, a computed tomography (CT) scan to get clear cross-sectional images of the brain, and magnetic resonance imaging (MRI) for an even more detailed vi ew of the soft tissues inside the skull. The doctor might also request positron emission tomography (PET) to detect structural problems of the head and the brain.

TREATMENT Alzheimer's disease cannot be cured, but drug therapy can help slow its progress in the early stages. Some improvement in memory and mental functioning is possible with tacrine (Cognex), a drug that slows the breakdown of a neurotransmitter tha t helps coordinate memory and learning. The drug's effect is temporary, but it might help for as long as 6 months. Doctors might also prescribe a wide variety of other types of drugs to help control the agitation, mental problems, depression, anxiety, ap athy, hostility, and sleep and appetite disturbances common in Alzheimer's patients.

To help keep the patient functioning as well as possible for as long as possible, the following measures might also help:

eating a proper diet getting daily exercise, including walking keeping the home environment safe and stable sticking to familiar routines

writing down simple instructions and reminders, such as lists of daily activities, labels on frequently used items, and notes on a prominently displayed calendar

continuing intellectual stimulation and social contact having the patient wear an identification bracelet

distracting the patient when he is frustrated or agitated

encouraging the patient to reminisce, as long-term memory is usually less impaired

participating in support groups (for the patient as well as for the family and caregivers)

The physical, emotional and financial burdens of caring for a person with Alzheimer's disease can be enormous. Family members and other caregivers can become exhausted and demoralized by the all-consuming task. They lose freedom and privacy and sacrifice their own needs, often without getting any thanks in return. Any resentment they feel builds as they worry about inheriting the disease and feel guilty about their anger, about past mistakes, about lying to the patient in small ways, or about denying th e patient's wishes.

Existing family problems may worsen as the patient becomes more dependent. A formerly passive spouse might find it difficult to make decisions for the patient. It is not surprising that caregivers have a higher rate of depression than the actual patients with Alzheimer's disease do. Some caregivers join support groups to help deal with the isolation they feel, to comfort one another, and to exchange advice. Such groups are available through local chapters of the Alzheimer's Association, and can help car egivers realize that they need time to lead their own lives. That's where respite care can help, with services like housekeepers, home attendants, visiting nurses, day care centers, senior citizen programs, and day hospitals, not to mention case managers to coordinate such services. Sadly, many families know too little about these services or are too shy or too proud to seek help.

Although family members are the usual caregivers for people with Alzheimer's disease in the earlier stages, the demands eventually become too great even for the most devoted wife, daughter, husband, or son. Most Americans with the disease ultimately wind up in nursing homes or long-term care facilities. Many families take this step only after their resources are exhausted and the patient is already near death. Families sometimes wait too long and have to be persuaded by outsiders to do what is best for  all involved. To avoid having to make a hasty decision during a crisis, it is best to start exploring the options as soon as the patient begins to need supervision.

PREVENTION Although Alzheimer's disease cannot be prevented, early detection and appropriate treatment might help slow its progress. Toward that end, the Agency for Health Care Policy Research, part of the U.S. Department of Health and Human Services, su ggests the following series of questions to ask to help recognize the condition:

Does the person have problems with any of these activities?

Learning and remembering new info. Does he repeat things he says or does? Forget conversations or appts? Forget where he put things? Handling complex tasks. Does he have trouble performing tasks that require many steps, such as balancing a checkbook or  cooking a meal? Reasoning ability. Does he have trouble solving everyday problems at work or at home, such as knowing what to do if the bathroom is flooded? Spatial ability and orientation. Does he have trouble driving or finding his way around familia r places? Language. Does he have trouble finding the words to express what he wants to say? Behavior. Does he have trouble paying attention? Is he more irritable or less trusting than usual?

GLOSSARY OF MEDICAL TERMS

anemia: condition of having too few or inadequate red blood cells

antibodies: drugs that block the action of histamine, a compound that expands blood vessels and constricts breathing passages

Down syndrome: a combination of physical abnormalities and mental retardation caused by a defective gene

gene: basic unit of protein molecules that transmits inherited traits, like eye color or blood type

immune system: the sum total of the body's response to foreign invaders, such as bacteria or transplanted tissue

neurological: pertaining to the brain and spinal cord, the body's main coordinating and controlling center

In Struggle Against Alzheimer's, Hope May Be Over the Counter
 By DENISE GRADY Jan 22 02.

For people worried about developing Alzheimer's disease, a recent study seemed to offer a rare hint of good news. Dutch researchers found that people who took anti-inflammatory drugs like ibuprofen or naproxen for at least two years were only one-sixth a s likely to get Alzheimer's as people who did not take the drugs. The medicines are widely used: ibuprofen is the main ingredient in Advil and Motrin, and naproxen is found in Aleve.

The study, published in November in The New England Journal of Medicine, was not considered definitive, but several other trials are under way, also testing anti-inflammatory drugs in people with Alzheimer's disease or at high risk of developing it. The  newer trials, more rigorously designed than the Dutch one, are expected to provide clearer answers about whether the drugs can ward off Alzheimer's.

The studies reflect scientists' growing interest in the idea that a common condition, inflammation, may underlie many chronic and debilitating diseases  like Alzheimer's, heart disease, osteoporosis and diabetes  and that drugs that fight inflammation  may have a role in preventing or delaying those diseases, or at least slowing them down.

The drugs being studied belong to the class known as Nsaids (pronounced EN- seds)  nonsteroidal anti-inflammatory drugs. In addition to ibuprofen and naproxen, the class includes aspirin and the prescription drugs known as cox-2 inhibitors, celecoxib (C elebrex) and rofecoxib (Vioxx). Prescription anti-inflammatory drugs also include diclofenac (Voltaren), indomethacin (Indocin) and other less commonly used drugs.

Acetaminophen (Tylenol) is not part of the group; it treats pain and fever, but does not have the same anti-inflammatory properties as the other drugs.

Nonsteroidal anti-inflammatories are among the most popular medicines in America. They ease pain and fever, and millions of people take them for headaches, backaches, arthritis, colds and the flu. Millions with risk factors for cardiovascular disease hav e also been advised to take an aspirin a day to lower the risk of a heart attack or the most common type of stroke, which occurs when an artery supplying blood to the brain is blocked. Aspirin is the only anti-inflammatory drug that has been proved to ha ve this benefit. Originally, the effect was attributed to aspirin's ability to prevent blood clots, which can cause heart attacks or strokes. But now, researchers think part of the protective effect may come from aspirin's ability to quell inflammation i n the arteries, helping to prevent blockages.

But apart from recommending an aspirin a day, or a baby aspirin, to patients at risk for heart disease, doctors are not encouraging people to take other anti-inflammatory drugs to prevent Alzheimer's or any other chronic illnesses. They say it is too soo n: there is no definitive evidence that the drugs will work. And regular use is not safe for everyone.

Side effects can include stomachache or nausea in up to 20 percent of patients, and stomach or intestinal ulcers and bleeding in 2 percent to 4 percent of those who take the drugs for a year, especially people over 60. The stomach bleeding can occur with little warning, and it can be fatal. Even low doses of aspirin can cause stomach bleeding in some people. (Cox-2 drugs are thought less likely to cause stomach bleeding.)

Aspirin can also cause a slight increase in the risk of a less common type of stroke, one brought on by bleeding in the brain. In people with kidney disease, anti-inflammatory drugs may make the problem worse. A study has suggested  though it is not def initive  that cox-2 drugs may cause a slight increase in heart attack risk. Finally, researchers say that the anti- inflammatory drugs' interactions with other drugs, including aspirin, need further study.

Recent studies have highlighted some of the uncertainty about the effects of long- term use of Nsaids. Last month, a study suggested that if aspirin users took ibuprofen, too, it might cancel out aspirin's cardiovascular benefit. The researchers, led by  Dr. Garret A. FitzGerald at the University of Pennsylvania, did the study because they knew that many people took more than one anti-inflammatory drug at a time.

Aspirin helps prevent heart attacks by acting on blood cells known as platelets, which play a major role in clotting. Aspirin prevents platelets from sticking to each other; it does so by blocking the enzyme cyclooxygenase, or cox, and stopping productio n of a substance called thromboxane, which makes platelets sticky. Aspirin's effect on platelets is irreversible and lasts for as long as the cells live. But the body is constantly making new platelets.

The researchers found that if people took aspirin first, and took one dose of ibuprofen two hours later, the aspirin still prevented their platelets from clumping. But if for six days they took ibuprofen first, or took several doses a day after taking as pirin, the effect of aspirin was blunted, and the platelets became sticky. Ibuprofen temporarily attaches itself to the same part of the enzyme as aspirin, interfering with its action.

Unlike ibuprofen, other painkillers  acetaminophen, rofecoxib, diclofenac  did not interfere with aspirin because the molecules have a different structure. But indomethacin might act like ibuprofen, the researchers said. The study, published in The New England Journal of Medicine, was widely reported, and the findings worried many people who take aspirin in hope of preventing a heart attack.

Dr Leslie J. Crofford, a rheumatologist and assoc prof of internal medicine at the Univ of Michigan, said some of her patients called to ask, "Will I have a heart attack if I take an Advil?" Dr Crofford has been telling them that occasional use is of no  concern, especially since most people take their aspirin in the morning.

"This idea  that if you take Advil for a headache, it will interfere with aspirin's work  is nonsense," she said. But she and other experts cautioned that the Pennsylvania study did suggest that steady use of ibuprofen  several doses a day for weeks o r months at a time  might interfere with aspirin.

For patients who take aspirin to lower the risk of heart attacks but also need regular doses of an anti-inflammatory drug, Dr. Crofford said that she would recommend an anti-inflammatory other than ibuprofen.

For those who like ibuprofen best for chronic pain but also have a risk of heart attack, Dr. David P. Faxon, chief of cardiology at the University of Chicago and president of the American heart association, said: "They need to consult physicians. If they need to be on a blood thinner like aspirin, they may need to switch to another blood thinner like Plavix." Plavix is a prescription drug that makes platelets less sticky, but it is not an anti-inflammatory.

Another article in the same issue of The New England Journal as Dr. FitzGerald's study suggested that in people who already had chronic kidney failure, aspirin and acetaminophen might make the condition worse, with a slightly higher risk from acetaminoph en. The drugs may block the production of substances that are needed by the kidney.

But the researchers said that they could not be sure whether the patients' use of anti- inflammatory drugs was a cause of kidney disease, or an effect of it. In some of the patients, conditions that caused their kidney problems may also have caused pain, prompting them to use painkillers more often than healthy people.

Despite the uncertainty, though, Dr. Faxon and Dr. Crofford warned that people with kidney failure, which in its early stages often has no symptoms, had to be very careful in using anti-inflammatory drugs.

But, Dr Faxon said, "A lot of people with kidney disease also have heart disease, and we keep them on aspirin because the heart disease risk is worse. It's always a balancing of risks with medicines."


\9 heart palpitations, arrythmia

FUNCTIONAL AFFECTIONS OF THE HEART (1) Palpitation - This is a functional derangement of the heart that may have many causes. Indigestion is a common cause. Fright, worry--in fact, overworked emotions--may become a cause of heart palpitation. Heart palpitation is one of the first indications of depleted blood or loss of blood. Anemic people suffer with palpitation. Those who use tobacco, coffee, tea, or other stimulants daily and excessively arrive at a stage where they will be troubled severely with heart palpitation.

When women are going through the change of life, they are often troubled with this symptom. Young girls coming into puberty are troubled with this symptom very often. The hysteric and neurasthenic are very prone to have this symptom, but there is nearly always dyspepsia as the exciting cause.

Onanism and excessive venery are common causes. When a youth complains of palpitation, and there are dilation of the pupils, cold, clammy hands and feet, and a doughy skin, there is not only indigestion, but there is a strong probability of self-abuse. The same symptoms developed in maturity point to excessive venery. In some subjects the palpitation is accompanied by flushing of the skin; in others, by deathly pallor. A palpitation that follows exertion, or a short run, or violent exercise of any kind, indicates an absence of exercise. Those who carry a little too much flesh, and whose hearts are pressed upon, will have an increased action of the heart, with precordial oppression--they will be pressed for breath. This is an indication that more exercise should be taken.

