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Saturday, October 25, 2008
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Adenocarcinoma of the Kidney

Kidney cancer, Renal Cell Carcinoma, or Hypernephroma

* The cause of Kidney Cancer is unknown. Cigarette smoking certainly does increase the risk. Rarely, certain genetic (inherited) syndromes increase the risk as well (specifically von Hippel-Lindau syndrome). Those on long-term dialysis may also have increased risk of developing Renal Cell Carcinoma.

* Flank pain
* Flank mass
* Blood in the Urine

* Urinanalysis may show microscopic blood
* Intravenous pyelogam (IVP) -- X-Rays taken after the dye is injected
* Ultrasound or CT scan can detect tumors or further delineate tumors
* Chest X-Ray to check for lung metastases
* Bone scans to check for bone metastases
* MRI ordoppler Ultrasound to check for tumor thrombus in realigning the vein and inferior vena cava

* Surgical removal of the affected kidney (if the tumor is only in the kidney, there is a 90-100% chance of a 5-year survival rate).
* Chemotherapy may be tried in more advanced diseases. Vinblastine, alpha interferon, or inteleukin-2 may be considered.
* If you suspect this condition, seek medical treatment very soon. If this disease is caught early, there is more of a chance for recovery then if it is detected late.

* Bladder Cancer
* Angiomyolipomas
* Transitional cell cancers of the renal pelvis
* Adrenal tumors
* Oncocytomas
* Renal abscesses

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Addison's Disease

Chronic adrenocortical insufficiency

* Addison's disease is caused by the destruction of the central part of the adrenal glands. This area makes the following hormones: Cortisol (which responds to stress and affects the immune system, inflammation, and blood sugar), aldosterone (regulates kidneys and blood pressure), and androgens (sex hormones though not their primary source).

* Weakness
* Fatigue
* Lightheadedness
* Faintness
* Weight loss
* Muscle aches
* Joint aches
* Loss of appetite
* Nausea/vomiting
* Anxiety/irritability
* Emotional lability
* Chronic Diarrhea
* Salt craving
* Depression

* Autoimmune destruction is the most common cause -- i.e., the body's immune system mistakenly attacks the adrenal glands.
* Tuberculosis bacterium may infect the gland (now a rare cause in the USA).
* Hemorrhage (bleeding) into the adrenal glands generally occurs in patients on anticoagulants (blood thinners) during open-heart surgery and after trauma.
* Many other disorders, such as Metastatic Cancer (lung, breast, kidney, or colon), side effects of drugs (e.g., Ketoconazole), radiation therapy, surgical removal of adrenals, Sarcoidosis, Amyloidosis, and infections (e.g., Histoplasmosis, meningococcemia, etc.) may very rarely cause Addison's disease.

* Findings that may present on examination:

1. Low Blood Pressure
2. Increased heart rate
3. Dilated pupils
4. Confusion or memory problems
5. Tremors
6. Mouth -- may have pigmented areas inside the cheeks
7. Skin becomes darker (''appears tanned")
8. Multiple new freckles
9. Darkening of the skin of the elbows, knuckles, and knees.
10. Darkening of the skin of the back of the neck, palm creases, and nail beds.
11. Nipples and areolas (pigmented areas of the breast) become darker
12. Vitiligo (areas of skin lose all color)
13. Seizures
14. Hallucinations
15. Coma

* Blood tests:

1. White blood cell proportions in blood are altered
2. Blood sugar is often low
3. Sodium level is low
4. Potassium level is high
5. Calcium level may be high
6. High levels of very long chain fatty acids (VLCFAs)
7. Low morning plasma Cortisol
8. ACTH level is elevated
9. Cosyntropin stimulation test
10. Anti-adrenal antibodies

* Imaging Tests:

1. Chest X-Ray to look for cancer, Tuberculosis, infection
2. Abdominal X-Ray may show calcification (Calcium deposits) in the adrenals.
3. CT scan of abdomen to evaluate the adrenal glands

* Replacement therapy for hormones no longer being manufactured by the adrenal gland

1. Hydrocortisone or Prednisone
2. Fludrocortisone acetate
3. Extra salt (NaCl) in diet
4. Appropriate amounts of Potassium and water in the diet.

* Tuberculosis
* Metastatic Cancer
* Vitiligo
* Hemochromatosis
* Amyloid disease
* Scleroderma

* Special considerations

- The dose of Hydrocortisone or Prednisone must be increased when the body is under stress, such as with an infection or around the time of surgery. This is very important and can be life threatening if not properly monitored by a physician.

Friday, October 24, 2008
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Acute Subdural Hematoma

Subacute subdural hematoma

* The brain is covered by a membrane (layer of tissue) called the dura. If the veins located below the dura (subdural area) leak blood, then pressure in this area may build up and injure the brain. Head injuries may injure these veins, causing them to be torn and leak. This blood collects into a mass called a hematoma. Hence the name, Subdural Hematoma. For an acute hematoma, symptoms generally occur in the first 24 hours, while for a subacute Hematoma, they occur in the first 2-10 days after a head injury.



* Head injury (may be severe or a minor)
* Nausea
* Headache
* Personality changes
* Confusion
* Decreased level of consciousness
* Impaired vision
* Eye droop
* Speech difficulties
* Paralysis
* Numbness or decreased sensation in a limb
* Seizures
* Coma
* Other neurological problems
* Symptoms may initially improve, but then dramatically worsen

* Neurological exam by a physician
* Complete blood count, Chemistry panels, a PT, and a PTT should be performed
* CT scan of the head

* Very young (infants) or the elderly
* Use of blood thinners such as aspirin or Coumadin
* Alcoholism
* Diseases that increase the risk of falls such as Alzheimer's disease or narcolepsy.

* Goal is to reduce pressure on the brain
* Circulation support (intravenous fluids and medications to maintain blood pressure)
* Respiratory support (oxygen and mechanical ventilation if necessary)
* Dexamethasone (a corticosteroid medication) may be used to decrease the inflammation of the brain
* Mannitol (a diuretic) may be used to decrease the swelling of the brain
* Dilantin (a seizure medication) may be used to prevent or control Seizures
* Reversal of blood thinning agents such as Coumadin or Heparin
* Emergency Surgery may be needed to drain the hematoma (blood clot), and relieve the pressure on the brain. The hematoma is outside the brain, but still puts pressure on it. Therefore, the surgery involves drilling small holes in the skull and evacuating the blood. Occasionally, if the hematoma is very large or has solidified, a large opening in skull may be needed (this is called a craniotomy).

* The individual needs immediate emergency medical treatment. Untreated, this condition often leads to death.

* Meningitis
* Encephalitis
* Subarachnoid Hemorrhage
* Chronic Subdural Hematoma
* Stroke

Life and death 2: the brain (subdural hematoma surgery)

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Acute Sinusitis

* Sinuses are open cavities. An infected sinus is known as sinusitis. The maxillary and frontal sinuses are the two main sinuses that become infected. The maxillary sinuses are located on the inside cheeks of both sides of the nose. The maxillary sinuses drain through the nose. In addition, the ears drain fluid into the maxillary sinuses by way of the eustachian tube. The eustachian tube may become blocked or inflamed from a sinus infection, resulting in pressure, pain, or fullness in the ears. The frontal sinuses are located in the lower part of the forehead just above the bridge of nose.
* Sinusitis usually occurs either after a viral infection (cold/runny nose) or after allergy symptoms begin. This occurs because of swelling in the nasal tract tissue, which drains the sinuses, causing them to become swollen. The sinuses accumulate fluid and mucous, allowing bacteria to grow in the sinuses, which causes the sinusitis.



* Pain/pressure over the sinuses
* Occasional upper tooth pain
* Pain and tenderness over the forehead
* Ear pressure
* If symptoms do note resolve in three weeks, or do not respond to antibiotics, this may represent Chronic Sinusitis. Please see the section on Chronic Sinusitis for more details.

* Streptococcus pneumoniae
* Hemophilus Influenza
* Moraxella catarrhalis
* Staphylococcus aureus

* Transilluminator may show a fluid collection
* Sinus X-Rays
* A CT scan of the sinuses is more accurate than an X-Ray
* Cultures are not helpful unless done by a needle placed into the sinuses (and this is not done unless the case is extreme)

* Oral antibiotics are usually administered for 10 to 14 days. Commonly used antibiotics include Ceftin, augmentin, or cipro.
* Older antibiotics, such as Amoxicillin and Erythromycin may be prescribed, but you should be aware that they do not provide the same scope of coverage that Ceftin, augmentin, or cipro. They have poor coverage when dealing with Haemophilus Influenza as well.
* Oral Decongestants, such as Sudafed, and nasal sprays such as Afrin, for the first 3 days may be helpful (after 3 days a "rebound" may occur, and the decongestants may no longer be effective).
* Take a warm shower twice a day, and blow out your excessive mucous.
* Saline nasal sprays may be used multiple times during the day to loosen nasal secretions.

