Friday, December 19, 2014
Home Section Blog Your Health
Example of Section Blog layout (FAQ section)
C-Reactive Protein (CRP) PDF Print E-mail
Written by Ruai Pharmaceuticals   
Monday, 22 August 2011 06:08

C-Reactive Protein
(CRP)

 

View the Heart Disease Slideshow

 

Heart Disease Slideshow Pictures Heart Disease Slideshow
Medical Illustrations of the Heart Image Collection Medical Illustrations of the Heart Image Collection
Take the Heart Disease Quiz! Take the Heart Disease Quiz!
  • What is C-reactive protein (CRP)?
  • What are the main causes of an elevated C-reactive protein (CRP)?
  • Is there a link between C-reactive protein (CRP) and cardiovascular disease risk?
  • Is elevated C-reactive protein (CRP) a risk factor for cardiovascular disease?
  • How is C-reactive protein (CRP) measured?
  • How can C-reactive protein (CRP) values predict potential heart disease?
  • Should I have my C-reactive protein (CRP) level tested?
  • What is the treatment for high C-reactive (CRP) protein?
  • What is the outlook on elevated C-reactive (CRP) protein?
  • Patient Discussions: C-Reactive Protein Test (CRP)

What is C-reactive protein (CRP)?

C-reactive protein (CRP) is a blood test marker for inflammation in the body. CRP is produced in the liver and its level is measured by testing the blood.

CRP is classified as an acute phase reactant, which means that its levels will rise in response to inflammation. Other common acute phase reactants include the erythrocyte sedimentation rate (ESR) and blood platelet count.

What are the main causes of an elevated C-reactive protein?

In general, the main causes of increased CRP and other markers of inflammation are:

  • burns,
  • trauma,
  • infections,
  • inflammation,
  • active inflammatory arthritis, and
  • certain cancers.

Is there a link between C-reactive protein (CRP) and cardiovascular disease risk?

The elevation of CRP has also been recently linked to atherosclerosis and heart disease. Atherosclerosis, or cholesterol plaquing of the arteries, is known to have an inflammatory component that is thought to cause the rise in CRP levels in the blood. Atherosclerosis is also felt to be affected by age and other cardiovascular risk factors including diabetes mellitus, high cholesterol, high blood pressure, and cigarette smoking.

In atherosclerosis, the blood vessel wall becomes injured. This injury acts as focus of inflammation and leads to the formation of plaques in the blood vessel walls. The plaques typically contain blood cells of inflammation, cholesterol deposits, and debris from the injured cells in the blood vessel lining. The accumulation of these elements leads to narrowing of the wall of the blood vessel. The blood vessel narrowing can hinder the blood flow and the plaque can rupture and flake off of the blood vessel wall causing blockage and leading to strokes and heart attacks.

The burden of plaques in the body can be proportional to the degree of CRP elevation in persons with atherosclerosis. Atherosclerotic plaques can exist in different stages throughout the body.

Is elevated C-reactive protein (CRP) a risk factor for cardiovascular disease?

Because of the inflammatory component of atherosclerosis, elevated CRP level has been linked with cardiovascular disease. However, based on the current available data it cannot be considered an independent risk factor for cardiovascular disease.

The traditional risk factors for cardiovascular disease, including high blood pressure (hypertension), diabetes mellitus, elevated blood cholesterol, age, cigarette smoking, obesity, and family history of heart disease may correlate with an elevated CRP level. According to recent studies, after adjusting for these traditional risk factors, elevated CRP level alone is unlikely to be a cause of cardiovascular disease.

Nevertheless, CRP may be used as a predictor of cardiovascular disease based on its correlation with the other known cardiac risk factors and their role in the formation of atherosclerosis. In individuals with some or all of these traditional risk factors, the elevated CRP levels have been detected. Some data even suggest a trend of higher CRP elevation in the presence of higher number of risk factors.

How is C-reactive protein (CRP) measured?

CRP measurement is made using a blood sample from a vein. The sample is then taken to a laboratory and analyzed.

The traditional CRP measurement is often used to detect inflammation in the body. Currently, a more highly sensitive measurement to detect CRP is used for cardiovascular risk assessment. This high sensitive C-reactive protein is termed hsCRP.

Because measuring CRP levels at any point in time may be influenced by any infection or inflammation in the body, one time measurement is generally not regarded as an adequate predictor of cardiovascular risk. Therefore, the Center of Disease Control (CDC) recommends checking two separate CRP levels approximately two weeks apart and using the average number of the two readings for cardiovascular risk assessment and screening purposes.

How can C-reactive protein (CRP) values predict potential heart disease?

According to the American Heart Association (AHA) and the Center for Disease Control (CDC), the following guidelines are recommended for the assessment of cardiovascular risk in regards to CRP levels:

  • Low risk for cardiovascular disease if CRP is 1 milligram (mg) per liter or less
  • Moderate risk for cardiovascular disease if CRP is between 1 and 3 mg per liter
  • High risk for cardiovascular disease if CRP greater than 3 mg per liter

CRP level of greater than 10 mg per liter may be seen in an acute plaque rupture such as, a heart attack or stroke, provided there is no other explanation for the elevated level (other inflammatory or infectious process).

Should I have my C-reactive protein (CRP) level tested?

Checking the CRP level for the entire adult population is not recommended.

Some experts recommend checking the serum CRP level routinely along with the cholesterol level; however, although this is not widely accepted. Ideally, for cardiac risk testing, it is advisable to use the average between 2 separate CRP levels drawn 2 weeks part.

More importantly, the CRP level can provide additional information about an individual's cardiovascular risk in conjunction with other known cardiac risk factors, such as, diabetes mellitus, high blood pressure, high cholesterol, obesity, age, and smoking.

What is the treatment for high C-reactive protein (CRP)?

The treatment of an elevated CRP in the context of cardiovascular disease, in and of itself, may be meaningless. Instead, appropriate treatment and prevention of the underlying risks and conditions need to be the primary focus of cardiovascular risk reduction.

The most effective and reliable ways to reduce many cardiac factors are regular exercise, balanced diet, and cigarette smoking cessation. In individuals with elevated cholesterol levels who do not reach their target cholesterol level with diet modification and proper exercise, cholesterol lowering medication may be advised by their treating physicians. Statin drugs (simvastatin [Zocor], atorvastatin [Lipitor], etc.) are in the forefront of the recommended cholesterol lowering agents. Lowering of CRP may be seen with the use of statin drugs even without significant improvement of the cholesterol profile.

 

Reduction of CRP level has also been noted in individuals with known cardiovascular disease who begin aspirin therapy. In those without known cardiovascular disease or significant risk factors for it, aspirin use is not generally recommended. Some diabetic medications (thiazolidinediones) have also been shown to reduce CRP levels in people with or without diabetes mellitus. This effect was seen independent of the glucose their lowering effects.

What is the outlook for those with an elevated C- reactive protein (CRP)?

The overall outlook for those with an elevated CRP largely depends on the cause. In general, the level may be elevated as a response to any inflammation or infection present in the body. More specifically, as a risk assessment tool for cardiovascular disease, the elevation of CRP correlates with the presence of the traditional cardiac risk factors including, hypertension (high blood pressure), high cholesterol, diabetes mellitus, obesity, advanced age, cigarette smoking, and strong family history of cardiac disease. Diet, exercise, smoking cessation, and appropriate medical management of these risk factors in hopes of preventing future cardiovascular disease cannot be overemphasized.

Cesarean Birth
(C-Section)

 

View Stages of Pregnancy Slideshow Pictures

 

Stages of Pregnancy Slideshow Pictures Pregnancy Stages Slideshow Pictures
Early Pregnancy Symptoms Early Pregnancy Symptoms
Conception (Egg to Embryo) Slideshow Pictures Conception (Egg to Embryo) Slideshow Pictures
  • C-section introduction
  • What are the reasons for a C-section?
  • Can a women choose to have a C-section (patient requested C-section)?
  • What should I expect during a C-section?
  • Before surgery
  • During surgery
  • After surgery
  • What about a vaginal birth after C-section (VBAC)?
  • Find a local Obstetrician-Gynecologist in your town

C-Section Introduction

Cesarean delivery, also called c-section, is surgery to deliver a baby. The baby is taken out through the mother's abdomen. Most cesarean births result in healthy babies and mothers. But c-section is major surgery and carries risks. Healing also takes longer than with vaginal birth.

Most healthy pregnant women with no risk factors for problems during labor or delivery have their babies vaginally. Still, the cesarean birth rate in the United States has risen greatly in recent decades. Today, nearly 1 in 3 women have babies by c-section in this country. The rate was 1 in 5 in 1995.

Public heath experts think that many c-sections are unnecessary. So it is important for pregnant women to get the facts about c-sections before they deliver. Women should find out what c-sections are, why they are performed, and the pros and cons of this surgery.

What Are The Reasons For a C-Section?

Your doctor might recommend a c-section if she or he thinks it is safer for you or your baby than vaginal birth. Some c-sections are planned. But most c-sections are done when unexpected problems happen during delivery. Even so, there are risks of delivering by c-section. Limited studies show that the benefits of having a c-section may outweigh the risks when:

  • The mother is carrying more than one baby (twins, triplets, etc.)
  • The mother has health problems including HIV infection, herpes infection, and heart disease
  • The mother has dangerously high blood pressure
  • The mother has problems with the shape of her pelvis
  • There are problems with the placenta
  • There are problems with the umbilical cord
  • There are problems with the position of the baby, such as breech
  • The baby shows signs of distress, such as a slowed heart rate
  • The mother has had a previous c-section

Can a Woman Choose to Have a C-Section (Patient Requested C-Section)?

A growing number of women are asking their doctors for c-sections when there is no medical reason. Some women want a c-section because they fear the pain of childbirth. Others like the convenience of being able to decide when and how to deliver their baby. Still others fear the risks of vaginal delivery including tearing and sexual problems.

But is it safe and ethical for doctors to allow women to choose c-section? The answer is unclear. Only more research on both types of deliveries will provide the answer. In the meantime, many obstetricians feel it is their ethical obligation to talk women out of elective c-sections. Others believe that women should be able to choose a c-section if they understand the risks and benefits.

Experts who believe c-sections should only be performed for medical reasons point to the risks. These include infection, dangerous bleeding, blood transfusions, and blood clots. Babies born by c-section have more breathing problems right after birth. Women who have c-sections stay at the hospital for longer than women who have vaginal births. Plus, recovery from this surgery takes longer and is often more painful than that after a vaginal birth. C-sections also increase the risk of problems in future pregnancies. Women who have had c-sections have a higher risk of uterine rupture. If the uterus ruptures, the life of the baby and mother is in danger.

Supporters of elective c-sections say that this surgery may protect a woman's pelvic organs, reduces the risk of bowel and bladder problems, and is as safe for the baby as vaginal delivery.

The National Institutes of Health (NIH) and American College of Obstetricians (ACOG) agree that a doctor's decision to perform a c-section at the request of a patient should be made on a case-by-case basis and be consistent with ethical principles. ACOG states that "if the physician believes that (cesarean) delivery promotes the overall health and welfare of the woman and her fetus more than vaginal birth, he or she is ethically justified in performing" a c-section. Both organizations also say that c-section should never be scheduled before a pregnancy is 39 weeks, or the lungs are mature, unless there is medical need.

Before Surgery

Cesarean delivery takes about 45 to 60 minutes. It takes place in an operating room. So if you were in a labor and delivery room, you will be moved to an operating room. Often, the mood of the operating room is unhurried and relaxed. A doctor will give you medicine through an epidural or spinal block, which will block the feeling of pain in part of your body but allow you to stay awake and alert. The spinal block works right away and completely numbs your body from the chest down. The epidural takes away pain, but you might be aware of some tugging or pushing. See Medical Methods of Pain Relief for more information. Medicine that makes you fall asleep and lose all awareness is usually only used in emergency situations. Your abdomen will be cleaned and prepped. You will have an IV for fluids and medicines. A nurse will insert a catheter to drain urine from your bladder. This is to protect the bladder from harm during surgery. Your heart rate, blood pressure, and breathing also will be monitored. Questions to ask:

  • Can I have a support person with me during the operation?
  • What are my options for blocking pain?
  • Can I have music played during the surgery?
  • Will I be able to watch the surgery if I want?

During Surgery

The doctor will make two incisions. The first is about 6 inches long and goes through the skin, fat, and muscle. Most incisions are made side to side and low on the abdomen, called a bikini incision. Next, the doctor will make an incision to open the uterus. The opening is made just wide enough for the baby to fit through. One doctor will use a hand to support the baby while another doctor pushes the uterus to help push that baby out. Fluid will be suctioned out of your baby's mouth and nose. The doctor will hold up your baby for you to see. Once your baby is delivered, the umbilical cord is cut, and the placenta is removed. Then, the doctor cleans and stitches up the uterus and abdomen. The repair takes up most of the surgery time. Questions to ask:

  • Can my partner cut the umbilical cord?
  • What happens to my baby right after delivery?
  • Can I hold and touch my baby during the surgery repair?
  • When is it okay for me to try to breastfeed?
  • When can my partner take pictures or video?

After Surgery

You will be moved to a recovery room and monitored for a few hours. You might feel shaky, nauseated, and very sleepy. Later, you will be brought to a hospital room. When you and your baby are ready, you can hold, snuggle, and nurse your baby. Many people will be excited to see you. But don't accept too many visitors. Use your time in the hospital, usually about four days, to rest and bond with your baby. C-section is major surgery, and recovery takes about six weeks (not counting the fatigue of new motherhood). In the weeks ahead, you will need to focus on healing, getting as much rest as possible, and bonding with your baby — nothing else. Be careful about taking on too much and accept help as needed. Questions to ask:

  • Can my baby be brought to me in the recovery room?
  • What are the best positions for me to breastfeed?

What About a Vaginal Birth After a C-Section (VBAC)?

Some women who have delivered previous babies by c-section would like to have their next baby vaginally. This is called vaginal delivery after c-section or VBAC. Women give many reasons for wanting a VBAC. Some want to avoid the risks and long recovery of surgery. Others want to experience vaginal delivery.

Today, VBAC is a reasonable and safe choice for most women with prior cesarean delivery, including some women who have had more than one cesarean delivery. Moreover, emerging evidence suggests that multiple c-sections can cause serious harm. If you are interested in trying VBAC, ask your doctor if you are a good candidate. A key factor in this decision is the type of incision made to your uterus with previous c-sections.

Your doctor can explain the risks of both repeat cesarean delivery and VBAC. With VBAC, the most serious danger is the chance that the c-section scar on the uterus will open up during labor and delivery. This is called uterine rupture. Although very rare, uterine rupture is very dangerous for the mother and baby. Less than 1 percent of VBACs lead to uterine rupture. But doctors cannot predict if uterine rupture is likely to occur in a woman. This risk, albeit very small, is unacceptable to some women.

The percent of VBACs is dropping in the United States for many reasons. Some doctors, hospitals, and patients have concerns about the safety of VBAC. Some hospitals and doctors are unwilling to do VBACs because of fear of lawsuits and insurance or staffing expenses. Many doctors, however, question if this trend is in the best interest of women's health.

Choosing to try a VBAC is complex. If you are interested in a VBAC, talk to your doctor and read up on the subject. Only you and your doctor can decide what is best for you. VBACs and planned c-sections both have their benefits and risks. Learn the pros and cons and be aware of possible problems before you make your choice.

CA 125

 

View the Breast Cancer Slideshow Pictures

 

Breast Cancer Slideshow Pictures Breast Cancer Slideshow Pictures
Colorectal Cancer Slideshow Pictures Colorectal Cancer Slideshow Pictures
Skin Cancer Slideshow Pictures Skin Cancer Slideshow Pictures

 

  • What is CA 125?
  • How is CA 125 measured?
  • What is the normal range for CA 125?
  • What does an elevated CA 125 mean, and how is the test used?
  • What conditions other than ovarian cancer can cause an increased CA 125?
  • Is CA 125 testing useful as a cancer screening test?
  • Patient Discussions: Ca 125 - Results
  • Patient Discussions: CA 125

What is CA 125?

CA 125 is a protein that is a so-called tumor marker or biomarker, which is a substance that is found in greater concentration in tumor cells than in other cells of the body. In particular, CA 125 is present in greater concentration in ovarian cancer cells than in other cells. It was first identified in the early 1980s, and the function of the CA 125 protein is not currently understood. CA stands for cancer antigen.

How is CA 125 measured?

CA 125 is usually measured from a blood sample. It can also be measured in fluid from the chest or abdominal cavity. The tests currently in use are all based upon the use of an antibody that is directed against the CA 125 protein (monoclonal antibody technique).

In 1996, an improved version of the test was introduced and is sometimes denoted as CA 125 - II. The numerical figure of the second generation test results may be higher or lower than a first generation test. When comparing multiple test results over time, it can be important to know which method was used.

What is the normal range for CA 125?

The normal values for CA 125 may vary slightly among individual laboratories. In most laboratories, the normal value is less than 35 U /ml.

What does an elevated CA 125 mean, and how is the test used?

It is not possible to interpret the meaning of an abnormally high CA 125 without additional information about the particular patient being evaluated. The reason is that blood levels of this protein can be increased in many different benign and malignant conditions. The two most frequent situations in which CA 125 is used is to monitor patients with a known cancer (malignancy) or as one of several tests in the workup of a patient suspected of having a tumor.

The most common use of the test is the monitoring of women with known cancer of the ovary (ovarian cancer). In the patient who is known to have a malignancy, such as ovarian cancer, the CA 125 level can be monitored periodically. A decreasing level generally indicates that therapy, including chemotherapy, has been effective, while an increasing level indicates tumor recurrence. Because of test variation, small changes are usually not considered significant. A doubling or halving of the previous value would be important.

In the patient who is being evaluated for a pelvic mass, a CA 125 level greater than 65 is associated with malignancy in approximately 90% of cases. However, without a demonstrable mass, the association is much weaker.

What conditions other than ovarian cancer can cause an increased CA 125?

A number of benign conditions can cause elevations of the CA 125 level, including pregnancy, endometriosis, uterine fibroids (benign tumors), pancreatitis, normal menstruation, pelvic inflammatory disease, and liver disease. Benign tumors or cysts of the ovaries can also cause an abnormal test result. Increases can also be seen in cancers other than ovarian cancer, including malignancies of the uterine tubes, endometrium, lung, breast, pancreas, and gastrointestinal tract.

Is CA 125 testing useful as a cancer screening test?

Although CA 125 is a useful test in monitoring women who are being treated for ovarian cancer, a single CA 125 test is not considered to be a useful screening test for cancer. Some women with ovarian cancer (up to 20%) never have elevated CA 125 levels, while most women who do have elevated CA 125 levels do not have cancer. In fact, because CA 125 can be elevated in so many non-cancerous conditions, only about 3% of women with elevated CA 125 levels have ovarian cancer.

Coronary Artery Bypass Graft Surgery
(CABG)

 

Revising Medical Author:

 

Revising Medical Editor:

 

  • What is coronary artery bypass graft (CABG) surgery?
  • How does coronary artery disease develop?
  • How is coronary artery disease diagnosed?
  • How is coronary artery disease (CAD) treated?
  • How is CABG surgery done?
  • How do patients recover after CABG surgery?
  • What are the risks and complications of CABG surgery?
  • What are the long-term results after CABG surgery?
  • How do CABG surgery and PTCA (angioplasty) compare?
  • Coronary Artery Bypass Graft At A Glance
  • Patient Discussions: Coronary Artery Bypass Graft
  • Patient Discussions: Coronary Artery Bypass Graft - Describe Your Experience
  • Find a local Cardiothoracic Surgeon in your town

What is coronary artery bypass graft (CABG) surgery?

According to the American Heart Association 427,000 coronary artery bypass graft (CABG) surgeries were performed in the United States in 2004, making it one of the most commonly performed major operations. CABG surgery is advised for selected groups of patients with significant narrowings and blockages of the heart arteries (coronary artery disease). CABG surgery creates new routes around narrowed and blocked arteries, allowing sufficient blood flow to deliver oxygen and nutrients to the heart muscle.

How does coronary artery disease develop?

Coronary artery disease (CAD) occurs when atherosclerotic plaque (hardening of the arteries) builds up in the wall of the arteries that supply the heart. This plaque is primarily made of cholesterol. Plaque accumulation can be accelerated by smoking, high blood pressure, elevated cholesterol, and diabetes. Patients are also at higher risk for plaque development if they are older (greater than 45 years for men and 55 years for women), or if they have a positive family history for early heart artery disease.

The atherosclerotic process causes significant narrowing in one or more coronary arteries. When coronary arteries narrow more than 50 to 70%, the blood supply beyond the plaque becomes inadequate to meet the increased oxygen demand during exercise. The heart muscle in the territory of these arteries becomes starved of oxygen (ischemic). Patients often experience chest pain (angina) when the blood oxygen supply cannot keep up with demand. Up to 25% of patients experience no chest pain at all despite documented lack of adequate blood and oxygen supply. These patients have "silent" angina, and have the same risk of heart attack as those with angina.

When a blood clot (thrombus) forms on top of this plaque, the artery becomes completely blocked causing a heart attack.

Heart Attack illustration - Coronary Artery Bypass Graft Surgery

When arteries are narrowed in excess of 90 to 99%, patients often have accelerated angina or angina at rest (unstable angina). Unstable angina can also occur due to intermittent blockage of an artery by a thrombus that eventually is dissolved by the body's own protective clot-dissolving system.

How is coronary artery disease diagnosed?

The resting electrocardiogram (EKG) is a recording of the electrical activity of the heart, and can demonstrate signs of oxygen starvation of the heart (ischemia) or heart attack. Often, the resting EKG is normal in patients with coronary artery disease and angina. Exercise treadmill tests are useful screening tests for patients with a moderate likelihood of significant coronary artery disease (CAD) and a normal resting EKG. These stress tests are about 60 to 70% accurate in diagnosing significant CAD.

If the stress tests do not reveal the diagnosis, greater accuracy can be achieved by adding a nuclear agent (thallium or Cardiolite) intravenously during stress tests. Addition of thallium allows nuclear imaging of the blood flow to different regions of the heart, using an external camera. An area of the heart with reduced blood flow during exercise, but normal blood flow at rest, signifies significant artery narrowing in that region.

 

Combining echocardiography (ultrasound imaging of the heart muscle) with exercise stress testing (stress echocardiography) is also a very accurate technique to detect CAD. When a significant blockage exists, the heart muscle supplied by this artery does not contract as well as the rest of the heart muscle. Stress echocardiography and thallium stress tests are both at least 80% to 85% accurate in detecting significant coronary artery disease.

When a patient cannot undergo exercise stress test because of nervous system or joint problems, medications can be injected intravenously to simulate the stress on the heart due to exercise and imaging can be performed with a nuclear camera or ultrasound.

Cardiac catheterization with angiography (coronary arteriography) is the most accurate test to detect coronary artery narrowing. Small hollow plastic tubes (catheters) are advanced under x-ray guidance to the openings of the two main heart arteries (left and right). Iodine contrast, "dye," is then injected into the arteries while an x-ray video is recorded. Sometimes, an exercise study is then done to determine whether a moderate narrowing (40 - 60%) is actually causing ischemia and, therefore, requires treatment.

A newer modality, high speed CT scanning angiography has recently become available. This procedure uses powerful x-ray methods to visualize the arteries to the heart. Its role in the evaluation of CAD is currently being evaluated. For more, please read the CT Scanning Angiography article.

How is coronary artery disease (CAD) treated?

Medicines used to treat angina reduce the heart muscle demand for oxygen in order to compensate for the reduced blood supply. Three commonly used classes of drugs are the nitrates, beta blockers and calcium blockers. Nitroglycerin (Nitro-Bid) is an example of a nitrate. Examples of beta blockers include propranolol (Inderal) and atenolol (Tenormin). Examples of calcium blockers include nicardipine (Cardene) and  nifedipine (Procardia, Adalat). Unstable angina is also treated with aspirin and the intravenous blood thinner heparin. Aspirin prevents clumping of platelets, while heparin prevents blood clotting on the surface of plaques in a critically narrowed artery. When patients continue to have angina despite maximum medications, or when significant ischemia still occurs with exercise testing, coronary arteriography is usually indicated. Data collected during coronary arteriography help doctors decide whether the patient should be considered for percutaneous coronary intervention, or percutaneous transluminal angioplasty (PTCA), whereby a small balloon is used to inflate the blockage. Angioplasty (PTCA) is usually followed by placement of a stent or coronary artery bypass graft surgery (CABG) to increase coronary artery blood flow.

 

Angioplasty can produce excellent results in carefully selected patients. Under x-ray guidance, a wire is advanced from the groin to the coronary artery. A small catheter with a balloon at the end is threaded over the wire to reach the narrowed segment. The balloon is then inflated to push the artery open, and a steel mesh stent is generally inserted.

CABG surgery is performed to relieve angina in patients who have failed medical therapy and are not good candidates for angioplasty (PTCA). CABG surgery is ideal for patients with multiple narrowings in multiple coronary artery branches, such as is often seen in patients with diabetes. CABG surgery has been shown to improve long-term survival in patients with significant narrowing of the left main coronary artery, and in patients with significant narrowing of multiple arteries, especially in those with decreased heart muscle pump function.

How is CABG surgery done?

The cardiac surgeon makes an incision down the middle of the chest and then saws through the breastbone (sternum). This procedure is called a median (middle) sternotomy (cutting of the sternum). The heart is cooled with iced salt water, while a preservative solution is injected into the heart arteries. This process minimizes damage caused by reduced blood flow during surgery and is referred to as "cardioplegia." Before bypass surgery can take place, a cardiopulmonary bypass must be established. Plastic tubes are placed in the right atrium to channel venous blood out of the body for passage through a plastic sheeting (membrane oxygenator) in the heart lung machine. The oxygenated blood is then returned to the body. The main aorta is clamped off (cross clamped) during CABG surgery to maintain a bloodless field and to allow bypasses to be connected to the aorta.

 

Coronary Artery Bypass illustration

The most commonly used vessel for the bypass is the saphenous vein from the leg. Bypass grafting involves sewing the graft vessels to the coronary arteries beyond the narrowing or blockage. The other end of this vein is attached to the aorta. Chest wall arteries, particularly the left internal mammary artery, have been increasingly used as bypass grafts. This artery is separated from the chest wall and usually connected to the left anterior descending artery and/or one of its major branches beyond the blockage. The major advantage of using internal mammary arteries is that they tend to remain open longer than venous grafts. Ten years after CABG surgery, only 66% of vein grafts are open compared to 90% of internal mammary arteries. However, artery grafts are of limited length, and can only be used to bypass diseases located near the beginning (proximal) of the coronary arteries. Using internal mammary arteries may prolong CABG surgery because of the extra time needed to separate them from the chest wall. Therefore, internal mammary arteries may not be used for emergency CABG surgery when time is critical to restore coronary artery blood flow.

CABG surgery takes about four hours to complete. The aorta is clamped off for about 60 minutes and the body is supported by cardiopulmonary bypass for about 90 minutes. The use of 3 (triple), 4 (quadruple), or 5 (quintuple) bypasses are now routine. At the end of surgery, the sternum is wired together with stainless steel and the chest incision is sewn closed. Plastic tubes (chest tubes) are left in place to allow drainage of any remaining blood from the space around the heart (mediastinum). About 5% of patients require exploration within the first 24 hours because of continued bleeding after surgery. Chest tubes are usually removed the day after surgery. The breathing tube is usually removed shortly after surgery. Patients usually get out of bed and are transferred out of intensive care the day after surgery. Up to 25% of patients develop heart rhythm disturbances within the first three or four days after CABG surgery. These rhythm disturbances are usually temporary atrial fibrillation, and are felt to be related to surgical trauma to the heart. Most of these arrhythmias respond to standard medical therapy that can be weaned one month after surgery. The average length of stay in the hospital for CABG surgery has been reduced from as long as a week to only three to four days in most patients. Many young patients can even be discharged home after two days.

A new advance for many patients is the ability to do CABG with out going on cardiopulmonary bypass ("off pump"), with the heart still beating. This significantly minimizes the occasional memory defects and other complications that may be seen after CABG, and is a significant advance.

How do patients recover after CABG surgery?

Sutures are removed from the chest prior to discharge and from the leg (if the saphenous vein is used) after 7 to 10 days. Even though smaller leg veins will take over the role of the saphenous vein, a certain degree of swelling (edema) in the affected ankle is common. Patients are advised to wear elastic support stockings during the day for the first four to six weeks after surgery and to keep their leg elevated when sitting. This swelling usually resolves after about six to eight weeks. Healing of the breastbone takes about six weeks and is the primary limitation in recovering from CABG surgery. Patients are advised not to lift anything more than 10 pounds or perform heavy exertion during this healing period. They are also advised not to drive for the first four weeks to avoid any injury to the chest. Patients can return to normal sexual activity as long as they minimize positions that put significant weight on the chest or upper arms. Return to work usually occurs after the six week recovery, but may be much sooner for non-strenuous employment.

Exercise stress testing is routinely done four to six weeks after CABG surgery and signals the beginning of a cardiac rehabilitation program. Rehabilitation consists of a 12 week program of gradually increasing monitored exercise lasting one hour three times a week. Patients are also counseled about the importance of lifestyle changes to lower their chance of developing further CAD. These include stopping smoking, reducing weight and dietary fat, controlling blood pressure and diabetes, and lowering blood cholesterol levels.

What are the risks and complications of CABG surgery?

Overall mortality related to CABG is 3-4%. During and shortly after CABG surgery, heart attacks occur in 5 to 10% of patients and are the main cause of death. About 5% of patients require exploration because of bleeding. This second surgery increases the risk of chest infection and lung complications. Stroke occurs in 1-2%, primarily in elderly patients. Mortality and complications increase with:

  • age (older than 70 years),
  • poor heart muscle function,
  • disease obstructing the left main coronary artery,
  • diabetes,
  • chronic lung disease, and
  • chronic kidney failure.

Mortality may be higher in women, primarily due to their advanced age at the time of CABG surgery and smaller coronary arteries. Women develop coronary artery disease about 10 years later than men because of hormonal "protection" while they still regularly menstruate (although in women with risk factors for coronary artery disease, especially smoking, elevated lipids, and diabetes, the possibility for the development of coronary artery disease at a young age is very real). Women are generally of smaller stature than men, with smaller coronary arteries. These small arteries make CABG surgery technically more difficult and prolonged. The smaller vessels also decrease both short and long-term graft function.

What are the long-term results after CABG surgery?

A very small percentage of vein grafts may become blocked within the first two weeks after CABG surgery due to blood clotting. Blood clots form in the grafts usually because of small arteries beyond the insertion site of the graft causing sluggish blood run off. Another 10% of vein grafts close off between two weeks and one year after CABG surgery. Use of aspirin to thin the blood has been shown to reduce these later closings by 50%. Grafts become narrowed after the first five years as cells stick to the inner lining and multiply, causing formation of scar tissue (intimal fibrosis) and actual atherosclerosis. After 10 years, only 2/3 of vein grafts are open and 1/2 of these have at least moderate narrowings. Internal mammary grafts have a much higher (90%) 10 year rate of remaining open. This difference in longevity has caused a shift in surgical practices toward greater use of internal mammary and other arteries as opposed to veins for bypasses.

Recent data has shown that in CABG patients with elevated LDL cholesterol (bad cholesterol) levels, use of cholesterol-lowering medications (particularly the statin family of drugs) to lower LDL levels to below 80 will significantly improve long-term graft patency as well as improve survival benefit and heart attack risk. Patients are also advised about the importance of lifestyle changes to lower their chance of developing further atherosclerosis in their coronary arteries. These include stopping smoking, exercise, reducing weight and dietary fat, as well as controlling blood pressure and diabetes. Frequent monitoring of CABG patients with physiologic testing can identify early problems in grafts. PTCA (angioplasty) with stenting, in addition to aggressive risk factor modification, may significantly limit the need for repeat CABG years later. Repeat CABG surgery is occasionally necessary, but may have a higher risk of complication.

How do CABG surgery and angioplasty (PTCA) compare?

Ongoing studies are comparing the treatment results of angioplasty (PTCA) versus bypass (CABG surgery) in patients who are candidates for either procedure. Both procedures are very effective in reducing angina symptoms, preventing heart attacks, and reducing death. Many studies have either shown similar benefits or slight advantage to CABG (primarily in severe diabetics), although current studies are evaluating the two procedures utilizing the most current improved techniques (for example, newer "medicated" stents and the off-pump CABG); this data is still being collected. The best choice for an individual patient is best made by their cardiologist, surgeon, and primary doctor.

Coronary Artery Bypass Graft At A Glance
  • Coronary artery disease develops because of hardening of the arteries (arteriosclerosis) that supply blood to the heart muscle.
  • In the diagnosis of coronary artery disease, helpful tests include EKG, stress test, echocardiography, and coronary angiography.
  • Coronary artery bypass graft (CABG) surgery reestablishes sufficient blood flow to deliver oxygen and nutrients to the heart muscle.
  • The bypass graft for a CABG can be a vein from the leg or an inner chest wall artery.

Heart Disease
(Coronary Artery Disease)

 

View the Heart Disease Slideshow

 

Heart Disease Slideshow Pictures Heart Disease Slideshow
Medical Illustrations of the Heart Image Collection Medical Illustrations of the Heart Image Collection
Take the Heart Disease Quiz! Take the Heart Disease Quiz!

 

  • Introduction to heart disease
  • What are the risk factors for heart disease?
  • What are the symptoms of heart disease?
  • How is heart disease diagnosed?
  • Electrocardiogram (ECG or EKG)
  • Stress testing
  • Echocardiography
  • Perfusion studies
  • Computerized tomography
  • Heart catheterization or coronary angiography
  • What is the treatment for heart disease?
  • Prevention of heart disease
  • Modifying risk factors for heart disease
  • Medications
  • Angioplasty and stents
  • Surgery
  • Heart Disease At A Glance
  • Pictures of Heart Disease (Coronary Artery Disease) - Slideshow View Heart Disease (Coronary Artery Disease) Slideshow
  • Patient Discussions: Heart Disease
  • Find a local Cardiologist in your town

Introduction to heart disease

The heart is like any other muscle, requiring blood to supply oxygen and nutrients for it to function. The heart's needs are provided by the coronary arteries, which begin at the base of the aorta and spread across the surface of the heart, branching out to all areas of the heart muscle.

The coronary arteries are at risk for narrowing as cholesterol deposits, called plaques, build up inside the artery. If the arteries narrow enough, blood supply to the heart muscle may be compromised (slowed down), and this slowing of blood flow to the heart causes pain, or angina.

A heart attack or myocardial infarction occurs when a plaque ruptures, allowing a blood clot to form. This completely obstructs the artery, stopping blood flow to part of the heart muscle, and that portion of muscle dies.

What are the risk factors for heart disease

Risk factors for heart disease include:

  • Smoking
  • High blood pressure (hypertension)
  • High cholesterol
  • Diabetes
  • Family history
  • Peripheral artery disease
  • Obesity

What are the symptoms of heart disease?

The typical symptoms of coronary artery disease are associated chest pain with shortness of breath. Classically, the pain of angina is described as a pressure or heaviness behind the breast bone with radiation to the jaw and down the arm accompanied by shortness of breath and sweating. Unfortunately, angina has a variety of presentations, and there may not even be specific chest pain. There may be shoulder or back ache, nausea, indigestion or upper abdominal pain.

Women, the elderly, and people with diabetes may have different perceptions of pain or have no discomfort at all. Instead, they may complain of malaise or fatigue.

Healthcare providers and patients may have difficulty understanding each other when symptoms of angina are described. Patients may experience pressure or tightness but may deny any complaints of pain.

People with coronary artery disease usually have gradual progression of their symptoms over time. As an artery narrows over time, the symptoms that it causes may increase in frequency and/or severity. Healthcare providers may inquire about changes in exercise tolerance (How far can you walk before getting symptoms? Is it to the mailbox? Up a flight of stairs?) and whether there has been an acute change in the symptoms.

Once again, patients may be asymptomatic until a heart attack occurs. Of course, some patients also may be in denial as to their symptoms and procrastinate in seeking care.

Picture of the Heart and Heart Attack

How is heart disease diagnosed?

The diagnosis of heart disease begins with obtaining a history that the potential for coronary artery disease exists. Risk factors need to be assessed, and then testing may be required to confirm the presence of heart disease.

Heart disease tests

Not every patient with chest pain needs heart catheterization (the most invasive test). Instead, the healthcare provider will try to choose the testing modality that will best provide the diagnosis, and if coronary artery disease is present, decide what impairment, if any, is present.

Electrocardiogram (ECG or EKG)

The heart is an electrical pump, and the electrical impulses it generates can be detected on the surface of the skin. Normal muscle conducts electricity in a reproducible fashion. Muscle that has decreased blood supply conducts electricity poorly. Muscle that has lost its blood supply and has been replaced with scar tissue cannot conduct electricity. The electrocardiogram (EKG) is a noninvasive test used to reflect underlying heart conditions by measuring the electrical activity of the heart.

Some people have "abnormal" EKGs at baseline but this may be normal for them. It is important that an electrocardiogram be compared to previous tracings. If a patient has a baseline abnormal EKG, they should carry a copy with them for reference if they ever need another EKG.

Stress testing

If the baseline EKG is relatively normal, then monitoring the EKG tracing while the patient exercises may uncover electrical changes that may indicate the presence of coronary artery disease. There are a variety of testing protocols used to determine whether the exercise intensity is high enough to prove that the heart is normal.

Some patients are unable to exercise on a treadmill test, but they can still undergo cardiac stress testing by using intravenous medication that causes the heart to work harder.

Stress testing is done under the supervision of medical personnel because of the potential of provoking angina, shortness of breath, abnormal heart rhythms, and heart attack.

Echocardiography

Used with or without exercise, echocardiography can assess how the heart works. Using sound waves to generate an image, a cardiologist can evaluate many aspects of the heart. Echocardiograms can examine the structure of the heart including the thickness of the heart muscle, the septum (the tissues that separate the four heart chambers from each other) and the pericardial sac (the outside lining of the heart).

The test can indirectly assess blood flow to parts of the heart muscle. If there is decreased blood flow, then segments of the heart wall may not beat as strongly as adjacent heart muscle. These wall motion abnormalities signal the potential for coronary artery disease.

The echocardiogram can also assess the efficiency of the heart by measuring ejection fraction. Normally when the heart beats, it pushes more than 60% of the blood in the ventricle out to the body. Many diseases of the heart, including coronary artery disease, can decrease this percentage (the ejection fraction).

Perfusion studies

Radioactive chemicals like thallium or technetium can be injected into a vein and their uptake measured in heart muscle cells. Abnormally decreased uptake can signify decreased blood flow to parts of the heart because of coronary artery narrowing. This test may be used when the patient's baseline EKG is not normal and is less reliable when used to monitor a stress test.

Computerized tomography

The latest generation of CT scanners can take detailed images of blood vessels and may be used as an adjunct to determine whether coronary artery disease is present. In some institutions, the heart CT is used as a negative predictor. That means that the test is done to prove that the coronary arteries are normal rather than to prove that the disease is present.

Heart catheterization or coronary angiography

This test is the gold standard for the diagnosis of coronary artery disease. A cardiologist inserts and then threads a small tube through the groin or arm into the coronary arteries, where dye is injected to directly visualize the arteries on an x-ray. This test defines the anatomy of the coronary arteries.

CT coronary angiogram is a fairly new test to diagnose coronary artery disease. During this procedure, intravenous dye containing iodine is injected into the patient and CT scanning is performed to image the coronary arteries.

What is the treatment for heart disease?

Coronary artery disease is usually treated in a multi-step approach depending upon a patient's symptoms. The patient and healthcare provider need to work together to return the patient to a normal lifestyle.

Prevention of heart disease

The key to the treatment is prevention. A healthy lifestyle is the key, including exercise, proper nutrition, and smoking cessation.

An aspirin a day is recommended to decrease the risk for heart disease and should be started with the recommendation of a healthcare provider.

A little alcohol (one drink per day for women or two drinks per day for men) decreases the risk of heart disease compared to nondrinkers. However, it is not recommended that nondrinkers begin drinking.

Modifying risk factors for heart disease

While patients cannot choose their family and alter their genetic predisposition to coronary artery disease, the rest of the risk factors are under control of the patient. Keeping blood pressure, cholesterol and other lipid levels, and diabetes under control needs to become a life-long goal. Smoking cessation is highly encouraged.

Medications

The purpose of medications for coronary artery disease is to allow more efficient heart muscle function to overcome any blockage that might exist.

Aspirin is one of the cornerstones of coronary artery disease treatment. It prevents platelets from clumping together when blood becomes turbulent, like when it flows past a narrowing in an artery.

 

Beta blockers prevent the action of adrenaline on the heart and allow the heart to beat a more efficiently by reducing the heart rate and causing the heart muscle to contract less aggressively. Examples of beta blockers include:

  • atenolol (Tenormin)
  • metoprolol (Lopressor, Toprol XL)
  • propranolol (Inderal, Inderal LA)
  • carvedilol (Coreg)
  • labetalol (Normodyne, Trandate)
 

Calcium channel blockers can also be used to control heart rate and allow the heart to beat more efficiently. Examples of calcium channel blockers include:

  • diltiazem (Cardizem, Dilacor, Tiazac)
  • verapamil (Calan, Verelan, Verelan PM, Isoptin, Covera-HS)
 

Nitroglycerin dilates blood vessels and may be used sublingually, under the tongue, to treat angina. Some patients may be prescribed long-acting nitroglycerin to help control anginal symptoms.

Angioplasty and stenting

If the coronary angiogram (coronary=heart + angio=artery + gram=record) shows significant blockage in an artery, the cardiologist may attempt an angioplasty, in which a balloon is placed via a catheter (as with angiography) at the area of narrowing and when quickly inflated, compresses the offending plaque into the wall of the artery. Often a stent, or a metal cage, is placed at the site of angioplasty to keep the blood vessel from narrowing again.