Treatment.--Correct whatever the cause is. Where it is a result of the use of stimulants, stimulants must be stopped. If it is the result of imprudent eating, overeating, or anything of that kind, the cause must be removed,

(2) Arrhythmia - This means absence of rhythm of the heart-beat. A flushing of the skin about the face and neck, coming in patches, indicates sympathetic nervous irritation of the heart. Where this symptom is extreme it is an indication of chronic toxin poisoning from gastro-intestinal indigestion; or it may be due to the use of stimulants--coffee, tea, alcoholics, tobacco, etc. Excessive venery is one of the causes. Regulating the diet and correcting the life of the patient will usually control the worst forms of this derangement.

(3) Rapid Heart (Tachycardia) - Some people naturally have rapid hearts, and there are others who naturally have slow hearts. This is told by the profession, and laymen will readily believe that it is possible. Where the range is below sixty-four pulse-beats to the minute, or above seventy-eight, regularly day after day, there is a cause for it; it is not natural, but pathological. Where the pulse drops below the normal it is due to obstruction of the circulation, and also to abuse of the digestion and assimilation. This is one of the symptoms of excessive venery in youth, to self-abuse. This depressed condition, or slow heart-beat, may first be preceded by a too rapid heart; for over-stimulation and shocks of all kinds will first send the heart flying. Then, as the organism becomes accustomed to the abuse, the heart requires more and more stimulation to keep it at its high rate of speed; and as there is possibility of a falling-off of the exciting cause from many reasons, it would be perfectly natural for the heart to go below the normal, and continue below the normal until there has been a readjustment and a reorganizing of nerve impulses--until the enervation has been overcome and nerve resistance established.

Violent exercise and fever produce rapid heart action. A continuous state of fear will develop rapid action of the heart. Brain tumors, blood clots on the brain, etc., causing pressure on the nerves of the heart, will cause rapid heart action. Ovarian irritation and uterine diseases frequently cause rapid heart action. But beyond and back of these symptoms are indigestion and more or less emotionalism. Rapid heart action oftener comes from chronic irritation of the stomach than from any other cause. The irritation may be caused by acid fermentation of foods, coffee, tobacco, alcoholics, etc. We cannot have irritation of the stomach without a cause; hence where there is irritation of the stomach, causing rapid heart action, it must be considered that the stomach is only a go-between which passes on the effect from other causes.

(4) Slow Heart - This is supposed to be a family peculiarity. Napoleon's heart-beat was about forty to the minute, and he died of cancer of the stomach. No doubt the mental strain under which he lived had a depressing effect upon his digestion and heart action. There is no question but that he kept up a constant gastric irritation from the anxiety he must have had concerning his activities. His life was so intense that his nerve energy was drained away, enervating the stomach and bowels, When he ate, he did not have the nerve energy to do perfect digesting; hence more or less fermentation, decomposition, and toxin poisoning took place. This produced hardening of the tissues, especially ulceration and cancer of the stomach. This is the price that an ambitious man pays for success.

III. ANGINA PECTORIS - Neuralgia of the heart, or breast pang, is a sympathetic affection. It is caused by a hardening of the blood vessels. It is supposed that the root of the aorta, and the coronary arteries, are hardened. The fact of the matter is that such diseases often come from an enervated state of the nervous system from overindulgence in stimulating foods, stimulating drugs, and excessive venery.

Symptoms.--The disease is characterized by agonizing pain in the region of the heart. The patient will be walking along the street, be taken suddenly with a spasm, and be compelled to take hold of any object that comes to hand, and hold to it to keep him from falling. Not that the legs cannot hold him up, but the pain is so excruciating that is is liable to force him to the ground. More men are affected than women. In all severe cases the patients feel as if every attack they have would be the last. It is strictly a disease of adult life, and I should say it is a sign of premature aging.

If the disease follows apparently as a sequel of other diseases, such as influenza, so far as the preceding disease is concerned it has nothing to do, except that it is the last straw which breaks down complete resistance and makes the victim subject to the disease. The paroxysms are usually induced by a little exertion or overstimulation--a. cup of coffee, or smoking a strong cigar, or walking up a slight incline, or attempting to climb stairs; anything that takes sudden muscular effort is liable to precipitate an attack. I believe that those who have cultivated an irritable state of the mind and who are steeped in stimulating habits are the type of people who come down with this disease.

Diagnosis.--The patient may have a slight precordial pain and sense of distress or uneasiness in the region of the heart, which radiates down the arm or up the side of the neck. The first indication of it will probably follow a slight exertion; it may be induced by an unusual meal or overindulgence at the table. Pain in the region of the heart and radiating to the arm, in any subject who is advanced in years or who is prematurely broken down, and who has lived a strenuous life and is known to be the victim of stimulating habits, may be declared to be due to angina pectoris.

Toxic angina embraces those cases supposed to be brought on from tea, coffee, and tobacco.

Treatment.--Any change that will right the errors of life is the proper thing to do. Certainly stimulants must be tabooed. The patient should be put on fruit three times a day, and put to bed, and kept there until comfortable. If there is no desire for fruit, the eating of it is not to be urged; but the patient requires rest.

The bowels should be cleared out with copious enemas every day for a week. The attacks are remedied by most physicians by the use of nitrite of amyl. Such drugs are not necessary. Besides, the influence of this drug is detrimental. It may be a relief for the time, but the dilation of the blood vessels caused by it only builds more and worse trouble for the future.

Electricity is recommended. It should be recognized as a stimulant, and, instead of being a benefit, it certainly is injurious. Gentle massage to the region of the chest and over the spine should be beneficial if not practiced too often; but the cure must come from removing the causes, whatever they are.

\10 viruses and DNA

Smallest types of infectious agent. 1/2 to 1/100 the size of smallest bacteria with a simple structure. Being small makes it easier for them to infect. It is not definate whether these are living organisms or a collection of molecules capable of replication under specific conditions. The parasitic virus lack metabolism and can multiply only within living cells. There are many kinds of viruses that cause maladies from AIDS to warts.

Malignant transformation

A phenomenon analogous to bacterial cell lysogeny occurs in animal cells infected with certain viruses. These animal viruses do not generally cause disease immediately for certain animal cells. Instead, animal cells are persistently infected with such viruses, the DNA of which (provirus) is integrated into the chromosomal DNA of the host cell. In general, cells with integrated proviral DNA are converted into cancer cells, a phenomenon known as malignant transformation. As is the case with bacterial prophages, the transformed animal cell contains no infectious virus but only the integrated provirus DNA, which replicates along with the dividing cell's chromosomes. Therefore, following mitosis of the transformed cell, each new cell receives a copy of the proviral DNA. The hallmark of these transformed animal cells is that their growth is uncontrollable; unlike normal cells, their growth is not inhibited by contact with other cells, and they lose their capacity to adhere (anchor) to certain surfaces. Growth of normal tissues and organs is also controlled by a genetic phenomenon called programmed cell death, or apoptosis, in which a certain number of cells will die and be eliminated after a finite number of divisions. Malignant transformation can impede programmed cell death, thus allowing the cells to grow uncontrolled, resulting in cancer. Among the animal viruses that cause malignant transformation by integration of proviral DNA are several families of DNA viruses and one large family of RNA viruses, the Retroviridae. Viruses of the family Papovaviridae were perhaps the first to be associated with malignancy (causing death or illness) in animals. Polyoma virus is widespread in mice; it can infect other rodents, and it can cause tumours in infected animals. Another virus of the family Papovaviridae is simian virus 40 (SV40), originally isolated from cells of the African green monkey (Cercopithecus sabaeus), where it grows rapidly and kills the cells. Infection of rodent or human cells, however, results in an abortive infection (an incompatibility between the virus and the host cell) but sometimes induces malignancy (sarcomas or lymphomas) in the occasional cell that is transformed. Viruses related to polyoma virus and SV40 have been isolated from humans, one of which, the JC virus, appears to be the causative agent of a fatal neurological disease called progressive multifocal leukoencephalopathy. In general, however, the human papovaviruses are not clearly associated with disease. Other viruses of the family Papovaviridae include the papillomaviruses, which are also small polygonal viruses containing circular double-stranded DNA. The papillomaviruses are associated with usually benign (nonthreatening) but widespread tumours, called papillomas or polyps, occurring in human skin and the genital tract. Specific papillomaviruses have been identified in humans in common warts and in genital warts (condylomata acuminata). Cancers of the human genital tract, particularly uterine cancer of the cervix, are frequently found in association with human papillomavirus type 16 (HPV16); the virus undoubtedly is transmitted as a venereal disease. Certain viruses of the family Adenoviridae (Figure 5), originally found in the tonsils and adenoids of humans, cause malignant transformation in certain cells. This phenomenon of cancer induction under laboratory conditions has been studied widely, but there is no evidence that the common adenoviruses cause cancers in humans. The common viruses of the family Herpesviridae, however, including the common herpes simplex viruses that cause cold sores and the venereal disease genital herpes, are suspected of being causative agents of cancer. Like the adenoviruses, the herpesviruses can cause malignant transformations, and their DNA is integrated into the host cell chromosome. A herpesvirus known as the Epstein-Barr virus causes a frequently fatal childhood cancer called Burkitt's lymphoma as well as the nonmalignant disease infectious mononucleosis. The herpesvirus cytomegalovirus lies dormant in the tissues of most humans and can be induced to cause fatal diseases in infants and immunocompromised adults. A different herpesvirus causes chicken pox (varicella); the same virus lies latent in the tissues for long periods of time (perhaps years or decades) and later undergoes recrudescence (the recurrence of symptoms after they have abated) to cause the painful skin and neurological disease called herpes zoster, or shingles. In addition, there are herpesviruses that cause disease in animals--for example, the widespread and usually fatal disease in chickens called Marek's disease. The widespread distribution of viruses of the family Herpesviridae is evident from other diseases in monkeys and frogs. The viruses of the family Retroviridae are perhaps the most widely distributed of the transforming viruses that infect eukaryotic cells ranging from yeast to humans. It was suggested early in the 20th century that viruses cause leukemias and lymphomas in birds. In 1911 the American pathologist Peyton Rous first described a virus that causes sarcomas in chickens. The virions of retroviruses are spherical (or polygonal) and are surrounded by a lipid membrane containing a glycoprotein that recognizes and binds to cell receptors of a particular species (type-specific glycoproteins). Retrovirus genomes consist of two identical RNA molecules, each with 7,000 to 10,000 nucleotides. Associated with the virion RNA is an enzyme, an RNA-dependent DNA polymerase, also called a reverse transcriptase. Using the virion RNA as a template, the reverse transcriptase catalyzes the synthesis of a linear DNA molecule, complementary to the virion RNA. The new complementary strand of DNA also serves as a template for the reverse transcriptase, which makes a second anticomplementary DNA molecule, thus forming double-stranded DNA. The genomic RNA of fully infectious bird retroviruses, those that can replicate autonomously, has four genes that code sequentially for group-specific antigens, the reverse transcriptase, the envelope glycoprotein, and the sarcoma-transforming protein. At each end of the genome are homologous flanking nucleotide sequences, known as long terminal repeats (LTR), which code for double-stranded DNA that can recognize host cell DNA sequences for integration of the proviral DNA into the host cell chromosome. Many retroviruses are defective and cannot replicate in cells without helper (nondefective) retroviruses. The helper retroviruses generally transform fibroblastic cells, resulting in malignant sarcomas, whereas the defective retroviruses transform blood-cell precursors, resulting in leukemias. Many different retroviruses have been identified as causative agents of cancers in birds, rodents (particularly mice), domestic cats, monkeys, and humans. Certain lymphatic leukemias in humans are caused by human T-cell leukemia virus (HTLV); acquired immune deficiency syndrome (AIDS) is caused by a retrovirus called human immunodeficiency virus (HIV). Retroviruses originated from genes in many different species of animals and even lower forms of life. Individual retroviruses are limited in their host range and do not readily cross species barriers. Virtually every retrovirus studied to date is analogous to the genes normally found in animals (including humans), known as proto-oncogenes, genes that are involved with regulating normal cell growth and development that also have the potential to change into cancer-causing genes. These proto-oncogenes have deoxynucleotide sequences closely, but not entirely, homologous (i.e., of the same type and order) to the nucleotide sequences of a corresponding viral cancer-causing gene, called an oncogene. Integration of retrovirus DNA into cell chromosomes results in cancer, but the proto-oncogenes do not become cancer-causing genes unless triggered by another event. Cancers caused by chemical or physical carcinogens in the environment probably often, if not invariably, are due to alterations in the sequences of proto-oncogenes that have converted them to oncogenes. Some of the DNA tumour viruses, such as SV40 or adenoviruses, may induce malignant transformation when their DNA is integrated in proximity to the site of a proto-oncogene. All cancers studied to date appear to be due to either mutations in proto-oncogenes or the inheritance of mutated tumour suppressor genes, which normally regulate the function of proto-oncogenes. Disease Although viruses were originally discovered and characterized on the basis of the diseases they cause, most viruses that infect bacteria, plants, and animals (including humans) do not cause disease. In fact, bacteriophages may be helpful in that they rapidly transfer genetic information from one bacterium to another, and viruses of plants and animals may convey genetic information among similar species,
helping their hosts survive in hostile environments. In the future this could also be true for humans. Recombinant DNA biotechnology shows great promise for the repair of genetic defects. Afflicted persons are injected with cells transformed by viruses that carry a functional copy of the defective human gene. The virus integrates the normal gene into the DNA of the human cell. Of those viruses that cause disease, some cause short-term (acute) diseases and others recurring or long-term (chronic) diseases. Some viruses cause acute disease from which there is fairly rapid recovery but may persist in the tissues, remaining dormant for long periods of time, and then become active again, bringing about serious disease decades later. Slowly progressive viruses have long incubation periods before the onset of disease. As mentioned above, the DNA of certain viruses becomes integrated into the genome of the host cell, often resulting in malignant transformation of cells, which become cancers. The nature of the disease caused by a virus is generally a genetic property of the virus as well as of the host cells. Almost all viruses, however, can remain dormant in the tissues of the host (latency). Viruses that cause acute disease are generally, but not always, those that rapidly harm or destroy cells (cytopathic effects) and have the capacity to shut off protein or nucleic acid synthesis within the host cell. Human poliovirus and related picornaviruses that infect other animal species are examples of acute infectious agents that shut down protein synthesis in the host cell soon after infection; these picornaviruses also inhibit cellular RNA and DNA synthesis. Another virus that rapidly kills the infected cell is the negative-strand vesicular stomatitis virus (VSV) of the family Rhabdoviridae; viral RNA newly synthesized by infectious VSV rapidly shuts off cellular RNA synthesis and, to a somewhat lesser extent, cellular protein synthesis. In both poliovirus and VSV, the infected cell dies within hours of the inhibition of cellular RNA and protein synthesis. Other viruses that inhibit cellular macromolecule synthesis and produce acute infections include the poxviruses, reoviruses, togaviruses, adenoviruses, and herpesviruses; the latter two persist in host tissues for long periods of time and cause chronic infection as well. On the other hand, certain viruses, such as the influenza viruses, do not have the drastic effects on the synthesis of cellular macromolecules, such as proteins, but they still cause acute, usually self-limiting, infections. Many, if not most, diseases resulting from viral infection of vertebrates are caused not by a direct effect of the virus but rather by a secondary immune response. Essentially all viral proteins are recognized by vertebrate animals as immunologically foreign, and the immune systems of these animals mount two kinds of immune response, humoral and cellular. In humoral immunity, B lymphocytes, usually triggered by helper T lymphocytes, make antibodies (proteins that recognize and bind foreign molecules) to the viral protein. The antibody synthesized as a result of the immune response against a specific viral antigen usually benefits the infected host because that antibody can neutralize the infectivity of the specific virus in the blood and tissues of the infected host. Viruses inside the cell are not accessible to the antibody, because it cannot cross the cell membrane barrier. In cellular immunity, a killer T cell recognizes and kills a virus-infected cell because of the viral antigen on its surface, thus aborting the infection because a virus will not grow within a dead cell. If the virus-infected cells are not essential for host functions, the killer T cell can prevent the spread of the infecting virus to other cells and distant tissues. Not infrequently, the virus-specific T lymphocyte kills vital cells such as nerve cells (neurons), muscle cells, and liver cells, all of which carry out important functions. In addition, the death of cells results in an inflammatory response, which also can damage vital tissues. Therefore, the cellular immune response to a viral infection can cause disease. In general, diseases caused by chronic viral infections, but also occasionally by subacute (between acute and chronic) viral infections, are caused by cellular immune responses that damage the virus-infected tissue.