* Tooth Abscess
* Mucormycosis
* Sinus cancer

* Predisposing Causes

1. Viral Rhinitis (Cold)
2. Allergies
3. Dental problems
4. nasal polyps

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Acute Poststreptococcal Glomerulonephritis


* This is the most common form of glomerulonephritis, a disorder marked by inflammation of the kidneys' glomeruli.

* Dark brown urine
* Periorbital swelling
* Shortness of Breath
* Rapid breathing
* Pallor
* High blood pressure
* Diarrhea
* Decreased urine output
* Seizures

* Streptococcal infection (nephritogenic strain)
* Pharyngitis -- M type 12
* Skin Infection: M type 49

* Streptococcal infection evidence
* Laboratory tests:

1. Manual blood count shows anemia
2. Elevated blood urea nitrogen (BUN) level
3. Elevated creatinine (Cr) level
4. Streptococcus serologic tests (ASO, antihyaluronidase, antideoxyribonuclease) level
5. Decreased complement 3 level
Microscopic urine examine shows protein, RBC, WBC in urine

* Penicillin for 10 days
* For kidney failure:

1. Restrict fluid
2. Maintain calories
3. Correction of electrolyte disturbance

* For high blood pressure:

1. Hospitalization
2. Diazoxide for pulmonary edema

* Acute renal failure
* Hypertensive encephalopathy
* Heart failure

* Ninety-five percent of patients recover completely.

* Your child needs to be hospitalized if he/she has high blood pressure.

* Lupus nephritis
* Membranoproliferative glomerulonephritis (MPGN)
* Nephritis due to bacterial endocarditis
* Shunt nephritis

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Acute Peritonitis

* Acute peritonitis is an inflammatory process within the abdominal cavity. It is usually due to a bacterial infection and is treated with antibiotics.
* In some cases, the infection occurs independent of outside infection, and is known as Spontaneous Bacterial Peritonitis (SBP). SBP usually occurs in patients who have Ascites (fluid in the abdominal cavity) from some other cause. Most people normally have only a very small amount of fluid in the stomach cavity. However, certain diseases can lead to the accumulation of fluid within the abdomen. This fluid can get infected, in turn, and cause peritonitis.
* About 20 to 30% of patients with Ascites will develop SBP. In other cases, peritonitis is caused by some other condition, and this is known as secondary bacterial peritonitis.
* In a few cases, the condition may be due to less common causes, such as Tuberculosis, cancer, or other processes. In cases of bacterial peritonitis, treatment is with antibiotics. In other cases, the underlying condition has to be treated.

* Most patients with peritonitis will have abdominal pain and a fever.
* Also, they usually already have Ascites (a build-up of fluid within their stomach) and a distended stomach. Peritonitis may or may not cause the stomach to be more distended than normal.
* Some patients will have nausea, vomiting, loss of appetite, and weight loss. Which of these symptoms are present depends on the cause of the problem.
* Many patients with Ascites also have liver problems. When these patients develop peritonitis, they often experience deterioration in mental status because of the build-up of toxic substances in their blood.
* Patients with tuberculous peritonitis have low-grade fever, loss of appetite, and weight loss. Often, their Ascites will develop slowly.
* In patients with cancer, the cancer can spread to the peritoneum (the abdominal cavity). If this happens, it triggers a reaction and causes the accumulation of fluid. This can cause an abnormal increase in the size of the abdomen, loss of appetite, and lack of energy.
* If there is a large amount of fluid within the stomach cavity, the patient may have trouble breathing because the lungs cannot expand normally. Also, fluid may block the intestine and not allow food to pass through.
* Examination by a doctor usually reveals tenderness of the abdomen, and fever.

* As stated above, there are many factors that cause peritonitis.
* Secondary bacterial peritonitis is usually caused by an infection somewhere in the abdomen. For example, Diverticulitis, Appendicitis, pancreatitis, intestinal perforation, etc., all can cause this problem. Most abdominal infections stay within the infected organ. When the infection spreads out of the organ and into the abdominal cavity, it causes peritonitis. This is known as secondary bacterial peritonitis. Also, any type of trauma that introduces bacteria into the abdominal cavity can lead to peritonitis.
* Spontaneous Bacterial Peritonitis occurs when the fluid within the abdominal cavity becomes infected on its own. This process almost always occurs in patients who already have Ascites. It is called spontaneous because the bacteria enter the abdominal cavity on their own by moving through the wall of the intestine. There is no outside source for the infection, such as in secondary bacterial peritonitis.
* The risk of Spontaneous Bacterial Peritonitis (SBP) is higher in patients who have liver disease and who have a low amount of protein in their Ascites fluid.
* Another cause of peritonitis is Tuberculosis infection of the abdominal cavity.
* Cancer can also spread to the abdominal cavity and cause the development of Ascites. The most common tumors that spread to the abdominal cavity include cancer from the ovaries, uterus, pancreas, stomach, colon, lungs, and breasts.
* A disease called familial Mediterranean fever also can cause peritonitis.

* The symptoms and doctor's examination may suggest the presence of peritonitis, or peritonitis might be diagnosed during abdominal surgery.
* However, the only way to be sure is to remove some of the fluid and send it to the lab. This is done by a process known as paracentesis. In a paracentesis, a needle is inserted into the abdomen and a sample of the fluid is removed. The fluid is then sent to the lab where it is analyzed.
* Once, the test results are back, decisions regarding treatment can be made.
* This test will only tell you whether or not an infection is present. It will not necessarily tell you the source of the infection.
* Once the diagnosis of an infection (peritonitis) is made, then it has to be determined whether this is spontaneous or secondary bacterial peritonitis.
* Spontaneous Bacterial Peritonitis usually responds to antibiotic therapy within 24 to 48 hours.
* If the patient is placed on antibiotics and is not improving after 1 to 2 days, the doctor may need to repeat the paracentesis to recheck the fluid. The doctor has to take into consideration that the lack of improvement may be due to secondary bacterial peritonitis or some other disease.
* If secondary bacterial peritonitis is felt to be present, the doctor will have to do more testing to see what is causing the problem. Tests may include Ultrasound, CAT scan, and special X-Rays (such as an upper gastrointestinal series or a gastrograffin enema). The most appropriate test will be determined by your doctor.
* Tuberculous peritonitis is often very hard to diagnose. Often, the fluid collected from the abdomen will not give a specific diagnosis. In such cases, the patient may need a biopsy to see if the infection is due to Tuberculosis. The biopsy can be done by laparoscopic surgery, in which a camera is inserted into the abdomen via 2 or 3 small incisions. The doctor can then look around and perform a biopsy.
* In patients with peritonitis due to cancer, the fluid can be collected and analyzed in the laboratory to see if any cancer cells are present. If this does not give a final diagnosis, then laparoscopic surgery can be done (as described above) to obtain a biopsy.
* In patients with familial Mediterranean fever, they can undergo genetic testing to see if they have this disease.

* Risk factors for developing peritonitis include the presence of Ascites. Therefore, any condition that leads to the formation of Ascites can also be considered a risk factor for peritonitis.
* Also, a low amount of protein (less than 1 gram per deciliter) in the Ascites fluid is a risk factor for developing peritonitis.
* Any other abdominal infection such as Appendicitis, Diverticulitis, perforation, etc can lead to peritonitis.
* Having had peritonitis previously is a risk factor for developing peritonitis again.