Surgery

For those patients with multiple coronary artery blockages, coronary artery bypass grafting may be a consideration.

Heart Disease At A Glance
  • Coronary artery disease is the most common cause of death in the United States. Over a million people each year will have a heart attack and 25% will die before they get to the hospital or in the Emergency Department.
  • Prevention is the key to treatment.
  • Diagnosis is often made by careful history taken by a healthcare provider. Some patients may have atypical symptoms, including almost none at all.
  • The testing strategy to confirm the diagnosis and plan appropriate treatment needs to be individualized for each patient.
  • Treatment depends upon the severity of disease and is often directed by the symptoms experienced by the patient.

Calcific Bursitis

 

View the RA Slideshow Pictures
Rheumatoid Arthritis Slideshow Pictures Rheumatoid Arthritis
Joint-Friendly Exercises Slideshow Pictures Joint-Friendly Exercises
Simple Exercises to Relieve OA Pain Slideshow Simple Exercises to Relieve Osteoarthritis Pain Slideshow
  • What is calcific bursitis?
  • How is calcific bursitis diagnosed?
  • What is the treatment of calcific bursitis?
  • What is the outlook for a patient with calcific bursitis?
  • Find a local Rheumatologist in your town

What is calcific bursitis?

A bursa is a thin fluid-filled sac that reduces friction forces between tissues of the body. Chronic (repeated or long-standing) inflammation of the bursa (bursitis) can lead to calcification of the bursa. This is referred to as "calcific bursitis." The calcium deposits (calcification) can occur as long as the inflammation is present and remain after it has resolved. Calcific bursitis occurs most commonly in the shoulder.

How is calcific bursitis diagnosed?

Calcific bursitis is diagnosed when viewed with an x-ray test or MRI scan of the inflamed, painful bursa.

What is the treatment of calcific bursitis?

Treatment of the inflammation of calcific bursitis can help to prevent further calcification as well as relieve pain and stiffness. Treatments include medications for inflammation, cold packs, immobilization, injections of cortisone into the bursa, physical therapy, and occasionally surgical removal of the inflamed bursa.

What is the outlook for a patient with calcific bursitis?

When the inflammation is quieted, the long-term outlook (prognosis) is excellent. Optimal improvement can require physical therapy treatment. The calcium deposit can remain indefinitely and may not cause any problems. Significant calcium deposits can sometimes, however, cause a mechanically abrasive area of tenderness. These deposits that continue to cause symptoms are considered for surgical removal.

Pseudogout

 

Take the Gout Quiz

 

Take the Gout Quiz Take the Gout Quiz
Gout Overview Slideshow Pictures Gout Overview Slideshow Pictures
Rheumatoid Arthritis Slideshow Pictures Rheumatoid Arthritis Slideshow Pictures
  • What is pseudogout?
  • What are symptoms of pseudogout?
  • How does a doctor diagnose pseudogout?
  • What are treatments for pseudogout?
  • What other conditions can accompany pseudogout?
  • Are there special circumstances that can promote attacks of pseudogout?
  • Pseudogout At A Glance
  • Find a local Rheumatologist in your town

What is pseudogout?

Pseudogout is a type of inflammation of joints (arthritis) that is caused by deposits of crystals, called calcium pyrophosphate, in and around the joints. Pseudogout literally means "false gout."

Pseudogout has many similarities to true gout, which also can cause arthritis. However, the crystal that incites the inflammation of gout is monosodium urate. The crystals that cause pseudogout and gout each have distinct appearances when joint fluid containing them is viewed under a microscope. This makes it possible to precisely identify the cause of the joint inflammation when joint fluid is available.

Pseudogout has been reported to occasionally coexist with gout. This means that the two types crystals can sometimes be found in the same joint fluid. Researchers have also noted that the cartilage of patients who had both forms of crystals in their joint fluid was often visibly calcified, as seen on x-ray images.

 

What are symptoms of pseudogout?

Pseudogout can result in arthritis of a number of joints but commonly involves the knees, wrists, shoulders, hips, and/or ankles. Pseudogout usually affects only one or a few joints at a time. The "attacks" of joint inflammation, characterized by acute joint swelling, warmth, stiffness, and pain, may last for days to weeks and can resolve spontaneously.

How does a doctor diagnose pseudogout?

Pseudogout is suggested when abnormal calcifications are seen in the cartilage of joints on x-ray testing. These calcifications are referred to as chondrocalcinosis.

The arthritis of pseudogout is common in older adults, particularly in the context of dehydration such as occurs with hospitalization or surgery.

The diagnosis of pseudogout is ultimately made when fluid from a joint is examined under a special microscope called a polarizing microscope. With this microscope, the calcium pyrophosphate crystals are identified.

What are treatments for pseudogout?

The treatment of pseudogout is directed toward stopping the inflammation in the joints. Local ice applications and resting can help. Nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen and others are often first drugs of choice.

Removing fluid containing the crystals from the joint can reduce pain and help the inflammation to diminish more quickly. Cortisone injected into an inflamed joint and oral colchicine are also used.

Long-term prevention of recurrent pseudogout is often best achieved with small daily doses of colchicine.

What other conditions can accompany pseudogout?

Pseudogout can occur along with aging, be inherited, or be associated with hemophilia, hemochromatosis, ochronosis, amyloidosis, or hormonal disorders (such as hyperparathyroidism and hypothyroidism). These illnesses are considered in the initial evaluation of a patient with pseudogout.

Are there special circumstances that can promote attacks of pseudogout?

Arthritis attacks of pseudogout can be precipitated by dehydration and not infrequently follow surgical procedures in elderly patients. Patients with known pseudogout should stay well hydrated before and after operations.

Pseudogout At A Glance
  • Pseudogout is caused by crystals in a joint.
  • Pseudogout causes arthritis (joint inflammation).
  • Pseudogout can cause calcification of cartilage.
  • The arthritis of pseudogout is diagnosed by detecting typical crystals in joint fluid.
  • Treatment of pseudogout is directed at the inflammation.
  • Pseudogout can be associated with other illnesses.

Vitamin and Calcium Supplements

 

View Slideshow Pictures
Amazing Vitamin D Slideshow Pictures Vitamin D Slideshow Pictures
Take the Vitamins & Supplements Quiz! Take the Vitamins & Supplements Quiz!

 

 

  • What are vitamins, and why are they important?
  • Calcium
  • Vitamin D
  • Folic acid
  • Vitamin E
  • Vitamin A
  • Vitamin C
  • Vitamin B12
  • Vitamin B6
  • Thiamin (vitamin B1)
  • Niacin
  • Riboflavin
  • Vitamin K

What are vitamins, and why are they important?

There are six nutrients that are considered essential to life: proteins, carbohydrates, fats, vitamins, minerals, and water. These nutrients are needed for your body to function properly, and your diet is the source of them. Vitamins and minerals are considered micronutrients because they are needed in smaller quantities than the macronutrients (protein, carbohydrates, and fat). Micronutrients do not provide calories. When your body does not absorb an adequate amount of any of the micronutrients, diseases can occur. It's important to understand what your nutritional needs are and how to reach them.

Vitamins are broken down into two categories: water-soluble and fat-soluble. Water-soluble vitamins dissolve in water. Leftover amounts are not stored and will leave your body through your urine. For this reason, you must consume them on a continuous basis. The water-soluble vitamins are the B vitamins and vitamin C. Fat-soluble vitamins dissolve in fat, not water. These vitamins need dietary fat in order to be absorbed in the small intestines. They are then stored in the liver and fatty tissues (adipose tissues) and can accumulate to toxic levels when consumed in excess quantities. The fat-soluble vitamins are vitamins A, D, E, and K.

Recommendations for essential nutrients are provided in the Dietary Reference Intakes (DRIs) developed by the Institute of Medicine of the National Academies. Dietary Reference Intakes is the general term for a set of reference values used for planning and assessing nutrient intake for healthy people. There are three important types of DRI reference values; Recommended Dietary Allowances (RDA), Adequate Intakes (AI), and Tolerable Upper Intake Levels (UL). The RDA is set to meet the nutrient requirements for the average daily intake of nearly all (97%-98%) healthy individuals in each age and gender group. When there is insufficient data to set an RDA for a nutrient, an AI is set. AIs meet or exceed the amount needed to maintain an adequate nutritional state in nearly everyone of a specific age and gender group. Some nutrients can cause health problems when consumed in excessive quantities. The UL was set to provide the maximum daily intake that is unlikely to result in adverse health effects. Numerous health conditions, however, can impact your nutritional needs. A registered dietitian or physician can help you determine your specific needs based upon your overall health and condition.

Calcium

What is calcium, and what does it do?

Most people know that calcium is needed for strong bones, but it's also needed to help blood vessels and muscles contract and expand, to send messages through the nervous system, and to secrete hormones and enzymes. This is the most abundant mineral in your body and makes up 1%-2% of adult human body weight. Over 99% of it is stored in bones and teeth with the rest stored in blood, muscle, and other tissues.

How much do you need to consume?

There is a great deal of concern over Americans not meeting the recommendations for calcium intake. The recommendations for calcium are listed as an Adequate Intake:

Age Adequate Intake for Calcium
0 to 6 months *210 mg from breast milk 315 mg from formula
7 to 12 months *270 mg from breast milk 335 mg from formula
1 to 3 years 500 mg
4 to 8 years 800 mg
9 to 13 years 1,300 mg
14 to 18 years 1,300 mg
19 to 50 years 1,000 mg
51+ years 1,200 mg

 

*Breast milk has been shown to have a higher rate of calcium absorption than formula, so calcium requirements are higher for formula-based diets. Calcium needs during pregnancy and lactation do not change from ages 14 to 50.

What are sources of calcium?

Calcium is found in a variety of foods, but the amount that your body absorbs varies. Oxalic acid and phytic acid both interfere with the absorption of calcium. Foods rich in oxalic acid are spinach, rhubarb, sweet potatoes, and beans. Foods rich in phytic acid are unleavened bread, nuts, seeds, and raw beans. You will absorb some of the calcium in these foods, but not as much as you would from foods that do not contain oxalic acid or phytic acid. For example, calcium absorption from dried beans is about half of what you absorb from milk, and calcium absorption from spinach is about one-tenth of that absorbed from milk. There is no need to omit these foods from your diet. Instead, consume a variety of calcium-rich foods throughout the day.

According to the USDA Nutrient Database, the calcium content of some common foods is shown below:

Food Amount Calcium Content
Cheese, cheddar 1 ½ oz shredded 306 mg
Collards, frozen, boiled 1 cup 357 mg
Cottage cheese, 1% milk fat 1 cup 138 mg
Milk, nonfat 1 cup 306 mg
Powdered milk, nonfat 1 tbsp 50 mg-100 mg
Salmon, canned with bones 3 oz 181 mg
Sardines, canned in oil, with bones 3 oz 324 mg
Soy milk 1 cup 93 mg
Tofu, soft, made w/calcium sulfate ½ cup 138 mg
Yogurt, plain, low-fat 1 cup 415 mg
Yogurt, fruit, low-fat 1 cup 245 mg-385 mg

You can find more sources at http://www.nal.usda.gov/fnic/foodcomp/Data/SR20/nutrlist/sr20a301.pdf.

You can also increase your calcium intake by

  • adding nonfat powdered milk to cereals (hot and cold), soups, gravy, baked goods, or casseroles,
  • using nonfat milk in place of water in recipes (pancakes, pudding, hot cereals, and mashed potatoes), and
  • having yogurt dips for vegetable and chips.

Do I need to take a calcium supplement?

A well-balanced diet can be enough to reach your recommended intake of calcium. When diet is not enough, a calcium supplement may be necessary. In the case of calcium supplements, more is definitely not better. Calcium absorption is most efficient when the dose is 500 mg or less. This means that taking 1,000 mg at one time is less effective than taking two separate doses of 500 mg.

Calcium exists in nature combined with other chemicals. These compounds are what you will find in supplements and include calcium carbonate, calcium phosphate, calcium lactate, and calcium citrate. Calcium carbonate is the most common one because it is inexpensive and convenient. People who have decreased stomach acid (for example, older adults and those who take antacids) are better off taking calcium citrate. According to the National Osteoporosis Foundation, "Calcium supplements prepared from unrefined oyster shell, bone meal, or dolomite may contain lead or other toxic metals," so you need to pay attention to the source of calcium in your supplement.

Calcium supplements may cause gas, bloating, and/or constipation. There may be options to help relieve this. You can try spreading out dosages of the supplement throughout the day, try taking it with food, try a different brand, or speak with your doctor or pharmacist for assistance.

What happens if I do not have enough calcium?

Bone is a living tissue that constantly breaks down and builds back up. Up until around the age of 30, consuming an adequate amount of calcium with enough physical activity ensures that your body builds more bone than it breaks down. The majority of adult bone mass is acquired by age 18 in girls and 20 in boys. After that, breakdown typically exceeds the amount of bone being built. For this reason, it's essential to maximize bone stores when it's still possible. The amount that you lose after age 30 will be impacted by genetics, ethnicity, physical activity level, sex hormone levels, diet, and gender. You can replace what you lose with the foods you eat and your activity level, but you can't increase how much you store. When bone mass drops and there is a deterioration of bone tissue, osteoporosis can occur. Osteoporosis causes bones to be susceptible to fractures. Depending on the severity of the damage, bones can break from a minor fall, or in severe cases, from sneezing.

Other factors can put you at risk for low calcium levels.

Amenorrhea: Research has shown that young women who do not get their period due to anorexia nervosa have reduced net calcium absorption, higher urinary calcium excretion, and a lower rate of bone formation in comparison to those who menstruate regularly. Reduced calcium retention and lower bone mass have also been seen in exercise-induced amenorrhea.

Lactose intolerance: Many people find that consuming dairy products causes bloating, gas, cramping, and/or diarrhea. This is often from your body's inability to break down the lactose found in dairy foods. Lactose is the sugar that naturally occurs in these foods. Avoiding dairy foods can put you at risk for calcium deficiency. Fortunately, there are things that you can do to help with these symptoms. The first thing is to try to consume smaller amounts of dairy foods. Studies have shown that people with lactose intolerance can often tolerate 8 oz of milk at once. When this doesn't work, you can purchase dairy products that have the lactose broken down for you. Lactaid products have taken the lactose and broken it up so that your body does not have to.

Is there such a thing as too much calcium?

The Tolerable Upper Limit (UL) for calcium for children and adults ages 1 year and older is 2,500 mg/day. Excessively high intakes would have to come from supplements alone or supplements in combination with dietary sources. The dangers of excessive consumption are impaired kidney function, hypercalcemia, and decreased absorption of other minerals (iron, zinc, magnesium, and phosphorus). Calcium has been shown to interfere with iron absorption. It's best to take the recommended amounts of calcium separate from iron-containing foods or supplements.

Calcium also has the potential to interact with medications by decreasing the absorption of the medication. Some common affected medications are digoxin, fluoroquinolones, levothyroxine, antibiotics in tetracycline family, and phenytoin. Your doctor and pharmacist can provide further information about this.

Vitamin D

What is it, and what does it do?

Vitamin D is probably most well-known for being the "sunshine vitamin." The ultraviolet rays from the sunlight strike the skin, causing vitamin D to be made. It can also be found in food and supplements. This is one of the four fat-soluble vitamins. That means that it's stored in the body's fatty tissue and can build up to toxic levels with excessive consumption.

The major function of vitamin D is to maintain optimal blood levels of calcium and phosphorus. Studies have shown that it provides protection from hypertension, cancer, osteoporosis, type 1 diabetes, and several autoimmune diseases.

How much do I need to consume?

The recommendations for vitamin D are listed as an Adequate Intake in micrograms (mcg) and International Units (IU):

Age Vitamin D
Birth to 13 years 5 mcg (200 IU)
14 to 18 years 5 mcg (200 IU)
19 to 50 years 5 mcg (200 IU)
51 to 70 years 10 mcg (400 IU)
71+ years 15 mcg (600 IU)

 

What are sources of vitamin D?

The sunshine vitamin got its name from the fact that the sun helps our body produce vitamin D. The concern about skin cancer has caused many people to avoid unprotected exposure to the sun. Fortunately, it is possible to consume enough vitamin D in your diet, so it is not necessary to risk the dangers of skin cancer by exposing yourself to the sun. For those who do rely on the sun as one of their sources, there are many factors that will impact how much you need. The season, time of day, cloud coverage, smog, amount and SPF of sunscreen, geographic latitude, and melanin content of your skin are all possible barriers. It can take anywhere from five to 30 minutes of sun on unexposed skin between the hours of 10 a.m. and 3 p.m. at least twice a week.

The foods that naturally contain vitamin D are seafood, mushrooms, and egg yolks. Dietary sources of vitamin D are:

Food Amount Vitamin D Content
Bluefish 3 oz 415 IU
Catfish 3 oz 425 IU
Cod liver oil 1 teaspoon 450 IU
Egg yolk 1 whole 25 IU
Mackerel 3 oz 395 IU
Milk, vitamin D fortified 1 cup 100 IU
Mushrooms, Chanterelle 2 oz 50 IU
Mushrooms, Shitake 2 oz 55 IU
Oysters 3 oz 545 IU
Salmon, farmed 3 oz 275 IU
Salmon, wild 3 oz 1,000 IU
Sardines, canned in oil 1 ¾ oz 230 IU
Shrimp 3 oz 120 IU
Tuna, bluefin 3 oz 170 IU
Tuna, canned in water 3 oz 135 IU


You can find more sources at http://www.nal.usda.gov/fnic/foodcomp/Data/Other/vit_d99.pdf.

Do I need to take a vitamin D supplement?

When diet is not enough, you may need to take a supplement to help you reach the desired intake of vitamin D. As you will see, vitamin D can be toxic at high levels, so the goal is to reach the appropriate level, not exceed it.

The two primary types of vitamin D supplements are vitamin D2 (ergocalciferol) and vitamin D3 (cholecalciferol). Most experts believe that vitamin D3 is the ideal choice for these reasons:

  • Vitamin D3 is the most potent form, it's more stable on the shelf, and it's less toxic than D2.
  • Vitamin D3 is the one that is synthesized when the sun hits your skin, so it's considered to be the most natural.
  • Most of the research that has been done on vitamin D and its health benefits has used vitamin D3.

What happens if I don't have enough vitamin D?

You can have blood tests done to determine if you are deficient in vitamin D. Your 25(OH)D level will be measured. Most experts agree that 25(OH)D level of <20 ng/mL is considered to be vitamin D deficiency, whereas a 25(OH)D level of 21-29 ng/mL is considered to be insufficient.

Research has shown strong relationships between lower rates of chronic diseases and higher levels of vitamin D. The most well-known disease related to vitamin D deficiency is rickets. Rickets is the disease that was found to be cured by consuming cod liver oil in the early 20th century. Rickets causes soft, weak bones in children, resulting in skeletal deformities (bowed legs), impaired growth, bone pain, dental problems, and fragile bones. Unfortunately, rickets has still been seen in children not being fed an adequate amount of vitamin D. In adults, vitamin D deficiency can lead to osteoporosis and osteomalacia (both are conditions of weakened bones).

There are several other factors that can contribute to a deficiency in vitamin D:

Age: People over 50 years old have a decreased ability to synthesize and absorb vitamin D. This occurs regardless of the amount of sun exposure time.

Medical conditions: Vitamin D requires fat for absorption, so anyone with a medical condition that reduces the ability to absorb dietary fat can be at risk for a deficiency. It is important to have vitamin D levels monitored in people with conditions such as Crohn's disease, celiac disease, cystic fibrosis, pancreatic enzyme deficiency, and surgical removal of any part of the stomach or intestines.

Obesity: Research has shown lower vitamin D concentrations in overweight and obese individuals. One possible reason for this is that vitamin D gets absorbed by fat tissue and is not easily absorbed in the bloodstream.

Sun exposure: The ultraviolet rays from the sun have served as a source of vitamin D over the years. Due to the danger of skin cancer, many people have cut back on their exposure to the sun and have begun using sunscreen when they are being exposed, so this can contribute to lower levels if adjustments are not made to compensate for this loss via dietary sources and/or supplements.

Skin pigmentation: There is more melanin in darker-skinned individuals. Melanin blocks the ultraviolet rays and interferes with vitamin D synthesis.

Are there any dangers to consuming too much vitamin D?

Consuming excessive amount of vitamin D can pose health problems. This is most likely to occur from taking supplements or high doses of cod liver oil. There is no danger of vitamin D toxicity from sun exposure. Symptoms of toxicity can be nausea, poor appetite, weakness, weight loss, constipation, and high blood levels of calcium. A blood level of over 200 ng/mL for vitamin D, measured as 25(OH)D, can be potentially toxic. For this reason, the tolerable upper intake (UL) for vitamin D has been set at 2,000 IU (50 mcg) per day for ages 1 and above. The UL for birth to 12 months is 1,000 IU (25 mcg) per day.

Folic Acid

What is folic acid, and what does it do?

Folic acid is the man-made form of folate, a naturally occurring B vitamin. Because it's a water-soluble vitamin, it cannot be stored in the body so it needs to be supplied on a continuous basis.

Folic acid helps form and maintain new cells. It is needed to make red blood cells and for the metabolism of homocysteine. It helps produce DNA, and it helps prevent changes in DNA that may lead to cancer.

How much do I need to consume?

The Recommended Dietary Allowances (RDA) for folate are expressed in a term called Dietary Folate Equivalent (DFE). The naturally occurring folate is absorbed differently than the man-made folic acid, so the DFE was developed to help account for these differences. One DFE is equal to 1 microgram (mcg) of food folate and 0.6 mcg of folic acid from supplements and fortified foods.

The RDA for folate:

Age Males and Females Pregnancy Lactation
1 to 3 years 150 mcg N/A N/A
4 to 8 years 200 mcg N/A N/A
9 to 13 years 300 mcg N/A N/A
14 to 18 years 400 mcg 600 mcg 500 mcg
19+ years 400 mcg 600 mcg 500 mcg


There is insufficient information to establish an RDA for folate for infants. In this case, an Adequate Intake (AI) has been established:

Age Males and Females
0 to 6 months 65 mcg
7 to 12 months 80 mcg

 

What are sources of folic acid?

Folate can be found naturally in many foods, including fruits, leafy green vegetables, and dried beans. Folic acid is added to certain foods because of regulations published by the Food and Drug Administration in 1996. These foods are considered enriched because the folic acid is replacing the folate that was lost during processing. Some common folic acid-enriched foods are cereals, breads, pasta, rice, flours, and cornmeal. Folic acid can also be added to foods and beverages in addition to the nutrients that they already contain. These foods are considered fortified with folic acid. In 1998, the folic acid fortification program was initiated to help Americans reach their folic acid recommendations.

Food sources of folate and folic acid are:

Food Amount Folate/Folic Acid Content
Asparagus, cooked 4 spears 85 mcg
Avocado, sliced, raw ½ cup 45 mcg
Banana, raw 1 medium 20 mcg
Beef liver 3 oz 185 mcg
Broccoli, chopped, frozen, cooked ½ cup 50 mcg
Broccoli, raw 2 spears 45 mcg
Cantaloupe, raw ¼ medium 25 mcg
Great Northern beans ½ cup 90 mcg
Green peas, frozen, cooked ½ cup 50 mcg
Papaya, raw, cubes ½ cup 25 mcg
Rice, white, enriched, cooked ½ cup 65 mcg
Spinach, frozen, cooked ½ cup 100 mcg
Spinach, raw 1 cup 60 mcg
Tomato juice 6 oz 35 mcg


You can find more sources at http://www.nal.usda.gov/fnic/foodcomp/Data/SR20/nutrlist/sr20a435.pdf.

Do I need to take a folic acid supplement?

The goal is to consume a balanced diet that provides your daily folate needs. The folate-enriched and -fortified foods make this much easier to accomplish. When you have a medical condition that interferes with the amount that you can consume, if you are unable to absorb all of what you consume, if your diet is limited, or if you have an increased need for folate, a supplement would be the best option. It is recommended that women who may become pregnant take 400 mcg of folic acid from fortified foods and/or dietary supplements along with consuming a well-balanced diet.

Another possible reason to take a supplement would be for heart protection. There are some studies that have shown that folic acid can lower homocysteine levels by up to 25%. High blood levels of homocysteine can damage the inner surface of blood vessels, promote blood clotting, accelerate atherosclerosis, and thus lead to heart attacks and strokes.

What happens if I don't have enough folic acid?

One very severe consequence of not getting enough folic acid is the possibility of neural tube defects during pregnancy. Neural tube defects usually develop in the first 28 days of pregnancy. Many women do not know that they are pregnant during this time and are not monitoring their folic acid intake. For this reason, it's a good idea to make sure that you have an adequate daily intake before trying to conceive.

A deficiency in folate can lead to megaloblastic (or macrocytic) anemia. It may also cause poor growth, gray hair, glossitis, mouth ulcers, diarrhea, and peptic ulcers. Studies have shown that low blood folate levels are associated with high blood homocysteine levels. High blood levels of homocysteine can damage the inner surface of blood vessels, promote blood clotting, accelerate atherosclerosis, and thus lead to heart attacks and strokes.

There are medical conditions and medications that can increase the need for folate, increase its excretion, or interfere with its utilization:

  • pregnancy and lactation,
  • liver disease,
  • kidney dialysis,
  • malabsorption,
  • alcohol abuse,
  • triamterene,
  • barbiturates,
  • anticonvulsant medications,
  • sulfasalazine,
  • metformin, and
  • methotrexate.

It's best to speak with your doctor if any of these applies to you.

Is there such a thing as too much folic acid?

There is no Tolerable Upper Limit (UL) set for natural sources of folate found in food.

There are UL set for folate from fortified foods and supplements.

Age Males and Females Pregnancy Lactation
1 to 3 years 300 mcg N/A N/A
4 to 8 years 400 mcg N/A N/A
9 to 13 years 600 mcg N/A N/A
14 to 18 years 800 mcg 800 mcg 800 mcg
19+ years 1,000 mcg 1,000 mcg 1,000 mcg


Going above the UL increases your risk for adverse health effects.

Vitamin E

What is it, and what does it do?

Vitamin E represents a family of eight fat-soluble antioxidant vitamins. Each form has its own function. Alpha-tocopherol is the most important E vitamin in humans. Vitamin E is involved in maintaining cell integrity, and it protects vitamin A and essential fatty acids from oxidation in the body cells.

How much do I need to consume?

The Recommended Dietary Allowances (RDA) for vitamin E is based on the alpha-tocopherol form. The recommendations below are in milligrams (mg) and International Units (IU). You can use the milligrams when looking at the content in food and the International Units when looking at the content in supplements.

The RDA for vitamin E is:

Age Males and Females Pregnancy Lactation
1 to 3 years 6 mg (9 IU) N/A N/A
4 to 8 years 7 mg (10.5 IU) N/A N/A
9 to 13 years 11 mg (16.5 IU) 15 mg (22.5 IU) 19 mg (28.5 IU)
14 + years 15 mg (22.5 IU) 15 mg (22.5 IU) 19 mg (28.5 IU)


There is insufficient information to establish an RDA for vitamin E for infants. In this case, an Adequate Intake (AI) has been established:

Age Males and Females
0 to 6 months 4 mg (6 IU)
7 to 12 months 5 mg (7.5 IU)


What are sources of vitamin E?

There are many foods rich in vitamin E. The most common ones are fortified cereals, green leafy vegetables, vegetable oil, eggs, and nuts. The content of vitamin E in food is based on the alpha-tocopherol content:

Food Amount Vitamin E Alpha-tocopherol
Almonds, dry roasted 1 oz 7.4 mg
Broccoli, frozen, cooked ½ cup 1.2 mg
Corn oil 1 tablespoon 1.9 mg
Egg 1 large 5.3 mg
Kiwi, no skin 1 medium 1.1 mg
Mango, raw ½ cup sliced 0.9 mg
Peanut butter, smooth style, fortified 2 tablespoons 4.2 mg
Safflower oil 1 tablespoon 4.6 mg
Soybean oil 1 tablespoon 1.3 mg
Spinach, frozen, cooked ½ cup 1.6 mg
Spinach, raw 1 cup 0.6 mg
Sunflower oil 1 tablespoon 5.6 mg
Sunflower seed kernels, dry roasted 1 oz 6.0 mg
Wheat germ oil 1 tablespoon 20.3 mg


You can find more sources at http://www.nal.usda.gov/fnic/foodcomp/Data/SR20/nutrlist/sr20a323.pdf.

Do I need to take a vitamin E supplement?

Most research shows that we do not consume an adequate amount of vitamin E, but a deficiency is rare. According to the USDA, the intake of vitamin E by women 19 to 50 years is less than 90% of the RDA. The average consumption for American adults is 7 to 9 mg compared to the recommended 15 mg. There is, however, a possibility that we are consuming more than we think. Many people under-report their fat intake, so there is a chance that you are reaching your recommended amount of vitamin E if you do consume a large amount of the oils that contain it. Unfortunately, the amount of oil that it would take to reach the recommendations is high, and with that comes a lot of calories. It would be best to consume a variety of the foods that contain vitamin E with limited amounts of oil and take a supplement for what you are missing.

There is some evidence that vitamin E supplements help protect against heart disease, but this evidence is controversial. In a study of approximately 90,000 nurses, the incidence of heart disease was 30%-40% lower in those with the highest intake of vitamin E from supplements, not from food. This study was looking at what happened to these nurses without any kind of intervention. The studies that gave people vitamin E supplements have not seen any protection against heart disease. The reason for the difference is still unclear, so there is more research being done to determine what role vitamin E plays in protecting against heart disease. At this time, the American Heart Association does not recommend antioxidant vitamins -- including vitamin E -- for preventing cardiovascular disease.

Some cancers develop from oxidation damage to DNA. In the Alpha-Tocopherol Beta Carotene (ATBC) study, scientists found a 32% reduction in the incidence of prostate cancer among subjects taking alpha-tocopherol supplements compared to those not taking the vitamin. However, several studies have found no benefit of vitamin E in preventing lung and breast cancers. More randomized controlled trials are needed to determine the effect of vitamin E on cancer risks.

Alzheimer's disease is a degenerative brain disease with progressive loss of mental capacity, thought in part to be due to oxidation. High doses of alpha-tocopherol supplementation in one study slowed the progression of Alzheimer's disease. Although these results are promising, large-scale placebo-controlled prospective trials will be required to determine the role of a-tocopherol supplementation in the treatment of Alzheimer's disease.

When purchasing vitamin E supplements, you will see that they are often sold as alpha-tocopheryl acetate. This form of alpha-tocopherol protects its ability to function as an antioxidant. A "DL" on the label means that it's the synthetic form and is about half as active as the natural form, which is listed as "D."

What happens if I don't have enough vitamin E?

Dietary vitamin E deficiency is common in developing countries and among people with fat-malabsorption diseases. The main symptoms are hemolytic anemia and neurologic deficits.

Is there such a thing as too much vitamin E?

Vitamin E can act as an anticoagulant, which means that it can increase the risk of bleeding problems. This means that people taking warfarin (Coumadin) should not take vitamin E supplements without their doctor's approval. The Tolerable Upper Limit (UL) was set at the highest dose unlikely to result in bleeding problems.

 

There are UL set for vitamin E:

Age Males and Females Pregnancy Lactation
1 to 3 years 200 mg (300 IU) N/A N/A
4 to 8 years 300 mg (450 IU) N/A N/A
9 to 13 years 600 mg (900 IU) N/A N/A
14 to 18 years 800 mg (1,200 IU) 800 mg (1,200 IU) 800 mg (1,200 IU)
19+ years 1,000 mg (1,500 IU) 1,000 mg (1,500 IU) 1,000 mg (1,500 IU)

Vitamin A

What is it, and what does it do?

Vitamin A is a fat-soluble vitamin that is broken down into two categories: preformed vitamin A comes from animal foods, and provitamin A carotenoid comes from plant foods.

Vitamin A serves many functions:

  • helps regulate the immune system to prevent and fight infections
  • helps form and maintain healthy teeth, skin, and tissues
  • produces the pigments in the retina of the eye
  • promotes good vision

How much do I need to consume?

The Recommended Dietary Allowances (RDA) for vitamin A are listed as International Units (IU) of Retinol Activity Equivalents (RAE). This is done to account for the different actions of both forms of vitamin A.

RDA for vitamin A:

Age Males Females Pregnancy Lactation
1 to 3 yrs 1,000 IU 1,000 IU N/A N/A
4 to 8 yrs 1,320 IU 1,320 IU N/A N/A
9 to 13 yrs 2,000 IU 2,000 IU N/A N/A
14 to 18 yrs 3,000 IU 2,310 IU 2,500 IU 4,000 IU
19+ 3,000 IU 2,310 IU 2,565 IU 4,300 IU



There is insufficient information to establish an RDA for vitamin A for infants. In this case, an Adequate Intake (AI) has been established:

Age Males and Females
0 to 6 months 1,320 IU
7 to 12 months 1,650 IU


What are sources of vitamin A?

Vitamin A can be found in animal and plant foods. The animal food sources are better absorbed and used by the body than the plant sources. There are also many foods that are fortified and enriched with vitamin A.

The content of vitamin A in animal and plant foods (from beta-carotene):

Food Amount Vitamin A
Apricot nectar, canned ½ cup 1,651 IU
Cantaloupe 1 cup cube 5,411 IU
Carrot juice, canned ½ cup 22,567 IU
Carrots, boiled ½ cup slices 13,418 IU
Carrots, raw 1 - 7 ½ inches 8,666 IU
Cheese, cheddar 1 oz 249 IU
Kale, frozen, boiled ½ cup 9,558 IU
Liver, beef, cooked 3 oz 27,185 IU
Liver, chicken, cooked 3 oz 12,325 IU
Milk, fortified skim 1 cup 500 IU
Oatmeal, instant, fortified 1 cup 1,252 IU
Papaya 1 cup cubed 1,532 IU
Peach 1 medium 319 IU
Peas, frozen, boiled ½ cup 1,050 IU
Pepper, red, raw 1 ring 313 IU
Spinach, frozen, boiled ½ cup 11,458 IU
Spinach, raw 1 cup 2,813 IU
Vegetable soup, canned 1 cup 5,820 IU


You can find more sources at http://www.nal.usda.gov/fnic/foodcomp/Data/SR20/nutrlist/sr20a320.pdf.

Do I need to take a vitamin A supplement?

Vitamin A is stored in the liver, so there is a supply that can be used during short-term periods when intake is not adequate to meet your needs. People with medical conditions that interfere with the absorption of vitamin A may need to take a supplement. These conditions include celiac disease, Crohn's disease, inflammatory bowel disease, and pancreatic disorders. Because vitamin A can be toxic at high levels, it's best to discuss supplements with your physician.

What happens if I don't have enough vitamin A?

Early vitamin A deficiency leads to impaired night vision, and advanced vitamin A deficiency can lead to corneal ulcers, xerophthalamia (dry eye), scarring, night blindness or total blindness. In developing countries, vitamin A deficiency is an important cause of blindness among children. Children with vitamin A deficiency are also more likely to develop diarrhea and respiratory infections than children who are not vitamin A deficient. Vitamin A deficiency is rare among healthy adults in the United States.

Vitamin A deficiency can also be a problem for people with Crohn's disease, celiac disease, pancreatic disorders, and people who do not consume animal foods.

Is there such a thing as too much vitamin A?

When excess amounts of vitamin A are being stored in your body, the condition is called hypervitaminosis A. The harmful effects of hypervitaminosis A are birth defects, reduced bone density that may result in osteoporosis, central nervous system disorders, and liver abnormalities.

Acute vitamin A toxicity may result from consuming very large quantities of vitamin A over a short period of time. The symptoms are nausea, vomiting, irritability, drowsiness, altered mental status, anorexia, abdominal pain, blurred vision, muscle pain with weakness, and/or headache. Elderly people and people who drink alcohol heavily are more susceptible to vitamin A toxicity.

The Institute of Medicine states that "beta-carotene supplements are not advisable for the general population," although they also state that this advice "does not pertain to the possible use of supplemental beta-carotene as a provitamin A source for the prevention of vitamin A deficiency in populations with inadequate vitamin A."

The Tolerable Upper Limit (UL) for vitamin A is:

Age Males and Females Pregnancy Lactation
0 to 1 year 2,000 IU N/A N/A
1 to 3 years 2,000 IU N/A N/A
4 to 8 years 3,000 IU N/A N/A
9 to 13 years 5,610 IU N/A N/A
14 to 18 years 9,240 IU 9,240 IU 9,240 IU
19+ years 10,000 IU 10,000 IU 10,000 IU


In the ATBC trial, subjects given beta-carotene had a higher incidence of lung cancer than subjects not given beta-carotene. The Institute of Medicine did not set ULs for carotene or carotenoids. However, the recommendation is that beta-carotene supplements are not advisable for the general population.

Vitamin C

What is it, and what does it do?

Vitamin C, also known as ascorbic acid, is a water-soluble antioxidant vitamin. Vitamin C is required for the synthesis of collagen and dentin. Collagen is the structural component of blood vessels, bones, ligaments, and tendons, while dentin is the structural component of teeth. Vitamin C is also an effective antioxidant that protects proteins and genetic materials (RNA and DNA) from damage by free radicals. Vitamin C cannot be made or stored by your body, so it's important to consume a well-balanced diet containing vitamin C.

 

How much do I need to consume?

There is insufficient information to establish an RDA for vitamin C for infants. In this case, an Adequate Intake (AI) has been established:

Age Males and Females
0 to 6 months 40 mg/day
7 to 12 months 50 mg/day


The Recommended Dietary Allowance (RDA) for vitamin C is:

Age Males Females Pregnancy Lactation
1 to 3 years 15 mg 15 mg N/A N/A
4 to 8 years 25 mg 25 mg N/A N/A
9 to 13 years 45 mg 45 mg N/A N/A
14 to 18 years 75 mg 65 mg 80 mg 115 mg
19 + years 90 mg/day 75 mg/day 85 mg/day 120 mg/day

 

What are sources of vitamin C?

All fruits and vegetables contain some amount of vitamin C, so consuming a well-balanced diet with plenty of fruits and vegetables is the key.

 

Food Amount Vitamin C
Broccoli, cooked ½ cup 37 mg
Broccoli, raw ½ cup 39 mg
Brussels sprouts, cooked ½ cup 48 mg
Cantaloupe ¼ medium 47 mg
Cauliflower, cooked ½ cup 28 mg
Grapefruit juice ¾ cup 50 mg-70 mg
Green pepper, cooked ½ cup 51 mg
Green pepper, raw ½ cup 60 mg
Guava, raw ½ cup 188 mg
Kale, cooked ½ cup 27 mg
Kiwi 1 medium 70 mg
Mango ½ cup 23 mg
Orange 1 medium 70 mg
Orange juice ¾ cup 61 mg-93 mg
Papaya ¼ medium 47 mg
Pineapple, raw ½ cup 28 mg
Pod peas, cooked ½ cup 38 mg
Red sweet pepper, cooked ½ cup 116 mg
Red sweet pepper, raw ½ cup 142 mg
Strawberries ½ cup 49 mg
Sweet potato, canned ½ cup 34 mg
Tomato juice ¾ cup 33 mg
Vegetable juice ¾ cup 50 mg


You can find more sources at http://www.nal.usda.gov/fnic/foodcomp/Data/SR20/nutrlist/sr20a401.pdf.

Do I need to take a vitamin C supplement?

Many people believe that taking vitamin C will help prevent colds. Research has not shown this to be the case. More than 30 clinical trials that included over 10,000 participants have not found any relationship between vitamin C and a reduced risk of colds. There has been a small reduction in the duration of colds, so paying attention to your vitamin C intake once you have the cold is advisable.

Research has shown that vitamin C enhances the absorption of iron. For this reason, anyone who needs an iron supplement is usually advised to take it with a food that is high in vitamin C or with a vitamin C supplement. Iron can be toxic at high levels, so speak with your doctor before taking any supplements.

There is an increased need for vitamin C for individuals who smoke. There is an additional 35 mg/day requirement for smokers versus nonsmokers. This can be achieved with dietary sources or a supplement.

What happens if I don't have enough vitamin C?

Scurvy is a severe deficiency of vitamin C. It would be uncommon for most of us, but it can be found in someone who is malnourished. Less severe deficiencies can occur. Not consuming an adequate amount of vitamin C can lead to symptoms, including feeling weak, tired, and irritable, having dry and splitting hair, bleeding gums, rough, dry, and scaly skin, gingivitis, easy bruising, anemia, and a decreased ability to fight infection.

Is there such a thing as too much vitamin C?

Vitamin C is generally safe. Large doses of vitamin C may cause stomach upset and diarrhea in adults and have been reported to cause kidney stones. There is also a risk of excess iron absorption with high doses of vitamin C.

Vitamin B12

What is it, and what does it do?

Vitamin B12 is needed for producing and maintaining new cells, including nerve cells and red blood cells. It is also needed to help make DNA.

Vitamin B12 is bound to the proteins in food. Once you consume B12, the hydrochloric acid in your stomach releases the B12 from the protein. B12 then combines with a substance called intrinsic factor to be absorbed by the intestines.

 

How much do I need to consume?

There is insufficient information to establish an RDA for vitamin B12 for infants. In this case, an Adequate Intake (AI) has been established:

Age Males and Females
0 to 6 months 0.4 mcg/day
7 to 12 months 0.5 mcg/day



The Recommended Dietary Allowance (RDA) for vitamin B12 is:

Age Males and Females Pregnancy Lactation
1 to 3 years 0.9 mcg N/A N/A
4 to 8 years 1.2 mcg N/A N/A
9 to 13 years 1.8 mcg N/A N/A
14 to 19 years 2.4 mcg 2.6 mcg 2.8 mcg
19+ years 2.4 mcg/day 2.6 mcg/day 2.8 mcg/day

 

What are sources of vitamin B12?