\11 warts

Warts are non-cancerous skin growths caused by a viral infection in the top layer of the skin. Viruses that cause warts are called human papillomavirus (HPV). Warts are usually skin-colored and feel rough to the touch, but they can be dark, flat and smooth. The appearance of a wart depends on where it is growing.

How many kinds of warts are there? There are several different kinds of warts including: Common warts, Foot (Plantar) warts, Flat warts

Common warts - usually grow on the fingers, around the nails and on the backs of the hands. They are more common where skin has been broken, for example where fingernails are bitten or hangnails picked. These are often called "seed" warts because the blood vessels to the wart produce black dots that look like seeds.

Foot warts - are usually on the soles (plantar area) of the feet and are called plantar warts. When plantar warts grow in clusters they are known as mosaic warts. Most plantar warts do not stick up above the surface like common warts because the pressure of walking flattens them and pushes them back into the skin. Like common warts, these warts may have black dots. Plantar warts have a bad reputation because they can be painful, feeling like a stone in the shoe.

Plantar (flat) warts - are smaller and smoother than other warts. They tend to grow in large numbers - 20 to 100 at any one time. They can occur anywhere, but in children they are most common on the face. In adults they are often found in the beard area in men and on the legs in women. Irritation from shaving probably accounts for this.

How do you get warts? Warts are passed from person to person, sometimes indirectly. The time from the first contact to the time the warts have grown large enough to be seen is often several months. The risk of catching hand, foot, or flat warts from another person is small.

Why do some people get warts and others don't? Some people get warts depending on how often they are exposed to the virus. Wart viruses occur more easily if the skin has been damaged in some way, which explains the high frequency of warts in children who bite their nails or pick at hangnails. Some people are just more likely to catch the wart virus than are others, just as some people catch colds very easily. Patients with a weakened immune system also are more prone to a wart virus infection.

Do warts need to be treated? In children, warts can disappear without treatment over a period of several months to years. However, warts that are bothersome, painful, or rapidly multiplying should be treated. Warts in adults often do not disappear as easily or as quickly as they do in children.

How do dermatologists treat warts? Dermatologists are trained to use a variety of treatments, depending on the age of the patient and the type of wart.

Common warts - in young children can be treated at home by their parents on a daily basis by applying salicylic acid gel, solution or plaster. There is usually little discomfort but it can take many weeks of treatment to obtain favorable results. Treatment should be stopped at least temporarily if the wart becomes sore. Warts may also be treated by "painting" with cantharidin in the dermatologist's office. Cantharidin causes a blister to form under the wart. The dermatologist can then clip away the dead part of the wart in the blister roof in a week or so.

Common warts - For adults and older children cryotherapy (freezing) is generally preferred. This treatment is not too painful and rarely results in scarring. However, repeat treatments at one to three week intervals are often necessary. Electrosurgery (burning) is another good alternative treatment. Laser treatment can also be used for resistant warts that have not responded to other therapies.

Foot warts - are difficult to treat because the bulk of the wart lies below the skin surface. Treatments include the use of salicylic acid plasters, applying other chemicals to the wart, or one of the surgical treatments including laser surgery, electrosurgery, or cutting. The dermatologist may recommend a change in footwear to reduce pressure on the wart and ways to keep the foot dry since moisture tends to allow warts to spread.

Causes: We do not know why some people get plantar warts easily while others never get them. There is no way to prevent plantar warts. Plantar warts are common. They may bleed if injured. Since plantar warts are caused by a virus, they are slightly contagious (can spread from person to person). You should not share clothing or linen with someone who has plantar warts. Plantar warts may spread on the body and seed other areas. Plantar warts should be treated because they are contagious and rarely a plantar wart left untreated for years can become cancerous.

Flat warts - are often too numerous to treat with methods mentioned above. As a result, "peeling" methods using daily applications of salicylic acid, tretinoin, glycolic acid or other surface peeling preparations are often recommended. For some adults, periodic office treatments for surgical treatments are sometimes necessary.

What are some of the other treatments for warts? There are several different lasers used for the treatment of warts. Laser therapy is used to destroy some types of warts. Lasers are more expensive and require the injection of a local anesthesia to numb the area treated. Another treatment is to inject each wart with an anti-cancer drug called bleomycin. The injections may be painful and can have other side effects.

Immunotherapy, which attempts to use the body's own rejection system is another method of treatment. Several methods of immunotherapy are being used. With one method the patient is made allergic to a certain chemical which is then painted on the wart. A mild allergic reaction occurs around the treated warts, and may result in the disappearance of the warts. Warts may also be injected with interferon, a treatment to boost the immune reaction and cause rejection of the wart.

Can I treat my own warts without seeing a doctor? There are some wart remedies available without a prescription. However, you might mistake another kind of skin growth for a wart, and end up treating something more serious as though it were a wart. If you have any questions about either the diagnosis or the best way to treat a wart, you should seek your dermatologist's advice.

What about the use of hypnosis or "folk" remedies? Many people, patients and doctors alike, believe folk remedies and hypnosis are effective. Since warts, especially in children, may disappear without treatment, it's hard to know whether it was a folk remedy or just the passage of time that led to the cure. Since warts are generally harmless, there may be times when these treatments are appropriate. Medical treatments can always be used if necessary.

What about the problem of recurrent warts? Sometimes it seems as if new warts appear as fast as old ones go away. This may happen because the old warts have shed virus into the surrounding skin before they were treated. In reality new "baby" warts are growing up around the original "mother" warts. The best way to limit this is to treat new warts as quickly as they develop so they have little time to shed virus into nearby skin. A check by your dermatologist can help assure the treated wart has resolved completely.

Is there any research going on about warts? Research is moving along very rapidly. There is great interest in new treatments, as well as the development of a vaccine against warts. We hope there will be a solution to the annoying problem of warts in the not too distant future.

Are there different types of warts? Didn't your mother always tell you not to play with frogs or you would get warts? Are warts really caused by frogs? The truth is that warts are caused by a virus. The viruses that cause warts are called papillomaviruses. You may have heard of these. So, to put an old myth to rest, the answer is no, warts are not caused by holding, touching or kissing frogs.

Is there more than one type of wart? Actually, there are several different kinds of warts, but, basically two common types of warts. The first one is called called the verucca wart. These warts are small and hard with irregular surfaces. The second type of wart is called the flat wart. With these warts, they generally grow in clusters, they are only slightly raised and they have smooth surfaces.

There are some places that warts will grow on the body that are more common sites. Some of them include the hands, the feet, the ankles and the knees. Warts that grow on the soles of the feet are called plantar warts. Plantar warts develop on the weight bearing part of the foot and may be painful. Warts may also be located on the genitals, usually when the person has a disease like gonorrhea or syphilis. Genital warts should be treated by a doctor. Do not attempt to put any over the counter medications on genital warts.