* Treatment depends on the cause of the peritonitis.
* In general, patients who have Ascites are placed on diuretics. A diuretic is a type of medication that increases urine output and helps remove excess fluid from the body. It is often also known as a "water pill."
* Treatment for secondary peritonitis is addressed at taking care of the underlying infection or problem. The person will need to be placed on antibiotics. However, the most appropriate treatment depends on the cause of the problem.
* Treatment for SBP is with antibiotics. Usually the person is treated with an antibiotic such as cefotaxime. If needed, another antibiotic called ampicillin can be also be used. Antibiotics are usually continued for 1-2 weeks.
* In certain special circumstances (for example those who do peritoneal dialysis), they may need different antibiotics. Therefore, the doctor treating the person will help decide which antibiotic is most appropriate.
* Patients with Ascites due to cancer usually do not require antibiotics. They also usually do not respond to medicines that increase urine output (diuretics). These individuals usually require a procedure known as large volume paracentesis. This procedure is the same as that described above (in the diagnosis section). However, instead of removing just a small sample for analysis, a large amount of the fluid is removed to help reduce the person's symptoms.
* Patients with familial Mediterranean fever sometimes can be treated with a medicine called Colchicine (which is often used in patients with gout) to help reduce the frequency and severity of symptoms. However, no specific cure for this condition is currently available.

* Usually, most cases of peritonitis due to an infection respond to antibiotics.
* If the infection does not respond, the infection may get worse or spread to other parts of the body.
* Other complications include Intestinal Obstruction, shortness of breath, or development of fluid build-up around the lungs (called a pleural effusion).

* If you suspect this condition, please seek medical attention as soon as possible.

* Things such as fluid collections due to cancer cannot really be prevented.
* Peritonitis due to other causes (secondary bacterial peritonitis) can potentially be prevented if those conditions are diagnosed and treated quickly.
* Tuberculous peritonitis can sometimes be prevented if the infection is detected elsewhere in the body and treatment is started early.
* Spontaneous Bacterial Peritonitis has a high rate of occurring again in patients who have already had it once. Therefore, antibiotics are often given to these patients to prevent repeat infections. These antibiotics are also given to patients with very low amounts of protein in their Ascites (remember a low protein level greatly increases the risk of developing SBP).
* The antibiotics most often used are ciprofloxacin (750 milligrams once a week), Norfloxacin (400 milligrams once a day), or Trimethoprim-sulfamethoxazole (one double-strength tablet a day).
* These antibiotics, though not a 100% effective, do greatly reduce the risk of developing an infection.

* Diverticulitis
* Pancreatitis
* Cholecystitis
* Cholangitis
* Pancreatitis
* Chylous, pancreatic, or bile Ascites
* Bowel obstruction
* Appendicitis

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Acute Nonsuppurative Pericarditis

Pericarditis, ANP, Constrictive Pericarditis, CP, or pericardial tamponade

* The heart and the blood vessels emerging from it are covered by a sac called the pericardium. This sac has an outer and inner layer normally separated by a small amount of lubricating fluid. Conditions that irritate the pericardium cause a localized and protective body response known as inflammation. This may result in an increase in the amount of fluid (pericardial effusion) between the outer and inner layers that may compress the heart and restrict its pumping action.
* In constrictive Pericarditis there is a thickening of the pericardium and attachment to the heart that may restrict its normal movements.
* In pericardial or Cardiac Tamponade (PT), blood or fluid can also collect in the pericardium and cause heart problems. PT can result with any type of Pericarditis.
* Pericarditis may be acute (less than 6 weeks) or chronic (>6 weeks).

* Chest pain:

1. Sharp or stabbing
2. Sudden
3. Worse on breathing in or with movement
4. Radiating to neck, back, shoulders, or abdomen
5. Reduced by sitting up or leaning forward

* Difficulty breathing:

1. Worse with lying down
Better when standing, sitting, or bent forward
2. Racing Heart
3. Pounding in the Chest
4. Fever
5. Cough
6. Sweating
7. Dizziness
8. Fatigue
9. Loss of appetite

* With constrictive Pericarditis and Pericardial Tamponade, there is pressure on the heart from thick fibrous material or fluids (>120cc) that compromises the heart's ability to pump, and fluids may build up in the abdomen, ankles, and feet (right-sided Heart Failure).

Idiopathic -- i.e., no cause is identified. This is the most common type.

Viruses -- Coxsackie B (especially children), adenovirus (especially children), Mumps , Epstein-Barr, echo virus, Herpes Simplex
2. Bacteria -- Staphylococcus, Haemophilus (especially children), pneumococcus,
Salmonella, Lyme Disease, meningococcus, mycoplasma
3. Acute Rheumatic Fever
4. Mycobacterium -- M.Tuberculosis
5. Fungi -- candida, nocardi, Histoplasmosis

* Drugs:

1. Phenytoin
2. Procainamide
3. Hydralazine
4. Minoxidil

* Others:

1. Cancers:
2. Lung
3. Breast
4. Lymphoma
5. Mesothelioma -- tumors caused by exposure to asbestos

* Connective tissue diseases:

1. Rheumatoid Arthritis
2. SLE ( Systemic Lupus Erythematosus )

* Diseases and other conditions:

1. Pancreatitis
2. Uremia -- kidney failure
3. Sarcoidosis
5. Aortic Dissection -- aorta (major artery) can rupture
6. Chylopericardium (milky fluid inside the pericardium)
7. Myxedema -- severe thyroid disease
8. Dressler's syndrome -- Pericarditis long after a heart attack
9. Radiation of any cause -- constrictive Pericarditis
10. Radiation therapy
11. Acute Pericarditis can result in Pericardial Tamponade and can lead to chronic or constrictive Pericarditis.

* Examination and history
* Physician may consult with a heart specialist (cardiologist)
* History:

1. Symptoms
2. Medications
3. Illnesses
4. Surgeries
5. Habits
6. Job
7. Family
8. Travel
9. Allergies


o Acute Pericarditis:

1. Patient is in pain and anxious.
2. Patient is leaning forward and unable to lie flat.
3. Rapid shallow breathing may be present.
4. Doctor may hear a friction rub -- (using a stethoscope) a scratchy noise is heard over the chest, as the two layers of the pericardium rub against each other.
5. Listening to the lower back, the doctor may hear Fluid in the Lungs (rales).
6. Pulse rate may speed up and then normalize.
7. Fever may be detected.

* Pericardial Tamponade:

1. All the same signs or symptoms as with acute Pericarditis
2. Patient is pale or with bluish lips (cyanosis)
3. Weak or absent pulse
4. Rapid, thready pulse rate
5. Low or no blood pressure (BP)
6. There may be >10 mm Hg drop in systolic BP (the number on top when BP is measured) when the patient breaths in (pulsus paradoxus).
7. Putting his hands over the heart, the doctor may feel little activity.
8. Lungs may be clear when listened to.
9. There may be friction rub.
10. There may be muffled or distant heart sounds, Low BP, and distended neck veins (jugular veins) known as Beck's triad.

* Constrictive Pericarditis:

1. Often a history of acute Pericarditis or viral illness
2. Shortness of breath (dyspnea)
3. Fatigue.
4. Listening to the lungs one may hear rales.
5. Listening to the heart, one may hear an abnormal sound known as a knock.
6. Swollen ankles, legs, arms, and abdomen
7. Distended jugular veins
8. Kussmaul's sign -- upon inspiration, the pressure in the jugular veins increase and distend the veins.

o Tests:

1. Blood samples -- show an increase in white blood cells and ESR, due to inflammation.
2. Heart chemicals (enzymes) can also be elevated (i.e., CK, LDH) in the blood. Liver enzymes may be elevated if there is right-sided Heart Failure.
3. Electrocardiogram or EKG -- (recording of electrical activities of the heart) in Pericarditis has a characteristic pattern.
4. Echocardiograph (echo) - uses sound waves to show a picture of the heart and pericardium. Echo can show if fluid is present. Using echo, a cardiologist can insert a needle in between the pericardial layers, and draw out a small amount of fluid (percardiocentesis), or take a small piece of pericardium (pericardial biopsy). The fluid or sample is then sent to a laboratory, where its contents and source are identified.
5. Cardiac catheterization (CC) -- uses a long wire inserted through the thigh vein and guided to the heart, in order to measure pressure changes inside the heart.
6. CC is useful when constrictive or tamponade Pericarditis is compressing the heart.
7. Chest CAT scan and MRI can provide detailed and clear pictures of the heart, such as the presence of a thick and calcified (Calcium deposits) pericardium in the case of chronic or constrictive Pericarditis.

* See causes
* Chest Trauma -- open-heart surgery (postpericardiotomy) and stabbing may cause constrictive Pericarditis
* Men > Women
* Age -- adolescents and young men
* Upper respiratory infections -- colds

* Mild cases -- outpatient treatment:

1. Rest
2. Aspirin or other nonsteroidal anti-inflammatory drugs (i.e., NSAIDS such as Motrin, Indocin, etc.) for 2 weeks. Side effects include stomach upset, bleeding, and others.
3. Prednisone pills for 2-4 weeks can also be used to reduce inflammation of the pericardium. Side effects include stomach ulcers and infections. This medicine cannot be stopped suddenly, but must be tapered.
4. Azothioprine and Phenylbutazone are also used in some cases, but have many side effects.