Vitamin B12 is attached to the proteins in animal foods. Breakfast cereals are fortified with vitamin B12, which is very important for people who do not consume an adequate amount of animal foods.

Food Amount Vitamin B12
Beef, top sirloin, lean, choice, broiled 3 oz 2.4 mcg
Breakfast cereals, fortified ¾ cup 6 mcg
Chicken, breast, cooked ½ breast 0.3 mcg
Egg 1 large 0.6 mcg
Haddock, cooked 3 oz 1.2 mcg
Liver, beef 1 slice 47.9 mcg
Milk 1 cup 0.9 mcg
Mollusks, clam 3 oz 84.1 mcg
Salmon, sockeye, cooked 3 oz 4.9 mcg
Trout, rainbow, farmed, cooked 3 oz 4.2 mcg
Trout, rainbow, wild, cooked 3 oz 5.4 mcg
Tuna, white, canned in water 3 oz 1.0 mcg
Yogurt, plain, skim 1 cup 1.4 mcg



You can find more sources at http://www.nal.usda.gov/fnic/foodcomp/Data/SR20/nutrlist/sr20a418.pdf.

Do I need to take a vitamin B12 supplement?

Studies reveal that the majority of Americans consume an adequate amount of vitamin B12. People who do not consume meat or who have a stomach or intestinal disorder that interferes with absorption may need to take a vitamin B12 supplement. Older adults may have atrophic gastritis and may need to consume additional food sources and/or supplements. There are also some medications that can influence vitamin B12 absorption, including H2 receptor antagonists used to treat peptic ulcers, metformin, and proton pump inhibitors. Your doctor can determine your vitamin B12 levels with a blood test.

What happens if I don't have enough vitamin B12?

An inadequate amount of vitamin B12 can cause pernicious anemia. Signs of vitamin B12 deficiency are fatigue, constipation, weakness, loss of appetite, weight loss, and numbness and tingling in the hands and feet. You may also experience a difficulty in maintaining balance, confusion, dementia, depression, and poor memory. An excess intake of folate can mask the symptoms of B12 deficiency, so it's important to have your levels checked with blood tests if there is a concern, especially if you consume a vegetarian diet.

Is there such a thing as too much vitamin B12?

Currently, there is no Tolerable Upper Limit set for vitamin B12. This does not mean that consuming excessive amounts will provide any additional health benefits. It means that there is a very low potential for toxicity at high levels. The RDA was set for optimal health, so it's best to stick with those recommendations.

Vitamin B6

What is vitamin B6, and what does it do?

Vitamin B6 is one of the water-soluble B vitamins. It comes in three forms: pyridoxine, pyridoxal, and pyridoxamine. It serves numerous functions in your body, including

  • red blood cell metabolism,
  • making hemoglobin,
  • assisting in the proper functioning of the nervous system,
  • assisting in the proper functioning of the immune system,
  • protein metabolism, and
  • synthesis of serotonin and norepinephrine.

How much vitamin B6 do I need to consume?

The Recommended Dietary Allowance (RDA) for vitamin B6 is:

Age Males Females Pregnancy Lactation
1 to 3 yrs 0.5 mg 0.5 mg N/A N/A
4 to 8 yrs 0.6 mg 0.6 mg N/A N/A
9 to 13 yrs 1.0 mg 1.0 mg N/A N/A
14 to 18 yrs 1.3 mg 1.2 mg 1.9 mg 2.0 mg
19 to 50 yrs 1.3 mg 1.3 mg 1.9 mg 2.0 mg
51+ yrs 1.7 mg 1.5 mg N/A N/A



There is insufficient information to establish an RDA for vitamin B6 for infants. In this case, an Adequate Intake (AI) has been established:

Age Males and Females
0 to 6 months 0.1 mg/day
7 to 12 months 0.3 mg/day



What are sources of vitamin B6?

Vitamin B6 is found naturally in many foods and can also be found in foods that are fortified with it:

Food Amount Vitamin B6
Avocado, raw, California 1 oz 0.08 mg
Banana 1 medium 0.43 mg
Cereal, 100% fortified ¾ cup 2 mg
Chicken breast, meat only 3 oz 0.52 mg
Garbanzo beans ½ cup 0.51 mg
Lima beans, frozen, cooked ½ cup 0.10 mg
Oatmeal, instant, fortified 1 packet 0.42 mg
Peanut butter, smooth 1 tablespoon 0.09 mg
Pistachio nuts, dry roasted 1 oz (47 nuts) 0.36 mg
Pork loin, cooked 3 oz 0.42 mg
Potato, with skin 1 medium 0.47 mg
Roast beef, eye of round, cooked 3 oz 0.42 mg
Salmon, Sockeye, cooked 3 oz 0.19 mg
Soybeans, green ½ cup 0.05 mg
Spinach, frozen, cooked ½ cup 0.14 mg
Sunflower seeds, kernels 1 oz 0.23 mg
Tomato juice, canned 8 oz 0.27 mg
Trout, rainbow, cooked 3 oz 0.29 mg
Tuna, canned in water 3 oz 0.18 mg
Walnuts, English/Persian 1 oz 0.15 mg
Wheat bran ¼ cup 0.18 mg
Yogurt, plain, skim milk 8 oz 0.12 mg


Do I need to take a vitamin B6 supplement?

Vitamin B6 is available as pyridoxine hydrochloride in supplements. The requirements for vitamin B6 can easily be met with a well-balanced diet. When your diet is limited in variety, you may need to take a supplement. Older adults and alcoholics are people whose diets may be lacking and require supplementation. Studies have shown that supplementing with large doses of vitamin B6 can increase the immune response in critically ill patients.

What happens if I don't have enough vitamin B6?

In the early 1950s, an error in the manufacturing of baby formula lead to vitamin B6 deficiencies and caused seizures in the infants who were deficient in it. Other symptoms of vitamin B6 deficiency are depression, confusion, sores or ulcers on the mouth, ulcers at the corners of the mouth, confusion, and irritability.

Is there such a thing as too much vitamin B6?

There are no documented health problems associated with consuming vitamin B6 from food sources. There have been problems associated with excess supplementation of vitamin B6. Large doses, above 1,000 mg/day, have been shown to cause sensory neuropathy. Symptoms of this include difficulty walking and pain and numbness of the extremities. There have even been some reported cases of this with doses under 500 mg/day. Even though this is a water-soluble vitamin, limits had to be set on how much can be safely consumed.

The Tolerable Upper Limit (UL) for vitamin B6 was set for the general population:

Age Males and Females
1 to 3 years 30 mg/day
4 to 8 years 40 mg/day
9 to 13 years 60 mg
14 to 18 years 80 mg
19+ years 100 mg

Thiamin

What is thiamin, and what does it do?

Thiamin is another one of the water-soluble B vitamins. It was previously known as vitamin B1 or aneurine and can also be spelled thiamine. Thiamin is involved in numerous functions:

  • metabolism of carbohydrates,
  • nervous system functioning,
  • producing hydrochloric acid,
  • muscle functioning,
  • flow of electrolytes in and out cells, and
  • multiple enzyme processes.

How much thiamin do I need to consume?

The Recommended Dietary Allowance for thiamin is:

Age Males Females Pregnancy Lactation
1 to 3 yrs 0.5 mg 0.5 mg
4 to 8 yrs 0.6 mg 0.6 mg
9 to 13 yrs 0.9 mg 0.9 mg
14 to 18 yrs 1.2 mg 1.0 mg
19+ years 1.2 mg 1.1 mg
All Ages 1.4 mg 1.4 mg



There is insufficient information to establish an RDA for thiamin for infants. In this case, an Adequate Intake (AI) has been established:

Age Males and Females
0 to 6 months 0.2 mg
7 to 12 months 0.3 mg



What are sources of thiamin?

Food Amount Thiamin Content
Beans, black, cooked 1 cup 0.42 mg
Bread, white, enriched 1 slice 0.11 mg
Bread, whole wheat 1 slice 0.10 mg
Cantaloupe ½ fresh 0.11 mg
Carrot juice, canned 1 cup 0.217 mg
Cereal, fortified 1 cup 0.5 mg-4.0 mg
Cereal, wheat germ 1 cup 4.47 mg
Egg, whole 1 large 0.03 mg
Lentils, cooked ½ cup 0.17 mg
Long grain brown rice, cooked 1 cup 0.19 mg
Long grain white rice, enriched, cooked 1 cup 1.06 mg
Long grain, white rice, not enriched, cooked 1 cup 0.25 mg
Milk 1 cup 0.10 mg
Nuts, Brazil 1 oz (6-8) 0.18 mg
Nuts, pecans 1 oz (20 halves) 0.19 mg
Orange 1 medium 0.10 mg
Peas, cooked ½ cup 0.21 mg
Pecans 1 oz 0.19 mg
Pork, cooked 3 oz 0.72 mg
Spinach, cooked ½ cup 0.09 mg


For more sources go to http://www.nal.usda.gov/fnic/foodcomp/Data/SR20/nutrlist/sr20a404.pdf.

Do I need to take a thiamin supplement?

Your body can run out of the small amount of thiamin that it can store in only 14 days, so you need to consume it on a consistent basis. Thiamin deficiency has been seen in people taking strong diuretics and in alcoholics. Thiamin can also be lost during cooking. One study determined the amount lost based on the source of thiamin and cooking method and found

  • 20%-35% lost in water that is discarded after cooking vegetables,
  • 43% loss in pork loin that is roasted (three times as much as lost during braising),
  • 15% loss in bread that is baked, and
  • no loss in double broiler cooking of whole grain cereals.

Thiamin can be in the form of thiamin hydrochloride and thiamin mononitrate in multivitamins, B complex vitamins, or individual supplements.

What happens if I don't have enough thiamin?

Thiamin was one of the first vitamins to be discovered. A deficiency in thiamin can cause weakness, fatigue, nerve damage, and psychosis. Beriberi is the disease that is caused by a severe thiamin deficiency. Beriberi is categorized as wet, dry, or cerebral, depending on the systems that it affects. Wernicke-Korsakoff syndrome can also be caused by a severe thiamin deficiency. Brain damage can occur as a result of this.

Is there such a thing as too much thiamin?

Thiamin is safe enough that no tolerable upper limit (UL) has been established for it. There are no health benefits from extremely high supplementation, so there is no need to take excessive quantities.

Niacin

What is niacin, and what does it do?

Niacin is a water-soluble B vitamin that is also known as vitamin B3, nicotinamide, or nicotinic acid. Niacin assists in the proper functioning of the nervous and digestive system, maintaining healthy skin, and conversion of food to energy.

How much niacin do I need to consume?

There is insufficient information to establish an RDA for niacin for infants. In this case, an Adequate Intake (AI) has been established:

Age Males and Females
0 to 6 months 2 mg
7 to 12 months 4 mg



The Recommended Dietary Allowance (RDA) for niacin is:

Age Males Females Pregnancy Lactation
1 to 3 years 6 mg 6 mg N/A N/A
4 to 8 years 8 mg 8 mg N/A N/A
9 to 13 years 12 mg 12 mg N/A N/A
14 to 18 years 16 mg 14 mg 18 mg 17 mg
19+ years 16 mg 14 mg 18 mg 17 mg


What are sources of niacin?

Niacin is found in animal products, nuts, green vegetables, legumes, and enriched and fortified cereals.

Food Amount Niacin Content
Bagel 4" 3.06 mg
Barley, pearled, cooked 1 cup 3.24 mg
Beans, kidney, red, boiled 1 cup 1.02 mg
Beef, eye of round, roasted 3 oz 5.24 mg
Bread, rye 1 slice 1.22 mg
Carrots, cooked 1 cup 1.01 mg
Cereal, fortified 1 cup 5.00 mg
Ham, sliced, extra lean 2 slices 2.23 mg
Mango, raw 1 mango 1.21 mg
Milk, nonfat 1 cup 0.23 mg
Peanut butter, smooth 1 tablespoon 2.14 mg
Peas, frozen, cooked 1 cup 2.37 mg
Potato, no skin 1 cup 2.05 mg
Rice, brown, long-grain, cooked 1 cup 2.98 mg
Soybeans, cooked 1 cup 2.25 mg
Tomato, canned, sauce 1 cup 2.39 mg



For more sources go to http://www.nal.usda.gov/fnic/foodcomp/Data/SR20/nutrlist/sr20a406.pdf.

Do I need to take a niacin supplement?

A well-balanced diet can provide enough niacin to reach your needs. When you have a medical need, a deficiency, or an inadequate diet, you should consult with your physician before taking a niacin supplement. High doses must be prescribed by a physician since niacin can be used as a drug (see below). Niacin supplements come in several forms: niacin, inositol hexaniacinate, and niacinamide

What happens if I don't have enough niacin?

Niacin was discovered in low-income populations where corn products were the primary source of calories, and the disease pellagra was occurring. The symptoms of pellagra are known as the four Ds: dermatitis, diarrhea, dementia, and death. Pellagra occurs at the late stage of niacin deficiency. Niacin deficiency symptoms will involve the digestive system (diarrhea, vomiting, and bright red tongue), the skin (thick, scaly skin and dark pigmented rash that develops symmetrically in areas exposed to sunlight), and the nervous system (fatigue, depression, headache, apathy, disorientation, and memory loss).

Is there such a thing as too much niacin?

Doses much higher than the ULs are used medically to improve cholesterol levels. High doses of niacin can cause dangerous liver inflammation, peptic ulcers, and skin rashes. "Niacin flushing" is a side effect that causes redness, itching, and burning and can occur within 10 to 15 minutes after taking it and can last up to one hour. Research has shown that there are conditions that make people susceptible to these symptoms, including diabetes mellitus, gout, cardiac arrhythmias, hepatic dysfunction or a history of liver disease, migraine headaches, alcoholism, and inflammatory bowel disease. These conditions may not be protected by the UL that has been set for the general population, so extreme caution needs to be used when taking niacin supplements. For everyone, the only time that high doses of niacin should be taken would be under the supervision of your physician.

The Tolerable Upper Limit (UL) for niacin is:

Age Males and Females Pregnancy Lactation
1 to 3 years 10 mg/day N/A N/A
4 to 8 years 15 mg/day N/A N/A
9 to 13 years 20 mg/day N/A N/A
14 to 18 years 30 mg/day 30 mg/day 30 mg/day
19+ years 30 mg/day 35 mg/day 35 mg/day

Riboflavin

What is riboflavin, and what does it do?

Riboflavin is one of the water-soluble B vitamins and is also known as vitamin B2. It is needed for converting food to energy, works as an antioxidant by scavenging damaging free radicals, and is needed to convert vitamin B6 and folate into active forms.

How much riboflavin do I need to consume?

There is insufficient information to establish an RDA for vitamin riboflavin for infants. In this case, an Adequate Intake (AI) has been established:

Age Males and Females
0 to 6 months 0.3 mg
7 to 12 months 0.4 mg



The Recommended Dietary Allowance (RDA) for riboflavin is:

Age
Males
Females
Pregnancy
Lactation
1 to 3 years 0.5 mg 0.5 mg N/A N/A
4 to 8 years 0.6 mg 0.6 mg N/A N/A
9 to 13 years 0.9 mg 0.9 mg N/A N/A
14 to 18 years 1.3 mg 1.0 mg 1.4 mg 1.6 mg
19 + years 1.3 mg 1.1 mg 1.4 mg 1.6 mg


What are sources of riboflavin?

Though riboflavin can be found in most animal and plant foods, it is destroyed by light, so these foods need to be stored away from light to protect it. It can be lost in the water if foods are boiled or soaked, so avoid doing this or consume the water along with the food (for example, soup).

Food Amount Riboflavin Content
Asparagus, cooked 4 spears 0.08 mg
Broccoli, cooked 1 cup 0.15 mg
Cereal, fortified 1 cup 0.42 mg
Egg, cooked 1 large 0.24 mg
Milk, nonfat 1 cup 0.45 mg
Nuts, cashews, dry roasted 1 oz 0.06 mg
Peaches, raw 1 cup 0.05 mg
Peas, frozen, cooked 1 cup 0.16 mg
Raisins seedless 1 cup 0.18 mg
Spaghetti, cooked, enriched 1 cup 0.19 mg
Spinach, cooked 1 cup 0.43 mg



For more sources go to http://www.nal.usda.gov/fnic/foodcomp/Data/SR20/nutrlist/sr20a405.pdf.

Do I need to take a riboflavin supplement?

A well-balanced diet can provide enough riboflavin to reach your RDA. When your diet is limited in variety or you have a medical condition that interferes with the absorption of riboflavin, you may need a supplement. The most common forms of riboflavin found in supplements are riboflavin 5-monophosphate and riboflavin. These can be purchased alone, in a multivitamin, or in a B complex supplement.

What happens if I don't have enough riboflavin?

Riboflavin deficiency can occur from not consuming enough in your diet and from conditions that decrease the amount absorbed, including malabsorption syndromes, chronic diarrhea, long-term use of barbiturates, peritoneal dialysis, and alcoholism. Ariboflavinosis is caused by riboflavin deficiency. The symptoms include fatigue, cracks and sores around the corners of the mouth (angular stomatitis/cheilosis), eye fatigue, swollen magenta tongue (glossitis), skin irritation (dermatitis), soreness and swelling of the throat, sensitivity to light, and eye fatigue.

Is there such a thing as too much riboflavin?

No Tolerable Upper Limit (UL) has been set for riboflavin. Possible reactions to very high doses include burning/prickling sensations, itching, numbness, and yellow discoloration of the urine. There is also a possibility that riboflavin's photosensitizing (sensitivity to light) properties can pose health risks.

Vitamin K

What is vitamin K, and what does it do?

Vitamin K is a fat-soluble vitamin known for its role in blood clotting. There are three main types of vitamin K: vitamin K1 (phytonadione) if the natural form found in plants; vitamin K2 (menaquinones) is made by the human gut; and vitamin K3 (menadione) is the water-soluble form that is made for use in supplements.

People taking the blood-thinning medication warfarin (Coumadin) are at an increased risk for blood clotting. Warfarin works by decreasing the activity of vitamin K, lengthening the time it takes for a clot to form. The goal for vitamin K intake while taking warfarin is to keep your intake constant. This does not mean that you can't consume any vitamin K-containing foods. Instead, you want to consume a consistent amount so that the dose of warfarin that you are taking is working on the same amount. Sudden increases and/or decreases in vitamin K while taking warfarin can cause problems.

How much vitamin K do I need to consume?

There is no data to establish RDAs for vitamin K. Therefore, Adequate Intakes (AI) have been established:

Age Males Females Pregnancy Lactation
0 to 6 months 2.0 mcg 2.0 mcg N/A N/A
7 to 12 months 2.5 mcg 2.5 mcg N/A N/A
1 to 3 years 30 mcg 30 mcg N/A N/A
4 to 8 years 55 mcg 55 mcg N/A N/A
9 to 13 years 60 mcg 60 mcg N/A N/A
14 to 18 years 75 mcg 75 mcg 75 mcg 75 mcg
19+ years 120 mcg 90 mcg 90 mcg 90 mcg



What are sources of vitamin K?

Vitamin K is found primarily in green leafy vegetables and fruit. It can also be found in some animal foods.

Food Amount Vitamin K Content
Banana 1 medium 0.6 mcg
Beans, kidney, red, cooked 1 cup 14.9 mcg
Blueberries, raw 1 cup 28 mcg
Broccoli, raw 1 cup 89.4 mcg
Brussels sprouts, frozen, cooked 1 cup 299.9 mcg
Cabbage, cooked, boiled 1 cup 163.1 mcg
Carrot juice, canned 1 cup 36.6 mcg
Collards, frozen, chopped, cooked 1 cup 1,059 mcg
Dandelion greens, cooked 1 cup 579.0 mcg
Endive, raw 1 cup 115.5 mcg
Kale, frozen, cooked 1 cup 1,146.6 mcg
Lettuce, green leaf, raw 1 cup 97.2 mcg
Mustard greens, cooked 1 cup 419.3 mcg
Onions, spring or scallion 1 cup 207.0 mcg
Spinach, frozen, cooked 1 cup 1,027.3 mcg
Turnip greens, frozen, cooked 1 cup 851.0 mcg



For more sources go to http://www.nal.usda.gov/fnic/foodcomp/Data/SR20/nutrlist/sr20a430.pdf.

Do I need to take a vitamin K supplement?

A well-balanced diet can provide an adequate amount of vitamin K. There are conditions that can interfere with the absorption of vitamin K, including celiac disease, ulcerative colitis, cystic fibrosis, biliary obstruction, regional enteritis, or intestinal resection. Medications that alter your liver function or kill the intestinal flora can also negatively impact your vitamin K levels. These medications include antibiotics, antiseizure medications, salicylates, and some sulfa drugs.

What happens if I don't have enough vitamin K?

Vitamin K is needed by the liver to make factors that are necessary for blood to clot properly. A deficiency in vitamin K can lead to defective blood clotting and increased bleeding.

Is there such a thing as too much vitamin K?

The Tolerable Upper Limit (UL) for vitamin K has not been established. Amounts exceeding 1,000 times the AI can promote formation of blood clots (thrombogenesis), breakdown of red blood cells (hemolysis), and raise the risk of jaundice.

Hypercalcemia
(Elevated Calcium Levels)

 

View Birth Control Slideshow Pictures
Take the Blood and Bleeding Disorders Quiz! Take the Blood and Bleeding Disorders Quiz!

 

  • Hypercalcemia Introduction
  • What are the causes of hypercalcemia?
  • What are the signs and symptoms of hypercalcemia?
  • How is hypercalcemia diagnosed?
  • How is hypercalcemia treated?
  • What is the prognosis for hypercalcemia?
  • Can hypercalcemia be prevented?
  • Hypercalcemia At A Glance
  • Related hypercalcemia article:
    Hypercalcemia (Elevated Calcium Levels) - on eMedicineHealth
  • Patient Discussions: Hypercalcemia - Describe Your Experience

Hypercalcemia Introduction

Calcium is a mineral that is important in the regulation and processes of many body functions including bone formation, hormone release, muscle contraction, and nerve and brain function. Hypercalcemia is the term that refers to elevated levels of calcium in the bloodstream.

Regulation of Calcium

Calcium levels are tightly regulated in the body. Calcium regulation is primarily controlled by parathyroid hormone (PTH), vitamin D, and calcitonin.

  • Parathyroid hormone is a hormone produced by the parathyroid glands, which are four small glands that surround the thyroid and are found in the anterior part of the lower neck.
  • Vitamin D is obtained through a process that begins with sun exposure to the skin, the process then continues in the liver and kidneys. Vitamin D can also be found in foods such as eggs and dairy products.
  • Calcitonin is produced in specialized cells in the thyroid gland.

Together, these three hormones act on the bones, the kidneys, and the GI tract to regulate calcium levels in the bloodstream.

Picture of the Parathyroid Glands

 

What are the causes of hypercalcemia?

One of the most common causes of high calcium levels (hypercalcemia), is an overproduction of parathyroid hormone, or hyperparathyroidism.

  • Hyperparathyroidism occurs in 25 out of every 100,000 persons and tends to be more common in women.
  • It can be the result of all four parathyroid glands producing too much PTH (parathyroid hyperplasia), or one gland specifically producing an excessive amount of hormone (usually the result of a parathyroid adenoma, or benign tumor).

Hypercalcemia can occur due to other medical conditions. These conditions can vary in severity and chronicity, and may be life-threatening. Malignancy is a common cause of elevated blood calcium. Up to 20% of individuals with cancer will develop hypercalcemia at some point in their disease.

Other conditions associated with hypercalcemia include:

  • Cancers, especially lung cancer and breast cancer
  • Immobilization over a long period of time
  • Kidney failure
  • Overactive thyroid (hyperthyroidism) or excessive thyroid hormone intake
  • Use of certain medications such as the thiazide diuretics
  • Inherited kidney or metabolic conditions
  • Excessive vitamin D levels from vitamins, excessive dietary calcium, or from diseases that may result in excess vitamin D production

What are the signs and symptoms of hypercalcemia?

In the majority of patients with hypercalcemia, the signs and symptoms are minimal. In general, the symptoms increase with higher levels of calcium in the blood. In severe cases, the elevated calcium levels can cause abnormal heart rhythms with specific findings on electrocardiogram (EKG).

Because of the clinical findings that are seen in hypercalcemia, the symptoms are often described as "moans, stones, groans, and bones".

Some of the symptoms include the following:

Moans (gastrointestinal conditions)

  • Constipation
  • Nausea
  • Decreased appetite
  • Abdominal pain
  • Peptic ulcer disease

Stones (kidney-related conditions)

  • Kidney stones
  • Flank pain
  • Frequent urination

Groans (psychological conditions)

  • Confusion
  • Dementia
  • Memory loss
  • Depression

Bones (bone pain and bone-related conditions)

  • Bone aches and pains
  • Fractures
  • Curving of the spine and loss of height

How is hypercalcemia diagnosed?

Hypercalcemia is easily diagnosed with a blood test. Diagnosing the causes of hypercalcemia, however, is a more involved process; in addition to a detailed history and physical examination, it may require further blood tests (such as a PTH level and vitamin D level), urine evaluation, X-rays, and other imaging procedures.

How is hypercalcemia treated?

The treatment of elevated levels of calcium in the blood involves the evaluation of the following:

  1. Is the level of calcium elevated enough to be dangerous, or is it causing symptoms?
  2. What is the underlying cause of the hypercalcemia, and does it need treatment?

If the hypercalcemia is causing severe symptoms, or if the values are critically high, lowering the blood levels may require hospitalization and the use of hydration, steroids, or even dialysis. There are intravenous medications that can be used to lower calcium as well.

If the hypercalcemia is modest, treatment with medications can be administered on an outpatient basis.

If the underlying cause is hyperparathyroidism (particularly from an adenoma), there are certain criteria that are reviewed to discuss if surgery should be considered. These criteria include the absolute calcium level, a history of kidney stones or other calcium-related complications, and the amount of calcium seen in a 24-hour urine collection. Based on these findings, surgical removal of the adenoma may be considered.

What is the prognosis for hypercalcemia?

The results of treatment for hypercalcemia depend on the underlying cause of the condition. If hypercalcemia is seen in the presence of cancer, the average one year survival rate is less than 30%. The prognosis is excellent for many of the other causes of hypercalcemia provided the underlying cause is addressed and treated.

Can hypercalcemia be prevented?

Hypercalcemia cannot be prevented, but early detection can both allow for normalization of calcium levels and lead to an early work-up to define the cause. If there is a known family history of hypercalcemia or hyperparathyroidism, it is worth mentioning this to the health care practitioner; together the patient and health care practitioner can determine if screening is warranted.

Hypercalcemia at a glance
  • Calcium is important for bone strength, as well as muscle and nerve function
  • Calcium levels in the bloodstream are regulated by PTH, vitamin D, and calcitonin
  • Hypercalcemia can vary in severity and in chronicity
  • The main cause of hypercalcemia is hyperparathyroidism
  • Malignancies may be associated with hypercalcemia, and the presence of hypercalcemia usually heralds a worse prognosis
  • The signs and symptoms of hypercalcemia can be remembered by the phrase "moans, stones, groans, and bones."
  • Treatment depends on the underlying cause of hypercalcemia as well as the degree of severity
  • Both surgical and medical treatments are available as treatment options
  • Prognosis depends on the underlying cause of hypercalcemia

Pregnancy: Trying to Conceive

 

View Stages of Pregnancy Slideshow Pictures

 

Stages of Pregnancy Slideshow Pictures Pregnancy Stages Slideshow Pictures
Early Pregnancy Symptoms Early Pregnancy Symptoms
Take the Quiz: Early Pregnancy Symptoms Test Your Medical IQ: Take the Early Pregnancy Symptoms Quiz

How do you figure out when you're fertile and when you're not? Wondering if you or your partner is infertile? Read on to boost your chances of conception and get help for fertility problems.

  • Fertility Awareness
  • Charting your fertility pattern
  • Basal body temperature method
  • Calendar method
  • Cervical mucus method
  • Infertility
  • Reasons for infertility
  • Age
  • Health Problems
  • Treating infertility
  • Tests
  • Drugs and surgery
  • Counseling and support groups
  • Find a local Obstetrician-Gynecologist in your town

Fertility Awareness

The Menstrual Cycle

Being aware of your menstrual cycle and the changes in your body that happen during this time can be key to helping you plan a pregnancy, or avoid pregnancy. During the menstrual cycle (a total average of 28 days), there are two parts: before ovulation and after ovulation.

  • Day 1 starts with the first day of your period.
  • Usually by Day 7, a woman's eggs start to prepare to be fertilized by sperm.
  • Between Day 7 and 11, the lining of the uterus (womb) starts to thicken, waiting for a fertilized egg to implant there.
  • Around Day 14 (in a 28-day cycle), hormones cause the egg that is most ripe to be released, a process called ovulation. The egg travels down the fallopian tube towards the uterus. If a sperm unites with the egg here, the egg will attach to the lining of the uterus, and pregnancy occurs.
  • If the egg is not fertilized, it will break apart.
  • Around Day 25 when hormone levels drop, it will be shed from the body with the lining of the uterus as a menstrual period.

The first part of the menstrual cycle is different in every woman, and even can be different from month-to-month in the same woman, varying from 13 to 20 days long. This is the most important part of the cycle to learn about, since this is when ovulation and pregnancy can occur. After ovulation, every woman (unless she has a health problem that affects her periods) will have a period within 14 to 16 days.

Charting Your Fertility Pattern

Knowing when you're most fertile will help you plan or prevent pregnancy. There are three ways you can keep track of your fertile times. They are:

Basal body temperature method

Basal body temperature is your temperature at rest as soon as you awake in the morning. A woman's basal body temperature rises slightly with ovulation. So by recording this temperature daily for several months you'll be able to predict your most fertile days.

Basal body temperature differs slightly from woman to woman. Anywhere from 96 to 98 degrees orally is average before ovulation. After ovulation most women have an oral temperature between 97 and 99 degrees. The rise in temperature can be a sudden jump or a gradual climb over a few days.

Usually a woman's basal body temperature rises by only 0.4 to 0.8 degrees Fahrenheit. To detect this tiny change, women must use a basal body thermometer. These thermometers are very sensitive. Most pharmacies sell them for around $10. You then record your temperature on a special chart.

The rise in temperature doesn't show exactly when the egg is released. But almost all women have ovulated within three days after their temperatures spike. Body temperature stays at the higher level until your period starts.

You are most fertile and most likely to get pregnant:

  • two to three days before your temperature hits the highest point (ovulation), and
  • 12 to 24 hours after ovulation.

A man's sperm can live for up to three days in a woman's body. The sperm can fertilize an egg at any point during that time. So if you have unprotected sex a few days before ovulation there is a chance of becoming pregnant.

Many things can affect basal body temperature. To get the most useful chart you should take your temperature every morning at about the same time. Things that can alter your temperature include:

  • drinking alcohol the night before
  • smoking cigarettes the night before
  • getting a poor night's sleep
  • having a fever
  • doing anything in the morning before you take your temperature -- including going to the bathroom and talking on the phone

Calendar method

This involves keeping a written record of each menstrual cycle on a calendar. The first day of your period is Day 1. Circle Day 1 on the calendar. Do this for eight to 12 months so you know how many days are in your cycle. The length of your cycle may vary from month to month. So write down the total number of days it lasts each time. To find out the first day when you are most fertile, check your list for the cycle with the fewest days. Then subtract 18 from that number. Take this new number and count ahead that many days on the calendar. Draw an X through this date. The X marks the first day you're likely to be fertile. To find out the last day when you are fertile, subtract 11 days from your longest cycle and draw an X through this date. This method always should be used with other fertility awareness methods, especially if your cycles are not always the same lengths.

Cervical mucus method (also known as the ovulation method)

This involves being aware of the changes in your cervical mucus throughout the month. The hormones that control the menstrual cycle also change the kind and amount of mucus you have before and during ovulation. Right after your period, there are usually few days when there is no mucus present or "dry days." As the egg starts to mature, mucus increases in the vagina, appears at the vaginal opening, and is white or yellow and cloudy and sticky. The greatest amount of mucus appears just before ovulation. During these "wet days" it becomes clear and slippery, like raw egg whites. Sometimes it can be stretched apart. This is when you are most fertile. About four days after the wet days begin the mucus changes again. There will be much less and it becomes sticky and cloudy. You might have a few more dry days before your period returns. Describe changes in your mucus on a calendar. Label the days, "Sticky," "Dry," or "Wet." You are most fertile at the first sign of wetness after your period or a day or two before wetness begins. This method is less reliable for some women. Women who are breastfeeding, taking hormonal contraceptives (like the pill) using feminine hygiene products, have vaginitis or sexually transmitted diseases (STDs), or have had surgery on the cervix should not rely on this method.

To most accurately track your fertility, use a combination of all three methods. This is called the symptothermal method.

Infertility

It is not uncommon to have trouble becoming pregnant or to experience infertility. Infertility is defined as not being able to become pregnant, despite trying for one year, in women under age 35, or after six months in women 35 and over. Pregnancy is the result of a chain of events. As described in the Fertility Awareness section above, a woman must release an egg from one of her ovaries (ovulation). The egg must travel through a fallopian tube toward her uterus. A man's sperm must join with (fertilize) the egg along the way. The fertilized egg must then become attached to the inside of the uterus. While this may seem simple, in fact many things can happen to prevent pregnancy.

Reasons for Infertility

Age

There are many different reasons why a couple might have infertility. One is age-related. Women today are often delaying having children until later in life, when they are in their 30s and 40s. A couple of things add to this trend. Birth control is easy to obtain and use, more women are in the work force, women are marrying at an older age, the divorce rate remains high, and married couples are delaying pregnancy until they are more financially secure. But the older you are, the harder it is to become pregnant. Women generally have some decrease in fertility starting in their early 30s. And while many women in their 30s and 40s have no problems getting pregnant, fertility especially declines after age 35.

As a woman ages, there are normal changes that occur in her ovaries and eggs. All women are born with over a million eggs in their ovaries (all the eggs that they will ever have), but only have about 300,000 left by puberty. Then of these, only about 300 eggs will be ovulated during the reproductive years. Even though menstrual cycles continue to be regular in a woman's 30s and 40s, the eggs that ovulate each month are of poorer quality than those from her 20s. It is harder to get pregnant when the eggs are poorer in quality.

Ovarian reserve is the number and quality of eggs in your ovaries and how well the ovarian follicles respond to hormones in your body. As you approach menopause, your ovaries don't respond as well to your hormones, and in time they may not release an egg each month. A reduced ovarian reserve is natural as a woman ages, but young women might have reduced ovarian reserves due to smoking, a prior surgery on their ovaries, or a family history of early menopause. Also, as a woman and her eggs age, if she becomes pregnant, there is a greater chance of having genetic problems, such as having a baby with Down Syndrome. Embryos formed from eggs in older women also are less likely to fully develop, a main reason for miscarriage (early pregnancy loss).

Health Problems

Couples also can have fertility problems because of health problems, in either the woman or the man. Common problems with a woman's reproductive organs, like uterine fibroids, endometriosis, and pelvic inflammatory disease can worsen with age and also affect fertility. These conditions might cause the fallopian tubes to be blocked, so the egg can't travel through the tubes into the uterus.

Some people also have diseases or conditions that affect their hormone levels, which can cause infertility in women and impotence and infertility in men. Polycystic Ovarian syndrome (PCOS) is one such hormonal condition that affects many women, and is the most common cause of anovulation, or when a woman rarely or never ovulates. Another hormonal condition that is a common cause of infertility is when a woman has a luteal phase defect (LPD). A luteal phase is the time in the menstrual cycle between ovulation and the start of the next menstrual period. LPD is a failure of the uterine lining to be fully prepared for a fertilized egg to implant there. This happens either because a woman's body is not producing enough progesterone, or the uterine lining isn't responding to progesterone levels at some point in the menstrual cycle. Since pregnancy depends on a fertilized egg implanting in the uterine lining, LPD can interfere with a woman getting pregnant and with carrying a pregnancy successfully.

Certain lifestyle choices also can have a negative effect on a woman's fertility, such as smoking, alcohol use, weighing much more or much less than an ideal body weight, a lot of strenuous exercise, and having an eating disorder.

Unlike women, some men remain fertile into their 60s and 70s. But as men age, they might begin to have problems with the shape and movement of their sperm, and have a slightly higher risk of sperm gene defects. They also might produce no sperm, or too few sperm. Lifestyle choices also can affect the number and quality of a man's sperm. Alcohol and drugs can temporarily reduce sperm quality. And researchers are looking at whether environmental toxins, such as pesticides and lead, also may be to blame for some cases of infertility. Men also can have health problems that affect their sexual and reproductive function. These can include sexually transmitted diseases (STDs), diabetes, surgery on the prostate gland, or a severe testicle injury or problem.

If you or your partner has a problem with sexual function or libido, don't delay seeing your doctor for help.

Treating Infertility

You should talk to your doctor about your fertility if you:

  • are under age 35 and, after a year of frequent sex without birth control, you are having problems getting pregnant, or
  • are age 35 or over and, after six months of frequent sex without birth control, you are having problems getting pregnant, or
  • believe you or your partner might have fertility problems in the future (even before you begin trying to get pregnant).

Your doctor can refer you to a fertility specialist, a doctor who focuses in treating infertility . This doctor can recommend treatments such as drugs, surgery, or assisted reproductive technology. Don't delay seeing your doctor because age also affects the success rates of these treatments.

There are many ways to treat infertility. They include the following.

Tests

The first step to treat infertility is to see a doctor for a fertility evaluation . He or she will test both the woman and the man, to find out where the problem is. Testing on the man focuses on the number and health of his sperm. The lab will look at a sample of his sperm under a microscope to check sperm number, shape, and movement. Blood tests also can be done to check hormone levels. More tests might be needed to look for infection, or problems with hormones. These tests can include:

  • an x-ray (to look at his reproductive organs)
  • a mucus penetrance test (to see if sperm can swim through mucus)
  • a hamster-egg penetrance assay (to see if sperm can go through hamster egg cells, somewhat showing their power to fertilize human eggs)

Testing for the woman first looks at whether she is ovulating each month. This can be done by having her chart changes in her morning body temperature, by using an FDA-approved home ovulation test kit (which she can buy at a drug store), or by looking at her cervical mucus, which changes throughout her menstrual cycle. Ovulation also can be checked in her doctor's office with an ultrasound test of the ovaries, or simple blood tests that check hormone levels, like the follicle-stimulating hormone (FSH) test. FSH is produced by the pituitary gland. In women, it helps control the menstrual cycle and the production of eggs by the ovaries. The amount of FSH varies throughout the menstrual cycle and is highest just before an egg is released. The amounts of FSH and other hormones (luteinizing hormone, estrogen, and progesterone) are measured in both a man and a woman to determine why the couple cannot achieve pregnancy. If the woman is ovulating, more testing will need to be done. These tests can include:

  • an hysterosalpingogram (an x-ray to check if the fallopian tubes are open and to show the shape of the uterus)
  • a laparoscopy (an exam of the tubes and other female organs for disease)
  • an endometrial biopsy (an exam of a small shred of the uterine lining to see if monthly changes in it are normal)

Other tests can be done to show whether the sperm and mucus are interacting in the right way, or if the man or woman is forming antibodies that are attacking the sperm and stopping them from getting to the egg.

Drugs and Surgery

Different treatments for infertility are recommended depending on what the problem is. About 90 percent of cases are treated with drugs or surgery. Various fertility drugs may be used for women with ovulation problems. It is important to talk with your doctor about the drug to be used. You should understand the drug's benefits and side effects. Depending on the type of fertility drug and the dosage of the drug used, multiple births (such as twins) can occur in some women. If needed, surgery can be done to repair damage to a woman's ovaries, fallopian tubes, or uterus. Sometimes a man has an infertility problem that can be corrected by surgery.

Assisted Reproductive Technology (ART)

Assisted reproductive technology (ART) uses special methods to help infertile couples, and involves handling both the woman's eggs and the man's sperm. Success rates vary and depend on many factors. But ART has made it possible for many couples to have children that otherwise would not have been conceived. ART can be expensive and time-consuming. Many health insurance companies do not provide coverage for infertility or provide only limited coverage. Check your health insurance contract carefully to learn about what is covered. Also, some states have laws for infertility insurance coverage. Some of these include Arkansas, California, Connecticut, Hawaii, Illinois, Maryland, Massachusetts, Rhode Island, Texas, and West Virginia.

In vitro fertilization (IVF) is a type of ART that is often used when a woman's fallopian tubes are blocked or when a man has low sperm counts. A drug is used to stimulate the ovaries to produce multiple eggs. Once mature, the eggs are removed and placed in a culture dish with the man's sperm for fertilization. After about 40 hours, the eggs are examined to see if they have become fertilized by the sperm and are dividing into cells. These fertilized eggs (embryos) are then placed in the woman's uterus, thus bypassing the fallopian tubes. Gamete intrafallopian transfer(GIFT) is similar to IVF, but used when the woman has at least one normal fallopian tube. Three to five eggs are placed in the fallopian tube, along with the man's sperm, for fertilization inside the woman's body. Zygote intrafallopian transfer (ZIFT), also called tubal embryo transfer, combines IVF and GIFT. The eggs retrieved from the woman's ovaries are fertilized in the lab and placed in the fallopian tubes rather than the uterus.

ART sometimes involves the use of donor eggs (eggs from another woman) or previously frozen embryos. Donor eggs may be used if a woman has impaired ovaries or has a genetic disease that could be passed on to her baby. And if a woman does not have any eggs, or her eggs are not of a good enough quality to produce a pregnancy, she and her partner might want to consider surrogacy. A surrogate is a woman who agrees to become pregnant using the man's sperm and her own egg. The child will be genetically related to the surrogate and the male partner, but the surrogate will give the baby to the couple at birth.