You may think that you have had your wart or warts forever, but somewhere along the line, you came in contact with a person who had a wart or was carrying the virus that causes warts. Warts are contagious, but exactly how they are transmitted is not known. A wart begins when a virus invades the skin cells, the papillomavirus. The skin cells then begin reproducing at a faster rate than normal tissue. This results in overgrowth of the skin cells, causing warts. Warts are known to have a lot of very small blood vessels within them. Those black dots you may see in warts are the tiny blood vessels. Warts do not cause pain because warts contain no nerves. Picking at the wart can, however cause it to bleed or cause pain. Do not attempt to cut or peel the wart. Also, the plantar warts can be painful because they are at the bottom of the foot and weight bearing or stepping down on them, causes the pain.

The papillomvirus is spread by contact with someone who carries the virus. Warts can occur at any age, however, the largest number of warts are found in persons between the ages of ten and thirty years old. In adults, however, it is best to have a skin lesion checked, because some skin cancers look like warts. Many warts, especially flat warts, will dissappear on their own within a few months or so. Warts can be removed by a doctor for cosmetic reasons or if it is in an awkward place. There are also many over the counter wart removal systems. Follow these directions carefully. When a layer of dead skin forms, it can be soaked to soften, then gently removed with a rubbing stone. If self treatment is not successful, your doctor can freeze or burn the wart off. A numbing agent is used to deaden the area first.

Wart virus can be deep in the skin and often warts that you thought were gone will reappear in the same place after treatment, even months later. Treating warts soon, while they are small, increases the chances of permannent successful removal. Don't touch a wart, and wear rubber shoes in public shower to protect the soles of your feet.

Alternative names: plane juvenile warts; periungual warts; subungual warts; plantar warts; verruca; verrucae planae juveniles; filiform warts; verruca vulgaris. Definition: A benign skin growth caused by a virus.

Causes, incidence, and risk factors: Warts are an infectious disease of low infectivity caused by a virus. They may occur anywhere on the body but are frequently seen on the hands, feet, and face (areas of frequent contact). Warts may be named by their location and appearance. On the soles of the feet they are called planter warts. Around and under the fingernails or toenails they are periungual or subungual warts, respectively.

Common warts on the hands, arms, legs, and elsewhere are verrucae vulgaris but often just called common warts. Numerous very small smooth flat warts (pinhead size) often seen in large numbers on children's faces, foreheads, arms and legs are called verrucae planae juveniles. These are seen less often in adolescents and seldom in adults.

The typical wart is a rough round or oval raised lump on the skin that may be lighter or darker than the surrounding normal skin, skin colored or even (rarely) black. Most parents are familiar with the look of a typical wart and have little trouble in diagnosing the condition. Warts with a smooth surface and the small flat warts in children may cause some difficulty in diagnosis for the average parent. Common warts cause no discomfort unless they are in areas of repeated trauma.

Plantar warts are no different than the common wart but, because of their location on the soles of the feet, they can become extremely painful. Large numbers of planter warts on the foot may cause difficulty running and walking and can be debilitating. Warts around and under the fingernail are similar to the common wart but much more difficult to cure.

The common wart may disappear spontaneously, often within 2 years of its appearance. Because people generally consider warts unsightly and there appears to be a social stigma (among school children) associated with having warts, parents often seek treatment. Treatment of warts has improved significantly in the last 10 years but even with effective treatment recurrence is not uncommon.

Prevention: Avoid direct skin contact with another wart.

Symptoms: small, hard flat to raised skin lesion or lump skin colored, lighter or darker than surrounding skin, dark speckles, black skin abnormally dark or light may occur in a small area numerous small, smooth, flat (pinhead sized) lesions on forehead, cheeks, arms, or legs rough round or oval lesions on soles of feet, flat to slightly raised and painful to pressure rough growths around fingernails or toenails or protruding from beneath them

Signs and tests: The diagnosis is based on the appearance of the skin lump.

DIAGNOSIS - Warts are diag with a physical exam. Hands and feet are the most common sites. On the hands, warts form the horny nodule usually associated with the name "wart." When they grow on the soles of feet, they may resemble small calluses, because the body's weight causes them to grow beneath the skin's surface rather than being raised. Except for plantar warts growing at pressure points on the heel or ball of the foot, most warts are not painful or itchy.

Treatment: Fifty percent of all warts disappear within 2 years with no therapy at all. There are several ways to remove warts, if removal is desired. A doctor can help choose the most appropriate treatment based on the size and location of the wart, the patient's age, and other factors. Although not always necessary, is often desired by both the affected child and the parent. OTC meds can be effective in removal of warts. These topically applied chemicals frequently consist of various mixtures of salicylic acid and lactic acid and are applied on a daily basis for several weeks. Stronger (prescription) medications may be required for removal of persistent warts. Surgical removal or removal by freezing (cryotherapy), burning (electrocautery), or laser treatment may be needed. Immunotherapy, done by causing a localized allergic reaction, is also used.

Expectations (prognosis): Warts are benign growths that often disappear spontaneously within 2 years. They are contagious but of a very low order. Warts may be unsightly or cause discomfort, especially on the feet.

Note: Regardless of therapy, there is a 25% chance that warts will recur after treatment.

Complications: spread or recurrence of warts minor scar formation if the wart is removed formation of keloids after removal.

Calling your health care provider: if warts are present and there are signs of complications, or if warts do not respond to over-the-counter treatment and removal is desired. Also call if new symptoms develop, including change in the appearance, or the development of pain, bleeding, ulceration, or color changes of a wart or any skin lesion.

The Duct Tape Cure By JOHN O'NEIL NYT 10/15/02. An article being pub today adds one more item to the list of uses for duct tape. Now, it turns out, it helps get rid of warts.

The recommended technique does not involve ripping, and in fact was investigated by Dr. Dean R. Focht III and colleagues at the Madigan Army Medical Center in Tacoma, Wash., as a less painful alternative to the practice of briefly freezing warts, which are most common in children.

In the study, pub in The Archives of Pediatrics & Adolescent Med, Dr. Focht found that warts disappeared for 85%  22 of 26 children and young adults treated with duct tape  compared with 60 percent of a similar group treated with cold.

The duct tape was cut to fit over the wart, Dr. Focht said. Once a week, the tape was removed and replaced after the wart was rasped clean with an emery board or pumice stone.

Dr. Focht said he believed the tape worked in the same way that most other wart treatments work  by irritating the skin, thereby stimulating an immune system response that wiped out the viral infection that had caused the wart.

He said that children with warts should see their doctors to make sure the growths are actually warts. After that, he said, simply waiting for the wart to disappear is one option. But if the parents want to treat it, he said, duct tape "is a great, simple option."


\12 knee injury, problems

The knee is the largest joint in the body. It is a hinge joint because the knee can flex (bend) and extend (straighten), somewhat like the hinge on a door. It can also rotate and glide. The tibia (shin bone), the femur (thigh bone), and the patella (kneecap) form the knee joint. Each bone is covered with a layer of cartilage that cushions and protects the bones, and keeps them from rubbing together.

Ligaments (bands of fibrous tissue that connect bones) and tendons (bands of fibrous tissue that connect muscle to bone) stabilize the knee, allowing it to move in some directions and keeping it from moving beyond its normal limits. The patella helps protect the knee joint and anchor the supporting structures.

Knee injuries and problems are caused by a wide variety of events from contact sports, to slips and falls, to improper footwear, to inadequate warm-up and stretching before exercise, to medical problems like osteoarthritis, rheumatoid arthritis, and post-traumatic arthritis.

Osteoarthritis of the knee is a gradual deterioration of the joint, caused by wear and tear on the cartilage between the femur and the tibia. Almost all people past the age of 60 have some degree of osteoarthritis of the knees, but younger people can also have it, due either to an injury to the knee or to a congenital (present at birth) joint deformity. Symptoms of osteoarthritis are inflammation, pain, swelling, creaking, and stiffness of the affected joint.

Rheumatoid arthritis is an autoimmune disorder (which means that the immune system attacks the body's own tissues) causing the tissues and structures of joints to become inflamed and to deteriorate. Usually starting in early adulthood or middle age, this disorder affects knees by causing pain, swelling, and stiffness. Post-traumatic arthritis of the knee is a type of arthritis that results from a knee injury.

Knee problems can affect any part of the knee: cartilage, ligaments, tendons, or bones. The following are the most common types of knee problems:

Cartilage problems: Meniscal tear. This is a rip in a meniscus, one of the two crescent-shaped pads of cartilage between the upper and lower leg bones in each knee. Certain types of impact injuries, such as landing on a very flexed knee and twisting injuries, can cause meniscal tears.

Symptoms include pain, swelling, "popping," locking of the joint, and a sudden "giving way." Chondromalacia. When the smooth cartilage that covers the back of the patella softens and erodes, the patient feels pain when moving the knee, especially when kneeling or going up or down stairs. This problem often leads to osteoarthritis.

Ligament problems: Knee sprain. When a ligament in the knee is violently overstretched, it becomes tense and gives way at its weakest point. The result is a sprain or a "torn ligament." It is almost always the result of sudden force, typically a twisting motion, that the surrounding muscles are not strong enough to control. Sprains can range from minor tears in some ligament fibers to complete ruptures, where the ligament is totally separated from the bone.

Symptoms include pain and rapid swelling in the joint, a "giving way" of the knee, bruising at the site of injury, stiffness, difficulty moving the joint, and a feeling of tearing at the time of the accident. The knee ligament most often torn is the anterior cruciate ligament (ACL), a major stabilizing ligament located in the center of the knee joint.

Tendon problems: Knee strain. A strain or "muscle pull" is an overstretching of muscle or tendon to the point of injuring the fibers. When a muscle is forcefully contracted, but is pulled in the opposite direction, the fibers are strained. They tear when the force is stronger, in fact, in serious cases, the entire attachment is severed.

Symptoms include sharp pain while moving or stretching the knee, stiffness, swelling, muscle spasms, cracking sounds, and weakness. Tendinitis. When a tendon becomes inflamed, the patient feels pain, tenderness, weakness, and sometimes restricted movement of the muscle attached to the affected tendon. Patellar tendinitis (also called "jumper's knee") causes pain when landing from a jump, going down stairs, or sitting for long periods of time.

Quadriceps tendinitis affects athletes who do a lot of rapid acceleration and deceleration. Popliteus tendinitis arises from the repeated stress of downhill running. Iliotibial band syndrome. The structure involved is the tendon running along the outside of the thigh from the hip to the knee. When it rubs excessively against the femur, such as running on a slanted surface causes in the downside leg, the patient feels pain.

Patella problems: Infrapatellar bursitis. Also called "housemaid's knee," this is a painful inflammation or irritation of the bursa beneath the patella. The bursa is a soft, fluid-filled, fibrous sac that cushions the movement of muscles and tendons over the bones in and around the joints.

Symptoms include pain that worsens with movement, tenderness, limited movement, swelling, and redness in the affected area. Patellofemoral stress syndrome. A common problem for runners, this condition causes pain especially while running on hilly terrain. The irritat on inflammation, and misalignment can progress to displace-ment of the patella and its surrounding tissues. Pain around or behind the patella develops toward the middle or the end of a run.

Other problems: Fracture. This a broken bone, either partially or completely broken, with pain, swelling, and possibly deformity. Knee swelling. Knee synovitis with effusion is the medical term for "water on the knee," an excessive build-up of fluid between the membranes lining the fibrous capsule surrounding the knee joint.

This fluid is usually a reaction to some type of inflam-mation or injury. Crepitus. This is a grinding or crackling sensation or sound made by the knee. Popliteal cyst. This is a sac containing fluid, blood, and sweat-gland secretions that forms behind the knee as a result of inflammation of the membranes containing fluids that lubricate the knee joint.

DETECTION AND DIAGNOSIS of a knee problem by asking about its origin and symptoms, checking the knee's condition, and doing a number of tests, such as an x-ray, arthrography, or magnetic resonance imaging (MRI), to determine the extent of the problem. An x-ray uses the electromagnetic energy of short wavelengths to create an image of the joint.

Arthrography involves injecting a dye into the joint space and taking x-rays of the area. MRI yields a computerized image of the inside structures of an area. An x-ray or MRI may be done to make sure the pain is not a result of a broken bone, as well as to check for ruptured tissues.