* In-patient therapy is recommended if there are signs of heart problems (shock, Low Blood Pressure, very irregular or rapid heart beat):

1. Monitor patient with serial EKG
2. Drain fluids as soon as possible

* If medication and fluid drainage is not effective, or in cases of severe constrictive Pericarditis with Heart Failure, a cardiac surgeon may be called in to remove the pericardium (pericardiectomy).

* See a doctor immediately. Call 911 if there is any pressure or pain in the chest, sweating or shortness of breath.

* Heart attack
* Pneumonia -- lung infection
* Pleurisy -- inflammation of the sac covering the lung
* Pancreatitis -- inflammation of the pancreas
* Pulmonary Emboli -- blood clot in the lung
* Cholecystitis -- inflammation of the gallbladder

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Acute Necrotizing Gingivitis

Vincent's infection or trench mouth

* This condition is due to a severe bacterial infection (Treponema vincenti) of the gums and is most often caused by stress. It used to be very common during wars when soldiers in trenches fought under extremely stressful conditions, and would develop gum infections -- thus the derivation of the name trench mouth.

* Symptoms include painful, severely inflamed gums. Also, patients with this condition often have enlarged and tender lymph nodes in the neck, Bad Breath, fever, and bleeding gums.

* It is due to a bacterial infection of the gums (i.e., Treponema vincenti).
* It is usually seen in people who are under extreme stress.
* Patients with severe medical illness often develop trench mouth.

* Examination of the mouth by a doctor is usually sufficient to make the diagnosis.

* Treatment is with antibiotics such as penicillin, for 10 days.
* If possible, ideally eliminate stress.
* Eat a healthy diet.
* Half-strength peroxide can be used to rinse the mouth 3 to 4 times a day.
* If these remedies fail, see your dentist for more treatment.

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Acute Leukemia


* Leukemia is a life-threatening cancer of the white blood cells in the bone marrow. White blood cells normally function to fight infections. There are two major types of white blood cells -- neutrophils and lymphocytes -- allowing for two types of acute Leukemias: myelocytic (also known as AML, i.e., acute myelocytic Leukemia) and lymphocytic (also known as ALL, i.e., acute lymphocytic Leukemia).
* Both forms of acute Leukemia inhibit the bone marrow's production of needed blood components, including red blood cells and platelets (structures involved in clotting blood).
* ALL is the most common cause of cancer in children, generally occurring between ages 3 and 5, but it can also affect adolescents and, occasionally, adults.
* AML affects people of all ages but is more common in adults. It is a life-threatening cancer that rapidly replaces the normal cells in the bone marrow.

* Bleeding in gums
* Bleeding under the skin, such as bruises or spots
* Nosebleeds
* Increased menstrual bleeding
* Thickened and swollen gums
* Bone pain
* Joint pain
* Weight loss
* Fatigue
* Enlarged lymph nodes
* Shortness of breath
* Severe infections are rare.

* Usually unknown
* Radiation
* Benzene
* Cancer chemotherapy

* Examination:

1. Skin is pale
2. Rash with red dots on the skin called petechiae
3. Enlarged liver
4. Enlarged spleen
5. Enlarged lymph nodes
6. Bone tenderness

* Laboratory Findings:

1. Manual Complete blood count shows diffuse decrease in all blood records with the presence of blast cells (immature white blood cells).
2. Acute lymphocytic Leukemia (ALL) will have granules in blast cells. A special cell marker called TdT is present in 95 percent of cases. It is subtyped to either B-cell or T-cell type.
3. Genetic testing on the cells is performed.
4. Acute myelogenous Leukemia (AML) shows Auer rods in the blast cells. Special stains may also be done.
5. Genetic testing is performed and t (8,21), t (15,17), and inv16q have a more favorable prognosis.
6. A bone marrow biopsy showing 30 percent or more blast forms, confirming the diagnosis
7. Other lab findings may include disseminated intravascular coagulation (DIC), which is a severe depletion of clotting factors in the blood.
8. Uric acid level may be elevated.
9. Lumbar puncture (spinal tap) will show blasts if meningeal Leukemia is present.

* Intensive chemotherapy is recommended. During this period, there is a high risk of infection. Transfusion of blood products may be needed.
* Drug agents prescribed for AML include daunorubicin (antibiotic) and cytarabine.
* Drug agents prescribed for ALL include Daunorubicin, Vincristine, Prednisone, and Asparaginase.
* After initial therapy, intense chemotherapy, high dose chemotherapy, and radiation with bone marrow transplant may be recommended to cure the disease.

* You need immediate medical treatment. This is a curable disease. In AML, nearly 80 percent of adults younger than 60 years of age can be cured. 50 percent of patients older than 60 years may also be cured. In ALL, usually 80 percent of adults and 95 percent of children are cured.

* Lymphoma
* Chronic Myelogenous Leukemia
* Myelodysplastic Syndromes
* Chronic Lymphocytic Leukemia
* Hairy cell Leukemia
* Mononucleosis

* Blast Crisis

- This is a severe elevation of the white blood cell count to greater than 200,000/ml. Normal levels of white blood cells are 10,0000/ml. The high level of white bloods cells interferes with the circulation of red blood cells, which carry oxygen. Confusion, headaches, and shortness of breath are some of the symptoms. This is a life-threatening emergency. Blood must be filtered in a process called leukapheresis, and chemotherapy administered immediately.

Wednesday, October 22, 2008
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Women and Smoking


# Smoking is an addiction. Tobacco smoke contains nicotine, a drug that is addictive and can make it very hard, but not impossible, to quit. If you smoke, your body is exposed to chemicals that cause cancer, coronary heart disease, stroke, and respiratory conditions such as emphysema and chronic bronchitis. Smoking is also linked to a variety of disorders and conditions including infertility and the slow healing of wounds.

# We all have heard the warnings: Cigarettes can cause cancer and increase the risk of heart disease. But the sad fact is that approximately 23 million women in the United States (23% of the female population) smoke. Smoking is the most preventable cause of death in this country; yet more than 140,000 women die each year from smoking-related causes. Approximately one fifth of all deaths in the United States can be blamed on smoking.
# Smoking harms not just the smoker, but also family members, co-workers, and others who breathe the smoker's cigarette smoke (second-hand smoke).
# Among infants 18 months of age and younger, second-hand smoke is associated with nearly 300,000 cases of bronchitis and pneumonia annually.
# Second-hand smoke increases a child's risk for middle ear problems, causes coughing and wheezing, and worsens asthma.
# If both parents smoke, a teenager is more than twice as likely to smoke than a young person whose parents are both non-smokers. In households where one parent smokes, young people are also more likely to start smoking.

Women smokers

# Twenty-seven percent of women smokers are between ages 25 and 44.
# Women smokers suffer all the consequences of smoking that men do, such as increased risk of respiratory diseases and various cancers (lung, mouth, larynx, pharynx, esophagus, kidney, pancreas, kidney, and bladder).
# In general, women smokers experience more illness and chronic conditions than women who have never smoked. According to the American Cancer Society, women who smoke heavily have nearly 3-fold more bronchitis and emphysema, 75% more chronic sinusitis, and 50% more peptic ulcers than non-smokers. The incidence of illness, such as influenza, is 20% higher for women smokers than women who are non-smokers. Currently, employed women smokers report more days lost from work due to illness and injury than do working women who do not smoke. In addition, women smokers younger than 65 years of age have more limited physical activity than those who have never smoked.