A gestational carrier might be an option for women who do not have a uterus, from having had a hysterectomy, but still have their ovaries, or for women who shouldn't become pregnant because of a serious health problem. In this case, the woman's eggs are fertilized by the man's sperm and the embryo is placed inside the carrier's uterus. In this case, the carrier will not be related to the baby, and will give the baby to the parents at birth.

Counseling and Support Groups

If you've been having problems getting pregnant, you know how frustrating it can feel. Not being able to get pregnant can be one of the most stressful experiences a couple has. Both counseling and support groups can help you and your partner talk about your feelings, and to help you meet other couples like you in the same situation. You will learn that anger, grief, blame, guilt, and depression are all normal. Couples do survive infertility, and can become closer and stronger in the process. Ask your doctor for the names of counselors or therapists with an interest in fertility.

Natural Methods of Birth Control

 

View Birth Control Slideshow Pictures
Birth Control Slideshow Pictures Birth Control Slideshow Pictures
  • Introduction to birth control
  • "Natural" methods of contraception

     

  • Calendar rhythm method
  • Basal body temperature method
  • Mucus inspection method
  • Symptothermal method
  • Ovulation indicator testing kits
  • Withdrawal method
  • Lactational infertility
  • Douching and urination
  • Abstinence
  • Find a local Obstetrician-Gynecologist in your town

Introduction to birth control

If a woman is sexually active and she is fertile and physically able to become pregnant, she needs to ask herself, "Do I want to become pregnant now?" If her answer is "No," she must use some method of birth control (contraception).

Terminology used to describe birth control methods include contraception, pregnancy prevention, fertility control, and family planning. But no matter what the terminology, sexually active people can choose from a variety of methods to reduce the possibility of their becoming pregnant. Nevertheless, no method of birth control available today offers perfect protection against sexually transmitted infections (sexually transmitted diseases, or STDs), except abstinence.

In simple terms, all methods of birth control are based on either preventing a man's sperm from reaching and entering a woman's egg (fertilization) or preventing the fertilized egg from implanting in the woman's uterus (her womb) and starting to grow. New methods of birth control are being developed and tested all the time. And what is appropriate for a couple at one point may change with time and circumstances.

Unfortunately, no birth control method, except abstinence, is considered to be 100% effective.

 

"Natural" methods of contraception

Natural methods of contraception are considered "natural" because they are not mechanical and not a result of hormone manipulation. Instead, these methods require that a man and woman not have sexual intercourse during the time when an egg is available to be fertilized by a sperm.

The fertility awareness methods (FAMs) are based upon knowing when a woman ovulates each month. In order to use a FAM, it is necessary to watch for the signs and symptoms that indicate ovulation has occurred or is about to occur.

On the average, the egg is released about 14 (plus or minus 2) days before a woman's next menstrual period. But because the egg survives 3 to 4 days (6 to 24 hours after ovulation) and the sperm can live 48 to 72 hours (up to even 5 days in fertile mucus), the actual time during which a woman may become pregnant is measured not in hours, not in days, but in weeks.

FAMS can be up to 98% effective, but they require a continuous and conscious commitment with considerable monitoring and self-control. Although these methods were developed to prevent pregnancy, they can equally well be used by a couple to increase fertility and promote conception.

Calendar rhythm method

The calendar rhythm method to avoid pregnancy relies upon calculating a woman's fertile period on the calendar. Based upon her 12 previous menstrual cycles, a woman subtracts l8 days from her shortest menstrual cycle to determine her first fertile day, and 11 days from her longest menstrual cycle to determine her last fertile day. She can then calculate the total number of days during which she may ovulate. If a woman's menstrual cycles are quite irregular from month to month, there will be a greater number of days during which she might become pregnant.

The calendar method is only about 80% effective in preventing pregnancy and when used alone is considered outdated and ineffective.

Basal body temperature (BBT)

The basal body temperature (BBT) method is based upon the fact that a woman's temperature drops 12 to 24 hours before an egg is released from her ovary and then increases again once the egg has been released. Unfortunately, this temperature difference is not very large. It is less than 1 degree F (about a half degree C) in the body at rest.

The basal body temperature method requires that a woman take her temperature every morning before she gets out of bed. A special thermometer that is more accurate and sensitive than a typical oral thermometer must be used, and the daily temperature variations carefully noted. This must be done every month. Online calculators are available to help a woman chart her basal body temperature.

To use the basal body temperature as a birth control method, a woman should refrain from having sexual intercourse from the time her temperature drops until at least 48 to72 hours after her temperature increases again.

Mucus inspection method

The mucus inspection method depends on the presence or absence of a particular type of cervical mucus that a woman produces in response to estrogen. A woman will generate larger amounts of more watery mucus than usual (like raw egg white) just before release of an egg from her ovary. This so-called egg-white cervical mucus (EWCM) stretches for up to an inch when pulled apart. A woman can learn to recognize differences in the quantity and quality of her cervical mucus by examining its appearance on her underwear, pads, and toilet tissue; or she may gently remove a sample of mucus from the vaginal opening using two fingers.

She may choose to have intercourse between the time of her last menstrual period and the time of change in the cervical mucus. During this period, it is recommended that she have sexual intercourse only every other day because the presence of seminal fluid makes it more difficult to determine the nature of her cervical mucus. If the woman does not wish to become pregnant, she should not have sexual intercourse at all for 3 to 4 days after she notices the change in her cervical mucus.

Symptothermal method

The symptothermal method combines certain aspects of the calendar, the basal body temperature, and the mucus inspection methods. Not only are all these factors taken into consideration, but so are other symptoms such as slight cramping and breast tenderness. Some women experience lower abdominal discomfort (in the area of the ovaries) during release of an egg (ovulation).

Ovulation indicator testing kits

A woman can use an ovulation prediction kit to determine when she is most likely to ovulate. This is a special kit that measures the amount of luteinizing hormone (LH). Because luteinizing hormone promotes the maturation of an egg in the ovary, the amount of LH usually increases 20 to 48 hours before ovulation. This increase is called the luteinizing hormone surge, which can then be detected in a woman's urine 8 to 12 hours later. The ovulation prediction kit is designed to measure the amount of luteinizing hormone in the urine.

There are a number of ovulation prediction kits available on the market which range from simple to complex. In the simplest, the woman urinates onto a test stick and the amount of luteinizing hormone is indicated by a color change. The intensity of the color is proportional to the amount of luteinizing hormone in her urine. A woman begins testing her urine 2 to 3 days before she expects to ovulate based upon the dates of her previous monthly cycles.

The optimum days for fertilization are the two days before ovulation, the day of ovulation, and the day after ovulation. The greatest chance of becoming pregnant is if intercourse occurs within 24 hours after the luteinizing hormone surge. Ovulation prediction kits are used primarily to increase the chance of a woman becoming pregnant, but they can also indicate to the woman that she is about to ovulate and should take appropriate contraceptive precautions.

Withdrawal method

Using the withdrawal method, the man withdraws his penis from a woman's vagina before he ejaculates so that the sperm released from his penis does not enter her vagina. Withdrawal is also called coitus interruptus.

There are problems with using withdrawal as a contraceptive method. First, a man may release small amounts of sperm before actual ejaculation. Secondly, a man needs self-control and a precise sense of timing to be able to withdraw his penis from the woman's vagina before he ejaculates. Because this can be difficult for the man to do successfully, the withdrawal method is only about 75-80% effective in preventing pregnancy.

Lactational infertility

Lactational infertility is based upon the idea that a woman cannot become pregnant as long as she is breastfeeding her baby. It is true that a woman may not ovulate quite as soon after giving birth as she would if she were not breastfeeding. Women who are breastfeeding usually start ovulating again between 10-12 weeks after delivery.

A nursing mother may start ovulating again and not realize she is fertile, as ovulation can occur prior to the return of her menstrual period. If this happens and the mother has unprotected sexual intercourse, she can become pregnant at the same time she is still breastfeeding her baby. If a nursing mother does not wish to become pregnant again, she must again start to use an appropriate method of contraception.

Douching and urination

Vaginal douching is the use of a liquid solution to wash out mucus and other types of bodily debris from a woman's vagina. Many women choose to make regular douching a part of their routine for maintaining vaginal hygiene, although most doctors and the American College of Obstetricians and Gynecologists (ACOG) do not recommend the practice.

Regardless of whether a woman does it for hygienic reasons, vaginal douching does not work as a contraception method. During intercourse, active sperm can reach a woman's cervix and even the upper part of her uterus within five minutes of ejaculation. Douching after intercourse cannot be done soon enough to have any contraceptive benefits, and the douching could even force sperm higher up into the uterus. In addition, if a woman douches within a 6-8 hour period after using a spermicide, she may actually reduce the effectiveness of this contraceptive method.

Some women used to think that standing up and urinating immediately after sexual intercourse might reduce the chances of them becoming pregnant. They hoped that gravity might make it more difficult for sperm to swim "uphill" to the uterus and that the stream of urine running over their vaginal area would wash away sperm, similar to the process of douching. However, just like douching, urination after intercourse does not have any contraceptive value.

Abstinence

Abstinence from sexual activity means not having any sexual intercourse at all. No sexual intercourse with a member of the opposite sex means that there is no chance that a man's sperm can fertilize a woman's egg.

A man or a woman can practice abstinence from sexual activity for a specific period of time, or continuously throughout one's lifetime. Abstinence is essentially 100% effective in preventing pregnancy. Another significant benefit of abstinence is that it markedly reduces the likelihood of contracting a sexually transmitted infection (STD).

In this context, abstinence means refraining from all vaginal, anal, and oral sexual activity because sexually transmitted infections can be passed from one person to another in any and all of these ways. It should be noted that sexual activity such as mutual masturbation and touching of the other partner's genitals can, in some instances, transfer sperm during heavy mutual foreplay possibly leading to pregnancy.

Heat Cramps

 

View How to Build a Better Butt Slideshow Pictures
How to Build a Better Butt Slideshow Pictures View How to Build a Better Butt Slideshow Pictures
7 Most Effective Exercises Slideshow Pictures View 7 Most Effective Exercises Slideshow Pictures
9 Tips for Flat Abs Slideshow Pictures View 9 Tips for Flat Abs

 

  • Heat cramps facts
  • What are heat cramps?
  • Who is at risk for heat cramps?
  • What causes heat cramps?
  • What are the signs and symptoms of heat cramps?
  • When should an individual seek medical care for heat cramps?
  • How are heat cramps diagnosed?
  • How are heat cramps treated?
  • What are the complications of heat cramps?
  • How can heat cramps be prevented
  • What is the prognosis for heat cramps?
  • Find a local Doctor in your town

Heat cramps facts

  • Heat cramps are intermittent, involuntary muscle spasms that occur in an individual who is physically active in hot weather.
  • Heat cramps, heat exhaustion, and heat stroke are collectively known as heat-related illness. Heat cramps are the least serious of the three, but still can be very painful and alarming.
  • Heat cramps usually affect the major muscles that are being stressed in a hot environment.
  • Individuals at risk for heat cramps include those who work or are active in a hot environment.
  • Individuals with impaired temperature control mechanisms, such as infants, young children, and the elderly, are also at a greater risk of heat cramps.
  • Heat cramps are the earliest symptoms of a heat-related illness.
  • Symptoms of heat cramps include profuse sweating with involuntary spasms of the large muscles in the body.
  • Heat cramps also may be a symptom of heat exhaustion.
  • The diagnosis of heat cramps is usually made by reviewing the patient history and identifying the muscle groups that are involuntarily spasming.
  • Treatment of heat cramps include resting, cooling the body, hydration, and stretching the muscles that are cramping.
  • Heat cramps can be prevented by avoiding exercise or work during the heat of the day, drinking plenty of fluids, and resting in cool or shaded areas when possible.

What are heat cramps?

Heat cramps are the intermittent, involuntary spasm of muscles that occur in an individual who is physically active (for example, working or exercising) in hot or humid weather. They are often associated with dehydration. Heat cramps usually affect the major muscles that are being stressed in the hot environment. Most often these are the thigh and leg (quadriceps, hamstrings, gastrocnemius), the core muscles (abdominal wall and back) and the arm muscles (biceps, triceps).

Heat cramps can also occur after the activity has been completed. For example, construction workers or roofers can develop cramps a few hours after their work shift is over.

Who is at risk for heat cramps?

While heat cramps tend affect those who are active in a hot environment, it should be noted that heat cramps are one of the symptoms associated with heat exhaustion as part of the spectrum of heat-related illness. Those individuals who have impaired temperature control mechanisms are at higher risk for developing heat-related illness. The body's most effective way of cooling itself is through sweat, and then the sweat evaporates into the environment. Those at most risk for heat cramps include:

  • Infants and young children because they depend upon others to avoid the heat, dress them appropriately (avoid swaddling an infant since it prevents air movement over the skin to promote sweat evaporation) and provide enough fluid to drink
  • The elderly because they may have underlying medical conditions, including heart and lung disease, and they can easily become dehydrated
  • People who live by themselves or who cannot afford air conditioning are at higher risk for heat related illness
  • A variety of medications can impair the body's sweat and heat regulation. Examples of drugs include medication prescribed for psychiatric conditions, including antipsychotic medications and tranquilizers. Over-the-counter cold medications and antihistamines also impair the body's temperature control mechanism.
  • Alcohol consumption

What causes heat cramps?

While it was thought that dehydration and electrolyte imbalance was the cause of muscle cramping, there are alternative theories as to why muscles cramp when the body is exposed to heat.

Since heat cramps begin after significant exercise in a hot environment where the affected individual begins sweating profusely, the theory was that muscles were depleted of water and sodium affecting their ability to contract and relax. Some new research suggests that as the muscles tire from excess activity and work, the ability for the muscle to regulate its own contraction is lost and this is called altered neuromuscular control. Regardless of the cause, the diagnosis and treatment for heat cramps remain the same.

What are the signs and symptoms of heat cramps?

Heat cramps are the earliest symptoms of the spectrum of heat-related illness. There is usually significant sweating with involuntary spasm of the large muscles in the body. The muscles that cramp are usually those that have been stressed. Runners and football players tend to get leg muscle cramps, but people who lift can get cramps in the muscles of the arms or the core trunk muscles like the abdominal muscles (rectus abdominus). Heat cramps usually begin after significant activity has occurred but they can occur after the activity has been completed.

Individuals with heat cramps tend only to have muscle cramps. If an individual has other signs or symptoms such as lightheadedness, weakness, nausea and vomiting, and headache he or she may be suffering from heat exhaustion. Affected individuals who have stopped sweating or who develop a fever and become confused may have heat stroke which is a true medical emergency.

When should an individual seek medical care for heat cramps?

Heat cramps can usually be treated when and where they occur. The affected individual should stop all activity and find a cool place to rest. The muscle cramps and spasms can be overcome by gently stretching the cramped muscle(s). Individuals can often replace their fluid loss by drinking a combination of water, sports drinks, or other electrolyte replacement solutions.

If the cramps cannot be controlled, the affected individual should seek medical care. There is no specific condition that differentiates heat cramps from heat exhaustion. The symptoms of these conditions form a spectrum from mild to moderate heat-related illness and symptoms can overlap. Severe heat cramps may actually be heat exhaustion. This is especially true if the person has nausea or vomiting and cannot replace the fluid loss, if they have significant fatigue and weakness, or of they have profuse sweating that does not stop when placed in a cooler environment.

Heat stroke is a true medical emergency and can be deadly. The body's ability to cool itself no longer functions, and as the temperature spikes, sometimes greater than 106 F (41 C), confusion and coma can occur. Emergency medical services should be activated (call 911) immediately if an individual is thought to have heat stroke. While waiting for help to arrive, the person should be moved to a cool place, clothes should be removed to help air circulate over the body, and cool water should be sprayed or sponged to attempt to cool the affected individual's body.

Prevention is the key to avoiding heat cramps, or other heat-related illness. A person who has had heat cramps is more prone to developing them again. Some professions are at higher risk for heat cramps, for example, construction workers and roofers are potentially exposed not only to the heat from the sun but also from the radiant heat from the hot shingles and liners on the roof. It may be helpful to acclimate to the hot environment over a period of days to allow the body and its muscles to adapt to its water and electrolyte needs.

How are heat cramps diagnosed?

The diagnosis of heat cramps is usually made after taking the patient's history. It is important to know about the environment where the person affected by heat cramps.

  • How hot was it?
  • How humid was it?
  • Was there adequate air circulation?
  • What activity was being performed and for how long?
  • When did the cramps start? What muscles were involved?
  • Was there associated sweating?
  • Had the affected individual been acclimated to the hot environment?
  • Was the person drinking enough water? One sign of heat cramps or a heat-related illness may be the color of urine. When the body becomes dehydrated, the kidneys conserve water and the result is concentrated, strong smelling, darker, yellow urine. If there is adequate water in the body the urine tends to be clear.

Often the physical examination will be relatively normal. The cramped muscles may be sore to touch and if there hasn't been adequate fluid replacement, the muscle may cramp again when taken through its normal range of motion. The physical exam may find signs of dehydration such as a dry mouth and tongue, lack of sweat in the armpits and groin, and decreased urine output. The vital signs can be a clue (for example, low blood pressure) and rapid heart rate (tachycardia). The affected person's blood pressure may be much lower upon standing compared to lying down (orthostatic hypotension).

How are heat cramps treated?

Most treatment for heat cramps can occur before seeking medical care:

  • stop the activity being performed,
  • get to a cooler place,
  • drink plenty of fluids, and
  • gently stretch the muscles that are cramping.

At the health care practitioner's office or a hospital, medical care focuses on symptom relief.

It makes it difficult to replace body fluids if the patient has nausea or vomiting, so intravenous fluids may be administered. Anti-nausea medications like promethazine (Phenergan), droperidol (Inapsine), or ondansetron (Zofran) may be used to control those symptoms.

 

Painful muscles may be treated with over-the-counter anti-inflammatory medications, such as ibuprofen or naproxen. Though it is a non-prescription medication, it is important to remember that there may side effects or interactions with prescription medications. When you are not certain which medication to consider, consult your health care practitioner as a helpful information resource.

What are the complications of heat cramps?

There are few long-term consequences of heat cramps, however, once a person experiences heat cramps, they may be at risk for future episodes.

How can heat cramps be prevented?

Prevention is the best treatment for heat cramps. If possible, try to avoid working or exercising in the heat of the day, but if it is required, acclimating to the hot weather is important. Drink plenty of fluids and if the activity lasts a prolonged period of time, consider using sports or balanced electrolyte drinks. This is especially true if significant sweating occurs and electrolytes are lost through sweat. Try to rest in cool or shaded areas whenever possible.

What is the prognosis for heat cramps?

Heat cramps resolve with relatively simple treatments including rest, hydration and stretching. It is important to remember that heat cramps are the initial presentation of heat related illness and may progress to the more serious conditions of heat exhaustion or heat stroke.

Norovirus Infection

 

Take the MRSA Quiz!

 

 

 

Take the MRSA Quiz! Take the MRSA Quiz!
Strep or Sore Throat Slideshow Pictures Strep or Sore Throat
Infectious Mononucleosis Slideshow Pictures Strep or Sore Throat

 

  • Norovirus infection facts
  • What is a norovirus?
  • What causes a norovirus infection?
  • What are norovirus infection symptoms and signs in adults, children, and babies?
  • What is the incubation period for a norovirus infection? How long are people infected with norovirus contagious?
  • How is a norovirus infection diagnosed?
  • What is the treatment for norovirus infections in adults, children, and babies?
  • What are possible complications of a norovirus infection?
  • What is the prognosis of a norovirus infection?
  • Can norovirus infections be prevented?
  • Where can people get more information about norovirus infections?
  • Patient Discussions: Norovirus Infection
  • Find a local Gastroenterologist in your town

Norovirus infection facts

  • Norovirus is a small virus that is highly contagious.
  • People acquire the virus by ingesting material contaminated with small amounts of infected feces or fluids. Food and water may be contaminated during processing or handling.
  • Noroviruses are the most common cause of gastroenteritis in the United States.
  • Infected people usually experience vomiting or watery diarrhea or both.
  • The illness usually lasts two to three days and resolves by itself.
  • There is no specific treatment for norovirus, but it is important that infected people stay well hydrated. Fluids containing sugar and electrolytes should be encouraged. Intravenous fluids may be needed if the person cannot maintain an adequate oral intake of fluids.
  • Complications are related to the degree of dehydration. Young children and the elderly are at special risk for dehydration.
  • Because the disease is highly contagious, it is important for caretakers to clean their hands whenever they come into contact with the ill person or his/her environment.
  • The risk of food-borne outbreaks or outbreaks within hospitals or nursing homes may be minimized by following established standards that include hand hygiene.

What is a norovirus?

A norovirus is a small virus that contains RNA and is surrounded by a protein coating. By sequencing the RNA, scientists have discovered that there are many different types of norovirus. Originally, strains were named based on the city in which they were first identified. Thus, one common strain used to be called Norwalk virus. Based on genetic typing, we now know that there are at least 25 different strains of norovirus that affect humans.

Norovirus infection is the most common cause of gastroenteritis outbreaks. Although some people call this the "stomach flu," norovirus is not related to the influenza virus. According to statistics from the CDC, there are 21 million cases of norovirus infection annually in the U.S., of which one-quarter are related to food-borne outbreaks. Outbreaks occur throughout the year but are more common in the winter months. There is no specific treatment for norovirus. Fortunately, the disease is self-limited and simple supportive measures are sufficient to care for most people unless they become dehydrated.

Picture of norovirus particles seen using transmission electron microscopy.
Figure 1: Picture of norovirus particles seen using transmission electron microscopy.

What causes a norovirus infection? How are norovirus infections transmitted?

Infection occurs when humans inadvertently ingest material contaminated with small amounts of fluids or feces from an infected person. It only takes a small number of viruses to cause infection, so even microscopic amounts of feces or fluids can be contagious.

An infected person with vomiting or diarrhea can contaminate their environment directly or spread virus particles through aerosolized droplets when throwing up. Contamination may also occur in food and/or in water, which has led to infection spreading widely in restaurants or aboard cruise ships. Outbreaks in school systems occur regularly, sometimes spreading widely as was the case with an outbreak in the Chicago public schools in 2010. The virus is very hardy and can live for days or weeks on surfaces.

What are norovirus infection symptoms and signs in adults, children, and babies?

Most people get sick within one day of ingesting norovirus (range 12-48 hours). Symptoms and signs include vomiting or watery diarrhea or both. Fever occurs in one-third to one-half of infected people. Cramping abdominal or stomach pain and a general feeling of tiredness, headache, and muscle aches are common.

People are usually thirsty, although they may have trouble keeping fluids down. In general, patients who can orally ingest about the same amount of fluid they lose through diarrhea, vomiting, or both do well. Symptoms in adults may be different than symptoms in children. Young children and babies may not complain of thirst but may appear listless or lethargic as they become dehydrated. Symptoms may be more severe in debilitated, elderly patients. People who are unable to replace their fluids and develop signs of dehydration need medical care.

Most people have a mild illness that lasts two to three days. In contrast to bacterial diarrheas, such as those caused by Shigella or Campylobacter bacteria, norovirus does not cause blood or pus in the stool. The length of infection may be prolonged in patients who are in the hospital or in young children.

Norovirus has been associated with severe inflammation of the colon in newborns and with disease flares in children who have inflammatory bowel disease, but it is not yet clear what role norovirus is playing in these conditions.

What is the incubation period for a norovirus infection? How long are people infected with norovirus contagious?

Norovirus may have a prolonged infection period that starts even before a patient gets sick. There is a short lag (up to two days) between the time that people acquire the virus and the time they get symptoms. People may be contagious during this period. All people are contagious while they are having symptoms.

Even people who appear to have recovered completely after a norovirus infection may continue to shed the virus for weeks in their stool and may be a source of infection to others. People with compromised immune systems (for example, those receiving chemotherapy or undergoing organ transplant) may shed the virus for months.

How is a norovirus infection diagnosed?

Because the symptoms of norovirus are similar to those of other common viral diarrheas like rotavirus, it is necessary to do specific tests to identify the virus. Norovirus cannot be cultured in a laboratory. However, the RNA inside the virus may be detected directly using polymerase chain reaction (PCR) tests, and these tests are the ones that are most commonly used. Enzyme-based immunoassays (EIA) can also be used to detect the virus in stool samples. EIAs use special antibodies that attach to virus particles. In addition, the Ridascreen Norovirus 3rd Generation EIA assay is set to be approved for use by the FDA in February 2011 to detect norovirus when a number of people have simultaneously contracted gastroenteritis and there is a clear avenue for virus transmission, such as a shared location or food source. However, this new test is not sensitive enough for definitive diagnosis of norovirus infection in an individual. The CDC updated its recommendations for use in March 2011.The human body makes antibodies against norovirus, and these can be identified with immunoassay testing of blood samples. Unfortunately, it takes 10 to 14 days for the body to make antibodies, so this test is not useful for real-time diagnosis. It is also possible to see the virus particles using electron microscopy (see figure), although this is mostly a research tool.

Once norovirus has been confirmed in an outbreak setting, it is not necessary to test every person. Rather, people with typical symptoms are assumed to have acquired the virus.

What is the treatment for norovirus infections in adults, children, and babies?

There is no specific treatment or medication for norovirus. It is important that infected individuals remain well hydrated, drinking plenty of fluids. Fluids containing electrolytes and sugars should be encouraged. Over the counter antidiarrheal medications may be used according to directions but should be avoided in cases with severe abdominal pain or fever. Some researchers advise people to avoid these medications if possible as they may prolong the disease.

What are possible complications of a norovirus infection?

Although most cases of norovirus infection are mild, complications may occur. Complications are related to the degree of dehydration. People who cannot keep up with fluid losses may require hospitalization for intravenous fluids.

Approximately 10% of infected people seek medical attention. Very young children and infants are at high risk for dehydration because they cannot communicate their symptoms and because dehydration may occur rapidly. Pregnant women should pay particular attention to keeping up with fluid losses.

Although norovirus infection is not fatal, it can contribute to mortality by causing underlying illnesses to become worse. Elderly, debilitated people are especially at risk for complications related to dehydration, including kidney failure.

What is the prognosis of a norovirus infection?

Norovirus infection is a self-limited illness that lasts two to three days in most people. As discussed above, complications are usually related to dehydration or underlying illnesses. In some countries where poor hydration already may exist in children, many may die from dehydration if IV replenishment is not available. In 2006, the World Health Organization recommended a new prepackaged oral rehydration salts (ORS) formula that can be shipped to underdeveloped countries and simply poured into clean water that can prevent dehydration in many patients. This approach has improved the prognosis for many children in underdeveloped countries.

Can norovirus infections be prevented?

Once a person is sick, it is important for caretakers and household contacts to use good hand hygiene. This includes washing hands after coming into contact with the person or his environment. Hands should also be washed before preparing food or touching the face. Alcohol-based hand sanitizers are effective and have been shown to reduce the rate of transmission in some settings. Silverware and dishes should not be shared. Diluted chlorine bleach (5 to 25 tablespoons of bleach per gallon of water) may be used to clean solid surfaces.

Norovirus infections can be prevented by using good hand hygiene and avoiding contact with sick individuals and their environment. This is much harder than it sounds. One sick crew member on a cruise ship can contaminate food served to hundreds of people. Contamination while picking fresh vegetables or fruit can lead to widespread outbreaks as the product is sold across the country. Strict hygiene standards for food handlers can help reduce the risk of outbreaks. Many investigators suggest routine washing of fruits and vegetables before serving may also help reduce or prevent infections.

Noroviruses may also be spread in a hospital or nursing-home environment. The CDC has published guidelines for institutions to follow to reduce the infection rate. Hand hygiene is highlighted as the single most important component of these infection-control measures. Hospital epidemiologists and people with infection-control training should be contacted whenever an outbreak is suspected within a hospital or institution. Public-health officials should be notified whenever there is suspicion for a community-based outbreak.

Unfortunately, people who get norovirus do not have immunity against future infections. Although the body makes antibodies against the infecting strain, there are many strains that cause infection. The virus constantly creates small mutations in its RNA to make new strains that evade the human immune system.

Because there are many different strains of norovirus, it has been difficult to make a vaccine. However, this is an active area of research and there are some vaccines that have shown promise in mouse (murine) models. Vaccine trials are now beginning in humans.

 

 

Last Updated on Monday, 07 November 2011 05:27
 
Mad Cow Disease PDF Print E-mail
Written by Ruai Pharmaceuticals   
Sunday, 21 August 2011 17:38

 

 

Mad Cow Disease

 

Take the MRSA Quiz!

 

 

 

Take the MRSA Quiz! Take the MRSA Quiz!
Strep or Sore Throat Slideshow Pictures Strep or Sore Throat
Infectious Mononucleosis Slideshow Pictures Strep or Sore Throat
  • What is "Mad Cow Disease" (Bovine Spongiform Encephalopathy/BSE)?
  • What causes BSE?
  • Was a second case of BSE identified in the U.S. in June 2005?
  • Did meat and meat products from the June 2005 cow enter the food supply?
  • Was a case of BSE identified in the U.S. in December 2003?
  • Did meat and meat products from the 2003 BSE cow enter the food supply?
  • Will there be additional cases?
  • Does BSE affect people?
  • What measures are being taken to ensure food safety in the U.S. from BSE?
  • Are the protective measures in place sufficient to ensure the safety of the human food supply in light of the June 2005 BSE positive cow?
  • Is the food in the U.S. likely to be a BSE risk to consumers?
  • Is cow's milk a source of BSE?
  • Can milk be infected with BSE from a BSE-positive cow?
  • Does the use of bovine-derived ingredients in dietary supplements mean that they are not safe?
  • Since the BSE-positive cows were discovered in the U.S., does that mean that dietary supplements made with domestic ingredients might be unsafe?
  • What steps is FDA currently taking to ensure the safety of dietary supplements that contain bovine ingredients?
  • Given the BSE case in Washington State and the case in Texas, should consumers be concerned about cosmetics made using tallow from the rendering process?
  • What about the use of gelatin, another bovine-related material, in cosmetics and dietary supplements and other foods?
  • When and how did BSE in cattle occur?
  • Is BSE in cattle the same disease as CWD in deer and elk in the U.S.?
  • What countries have reported cases of BSE or are considered to have a substantial risk associated with BSE?

What is "Mad Cow Disease" (Bovine Spongiform Encephalopathy/BSE)?

Mad Cow Disease is the commonly used name for Bovine Spongiform Encephalopathy (BSE), a slowly progressive, degenerative, fatal disease affecting the central nervous system of adult cattle. Since 1990, the U.S. Department of Agriculture (USDA) has conducted aggressive surveillance of the highest risk cattle going to slaughter in the United States.

What causes BSE?

The exact cause of BSE is not known but it is generally accepted by the scientific community that the likely cause is infectious forms of a type of protein, prions, normally found in animals cause BSE. In cattle with BSE, these abnormal prions initially occur in the small intestines and tonsils, and are found in central nervous tissues, such as the brain and spinal cord, and other tissues of infected animals experiencing later stages of the disease.

Was a second case of BSE identified in the U.S. in June 2005?

Yes, the USDA surveillance program identified the second BSE case in the U.S. This cow was originally identified in November 2004. Results from this animal were inconclusive in screening tests, but negative in confirmatory immunohistochemical tests. USDA recently conducted an additional confirmatory test, Western Blot, and the results were positive for BSE. USDA sent the samples to the Weybridge, UK lab where BSE was confirmed. An epidemiological investigation to trace the origins of the cow is underway. USDA confirms that the cow was born before the U.S. instituted its ban on the use of most mammalian protein in feed for ruminant animals-believed to be the most critical protective measure in preventing the spread of BSE among cattle.

Did meat and meat products from the June 2005 cow enter the food supply?

No, the cow was presented at slaughter as non-ambulatory (a downer). Therefore, in accordance with BSE regulations established by USDA and FDA the material from the animal did not enter the human food supply.

Was a case of BSE identified in the U.S. in December 2003?

Yes, the USDA surveillance program identified the first BSE case in the U.S. in a dairy cow in Washington State. The cow was bought from a farm in Canada.

Did meat and meat products from the 2003 BSE cow enter the food supply?

As soon as the BSE case was identified, both USDA and FDA activated their BSE Emergency Response Plans, and USDA immediately recalled the meat. Meat that did enter the food supply was quickly traced and was removed from the marketplace. Moreover, all the organs in which infectious prions occur were removed at slaughter and did not enter the food supply. Consumers should feel very confident that the system of multiple firewalls maintained by Federal agencies protects them from possible exposure to BSE. In addition, we believe it is important for consumers to also understand that scientific research indicates that muscle meat is not a source of infectious prions.

Will there be additional cases?

In 1998, USDA commissioned the Harvard Center for Risk Analysis to conduct an analysis and evaluation of the U.S. regulatory measures to prevent the spread of BSE in the U.S. and to reduce the potential exposure of U.S. consumers to BSE. The Harvard study concluded that, if introduced, due to the preventive measures currently in place in the U.S., BSE is extremely unlikely to become established in the United States.

FDA and other Federal agencies have been vigilant in strengthening protective measures to reduce the U.S. consumer's risk of exposure to BSE-contaminated food and cosmetic products. Since 1989, USDA has banned imports of live ruminants, such as cattle, sheep and goats, and most products from these animals from countries known to have BSE. Subsequently, USDA expanded this ban to include both countries with BSE and countries at risk for BSE. In 1997, FDA prohibited, with some exceptions, the use of protein derived from mammalian tissues in animal feed intended for cows and other ruminants. See the FDA/CVM website at www.fda.gov/cvm for information on the "ruminant feed ban."

On Jan. 8, 2004, the USDA's Food Safety and Inspection Service issued new rules to enhance safeguards against BSE. Details on these rules may be found at USDA's website, www.usda.gov. Also in 2004, FDA issued a rule that prohibits the use of certain cattle material, because of the risk of BSE, in human food and cosmetics.

Does BSE affect people?

There is a disease similar to BSE called Creutzfeldt-Jacob Disease (CJD) that is found in people. A variant form of CJD (vCJD) is believed to be caused by eating contaminated beef products from BSE-affected cattle. To date, there have been 155 confirmed and probable cases of vCJD worldwide among the hundreds of thousands of people that may have consumed BSE-contaminated beef products. The one reported case of vCJD in the United States was in a young woman who contracted the disease while residing in the UK and developed symptoms after moving to the U.S.

What measures are being taken to ensure food safety in the U.S. from BSE?

Since 1989, the FDA and other federal agencies have had ongoing regulatory measures in place to prevent BSE contamination of U.S. food and food products. Following the identification in a Washington state dairy herd of a BSE-positive cow imported from Canada, USDA issued new regulations containing additional safeguards to further minimize risk for introduction of the BSE agent into the U.S. food supply. See USDA's website www.usda.gov for further information.

Similarly, FDA has prohibited the use of the cattle materials that carry the highest risk of BSE in human food, including dietary supplements, and in cosmetics. FDA's rule (and September 2005 amendments) prohibit use of the following cattle material in human food and cosmetics:

 
    a. cattle material from non-ambulatory, disabled cattle,

    b. cattle material from organs from cattle 30 months of age or older in which infectious prions are most likely to occur, and the tonsils and the distal ileum of the small intestine of cattle of all ages,

    c. cattle material from mechanically separated (MS) (beef), and

    d. cattle material from cattle that are not inspected and passed for human consumption

FDA's rule also requires that food and cosmetics manufacturers and processors make available to FDA any existing records relevant to their compliance with these prohibitions. FDA has also published a proposal requiring manufacturers and processors of food and cosmetics made with cattle material to establish and maintain records demonstrating that their products do not contain prohibited cattle material.

In September 2005, FDA amended the interim final rule to allow use of the small intestine in human food and cosmetics, provided the distal ileum has been removed. FDA also clarified that milk and milk products, hide and hide-derived products and tallow derivatives are not considered prohibited cattle materials. Finally, in response to comments the agency has reconsidered the method cited in the interim final rule for determining insoluble impurities in tallow and is citing a method that is less costly and requires less specialized equipment.

Are the protective measures in place sufficient to ensure the safety of the human food supply in light of the June 2005 BSE positive cow?

Yes, the protective measures put into place in July 2004 by FDA ensure that cattle materials that carry the highest risk of transmitting the agent that causes BSE are excluded from human food, including dietary supplements, and cosmetics. These measures, along with similar measures established by USDA, provide a uniform national BSE policy and ensure the safety of human food.

Is the food in the U.S. likely to be a BSE risk to consumers?

FDA and other federal agencies have had preventive measures in place to reduce the U.S. consumer's risk of exposure to any BSE-contaminated meat and food products. Since 1989, USDA has prohibited the importation of live animals and animal products from BSE-positive countries. Subsequently, USDA expanded the ban to include both countries with BSE and countries at risk for BSE. Since 1997, FDA has prohibited the use of most mammalian protein in the manufacture of ruminant feed. In 2004, FDA issued a rule prohibiting the use of certain cattle materials in human food and cosmetics, and USDA issued a rule prohibiting certain cattle materials from use as human food.

Is cow's milk a source of BSE?

Scientific research indicates that BSE is not transmitted in cow's milk, even if the milk comes from a cow with BSE. Milk and milk products, even in countries with a high incidence of BSE are, therefore, considered safe.

Can milk be infected with BSE from a BSE-positive cow?

No detectable infectivity in cow's milk has been reported from any BSE-infected cows. Infectious prions have not been detected by bioassay of milk from cattle with BSE.

Does the use of bovine-derived ingredients in dietary supplements mean that they are not safe?

No. The requirements that FDA has in place should give consumers confidence that their food, including dietary supplements, is safe. Most recently, FDA published a rule that prohibits the use in human food, including dietary supplements, of the cattle materials that have the highest risk of harboring BSE infectivity. The rule applies to both imported and domestic dietary supplements and their ingredients. Furthermore, most ingredients used to produce dietary supplements and most other food ingredients come from cattle that are slaughtered when they are less than 30-months of age and, because of their age, present little risk of being BSE-positive. It is not a common occurrence for animals younger than 30 months to develop BSE.

Since the BSE-positive cows were discovered in the U.S., does that mean that dietary supplements made with domestic ingredients might be unsafe?

No. The requirements that FDA has in place should give consumers confidence that their food, including dietary supplements, is safe. Most recently, FDA published a rule that prohibits the use in human food, including dietary supplements, of the cattle materials that have the highest risk of harboring BSE infectivity. Furthermore, most ingredients used to produce dietary supplements and most other food ingredients come from cattle that are slaughtered when they are less than 30-months of age and, because of their age, present little risk of being BSE-positive.

Even though BSE-positive cows have been identified in the U.S., one of which was imported, the risk to human health from dietary supplements and other foods containing cattle-derived ingredients is extremely low.

What steps is FDA currently taking to ensure the safety of dietary supplements that contain bovine ingredients?

Most recently, FDA published a rule that prohibits the use in human food, including dietary supplements, of the cattle materials that have the highest risk of harboring BSE infectivity. The rule applies to both domestic and imported dietary supplements and their ingredients. In addition, most ingredients used to produce dietary supplements and most other food ingredients come from cattle that are slaughtered when they are less than 30-months of age and, because of their age, present little risk of being BSE-positive. Further, the restrictions by USDA on the use of certain cattle and cattle tissues in human food also reduce the risks that potentially infective tissue would be used in dietary supplements. FDA also has proposed a requirement that manufacturers and processors that use cattle material in their products would be required to keep records demonstrating that these materials do not contain prohibited cattle material and that these records be made available to FDA for inspection.

Given the BSE case in Washington State and the case in Texas, should consumers be concerned about cosmetics made using tallow from the rendering process?

No. The World Health Organization considers tallow to be a low risk for transmission of BSE. Specifically, the rendering process separates fats from proteins. Because the disease is transmitted by prions, which are a type of protein, they would be separated by the rendering process from the tallow or fat, which is the portion that goes into cosmetics. Additionally, the tallow is processed with excessive heat and pressure which may further minimize any risk of infectivity prior to use in cosmetics.

What about the use of gelatin, another bovine-related material, in cosmetics and dietary supplements and other foods?

FDA's rule prohibiting the use of the cattle materials that have the highest risk of harboring BSE infectivity in human food applies to gelatin. Therefore, gelatin used in human food may not be made from these cattle materials.

When and how did BSE in cattle occur?

BSE in cattle was first reported in 1986 in the United Kingdom (UK). The exact origins of BSE remain uncertain, but it is thought that cattle initially may have become infected when fed feed contaminated with scrapie-infected sheep meat-and-bone meal (MBM). Scrapie is a prion disease in sheep similar to BSE in cattle. The scientific evidence suggests that the U.K. BSE outbreak in cattle then was expanded by feeding BSE-contaminated cattle protein (MBM) to calves. The definitive nature of the BSE agent is not completely known. The agent is thought to be a modified form of a protein, called a prion, which becomes infectious and accumulates in neural tissues causing a fatal, degenerative, neurological disease. These abnormal prions are resistant to common food disinfection treatments, such as heat, to reduce or eliminate their infectivity or presence. Research is ongoing to better understand TSE diseases and the nature of prion transmission.

Is BSE in cattle the same disease as CWD in deer and elk in the U.S.?

BSE is a Transmissible Spongiform Encephalopathy (TSE), a family of similar diseases that may infect certain species of animals and people such as scrapie in sheep and goats, BSE in cattle, chronic wasting disease (CWD) in deer and elk, and variant Creutzfeldt-Jakob disease (vCJD) in people.

To date, there is no scientific evidence that BSE in cattle is related to CWD in deer and elk. FDA is working closely with other government agencies and the public health community to address CWD in wild and domesticated deer and elk herds. Wildlife and public health officials advise people not to harvest, handle, or consume any wild deer or elk that appear to be sick, regardless of the cause, especially in those states where CWD has been detected.