TREATMENT: Standard treatment methods for knee problems are R.I.C.E., medications, physical therapy, splinting, casting, bracing, and possibly surgery.

R.I.C.E. is a common treatment for sprains, strains, iliotibial band syndrome, infrapatellar bursitis, tendinitis, and patellofemoral pain syndrome. It includes the following: Resting for at least 24-48 hrs, keeping the injured area still and avoiding pressure on it.

The doctor might also recommend crutches or a cane, and, depending on the type and severity of the injury, splint-ing, casting, or bracing. Icing the affected area for the first 24 to 48 or 72 hours to reduce swelling. It is best to apply a covered ice pack for 10 to 20 minutes at a time, depending on the depth of the injured tissue, the size of the injury, and its site, and to repeat the proc every few hours until the swelling has gone down.

NB: Once the swelling resolves, heat is recommended for 20 minutes at a time, up to 3 times a day. Compressing the joint by wrapping it in an elastic (Ace) bandage to help reduce swelling and pain. Wrapping snugly (not tightly) from the point farthest from the heart and wrapping twd the center of the body is best. Elevating the injured area higher than the heart if possible, even while applying ice as well as when sleeping.

Medications used to relieve the pain and swelling of knee problems include pain relievers, anti-inflammatory drugs, and heat-producing creams and ointments. The doctor might also prescribe physical therapy, which includes various strengthening and stretching exercises.

For some problems, surgery might be the only alternative. Arthroscopic knee surgery is done to repair meniscal tears, torn ligaments (sprains), patellofemoral pain syndrome, chondromalacia, and severe cases of osteoarthritis and tendinitis. Using a fiberoptic device called an arthroscope, an orthopedic surgeon can evaluate the condition of the knee's cartilage, ligaments, and membranes.

The arthroscope is equipped with a light and magnifying lenses that relay a clear view of the inside of the knee via a monitor and an eyepiece. After giving the patient general, regional, or local anesthesia, the surgeon makes two small incisions (cuts) in the skin of knee, one for the insertion of the arthroscope and the other for a device that irrigates (flushes out) the inside of the knee. The surgeon will make additional cuts if needed for shaving or repairing tissue. Then the incisions are taped or stitched and the knee bandaged. The patient can usually go home a few hours later.

Total knee replacement is done for severe cases of osteoarthritis, rheumatoid arthritis, and post-traumatic arthritis. With the patient under general or regional anesthesia, the orthopedic surgeon makes an incision that runs 3 to 4 inches above the knee and down along the inside of the patella to several inches below the knee.

The surgeon moves the muscles, patella, and connective tissue aside and removes the diseased bone. In its place the surgeon inserts a prostheses, artificial parts made of plastic and metal that will replace the damaged bone. With the muscles and connective tissues back in place and repaired, the surgeon closes the incision.

PREVENTION Here are some tips for preventing a new injury building up the leg muscles maintaining a weight appro-priate for height, frame, age, and gender, as extra pounds add extra pressure to the knee avoiding sports or physical activities until full strength returns to the knee wearing appropriate footwear for the activity choosing activities appropriate for knee strength and capacity warming up and stretching properly prior to exercise.

QUESTIONS TO ASK YOUR DOCTOR: What is the extent of the injury to the knee? How do you plan to treat the knee? Should I apply heat or ice? Should I do any particular exercises? How much should I rest the knee? How long will it take to recover fully? What tests are avail to find out what is wrong with the knee?

\13 head lice

Head lice are parasitic insects that only live on the heads of people. There are three forms of head lice: Nits are head lice eggs. The oval, yellowy white eggs are hard to see and may be confused with dandruff. They attach themselves to the hair shaft and take about a week to hatch. The eggs remain after hatching and many nits are empty egg cases. Nymphs hatch from the nits. The baby lice look like the adults, but are smaller. They take about 7 days to mature to adults and feed on blood to survive. Adults are about the size of a sesame seed. They have six legs and are tan to greyish-white. The legs have hook-like claws to hold onto the hair with. Adults can live up to 30 days and feed on blood. Head lice cannot jump, hop or swim.

Who catches head lice? Anyone can catch head lice, but preschool children, primary school children and their families are most at risk. Studies in the US have shown that black African Americans rarely get head lice.

How do you catch head lice? Head lice are transmitted through direct, prolonged head-to-head contact with an infested person. This is especially common during play or sport at school and with close contacts at home. Trans-mission is possible through infected clothes, combs, brushes or towels, but extremely unlikely. The lifespan of a louse is very short once detached from the hair so fumigation is not necessary.

How infectious is head lice? The rate of transmission is low.

What is having head lice like? The head lice are most commonly found behind the ears and at the back of the neck. It is rare to find them on the body, eyelashes, or eyebrows. A person with head lice may feel a tickling or itching feeling of something moving in the hair. Most people only realise that they have head lice after the itch has developed which can take from one week to 2-3 months after initial infection. Itching may also occur due to an allergic reaction to the bites. Sores can develop due to scratching and can become infected.

How serious are head lice? Head lice are not a serious health problem. Head lice rarely cause anything more than an itchy scalp.

Can you prevent head lice? Head lice are a mild disease. Some schools used to have routine screening, followed by the exclusion of those affected. This was a waste of time. It was also ineffective in preventing spread. The best way to stop infection is for people to learn how to check their heads for lice. Good hair care only helps to control lice in as much as it will help to spot and treat lice early.

Should a child with head lice be kept off school? No! The DfEE/DoH guidelines for infection control in schools and nurseries state that there is no need for a child who has head lice to stay away from school. One reason for this is that if a child does have lice, he or she will have had them at school for several weeks before diagnosis. Letters notifying other parents of cases have not been found to curtail spread but often provoke itching and anxiety as a psychological response.

How can you treat someone with head lice? A diagnosis of head lice can only be made if a living, moving louse is found. Detection combing by parents/family members according to instructions is the best method of diags. Chemical treatments are available, but must only be given after a doctor or experienced nurse has made a diagnosis. Close contacts of patients living in the same house are usually checked and treated if they have head lice.

Head lice are brownish-gray wingless insects that live on and suck blood from the scalp. About the size of sesame seeds, lice lay shiny, oval, grayish-white eggs called nits that stick stubbornly to hair shafts. When lice infest the hair and scalp, the condition is called pedi-culosis capitis. Lice infest about 10 million kids in the US each year.

Head lice live on hair shafts where they can lay their eggs.

Head lice are parasites that get their nourishment from the blood they suck from humans. Their favorite feeding area is the scalp behind the ears and at the nape of the neck. Their sucking activity and salivary juices are responsible for the intense itching that is usually the first symptom of a lice infestation. Although usually confined to the scalp, head lice also live in beards, moustaches, eyebrows, and eyelashes.

Although they don't fly, lice travel easily from head to head when those heads are in close contact. Cases of head lice seem to increase in cold weather, possibly because children are often close together indoors at that time, sharing hats, scarves, combs, brushes, hair clips, head phones, and other personal items. Another risk factor is living in overcrowded or unsanitary conditions.

SIGNS AND SYMPTOMS of head lice infestation include: itchiness and scratching around the hairline or ears white specks (nits) on the hair shaft that can't be removed with brushing or shampooing, & unlike dandruff, resist removal with a fingernail gliding firmly along the hair shaft grayish bugs crawling on the scalp, especially around the ears and the nape of the neck matted, foul-smelling, lusterless hair (in severe cases) swollen lymph glands in the back of the neck red bite marks and hives scalp inflammation, bleeding, and infection

DETECTION AND DIAGNOSIS of pediculosis is made by med hist and exam of the hair and scalp for nits (as lice are difficult to see).

Treatment: Head lice are eliminated by applying pediculocides (lice-killing products) and then manually removing nits and empty (translucent) nit cases. Several lotions, creams, shampoos, and rinses are available, including permethrin 1% (Nix), considered by many to be the safest and most effective pediculocide. Other products include lindane lotion (Kwell), synergized pyrethrins (Rid), and malathion lotion (Prioderm). Following package instructions and precautions is strongly advised. Pediculocides cannot be used on the eyelashes, so eyelash infestations are treated by applying a thick coating of petroleum jelly twice daily for 7-8 days to kill or weaken the lice. The remaining nits can then be plucked off.

Removing lice and nits manually includes the following measures: working in good light, such as natural sunlight near a window or outdoors or a bright lamp using a grooming comb or hairbrush first to remove tangles dividing the hair into sections and fastening off all but one section at a time using a nit-removal comb and passing it through each section repeatedly from the scalp to the end of the hair. Dipping the comb into a cup of hot vinegar before each stroke helps remove nits, and dipping it in water after each stroke helps remove debris from the comb. If the hair is too fine for the nit comb to work, each egg-bearing hair has to be cut out with scissors. Sifting through that same section of hair and looking for any attached nits the comb missed going on to the next section until all sections are free of lice and nits removing any visible lice that remain with tweezers, fingernails, or double-sided tape re-checking every day for at least 2 weeks to be sure the hair is still free of lice and nits keeping the patient home until after the first pediculocide treatment is completed, or according to school or workplace policy

To prevent acquiring head lice, the following measures are advised: Avoiding the use of anyone else's combs, brushes, hats, clothing, or other personal items. Avoiding contact with anyone who has or has recently had head lice. To prevent reinfestation, the following measures might be helpful: making sure all family and friends of the pateint are checked for lice and treated as needed. Machine-washing all clothing and bedding used by any infested person in hot water, then drying the items in a dryer's hot-air cycle for at least 20 minutes, then ironing them. Any contaminated items that cannot be laundered should be stored in airtight plastic bags for 2 weeks or dry cleaned. Vacuuming chairs, pillows in living and bedroom areas, mattresses, car seats, headrests, and rugs that might have been in contact with infested hair and discarding or emptying the bag. Sprays are also available for disinfecting furniture and bedding. disinfecting combs, brushes, sports helmets, and other objects that came in contact with the infested hair by soaking them in pediculocide or in very hot soapy water rechecking family and friends 7 to 14 days and then 21 to 28 days after treatment to be sure lice have not reappeared, since eggs that remain after treatment hatch 7 to 14 days later

GLOSSARY OF MEDICAL TERMS inflammation: the body's reaction to injury, specifically redness, swelling, excessive warmth, and pain

parasite: an organism that lives in or on another organism (host), obtaining nourishment from it

synergized pyrethrins: over-the-counter chemical pediculocide solutions that are applied undiluted to infested hair.

QUESTIONS TO ASK YOUR DOCTOR Is any particular over-the-counter lice remedy more effective than the others?

Will you prescribe any medication?

Do these products have side effects?

Do you recommend treat all family members even if they have no symptoms? Should I notify the school (or workplace)?

\14 prostate

Benign Prostatic Hyperplasia - Prostate disease. Researchers think drugs can effectively treat an increas-ingly common prostate disease. They're looking for 3000 men to help them prove their theory. The latest, benign prostatic hyperplasia, or B-P-H, trial will test whether two drugs can prevent further growth of the prostate. Enlarged prostates must often be treated surgically. Left untreated, prostate enlargement can lead to urinary tract infections, urinary retention and kidney disease.

The two drugs being tested; Proscar and Cardura have been approved by the US govt to relieve the symptoms of B-P-H. But researchers at 17 ctrs, led by urologists at the UT SW Med Ctr at Dallas, want to find out if those drugs can actually prevent the need for surgery or other treatment.

Eventually most men, usually by age 60, will have B-P-H. The most common symptom is frequent urination. Men with B-P-H often have trouble starting the urine flow and may continue feeling the need to urinate after they think their bladder is empty.

About 7-and-a-half-million men have B-P-H. About 250,000 undergo prostate surgery each year. Researchers believe nearly 9-million men will have B-P-H symptoms by the turn of the century. Clinical trial centers are located across the U.S. Call this toll free number for more info or to locate the ctr nearest you. The nbr is 800-BPH-1221.