Pregnancy and Smoking

# Pregnant women who smoke are more likely to deliver low birth-weight babies. If all women quit smoking during pregnancy, approximately 4,000 additional babies would live each year.
# Chemicals in tobacco are passed from pregnant mothers through the bloodstream to the fetus. These toxic chemicals present serious risks to the unborn child, as well as the mother. According to Our Bodies, Ourselves for the New Century, by the Boston Women's Health Book Collective, 'Smoking during pregnancy is associated with preterm delivery, low birth-weight, premature rupture of membranes, placenta previa, miscarriage, and neonatal death. Newborns whose mothers smoked during pregnancy have the same nicotine levels in their bloodstreams as adults who smoke, and they go through withdrawal during their first days of life.'
# Children born to mothers who smoke experience more colds, earaches, respiratory problems, and illnesses requiring visits to the pediatrician than children born to non-smokers
# Is a baby part of your future plans? Many women today delay childbirth until they are in their 30s or even 40s, which can cause fertility problems even for non-smoking women. But women who smoke and delay childbirth are putting themselves at a substantially greater risk of future infertility than non-smokers.
# Increasingly, studies are showing that decreased ovulatory response, as well as the fertilization and implantation of the zygote, may be impaired in women who smoke. Chemicals in tobacco are suspected of altering the cervical fluid, making it toxic to sperm, and making pregnancy to be difficult to achieve.
# We cannot leave the men out on this one, either. Male smokers are 50% more likely to become impotent. Some of the toxic chemicals found in cigarettes may result in gene mutations that can cause miscarriage, birth defects, cancer, and other health problems in children.

Smoking cessation

# Research suggests that smoking cessation should be a gradual process because withdrawal symptoms are less severe in those who quit gradually than in those who quit all at once. Relapse rates are highest in the first few weeks and months and diminish considerably after 3 months.
Studies have shown that pharmacological treatment combined with psychological treatment, including psychological support and skills training to overcome high-risk situations, results in some of the highest long-term abstinence rates.
Nicotine chewing gum is one medication approved by the Food and Drug Administration (FDA) for the treatment of nicotine dependence. Nicotine gum acts as a nicotine replacement.
# The success rates for smoking cessation treatment with nicotine chewing gum vary considerably across studies, but evidence suggests that it is a safe means of facilitating smoking cessation if chewed according to instructions and restricted to patients who are under medical supervision.
# Another approach to smoking cessation is the nicotine transdermal patch, a skin patch that delivers a relatively constant amount of nicotine to the person wearing it. A research team at NIDA Division of Intramural Research studied the safety, mechanism of action, and abuse liability of the FDA-approved patch. Both nicotine gum and the nicotine patch, as well as other nicotine replacements such as sprays and inhalers, are used to help people quit smoking by reducing withdrawal symptoms and preventing relapse while undergoing behavioral treatment.
# Another tool in treating nicotine addiction is Zyban. This is not a nicotine replacement, as are the gum and patch. Rather, this works on other areas of the brain, and its effectiveness is in helping to control nicotine craving or thoughts in people trying to quit.
# In the future, a nicotine vaccine may be an effective method for preventing and treating tobacco addiction. The vaccine would prevent nicotine from reaching the brain, so as to reduce its effects and help keep people from becoming addicted

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Vaginal Infection


# Vaginitis is an inflammatory condition of the vagina. It is the most common problem found in women of all ages. It causes distress and discomfort in women. It can be transmitted through sexual contact, sexually transmitted disease, most commonly trichomoniasis.

# Most men with trichomoniasis may not have any symptoms, so the infection cannot be diagnosed in either partner until the woman has symptoms of vaginitis. One of the most common types of vaginitis is yeast infection, usually called candidiasis. Various microorganisms normally populate the vagina and prevent infection. If a woman takes antibiotics to treat an infection, even if it is not for vaginitis, the antibiotics can kill both the bad and the good microorganisms, ultimately creating various imbalances in the body, including yeast infections.


# Bacteria (bacterial vaginosis)
# Protozoa (trichomoniasis)
# Yeast infection (candidiasis)


# Non-bloody vaginal discharge (leukorrhea)
# Vaginal odors
# Vulva irritation


Examine a sample of vaginal secretion through a microscope, either stained or in special lighting, for evidence of infection forms.


Various effective drugs are available for treating vaginal infections and accompanying vaginitis.
# Bacterial vaginitis: metronidazole, clindamycin
# Trichomoniasis: metronidazole. Candidiasis: Antifungal creams, tablets, or suppositories (i.e., Butoconazole, Biconazole, Clotrimazole, and Tioconazole)

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Uterine Fibroids


# Uterine fibroids are benign smooth muscle tumors known as leiomyoma.
# About 20% of women develop uterine fibroids by age 40.
# They develop within the wall of the uterus as nodules of smooth muscle cells and fibrous connective tissue. The uterus becomes large and irregular in shape. It is an extremely common disease. There can be one or many fibroid tumors on the uterus.
# It is the second most common indication for major surgery in women after cesarean section.
# It can develop as a single nodule or many fibroid tumors that may range in size from 1 mm to more than 20 cm (8 inches) in diameter. They can grow within the uterine wall and may protrude toward the outer uterine surface and the pelvic cavity.


# The etiology is not clear. Most likely, they develop from uterine smooth muscle cells.


# Many women do not have any symptoms.
# Heavy, prolonged, unusual monthly menstrual bleeding is the most common symptom.
# An increase in menstrual cramps and pelvic pain
# Pain in the back, flank, or legs, as the fibroids press on nerves that supply the pelvis and legs
# Pain during sexual intercourse
# Pressure on the urinary system, increased frequency of urination
# Pressure on the bowel, leading to constipation and bloating
# Abnormally enlarged (distended) abdomen


# Pelvic exam
# Ultrasound
# If necessary, a hysteroscopy (in which a camera is used to look into the uterus) or hysterography (in which a dye is injected into the uterus and x-rays are taken) can be done.

Similar conditions

# Pregnancy
# Leiomyosarcoma
# Ovarian cancer
# Adenomyosis


# No treatment is necessary, just follow-up every 6 months, if the woman does not have symptoms.
# If the fibroid's blood supply is cut off, then the woman will have a lot of pain. This is an emergency and needs immediate medical attention.
# If bleeding is heavy, medroxyprogesterone or estrogen can help decrease the bleeding.
# If the woman is severely anemic (low blood count), this needs to be treated before any surgery is attempted. Surgical removal of the fibroid is required if the uterus is getting bigger very quickly, if it is causing symptoms, or bleeding is excessive.
# The smaller the fibroids, the less risky the surgery. Therefore, when possible, women are given medicines such as Leuprolide or Nafarelin for 2 to 3 months before surgery to shrink the fibroids.
# Surgery to remove either the individual fibroids or the entire uterus is the main treatment.
# If a woman desires pregnancy, the fibroids can be surgically removed and the uterus is left intact.
# If a woman does not desire pregnancy, the entire uterus is removed. This can be done through the stomach (abdominal hysterectomy), through the vagina (vaginal hysterectomy), or by laparoscopy-assisted vaginal hysterectomy (a camera-assisted surgery).
# Women can still become pregnant if the uterus is left in place, but they may have to have a C-section.

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Uterine Atony

Also known as

The failure of the uterus to contract maximally after the delivery of the baby and placenta, resulting in heavy uterine bleeding.


# Uterine atony is the most common cause of postpartum hemorrhage and the most common indication for postpartum hysterectomy or blood transfusion.
# Normally, bleeding after delivery is stopped by uterine contractions and compression of the vessels. If uterine contractions are not adequate, bleeding can continue. At times, the uterus is prevented from contracting effectively by fragments of placenta that remain in the uterus after delivery or by benign growths of uterine muscle within the uterine wall (fibroids). In these cases, the term 'atony' usually is not applied. In most cases, the uterine muscle simply fails to contract adequately.


# Multiple gestation, high parity
# Fetal macrosomia
# Polyhydramnios
# General anesthetics
# Prolonged labor, precipitous labor, augmented labor
# Infection (chorioamnionitis)


# Excessive bleeding at the time of delivery


# The presenting signs are a soft uterus with vaginal bleeding.
# After delivery, uterine atony is detected when there is excessive bleeding and a large, relaxed uterus. Your doctor may perform an examination to be certain that there are no tears of the cervix or the vagina and that all fragments of placenta have been removed from the uterus.
# Alternate sources of bleeding, such as vaginal or cervical lacerations or retained placental fragments, must be excluded.


# Initial treatment consists of bimanual compression, uterine massage.
# Uterine contraction medications: Oxytocin, Methylergonovine, and Prostaglandins
# Surgery: uterine vessel ligation or hysterectomy (the latter is rarely used)
# Blood and fluids must be replaced as needed.

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Uterine Anomalies


Uterine anomalies occur in 0.1 to 0.5% of women, depending on the population. Uterine anomalies that are large enough to decrease the size of the uterine cavity (womb) are a major cause of recurring abortions, premature labor and/or abnormal presentation of the fetus during labor. Uterine anomalies are detected in 15% to 25% of women with recurrent pregnancy loss. Unfortunately, uterine anomalies are usually not diagnosed until a woman becomes pregnant.