What countries have reported cases of BSE or are considered to have a substantial risk associated with BSE?

These countries are: Albania, Austria, Belgium, Bosnia-Herzegovina, Bulgaria, Croatia, Czech Republic, Denmark, Federal Republic of Yugoslavia, Finland, France, Germany, Greece, Hungary, Ireland, Israel, Italy, Liechtenstein, Luxembourg, former Yugoslavia Republic of Macedonia, The Netherlands, Norway, Oman, Poland, Portugal, Romania, Slovak Republic, Slovenia, Spain, Sweden, Switzerland, Japan, and United Kingdom (Great Britain including Northern Ireland and the Falkland Islands).

Plague

 

Take the MRSA Quiz!

 

 

 

Take the MRSA Quiz! Take the MRSA Quiz!
Strep or Sore Throat Slideshow Pictures Strep or Sore Throat
Infectious Mononucleosis Slideshow Pictures Strep or Sore Throat
  • Plague facts
  • What is plague?
  • What is the history of the plague?
  • What causes plague?
  • How is plague spread?
  • What are the symptoms and signs of plague?
  • How is plague diagnosed?
  • What is the treatment for the plague?
  • How can plague be prevented?
  • Is there a vaccine against plague?
  • What research is being done on plague?
  • Where can more information be found on plague?

Plague facts

  • A bacterium, Yersinia pestis, causes the disease in animals and humans.
  • Plague is a disease that is transmitted from infected animals, usually by fleas, to humans. Plague then may be transmitted from humans to others by direct contact or by touching or breathing droplets that contain the bacterium, Yersinia pestis. Untreated plague causes much suffering and deaths in humans.
  • Symptoms of plague vary and are grouped into three types:
      Bubonic: The lymph nodes become swollen, tender, and are termed buboes. The patient may also develop fever, chills, and weakness.

      Septicemic: In general, septicemic plague patients do not develop buboes. Instead symptoms may include fever, chills, weakness, bleeding under the skin, abdominal pain, and septic shock with low blood pressure.

      Pneumonic: Shortness of breath, cough (sometimes with bloody sputum), and chest pain quickly develop along with weakness, fever, and headaches.

  • Plague is preliminarily diagnosed by physical examination and by cultures of blood or other sites; definitive diagnosis is done by immunological tests that identify Y. pestis specifically.
  • Plague is treated by several types of antibiotics.
  • The history of plague infections of humans is extensive, and plague bacteria are considered to be biological weapons by some governments.
  • Although plague is endemic in some animal populations, fleas can transfer Y. pestis from animals to man; once a person is infected, the disease can easily be transmitted to other humans by direct and indirect contact with droplets or material touched by the infected person.
  • Prevention of plague is done by eliminating areas where animals, especially rodents, congregate and by avoiding the fleas the rodents carry. Some infections can be prevented by taking antibiotics soon after exposure to the disease.
  • There are no commercially available vaccines against plague; however, there is a small amount available from the U.S. government for researchers that work with Y. pestis.
  • Ongoing research includes trying to develop a plague vaccine with few side effects; others are exploring the Y. pestis genome for insights into its pathogenic mechanisms.

What is plague?

Plague, a disease that is endemic in some animal populations (mainly rodents), is caused by the Yersinia pestis bacterium. This bacterium can be transmitted to humans, usually by a vector such as fleas. Plague usually starts with a flea bite where Y. pestis is transmitted from the flea bite site to lymph nodes that swell (buboes). This type of plague is termed bubonic plague. The bacteria can spread into the bloodstream and eventually infect other organs. In some patients, the bacteria can enter the bloodstream without lymph node swelling (termed septicemic plague); in others, the patients can inhale or swallow droplets that contain Y. pestis that infect the lungs (termed pneumonic plague). Death occurs in about 50%-90% of all people who develop infection with Y. pestis and are not treated; even with treatment, about 15% of infected people will still die. Epidemics of this devastating disease have occurred many times in the past. Skin areas and buboes in untreated people may become dark or a black color as the disease progresses, so plague was originally termed "Black Death."

What is the history of the plague?

Plague or Black Death has been mentioned in most regions of the world for centuries. Once it became established in a population before effective treatments were established, it would rapidly travel through a population in a settlement, town, or city and kill so many people that historians said there were not enough people left alive to bury all of the dead. In the 1300s, the Black Death killed about one-third of Europe's population. In 1894, two investigators, Dr. Alexandre Yersin and Dr. Shibasaburo Kitasato, almost simultaneously described bipolar staining organisms in buboes and organs of people who died from plague. Yersin also deduced the connection between rats and plague; the organism was named Yersinia after Yersin. Dr. Paul-Louis Simond, in 1898, discovered the vector of the disease was a flea. Plague or its cause, Y. pestis, has been used by humans as a weapon (bioterrorist weapon) against other humans for centuries, including this current time. In medieval times, bodies of plague victims were hurled over city walls in an attempt to infect many inhabitants and thus weaken the defense capability of the city. Currently, the CDC considers Y. pestis a category A microbial agent for potential or actual use as a weapon for use against other humans. Although people may be vaccinated (not readily available to most individuals) or treated with antibiotics, the organism is still attractive to some biological weapon designers because Y. pestis may be aerosolized (for example, Y. pestis may be placed in droplets or small inhalable particles that may be sprayed by several methods into the air) and thus easily inhaled by unprotected individuals to produce a rapidly debilitating or lethal infection in many individuals exposed to the aerosol. Although most world countries say this type of weapon should never be used, the potential for development and use is likely to be explored or even exploited by some individuals.

What causes plague?

Infection with Y. pestis causes plague in humans. Y. pestis is a bacterium that is gram-negative rod-shaped bacterium genetically related to Escherichia coli that resembles a "safety pin" when stained with chemicals and viewed with a microscope. In general, plague circulates in rodent populations where infected fleas on rodents transfer the bacteria to other rodents. When the rodent population invades human habitats or when humans invade rodent habitats, the infected fleas on the rodents will also bite humans. This flea bite begins plague in an individual. However, once a human is infected, it is fairly easy for that person to infect other people with the organisms especially if they develop pulmonary infection because droplets containing Y. pestis from the lungs are expelled into the air and can infect other humans.

Picture of Yersinia pestis, showing bipolar staining or safety pin appearance
Figure 1: Picture of Yersinia pestis, showing bipolar staining or "safety pin" appearance. SOURCE: CDC/Courtesy of Larry Stauffer, Oregon State Public Health Laboratory

How is plague spread?

Plague is a zoonotic (animal to animal) disease that can be spread to humans by several methods. The usual way humans encounter plague is from getting a flea bite from a flea that has previously been infected from biting an animal where the disease is endemic. Most often this is attributed to a plague-infected rat population, but it could be from many other animals such as mice, prairie dogs, squirrels, and other rodents. Unfortunately, even domestic cats and dogs can become infected and potentially may transmit the disease to humans. Dead animals can still contain many viable Y. pestis; humans can become infected when they handle these animals; people should use caution when touching touch dead animals or even getting close to them as they may have fleas looking for another warm (human) body to bite. Human-to-human spread is easily done by people with pneumonic plague as they can spread infected droplets expelled from the lungs to other people or to objects that are subsequently touched by others. Individuals with bubonic or septicemic plague can also transmit the disease, usually by direct or indirect contact with infected body fluids or objects that come in contact with these fluids. Spread of plague can be facilitated when conditions arise that encourage rat populations to rapidly increase. For example, when cities reduce or fail trash pickup for any extended time period, a rat population may flourish, and so may the flea population. Consequently, human behaviors (warfare, economic failures, urban expansion, and others) may augment the development of plague.

What are the symptoms and signs of plague?

The symptoms of plague can be progressive; however, most investigators break the symptoms into three different groups because plague is often described in three types; bubonic, septicemic, and pneumonic. A patient can also present with the symptoms of only one type of plague. Untreated plague may show progressive symptoms that can overlap; however, the following will describe those symptoms and signs that predominate during the three general types of plague:

  • Bubonic: In about three to seven days, lymph nodes become swollen, tender, and are termed buboes (the term bubonic is derived from buboes) and the patient may also develop fever, chills, and weakness.
  • Septicemic: In general, septicemic plague patients do not develop buboes; instead symptoms may include fever, chills, weakness, bleeding under the skin, abdominal pain, and septic shock with low blood pressure. Septicemic plague may develop in about one to seven days after exposure.
  • Pneumonic: In about one to three days after the person is exposed to airborne droplets that contain Y. pestis, shortness of breath, cough (sometimes with bloody sputum), and chest pain quickly develop along with weakness, fever, and headaches.

Untreated bubonic plague may progress and produce symptoms of both septicemic and pneumonic plague, while septicemic plague may progress to produce pneumonic plague. However, pneumonic plague is the most serious and lethal form of plague, and while the patient may develop septicemic symptoms, the pneumonic symptoms are the most serious. Nonetheless, all three plague types can be fatal to a patient.

Picture of an inguinal bubo in a patient with plague.
Figure 2: Picture of an inguinal bubo in a patient with plague.

How is plague diagnosed?

The history and physical exam is an important first step in the diagnosis of plague. The patients' exposure to animals (and the fleas that accompany them) or exposure to humans that have plague or the symptoms of plague, or have visited or reside in a plague-endemic area can help trigger the medical caregivers' ability to do further tests for plague. In addition, if buboes develop in about three to seven days after exposures listed above, bubonic plague may be presumptively diagnosed. Unless septicemic or pneumonic plague develop directly from the bubonic form, the presumptive diagnosis is somewhat more difficult to make; sometimes because plague is seen so infrequently by many doctors (for example, see reference 1). However, a good patient history can help make a more timely presumptive diagnosis. In addition, bleeding under the skin and other septicemic symptoms may be helpful. Laboratory tests are usually based on the detection of the F1 antigen of Y. pestis and can provide both a presumptive and definitive diagnosis of plague. The CDC currently (2011) provides the following guidelines for diagnosis of plague:

SUSPECTED PLAGUE SHOULD BE CONSIDERED IF THE FOLLOWING CONDITIONS ARE MET:

1. Clinical symptoms that are compatible with plague, i.e., fever and lymphadenopathy in a person who resides in or recently traveled to a plague-endemic area.

2. If small gram-negative and/or bipolar-staining coccobacilli are seen on a smear taken from affected tissues, e.g.:

  • Bubo (bubonic plague)
  • Blood (septicemic plague)
  • Tracheal/lung aspirate (pneumonic plague)

PRESUMPTIVE PLAGUE SHOULD BE CONSIDERED WHEN ONE OR BOTH OF THE FOLLOWING CONDITIONS ARE MET:

    1. If immunofluorescence stain of smear or material is positive for the presence of Yersinia pestis F1 antigen.

    2. If only a single serum specimen is tested and the anti-F1 antigen titer by agglutination is >1:10.*

CONFIRMED PLAGUE IS DIAGNOSED IF ONE OF THE FOLLOWING CONDITIONS IS MET:

    1. If a culture isolated is lysed by specific bacteriophage.

    2. If two serum specimens demonstrate a four fold anti-F1 antigen titer difference by agglutination testing.*

    3. If a single serum specimen tested by agglutination has a titer of >1:128 and the patient has no known previous plague exposure or vaccination history.*

*Agglutination testing must be shown to be specific to Y. pestis F1 antigen by hemagglutination inhibition.

 

Definitive diagnosis of plague has also been done by PCR tests to detect Y. pestis antigens in animal, flea, and human tissues.

What is the treatment for the plague?

Currently, plague is treated with antibiotics. The following antibiotics have been used to successfully treat plague if the person's disease has not yet overwhelmed the body's defenses (earlier treatments have a better chance to stop the disease):

  • Streptomycin
  • Gentamicin (Garamycin)
  • Chloramphenicol
  • Tetracyclines (Sumycin)
  • Fluoroquinolones

Patients who are suspected of being exposed to plague should be treated immediately. The antibiotic, route of administration (IV or oral), duration of treatment and supportive care, if necessary, are determined by the patient's caregiver and usually in consultation with CDC or infectious-disease specialists. Plague is rarely seen in the U.S. (about 13 infections diagnosed per year with one recent year with 40 diagnosed); however, about 14% of people who are diagnosed in the U.S. still die from the disease. The World Health Organization estimates about 2,900 individuals per year are diagnosed with plague currently.

 

How can plague be prevented?

The CDC provides the following preventive recommendations related to zoonosis diseases caused by rodents and their vectors, including plague:

  • Watch for plague activity in rodent populations where plague is known to occur. Report any observations of sick or dead animals to the local health department or law-enforcement officials.
  • Eliminate sources of food and nesting places for rodents around homes, work places, and recreation areas; remove brush, rock piles, junk, cluttered firewood, and potential-food supplies, such as pet and wild animal food. Make your home rodent-proof.
  • If you anticipate being exposed to rodent fleas, apply insect repellents to clothing and skin, according to label instructions, to prevent flea bites. Wear gloves when handling potentially infected animals.
  • If you live in areas where rodent plague occurs, treat pet dogs and cats for flea control regularly and not allow these animals to roam freely.
  • Health authorities may use appropriate chemicals to kill fleas at selected sites during animal plague outbreaks.
  • To avoid potential risk of exposure to hantavirus infection,
    • safely clean up rodent-infested areas;
    • air out infested spaces before cleanup;
    • spray areas of infestation and all excreta, nesting, and other materials with household disinfectant or 10% bleach solution then clean up, seal in bags, and dispose;
    • avoid sweeping, vacuuming, or stirring dust until the area is thoroughly wet with disinfectant;
    • and wear rubber gloves; disinfect gloves before removal, and wash hands afterward.

Prophylactic (preventive) antibiotics: Health authorities advise that antibiotics be given for a brief period to people who have been exposed to the bites of potentially infected rodent fleas (for example, during a plague outbreak) or who have handled an animal known to be infected with the plague bacterium. Such experts also recommend that antibiotics be given if a person has had close exposure to a person or an animal (for example, a house cat) with suspected plague pneumonia. People who must be present in an area where a plague outbreak is occurring can protect themselves for two to three weeks by taking antibiotics. The preferred antibiotics for prophylaxis against plague are the tetracyclines or the sulfonamides. There is no commercially available vaccine against plague available in the U.S.

Is there a vaccine against plague?

There are vaccines against plague, but there are none commercially available in the U.S. Most vaccines are made from heat-killed and chemically treated Y. pestis bacterial cells. The small amount currently available is obtainable from the U.S. government and usually given to only a small number of individuals (for example, researchers working with Y. pestis). Currently, there is interest in further vaccine development and possible production because of potential bioterrorist use of this disease.

What research is being done on plague?

Research on the cause of plague, Y. pestis, has increased in recent years due to the threat of its use in potential bioterrorism attacks or as a weapon to subdue or decimate human populations. Genetic studies are underway to help design better vaccines with few side effects. Some Y. pestis strains have been found to have plasmid-generated antibiotic resistance so newer drugs are being tested, alone or in combination, to be ready to treat any outbreaks of these strains. Rapid diagnostic tests are being studied to quickly detect the organisms, especially under battlefield conditions. Such tests may allow better testing to undercover potential environmental (endemic) sites that could lead to outbreaks.

Oral Cancer

  • What is the oral cavity?
  • What is cancer?
  • Who's at risk for oral cancer?
  • What are the symptoms of oral cancer?
  • How is oral cancer diagnosed?
  • How is oral cancer treated?
  • Methods of treatment
  • What are the side effects of treatment for oral cancer?
  • What is rehabilitation for oral cancer?
  • What happens after treatment for oral cancer?
  • What does the future hold for patients with oral cancer?
  • What resources are available to patients with oral cancer?
  • Oral Cancer At A Glance
  • Patient Discussions: Oral Cancer - Symptoms
  • Find a local Oncologist in your town

The mouth and throat

This booklet is about cancers that occur in the mouth (oral cavity) and the part of the throat at the back of the mouth (oropharynx). The oral cavity and oropharynx have many parts:

  • Lips
  • Lining of your cheeks
  • Salivary glands (glands that make saliva)
  • Roof of your mouth (hard palate)
  • Back of your mouth (soft palate and uvula)
  • Floor of your mouth (area under the tongue)
  • Gums and teeth
  • Tongue
  • Tonsils

Understanding cancer

Cancer begins in cells, the building blocks that make up tissues. Tissues make up the organs of the body.

Normally, cells grow and divide to form new cells as the body needs them. When cells grow old, they die, and new cells take their place.

Sometimes this orderly process goes wrong. New cells form when the body does not need them, and old cells do not die when they should. These extra cells can form a mass of tissue called a growth or tumor.

Tumors can be benign or malignant:

  • Benign tumors are not cancer:
    • Benign tumors are rarely life-threatening.
    • Generally, benign tumors can be removed, and they usually do not grow back.
    • Cells from benign tumors do not invade the tissues around them.
    • Cells from benign tumors do not spread to other parts of the body.
  • Malignant tumors are cancer:
    • Malignant tumors are generally more serious than benign tumors. They may be life-threatening.
    • Malignant tumors often can be removed, but sometimes they grow back.
    • Cells from malignant tumors can invade and damage nearby tissues and organs.
    • Cells from malignant tumors can spread to other parts of the body. The cells spread by breaking away from the original cancer (primary tumor) and entering the bloodstream or lymphatic system. They invade other organs, forming new tumors and damaging these organs. The spread of cancer is called metastasis.

Oral cancer

Oral cancer is part of a group of cancers called head and neck cancers. Oral cancer can develop in any part of the oral cavity or oropharynx. Most oral cancers begin in the tongue and in the floor of the mouth. Almost all oral cancers begin in the flat cells (squamous cells) that cover the surfaces of the mouth, tongue, and lips. These cancers are called squamous cell carcinomas.

When oral cancer spreads (metastasizes), it usually travels through the lymphatic system. Cancer cells that enter the lymphatic system are carried along by lymph, a clear, watery fluid. The cancer cells often appear first in nearby lymph nodes in the neck.

Cancer cells can also spread to other parts of the neck, the lungs, and other parts of the body. When this happens, the new tumor has the same kind of abnormal cells as the primary tumor. For example, if oral cancer spreads to the lungs, the cancer cells in the lungs are actually oral cancer cells. The disease is metastatic oral cancer, not lung cancer. It is treated as oral cancer, not lung cancer. Doctors sometimes call the new tumor "distant" or metastatic disease.

Oral cancer: Who's at risk?

Doctors cannot always explain why one person develops oral cancer and another does not. However, we do know that this disease is not contagious. You cannot "catch" oral cancer from another person.

Research has shown that people with certain risk factors are more likely than others to develop oral cancer. A risk factor is anything that increases your chance of developing a disease.

The following are risk factors for oral cancer:

  • Tobacco: Tobacco use accounts for most oral cancers. Smoking cigarettes, cigars, or pipes; using chewing tobacco; and dipping snuff are all linked to oral cancer. The use of other tobacco products (such as bidis and kreteks) may also increase the risk of oral cancer. Heavy smokers who use tobacco for a long time are most at risk. The risk is even higher for tobacco users who drink alcohol heavily. In fact, three out of four oral cancers occur in people who use alcohol, tobacco, or both alcohol and tobacco.
  • Alcohol: People who drink alcohol are more likely to develop oral cancer than people who don't drink. The risk increases with the amount of alcohol that a person consumes. The risk increases even more if the person both drinks alcohol and uses tobacco.
  • Sun: Cancer of the lip can be caused by exposure to the sun. Using a lotion or lip balm that has a sunscreen can reduce the risk. Wearing a hat with a brim can also block the sun's harmful rays. The risk of cancer of the lip increases if the person also smokes.
  • A personal history of head and neck cancer: People who have had head and neck cancer are at increased risk of developing another primary head and neck cancer. Smoking increases this risk.

Quitting tobacco reduces the risk of oral cancer. Also, quitting reduces the chance that a person with oral cancer will get a second cancer in the head and neck region. People who stop smoking can also reduce their risk of cancer of the lung, larynx, mouth, pancreas, bladder, and esophagus. There are many resources to help smokers quit:

  • The Cancer Information Service at 1-800-4-CANCER can talk with callers about ways to quit smoking and about groups that offer help to smokers who want to quit. Groups offer counseling in person or by telephone.
  • Also, your doctor or dentist can help you find a local smoking cessation program.
  • Your doctor can tell you about medicine (bupropion) or about nicotine replacement therapy, which comes as a patch, gum, lozenges, nasal spray, or inhaler.
  • The "National Cancer Institute Information Resources" section has information about the Federal Government's smoking cessation Web site, http://www.smokefree.gov.

Some studies suggest that not eating enough fruits and vegetables may increase the chance of getting oral cancer. Scientists also are studying whether infections with certain viruses (such as the human papillomavirus) are linked to oral cancer.

If you think you may be at risk, you should discuss this concern with your doctor or dentist. You may want to ask about an appropriate schedule for checkups. Your health care team will probably tell you that not using tobacco and limiting your use of alcohol are the most important things you can do to prevent oral cancers. Also, if you spend a lot of time in the sun, using a lip balm that contains sunscreen and wearing a hat with a brim will help protect your lips.

What are the symptoms of oral cancer?

Early detection

Your regular checkup is a good time for your dentist or doctor to check your entire mouth for signs of cancer. Regular checkups can detect the early stages of oral cancer or conditions that may lead to oral cancer. Ask your doctor or dentist about checking the tissues in your mouth as part of your routine exam.

Symptoms

Common symptoms of oral cancer include:

  • Patches inside your mouth or on your lips that are white, a mixture of red and white, or red
    • White patches (leukoplakia) are the most common. White patches sometimes become malignant.
    • Mixed red and white patches (erythroleukoplakia) are more likely than white patches to become malignant.
    • Red patches (erythroplakia) are brightly colored, smooth areas that often become malignant.
  • A sore on your lip or in your mouth that won't heal
  • Bleeding in your mouth
  • Loose teeth
  • Difficulty or pain when swallowing
  • Difficulty wearing dentures
  • A lump in your neck
  • An earache

Anyone with these symptoms should see a doctor or dentist so that any problem can be diagnosed and treated as early as possible. Most often, these symptoms do not mean cancer. An infection or another problem can cause the same symptoms.

Diagnosis of oral cancer

If you have symptoms that suggest oral cancer, the doctor or dentist checks your mouth and throat for red or white patches, lumps, swelling, or other problems. This exam includes looking carefully at the roof of the mouth, back of the throat, and insides of the cheeks and lips. The doctor or dentist also gently pulls out your tongue so it can be checked on the sides and underneath. The floor of your mouth and lymph nodes in your neck also are checked.

If an exam shows an abnormal area, a small sample of tissue may be removed. Removing tissue to look for cancer cells is called a biopsy. Usually, a biopsy is done with local anesthesia. Sometimes, it is done under general anesthesia. A pathologist then looks at the tissue under a microscope to check for cancer cells. A biopsy is the only sure way to know if the abnormal area is cancerous.

 

If you need a biopsy, you may want to ask the doctor or dentist some of the following questions:

  • Why do I need a biopsy?
  • How much tissue do you expect to remove?
  • How long will it take? Will I be awake? Will it hurt?
  • How soon will I know the results?
  • Are there any risks? What are the chances of infection or bleeding after the biopsy?
  • How should I care for the biopsy site afterward? How long will it take to heal?
  • Will I be able to eat and drink normally after the biopsy?
  • If I do have cancer, who will talk with me about treatment? When?

Treatment for oral cancer

Staging

If the biopsy shows that cancer is present, your doctor needs to know the stage (extent) of your disease to plan the best treatment. The stage is based on the size of the tumor, whether the cancer has spread and, if so, to what parts of the body.

Staging may require lab tests. It also may involve endoscopy. The doctor uses a thin, lighted tube (endoscope) to check your throat, windpipe, and lungs. The doctor inserts the endoscope through your nose or mouth. Local anesthesia is used to ease your discomfort and prevent you from gagging. Some people also may have a mild sedative. Sometimes the doctor uses general anesthesia to put a person to sleep. This exam may be done in a doctor's office, an outpatient clinic, or a hospital.

The doctor may order one or more imaging tests to learn whether the cancer has spread:

  • Dental x-rays: An x-ray of your entire mouth can show whether cancer has spread to the jaw.
  • Chest x-rays: Images of your chest and lungs can show whether cancer has spread to these areas.
  • CT scan: An x-ray machine linked to a computer takes a series of detailed pictures of your body. You may receive an injection of dye. Tumors in the mouth, throat, neck, or elsewhere in the body show up on the CT scan.
  • MRI: A powerful magnet linked to a computer is used to make detailed pictures of your body. The doctor can view these pictures on a monitor and can print them on film. An MRI can show whether oral cancer has spread.

Treatment

Many people with oral cancer want to take an active part in making decisions about their medical care. It is natural to want to learn all you can about your disease and your treatment choices. However, shock and stress after the diagnosis can make it hard to think of everything you want to ask the doctor. It often helps to make a list of questions before an appointment. To help remember what the doctor says, you may take notes or ask whether you may use a tape recorder. You may also want to have a family member or friend with you when you talk to the doctor -- to take part in the discussion, to take notes, or just to listen.

Your doctor may refer you to a specialist, or you may ask for a referral. Specialists who treat oral cancer include oral and maxillofacial surgeons, otolaryngologists (ear, nose, and throat doctors), medical oncologists, radiation oncologists, and plastic surgeons. You may be referred to a team that includes specialists in surgery, radiation therapy, or chemotherapy. Other health care professionals who may work with the specialists as a team include a dentist, speech pathologist, nutritionist, and mental health counselor.

Getting a second opinion

Before starting treatment, you might want a second opinion about the diagnosis and the treatment plan. Some insurance companies require a second opinion; others may cover a second opinion if you or your doctor requests it.

There are a number of ways to find a doctor for a second opinion:

  • Your doctor may refer you to one or more specialists. At cancer centers, several specialists often work together as a team.
  • The Cancer Information Service, at 1-800-4-CANCER, can tell you about nearby treatment centers.
  • A local or state medical or dental society, a nearby hospital, or a medical or dental school can usually provide the names of specialists in your area.
  • The American Board of Medical Specialties (ABMS) has a list of doctors who have had training and exams in their specialty. You can find this list in the Official ABMS Directory of Board Certified Medical Specialists. The directory is available in most public libraries. Or you can look up doctors at http://www.abms.org. (Click on Who's Certified.)
  • The American Dental Association (ADA) Web site provides a list of dentists by specialty and location. The ADA Member Directory is available on the Internet at http://www.ada.org.
  • The NCI provides a helpful fact sheet on how to find a doctor called "How To Find a Doctor or Treatment Facility If You Have Cancer." It is available on the Internet at http://cancer.gov/publications.

You may want to ask the doctor these questions before treatment begins:

  • What is the stage of the disease? Has the cancer spread? If so, where?
  • What are my treatment choices? Which do you recommend for me? Will I have more than one kind of treatment?
  • What are the expected benefits of each kind of treatment?
  • What are the risks and possible side effects of each treatment? How will treatment affect my normal activities? Will I be given anything to control side effects?
  • How long will treatment last?
  • Will I have to stay in the hospital?
  • What is the treatment likely to cost? Is this treatment covered by my insurance plan?
  • Would a clinical trial (research study) be appropriate for me? (See "The Promise of Cancer Research" for more information about clinical trials.)
  • Should I try to quit smoking?

Preparing for treatment

The choice of treatment depends mainly on your general health, where in your mouth or oropharynx the cancer began, the size of the tumor, and whether the cancer has spread. Your doctor can describe your treatment choices and the expected results. You will want to consider how treatment may affect normal activities such as swallowing and talking, and whether it will change the way you look. You and your doctor can work together to develop a treatment plan that meets your needs and personal values.

You do not need to ask all your questions or understand all the answers at once. You will have other chances to ask your doctor to explain things that are not clear and to ask for more information.

Methods of treatment

Oral cancer treatment may include surgery, radiation therapy, or chemotherapy. Some patients have a combination of treatments.

At any stage of disease, people with oral cancer may have treatment to control pain and other symptoms, to relieve the side effects of therapy, and to ease emotional and practical problems. This kind of treatment is called supportive care, symptom management, or palliative care. Information about supportive care is available on NCI's Web site at http://cancer.gov and from NCI's Cancer Information Service at 1-800-4-CANCER.

You may want to talk to the doctor about taking part in a clinical trial, a research study of new treatment methods. The section on "The Promise of Cancer Research" has more information about clinical trials.

Surgery

Surgery to remove the tumor in the mouth or throat is a common treatment for oral cancer. Sometimes the surgeon also removes lymph nodes in the neck. Other tissues in the mouth and neck may be removed as well. Patients may have surgery alone or in combination with radiation therapy.

You may want to ask the doctor these questions before having surgery:

  • What kind of operation do you recommend for me?
  • Do I need any lymph nodes removed? Why?
  • How will I feel after the operation? How long will I be in the hospital?
  • What are the risks of surgery?
  • Will I have trouble speaking, swallowing, or eating?
  • Where will the scars be? What will they look like?
  • Will I have any long-term effects?
  • Will I look different?
  • Will I need reconstructive or plastic surgery? When can that be done?
  • Will I lose my teeth? Can they be replaced? How soon?
  • Will I need to see a specialist for help with my speech?
  • When can I get back to my normal activities?
  • How often will I need checkups?
  • Would a clinical trial be appropriate for me?

Radiation therapy

Radiation therapy (also called radiotherapy) is a type of local therapy. It affects cells only in the treated area. Radiation therapy is used alone for small tumors or for patients who cannot have surgery. It may be used before surgery to kill cancer cells and shrink the tumor. It also may be used after surgery to destroy cancer cells that may remain in the area.

Radiation therapy uses high-energy rays to kill cancer cells. Doctors use two types of radiation therapy to treat oral cancer:

  • External radiation: The radiation comes from a machine. Patients go to the hospital or clinic once or twice a day, generally 5 days a week for several weeks.
  • Internal radiation (implant radiation): The radiation comes from radioactive material placed in seeds, needles, or thin plastic tubes put directly in the tissue. The patient stays in the hospital. The implants remain in place for several days. Usually they are removed before the patient goes home.

Some people with oral cancer have both kinds of radiation therapy.

You may want to ask the doctor these questions before having radiation therapy:

  • Which type of radiation therapy do you recommend for me? Why do I need this treatment?
  • When will the treatments begin? When will they end?
  • Should I see my dentist before I start treatment? If I need dental treatment, how much time does my mouth need to heal before radiation therapy starts?
  • What are the risks and side effects of this treatment? What can I do about them?
  • How will I feel during therapy?
  • What can I do to take care of myself during therapy?
  • How will my mouth and face look afterward?
  • Are there any long-term effects?
  • Can I continue my normal activities?
  • Will I need a special diet? For how long?
  • How often will I need checkups?
  • Would a clinical trial be appropriate for me?

Chemotherapy

Chemotherapy uses anticancer drugs to kill cancer cells. It is called systemic therapy because it enters the bloodstream and can affect cancer cells throughout the body.

Chemotherapy is usually given by injection. It may be given in an outpatient part of the hospital, at the doctor's office, or at home. Rarely, a hospital stay may be needed.

You may want to ask the doctor these questions before having chemotherapy:

  • Why do I need this treatment?
  • Which drug or drugs will I have?
  • How do the drugs work?
  • Should I see my dentist before I start chemotherapy? If I need dental treatment, how much time does my mouth need to heal before the chemotherapy begins?
  • What are the expected benefits of the treatment?
  • What are the risks and possible side effects of treatment? What can I do about them?
  • When will treatment start? When will it end?
  • Will I need to stay in the hospital? How long?
  • How will treatment affect my normal activities?
  • Would a clinical trial be appropriate for me?

Side effects of treatment for oral cancer

Because treatment often damages healthy cells and tissues, unwanted side effects are common. These side effects depend mainly on the location of the tumor and the type and extent of the treatment. Side effects may not be the same for each person, and they may even change from one treatment session to the next. Before treatment starts, your health care team will explain possible side effects and suggest ways to help you manage them.

may be viewed, downloaded, and ordered from http://cancer.gov/publications. These materials also may be ordered by calling the Cancer Information Service at 1-800-4-CANCER.

The National Institute of Dental and Craniofacial Research (NIDCR) also provides helpful materials. Head and Neck Radiation Treatment and Your Mouth, Chemotherapy and Your Mouth, and other booklets are available from NIDCR. See "National Institute of Dental and Craniofacial Research Information Resources" for a list of publications.

Surgery

It takes time to heal after surgery, and the time needed to recover is different for each person. You may be uncomfortable for the first few days after surgery. However, medicine can usually control the pain. Before surgery, you should discuss the plan for pain relief with your doctor or nurse. After surgery, your doctor can adjust the plan if you need more pain relief.

It is common to feel tired or weak for a while. Also, surgery may cause tissues in your face to swell. This swelling usually goes away within a few weeks. However, removing lymph nodes can result in swelling that lasts a long time.

Surgery to remove a small tumor in the mouth may not cause any lasting problems. For a larger tumor, however, the surgeon may remove part of the palate, tongue, or jaw. This surgery may change your ability to chew, swallow, or talk. Also, your face may look different after surgery. Reconstructive or plastic surgery may be done to rebuild the bones or tissues of the mouth. (See "Reconstruction.")

Radiation therapy

Almost all patients who have radiation therapy to the head and neck area develop oral side effects. That is why it is important to get the mouth in good condition before cancer treatment begins. Seeing a dentist two weeks before cancer treatment begins gives the mouth time to heal after dental work.

The side effects of radiation therapy depend mainly on the amount of radiation given. Some side effects in the mouth go away after radiation treatment ends, while others last a long time. A few side effects (such as dry mouth) may never go away.

Radiation therapy may cause some or all of these side effects:

  • Dry mouth: Dry mouth can make it hard for you to eat, talk, and swallow. It can also lead to tooth decay. You may find it helpful to drink lots of water, suck ice chips or sugar-free hard candy, and use a saliva substitute to moisten your mouth.
  • Tooth decay: Radiation can cause major tooth decay problems. Good mouth care can help you keep your teeth and gums healthy and can help you feel better.
    • Doctors usually suggest that people gently brush their teeth, gums, and tongue with an extra-soft toothbrush and fluoride toothpaste after every meal and before bed. If brushing hurts, you can soften the bristles in warm water.
    • Your dentist may suggest that you use fluoride gel before, during, and after radiation treatment.
    • It also helps to rinse your mouth several times a day with a solution made from 1/4 teaspoon baking soda and 1/8 teaspoon salt in one cup of warm water. After you rinse with this solution, follow with a plain water rinse.
  • Sore throat or mouth: Radiation therapy can cause painful ulcers and inflammation. Your doctor can suggest medicines to help control the pain. Your doctor also may suggest special rinses to numb the throat and mouth to help relieve the soreness. If your pain continues, you can ask your doctor about stronger medicines.
  • Sore or bleeding gums: It is important to brush and floss teeth gently. You may want to avoid areas that are sore or bleeding. To protect your gums from damage, it is a good idea to avoid the use of toothpicks.
  • Infection: Dry mouth and damage to the lining of the mouth from radiation therapy can cause infection to develop. It helps to check your mouth every day for sores or other changes and to tell your doctor or nurse about any mouth problems.
  • Delayed healing after dental care: Radiation treatment may make it hard for tissues in the mouth to heal. It helps to have a thorough dental exam and complete all needed dental treatment well before radiation therapy begins.
  • Jaw stiffness: Radiation can affect the chewing muscles and make it difficult for you to open your mouth. You can prevent or reduce jaw stiffness by exercising your jaw muscles. Health care providers often suggest opening and closing the mouth as far as possible (without causing pain) 20 times in a row, 3 times a day.
  • Denture problems: Radiation therapy can change the tissues in your mouth so that dentures do not fit anymore. Because of soreness and dry mouth, some people may not be able to wear dentures for as long as one year after radiation therapy. After the tissues heal completely and your mouth is no longer sore, your dentist may need to refit or replace your dentures.
  • Changes in the sense of taste and smell: During radiation therapy, food may taste or smell different.
  • Changes in voice quality: Your voice may be weak at the end of the day. It may also be affected by changes in the weather. Radiation directed at the neck may cause your larynx to swell, causing voice changes and the feeling of a lump in your throat. Your doctor may suggest medicine to reduce this swelling.
  • Changes in the thyroid: Radiation treatment can affect your thyroid (an organ in your neck beneath the voice box). If your thyroid does not make enough thyroid hormone, you may feel tired, gain weight, feel cold, and have dry skin and hair. Your doctor can check the level of thyroid hormone with a blood test. If the level is low, you may need to take thyroid hormone pills.
  • Skin changes in the treated area: The skin in the treated area may become red or dry. Good skin care is important at this time. It is helpful to expose this area to the air while protecting it from the sun. Also, avoid wearing clothes that rub the treated area, and do not shave the treated area. You should not use lotions or creams in the treated area without your doctor's advice.
  • Fatigue: You may become very tired, especially in the later weeks of radiation therapy. Resting is important, but doctors usually advise their patients to stay as active as they can.

Although the side effects of radiation therapy can be distressing, your doctor can usually treat or control them. It helps to report any problems that you are having so that your doctor can work with you to relieve them.

Chemotherapy

Chemotherapy and radiation therapy can cause some of the same side effects, including painful mouth and gums, dry mouth, infection, and changes in taste. Some anticancer drugs can also cause bleeding in the mouth and a deep pain that feels like a toothache. The problems you have depend on the type and amount of anticancer drugs you receive, and how your body reacts to them. You may have these problems only during treatment or for a short time after treatment ends.

Generally, anticancer drugs affect cells that divide rapidly. In addition to cancer cells, these rapidly dividing cells include the following:

  • Blood cells: These cells fight infection, help your blood to clot, and carry oxygen to all parts of the body. When drugs affect your blood cells, you are more likely to get infections, bruise or bleed easily, and feel very weak and tired.
  • Cells in hair roots: Chemotherapy can lead to hair loss. The hair grows back, but sometimes the new hair is somewhat different in color and texture.
  • Cells that line the digestive tract: Chemotherapy can cause poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores. Many of these side effects can be controlled with drugs.

Nutrition

Eating well during cancer treatment means getting enough calories and protein to prevent weight loss, regain strength, and rebuild healthy tissues. But eating well may be difficult after treatment for oral cancer. Some people with cancer find it hard to eat because they lose their appetite. They may not feel like eating because they are uncomfortable or tired. A dry or sore mouth or changes in smell and taste also may make eating difficult.

If your mouth is dry, you may find that soft foods moistened with sauces or gravies are easier to eat. Thick soups, puddings, and milkshakes often are easier to swallow. Nurses and dietitians can help you choose the right foods. Also, the National Cancer Institute booklet Eating Hints for Cancer Patients contains many useful ideas and recipes. The "National Cancer Institute Information Resources" section tells how to get this publication.

After surgery or radiation therapy for oral cancer, some people need a feeding tube. A feeding tube is a flexible plastic tube that is passed into the stomach through an incision in the abdomen. In almost all cases, the tube is temporary. Most people gradually return to a regular diet.

To protect your mouth during cancer treatment, it helps to avoid:

  • Sharp, crunchy foods like taco chips
  • Foods that are hot, spicy, or high in acid like citrus fruits and juices
  • Sugary foods that can cause cavities
  • Alcoholic drinks

Reconstruction

Some people with oral cancer may need to have plastic or reconstructive surgery to rebuild the bones or tissues of the mouth. Research has led to many advances in the way bones and tissues can be replaced.

Some people may need dental implants. Or they may need to have grafts (tissue moved from another part of the body). Skin, muscle, and bone can be moved to the oral cavity from the chest, arm, or leg. The plastic surgeon uses this tissue for repair.

If you are thinking about reconstruction, you may wish to consult with a plastic or reconstructive surgeon before your treatment begins. You can have reconstructive surgery at the same time as you have the cancer removed, or you can have it later on. Talk with your doctor about which approach is right for you.

Rehabilitation

The health care team will help you return to normal activities as soon as possible. The goals of rehabilitation depend on the extent of the disease and type of treatment. Rehabilitation may include being fitted with a dental prosthesis (an artificial dental device) and having dental implants. It also may involve speech therapy, dietary counseling, or other services.

Sometimes surgery to rebuild the bones or tissues of the mouth is not possible. A dentist with special training (a prosthodontist) may be able to make you a prosthesis to help you eat and talk normally. You may need special training to learn to use it.

If oral cancer or its treatment leads to problems with talking, speech therapy will generally begin as soon as possible. A speech therapist may see you in the hospital to plan therapy and teach speech exercises. Often speech therapy continues after you return home.

Follow-up care for oral cancer

Follow-up care after treatment for oral cancer is important. Even when the cancer seems to have been completely removed or destroyed, the disease sometimes returns because undetected cancer cells remained in the body after treatment. The doctor monitors your recovery and checks for recurrence of cancer. Checkups help ensure that any changes in your health are noted. Your doctor will probably encourage you to inspect your mouth regularly and continue to have exams when you visit your dentist. It is important to report any changes in your mouth right away.

Checkups include exams of the mouth, throat, and neck. From time to time, your doctor may do a complete physical exam, order blood tests, and take x-rays.

People who have had oral cancer have a chance of developing a new cancer in the mouth, throat, or other areas of the head and neck. This is especially true for those who use tobacco or who drink alcohol heavily. Doctors strongly urge their patients to stop using tobacco and drinking to cut down the risk of a new cancer and other health problems.

The NCI has prepared a booklet for people who have completed their treatment to help answer questions about follow-up care and other concerns. Facing Forward Series: Life After Cancer Treatment provides tips for making the best use of medical visits. It describes how to talk to your health care team about creating a plan of action for recovery and future health.