 Prostate cancer is a malignancy that develops in the prostate gland, a gland that is important for the proper function of the male reproductive tract. Prostate Cancer is the most common cancer among American men, affecting about one in five men during the course of a lifetime.

Although incidence increases with age, this cancer can occur in younger men as well. This form of cancer very often occurs even without symptoms. The prostate is a walnut-shaped gland located just below the bladder and just in front of the rectum. The prostate secretes fluids and enzymes that make up about one-third of the spermatic fluid leaving the body during ejaculation.

The sperm in the ejaculate is made in the testicles and moves through a tube called the vas deferens. This tube also passes through and receives contributions from the prostate before reaching the urethra. The urethra is the tube inside the penis through which urine and ejaculate pass. The seminal vesicles are glands that lie right behind and slightly above the prostate. These glands also secrete fluids, which are added to the ejaculate.

Because of the proximity and direct physical connection to the prostate, cancer can sometimes spread to the seminal vesicles or the prostate capsule (fibrous capsule that surrounds the prostate). If this occurs, surgery is usually unable to remove the entirety of the cancer.

Because the prostate is situated immediately in front of the rectum, the doctor can feel the contour of the prostate when he or she performs a rectal examination. A normal prostate gland is smooth and firm, but not hard.

Who Gets Prostate Cancer? The cause of prostate cancer is not yet known. However, doctors do know that certain factors increase the risk of getting the cancer. One factor is a family history of prostate cancer. If the patient has a father or brother with the disease, his chances of developing prostate cancer are two times greater. Older men are also at greater risk. Three-quarters of all reported cases occur in men age 65 and older. Race is another factor that affects one's risk.

African-American men have the highest incidence of prostate cancer in the world, are two times more likely to be diagnosed with the disease, and two-and-a-half to three times more likely to die of prostate cancer. There is evidence that suggests that prostate cancer may be related to male hormone levels. Eunuchs (men that have been castrated) do not get the disease, suggesting that the male hormones produced by the testicles influence the development of prostate cancer.

Men with severe liver disease leading to increased blood levels of estrogen (the female sex hormone) have a decreased risk in prostate cancer. Prostate cancer also may be related to environmental factors. As mentioned above, African Americans have one of the highest rates of prostate cancer in the world. Blacks, however, have a low incidence of prostate cancer when compared to the high rates in African Americans.

The Asian population has a low risk of prostate cancer. For instance, Japs have an incidence of prostate cancer that is 40 times lower than in Afican American men. It is interesting to note that when Asians immigrate to the US, their incidence of prostate cancer rises. It is possible that differences in the environment, or the types of food people eat, may help to explain these observations, but that remains to be proven.

Prostate cancer trial links diet, prevention By Julie Deardorff CT Jul 25 2001

Suspecting that two ordinary over-the-counter dietary supplements may contain valuable cancer-fighting properties, the National Cancer Inst announced the start of the largest study ever devoted to the prevention of prostate cancer. Researchers conducting the 12-year clinical trial will recruit 32,400 healthy men across the US and Canada to determine whether taking vit-E and selenium, which are found naturally in foods, can protect against a disease that kills about 31,500 men each year.

The study follows a similar effort that recruited 22,000 women in 1999 to look at the effectiveness of tamoxifen and raloxifene in preventing breast cancer. The current research, however, focuses on diet rather than drugs, and some med experts believe it represents a significant step toward the mainstreaming of vitamins and nutritional therapies.

"It has always been our dream that taking a vitamin may prevent cancer, and vitamin E may be it," said Dr. Daniel Shevrin, an oncologist at Evanston Northwestern Healthcare. "The whole idea of diet and prostate cancer is poorly understood."

Until recently prostate cancer was an embarrassing topic seldom discussed. But with increasing numbers of high-profile cases--including former South African President Nelson Mandela, who began radiation therapy Tuesday--the disease is gaining more attention.

Prostate cancer rates are rising around the world; this year alone the disease will be diagnosed in about 198,100 American men. Rates are especially high among black men, whose cancer also tends to be more advanced when diagnosed. Although treatments are available for prostate cancer, including surgery and radiation, little is known about how to prevent it.

On 7/24/00, scientists gathered at the Metropolitan Chicago Healthcare Council to announce the new study, signaling the start of a massive search for volunteers. Sixteen Chicago-area hospitals have teamed up for the project, and more than 400 hosp in the U.S., Puerto Rico and Canada are participating.

Choosing supplements - Selenium and vitamin E were chosen because two other large cancer trials--studies whose primary focus was other kinds of cancer--suggested the nutrients might prevent prostate cancer. Additionally, several decades of research have showed that selenium can prevent cancer in animals.

"The focus is on prostate cancer, but its applications could reach beyond that," said Alan Diamond, head of the Department of Human Nutrition at the Univ of Illinois at Chicago. The research will consider the effects of vit-E and selenium individually and when taken together. Though the researchers caution against overloading on these or any supplements, research has indicated 200 micrograms of selenium and 400 milligrams of vit-E per day--the dosages to be used in the study--are safe for healthy men.

Selenium, a trace mineral absorbed by plants through the soil, is found in brewer's yeast, seafood, meats and Brazil nuts, as well as in plant foods. It can be toxic at 2400 micrograms per day, Diamond said; the first signs of selenium toxicity are bad breath and brittle hair.

Vitamin E is found in seed and vegetable oils, wheat germ, green leafy vegetables, butter, nuts and egg yolks. Like selenium, it is an antioxidant and can neutralize toxins known as free radicals that might otherwise damage the genetic material of cells and possibly lead to cancer. In a 96 study of selenium's effectiveness on non-melanoma skin cancer, investigators found the supplement did not reduce skin cancer but did decrease the incidence of prostate cancer by more than 60%.

In 1998 researchers looked into whether taking beta carotene and vit-E might prevent lung cancer in 29,000 Finnish men who smoked. Neither beta carotene nor vitamin E prevented lung cancer--in fact, the men who smoked and took beta carotene were more apt to get lung cancer and die from it--but the group taking vit-E had 32% fewer cases of prostate cancer.

Conducting the study - Participants in the current study will be asked to chronicle their diet carefully and visit their assigned hospital every six months for at least seven years. Upon enrollment they will provide toenail clippings, which contain selenium, and blood, to assess vit-E levels. They will be randomly assigned to one of four groups.

One group will take 200 micrograms of selenium daily plus an inactive capsule, or placebo, that looks like vitamin E. Another will take 400 milligrams of vitamin E daily along with a placebo that looks like selenium. A third will take selenium and vit-E. And a final group will be given two placebos. Scientists will compare prostate cancer rates among the groups.

A possible benefit for participants is early detection of the disease if it does occur. William Glennon, who took part in a drug study seven years ago through Evanston Northwestern Healthcare, said it saved his life. "Because of my participation, my prostate cancer was diagnosed at a very early stage," he said. "I was able to have surgery. Instead of simply controlling it, I was cured."

 A Prostate Check-up by Erica Heilman NYP Sep 12 02. Prostate cancer is the most common form of cancer in men today, affecting an estimated one in six American men. In an effort to educate men about this important disease, Sep has been designated Prostate Cancer Awareness Month.

If Dr David Crawford could say one thing to men during this month of awareness, it would be: "Get checked." Crawford is the head of the Sect of Urologic Oncology at the Univ of CO. Below he discusses current prostate cancer screening tests, and what can be learned from regular screening.

What are the current recommendations for prostate cancer screening? In general, the recommendation is that men should be screened for prostate cancer with a PSA blood test, or prostate specific antigen blood test, combined with a digital rectal exam beginning at the age of 50 and then on a yearly basis until age 70. Other groups, such as the National Cancer Institute, recommend that men at high risk should start yearly screening at age 45.

For those at higher risk of prostate cancer, the Prostate Cancer Education Council recommends an initial PSA at age 40, a second screening at 45, then yearly after that. Risk factors include family history of the disease, and if you are African American you are at significantly higher risk.

There is some contention about whether or not screening for prostate cancer actually saves lives. What do you think about this? Unlike breast cancer, there are no completed randomized trials comparing screening to no screening for prostate cancer. They are going on right now. Ten years ago most of the cases of prostate cancer we found were advanced and not curable. Now the opposite is true. We're finding it early, when it's treatable and curable.

There are those, however, who argue that detecting a lot of cancers that don't need to be treated leads to over-treatment. But my argument is, if 30,000 people die from prostate cancer every year, it's worth trying to chip away at those deaths by finding the disease early, treating it and curing it.

What does a standard screening test for prostate cancer include? Standard screening recommendations include the PSA test plus a digital rectal exam, or DRE.

What is a DRE for? And does it hurt? The exam involves the insertion of a gloved, lubricated finger up your asshole to feel for any type of growth, and though it is uncomfortable, it is not painful.

What is a PSA test? What does it measure? PSA stands for prostate-specific antigen, which is a protein made in the prostate that is fairly specific to prostate tissue. The bigger your prostate, the more PSA you make, and the level of it goes up in the blood. So one of the signs or warnings of prostate cancer is that the PSA blood level goes up. But there are other prostate conditions that can cause a raised PSA level in the blood, and that's when the PSA test may be positive even when the man does not have prostate cancer.

What can men hope to learn from PSA results? If your PSA test is really high, like 50 or 100 ng/ml, there is high likelihood you have prostate cancer. It is a very sensitive test. So the number in and of itself can be an indicator of cancer. We then biopsy the prostate to make a diags of cancer. Also, tracking changes in PSA levels from year to year is a very effective way to screen for cancer. Perhaps a man is screened and his PSA is low. A year later it goes up a little bit. A year later it goes up a little bit more. And it still may not be very high. So we can find cancers at an earlier stage.

There are many types of PSA measurements. What are the differences between them? PSA exists in various types in the blood. The total PSA, which we have been using to screen for cancer, is really comprised of two components, called "free PSA" and "complex PSA," or "cPSA."

A test to detect free PSA was developed several years ago, and was found to be helpful in differentiating men who had cancer from those who did not.

More recently the cPSA test has been approved as a screening test for prostate cancer. The advantage of this test is that it's able to screen for cancer as well as the total and the free PSA tests, but there aren't as many false pos with it. If the test is pos, there is a higher risk of cancer than would be implied with either the PSA or the free PSA tests.

What, in your opinion, is the most important reason to get screened? Knowledge is power. If you know that you have prostate cancer, you can decide to do nothing. You can decide to have surgery. You can decide to have radiation, or hormonal therapy. But the point is, you will have enough info to make a decision.

Prostate Cancer Awareness Month also features Prostate Cancer Awareness Week, which is Sep 15-21. What is PCAW? PCAW is the largest screening event for any cancer in the world. It was started fourteen years ago by a group of healthcare folks like myself around the country. At that time, men did not talk about prostate cancer, and. most of those diagnosed were advanced and incurable. We wanted to get the word out that men ought to think about trying to find it early.Over a million men are screened for prostate cancer during PCAW.

Are the screening tests free during Prostate Cancer Awareness Week? In most places it's free or low-cost, like $5 and $10.

How can people find a testing site near where they live? Our Web site, www.pcaw.com, offers information about testing sites nationwide.

What is your primary message to men during this awareness month? Get out and get checked. Fifty percent of men in this country have not been screened, even though most men know about prostate cancer. There's fear. I just saw a 52-year old man who had a family history of the disease, and knew that he should have come in earlier. When he finally came in, his PSA was 400, and he had incurable disease. For seven years he was afraid to find out if he had prostate cancer. Well, now he knows, and it's too late. If he had been screened at age 45, it likely would've been curable.

BPH comes with aging and means that the prostate has grown larger. It is not cancer nor causes cancer. Most men over 60 have it, by 80, 8 out of 10 have it. Asians have the lowest incidence.

Symptoms are Frequent pissing. Start & stop attemps to piss. Strong and urgent need to piss. Weak piss stream. Need to push and strain to start piss. Frequent awaking at night to pee. Feel that bladder s not completely empty.

It is common for the prostate gland to become enlarged as a man ages. Doctors call the condition benign prostatic hyperplasia (BPH), or benign prostatic hypertrophy.