# The cause of most congenital uterine anomalies is unknown.
# In the past, pregnant women were sometimes given diethylstilbestrol (DES) to prevent miscarriage. Female offspring of these women had a higher frequency than usual of uterine anomalies, as well as an increase in cancers of the female reproductive tract.
# A genetic cause has not been found.
# Environmental factors, as yet undetermined, may affect uterine development.


# Recurrent miscarriages (spontaneous abortions)
# Premature delivery
# Intrauterine fetal growth retardation
# Abnormal fetal presentation (defined as any part of the fetus that presents other than the top (vertex) of the fetal head facing the cervix towards the floor)
# Pelvic examination reveals two vaginas and/or two cervix (associated with uterine anomalies) or sometimes two horns are felt on the uterus.
# Usually there is no sign of a uterine anomaly on a routine pelvic examination.


# History of pregnancy losses or prenatal exposure to DES
# Pelvic examination
# Ultrasound
# Magnetic resonance imaging (MRI)
# Hysterosalpingogram
# Hysteroscopy
# Laparoscopy


# Aggressive obstetrical, nonsurgical management of patients with prior reproductive failure.
# Surgery to redesign the uterus is a highly successful procedure. Postoperative success rates (i.e., term pregnancy) generally range from 70% to 80%, with premature delivery rates less than 10%.

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Urinary Incontinence


Urinary incontinence is the involuntary loss of urine, sufficient enough to cause a social or cleanliness problem.

By age 65, 1 in 10 women experiences urinary incontinence. It is most commonly seen in women who have had one or more vaginal deliveries, which cause a change in the anatomy of the uterus, vagina, and supporting structures of the bladder, urethra, and rectum. Changes may be temporary, mild, or very significant.

If you suffer from urinary incontinence, there are many new products and surgical methods available to treat this condition.


Urinary incontinence is often caused by a combination of the following:

* Pregnancy, particularly vaginal delivery.
* Weakened or damaged pelvic muscles that support the bladder.
* Lack of estrogen, e.g., menopause.
* Medical problems that affect the bladder function, e.g., diabetes mellitus.
* Urinary tract infections.
* Constipation causing straining.
* Repeated coughing, e.g., smoker's cough.
* Certain prescription and nonprescription medications.


Symptoms vary depending on the type of incontinence:

Stress incontinence is the loss of urine when there is a sudden increase in pressure in the abdomen caused by laughing, coughing, sneezing, exercising, or lifting something heavy.

Urge incontinence is the most common type of incontinence. It occurs when someone suddenly feels as though they need to use the toilet, but is unable to reach it in time. Urge incontinence has many causes.

Mixed incontinence is a combination of stress and urge incontinence.

Overflow incontinence occurs when the bladder cannot empty properly. A person makes frequent trips to the toilet, letting out small amounts of urine each time. Because the bladder never empties completely, it may feel full again very quickly. Some people may have periodic leaking without any sensation of fullness.

Functional incontinence is not caused by problems with the bladder. Accidents occur because it may be difficult for a person to get to the toilet due to illness, arthritis, or lack of available facilities.


* Review of medical history.
* Physical exam, including pelvic examination.
* Laboratory tests, including urinalysis and urine culture to rule out a urinary tract infection; blood sugars to rule out diabetes mellitus.
* Urodynamic studies where the physician tests the function of bladder and urethra by measuring bladder pressure and urine flow.
* Cystoscopy, which involves the direct visualization of the urinary bladder and urethra from inside by inserting an endoscopic tube through the urethra. Please see cystoscopy for more information.
* Cystogram to show abnormal anatomy and functions that may be causing incontinence. For a cystography or voiding cystourethrography, the bladder is filled with iodine containing X-Ray dye, and an X-Ray is taken of the bladder and urethra when filled, during urination, and immediately after urination.


Treatment depends on the type of incontinence and may require one or more of the following:

* Estrogen creams, if estrogen deficiency (from menopause) is suspected.
* Antibiotics to treat a urinary tract infection.
* Medication to help regulate the bladder and urethra.
* Surgery to support the bladder and correct the pelvic anatomy.
* Kegel exercises to strengthen the pelvic muscles.
* Bladder training to help a person control the urgent need to urinate.
* Vaginal pessaries to support a partially prolapsed bladder.

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Secondary Dysmenorrhea

Also known as

# Secondary dysmenorrhea is also known as painful or difficult menstruation.


# Secondary dysmenorrhea is related to the presence of pelvic lesions secondary to organic pelvic disease such as endometriosis, salpingitis, PID (pelvic inflammatory disease), postsurgical adhesions, etc. Secondary dysmenorrhea begins a few days before menstruation and lasts several days after the onset of flow. Often, it is lateralized to one side, and it does not characteristically peak and diminish as clearly or quickly as primary dysmenorrhea. Its onset is later in life, in women who have not had primary dysmenorrhea; however, it can be superimposed onto a pre-existing case of primary dysmenorrhea. An intrauterine device (IUD) may cause secondary dysmenorrhea.


# Endometriosis
# Pelvic inflammation
# Adenomyosis
# Uterine myoma
# Ovarian cyst
# Pelvic congestion
# Uterine polyp
# Uterine malformation
# Cervical stenosis


# Pain may be continuous or intermittent
# Pelvic tenderness
# Nausea and/or vomiting
# Sweating, headaches, rapid heartbeat
# Diarrhea
# Tremulousness


History and physical examination by the health care provider will differentiate between functional dysmenorrhea and those rare cases associated with a medical condition. Younger adolescents who have not become sexually active usually do not require a pelvic examination.


Treatment of underlying disease:
# Pain relievers: aspirin, ibuprofen, naproxen, acetaminophen
# Birth control pills
# Surgery is not usually helpful in alleviating pain

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Primary Amenorrhea


Amenorrhea means a woman is not menstruating. A female who has not had her first period by age 16 has primary amenorrhea. This should be distinguished from infrequent or light menstrual cycles (oligomenorrhea), which are very common and usually normal in teenagers, particularly in the first couple of years after menses begin, a time called menarche. If a woman starts her periods, but then stops having periods for at least 3 cycles (90 days), she is said to have secondary amenorrhea.


# Imperforate hymen (the opening to the vagina is covered by skin)
# Cervical stenosis (the cervix is closed)
# Eating disorders: sudden weight reduction, obesity, anorexia nervosa, fad dieting
# Intense exercise
# Stress
# Malnutrition
# Chronic disease, e.g., diabetes, anemia, congenital heart disease, thyroid disease
# Pituitary or hypothalamic failure
# Chromosomal anomaly, e.g., Turner's syndrome
# Congenital adrenal hyperplasia
# Ovarian dysfunction
# Absence or abnormality of one or more of the female reproductive organs


# Medical history
# Physical examination including pelvic and bimanual examination
# Laboratory tests for levels of luteinizing hormone, follicle-stimulating hormone, thyroid hormone, prolactin, etc.
# Ultrasound
# CT
# Chromosomal testing
# Laparoscopy


Varies, depending on the cause, and may include:
# Hormonal replacement therapy and/or other medications
# Surgery minor and/or major
# Psychosocial counseling
# Long-term follow-up by an internist or other medical specialist

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Painful Menstruation


Dysmenorrhea, or painful menstruation, is experienced by approximately 50% of woman; it is severe or disabling in 10%, causing a loss of workdays and poor performance at school. Dysmenorrhea is caused by the production of prostaglandins during menstruation. Prostaglandins enhance uterine contractions, causing pelvic pain. Primary dysmenorrhea is caused by normal uterine muscle contractions and affects more than half of menstruating women. Secondary dysmenorrhea is menstrual-related pain that is caused by abnormal medical conditions, such as endometriosis. The pain begins with the onset of menstrual flow and lasts 2-3 days. It is characterized by crampy, lower abdominal pain that radiates to the back region or inner thigh region. Nausea, headache, or fatigue may accompany the pain.


# Prostaglandins. These are chemicals that occur naturally in the body. Certain prostaglandins cause uterine muscles to spasm.