Support for people with oral cancer

Living with a serious disease such as oral cancer is not easy. You may worry about caring for your family, keeping your job, or continuing daily activities. You may have concerns about treatments and managing side effects, hospital stays, and medical bills. Doctors, nurses, and other members of the health care team can answer your questions about treatment, working, or other activities. Meeting with a social worker, counselor, or member of the clergy can be helpful if you want to talk about your feelings or discuss your concerns. Often, a social worker can suggest resources for financial aid, transportation, home care, or emotional support.

Support groups also can help. In these groups, patients or their family members meet with other patients or their families to share what they have learned about coping with the disease and the effects of treatment. Groups may offer support in person, over the telephone, or on the Internet. You may want to talk with a member of your health care team about finding a support group. The NCI's fact sheets "Cancer Support Groups: Questions and Answers" and "National Organizations That Offer Services to People With Cancer and Their Families" tell how to find a support group. See "National Cancer Institute Information Resources" for ordering information.

The Cancer Information Service can provide information to help patients and their families locate programs, services, and publications.

The promise of cancer research

Doctors all over the country are conducting many types of clinical trials. These are research studies in which people volunteer to take part. In clinical trials, doctors are testing new ways to treat oral cancer. Research has already led to advances, and researchers continue to search for more effective approaches.

People who join clinical trials may be among the first to benefit if a new approach is shown to be effective. And if participants do not benefit directly, they still make an important contribution to medical science by helping doctors learn more about the disease and how to control it. Although clinical trials may pose some risks, researchers do all they can to protect their patients.

Researchers are testing anticancer drugs and combinations of drugs. They are studying radiation therapy combined with drugs and other treatments. They also are testing drugs that prevent or reduce the side effects of radiation therapy.

If you are interested in learning more about joining a clinical trial, you may want to talk with your doctor. You may want to read Taking Part in Clinical Trials: What Cancer Patients Need To Know. The NCI also offers an easy-to-read brochure called If You Have Cancer...What You Should Know About Clinical Trials. These NCI publications describe how research studies are carried out and explain their possible benefits and risks.

Oral Cancer At A Glance
  • Oral cancer is caused by tobacco (smoking and chewing) and alcohol use.
  • A sore in the mouth that does not heal can be a warning sign of oral cancer.
  • A biopsy is the only to know whether as abnormal area in the oral cavity is cancer.
  • Treatment of oral cancer depends on the location, size, type, and extent of the tumor, as well as the age and health of the patient.
  • Surgery to remove the tumor in the mouth is the usual treatment for patients with oral cancer.

The Heart and Vascular Disease

 

  • Peripheral artery disease
  • Aneurysm
  • Renal (kidney) artery disease
  • Raynaud's Phenomenon
  • Buerger's Disease
  • Peripheral venous disease
  • Varicose veins
  • Blood clots in the veins
  • Blood clotting disorders
  • Lymphedema
  • Find a local Cardiologist in your town

Vascular disease includes any condition that affects the circulatory system. As the heart beats, it pumps blood through a system of blood vessels called the circulatory system. The vessels are elastic tubes that carry blood to every part of the body. Arteries carry blood away from the heart while veins return it.

Vascular disease ranges from diseases of your arteries, veins, and lymph vessels to blood disorders that affect circulation. The following are conditions that fall under the category of vascular disease.

 

Peripheral Artery Disease

Like the blood vessels of the heart (coronary arteries), your peripheral arteries (blood vessels outside your heart) also may develop atherosclerosis, the build-up of fat and cholesterol deposits, called plaque, on the inside walls. Over time, the build-up narrows the artery. Eventually the narrowed artery causes less blood to flow and a condition called "ischemia" can occur. Ischemia is inadequate blood flow to the body's tissue.

  • A blockage in the coronary arteries can cause symptoms of chest pain (angina) or a heart attack.
  • A blockage in the carotid arteries (the arteries supplying the brain) can lead to a transient ischemic attack (TIA) or stroke.
  • A blockage in the legs can lead to leg pain or cramps with activity (a condition called claudication), changes in skin color, sores or ulcers, and feeling tired in the legs. Total loss of circulation can lead to gangrene and loss of a limb.
  • A blockage in the renal arteries (arteries supplying the kidneys) can cause renal artery disease (stenosis). The symptoms include uncontrolled hypertension (high blood pressure), heart failure, and abnormal kidney function.

Aneurysm

An aneurysm is an abnormal bulge in the wall of a blood vessel. They can form in any blood vessel, but they occur most commonly in the aorta (aortic aneurysm) which is the main blood vessel leaving the heart. The two types of aortic aneurysm are:

  • Thoracic aortic aneurysm (part of aorta in the chest)
  • Abdominal aortic aneurysm

Small aneurysms generally pose no threat. However, one is at increased risk for:

  • Atherosclerotic plaque (fat and calcium deposits) formation at the site of the aneurysm.
  • A clot (thrombus) may form at the site and dislodge.
  • Increase in the aneurysm size, causing it to press on other organs, causing pain.
  • Aneurysm rupture -- because the artery wall thins at this spot, it is fragile and may burst under stress. A sudden rupture of an aortic aneurysm may be life threatening.

Renal (Kidney) Artery Disease

Renal artery disease is most commonly caused by atherosclerosis of the renal arteries (see above). It occurs in people with generalized vascular disease. Less often, renal artery disease can be caused by a congenital (present at birth) abnormal development of the tissue that makes up the renal arteries. This type of renal artery disease occurs in younger age groups.

Raynaud's Phenomenon (Also Called Raynaud's Disease or Raynaud's Syndrome)

Raynaud's phenomenon consists of spasms of the small arteries of the fingers and sometimes the toes, brought on by exposure to cold or excitement. Certain occupational exposures bring on Raynaud's. The episodes produce temporary lack of blood supply to the area, causing the skin to appear white or bluish and cold or numb. In some cases, the symptoms of Raynaud's may be related to underlying diseases (ie, lupus, rheumatoid arthritis, scleroderma).

Buerger's Disease

Buerger's disease most commonly affects the small and medium sized arteries, veins, and nerves. Although the cause is unknown, there is a strong association with tobacco use or exposure. The arteries of the arms and legs become narrowed or blocked, causing lack of blood supply (ischemia) to the fingers, hands, toes, and feet. Pain occurs in the arms, hands and, more frequently, the legs and feet, even when at rest. With severe blockages, the tissue may die (gangrene), requiring amputation of the fingers and toes.

Superficial vein inflammation and symptoms of Raynaud's occur commonly in patients with Buerger's disease.

Peripheral Venous Disease

Veins are flexible, hollow tubes with flaps inside called valves. When your muscles contract, the valves open and blood moves through the veins. When your muscles relax, the valves close, keeping blood flowing in one direction through the veins.

If the valves inside your veins become damaged, the valves may not close completely. This allows blood to flow in both directions. When your muscles relax, the valves inside the damaged vein(s) will not be able to hold the blood. This can cause pooling of blood or swelling in the veins. The veins bulge and appear as ropes under the skin. The blood begins to move more slowly through the veins, it may stick to the sides of the vessel walls and blood clots can form.

 

Varicose Veins

Varicose veins are bulging, swollen, purple, ropy veins, seen just under your skin, caused by damaged valves within the veins. They are more common in women than men and often run in families. They can also be caused by pregnancy, being severely overweight, or by standing for long periods of time. The symptoms of varicose veins include:

  • Bulging, swollen, purple, ropy, veins seen under the skin.
  • Spider veins -- small red or purple bursts on your knees, calves, or thighs, caused by swollen capillaries (small blood vessels).
  • Aching, stinging, or swelling of the legs at the end of the day.

Blood Clots In the Veins

Blood clots in the veins are usually caused by:

  • Long bed rest and/or immobility.
  • Damage to veins from injury or infection.
  • Damage to the valves in the vein, causing pooling near the valve flaps.
  • Pregnancy and hormones (such as estrogen or birth control pills).
  • Genetic disorders.
  • Conditions causing slowed blood flow or thicker blood, such as congestive heart failure (CHF), or certain tumors.

There are many types of blood clots that can occur in the veins:

  • Deep vein thrombosis (DVT) is a blood clot occurring in a deep vein.
  • Pulmonary embolism is a blood clot that breaks loose from a vein and travels to the lungs.
  • Chronic venous insufficiency isn't a blood clot, but a condition that occurs when damaged vein valves or a DVT causes long-term pooling of blood and swelling in the legs. If uncontrolled, fluid will leak into the surrounding tissues in the ankles and feet, and may eventually cause skin breakdown and ulceration.

Blood Clotting Disorders

Blood clotting disorders are conditions that make the blood more likely to form blood clots in the arteries and veins. These conditions may be inherited (congenital, occurring at birth) or acquired during life and include:

  • Elevated levels of factors in the blood which cause blood to clot (fibrinogen, factor 8, prothrombin).
  • Deficiency of natural anticoagulant (blood-thinning) proteins (antithrombin, protein C, protein S).
  • Elevated blood counts.
  • Abnormal fibrinolysis (the breakdown of fibrin).
  • Abnormal changes in the lining of the blood vessels (endothelium).

Lymphedema

The lymphatic system is a circulatory system that includes an extensive network of lymph vessels and lymph nodes. The lymphatic system helps coordinate the immune system's function to protect the body from foreign substances.

Lymphedema is an abnormal build-up of fluid that causes swelling, most often in the arms or legs. Lymphedema develops when lymph vessels or lymph nodes are missing, impaired, damaged, or removed.

Primary lymphedema is rare and is caused by the absence of certain lymph vessels at birth, or it may be caused by abnormalities in the lymphatic vessels.

Secondary lymphedema occurs as a result of a blockage or interruption that alters the lymphatic system. Secondary lymphedema can develop from an infection, malignancy, surgery, scar tissue formation, trauma, deep vein thrombosis (DVT), radiation, or other cancer treatment.

Bug Bites and Stings

 

View Slideshow Pictures

 

10 Common Allergy Triggers Slideshow Pictures 10 Common Allergy Triggers
Take the Quiz on Allergies Allergies Quiz: Test Your Medical IQ
Nasal Allergy Relief Slideshow Pictures Nasal Allergy Relief Slideshow Pictures

 

  • What can I do to keep insects away?
  • What's the proper way to use insect repellent?
  • What's the best way to remove a bee stinger?
  • What should I do if I find a tick on me or my child?
  • What can be done for itching and pain from bites and stings?
  • When is medical attention needed?
  • Where can I find more information on bug bites and stings?

Warm weather makes it easier to spend more time outdoors, but it also brings out the bugs. Ticks are usually harmless. But a tick bite can lead to Lyme disease, which is caused by the bacterium Borrelia burgdorferi. The bacteria are transmitted to people by the black-legged deer tick, which is about the size of a pinhead and usually lives on deer. Infected ticks can also cause other diseases, such as Rocky Mountain spotted fever.

Another insect-borne illness, West Nile virus, is transmitted by infected mosquitoes and usually produces mild symptoms in healthy people. But the illness can be serious for older people and those with compromised immune systems.

Most reactions to bees and other stinging insects are mild, but severe allergic reactions can be deadly. An allergic reaction can occur even if a person has been stung before with no complications.

Here are tips for preventing and treating bites and stings.

What can I do to keep insects away?

  • Use structural barriers such as window screens and netting.
  • Avoid wooded, brushy, and grassy areas when possible.
  • Don't wear heavily scented soaps and perfumes.
  • Use caution eating outside and drinking; don't leave drinks and garbage cans uncovered.
  • Don't wear bright colors, which attract bees.
  • Wear long sleeves and long pants when possible.
  • Tuck pant legs into socks or shoes.
  • Wear a hat for extra protection.
  • Get rid of containers with standing water that give mosquitoes a breeding ground. Examples include water in flowerpots and outdoor pet dishes.
  • Use insect repellent if nonchemical methods are ineffective and you spend time in tall grass and woody areas.
  • Treat camping gear, clothes, and shoes with permethrin, which repels and kills ticks, mosquitoes, and other insects. Clothing that is pre-treated with permethrin is also commercially available.

What's the proper way to use insect repellent?

It's okay to use insect repellent and sunscreen at the same time. The general recommendation is to apply sunscreen first, followed by repellent. There are also some combination products that contain both insect repellent and sunscreen. FDA regulates sunscreen as an over-the-counter (OTC) drug. The Environmental Protection Agency (EPA) regulates insect repellent products.

  • Use insect repellent that contains active ingredients that have been registered with EPA. An EPA registration number on the product label means the product has been evaluated by EPA to ensure that it will not pose unreasonable harmful effects on people and the environment.
  • Spray insect repellent on clothes or skin, but not on the face.
  • Don't use insect repellent on babies. Repellent used on older children should contain no more than 10 percent DEET. Oil of eucalyptus products should not be used in children under 3 years.
  • Don't use insect repellent that's meant for people on your pets.
  • Use insect repellent according to the labeled instructions.
  • Avoid applying it to children's hands, around the eyes, or to areas where there are cuts and irritated skin.
  • Store insect repellent out of children's reach.
  • Wash the repellent off with soap and water and contact a Poison Control Center (1-800-222-1222) if you (or your child) experience a reaction to insect repellent.
  • After returning indoors, wash skin with soap and water to remove repellent.

What's the best way to remove a bee stinger?

It's best to scrape a stinger away in a side-to-side motion with a straight-edged object like a credit card. Don't use tweezers because it may push more venom into the skin. After removing a stinger, wash the area with soap and water. You can apply ice or another cold compress to help reduce swelling.

What should I do if I find a tick on me or my child?

Wearing light-colored clothing makes it easier to spot ticks. Check for ticks after outdoor activities. If you find a tick, remove it with tweezers. Grasp the tick as close to the skin as possible and pull it straight out. Then drop it in a plastic bag, seal it up, and throw it away. Early removal of a tick is important because a tick generally has to be on the skin for 36 hours to transmit Lyme disease. People who want to get a tick tested for disease or other information could check with their local health departments to see if they offer tick testing. After removing a tick, you can cleanse the area of the tick bite with antiseptic, such as rubbing alcohol or soap and water.

What can be done for itching and pain from bites and stings?

Oral OTC antihistamines can bring itch relief. Oral OTC drugs, such as ibuprofen and acetaminophen, can provide relief of pain from bites and stings.

In addition, there are many topical OTC drugs that are applied to the skin and can provide itch and pain relief. Some of these topical OTC drugs are labeled as "external analgesics" or "topical analgesics." They contain ingredients such as hydrocortisone, pramoxine, and lidocaine. There are also topical OTC drugs labeled as "skin protectants" that provide itch relief for insect bites and stings. These products contain ingredients such as colloidal oatmeal and sodium bicarbonate.

 

Keep kids' nails short. If they scratch the area and break the skin, it can lead to a bacterial infection that will require treatment with antibiotics.

When is medical attention needed?

Most bites and stings are minor and can be treated at home. But you should seek medical attention if you experience the following symptoms:

Signs of allergic reaction: Some people can experience anaphylaxis, a severe, life-threatening allergic reaction. This is a medical emergency that warrants calling 9-1-1 immediately. Signs of an allergic reaction, which may occur within seconds to minutes, include sneezing, wheezing, hives, nausea, vomiting, diarrhea, sudden anxiety, dizziness, difficulty breathing, chest tightness, and itching or swelling of the eyes, lips, or other areas of the face. If you or your child has ever had an allergic reaction to a sting or bite, you should be evaluated by an allergist. In some cases, you may be advised to wear a medical identification tag that states the allergy, and to carry epinephrine, a medication used to treat serious or life-threatening allergic reactions. Sometimes allergy shots may also be recommended.

Symptoms of Lyme disease: Lyme disease, which is transmitted through the bite of an infected tick, can cause fever, headaches, fatigue, and a skin rash that looks like a circular red patch, or "bull's-eye." Left untreated, infection can spread to the joints, heart, and nervous system. It is rarely, if ever, fatal. Patients who are treated with antibiotics in the early stages of the infection usually recover rapidly and completely. Antibiotics commonly used for oral treatment include doxycycline, amoxicillin, or cefuroxime axetil (Ceftin). People with certain illnesses related to the heart or the nervous system require intravenous treatment with drugs such as ceftriaxone or penicillin.

 

Symptoms of West Nile virus: West Nile virus, which is transmitted by infected mosquitoes, can produce flu-like symptoms including fever, headache, body aches, and skin rash. While most infected individuals have mild disease and recover spontaneously, infection can be serious or even fatal. There is no specific treatment for West Nile virus.

Symptoms of Rocky Mountain spotted fever: Initial symptoms may include fever, nausea, vomiting, severe headache, muscle pain, and lack of appetite. The characteristic red, spotted rash of Rocky Mountain spotted fever is usually not seen until the sixth day or later after symptoms begin. But as many as 10 percent to 15 percent of patients may never develop a rash. Rocky Mountain spotted fever is treated with antibiotics.

Signs of infection: It is normal for a bite or sting to result in redness of the affected area and minor swelling. But if a bite or sting becomes infected, a fever may develop or the redness or soreness may worsen. In cases of infection, an antibiotic is the typical treatment.

Herniated Disc
(Disc Herniation of the Spine)

 

 

View the Back Pain Slideshow Pictures

 

Back Pain Slideshow Pictures View the Back Pain Slideshow Pictures
Slideshow: Good & Bad Exercises for Low Back Pain Good and Bad Exercises for Low Back Pain Slideshow
Take the Back Pain Quiz!
  • How are the spine and its discs designed?
  • What is a herniated disc? What causes it?
  • What are symptoms of a herniated disc?
  • How is a herniated disc diagnosed?
  • How is a herniated disc treated?
  • Herniated Disc At A Glance
  • Patient Discussions: Herniated Disc
  • Find a local Orthopedic Surgeon in your town

How are the spine and its discs designed?

The vertebrae are the bony building blocks of the spine. Between each of the largest parts (bodies) of the vertebrae are the discs. Ligaments are situated around the spine and discs. The spine has seven vertebrae in the neck (cervical vertebrae), 12 vertebrae in the mid-back (thoracic vertebrae), and five vertebrae in the low back (lumbar vertebrae). In addition, in the mid-buttock, beneath the fifth lumbar vertebra, is the sacrum, followed by the tailbone (coccyx).

The bony spine is designed so that vertebrae "stacked" together can provide a movable support structure while also protecting the spinal cord (nervous tissue that extends down the spinal column from the brain) from injury. Each vertebra has a spinous process, which is a bony prominence behind the spinal cord that shields the cord's nerve tissue. The vertebrae also have a strong bony "body" in front of the spinal cord to provide a platform suitable for weight-bearing.

The discs are pads that serve as "cushions" between the vertebral bodies that serve to minimize the impact of movement on the spinal column. Each disc is designed like a jelly donut with a central softer component (nucleus pulposus). Ligaments are strong fibrous soft tissues that firmly attach bones to bones. Ligaments attach each of the vertebrae and surround each of the discs. When ligaments are injured as the disc degenerates, localized pain in the area affected can result.

What is a herniated disc? What causes it?

As described above, each disc of the spine is designed much like a jelly donut. As the disc degenerates from age or injury, the softer central portion can rupture (herniate) through the surrounding outer ring (annulus fibrosus). This abnormal rupture of the central portion of the disc is referred to as a disc herniation.

The most common location for a herniated disc to occur is in the disc at the level between the fourth and fifth lumber vertebrae in the low back. This area is constantly absorbing the impact of bearing the weight of the upper body. This is especially important when we are standing or sitting. The lower back is also critically involved in our body's movements throughout the day, as we twist the torso in rotating side to side and as we hinge the back in flexion and extension while bending or lifting.

Picture of herniated disc between L4 and L5
Picture of herniated disc between L4 and L5

Cross-section picture of herniated disc between L4 and L5
Cross-section picture of herniated disc between L4 and L5

Picture of stapled incision post-surgery
Picture of stapled incision post-surgery

What are symptoms of a herniated disc?

The symptoms of a herniated disc depend on the exact level of the spine where the disc herniation occurs and whether or not nerve tissue is being irritated. A disc herniation may not cause any symptoms. However, disc herniation can cause local pain at the level of the spine affected.

If the disc herniation is large enough, the disc tissue can press on the adjacent spinal nerves that exit the spine at the level of the disc herniation. This can cause shooting pain in the distribution of that nerve and usually occurs on one side of the body. For example, a disc herniation at the level between the fourth and fifth lumbar vertebrae of the low back can cause a shooting pain down the buttock into the back of the thigh and down the leg. Sometimes this is associated with numbness and tingling in the leg. The pain often is worsened upon standing and decreases with lying down.

If the disc herniation is extremely large, it can press on spinal nerves on both sides of the body. This can result in severe pain down both lower extremities. There can be marked weakness of the lower extremities and even incontinence of bowel and bladder. This is medically referred to as cauda equina syndrome.

How is a herniated disc diagnosed?

The doctor will suspect a herniated disc when symptoms described above are present. The neurologic examination can reveal abnormal reflexes. Often pain can be elicited when the straight leg is raised when lying or sitting. This is referred to as a "positive straight leg raising test." There can be abnormal sensation in the foot or leg.

A variety of blood tests are frequently done to determine if there are signs of inflammation or infection.

Plain film X-rays can indicate "wear and tear" (degeneration) of the spine. They do not, however, demonstrate the status of discs. In order to determine whether or not a disc is herniated, an MRI scan or CT scan is performed for diagnosis.

An electromyogram (EMG) can be used to document precisely which nerves are being irritated by a disc herniation.

How is a herniated disc treated?

Occasionally, disc herniation is incidentally detected when a test such as an MRI is performed for other reasons. If no symptoms are present, no particular treatment is necessary.

Depending on the severity of symptoms, treatments for a herniated disc include physical therapy, muscle relaxant medications, pain medications, antiinflammation medications, local injection of cortisone (epidural injections), and surgical operations. In any case, all people with a disc herniation should rest and avoid reinjuring the disc. Sometimes, even people with relatively severe pain early on can respond to conservative measures without the need for surgical intervention.

There are now a variety of surgical approaches to treat disc herniation. Each type of operation is customized to the individual situation and depends a great deal on the condition of the spine around the disc affected. Surgical options include microdiscectomy using small surgical instruments and open surgical repair (either from a posterior or anterior approach). Urgent operation can be necessary when cauda equine syndrome is present (described above).

Herniated Disc At-A-Glance
  • The discs are pads that serve as "cushions" between the vertebral bodies, which minimize the impact of movement on the spinal column.
  • Each disc is designed like a jelly donut with a central softer component (nucleus pulposus).
  • Abnormal rupture of the central portion of the disc is referred to as a disc herniation.
  • The most common location for a herniated disc to occur is in the disc at the level between the fourth and fifth lumbar vertebrae in the low back.
  • If the disc herniation is large enough, the disc tissue can press on the adjacent spinal nerves that exit the spine at the level of the disc herniation.
  • The physical examination, imaging tests, and electrical tests can aid in the diagnosis of a herniated disc.
  • Depending on the severity of symptoms, treatments for a herniated disc include physical therapy, muscle relaxant medications, pain medication, antiinflammation medications, local injection of cortisone (epidural injections), and surgical operations.

Degenerative Disc Disease & Sciatica

 

 

View the Back Pain Slideshow Pictures

 

Back Pain Slideshow Pictures View the Back Pain Slideshow Pictures
Slideshow: Good & Bad Exercises for Low Back Pain Good and Bad Exercises for Low Back Pain Slideshow
Take the Back Pain Quiz!
  • How is the spine designed?
  • What is the purpose of the spine and its discs?
  • What is degenerative disc disease? What are the symptoms?
  • What are radiculopathy and sciatica? What are the symptoms?
  • How is radiculopathy diagnosed?
  • How is radiculopathy treated?
  • What is bony encroachment and spinal stenosis?
  • Degenerative Disc Disease & Sciatica At A Glance
  • Patient Discussions: Degenerative Disc Disease & Sciatica - Symptoms and Signs
  • Patient Discussions: Degenerative Disc Disease & Sciatica - Effective Treatments
  • Find a local Orthopedic Surgeon in your town

 

How is the spine designed?

The vertebrae are the bony building blocks of the spine. Between each of the largest part of the vertebrae are the discs. Ligaments are situated around the spine and discs. The spine has seven vertebrae in the neck (cervical vertebrae), 12 vertebrae in the mid-back (thoracic vertebrae), and five vertebrae in the low back (lumbar vertebrae). In addition, in the mid-buttock, beneath the fifth lumbar vertebra, is sacrum followed by the tailbone (coccyx).

What is the purpose of the spine and its discs?

The bony spine is designed so that vertebrae "stacked" together can provide a movable support structure while also protecting the spinal cord (nervous tissue that extends down the spinal column from the brain) from injury. Each vertebra has a spinous process, which is a bony prominence behind the spinal cord that shields the cord's nerve tissue. The vertebrae also have a strong bony "body" in front of the spinal cord to provide a platform suitable for weight-bearing.

The discs are pads that serve as "cushions" between each vertebral body that serve to minimize the impact of movement on the spinal column. Each disc is designed like a jelly donut with a central softer component (nucleus pulposus). This softer component can rupture (herniate) through the surrounding outer ring (annulus fibrosus) and irritate adjacent nervous tissue. Ligaments are strong fibrous soft tissues that firmly attach bones to bones. Ligaments attach each of the vertebrae and surround each of the discs. When ligaments are injured as the disc degenerates, localized pain in the area affected can result.

Picture of herniated disc between L4 and L5
Picture of herniated disc between L4 and L5

Cross-section picture of herniated disc between L4 and L5
Cross-section picture of herniated disc between L4 and L5

Picture of stapled incision post-surgery
Picture of stapled incision post-surgery

What is degenerative disc disease? What are the symptoms?

As we age, the water and protein content of the cartilage of the body changes. This change results in weaker, more fragile and thin cartilage. Because both the discs and the joints that stack the vertebrae (facet joints) are partly composed of cartilage, these areas are subject to wear and tear over time (degenerative changes). The gradual deterioration of the disc between the vertebrae is referred to as degenerative disc disease. Wear of the facet cartilage and the bony changes of the adjacent joint is referred to as degenerative facet joint disease or osteoarthritis of the spine.

Degeneration of the disc is medically referred to as spondylosis. Spondylosis can be noted on x-ray tests or MRI scanning of the spine as a narrowing of the normal "disc space" between the adjacent vertebrae.

Degeneration of the disc tissue makes the disc more susceptible to herniation. Degeneration of the disc can cause local pain in the affected area. Any level of the spine can be affected by disc degeneration. When disc degeneration affects the spine of the neck, it is referred to as cervical disc disease. When the mid-back is affected, the condition is referred to as thoracic disc disease. Disc degeneration that affects the lumbar spine is referred to as lumbago. Lumbago causes pain localized to the low back and is common in older people. Degenerative arthritis (osteoarthritis) of the facet joints is also a cause of localized lumbar pain that can be detected with plain x-ray testing. The pain from degenerative disc or joint disease of the spine is usually treated conservatively with intermittent heat, rest, rehabilitative exercises, and medications to relieve pain, muscle spasm, and inflammation.

What are radiculopathy and sciatica? What are the symptoms?

Radiculopathy refers to nerve irritation caused by damage to the disc between the vertebrae. This occurs because of degeneration ("wear and tear") of the outer ring of the disc or because of traumatic injury, or both. Weakness of the outer ring leads to disc bulging and herniation. As a result, the central softer portion of the disc can rupture through the outer ring of the disc and abut the spinal cord or its nerves as they exit the bony spinal column.

When nerves are irritated in the neck from degenerative disc disease, the condition is referred to as cervical radiculopathy. This can lead to painful burning or tingling sensations in the arms. When nerves are irritated in the low back from degenerative disc disease, the condition is called lumbar radiculopathy, and it often causes the commonly recognized "sciatica" pain that shoots down a lower extremity. This condition can be preceded by a localized low-back aching. Sciatica pain can follow a "popping" sensation at onset and be accompanied by numbness and tingling. The pain commonly increases with movements at the waist and can increase with coughing or sneezing. In more severe instances, lumbar radiculopathy can be accompanied by incontinence of the bladder and/or bowels.

How is radiculopathy diagnosed?

Radiculopathy is suspected when the symptoms described above are noted. The doctor can sometimes detect signs of irritated nerves during the examination. For example, increased radiating pain when the lower extremity is lifted supports the diagnosis of lumbar radiculopathy. Nerve testing (EMG/electromyogram and NCV/nerve conduction velocity) of the lower extremities can be used to detect the nerve irritation. The actual disc herniation can be detected with radiology testing, such as CAT or MRI scanning.

How is radiculopathy treated?

The treatment of radiculopathy ranges from nonsurgical (medical) management to surgery. Medical management of radiculopathy includes patient education of the condition, medications to relieve pain and muscles spasm, cortisone injection around the spinal cord (epidural injection), physical therapy (heat, massage, ultrasound, electrical stimulation), and rest (not strict bed rest, but avoiding re-injury). With unrelenting pain, severe impairment of function, or incontinence (which can indicate spinal cord irritation), surgery may be necessary. The operation performed depends on the overall status of the spine and the age and health of the patient. Procedures include removal of the herniated disc with laminotomy (producing a small hole in the bone of the spine surrounding the spinal cord), laminectomy (removal of the bony wall adjacent to the nerve tissues), by needle technique through the skin (percutaneous discectomy), disc-dissolving procedures (chemonucleolysis), and others.

What is bony encroachment and spinal stenosis?

Any condition that results in movement or growth of the bony vertebrae of the spine can limit the space (encroachment) for the adjacent spinal cord and nerves. Causes of bony encroachment of the spinal nerves include foramen narrowing (narrowing of the portal through which the spinal nerve passes from the spinal column, out of the spinal canal to the body), spondylolisthesis (slipping of one vertebra relative to another), and spinal stenosis (narrowing of the spinal canal caused by compression of the nerve roots or spinal cord by bony spurs or other soft tissues in the spinal canal). For example, lumbar spinal nerve compression in these conditions can lead to sciatica pain that radiates down the lower extremities.

Spinal stenosis (narrowing of the spinal canal) can occur at any level of the spine, but it's most common in the lumbar spine of the low back. Symptoms depend on the level affected. For example, lumbar spinal stenosis can cause lower-extremity pains which worsen with walking and are relieved by resting (mimicking poor circulation of the lower extremities).

Treatment of these conditions varies (depending on the severity and condition of the patient) from rest to surgical decompression by removing the bone that is compressing the nervous tissue.

Degenerative Disc Disease & Sciatica At A Glance
  • The discs of the spine serve as "cushions" between each vertebral segment.
  • The discs are designed somewhat like a jelly donut.
  • Degeneration (deterioration) of the disc makes the disc more susceptible to herniation (rupture) which can lead to localized or radiating pain.
  • Sciatica can result from disc herniation when nerves of sensation in the low back are irritated.

Bulimia

  • What is bulimia?
  • What causes bulimia?
  • How is bulimia diagnosed?
  • What medical complications and long-term effects can bulimia have?
  • How is bulimia treated?
  • Bulimia At A Glance
  • Patient Discussions: Bulimia - Tips
  • Patient Discussions: Bulimia - Describe Your Experience
  • Find a local Psychiatrist in your town

What is bulimia?

Bulimia, also called bulimia nervosa, is an eating disorder. Bulimia is characterized by episodes of secretive excessive eating (bingeing) followed by inappropriate methods of weight control, such as self-induced vomiting (purging), abuse of laxatives and diuretics, or excessive exercise. Like anorexia, bulimia is a psychological disorder. It is another condition that goes beyond out-of-control dieting. The cycle of overeating and purging can quickly become an obsession similar to an addiction to drugs or other substances. The disorder generally occurs after a variety of unsuccessful attempts at dieting.

Bulimia is estimated to affect between 3% of all women in the U.S. at some point in their lifetime. About 6% of teen girls and 5% of college-aged females are believed to suffer from bulimia. These numbers are somewhat lower than earlier estimates of the prevalence of bulimia due to the precise criteria now established for the diagnosis (see below). Approximately 10% of identified bulimic patients are men. Bulimics are also susceptible to other compulsions, affective disorders, or addictions. Twenty to 40% of women with bulimia also have a history of problems related to drug or alcohol use, suggesting that many affected women may have difficulties with control of behavioral impulses.

Unlike anorexics, bulimics experience significant weight fluctuations, but their weight loss is usually not as severe or obvious as anorexics. The long-term prognosis for bulimics is slightly better than for anorexics, and the recovery rate is felt to be higher. However, many bulimics continue to retain slightly abnormal eating and dieting behaviors even after the recovery period.

The secrecy of bulimia stems from the shame that bulimics often attach to the disorder. Binge eating is not triggered by intense hunger. It is a response to depression, stress, or other feelings related to body weight, shape, or food. Binge eating often brings on a feeling of calm or happiness (euphoria), but the self-loathing because of the overeating soon replaces the short-lived euphoria.

Often, the individual will feel an impairment or loss of control during the binge eating and the purging becomes a way of regaining control. Not all bulimics engage in self-induced vomiting or the misuse of laxatives, diuretics, or enemas during the current episode. Some may fast for days following a binge episode. Others may resort to excessive exercise as a method to regain their control and rid their body of the possible weight gained during the binge. Excessive exercise is that which interferes with normal daily activities or when it occurs at inappropriate times or in inappropriate settings, or when it continues despite illness or injury.

What causes bulimia?

As with anorexia, there is currently no definite known cause of bulimia. Because of the complexity of the disorder, researchers within the medical and psychological fields continue to explore its dynamics.

Bulimia is generally felt to begin with a dissatisfaction of the person's body. The individual may actually be underweight, but when the person looks in a mirror they see a distorted image and feel heavier than they really are. At first, this distorted body image leads to dieting. As the body image in the mirror continues to be seen as larger than it actually is, the dieting escalates and can lead to bulimic practices.

In certain neurological or medical conditions, there can be disturbed eating behavior, but the essential psychological feature of bulimia, the extreme concern with body shape and weight, is not present. For example, overeating is a common feature in depression, however, these individuals do not engage in inappropriate weight-loss behaviors and are not overly concerned with body image and weight loss as is characteristic of the person with bulimia.

Organic causes for bulimia are being investigated. There is evidence that bulimia and other eating disorders may be related to abnormalities in levels of chemical messengers (neurotransmitters) within the brain, specifically the neurotransmitter serotonin. Other studies of people with bulimia have found alterations in metabolic rate, decreased perceptions of satiety, and abnormal neuroendocrine regulation (the process by which the nervous system interacts with production of hormones and hormone-like substances).

How is bulimia diagnosed?

As with anorexia, denial and secrecy complicate the diagnosis of bulimia. The individual usually does not come to the attention of the practitioner until an associated medical condition or serious psychological problem manifests itself. Truthful disclosure of behaviors is critical for an accurate diagnosis. The actual criteria for bulimia nervosa are found in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). There are five basic criteria in the diagnosis of bulimia:

  1. Recurrent episodes of binge eating. This is characterized by eating within a two-hour period an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.
  2. A sense of lack of control over the eating during the episode, or a feeling that one cannot stop eating.
  3. In addition to the binge eating, there is an inappropriate compensatory behavior in order to prevent weight gain. These behaviors can include self-induced vomiting, misuse of laxatives, diuretics, enemas or other medications, fasting, or excessive exercise.
  4. Both the binge eating and the compensatory behaviors must occur at least two times per week for three months and must not occur exclusively during episodes of anorexia.
  5. Finally, there is dissatisfaction with body shape and/or weight.

The DSM-IV also identifies two subtypes of bulimia nervosa. The purging type regularly engages in self-induced vomiting or the misuse of laxatives, diuretics, or enemas. The nonpurging type engages in other inappropriate compensatory behaviors, such as fasting or excessive exercise, rather than purging methods.

What are signs that may suggest a person has bulimia?

It is not always possible to tell whether a person has bulimia. Those affected may be overweight, underweight, or of normal body weight. However, some warning signs may be present, although these do not confirm the diagnosis of bulimia:

  • going to the bathroom after every meal (to induce vomiting)
  • compulsive or excessive exercising
  • physical signs arising from excessive vomiting such as swollen cheeks or jaws, broken blood vessels in the eyes, or teeth that appear clear due to damage to tooth enamel
  • excessive preoccupation with body image or weight

What medical complications and long-term effects can bulimia have?

The medical complications that result from bulimia are generally due to continual bingeing and purging. The type of purging behavior used can have varied effects on different body systems.

Self-induced vomiting can result in oral complications. Repeated exposure to acidic gastric contents can erode tooth enamel, increase dental cavities, and create a sensitivity to hot or cold food. Swelling and soreness in the salivary glands (such as the parotid glands in the cheeks) from repeated vomiting can also be a concern.

The esophagus and the colon are the areas most affected by bulimic behaviors. Repeated vomiting can result in ulcers, ruptures, or strictures of the esophagus. Acid that backs up from the stomach (reflux) can also become a problem.

As with anorexia nervosa and other eating disorders, irregular menstrual periods or amenorrhea (the absence of menstrual periods) may result from malnutrition or weight fluctuations associated with bulimia.

There are a number of intestinal and systemic complications. The misuse of diuretics can create an abnormal buildup of fluid (edema). Continual use of laxatives can result in dependency on them and can cause the normal elimination process to become dysfunctional. Loss of normal colonic function can necessitate surgical intervention in some cases. Restoration of normal bowel function may take weeks after the misuse has been discontinued. The misuse of diuretics and laxatives combined can place the bulimic at great risk for electrolyte imbalance, which can have life-threatening consequences. The complex physical and chemical processes involved in the maintenance of life can be disrupted with serious consequences by the continuation of bulimic and purging behaviors. Additional complications can affect an unborn fetus of a practicing bulimic or the infant of an active bulimic mother. Psychological problems can escalate to serious levels if untreated and interfere with the restoration of normal body functions.

How is bulimia treated?

Patients with bulimia present a variety of medical and psychological complications which are usually considered to be reversible through a multidisciplinary treatment approach. Treatment can be managed by either a physician, psychiatrist, or in some cases, a clinical psychologist. The extent of the medical complications generally dictates the primary treatment manager. A psychiatrist, with both medical and psychological training, is perhaps the optimum treatment manager.

A number of antidepressant medications have been shown to be beneficial in the treatment of bulimia. Several studies have demonstrated that fluoxetine (Prozac), a member of the selective serotonin reuptake inhibitor (SSRI) class of antidepressants, has been effective in the treatment of bulimia. And the U.S. Food and Drug Administration has approved fluoxetine for the treatment of bulimia.

 

Other types of antidepressants, including the monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants, and buspirone (Buspar) have all been shown to decrease bingeing and vomiting in people suffering from bulimia. However, the SSRIs remain the first choice for treatment due to their relative safety and low incidence of side effects.

 

Other drugs are currently under investigation as possible treatments for bulimia. Examples are the antiepileptic drug topiramate and the serotonin antagonist ondansetron.

Some patients may require hospitalization due to the extent of the medical or psychological complications. Others may seek outpatient programs. Still others may require only weekly counseling and monitoring by a practitioner. Stabilization of the patient's physical condition will be the immediate goal if the individual is in a life-threatening state. The primary goals of treatment should address both physical and psychological needs of the patient in order to restore physical health and normal eating patterns. The patient needs to identify internal feelings and distorted beliefs that led to the disorder initially. An appropriate treatment approach addresses underlying issues of control, self-perception, and family dynamics. Nutritional education and behavior management provides the patient with healthy alternatives to weight management. Group counseling or support groups can assist the patient in the recovery process as well.

The ultimate goal should be for the patient to accept herself/himself and lead a physically and emotionally healthy life. Restoration of physical and mental health will probably take time, and results will be gradual. Patience is a vital part of the recovery process. A positive attitude coupled with much effort on the part of the affected individual is another integral component to a successful recovery.

Bulimia At A Glance
  • Bulimia (also called bulimia nervosa) is a psychological eating disorder.
  • Bulimia is felt to be related to a person's dissatisfaction with their own body image, although the exact cause is not known.
  • Bulimia is diagnosed according to defined criteria.
  • There are two types of bulimia: the purging and nonpurging types.
  • The purging type regularly engages in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
  • The nonpurging type engages in other inappropriate behaviors such as fasting or excessive exercise, rather than purging.
  • Bulimia can have serious medical complications.
  • The successful treatment of bulimia is often multidisciplinary involving both medical and psychological approaches.
  • The goals of treatment are to restore physical health and normal eating patterns.

Bulimia

  • What is bulimia?
  • What causes bulimia?
  • How is bulimia diagnosed?
  • What medical complications and long-term effects can bulimia have?
  • How is bulimia treated?
  • Bulimia At A Glance
  • Patient Discussions: Bulimia - Tips
  • Patient Discussions: Bulimia - Describe Your Experience
  • Find a local Psychiatrist in your town

What is bulimia?

Bulimia, also called bulimia nervosa, is an eating disorder. Bulimia is characterized by episodes of secretive excessive eating (bingeing) followed by inappropriate methods of weight control, such as self-induced vomiting (purging), abuse of laxatives and diuretics, or excessive exercise. Like anorexia, bulimia is a psychological disorder. It is another condition that goes beyond out-of-control dieting. The cycle of overeating and purging can quickly become an obsession similar to an addiction to drugs or other substances. The disorder generally occurs after a variety of unsuccessful attempts at dieting.

Bulimia is estimated to affect between 3% of all women in the U.S. at some point in their lifetime. About 6% of teen girls and 5% of college-aged females are believed to suffer from bulimia. These numbers are somewhat lower than earlier estimates of the prevalence of bulimia due to the precise criteria now established for the diagnosis (see below). Approximately 10% of identified bulimic patients are men. Bulimics are also susceptible to other compulsions, affective disorders, or addictions. Twenty to 40% of women with bulimia also have a history of problems related to drug or alcohol use, suggesting that many affected women may have difficulties with control of behavioral impulses.