Normal urine flow. Urine flow with BPH. As a man matures, the prostate goes through two main periods of growth. The first occurs early in puberty, when the prostate doubles in size. At around age 25, the gland begins to grow again. This second growth phase often results, years later, in BPH.

Though the prostate continues to grow during most of a man's life, the enlargement doesn't usually cause problems until late in life. BPH rarely causes symptoms before age 40, but more than half of men in their sixties and as many as 90 percent in their seventies and eighties have some symptoms of BPH.

As the prostate enlarges, the layer of tissue surrounding it stops it from expanding, causing the gland to press against the urethra like a clamp on a garden hose. The bladder wall becomes thicker and irritable. The bladder begins to contract even when it contains small amounts of urine, causing more frequent urination. Eventually, the bladder weakens and loses the ability to empty itself. Urine remains in the bladder. The narrowing of the urethra and partial emptying of the bladder cause many of the problems associated with BPH.

Many people feel uncomfortable talking about the pros-tate, since the gland plays a role in both sex and urina-tion. Still, prostate enlargement is as common a part of aging as gray hair. As life expectancy rises, so does the occurrence of BPH. In the US alone, 375,000 hosp stays each year involve a diagnosis of BPH.

It is not clear whether certain groups face a greater risk of getting BPH. Studies over the years suggest that BPH occurs more often among married men than single men and is more common in the US and Europe than in other parts of the world. However, these findings have been debated, and no definite info on risk factors exists.

Why BPH Occurs The cause of BPH is not well understood. For centuries, it has been known that BPH occurs mainly in older men and that it doesn't develop in men whose testes were removed before puberty. For this reason, some researchers believe that factors related to aging and the testes may spur the development of BPH.

Throughout their lives, men produce both testosterone, an important male hormone, and small amounts of estrogen, a female hormone. As men age, the amount of active testosterone in the blood decreases, leaving a higher proportion of estrogen. Studies done with animals have suggested that BPH may occur because the higher amount of estrogen within the gland increases the activity of substances that promote cell growth.

Another theory focuses on dihydrotestosterone (DHT), a substance derived from testosterone in the prostate, which may help control its growth. Most animals lose their ability to produce DHT as they age. However, some research has indicated that even with a drop in the blood's testosterone level, older men continue to produce and accumulate high levels of DHT in the prostate. This accumulation of DHT may encourage the growth of cells. Scientists have also noted that men who do not produce DHT do not develop BPH.

Some researchers suggest that BPH may develop as a result of "instructions" given to cells early in life. According to this theory, BPH occurs because cells in one section of the gland follow these instructions and "reawaken" later in life. These "reawakened" cells then deliver signals to other cells in the gland, instructing them to grow or making them more sensitive to hormones that influence growth.

Many symptoms of BPH stem from obstruction of the urethra and gradual loss of bladder function, which results in incomplete emptying of the bladder. The symptoms of BPH vary, but the most common ones involve changes or problems with urination, such as

a hesitant, interrupted, weak stream urgency and leaking or dribbling more frequent urination, especially at night The size of the prostate does not always determine how severe the obstruction or the symptoms will be. Some men with greatly enlarged glands have little obstruction and few symptoms while others, whose glands are less enlarged, have more blockage and greater problems.

Sometimes a man may not know he has any obstruction until he suddenly finds himself unable to urinate at all. This condition, called acute urinary retention, may be triggered by taking OTC cold or allergy meds. Such meds contain a decongestant drug, known as a sympathomimetic. A potential side effect of this drug may be to prevent the bladder opening from relaxing and allowing urine to empty. When partial obstruction is present, urinary retention also can be brought on by alcohol, cold temps, or a long period of immobility.

It is important to tell your doctor about urinary problems such as those described above. In 8 out of 10 cases, these symptoms suggest BPH, but they also can signal other, more serious conditions that require prompt treatment. These conditions, including prostate cancer, can be ruled out only by a doctor's exam.

Severe BPH can cause serious problems over time. Urine retention and strain on the bladder can lead to urinary tract infections, bladder or kidney damage, bladder stones, and incontinence. If the bladder is permanently damaged, treatment for BPH may be ineffective. When BPH is found in its earlier stages, there is a lower risk of developing such complications.

Diagnosis You may first notice symptoms of BPH yourself, or your doctor may find that your prostate is enlarged during a routine checkup. When BPH is suspected, you may be referred to a urologist. Several tests help the doctor identify the problem and decide whether surgery is needed. The tests vary from patient to patient, but the following are the most common.

Digital Rectal Exam (DRE) - This exam is usually the first test done. The doctor inserts a gloved finger into the rectum and feels the part of the prostate next to the rectum. This exam gives the doctor a general idea of the size and condition of the gland.

Prostate Specific Antigen (PSA) Blood Test - In order to rule out cancer as a cause of urinary symptoms, your doctor may recommend a PSA blood test. PSA, a protein produced by prostate cells, is frequently present at elevated levels in the blood of men who have prostate cancer. The U.S. Food and Drug Administration has approved a PSA test for use in conjunction with a digital rectal exam to help detect prostate cancer in men age 50 or older and for monitoring prostate cancer patients after treatment.

However, much remains unknown about the interpretation of PSA levels, the test's ability to discriminate cancer from benign prostate conditions, and the best course of action following a finding of elevated PSA.

Because many unanswered questions surround the issue of PSA screening, the relative magnitude of its potential risks and benefits is unknown. Both PSA and ultrasound tests enhance detection when added to DRE screening. But they are known to have relatively high false-positive rates, and they may identify a greater number of medically insignificant tumors.

Thus, PSA screening might lead to treatment of unproven benefit that could result in morbidity (including impotence and incontinence) and mortality. It cannot be determined from earlier studies whether PSA screening will reduce prostate cancer mortality. Ongoing studies are addressing this issue.

Rectal Ultrasound - If there is a suspicion of prostate cancer, your doctor may recommend a test with rectal ultrasound. In this procedure, a probe inserted in the rectum directs sound waves at the prostate. The echo patterns of the sound waves form an image of the prostate gland on a display screen.

Urine Flow Study - Sometimes the doctor will ask a patient to urinate into a special device that measures how quickly the urine is flowing. A reduced flow often suggests BPH.

Intravenous Pyelogram (IVP) - IVP is an x ray of the urinary tract. In this test, a dye is injected into a vein, and the x ray is taken. The dye makes the urine visible on the x ray and shows any obstruction or blockage in the urinary tract.

Cystoscopy - In this exam, the doctor inserts a small tube through the opening of the urethra in the penis. This procedure is done after a solution numbs the inside of the penis so all sensation is lost. The tube, called a cystoscope, contains a lens and a light system, which help the doctor see the inside of the urethra and the bladder. This test allows the doctor to determine the size of the gland and identify the location and degree of the obstruction.

Treatment Men who have BPH with symptoms usually need some kind of treatment at some time. However, a number of recent studies have questioned the need for early treatment when the gland is just mildly enlarged. These studies report that early treatment may not be needed because the symptoms of BPH clear up without treatment in as many as one-third of all mild cases. Instead of immediate treatment, they suggest regular checkups to watch for early problems. If the condition begins to pose a danger to the patient's health or causes a major inconvenience to him, treatment is usually recommended.

Since BPH may cause urinary tract infections, a doctor will usually clear up any infection with antibiotics before treating the BPH itself. Although the need for treatment is not usually urgent, doctors generally advise going ahead with treatment once the problems become bothersome or present a health risk.

The following section describes the types of treatment that are most commonly used for BPH.

Drug Treatment - Over the years, researchers have tried to find a way to shrink or at least stop the growth of the prostate without using surgery. The Food and Drug Administration (FDA) has approved four drugs to relieve common symptoms associated with an enlarged prostate.

Finasteride (marketed under the name Proscar), FDA-approved in 1992, inhibits production of the hormone DHT, which is involved with prostate enlargement. Its use can actually shrink the prostate in some men.

FDA also approved the drugs terazosin (marketed as Hytrin) in 1993, doxazosin (marketed as Cardura) in 1995, and tamsulosin (marketed as Flomax) in 1997 for the treatment of BPH. All three drugs act by relaxing the smooth muscle of the prostate and bladder neck to improve urine flow and to reduce bladder outlet obstruction. Terazosin, doxazosin, and tamsulosin belong to the class of drugs known as alpha blockers. Terazosin and doxazosin were developed first to treat high blood pressure. Tamsulosin is the first alpha blocker developed specifically to treat BPH.

NIDDK's Medical Therapy of Prostatic Symptoms (MTOPS) Trial recently found that using finasteride and doxazosin together is more effective than either drug alone to relieve symptoms and prevent BPH progression. The two-drug regimen reduced the risk of BPH progression by 67 percent, compared to 39 percent for doxazosin alone and 34 percent for finasteride alone.

Nonsurgical Treatment - Because drug treatment is not effective in all cases, researchers in recent years have developed a number of procedures that relieve BPH symptoms but are less invasive than surgery.

Transurethral Microwave Procedures. In May 1996, FDA approved the Prostatron, a device that uses microwaves to heat and destroy excess prostate tissue. In the procedure called transurethral microwave thermotherapy (TUMT), the Prostatron sends computer-regulated microwaves through a catheter to heat selected portions of the prostate to at least 111 degrees Fahrenheit. A cooling system protects the urinary tract during the procedure.

A similar microwave device, the Targis System, received FDA approval in September 1997. Like the Prostatron, the Targis System delivers microwaves to destroy selected portions of the prostate and uses a cooling system to protect the urethra. A heat-sensing device inserted in the rectum helps monitor the therapy.

Both procedures take about 1 hour and can be performed on an outpatient basis without general anesthesia. Neither procedure has been reported to lead to impotence or incontinence.

While microwave therapy does not cure BPH, it reduces urinary frequency, urgency, straining, and intermittent flow. It does not correct the problem of incomplete emptying of the bladder. Ongoing research will determine any long-term effects of microwave therapy and who might benefit most from this therapy.

Transurethral Needle Ablation. In October 1996, FDA approved Vidamed's minimally invasive Transurethral Needle Ablation (TUNA) System for the treatment of BPH.

The TUNA System delivers low-level radiofrequency energy through twin needles to burn away a well-defined region of the enlarged prostate. Shields protect the urethra from heat damage. The TUNA System improves urine flow and relieves symptoms with fewer side effects when compared with transurethral resection of the prostate (TURP). No incontinence or impotence has been observed.

Surgical Treatment - Most doctors recommend removal of the enlarged part of the prostate as the best long-term solution for patients with BPH. With surgery for BPH, only the enlarged tissue that is pressing against the urethra is removed; the rest of the inside tissue and the outside capsule are left intact. Surgery usually relieves the obstruction and incomplete emptying caused by BPH. The following section describes the types of surgery that are used.

Transurethral Surgery. In this type of surgery, no external incision is needed. After giving anesthesia, the surgeon reaches the prostate by inserting an instrument through the urethra.

A procedure called TURP (transurethral resection of the prostate) is used for 90 percent of all prostate surgeries done for BPH. With TURP, an instrument called a resectoscope is inserted through the penis. The resectoscope, which is about 12 inches long and 1/2 inch in diameter, contains a light, valves for controlling irrigating fluid, and an electrical loop that cuts tissue and seals blood vessels.

During the 90-min operation, the surgeon uses the resectoscope's wire loop to remove the obstructing tissue one piece at a time. The pieces of tissue are carried by the fluid into the bladder and then flushed out at the end of the operation. Most doctors suggest using TURP whenever possible. Transurethral procedures are less traumatic than open forms of surgery and require a shorter recovery period.

Another surgical procedure is called transurethral incision of the prostate (TUIP). Instead of removing tissue, as with TURP, this procedure widens the urethra by making a few small cuts in the bladder neck, where the urethra joins the bladder, and in the prostate gland itself. Although some people believe that TUIP gives the same relief as TURP with less risk of side effects such as retrograde ejaculation, its advantages and long-term side effects have not been clearly established.