# Lower abdominal, crampy pain that occurs before the beginning of the menstrual period and lasts 1 or 2 days into the period.
# Nausea, vomiting, diarrhea, constipation


# Common pain relievers: aspirin, ibuprofen, naproxen, acetaminophen
# Birth control pills

Self-Care Procedures

# Drink a hot cup of regular tea, chamomile or mint tea.
# Place heating pad or hot-water bottle on the abdomen.
# Take a warm bath.
# Gently massage your abdomen.
# Mild exercises
# Drink a glass of wine or other alcoholic beverage. Alcohol slows down uterine contractions.
# Rest
# Birth control pills

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Ovarian Cancer


There are many types of ovarian cancer, and cure and treatment success depends on how early ovarian cancer is detected. Ninety-five percent of women will live longer than five years, if ovarian cancer is detected before it has spread beyond the ovaries. Presently, only 25% of ovarian cancer cases in the U.S. are diagnosed in the early stages, because there is no simple screening test for ovarian cancer. Also, once symptoms develop and a woman seeks medical care, the cancer is often advanced. In advanced stages, 5-year survival rates drop to 28%. Ovarian cancer is the fifth leading cause of cancer deaths among women.


# None in the early stages
# Family history of ovarian cancer should alert a woman that she should be followed closely.
# Abdominal pressure or bloating
# Changes in bowel or bladder patterns
# Nausea, feeling full early when eating, constipation, and gas
# Excessive fatigue
# Weight loss
# Bowel obstruction


# Pelvic examination reveals an enlarged ovary
# Ultrasound
# Computed tomography (CT)
# Magnetic resonance imaging (MRI)
# Blood tests (CA-125, CEA)
# Laparoscopy
# Exploratory laparotomy


# Surgery to remove all visible cancer and involved structures
# Chemotherapy
# Radiation therapy
# Supportive care

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# Osteoporosis is a disease of progressive bone loss associated with an increased risk of fractures. It literally means 'porous bone.' The disease often develops unnoticed over many years, with no symptoms or discomfort, until a fracture occurs. Osteoporosis often causes a loss of height and dowager's hump (a severely rounded upper back region).

# Osteoporosis is a major public health threat for 28 million Americans, 80% of whom are women. In the U.S. today, 10 million individuals already have osteoporosis and 18 million more have low bone mass, placing them at increased risk for this disease. One out of every two women and one in eight men over 50 will have an osteoporosis-related fracture in their lifetime
# More than 2 million American men suffer from osteoporosis, and millions more are at risk. Each year, 80,000 men suffer a hip fracture and one-third of these men die within a year. Osteoporosis is responsible for more than 1.5 million fractures annually, including 300,000 hip fractures, and approximately 700,000 vertebral fractures, 250,000 wrist fractures, and more than 300,000 fractures at other sites.


Doctors do not know the exact medical causes of osteoporosis, but they do know many of the major factors that can lead to the disease.
# Aging. Everyone loses bone with age. After age 35, the body builds less new bone to replace losses of old bone. In general, the older you are, the lower your total bone mass and the greater your risk for osteoporosis.
# Heredity. A family history of fractures; a small, slender body build; fair skin; and a Caucasian or Asian background can increase the risk for osteoporosis. Heredity also may help explain why some people develop osteoporosis early in life.
# Nutrition and lifestyle. Poor nutrition, including a low calcium diet, low body weight and a sedentary lifestyle has been linked to osteoporosis, as have smoking and excessive alcohol use.
# Medications and other illnesses. Osteoporosis has been linked to some medications, including steroids, and to other illnesses, including some thyroid problems.


# The diagnosis of osteoporosis is usually made by your doctor using a combination of a complete medical history and physical examination, skeletal X-rays, bone densitometry and specialized laboratory tests. If your doctor finds low bone mass, he or she may want to perform additional tests to rule out the possibility of other diseases that can cause bone loss, including osteomalacia (a vitamin D deficiency) or hyperparathyroidism (overactivity of the parathyroid glands).
# Bone densitometry is a safe, painless x-ray technique that compares your bone density to the peak bone density that someone of your same sex and ethnicity should have reached at about age 20 to 25, when it is at its highest.
# It is often performed in women at the time of menopause. Several types of bone densitometry are used today to detect bone loss in different areas of the body. Dual beam X-ray absorptiometry (DXA) is one of the most accurate methods, but other techniques can also identify osteoporosis, including single photon absorptiometry (SPA), quantitative computed tomography (QCT), radiographic absorptometry and ultrasound. Your doctor can determine which method would be best suited for you.


# Because lost bone cannot be replaced, treatment for osteoporosis focuses on the prevention of further bone loss. Treatment is often a team effort involving a family physician or internist, orthopedist, gynecologist, and endocrinologist.
# While exercise and nutrition therapy are often key components of a treatment plan for osteoporosis, there are other treatments as well.
# Estrogen replacement therapy (ERT) is often recommended for women at high risk for osteoporosis to prevent bone loss and reduce fracture risk. A measurement of bone density when menopause begins may help you decide whether ERT is for you. Hormones also prevent heart disease, improve cognitive functioning, and improve urinary function. It should be discussed with your doctor.
# New anti-estrogens known as SERMs have been introduced. They increase bone mass, decrease the risk of spine fractures, and lower the risk of breast cancer.
# Calcitonin is another medication used to decrease bone loss. A nasal spray form of this medication increases bone mass, limits spine fractures, and may offer some pain relief. Bisphosphonates, including Alendronate, markedly increase bone mass and prevent both spine and hip fractures. HRT, Alendronate, SERMs, and calcitonin all offer the osteoporosis patient an opportunity to not only increase bone mass, but also to significantly reduce fracture risk. Prevention is preferable to waiting until treatment is necessary.


There is a lot you can do throughout your life to prevent osteoporosis, slow its progression, and protect yourself from fractures.
Include adequate amounts of calcium and vitamin D in your diet.
# Calcium. During the growing years, your body needs calcium to build strong bones and to create a supply of calcium reserves. Building bone mass when you are young is a good investment for your future. Inadequate calcium during growth can contribute to the development of osteoporosis later in life.
Whatever your age or health status, you need calcium to keep your bones healthy. Calcium continues to be an essential nutrient after growth because the body loses calcium every day. Although calcium cannot prevent gradual bone loss after menopause, it plays an essential role in maintaining bone quality. Even if you have gone through menopause or already have osteoporosis, increasing your intake of calcium and vitamin D can decrease your risk of fracture.
How much calcium you need will vary depending on your age and other factors. The National Academy of Sciences makes the following recommendations regarding daily intake of calcium:
Males and females 9 to 18 years: 1300 mg per day
Women and men 19 to 50 years: 1000 mg per day
Pregnant or nursing women up to age 18: 1300 mg per day
Pregnant or nursing women 19 to 50 years: 1000 mg per day
Women and men over 50: 1500 mg per day
Dairy products, including yogurt and cheese, are excellent sources of calcium. An eight-ounce glass of milk contains about 300 mg of calcium. Other calcium-rich foods include sardines with bones, and green leafy vegetables, including broccoli and collard greens.
If your diet does not contain enough calcium, dietary supplements can help. Talk to your doctor before taking a calcium supplement.
# Vitamin D. Vitamin D helps your body absorb calcium. The recommendation for vitamin D is 400 IU daily for adults and 800 IU daily for the elderly. Supplemented dairy products are an excellent source of vitamin D. (A cup of milk contains 100 IU. A multivitamin contains 400 IU of vitamin D.) Vitamin supplements can be taken if your diet does not contain enough of this nutrient. Again, consult with your doctor before taking a vitamin supplement. Too much vitamin D can be toxic.
# Exercise regularly. Like muscles, bones need exercise to stay strong. No matter what your age, exercise can help you minimize bone loss while providing many additional health benefits. Doctors believe that a program of moderate, regular exercise (3 to 4 times a week) is effective for the prevention and management of osteoporosis. Weight-bearing exercises such as walking, jogging, hiking, climbing stairs, dancing, treadmill exercises, and weight lifting are probably best. Falls account for 50% of fractures, therefore, even if you have low bone density you can prevent fractures if you avoid falls. Programs that emphasize balance training, especially, Tai Chi, should be emphasized. Consult your doctor before beginning any exercise program.

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# Menstruation is the periodic discharge of blood, mucus, and tissue from the uterus due to the change of the uterine lining (endometrium).
# From the pubertal stage, (which begins around age 11-12) first menstruation (menarche) cycle can be irregular for 2-3 years because of unbalanced hormonal secretion with or without ovulation.
# It then becomes more regular during the mid- to late teen years.
# Menstruation then continues throughout a women's life until she reaches menopause.