Unlike anorexics, bulimics experience significant weight fluctuations, but their weight loss is usually not as severe or obvious as anorexics. The long-term prognosis for bulimics is slightly better than for anorexics, and the recovery rate is felt to be higher. However, many bulimics continue to retain slightly abnormal eating and dieting behaviors even after the recovery period.

The secrecy of bulimia stems from the shame that bulimics often attach to the disorder. Binge eating is not triggered by intense hunger. It is a response to depression, stress, or other feelings related to body weight, shape, or food. Binge eating often brings on a feeling of calm or happiness (euphoria), but the self-loathing because of the overeating soon replaces the short-lived euphoria.

Often, the individual will feel an impairment or loss of control during the binge eating and the purging becomes a way of regaining control. Not all bulimics engage in self-induced vomiting or the misuse of laxatives, diuretics, or enemas during the current episode. Some may fast for days following a binge episode. Others may resort to excessive exercise as a method to regain their control and rid their body of the possible weight gained during the binge. Excessive exercise is that which interferes with normal daily activities or when it occurs at inappropriate times or in inappropriate settings, or when it continues despite illness or injury.

What causes bulimia?

As with anorexia, there is currently no definite known cause of bulimia. Because of the complexity of the disorder, researchers within the medical and psychological fields continue to explore its dynamics.

Bulimia is generally felt to begin with a dissatisfaction of the person's body. The individual may actually be underweight, but when the person looks in a mirror they see a distorted image and feel heavier than they really are. At first, this distorted body image leads to dieting. As the body image in the mirror continues to be seen as larger than it actually is, the dieting escalates and can lead to bulimic practices.

In certain neurological or medical conditions, there can be disturbed eating behavior, but the essential psychological feature of bulimia, the extreme concern with body shape and weight, is not present. For example, overeating is a common feature in depression, however, these individuals do not engage in inappropriate weight-loss behaviors and are not overly concerned with body image and weight loss as is characteristic of the person with bulimia.

Organic causes for bulimia are being investigated. There is evidence that bulimia and other eating disorders may be related to abnormalities in levels of chemical messengers (neurotransmitters) within the brain, specifically the neurotransmitter serotonin. Other studies of people with bulimia have found alterations in metabolic rate, decreased perceptions of satiety, and abnormal neuroendocrine regulation (the process by which the nervous system interacts with production of hormones and hormone-like substances).

How is bulimia diagnosed?

As with anorexia, denial and secrecy complicate the diagnosis of bulimia. The individual usually does not come to the attention of the practitioner until an associated medical condition or serious psychological problem manifests itself. Truthful disclosure of behaviors is critical for an accurate diagnosis. The actual criteria for bulimia nervosa are found in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). There are five basic criteria in the diagnosis of bulimia:

  1. Recurrent episodes of binge eating. This is characterized by eating within a two-hour period an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.
  2. A sense of lack of control over the eating during the episode, or a feeling that one cannot stop eating.
  3. In addition to the binge eating, there is an inappropriate compensatory behavior in order to prevent weight gain. These behaviors can include self-induced vomiting, misuse of laxatives, diuretics, enemas or other medications, fasting, or excessive exercise.
  4. Both the binge eating and the compensatory behaviors must occur at least two times per week for three months and must not occur exclusively during episodes of anorexia.
  5. Finally, there is dissatisfaction with body shape and/or weight.

The DSM-IV also identifies two subtypes of bulimia nervosa. The purging type regularly engages in self-induced vomiting or the misuse of laxatives, diuretics, or enemas. The nonpurging type engages in other inappropriate compensatory behaviors, such as fasting or excessive exercise, rather than purging methods.

What are signs that may suggest a person has bulimia?

It is not always possible to tell whether a person has bulimia. Those affected may be overweight, underweight, or of normal body weight. However, some warning signs may be present, although these do not confirm the diagnosis of bulimia:

  • going to the bathroom after every meal (to induce vomiting)
  • compulsive or excessive exercising
  • physical signs arising from excessive vomiting such as swollen cheeks or jaws, broken blood vessels in the eyes, or teeth that appear clear due to damage to tooth enamel
  • excessive preoccupation with body image or weight

What medical complications and long-term effects can bulimia have?

The medical complications that result from bulimia are generally due to continual bingeing and purging. The type of purging behavior used can have varied effects on different body systems.

Self-induced vomiting can result in oral complications. Repeated exposure to acidic gastric contents can erode tooth enamel, increase dental cavities, and create a sensitivity to hot or cold food. Swelling and soreness in the salivary glands (such as the parotid glands in the cheeks) from repeated vomiting can also be a concern.

The esophagus and the colon are the areas most affected by bulimic behaviors. Repeated vomiting can result in ulcers, ruptures, or strictures of the esophagus. Acid that backs up from the stomach (reflux) can also become a problem.

As with anorexia nervosa and other eating disorders, irregular menstrual periods or amenorrhea (the absence of menstrual periods) may result from malnutrition or weight fluctuations associated with bulimia.

There are a number of intestinal and systemic complications. The misuse of diuretics can create an abnormal buildup of fluid (edema). Continual use of laxatives can result in dependency on them and can cause the normal elimination process to become dysfunctional. Loss of normal colonic function can necessitate surgical intervention in some cases. Restoration of normal bowel function may take weeks after the misuse has been discontinued. The misuse of diuretics and laxatives combined can place the bulimic at great risk for electrolyte imbalance, which can have life-threatening consequences. The complex physical and chemical processes involved in the maintenance of life can be disrupted with serious consequences by the continuation of bulimic and purging behaviors. Additional complications can affect an unborn fetus of a practicing bulimic or the infant of an active bulimic mother. Psychological problems can escalate to serious levels if untreated and interfere with the restoration of normal body functions.

How is bulimia treated?

Patients with bulimia present a variety of medical and psychological complications which are usually considered to be reversible through a multidisciplinary treatment approach. Treatment can be managed by either a physician, psychiatrist, or in some cases, a clinical psychologist. The extent of the medical complications generally dictates the primary treatment manager. A psychiatrist, with both medical and psychological training, is perhaps the optimum treatment manager.

A number of antidepressant medications have been shown to be beneficial in the treatment of bulimia. Several studies have demonstrated that fluoxetine (Prozac), a member of the selective serotonin reuptake inhibitor (SSRI) class of antidepressants, has been effective in the treatment of bulimia. And the U.S. Food and Drug Administration has approved fluoxetine for the treatment of bulimia.

 

Other types of antidepressants, including the monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants, and buspirone (Buspar) have all been shown to decrease bingeing and vomiting in people suffering from bulimia. However, the SSRIs remain the first choice for treatment due to their relative safety and low incidence of side effects.

 

Other drugs are currently under investigation as possible treatments for bulimia. Examples are the antiepileptic drug topiramate and the serotonin antagonist ondansetron.

Some patients may require hospitalization due to the extent of the medical or psychological complications. Others may seek outpatient programs. Still others may require only weekly counseling and monitoring by a practitioner. Stabilization of the patient's physical condition will be the immediate goal if the individual is in a life-threatening state. The primary goals of treatment should address both physical and psychological needs of the patient in order to restore physical health and normal eating patterns. The patient needs to identify internal feelings and distorted beliefs that led to the disorder initially. An appropriate treatment approach addresses underlying issues of control, self-perception, and family dynamics. Nutritional education and behavior management provides the patient with healthy alternatives to weight management. Group counseling or support groups can assist the patient in the recovery process as well.

The ultimate goal should be for the patient to accept herself/himself and lead a physically and emotionally healthy life. Restoration of physical and mental health will probably take time, and results will be gradual. Patience is a vital part of the recovery process. A positive attitude coupled with much effort on the part of the affected individual is another integral component to a successful recovery.

Bulimia At A Glance
  • Bulimia (also called bulimia nervosa) is a psychological eating disorder.
  • Bulimia is felt to be related to a person's dissatisfaction with their own body image, although the exact cause is not known.
  • Bulimia is diagnosed according to defined criteria.
  • There are two types of bulimia: the purging and nonpurging types.
  • The purging type regularly engages in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
  • The nonpurging type engages in other inappropriate behaviors such as fasting or excessive exercise, rather than purging.
  • Bulimia can have serious medical complications.
  • The successful treatment of bulimia is often multidisciplinary involving both medical and psychological approaches.
  • The goals of treatment are to restore physical health and normal eating patterns.

Bullous Pemphigoid

 

View Slideshow Pictures

 

Adult Skin Problems Slideshow Pictures Adult Skin Problems
Quiz: Can You Identify These Skin Conditions? Take the Quiz: Test Your Skin Conditions IQ
Gallery of Skin Problems and Image Collection Gallery of Skin Problems Pictures and Images Collection
  • What is bullous pemphigoid?
  • What are symptoms of bullous pemphigoid?
  • How is it diagnosed?
  • How is bullous pemphigoid treated?
  • Find a local Dermatologist in your town

What is bullous pemphigoid?

Bullous pemphigoid is a skin disease characterized by tense blistering eruptions on the surface of the skin. Occasionally, the inner lining tissue of the mouth (mucous membrane tissue) can be involved. The condition is caused by antibodies and inflammation abnormally accumulating in a certain layer of the skin or mucous membranes. This layer of tissue is called the "basement membrane." These antibodies (immunoglobulins) bind to proteins in the basement membrane called hemidesmosomal BP antigens and this attracts cells of inflammation.

A majority of cases of bullous pemphigoid occur in people 50 years of age or older. While the cause is unknown, it is felt by some that an aging immune system may become activated in certain individuals with some genetic predisposition to develop bullous pemphigoid.

What are symptoms of bullous pemphigoid?

Symptoms of bullous pemphigoid include intense itching and burning sensation of the skin. When the mucous membranes of the mouth are affected, it can cause pain, burning, and sensitivity to acidic foods. Eating can be difficult, and involvement in the deeper areas of the throat can cause coughing. Involvement of the inner nose can cause nosebleeds.

How is bullous pemphigoid diagnosed?

Bullous pemphigoid is diagnosed based on the results of a biopsy of involved tissue. The biopsy can reveal the abnormal antibodies deposited in the basement membrane layer of skin or mucous membrane tissue.

Bullous pemphigoid-like condition can sometimes be associated with other illnesses, including systemic lupus erythematosus (SLE or lupus) and cancer.

How is bullous pemphigoid treated?

Bullous pemphigoid can be chronic and mild without affecting the general health of affected individuals. Treatment of bullous pemphigoid can resolve with topical cortisone creams but sometimes requires high doses of cortisone ("steroids") taken internally. Severe bullous pemphigoid can also require immune-suppression drugs such as azathioprine (Imuran). Tetracycline has been used as a treatment option. Other treatments that have been used for severe disease include intravenous immunoglobulin infusions, typically given monthly.

Recent research has indicated that large quantities of high-potency topical corticosteroids applied to the entire body surface were safer and more effective in controlling extensive bullous pemphigoid than oral corticosteroids. It was felt by the researchers that topical corticosteroids should now be the treatment of choice for bullous pemphigoid, particularly when the disease is not extensive.

Bumps & Bruises
(Contusions & Ecchymoses)

 

View the Bad Bugs Slideshow Pictures

 

Bad Bugs Slideshow Pictures Bad Bugs Slideshow Pictures
Take the Bed Bugs Quiz! Take the Bed Bugs Quiz!

 

  • What is a bruise?
  • Why do bruises occur more frequently in some people than in others?
  • What does a bruise look like, and why does it change color?
  • What if the bruise doesn't get better or the area stays swollen?
  • What are some less common causes of bruising, and what do they indicate?
  • What is the treatment for bruising?
  • Bumps & Bruises At A Glance
  • Patient Discussions: Bumps And Bruises - Effective Treatments

What is a bruise?

You fall off your bike, bang your shin on the coffee table (that you swore you would move months ago) or run into a wall and wake up with a wallop of a bruise. What is a bruise, and what can you do about it? A bruise (medically referred to as a contusion) is caused when tiny blood vessels are damaged or broken as the result of a blow to the skin (be it bumping against something or hitting yourself with a hammer). The raised area of a bump or bruise results from blood leaking from these injured blood vessels into the tissues as well as from the body's response to the injury. A purplish, flat bruise that occurs when blood leaks out into the top layers of skin is referred to as an ecchymosis.

Why do bruises occur more frequently in some people than in others?

The injury required to produce a bruise varies with age. While it may take quite a bit of force to cause a bruise in a young child, even minor bumps and scrapes may cause extensive bruising or ecchymosis in an elderly person. Blood vessels become more fragile as we age, and bruising may even occur without prior injury in the elderly.

The amount of bruising may also be affected by medications which interfere with blood clotting (and thus cause more bleeding into the skin or tissues). These drugs include many prescription arthritis medications called nonsteroidal antiinflammatories (for example, ibuprofen [Advil, Nuprin] and naproxen [Aleve]) as well as over-the-counter medications, such as aspirin. Warfarin (Coumadin) is often prescribed by doctors specifically to prevent clotting in patients who have had blood clots in their legs or heart. Warfarin can cause particularly severe bruising, especially if the level of the medication becomes too high. Cortisone medications, such as prednisone, promote bruising by increasing the fragility of the tiny blood vessels in the skin. In addition, patients with inherited clotting problems (such as in hemophilia) or acquired clotting problems (such as in patients with liver diseases like cirrhosis), can develop extensive bruising or even life-threatening bleeding.

What does a bruise look like, and why does it change color?

Bruises change in appearance over time, and it is possible to tell by looking at a bruise how old it is. When it first appears, a bruise will be reddish looking, reflecting the color of the blood in the skin. By one to two days, the reddish iron from the blood undergoes a change and the bruise will appear blue or purple. By day six, the color changes to green and by day eight to nine, the bruise will appear yellowish-brown. In general, the bruised area will be repaired by the body in two to three weeks after which the skin will return to normal.

What if the bruise doesn't get better or the area stays swollen?

On occasion, instead of going away, the area of a bruise will become firm and may actually start increasing in size. It may also continue to be painful. There are two major causes for this. First, if a large collection of blood is formed under the skin or in the muscle, instead of trying to clean up the area, the body may wall the blood off causing what is called a hematoma. A hematoma is nothing more than a small pool of blood that is walled off. This may need to be drained by your health-care practitioner.

A second and much less common problem occurs when the body deposits calcium, the material that makes up the majority of bone, in the area of injury. The area becomes tender and firm. This process is called heterotopic ossification or myositis ossificans.

This condition is diagnosed by x-ray and requires a trip to your health-care practitioner.

What are some less common causes of bruising, and what do they indicate?

The terminology describing different types of bruising often refers to not only their appearance but also to their cause. Petechiae refer to very small, 1- to 3-millimeter accumulations of blood beneath the skin. These can appear like multiple tiny red dots on any part of the body (most commonly the legs). Most often these are multiple, and they can suggest that there is serious health problem present. Examples of these are an infection of the valves of the heart (endocarditis) or abnormal function of the blood-clotting elements (platelets). Bruising around the navel (belly button) can be a result of bleeding within the abdomen. Bruising behind the ear (Battle's sign) can indicate that there is a skull fracture. Lastly, bruises that are raised, firm, multiple, and occur without any injury can be a sign of various types of "autoimmune" diseases (diseases in which the body attacks its own blood vessels). Each of these should be evaluated by a health-care practitioner.

What is the treatment for bruising?

There are a couple of things that you can do to prevent or minimize bruising after an injury. First, try a cold compress. Put ice in a plastic bag, wrap the bag in a towel (applying the ice directly to the skin can cause frostbite), and place it on the injured area. Commercial ice packs are also available, but a bag of frozen peas makes an excellent substitute. It molds to the shape of the injured area and can then be re-frozen and used again (but don't eat them!). The cold reduces the blood flow to the area and therefore limits bleeding into the skin and reduces the size of the bruise. The cold also decreases the inflammation in the area of the injury and limits swelling in this way as well. If possible, elevate the area above the level of the heart. The lower an extremity is below the heart, the more blood will flow to the area and increase the bleeding and swelling.

Avoid taking the medications listed above that can contribute to bruising. If you have any questions about whether or not your medication can contribute to bruising, ask your health-care practitioner or pharmacist. Do not stop any prescription medications without first contacting your health-care practitioner.

Finally, pressure applied to the area (by hand, not with tourniquets) can reduce bleeding.

People who take medicines that reduce clotting ("blood thinners") or have clotting abnormalities should seek the advice of a physician or other health-care provider immediately, as should the elderly or those who have experienced significantly severe trauma.

Bumps & Bruises At A Glance
  • A bruise is medically referred to as a contusion.
  • Bruises occur when tiny blood vessels are damaged or broken.
  • The injury required to produce a bruise varies with age and certain medications.
  • Individual bruises change in appearance over time.
  • Spontaneous bruising can indicate a serious bleeding tendency.

Bunions

 

View the Foot Problems Slideshow Pictures

 

 

 

Foot Problems Slideshow Pictures Foot Problems Slideshow Pictures
Worst Shoes Slideshow Pictures Worst Shoes Slideshow Pictures
Diabetes & Feet Slideshow Pictures Diabetes & Feet Slideshow Pictures

 

  • Bunions facts
  • What are bunions?
  • Who develops bunions?
  • What are symptoms and signs of a bunion?
  • How is a bunion diagnosed?
  • How are bunions treated?
  • Patient Discussions: Bunions - Treatments
  • Patient Discussions: Bunions - Describe Your Experience
  • Find a local Orthopedic Surgeon in your town

Bunions facts

  • Bunions involve enlargement and repositioning of joints at the ball of the foot.
  • Bunions most commonly affect the inner foot but also can affect the outside of the foot at the base of the little toe.
  • Bunions most commonly affect women.
  • Bunions may or may not cause symptoms.
  • Treatment of bunions can include rest, alteration of footwear, foot supports, medications, and/or surgery.

What are bunions?

The common bunion is a localized area of enlargement of the inner portion of the joint at the base of the big toe. The enlargement actually represents additional bone formation, often in combination with a misalignment of the big toe. The misalignment causes the big toe to move outward (medically termed hallux valgus deformity). The normal position of the big toe (straight forward) becomes outward-directed toward the smaller toes. The enlarged joint at the base of the big toe (the first metatarsophalangeal joint, or MTP joint) can become inflamed with redness, tenderness, and pain. A small fluid-filled sac (bursa) adjacent to the joint can also become inflamed (bursitis), leading to additional swelling, redness, and pain.

A less common bunion is located at the joint at the base of the smallest (fifth) toe. This bunion is sometimes referred to as a tailor's bunion.

Who develops bunions?

Bunions most commonly affect women. Some studies report that bunions occur nearly 10 times more frequently in women.. It has been suggested that tight-fitting shoes, especially high-heel and narrow-toed shoes, might increase the risk for bunion formation. Bunions are reported to be more prevalent in people who wear shoes than in barefoot people. While the precise causes are not known, there also seems to be inherited (genetic) factors that predispose to the development of bunions, especially when they occur in younger individuals.

 

Picture of a bunion.
Picture of a bunion. SOURCE: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health

 

 

Other risk factors for the development of bunions include abnormal formation of the bones of the foot at birth (congenital), nerve conditions that affect the foot, rheumatoid arthritis, and injury to the foot. Bunions are common in ballet dancers.

What are symptoms and signs of a bunion?

Bunions may or may not cause symptoms. A frequent symptom is foot pain in the involved area when walking or wearing shoes that is relieved by resting. A bunion causes enlargement of the base of the big toe and is usually associated with positioning of the big toe toward the smaller toes. This leads to intermittent or chronic pain at the base of the big toe.

Bunions that cause marked pain are often associated with swelling of the soft tissues, redness, and local tenderness. It is important to note that, in post-pubertal men and post-menopausal women, pain at the base of the big toe can be caused by gout and gouty arthritis that is similar to the pain caused by bunions.

How is a bunion diagnosed?

The doctor considers a bunion as a possible diagnosis when noting the symptoms described above. The anatomy of the foot is assessed during the examination. Radiographs (X-ray films) of the foot can be helpful to determine the integrity of the joints of the foot and to screen for underlying conditions, such as arthritis or gout. X-ray films are an excellent method of calculating the alignment of the toes.

How are bunions treated?

Nonsurgical treatments involve simply resting the foot by avoiding excessive walking and wearing loose (wider) shoes or sandals can often relieve the irritating pain of bunions. Walking shoes may have some advantages, for example, over high-heeled styles that tug the big toe outward.

Anti-inflammation medications, such as acetylsalicylic acid (Aspirin, Ecotrin), ibuprofen (Advil, Children's Advil/Motrin, Medipren, Motrin, Nuprin, PediaCare Fever) and naproxen (Anaprox, Naprelan, Naprosyn, Aleve), can help to ease inflammation as well as pain. Local cold-pack application is sometimes helpful as well

To reduce tension on the inner part of the joint of a bunion, stretching exercises are sometimes prescribed. A bunion splint is an orthotic device that is usually worn at night and can provide further relief. Depending on the structure of the foot, custom insoles might add further support and repositioning.

Inflammation of the joint at the base of the big toe can often be relieved by a local injection of cortisone.

Any signs of skin breakdown or infection can require antibiotics.

When the measures above are effective in relieving symptoms, patients should avoid irritating the bunion again by optimizing footwear and foot care.

For those whose bunions cause persisting pain, a surgical operation is considered for removal of the bunion. The surgical operation to remove a bunion is referred to as a bunionectomy. Surgical procedures can correct deformity and relieve pain leading to improved function. These procedures typically involve removing the bony growth of the bunion while realigning the big toe. Surgery is often, but not always, successful; failure to relieve pain can result from the big toe moving back to its previous deviated position even after surgery . However, proper footwear and activity restrictions can reduce the chances of surgical failure.

Burning Mouth Syndrome (BMS)

 

View Cosmetic Dentistry: Before and After Slideshow Pictures
Cosmetic Dentistry: Before and After Slideshow Pictures View Before and After Pictures of Cosmetic Dentistry Slideshow Pictures
Teeth Whitening Secrets Slideshow Pictures View Secrets to Brighter, Whiter Teeth Slideshow Pictures
Take the Dental (Oral) Health Quiz! Take the Dental (Oral) Health Quiz!

 

  • What are signs and symptoms of burning mouth syndrome?
  • What are causes of burning mouth syndrome?
  • How is burning mouth syndrome diagnosed?
  • What is the treatment for burning mouth syndrome?
  • What are helpful tips for dealing with burning mouth syndrome?
  • Find a local Doctor in your town

Burning mouth syndrome (BMS) is a painful, frustrating condition often described as a scalding sensation in the tongue, lips, palate, or throughout the mouth. Although BMS can affect anyone, it occurs most commonly in middle-aged or older women.

BMS often occurs with a range of medical and dental conditions, from nutritional deficiencies and menopause to dry mouth and allergies. But their connection is unclear, and the exact cause of burning mouth syndrome cannot always be identified with certainty.

Signs and Symptoms

Moderate to severe burning in the mouth is the main symptom of BMS and can persist for months or years. For many people, the burning sensation begins in late morning, builds to a peak by evening, and often subsides at night. Some feel constant pain; for others, pain comes and goes. Anxiety and depression are common in people with burning mouth syndrome and may result from their chronic pain.

Other symptoms of BMS include:

  • tingling or numbness on the tip of the tongue or in the mouth
  • bitter or metallic changes in taste
  • dry or sore mouth.

Causes

There are a number of possible causes of burning mouth syndrome, including:

  • damage to nerves that control pain and taste
  • hormonal changes
  • dry mouth, which can be caused by many medicines and disorders such as Sjögren's syndrome or diabetes
  • nutritional deficiencies
  • oral candidiasis, a fungal infection in the mouth
  • acid reflux
  • poorly-fitting dentures or allergies to denture materials
  • anxiety and depression.

In some people, burning mouth syndrome may have more than one cause. But for many, the exact cause of their symptoms cannot be found

Diagnosis

A review of your medical history, a thorough oral examination, and a general medical examination may help identify the source of your burning mouth. Tests may include:

  • blood work to look for infection, nutritional deficiencies, and disorders associated with BMS such as diabetes or thyroid problems
  • oral swab to check for oral candidiasis
  • allergy testing for denture materials, certain foods, or other substances that may be causing your symptoms.

Treatment

Treatment should be tailored to your individual needs. Depending on the cause of your BMS symptoms, possible treatments may include:

  • adjusting or replacing irritating dentures
  • treating existing disorders such as diabetes, Sjögren's syndrome, or a thyroid problem to improve burning mouth symptoms
  • recommending supplements for nutritional deficiencies
  • switching medicine, where possible, if a drug you are taking is causing your burning mouth
  • prescribing medications to
    • relieve dry mouth
    • treat oral candidiasis
    • help control pain from nerve damage
    • relieve anxiety and depression.

When no underlying cause can be found, treatment is aimed at the symptoms to try to reduce the pain associated with burning mouth syndrome.

Helpful Tips

You can also try these self-care tips to help ease the pain of burning mouth syndrome.

  • Sip water frequently.
  • Suck on ice chips.
  • Avoid irritating substances like hot, spicy foods; mouthwashes that contain alcohol; and products high in acid, like citrus fruits and juices.
  • Chew sugarless gum.
  • Brush your teeth/dentures with baking soda and water.
  • Avoid alcohol and tobacco products.

Talk with your dentist and doctor about other possible steps you can take to minimize the problems associated with burning mouth syndrome.

Tongue Problem Basics

 

View Cosmetic Dentistry: Before and After Slideshow Pictures
Cosmetic Dentistry: Before and After Slideshow Pictures View Before and After Pictures of Cosmetic Dentistry Slideshow Pictures
Teeth Whitening Secrets Slideshow Pictures View Secrets to Brighter, Whiter Teeth Slideshow Pictures
Take the Dental (Oral) Health Quiz! Take the Dental (Oral) Health Quiz!

 

  • What causes white tongue?
  • What causes red tongue or strawberry tongue?
  • What causes black hairy tongue?
  • What causes a sore tongue and tongue bumps?
  • Patient Discussions: Tongue Problems - Treatments
  • Patient Discussions: Tongue Problems - Describe Your Problems
  • Find a local Doctor in your town

 

Though often hailed as "the strongest muscle in the body," the tongue is actually made up of a group of muscles that allow us to taste food, swallow, and talk. A healthy tongue is pink and covered with small nodules called papillae.

Because you use your tongue constantly, it can be frustrating and uncomfortable when you experience tongue problems, including discoloration and soreness. There are a variety of causes for a number of common tongue symptoms. Fortunately, the majority of tongue problems are not serious and most can be resolved quickly.

In some instances, however, a discolored or painful tongue can indicate more serious conditions, including vitamin deficiencies, AIDS, or oral cancer. For this reason, it is important to seek medical advice if you experience any ongoing problems with your tongue.

What Causes a White Tongue?

There are a number of things that can cause a whitish coating or white spots to develop on the tongue, including:

  • Leukoplakia. This condition causes cells in the mouth to grow excessively. That, in turn, leads to the formation of white patches inside the mouth, including on the tongue. Although not dangerous on its own, leukoplakia can be a precursor to cancer. So it is important for your dentist to determine the cause of white patches on your tongue. Leukoplakia can develop when the tongue has been irritated and is often found in people who use tobacco products.
  • Oral thrush. Also known as candidiasis, oral thrush is a yeast infection that develops inside the mouth. The condition results in white patches that are often cottage cheese-like in consistency on the surfaces of the mouth and tongue. Oral thrush is most commonly seen in infants and the elderly, especially denture wearers, or in people with compromised immune systems. People with diabetes and people taking inhaled steroids for asthma or lung disease also can also get thrush. Oral thrush is more likely to occur after the use of antibiotics, which may kill the "good" bacteria in the mouth. Eating plain yogurt with live and active cultures may help restore the proper fauna in your mouth. Additionally, medications may be used to combat the infection.
  • Oral lichen planus. If you have a network of raised white lines on your tongue that has a lace-like appearance, you may be suffering from oral lichen planus. Doctors are often unable to determine the cause of this condition, which often resolves on its own. Practicing proper dental hygiene, avoiding tobacco, and limiting your consumption of foods that cause irritation to your mouth may helpful.

What Causes a Red or Strawberry Tongue?

There are multiple factors that can cause a normally pink tongue to turn red. In some instances, the tongue may even take on the appearance of a strawberry with enlarged, red taste buds dotting the surface. Possible causes include:

  • Vitamin deficiencies. Deficiencies of folic acid and vitamin B-12 may cause your tongue to take on a reddish appearance.
  • Geographic tongue. This condition, also known as benign migratory glossitis, is named for the map-like pattern of reddish spots that develop on the surface of the tongue. At times, these patches have a white border around them, and their location on the tongue may shift over time. Though usually harmless, you should check with your dentist to investigate red patches that last longer than two weeks. Once your dentist has determined that the redness is a result of geographic tongue, no further treatment is necessary. If the condition makes your tongue sore or uncomfortable, you may be prescribed topical medications to alleviate discomfort.
  • Scarlet fever. People suffering from this streptococcal infection may develop a strawberry tongue. Be sure to contact a doctor immediately if you have a high fever and red tongue. Antibiotic treatment is necessary for scarlet fever.
  • Kawasaki syndrome. This disease, usually seen in children under the age of five, affects the blood vessels in the body and can cause strawberry tongue. During the acute phase of illness, children often run an extremely high fever and may also have redness and swelling in the hands and feet.

What Causes Black Hairy Tongue?

Though incredibly disconcerting in appearance, a black, hairy tongue is typically nothing serious. The small bumps on the surface of your tongue, called papillae, grow throughout your lifetime. In some people, the papillae become excessively long, rather than being worn down by daily activities. That makes them more likely to harbor bacteria. When these bacteria grow, they may look dark or black and the overgrown papillae appear hair-like.

This condition is not particularly common and is most likely to occur in people who do not practice good dental hygiene. People who are on antibiotics or receiving chemotherapy and people with diabetes may be more likely to have a black hairy tongue.

What Causes a Sore or Bumpy Tongue?

There are many things that can make your tongue to become sore or cause painful bumps to form, including:

  • Trauma. Accidentally biting your tongue or scalding it on something straight out of the oven can result in a sore tongue until the damage heals. Grinding or clenching the teeth can also irritate the sides of the tongue and cause it to become painful.
  • Smoking. Smoking excessively can irritate your tongue and make it sore.
  • Canker sores. Many people will develop these mouth ulcers on the tongue at some point in their life. The cause is unknown, although they can be worse during periods of heightened stress.
  • Burning tongue syndrome. Some post-menopausal women develop this syndrome, which makes the tongue feel as if it has been burned.
  • Enlarged papillae. If one or more of your taste buds becomes inflamed or irritated, it can swell and form a painful bump on your tongue.
  • Certain medical conditions. Medical conditions, including diabetes and anemia, can have a sore tongue as a symptom.
  • Oral cancer. Though most sore tongues are nothing to worry about, you should consult a doctor if you have a lump or sore on your tongue that doesn't go away within a week or two. Many oral cancers don't hurt in the early stages, so don't assume a lack of pain means nothing is wrong.

First Aid for Burns

 

View the Bad Bugs Slideshow Pictures

 

Bad Bugs Slideshow Pictures Bad Bugs Slideshow Pictures
Take the Bed Bugs Quiz!
  • Introduction to burns
  • How are burns classified?
  • What is the significance of the amount of body area burned?
  • How important is the location of a burn?
  • What about electrical burns?
  • What about chemical burns?
  • First aid for burns
  • Patient Discussions: Burns (First Aid)

Introduction to burns

Picture of 2nd degree sunburnThe skin has an important role to play in the fluid and temperature regulation of the body. If enough skin area is injured, the ability to maintain that control can be lost. The skin also acts as a protective barrier against the bacteria and viruses that inhabit the world outside the body.

The anatomy of the skin is complex, and there are many structures within the layers of the skin. There are three layers:

  1. Epidermis, the outer layer of the skin
  2. Dermis, made up of collagen and elastic fibers and where nerves, blood vessels, sweat glands, and hair follicles reside.
  3. Hypodermis or subcutaneous tissue, where larger blood vessels and nerves are located. This is the layer of tissue that is most important in temperature regulation.

The amount of damage that a burn can cause depends upon its location, its depth, and how much body surface area that it involves.

How are burns classified?

Burns are classified based upon their depth.

A first degree burn is superficial and causes local inflammation of the skin. Sunburns often are categorized as first degree burns. The inflammation is characterized by pain, redness, and a mild amount of swelling. The skin may be very tender to touch.

Second degree burns are deeper and in addition to the pain, redness and inflammation, there is also blistering of the skin.

Third degree burns are deeper still, involving all layers of the skin, in effect killing that area of skin. Because the nerves and blood vessels are damaged, third degree burns appear white and leathery and tend to be relatively painless.

Burns are not static and may mature. Over a few hours a first degree burn may involve deeper structures and become second degree. Think of a sunburn that blisters the next day. Similarly, second degree burns may evolve into third degree burns.

Regardless of the type of burn, inflammation and fluid accumulation in and around the wound occur. Moreover, it should be noted that the skin is the body's first defense against infection by microorganisms. A burn is also a break in the skin, and the risk of infection exists both at the site of the injury and potentially throughout the body.

Only the epidermis has the ability to regenerate itself. Burns that extend deeper may cause permanent injury and scarring and not allow the skin in that area to return to normal function.

What is the significance of the amount of body area burned?

In addition to the depth of the burn, the total area of the burn is significant. Burns are measured as a percentage of total body area affected. The "rule of nines" is often used, though this measurement is adjusted for infants and children. This calculation is based upon the fact that the surface area of the following parts of an adult body each correspond to approximately 9% of total (and the total body area of 100% is achieved):

  • Head = 9%
  • Chest (front) = 9%
  • Abdomen (front) = 9%
  • Upper/mid/low back and buttocks = 18%
  • Each arm = 9%
  • Each palm = 1%
  • Groin = 1%
  • Each leg = 18% total (front = 9%, back = 9%)

As an example, if both legs (18% x 2 = 36%), the groin (1%) and the front chest and abdomen were burned, this would involve 55% of the body.

Picture of the Rule of Nines - Burns on an Adult

Only second and third degree burn areas are added together to measure total body burn area. While first degree burns are painful, the skin integrity is intact and it is able to do its job with fluid and temperature maintenance.

If more than15%-20% of the body is involved in a burn, significant fluid may be lost. Shock may occur if inadequate fluid is not provided intravenously. The Parkland formula (named for the trauma hospital in Dallas) estimates the amount of fluid required in the first few hours of care following a burn:

  • 4cc/ kg of weight/% burn = initial fluid requirement in the first 24 hours, with half given in the first 8 hours.
  • As an example: A 175lb (or 80kg) patient with 25% burn will need 4cc x 80kg x 25%, or 8000cc of fluid in the first 24 hours, or more than 7 pounds of fluid.

As the percentage of burn surface area increases, the risk of death increases as well. Patients with burns involving less than 20% of their body should do well, but those with burns involving greater than 50% have a significant mortality risk, depending upon a variety of factors, including underlying medical conditions and age.

How important is the location of a burn?

Burn location is an important consideration.

If the burn involves the face, nose, mouth or neck, there is a risk that there will be enough inflammation and swelling to obstruct the airway and cause breathing problems.

If there are circumferential burns to the chest, as the burn progresses, the tissue involved may not allow enough motion of the chest wall to allow adequate breathing to occur. If circumferential burns occur to arms, legs, fingers, or toes, the same constriction may not allow blood flow and put the survival of the extremity at risk. Burns to areas of the body with flexion creases, like the palm of the hand, the back of the knee, the face, and the groin may need specialized care. As the burn matures, the skin may scar and shorten, preventing full range of motion of the body area.

What about electrical burns?

Electrical burns may cause serious injury that is not readily apparent. Often the entry and exit points for the electrical shock may not be easily found.

Electricity flows more easily through tissues in the body that are designed to deal with electricity. Nerves and muscles are "wired" for this task and often are damaged. If significant muscle damage occurs, muscle fibers and chemicals can be released into the bloodstream causing electrolyte disturbances and kidney failure.

What about chemical burns?

Burns can also occur when chemicals are spilled onto the body and generate a reaction that creates heat. Chemical burns may be classified by their pH or acidity.

  • Acids are those with pH less than 7 and include common household compounds like acetic acid, hydrochloric acid, or sulfuric acid.
  • Bases or alkali compounds have a pH greater than 7. Ammonia is a common alkali found in the home.

First aid for burns

For major burns (second and third degree burns)

  1. Remove the victim from the burning area, remembering not to put the rescuer in danger.
  2. Remove any burning material from the patient.
  3. Call 911 or activate the emergency response system in your area if needed.
  4. Once the victim is in a safe place, keep them warm and still. Try to wrap the injured areas in a clean sheet if available. DO NOT use cold water on the victim; this may drop the body temperature and cause hypothermia.

Burns of the face, hands, and feet should always be considered a significant injury (although this may exclude sunburn.

For minor burns (first degree burns or second degree burns involving a small area of the body)

  • Gently clean the wound with lukewarm water.
  • Though butter has been used as a home remedy, it should NOT be used on any burn.
  • Rings, bracelets, and other potentially constricting articles should be removed (edema, or swelling from inflammation may occur and the item may cut into the skin).
  • The burn may be dressed with a topical antibiotic ointment like Bacitracin or Neosporin.
  • If there is concern that the burn is deeper and may be second or third degree in nature, medical care should be accessed.
  • Tetanus immunization should be updated if needed.
 

For electrical burns

Victims of electrical burns should always seek medical care.

For chemical burns

  1. Identify the chemical that was involved.
  2. Contact the Poison Control Center in your area or your local hospital's Emergency Department. The United States National Poison Hotline is 1-800-222-1222. You will be automatically linked to the nearest poison control center.  Many chemical burns may be treated with local wound care. Some chemicals can cause life- and limb-threatening injuries and need emergent intervention.
  3. Victims with chemical burns to their eyes should always seek emergency care.

Bursitis

 

View the Gout Slideshow

 

Gout Slideshow Pictures Gout Slideshow
Osteoarthritis Knee Exercises Slideshow Pictures Osteoarthritis Knee Exercises Slideshow
Rheumatoid Arthritis Slideshow Pictures Rheumatoid Arthritis Slideshow
  • What is bursitis?
  • What causes a bursa become inflamed?
  • What are bursitis symptoms and signs?
  • How is bursitis diagnosed?
  • What is the treatment for bursitis?
  • Bursitis At A Glance
  • Pictures of Gout - Slideshow View Gout Slideshow
  • Patient Discussions: Bursitis - Treatments
  • Patient Discussions: Bursitis - Describe Your Experience
  • Find a local Rheumatologist in your town

What is bursitis?

Bursitis is inflammation of a bursa. A bursa (the plural form is bursae) is a tiny fluid-filled sac that functions as a gliding surface to reduce friction between tissues of the body. There are 160 bursae in the body. The major bursae are located adjacent to the tendons near the large joints, such as the shoulders, elbows, hips, and knees.

What causes a bursa become inflamed?

A bursa can become inflamed from injury, infection (rare in the shoulder), or due to an underlying rheumatic condition. Examples of bursitis include injury as subtle as lifting a bag of groceries into the car to inflame the shoulder bursa (shoulder bursitis), infection of the bursa in front of the knee from a knee scraping on asphalt (septic prepatellar bursitis), and inflammation of the elbow bursa from gout crystals (gouty olecranon bursitis).

What are bursitis symptoms and signs?

The symptoms of bursitis are directly related to the degree of inflammation present in the bursa. The inflamed bursa can cause localized pain and tenderness. If the bursa is so inflamed that swelling occurs, it can cause local swelling and stiffness, sometimes associated with local redness and warmth. The inflammation can make it painful to support body pressure. For example, hip bursitis can make it difficult to lay on the affected side of the hip. Bursitis in the knee, for another example, can make it painful to lay with the knees touching each other.

 

How is bursitis diagnosed?

Bursitis is typically identified by localized pain or swelling, tenderness, and pain with motion of the tissues in the affected area. X-ray testing can sometime detect calcifications in the bursa when bursitis has been chronic or recurrent.

What is the treatment for bursitis?

The treatment of any form of bursitis depends on whether or not it involves infection. Bursitis that is not infected (from injury or underlying rheumatic disease) can be treated with ice compresses, rest, and anti-inflammatory and pain medications. Occasionally, it requires aspiration of the bursa fluid. This procedure involves removal of the fluid with a needle and syringe under sterile conditions. It can be performed in the doctor's office. Sometimes the fluid is sent to the laboratory for further analysis. Noninfectious bursitis can also be treated with a cortisone injection into the swollen bursa. This is sometimes done at the same time as the aspiration procedure and typically rapidly reduces the inflammation of the swollen bursa.

Infectious (septic) bursitis requires even further evaluation and aggressive treatment. The bursal fluid can be examined in the laboratory to identify the microbes causing the infection. Septic bursitis requires antibiotic therapy, sometimes intravenously. Repeated aspiration of the infected fluid may be required. Surgical drainage and removal of the infected bursa sac (bursectomy) may also be necessary. Generally, the adjacent joint functions normally after the surgical wound heals.

Bursitis At A Glance
  • Bursitis is inflammation of a bursa, a tiny fluid-filled sac that functions as a gliding surface to reduce friction between tissues of the body.
  • A bursa can become inflamed from injury, infection (rare in the shoulder), or due to an underlying rheumatic condition.
  • Bursitis is identified by localized pain or swelling, tenderness, and pain with motion of the tissues in the affected area.
  • Treatment of bursitis is directed toward reducing inflammation and treating any infection present.

Hip Bursitis

 

View Senior Exercise for Successful Aging Slideshow Pictures

 

Senior Exercise for Successful Aging Slideshow Pictures Senior Exercise for Successful Aging
Overcoming Sexual Problems as We Age Slideshow Pictures Overcoming Sexual Problems as We Age

 

What is the prognosis for hip bursitis?