Open Surgery. In the few cases when a transurethral procedure cannot be used, open surgery, which requires an external incision, may be used. Open surgery is often done when the gland is greatly enlarged, when there are complicating factors, or when the bladder has been damaged and needs to be repaired. The location of the enlargement within the gland and the patient's general health help the surgeon decide which of the three open procedures to use.

With all the open procedures, anesthesia is given and an incision is made. Once the surgeon reaches the prostate capsule, he scoops out the enlarged tissue from inside the gland.

Laser Surgery. In March 1996, FDA approved a surgical procedure that employs side-firing laser fibers and Nd: YAG lasers to vaporize obstructing prostate tissue. The doctor passes the laser fiber through the urethra into the prostate using a cystoscope and then delivers several bursts of energy lasting 30 to 60 seconds. The laser energy destroys prostate tissue and causes shrinkage. Like TURP, laser surgery requires anesthesia and a hospital stay. One advantage of laser surgery over TURP is that laser surgery causes little blood loss. Laser surgery also allows for a quicker recovery time. But laser surgery may not be effective on larger prostates. The long-term effectiveness of laser surgery is not known.

Your Recovery After Surgery in the Hospital If you have surgery, you'll probably stay in the hospital from 3 to 10 days depending on the type of surgery you had and how quickly you recover.

Foley Catheter - At the end of surgery, a special catheter is inserted through the opening of the penis to drain urine from the bladder into a collection bag. Called a Foley catheter, this device has a water-filled balloon on the end that is placed in the bladder, which keeps it in place.

This catheter is usually left in place for several days. Sometimes, the catheter causes recurring painful bladder spasms the day after surgery. These may be difficult to control, but they will eventually disappear.

You may also be given antibiotics while you are in the hospital. Many doctors start giving this medicine before or soon after surgery to prevent infection. However, some recent studies suggest that antibiotics may not be needed in every case, and your doctor may prefer to wait until an infection is present to give them.

After surgery, you will probably notice some blood or clots in your urine as the wound starts to heal. If your bladder is being irrigated (flushed with water), you may notice that your urine becomes red once the irrigation is stopped. Some bleeding is normal, and it should clear up by the time you leave the hospital. During your recovery, it is important to drink a lot of water (up to 8 cups a day) to help flush out the bladder and speed healing.

Do's and Don'ts Take it easy the first few weeks after you get home. You may not have any pain, but you still have an incision that is healing--even with transurethral surgery, where the incision can't be seen. Since many people try to do too much at the beginning and then have a setback, it is a good idea to talk to your doctor before resuming your normal routine. During this initial period of recovery at home, avoid any straining or sudden movements that could tear the incision. Here are some guidelines:

Continue drinking a lot of water to flush the bladder. Avoid straining when moving your bowel. Eat a balanced diet to prevent constipation. If constipation occurs, ask your doctor if you can take a laxative. Don't do any heavy lifting. Don't drive or operate machinery.

Getting Back to Normal Even though you should feel much better by the time you leave the hospital, it will probably take a couple of months for you to heal completely. During the recovery period, the following are some common problems that can occur.

Problems Urinating - You may notice that your urinary stream is stronger right after surgery, but it may take awhile before you can urinate completely normally again. After the catheter is removed, urine will pass over the surgical wound on the prostate, and you may initially have some discomfort or feel a sense of urgency when you urinate. This problem will gradually lessen, though, and after a couple of months you should be able to urinate less frequently and more easily.

Inability to Control Urination (Incontinence) - As the bladder returns to normal, you may have some temporary problems controlling urination, but long-term incontinence rarely occurs. Doctors find that the longer problems existed before surgery, the longer it will take for the bladder to regain its full function after the operation.

Bleeding - In the first few weeks after transurethral surgery, the scab inside the bladder may loosen, and blood may suddenly appear in the urine. Although this can be alarming, the bleeding usually stops with a short period of resting in bed and drinking fluids. However, if your urine is so red that it is difficult to see through or if it contains clots or if you feel any discomfort, be sure to contact your doctor.

Sexual Function After Surgery Many men worry about whether surgery for BPH will affect their ability to enjoy sex. Some sources state that sexual function is rarely affected, while others claim that it can cause problems in up to 30 percent of all cases. However, most doctors say that even though it takes awhile for sexual function to return fully, with time, most men are able to enjoy sex again.

Complete recovery of sexual function may take up to 1 year, lagging behind a person's general recovery. The exact length of time depends on how long after symptoms appeared that BPH surgery was done and on the type of surgery. Following is a summary of how surgery is likely to affect the following aspects of sexual function.

Erections - Most doctors agree that if you were potent (able to maintain an erection) shortly before surgery, you will probably be able to have erections afterward. Surgery rarely causes a loss of potency. However, surgery cannot usually restore potency that was lost before the operation.

Ejaculation - Although most men are able to continue having erections after surgery, a prostatectomy frequently makes them sterile (unable to father children) by causing a condition called "retrograde ejaculation" or "dry climax."

During sexual activity, sperm from the testes enters the urethra near the opening of the bladder. Normally, a muscle blocks off the entrance to the bladder, and the semen is expelled through the penis. However, the coring action of prostate surgery cuts this muscle as it widens the neck of the bladder. Following surgery, the semen takes the path of least resistance and enters the wider opening to the bladder rather than being expelled through the penis. Later it is harmlessly flushed out with urine.

Orgasm - Most men find little or no difference in the sensation of orgasm, or sexual climax, before and after surgery. Although it may take some time to get used to retrograde ejaculation, you should eventually find sex as pleasurable after surgery as before.

Many people have found that concerns about sexual function can interfere with sex as much as the operation itself. Understanding the surgical procedure and talking over any worries with the doctor before surgery often help men regain sexual function earlier. Many men also find it helpful to talk to a counselor during the adjustment period after surgery.

Is Further Treatment Needed? In the years after your surgery, it is important to continue having a rectal exam once a year and to have any symptoms checked by your doctor.

Since surgery for BPH leaves behind a good part of the gland, it is still possible for prostate problems, including BPH, to develop again. However, surgery usually offers relief from BPH for at least 15 years. Only 10 percent of the men who have surgery for BPH eventually need a second operation for enlargement. Usually these are men who had the first surgery at an early age.

Sometimes, scar tissue resulting from surgery requires treatment in the year after surgery. Rarely, the opening of the bladder becomes scarred and shrinks, causing obstruction. This problem may require a surgical procedure similar to transurethral incision (see section on Surgical Treatment). More often, scar tissue may form in the urethra and cause narrowing. This problem can usually be solved during an office visit when the doctor stretches the urethra.

Prostatic Stents - Stents are small devices inserted through the urethra to the narrowed area and allowed to expand, like a spring. The stent pushes back the prostatic tissue, widening the urethra. FDA approved the Urolume Endoprosthesis in 1996 to relieve urinary obstruction in men and improve ability to urinate. The device is approved for use in men for whom other standard surgical procedures to correct urinary obstruction have failed.

BPH and Prostate Cancer: No Apparent Relation - Although some of the signs of BPH and prostate cancer are the same, having BPH does not seem to increase the chances of getting prostate cancer. Nevertheless, a man who has BPH may have undetected prostate cancer at the same time or may develop prostate cancer in the future. For this reason, the National Cancer Institute and the American Cancer Society recommend that all men over 40 have a rectal exam once a year to screen for prostate cancer.

After BPH surgery, the tissue removed is routinely checked for hidden cancer cells. In about 1 out of 10 cases, some cancer tissue is found, but often it is limited to a few cells of a nonaggressive type of cancer, and no treatment is needed.

Chance to Sleep Through the Night By GINA KOLATA NYT 11/05/02 As surely as middle age brings on a receding hairline and, all too often, a growing waistline, it also brings, for most men, an embarrassing problem. Its medical name is B.P.H., for benign prostatic hypertrophy, or hyperplasia and, as its name implies, it is an enlargement of the prostate that is not caused by cancer. It shows up as a problem with urinating.

"Most men, by the time they get into their 50's and 60's, have a decrease in urinary function," said Dr. Albert G. Mulley Jr., a specialist in internal medicine and medical decision making at the Mass Gen Hosp. "A lot of men won't talk about it, but the stream isn't what it used to be. It becomes awfully hard to empty your bladder and not to feel like you have to empty it again. There's lots of dribbling."

What can men do about it? About a decade ago, the choices were bleak. "Men lived with their symptoms, and if they got really bad, they had surgery," said Dr. Peter C. Albertsen, a urologist at the Univ of Conn Health Ctr. Now, men with moderate symptoms are treated with meds and most get relief. The operation, which involves cutting much of the tissue inside the prostate, is for men who cannot be helped any other way.

Dr. John D. McConnell, a urologist at the University of Texas Southwestern Medical Center in Dallas, ticked off today's options: watchful waiting, medications, a half-dozen minimally invasive surgeries, traditional surgery and variations on those themes.

When a man visits Dr. McConnell about urination problems, he said, the first question he asks is how bothersome are the symptoms. "Many men with B.P.H. have symptoms, but they may just be getting up once a night to urinate or they may just have a slow urine stream. Often they just need reassurance that they don't have prostate cancer," he said.

The condition, in fact, has nothing to do with cancer. The prostate gland, which surrounds the tube that carries urine from the bladder to the penis, is about the size of a walnut. It often enlarges in middle-aged and older men, squeezing and narrowing the urethra while putting pressure on the bladder. The gland can continue to grow after symptoms of B.P.H. emerge, worsening urinary problems, but often it does not.

A new study by the National Institutes of Health indicates that only 20 percent of men with moderate symptoms progress to more severe ones over a five-year period. MOST men who are seriously bothered by their symptoms opt for medication, urologists said. These are men who get up repeatedly at night to urinate, or who can't get through a meeting without rushing to the men's room.

There are two types of drugs that can help. The alpha blockers relax muscles that contract the prostate and the neck of the bladder, allowing urine to flow more freely. Two alpha blockers, doxazosin and terazosin, are avail as generics. Orig developed as drugs to treat high blood pressure, they were later discovered to be effective against B.P.H. Their disadvantage is that doctors have to start with a low dose, gradually increasing it so the men do not get dizzy from excessively low blood pressure. A third drug, tamsulosin, also known as Flomax, was developed more recently for B.P.H., and avoids that low blood pressure problem, Dr. McConnell said.

A lot of men who take alpha blockers report a 50 percent reduction in their symptoms, as measured on a scale that asks questions like how frequently they urinate during the day and at night, and how often their bladder empties incompletely.

Another type of drug, finasteride, also known as Proscar, actually shrinks the prostate about 20%. By itself, Dr. McConnell said, it is not quite as useful as an alpha blocker. But in the long run, it reduces the risk that B.P.H. will progress. "If the goal is to prevent or delay progression, the combination of the two therapies is better than either alone," he said.

New data from the N.I.H. study predict which men with B.P.H. are likely to get worse over the years. A man's prostate must clearly be enlarged upon physical examination and he must have slightly elevated levels of a protein, P.S.A., whose levels soar when a man has prostate cancer.

Some men take an alpha blocker, then add finasteride, and still find their symptoms intolerable. For them, the only thing left is to remove the interior of the prostate gland.

Doctors can do this in their offices, with a variety of methods that use radio-frequency energy to essentially burn and destroy the tissue. The complications are a 10 to 30% chance that a man will be unable to urinate for a day or so afterward, requiring a catheter, and about a 50% chance that he will experience short-term symptoms, incl a burning sensation when he urinates and an increased frequency of urination. The question hanging over this expensive treatment  it can cost $3,000 to $6,000, Dr. McConnell said  is its long-term outcome. "There is not a single, well-designed long-term study that demonstrates five-year success rates," he said.

Finally, there is an operation, with a surgeon removing the tissue in the prostate. "It is still the single, most-effective treatment," Dr. McConnell said. But it does carry slight risks of temporary consequences, like narrowing of the urethra or bleeding. These days, only about 10-15% of men end up needing it.