# The mechanism that regulates the sloughing of the uterine lining is controlled by changing levels of female hormones. It begins every month when follicle-stimulating hormone (FSH) and luteinizing hormone (LH) are released from the pituitary gland, which is located at the base of the brain. Once FSH and LH are released, they influence the ovaries.
# During each cycle, FSH and LH cause one follicle to grow, and normally one egg is released from the follicle for possible fertilization. After this process, the follicle begins to produce estrogen and progesterone. Estrogen levels peak during the first half of the cycle as the newly released egg is maturing. Progesterone levels peak after midcycle when ovulation has occurred. Ovulation refers to the production of a mature egg.
# Estrogen and progesterone stimulate the lining of the uterus. During the first 2 weeks following menstruation, estrogen causes the uterine lining to grow gradually and the lining thickens by increasing the number of blood vessels.
# By midcycle, the inner lining of the uterus (endometrium) has increased 3 times in thickness and has a greatly increased blood supply.
# After midcycle, usually 14 days before menstruation, the egg is received by the fallopian tube.
# If the egg is fertilized, a large ovarian follicle, now called a corpus luteum cyst, secretes progesterone.
# If fertilization does not occur, the follicle begins to deteriorate and the progesterone levels decrease. The abrupt decrease in progesterone levels causes the lining of the uterus break down and menstruation begins.


# Bloody uterine discharge exits the vagina.
# Normal menstrual cycle: 21-25 days
# Menstruation period: 2-7 days
# Normal menstrual blood, 25-80 cc


# Tampons
# Sanitary napkins
# Sanitary towel
# Sanitary briefs

Tuesday, October 21, 2008
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Polycystic Ovary Syndrome

Also known as

# Polycystic ovary syndrome (PCOS), also called Stein-Leventhal syndrome, polycystic ovarian disease, or hyperandrogenic chronic anovulation, is an endocrine disorder that occurs in 5%-10% women. It can cause a myriad of symptoms that appear, on the surface, to be unrelated


# Polycystic ovary syndrome (PCOS) is a condition in which the ovaries accumulate tiny cysts, actually little follicles, 2 to 5 millimeters in diameter, each containing an egg. Instead of growing and going on to ovulate, the cysts stall and secrete male hormones into the blood. Ovulation is rare without the help of medications. In some women, there will be a long history of irregular periods and, perhaps, an increase in facial and body hair. Approximately 20% of women have mild polycystic ovaries (PCO).
# PCOS is a major cause of infertility.


# Unknown
# Genetic
# Insulin resistance, an abnormal response to oral glucose and/or elevated insulin levels in the blood disorder, may cause abnormal hormone responses in the ovaries.


# Irregular or absent periods secondary to a lack of ovulation
# Infertility
# Weight gain, particularly around the waist (the 'apple' shape as opposed to the 'pear' or 'hourglass' shape which is more typical for women)
# Hirsutism (excess body hair) that tends to worsen over time
# Insulin resistance, as measured by a person's abnormal response to oral glucose and/or elevated insulin levels in the blood
# Syndrome X: Insulin resistance is associated with high blood pressure, high triglyceride levels, and a decrease in HDL (the good cholesterol) and obesity.
# Acne, male-pattern baldness
# Multiple small cysts on the ovaries
# Acanthosis nigricans (darkening of the skin under the arms, breasts and back of neck)


# History
# Physical examination, including pelvic examination
# Ultrasound
# Blood tests to test the level of different hormones: High androgen levels (particularly free testosterone), high levels of luteinizing hormone (LH), or an elevated LH to follicle stimulating hormone ratio are characteristic of PCOS.


# In mild cases, treatment is not administered until a woman wants to become pregnant.
# Medication to induce ovulation when infertility is caused by anovulation:
a. Clomiphene citrate (Clomid or Serophene) is generally taken daily from days 3-7 of a cycle. Ovarian follicle development is usually monitored with a combination of home urinary LH testing and office ultrasound examination. Additional endometrial support may be promoted with the use of progesterone or HCG injections. There is an increased rate of multiple pregnancies with Clomiphene (6-7%), but no increased risk of birth defects. The majority of women who conceive on Clomiphene will do so in the first 4 cycles.
b. Gonadotropins are prescribed if Clomiphene fails to successfully induce ovulation.
# Medications are available to reverse hirsutism, regulate menstrual cycles, and control acne.
# Watch for development of diabetes mellitus, high blood pressure, high cholesterol and/or high triglyceride levels, and treat aggressively, if present, with diet and medication.

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Genital Fistula


Genital fistula is a condition in which the genital tract and the urinary and intestinal tract become connected (usually in the vagina) by a leak in the system. It usually occurs as a result of a difficult delivery, when the vagina and the urinary bladder may become swollen or damaged due to excessive pressure during labor.


Urine leaks into the vagina in amounts proportional to the size of the hole. When the urine settles in the pubic area, a very strong odor may be noticed. If the rectum and the vagina are connected by a fistula, excretion through the vagina is also possible.


The most common cause of genital fistula is childbirth complications. Other possible causes are obstetrics/gynecologic surgeries, x-rays, tumors, and necrosis due to the use of a pessary.


In the case of a urethral fistula, the diagnosis can be relatively simple. If leakage continues to occur when there does not appear to be a fistula, an over relaxed sphincter muscle may be the problem. For small urethral fistulas, a color pigment can be introduced into the urinary bladder to check to see if leakage occurs into the vagina. Or, cystoscopy (urinary bladder examination) can be performed to determine the location of the fistula in relation to the ureter. Depending on the situation, delicate urologic examination, or in rare cases, intravenous or retrograde pyelography can be used for diagnosis. For rectum-vaginal fistulas, a substance called barium is introduced into the intestinal canal, and an x-ray is taken to determine the whereabouts of the fistula.


Psychological problems, such as an avoidance of social contact, oversensitivity, insomnia, and depression may limit social activity.


Most small fissures that are not a result of major diseases (i.e., cancer) heal themselves, and, thus, surgery may not be necessary. However, most people tend to prefer the immediate results of surgery. The standard treatment is to undergo reconstructive surgery after 4-6 months the injury. The waiting period is necessary in order to allow the swelling and hardening to subside before operating.

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Fetal Alcohol Syndrome


# Fetal Alcohol Syndrome (FAS) is a pattern of mental and physical defects that develop in some unborn babies when the mother drinks too much alcohol during pregnancy.
# It includes mental retardation, growth deficiencies, central nervous system dysfunction, craniofacial abnormalities, and behavioral problems.

# A baby born with FAS may be seriously handicapped and require a lifetime of special care.
# The fetus is most vulnerable to various types of injuries depending on the stage of development in which alcohol is encountered. A safe amount of drinking during pregnancy has not been determined, and all major authorities agree that women should not drink at all during pregnancy. Unfortunately, women sometimes wait until a pregnancy is confirmed before they stop drinking. By then, the embryo/fetus has gone through several weeks of critical development, a period during which exposure to alcohol can be very damaging. Therefore, the Division of Alcohol and Drug Abuse urges women who are pregnant or anticipating a pregnancy to abstain from drinking alcoholic beverages. The incidence of FAS can conservatively be estimated at 0.33 cases per 1000 live births.


# Alcohol in a pregnant woman's bloodstream reaches the fetus by crossing the placenta. There, the alcohol interferes with the ability of the fetus to receive sufficient oxygen and nourishment for normal cell development in the brain and other body organs.
# Timing of alcohol use during pregnancy is important. Alcohol use during the first trimester is more damaging than during the second trimester, which is, in turn, more damaging than use in the third trimester.


The manifestations of specific growth, mental, and physical birth defects associated with the alcohol exposure during pregnancy
# Small birth weight, small head circumference
# Epicanthal folds, small, widely spaced eyes, flat mid-face
# Short, upturned nose, smooth, wide philtrum, thin upper lip
# Underdeveloped jaw
# Irritable, difficulty eating or sleeping, hypersensitivity to any form of stimulation

Neurological manifestations of FAS
# Attention deficits, memory deficits, hyperactive
# Difficulty with abstract concepts (math, time, money)
# Poor problem-solving skills, difficulty learning from consequences
# Poor judgment, immature behavior, poor impulse control


# There is no cure for FAS. Once the damage is done, it cannot be undone. However, FAS is completely preventable.


# FAS and FAE (Fetal Alcohol Effects) are 100% preventable when a pregnant woman abstains from alcohol. Communities, schools, and concerned individuals can help to prevent FAS/FAE, through education and intervention.


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