Usually hip bursitis responds completely to conservative treatments. Either oral or injectable anti-inflammatory medications frequently resolve the symptoms within a week. Infectious bursitis must be cured with antibiotic treatment often with surgical drainage.

  • Hip bursitis facts
  • What is bursitis?
  • What is hip bursitis?
  • What causes hip bursitis?
  • What are hip bursitis symptoms?
  • How is hip bursitis diagnosed?
  • What is the treatment for hip bursitis?
  • What is the prognosis for hip bursitis?
  • Patient Discussions: Hip Bursitis - Treatment
  • Patient Discussions: Hip Bursitis - Describe Your Experience
  • Patient Discussions: Hip Bursitis - Symptoms
  • Find a local Rheumatologist in your town

Hip bursitis facts

  • A bursa is a fluid-filled sac that functions as a gliding surface to reduce friction between moving tissues of the body.
  • There are two major bursae of the hip.
  • Bursitis is usually not infectious, but the bursa can become infected.
  • Treatment of noninfectious bursitis includes rest, ice, and medications for inflammation and pain. Infectious bursitis (uncommon) is treated with antibiotics, aspiration, and surgery.
  • Bursitis of the hip is the most common cause of hip pain.

What is bursitis?

A bursa is a closed fluid-filled sac that functions as a gliding surface to reduce friction between tissues of the body. "Bursae" is the plural form of "bursa." The major bursae are located adjacent to the tendons near the large joints, such as the shoulders, elbows, hips, and knees. When the bursa becomes inflamed, the condition is known as "bursitis."

What is hip bursitis?

There are two major bursae of the hip, the trochanteric bursa and the ischial bursa. Inflammation of either can be associated with stiffness and pain around the hip joint. The trochanteric bursa is located on the side of the hip. It is separated significantly from the actual hip joint by tissue and bone.

What causes hip bursitis?

Most commonly, bursitis is a noninfectious condition (aseptic bursitis) caused by inflammation resulting from local soft tissue trauma or strain injury. On rare occasions, the hip bursa can become infected with bacteria. This condition is called septic bursitis. Although uncommon, the hip bursa can become inflamed by crystals that deposit there from gout or pseudogout.

Picture of the Anatomy of the Hip

Picture of the Anatomy of the Hip

What are hip bursitis symptoms?

Trochanteric bursitis frequently causes tenderness of the outer hip, making it difficult for patients to lie on the involved side, frequently causing difficult sleep. Trochanteric bursitis also causes a dull, burning pain on the outer hip that is often made worse with excessive walking or stair climbing. The ischial bursa is located in the upper buttock area. Ischial bursitis can cause dull pain in this area that is most noticeable when climbing uphill. The pain sometimes occurs after prolonged sitting on hard surfaces, hence the names "weaver's bottom" and "tailor's bottom."

Bursitis of the hip is the most common cause of hip pain.

 

How is hip bursitis diagnosed?

Hip bursitis is diagnosed based on the history of outer hip pain, specific areas of tenderness of the outside of the hip, and confirmed by relief with local injection of anesthetic in the doctor's office. Patients frequently notice pain in the outer hip with stair climbing or descending and tenderness of the hip when lying on the affected side at night. The doctor can localize the tender areas to the location of the bursae of the hip. Occasionally, X-ray tests of the hip are used to rule out other conditions of the bone and joints, such as arthritis. Sometimes, but not always, X-rays can highlight areas of calcium deposits in an inflamed bursa.

What is the treatment for hip bursitis?

The treatment of any bursitis depends on whether or not it involves infection. Noninfectious or aseptic hip bursitis can be treated with ice compresses, rest, and anti-inflammatory and pain medications. Occasionally, it requires aspiration of the bursa fluid. This procedure involves removal of the fluid with a needle and syringe under sterile conditions. It can be performed in the doctor's office. Sometimes the fluid is sent to the laboratory for further analysis. Frequently, there is inadequate fluid accumulation for aspiration. Noninfectious hip bursitis can be treated with an injection of cortisone medication, often with an anesthetic, into the swollen bursa. This is sometimes done at the same time as the aspiration procedure.

Patients with hip bursitis can often benefit by weight reduction, stretching exercises, and wearing proper footwear for exercise activities. Sometimes physical-therapy programs can be helpful. Generally, patients should avoid hills and stairs and direct pressure on the affected hip (sleep on the other side), when possible, while symptoms are present. Affected people should also avoid exercising on inclined surfaces and stairs, especially running hills, until symptoms have resolved.

Septic bursitis (rare in the hip) requires even further evaluation by a doctor. This is unusual in the hip bursa but does occur. The bursal fluid can be examined in the laboratory to identify the precise bacteria causing the infection. Septic bursitis requires antibiotic therapy, often intravenously. Repeated aspiration of the infected fluid may be required. Surgical drainage and removal of the infected bursa sac (bursectomy) may also be necessary.

Bursitis of the Knee

 

Take the Pain Quiz!
Take the Pain Quiz!

 

  • What is bursitis?
  • What is knee bursitis?
  • How is prepatellar bursitis of the knee treated?
  • What about the other knee bursae?
  • Bursitis of the Knee At A Glance
  • Patient Discussions: Bursitis of the Knee
  • Find a local Rheumatologist in your town

What is bursitis?

A bursa is a closed fluid-filled sac that functions as a gliding surface to reduce friction between tissues of the body. Bursae is plural for bursa. The major bursae are located adjacent to the tendons near the large joints, such as the shoulders, elbows, hips, and knees. When a bursa becomes inflamed, the condition is known as bursitis. Most commonly, bursitis is caused by local soft tissue trauma or strain injury, and there is no infection (aseptic bursitis). On rare occasions, the bursa can become infected with bacteria. This condition is called septic bursitis.

 

What is knee bursitis?

The knee joint is surrounded by three major bursae. At the tip of the knee, over the kneecap bone, is the prepatellar bursa. This bursa can become inflamed (prepatellar bursitis) from direct trauma to the front of the knee. This commonly occurs when maintaining a prolonged kneeling position. It has been referred to as "housemaid's knee," "roofer's knee," and "carpet layer's knee," based on the patient's associated occupational histories. It can lead to varying degrees of swelling, warmth, tenderness, and redness in the overlying area of the knee. As compared with knee joint inflammation (arthritis), it is usually only mildly painful. It is usually associated with significant pain when kneeling and can cause stiffness and pain with walking. Also, in contrast to problems within the knee joint, the range of motion of the knee is frequently preserved.

Prepatellar bursitis can occur when the bursa fills with blood from injury. It can also be seen in rheumatoid arthritis and can occur from deposits of crystals, as seen in patients with gouty arthritis and pseudogout. The prepatellar bursa can also become infected with bacteria (septic bursitis). When this happens, fever may be present. This type of infection usually occurs from breaks in the overlying skin or puncture wounds. The bacteria involved in septic bursitis of the knee are usually those that normally cover the skin, called staphylococcus. Rarely, a chronically inflamed bursa can become infected by bacteria traveling through the blood.

How is prepatellar bursitis of the knee treated?

The treatment of any bursitis depends on whether or not it involves infection. Aseptic prepatellar bursitis can be treated with ice compresses, rest, and antiinflammatory and pain medications. Occasionally, it requires aspiration of the bursa fluid. This procedure involves removal of the fluid with a needle and syringe under sterile conditions and can be performed in the doctor's office. Sometimes the fluid is sent to the laboratory for further analysis. Noninfectious knee bursitis can also be treated with an injection of cortisone medication into the swollen bursa. This is sometimes done at the same time as the aspiration procedure.

Septic bursitis requires even further evaluation and treatment. The bursal fluid can be examined in the laboratory to identify the microbes causing the infection. It requires antibiotic therapy, often intravenously. Repeated aspiration of the inflamed fluid may be required. Surgical drainage and removal of the infected bursa sac (bursectomy) may also be necessary.

What about the other knee bursae?

A second bursa of the knee is located just under the kneecap beneath the large tendon that attaches the muscles in front of the thigh and the kneecap to the prominent bone in front of the lower leg. This bursa is called the infrapatellar bursa, and when inflamed, the condition is called infrapatellar bursitis. It is commonly seen with inflammation of the adjacent tendon as a result of a jumping injury, hence the name "jumper's knee." This condition is generally treated with ice, rest, and oral antiinflammatory and/or pain medicines.

A third bursa of the knee is called the "anserine bursa." It is located on the lower inner side of the knee. This bursa most commonly becomes inflamed in middle-aged women. This condition is referred to as anserine bursitis. Anserine bursitis is particularly common in those who are obese. These patients can notice pain in the inner knee while climbing or descending stairs. Anserine bursitis is generally treated with ice, rest, and oral antiinflammatory and/or pain medicines, although cortisone injections are also given.

Bursitis of the Knee At A Glance
  • A bursa is a fluid-filled sac that functions as a gliding surface to reduce friction between moving tissues of the body.
  • There are three major bursae of the knee.
  • Bursitis is usually not infectious, but the bursa can become infected.
  • Treatment of noninfectious bursitis includes rest, ice, and medications for inflammation and pain. Infectious bursitis is treated with antibiotics, aspiration, and surgery.

Calcific Bursitis

 

View the RA Slideshow Pictures
Rheumatoid Arthritis Slideshow Pictures Rheumatoid Arthritis
Joint-Friendly Exercises Slideshow Pictures Joint-Friendly Exercises
Simple Exercises to Relieve OA Pain Slideshow Simple Exercises to Relieve Osteoarthritis Pain Slideshow

 

  • What is calcific bursitis?
  • How is calcific bursitis diagnosed?
  • What is the treatment of calcific bursitis?
  • What is the outlook for a patient with calcific bursitis?
  • Find a local Rheumatologist in your town

What is calcific bursitis?

A bursa is a thin fluid-filled sac that reduces friction forces between tissues of the body. Chronic (repeated or long-standing) inflammation of the bursa (bursitis) can lead to calcification of the bursa. This is referred to as "calcific bursitis." The calcium deposits (calcification) can occur as long as the inflammation is present and remain after it has resolved. Calcific bursitis occurs most commonly in the shoulder.

How is calcific bursitis diagnosed?

Calcific bursitis is diagnosed when viewed with an x-ray test or MRI scan of the inflamed, painful bursa.

What is the treatment of calcific bursitis?

Treatment of the inflammation of calcific bursitis can help to prevent further calcification as well as relieve pain and stiffness. Treatments include medications for inflammation, cold packs, immobilization, injections of cortisone into the bursa, physical therapy, and occasionally surgical removal of the inflamed bursa.

What is the outlook for a patient with calcific bursitis?

When the inflammation is quieted, the long-term outlook (prognosis) is excellent. Optimal improvement can require physical therapy treatment. The calcium deposit can remain indefinitely and may not cause any problems. Significant calcium deposits can sometimes, however, cause a mechanically abrasive area of tenderness. These deposits that continue to cause symptoms are considered for surgical removal.

Shoulder Bursitis

 

Take the Pain Quiz!

 

Take the Pain Quiz! Take the Pain Quiz!

 

  • What is shoulder bursitis?
  • How does a bursa become inflamed?
  • What are the symptoms of shoulder bursitis? How is shoulder bursitis diagnosed?
  • How is shoulder bursitis treated?
  • Patient Discussions: Shoulder Bursitis
  • Find a local Rheumatologist in your town

What is shoulder bursitis?

A bursa is a tiny fluid-filled sac that functions as a gliding surface to reduce friction between tissues of the body. The plural of bursa is bursae. There are 160 bursae in the body. The major bursae are located adjacent to the tendons near the large joints, such as the shoulders, elbows, hips, and knees.

Bursitis is inflammation of a bursa. When injury or inflammation of a bursa around the shoulder joint occurs, shoulder bursitis is present.

How does a bursa become inflamed?

A bursa can become inflamed from injury, infection (rare in the shoulder), or an underlying rheumatic condition. Examples include infection of the bursa in front of the knee from a knee scraping on asphalt (septic prepatellar bursitis), inflammation of the elbow bursa from gout crystals (gouty olecranon bursitis), or injury as subtle as lifting a bag of groceries into the car, which could inflame the shoulder bursa (shoulder bursitis).

What are the symptoms of shoulder bursitis? How is shoulder bursitis diagnosed?

Bursitis is typically identified by localized pain or swelling, tenderness, and pain with motion of the tissues in the affected area. X-ray testing can sometimes detect calcifications in the bursa when bursitis has been chronic or recurrent. MRI scanning (magnetic resonance imaging) can also define bursitis.

How is shoulder bursitis treated?

The treatment of any form of bursitis depends on whether or not it involves infection. Infection of a shoulder bursa is uncommon, and bursitis that develops there is usually from injury. Bursitis that is not infected (from injury or an underlying rheumatic disease) can be treated with ice compresses, rest, and antiinflammatory and pain medications. Occasionally, it requires aspiration of the bursa fluid. This procedure involves removal of the fluid with a needle and syringe under sterile conditions and can be performed in the doctor's office. Sometimes the fluid is sent to the laboratory for further analysis. Noninfectious shoulder bursitis can also be treated with an injection of cortisone medication into the swollen bursa. This is sometimes done at the same time as the aspiration procedure. Physical therapy can sometimes be used to aid the recovery from bursitis, especially when it is accompanied by a frozen shoulder.

Infectious (septic) bursitis, which again is uncommon in the shoulder, requires even further evaluation and aggressive treatment. The bursal fluid can be examined in the laboratory to identify the microbes causing the infection. Septic bursitis requires antibiotic therapy, sometimes intravenously. Repeated aspiration of the inflamed fluid may be required. Surgical drainage and removal of the infected bursa sac (bursectomy) may also be necessary. Generally, the adjacent joint functions normally after the surgical wound heals.

Coronary Artery Bypass Graft Surgery
(CABG)

 

 

  • What is coronary artery bypass graft (CABG) surgery?
  • How does coronary artery disease develop?
  • How is coronary artery disease diagnosed?
  • How is coronary artery disease (CAD) treated?
  • How is CABG surgery done?
  • How do patients recover after CABG surgery?
  • What are the risks and complications of CABG surgery?
  • What are the long-term results after CABG surgery?
  • How do CABG surgery and PTCA (angioplasty) compare?
  • Coronary Artery Bypass Graft At A Glance
  • Patient Discussions: Coronary Artery Bypass Graft
  • Patient Discussions: Coronary Artery Bypass Graft - Describe Your Experience
  • Find a local Cardiothoracic Surgeon in your town

What is coronary artery bypass graft (CABG) surgery?

According to the American Heart Association 427,000 coronary artery bypass graft (CABG) surgeries were performed in the United States in 2004, making it one of the most commonly performed major operations. CABG surgery is advised for selected groups of patients with significant narrowings and blockages of the heart arteries (coronary artery disease). CABG surgery creates new routes around narrowed and blocked arteries, allowing sufficient blood flow to deliver oxygen and nutrients to the heart muscle.

How does coronary artery disease develop?

Coronary artery disease (CAD) occurs when atherosclerotic plaque (hardening of the arteries) builds up in the wall of the arteries that supply the heart. This plaque is primarily made of cholesterol. Plaque accumulation can be accelerated by smoking, high blood pressure, elevated cholesterol, and diabetes. Patients are also at higher risk for plaque development if they are older (greater than 45 years for men and 55 years for women), or if they have a positive family history for early heart artery disease.

The atherosclerotic process causes significant narrowing in one or more coronary arteries. When coronary arteries narrow more than 50 to 70%, the blood supply beyond the plaque becomes inadequate to meet the increased oxygen demand during exercise. The heart muscle in the territory of these arteries becomes starved of oxygen (ischemic). Patients often experience chest pain (angina) when the blood oxygen supply cannot keep up with demand. Up to 25% of patients experience no chest pain at all despite documented lack of adequate blood and oxygen supply. These patients have "silent" angina, and have the same risk of heart attack as those with angina.

When a blood clot (thrombus) forms on top of this plaque, the artery becomes completely blocked causing a heart attack.

Heart Attack illustration - Coronary Artery Bypass Graft Surgery

When arteries are narrowed in excess of 90 to 99%, patients often have accelerated angina or angina at rest (unstable angina). Unstable angina can also occur due to intermittent blockage of an artery by a thrombus that eventually is dissolved by the body's own protective clot-dissolving system.

How is coronary artery disease diagnosed?

The resting electrocardiogram (EKG) is a recording of the electrical activity of the heart, and can demonstrate signs of oxygen starvation of the heart (ischemia) or heart attack. Often, the resting EKG is normal in patients with coronary artery disease and angina. Exercise treadmill tests are useful screening tests for patients with a moderate likelihood of significant coronary artery disease (CAD) and a normal resting EKG. These stress tests are about 60 to 70% accurate in diagnosing significant CAD.

If the stress tests do not reveal the diagnosis, greater accuracy can be achieved by adding a nuclear agent (thallium or Cardiolite) intravenously during stress tests. Addition of thallium allows nuclear imaging of the blood flow to different regions of the heart, using an external camera. An area of the heart with reduced blood flow during exercise, but normal blood flow at rest, signifies significant artery narrowing in that region.

 

Combining echocardiography (ultrasound imaging of the heart muscle) with exercise stress testing (stress echocardiography) is also a very accurate technique to detect CAD. When a significant blockage exists, the heart muscle supplied by this artery does not contract as well as the rest of the heart muscle. Stress echocardiography and thallium stress tests are both at least 80% to 85% accurate in detecting significant coronary artery disease.

When a patient cannot undergo exercise stress test because of nervous system or joint problems, medications can be injected intravenously to simulate the stress on the heart due to exercise and imaging can be performed with a nuclear camera or ultrasound.

Cardiac catheterization with angiography (coronary arteriography) is the most accurate test to detect coronary artery narrowing. Small hollow plastic tubes (catheters) are advanced under x-ray guidance to the openings of the two main heart arteries (left and right). Iodine contrast, "dye," is then injected into the arteries while an x-ray video is recorded. Sometimes, an exercise study is then done to determine whether a moderate narrowing (40 - 60%) is actually causing ischemia and, therefore, requires treatment.

A newer modality, high speed CT scanning angiography has recently become available. This procedure uses powerful x-ray methods to visualize the arteries to the heart. Its role in the evaluation of CAD is currently being evaluated. For more, please read the CT Scanning Angiography article.

How is coronary artery disease (CAD) treated?

Medicines used to treat angina reduce the heart muscle demand for oxygen in order to compensate for the reduced blood supply. Three commonly used classes of drugs are the nitrates, beta blockers and calcium blockers. Nitroglycerin (Nitro-Bid) is an example of a nitrate. Examples of beta blockers include propranolol (Inderal) and atenolol (Tenormin). Examples of calcium blockers include nicardipine (Cardene) and  nifedipine (Procardia, Adalat). Unstable angina is also treated with aspirin and the intravenous blood thinner heparin. Aspirin prevents clumping of platelets, while heparin prevents blood clotting on the surface of plaques in a critically narrowed artery. When patients continue to have angina despite maximum medications, or when significant ischemia still occurs with exercise testing, coronary arteriography is usually indicated. Data collected during coronary arteriography help doctors decide whether the patient should be considered for percutaneous coronary intervention, or percutaneous transluminal angioplasty (PTCA), whereby a small balloon is used to inflate the blockage. Angioplasty (PTCA) is usually followed by placement of a stent or coronary artery bypass graft surgery (CABG) to increase coronary artery blood flow.

 

Angioplasty can produce excellent results in carefully selected patients. Under x-ray guidance, a wire is advanced from the groin to the coronary artery. A small catheter with a balloon at the end is threaded over the wire to reach the narrowed segment. The balloon is then inflated to push the artery open, and a steel mesh stent is generally inserted.

CABG surgery is performed to relieve angina in patients who have failed medical therapy and are not good candidates for angioplasty (PTCA). CABG surgery is ideal for patients with multiple narrowings in multiple coronary artery branches, such as is often seen in patients with diabetes. CABG surgery has been shown to improve long-term survival in patients with significant narrowing of the left main coronary artery, and in patients with significant narrowing of multiple arteries, especially in those with decreased heart muscle pump function.

How is CABG surgery done?

The cardiac surgeon makes an incision down the middle of the chest and then saws through the breastbone (sternum). This procedure is called a median (middle) sternotomy (cutting of the sternum). The heart is cooled with iced salt water, while a preservative solution is injected into the heart arteries. This process minimizes damage caused by reduced blood flow during surgery and is referred to as "cardioplegia." Before bypass surgery can take place, a cardiopulmonary bypass must be established. Plastic tubes are placed in the right atrium to channel venous blood out of the body for passage through a plastic sheeting (membrane oxygenator) in the heart lung machine. The oxygenated blood is then returned to the body. The main aorta is clamped off (cross clamped) during CABG surgery to maintain a bloodless field and to allow bypasses to be connected to the aorta.

 

Coronary Artery Bypass illustration

The most commonly used vessel for the bypass is the saphenous vein from the leg. Bypass grafting involves sewing the graft vessels to the coronary arteries beyond the narrowing or blockage. The other end of this vein is attached to the aorta. Chest wall arteries, particularly the left internal mammary artery, have been increasingly used as bypass grafts. This artery is separated from the chest wall and usually connected to the left anterior descending artery and/or one of its major branches beyond the blockage. The major advantage of using internal mammary arteries is that they tend to remain open longer than venous grafts. Ten years after CABG surgery, only 66% of vein grafts are open compared to 90% of internal mammary arteries. However, artery grafts are of limited length, and can only be used to bypass diseases located near the beginning (proximal) of the coronary arteries. Using internal mammary arteries may prolong CABG surgery because of the extra time needed to separate them from the chest wall. Therefore, internal mammary arteries may not be used for emergency CABG surgery when time is critical to restore coronary artery blood flow.

CABG surgery takes about four hours to complete. The aorta is clamped off for about 60 minutes and the body is supported by cardiopulmonary bypass for about 90 minutes. The use of 3 (triple), 4 (quadruple), or 5 (quintuple) bypasses are now routine. At the end of surgery, the sternum is wired together with stainless steel and the chest incision is sewn closed. Plastic tubes (chest tubes) are left in place to allow drainage of any remaining blood from the space around the heart (mediastinum). About 5% of patients require exploration within the first 24 hours because of continued bleeding after surgery. Chest tubes are usually removed the day after surgery. The breathing tube is usually removed shortly after surgery. Patients usually get out of bed and are transferred out of intensive care the day after surgery. Up to 25% of patients develop heart rhythm disturbances within the first three or four days after CABG surgery. These rhythm disturbances are usually temporary atrial fibrillation, and are felt to be related to surgical trauma to the heart. Most of these arrhythmias respond to standard medical therapy that can be weaned one month after surgery. The average length of stay in the hospital for CABG surgery has been reduced from as long as a week to only three to four days in most patients. Many young patients can even be discharged home after two days.

A new advance for many patients is the ability to do CABG with out going on cardiopulmonary bypass ("off pump"), with the heart still beating. This significantly minimizes the occasional memory defects and other complications that may be seen after CABG, and is a significant advance.

How do patients recover after CABG surgery?

Sutures are removed from the chest prior to discharge and from the leg (if the saphenous vein is used) after 7 to 10 days. Even though smaller leg veins will take over the role of the saphenous vein, a certain degree of swelling (edema) in the affected ankle is common. Patients are advised to wear elastic support stockings during the day for the first four to six weeks after surgery and to keep their leg elevated when sitting. This swelling usually resolves after about six to eight weeks. Healing of the breastbone takes about six weeks and is the primary limitation in recovering from CABG surgery. Patients are advised not to lift anything more than 10 pounds or perform heavy exertion during this healing period. They are also advised not to drive for the first four weeks to avoid any injury to the chest. Patients can return to normal sexual activity as long as they minimize positions that put significant weight on the chest or upper arms. Return to work usually occurs after the six week recovery, but may be much sooner for non-strenuous employment.

Exercise stress testing is routinely done four to six weeks after CABG surgery and signals the beginning of a cardiac rehabilitation program. Rehabilitation consists of a 12 week program of gradually increasing monitored exercise lasting one hour three times a week. Patients are also counseled about the importance of lifestyle changes to lower their chance of developing further CAD. These include stopping smoking, reducing weight and dietary fat, controlling blood pressure and diabetes, and lowering blood cholesterol levels.

What are the risks and complications of CABG surgery?

Overall mortality related to CABG is 3-4%. During and shortly after CABG surgery, heart attacks occur in 5 to 10% of patients and are the main cause of death. About 5% of patients require exploration because of bleeding. This second surgery increases the risk of chest infection and lung complications. Stroke occurs in 1-2%, primarily in elderly patients. Mortality and complications increase with:

  • age (older than 70 years),
  • poor heart muscle function,
  • disease obstructing the left main coronary artery,
  • diabetes,
  • chronic lung disease, and
  • chronic kidney failure.

Mortality may be higher in women, primarily due to their advanced age at the time of CABG surgery and smaller coronary arteries. Women develop coronary artery disease about 10 years later than men because of hormonal "protection" while they still regularly menstruate (although in women with risk factors for coronary artery disease, especially smoking, elevated lipids, and diabetes, the possibility for the development of coronary artery disease at a young age is very real). Women are generally of smaller stature than men, with smaller coronary arteries. These small arteries make CABG surgery technically more difficult and prolonged. The smaller vessels also decrease both short and long-term graft function.

What are the long-term results after CABG surgery?

A very small percentage of vein grafts may become blocked within the first two weeks after CABG surgery due to blood clotting. Blood clots form in the grafts usually because of small arteries beyond the insertion site of the graft causing sluggish blood run off. Another 10% of vein grafts close off between two weeks and one year after CABG surgery. Use of aspirin to thin the blood has been shown to reduce these later closings by 50%. Grafts become narrowed after the first five years as cells stick to the inner lining and multiply, causing formation of scar tissue (intimal fibrosis) and actual atherosclerosis. After 10 years, only 2/3 of vein grafts are open and 1/2 of these have at least moderate narrowings. Internal mammary grafts have a much higher (90%) 10 year rate of remaining open. This difference in longevity has caused a shift in surgical practices toward greater use of internal mammary and other arteries as opposed to veins for bypasses.

Recent data has shown that in CABG patients with elevated LDL cholesterol (bad cholesterol) levels, use of cholesterol-lowering medications (particularly the statin family of drugs) to lower LDL levels to below 80 will significantly improve long-term graft patency as well as improve survival benefit and heart attack risk. Patients are also advised about the importance of lifestyle changes to lower their chance of developing further atherosclerosis in their coronary arteries. These include stopping smoking, exercise, reducing weight and dietary fat, as well as controlling blood pressure and diabetes. Frequent monitoring of CABG patients with physiologic testing can identify early problems in grafts. PTCA (angioplasty) with stenting, in addition to aggressive risk factor modification, may significantly limit the need for repeat CABG years later. Repeat CABG surgery is occasionally necessary, but may have a higher risk of complication.

How do CABG surgery and angioplasty (PTCA) compare?

Ongoing studies are comparing the treatment results of angioplasty (PTCA) versus bypass (CABG surgery) in patients who are candidates for either procedure. Both procedures are very effective in reducing angina symptoms, preventing heart attacks, and reducing death. Many studies have either shown similar benefits or slight advantage to CABG (primarily in severe diabetics), although current studies are evaluating the two procedures utilizing the most current improved techniques (for example, newer "medicated" stents and the off-pump CABG); this data is still being collected. The best choice for an individual patient is best made by their cardiologist, surgeon, and primary doctor.

Coronary Artery Bypass Graft At A Glance
  • Coronary artery disease develops because of hardening of the arteries (arteriosclerosis) that supply blood to the heart muscle.
  • In the diagnosis of coronary artery disease, helpful tests include EKG, stress test, echocardiography, and coronary angiography.
  • Coronary artery bypass graft (CABG) surgery reestablishes sufficient blood flow to deliver oxygen and nutrients to the heart muscle.
  • The bypass graft for a CABG can be a vein from the leg or an inner chest wall artery.

Weight Loss: Gastric Bypass Operations

 

View Weight Gain Shockers Slideshow Pictures
Weight Gain Shockers Slideshow Pictures View Weight Gain Shockers Slideshow Pictures
Take the Quiz: Belly (Abdominal) Fat Take the Quiz: Belly (Abdominal) Fat
Ways to Get Ready for Swimsuit Season Slideshow 25 Ways to Get Ready for Swimsuit Season Slideshow Pictures

 

  • Introduction to gastric bypass operations
  • What types of gastric bypass operations are there?
  • Are there risks associated with gastric bypass surgery?
  • What health problems can nutritional deficiencies cause?

Introduction

Gastric bypass operations combine the creation of a small stomach pouch to restrict food intake and construction of bypasses of the duodenum and other segments of the small intestine to cause malabsorption (decreased ability to absorb nutrients from food).

What Types of Gastric Bypass Operations Are There?

  • Roux-en-Y gastric bypass (RGB). This operation is the most common gastric bypass procedure performed in the U.S. First, a small stomach pouch is created by stapling part of the stomach together or by vertical banding. This limits how much food you can eat. Next, a Y-shaped section of the small intestine is attached to the pouch to allow food to bypass the duodenum as well as the first portion of the jejunum. This causes reduced calorie and nutrient absorption. This procedure can now be done with a laparoscope (a thin telescope-like instrument for viewing inside the abdomen) in some people. This involves using small incisions and generally has a more rapid recovery time.
  • Extensive gastric bypass (biliopancreatic diversion). In this more complicated gastric bypass operation, the lower portion of the stomach is removed. The small pouch that remains is connected directly to the final segment of the small intestine, thus completely bypassing both the duodenum and jejunum. Although this procedure successfully promotes weight loss, it is not as widely used because of the high risk for nutritional deficiencies.

Roux-en-Y gastric bypass Illustration: Gastric Bypass Surgery

Gastric bypass operations that cause malabsorption and restrict food intake produce more weight loss than restriction operations, which only decrease food intake. People who have bypass operations generally lose two-thirds of their excess weight within 2 years.

Extensive Gastric Bypass Illustration: Gastric Bypass Surgery

Are There Risks Associated With Gastric Bypass Surgery?

Yes. People who undergo this procedure are at risk for:

  • Pouch stretching (stomach gets bigger overtime, stretching back to its normal size before surgery).
  • Band erosion (the band closing off part of the stomach disintegrates).
  • Breakdown of staple lines (band and staples fall apart, reversing procedure).
  • Leakage of stomach contents into the abdomen (this is dangerous because the acid can eat away other organs).
  • Nutritional deficiencies causing health problems.

Gastric bypass operations also may cause "dumping syndrome," whereby stomach contents move too rapidly through the small intestine. Symptoms include nausea, weakness, sweating, faintness, and, occasionally, diarrhea after eating, as well as the inability to eat sweets without becoming extremely weak. Gallstones can occur in response to rapid weight loss. They can be dissolved with medication taken after the surgery.

What Health Problems Can Nutritional Deficiencies Cause?

The limited absorption of vitamin B-12 and iron can cause anemia. The lack of calcium absorption can cause osteoporosis and metabolic bone disease. People who undergo this procedure are required to take nutritional supplements that usually prevent these deficiencies.

The more extensive the bypass operation, the greater is the risk for complications and nutritional deficiencies. People who undergo extensive bypasses of the normal digestive process require not only close monitoring, but also lifelong use of special foods and medications.

 

Last Updated on Sunday, 06 November 2011 15:30
 
Broken Finger PDF Print E-mail
Written by Ruai Pharmaceuticals   
Sunday, 21 August 2011 15:55

 

Broken Finger

View Adult Skin Problems Slideshow Pictures
  • Broken finger introduction
  • What are the causes of a broken finger?
  • What are the symptoms of a broken finger?
  • When should I see a doctor for a broken finger?
  • How is a broken finger diagnosed?
  • What is the treatment for a broken finger?
  • What are the complications of a broken finger?
  • How can a broken finger be prevented?
  • Broken Finger At A Glance
  • Find a local Doctor in your town

Broken finger introduction

Fingers are easily injured, and broken fingers are some of the most common traumatic injuries seen in an emergency room. Finger fractures may account for up to 10% of all bone fractures. Because fingers are used for many everyday activities, they are at higher risk than other parts of the body for traumatic injury, including sports injuries, workplace injuries, and other accidents.

Understanding the basic anatomy of the hand and fingers is useful in understanding different types of finger injuries, broken fingers, and how some treatments differ from others.

The hand is divided into three sections: 1) wrist, 2) palm, and 3) fingers.

  • The wrist has eight bones, which move together to allow the vast ranges of motion of the wrist.
  • The palm or mid-hand is comprised of the metacarpal bones. The metacarpal bones have muscular attachments and bridge the wrist to the individual fingers. These bones frequently are injured with direct trauma such as a crush injury, or most commonly, a punching injury.
  • The fingers are the most frequently injured part of the hand. Fingers are constructed of ligaments (strong supportive tissue connecting bone to bone), tendons (attachment tissue from muscle to bone), and three  phalanges (bones). There are no muscles in the fingers; and fingers move by the pull of forearm muscles on the tendons.

     

    • The three bones in each finger are named according to their relationship to the palm of the hand. The first bone, closest to the palm, is the proximal phalange; the second bone is the middle phalange; and the smallest and farthest from the hand is the distal phalange. The thumb does not have a middle phalange.
  • The knuckles are joints formed by the bones of the fingers and are commonly injured or dislocated with trauma to the hand.

     

    • The first and largest knuckle is the junction between the hand and the fingers - the metacarpophalangeal joint (MCP). This joint commonly is injured in closed-fist activities and is commonly known as a boxer's fracture.
    • The next knuckle out toward the fingernail is the proximal inter-phalangeal joint (PIP). This joint may be dislocated in sporting events when a ball or object directly strikes the finger.
    • The farthest joint of the finger is the distal inter-phalangeal joint (DIP). Injuries to this joint usually involve a fracture or torn tendon (avulsion) injury.

Bones of the Hand

What are the causes of a broken finger?

Traumatic injury is the main cause of broken fingers. Most commonly, traumatic injury to the finger occurs from playing sports, workplace injuries, falls, or other accidents.

What are the symptoms of a broken finger?

The main symptoms of a broken finger are pain immediately after the trauma, and sometimes a deformed finger.

  • A true fracture usually will be painful, but a broken finger may still have some range of motion and dull pain, and the individual may still be able to move it. Depending on the fracture stability, some fractures may be more painful than others.
  • Usually within 5-10 minutes, swelling and bruising of the finger will occur and the finger will stiffen. Swelling may affect the adjacent fingers as well.
  • Numbness of the finger may occur either from the trauma of the injury itself, or because swelling compresses the nerves in the fingers.
  • Fractures to the finger tip (distal phalanx) are common from smashing injuries to the fingernail. The symptoms of this type of injury may be swelling and bruising to the finger pad and purple-colored blood underneath the fingernail (subungual hematoma).
  • If the trauma is severe, broken bones may be exposed (called a compound fracture).

Picture of a Subungual Hematoma

When should I see a doctor for a broken finger?

  • After injury, if pain or swelling limits the motion or use of the fingers, or if the finger becomes numb, seek medical care.
  • If the injury to the finger includes a laceration, crushed tissue, or exposure of bone, the individual should go to an emergency department for immediate medical care.
  • Some fractures of the fingers may be subtle and the pain may be tolerable, so if a person suspects that they may have a finger fracture, seek medical attention.

How is a broken finger diagnosed?

X-ray is the primary tool used to diagnose a broken finger. The doctor will need an X-ray to evaluate the position of the broken finger bones.

With more complex injuries, the doctor may seek the advice of an orthopedic (bone and joint specialist) or hand surgeon (an orthopedic surgeon with post-residency, fellowship level training in hand surgery).

What is the treatment for a broken finger?

Broken fingers should be treated by medical professionals; however, a person can minimize some pain and stabilize the injury on the way to seek medical treatment.

  • To reduce swelling and bruising, apply ice to the injured finger on the way to an emergency department. Do not apply ice directly to the skin; put a towel between the ice and the finger.
  • Make a splint to immobilize the finger. A Popsicle stick or pen may be placed next to the broken finger, and then wrap something around the stick and the finger to hold it in place.
  • Keep the injured finger elevated.

Medical treatment

The doctor will assess the stability of the broken finger. The treatment for a broken finger depends on the type of fracture, and the particular bone in the finger that is injured.

If the fracture is stable (not likely to worsen or cause complications with the movement of the finger), treatment may be as simple as buddy taping (splinting one finger to another by taping them together) for about four weeks, followed by an additional two weeks of limiting use of the finger.

If the fracture is unstable, the injured finger will need to be immobilized. A splint may be applied after reduction (re-aligning of the fractured fragments). If this does not maintain enough stability a surgical procedure may be needed.

A surgeon has many different techniques for surgical immobilization, ranging from pinning the fracture with small wires to procedures with plates and screws.

The patient will most likely leave the hospital in some type of immobilizing splint or dressing. Keep the dressing clean, dry, and elevated. It is best not to use the involved hand until a hand specialist is consulted (about one week after the injury) for another X-ray to evaluate the position of the fracture fragments. If the finger is not aligned correctly, it may affect the healing of the finger and leave a permanent disability.

What are the complications of a broken finger?

After reduction, immobilization, and four to six weeks of healing, the prognosis for healing is excellent for a broken finger.

  • Joint stiffness is the most common problem encountered after treatment of fractures in the fingers due to scar tissue formation and the long immobilization period. Physical therapy may be prescribed (preferably by a hand therapist) to regain range of motion.
  • Rotation can occur when one of the bones in the finger rotates abnormally during the healing process. This can cause deformity and decreased ability to use the injured finger when grasping.
  • Nonunion is a complication of some fractures when the two ends of the bone do not heal together properly, leaving the fractured area unstable.
  • If the skin is injured or if surgery is necessary to fix the fractured bone, infection may result.

How can a broken finger be prevented?

The best medicine for prevention of finger fractures is safety. Most fingers are broken from machines or sporting injuries. Always use safety equipment when doing activities that may injure the hands. Despite all efforts and precautions, injuries do occur and should be evaluated as soon possible.

Broken Finger At A Glance
  • Finger fractures may account for up to 10% of all fractures.
  • The finger bones are named according to their relationship to the palm of the hand. The first bone, closest to the palm, is the proximal phalange. The second bone is the middle phalange. The smallest and farthest from the hand is the distal phalange. The thumb does not have a middle phalange.
  • Traumatic injury is the main cause of broken fingers, and it occurs from playing sports, workplace, falls, or in other accidents.
  • The main symptoms of a broken finger are pain immediately after the trauma, and sometimes a deformed finger. If the trauma is severe, broken bones may be exposed (called a compound fracture).
  • If pain or swelling limits the motion or use of the fingers, if the finger becomes numb, or if the injury includes a laceration, crushed tissue, or exposure of bone, seek medical care.
  • The mainstay of diagnosing finger fractures is an X-ray.
  • Treatment of broken fingers depends on the type of fracture and the particular bone in the finger that is injured.
  • Complications of a broken finger can include join stiffness, rotation, nonunion, and infection.
  • After reduction, immobilization, and four to six weeks of healing, the prognosis for healing is excellent for a broken finger.
  • The best medicine for prevention of finger fractures is safety. Always use safety equipment when doing activities that may injure the hands.

Broken Foot

 

View Adult Skin Problems Slideshow Pictures

 

Adult Skin Problems Slideshow Pictures View Adult Skin Problems Slideshow Pictures
Gallery of Skin Problems and Image Collection Gallery of Skin Problems and Image Collection
Medical Author:

 

Medical Editor:

 

  • What is the structure of the foot?
  • What are the causes of a broken foot?
  • What are the symptoms of a broken foot?
  • When should I call the doctor for foot pain?
  • How is a broken foot diagnosed?
  • What is the treatment for a broken foot?
  • What are the complications of a broken foot?
  • Can a broken foot be prevented?
  • Broken Foot At A Glance
  • Find a local Doctor in your town

What is the structure of the foot?

Picture of the footThe foot is designed to withstand the considerable forces placed on it by walking, running, and jumping. The 26 bones of the foot are connected by joints and supported by thickened ligaments to absorb the impact of movement. As well, the joints of the foot are acted upon by tendons that allow flexing and extending to permit walking and running to occur.

The bony anatomy can be described as follows:

  • The talus articulates with the tibia (shin bone) to form the ankle joint.
  • The calcaneus or the heel bone is attached by ligaments to the tibia to provide stability to the ankle joint.
  • The midfoot consists of the navicular, the cuboid, and the three cuneiform bones. The midfoot is where inversion and supination of the foot occurs. These motions allow the sole of the foot to turn inwards and upwards.
  • The five metatarsal bones are connected to each toe.
  • The toe bones are called phalanges (single = phalanx) with the great toe having two and the other four toes having three each. These bones are named based upon their relationship to the body: proximal, middle and distal. Proximal means closest to the center of the body while distal is furthest from the center.
  • The arch of the foot is maintained by the plantar fascia, a thick fibrous band of tissue that runs from the calcaneus to the metatarsal, preventing the bones of the foot from flattening.
  • Injuries to the foot include fractures of the bone, sprains of the ligaments that stabilize the joints, and strains of the muscles and tendons that move the foot.

Picture of the Bones in the Foot

Picture of the metatarsal (foot) and calcaneus (heel) bones, the plantar fascia ligament, and the Achilles tendon of the lower leg and foot

What are the causes of a broken foot?

A fracture, break, or crack all mean the same thing when it comes to a bone injury: the integrity of the bone has been damaged. The cause of injury may be obvious, such as jumping from a height or a heavy object falling and landing on the foot, or it may develop gradually over time, such as the result of the constant stress of walking or running.

  • Foot fractures account for 10% of all the broken bones in the body, and the mechanism of injury usually can give a clue as to what bone might be injured.
  • Fractures of the calcaneus usually occur when a person jumps or falls from a height, landing directly on their feet. The force of the landing may also be transmitted up the body to cause fractures of the ankle, knee, hip, and lumbar spine.
  • Injuries to the midfoot, the metatarsals, and phalanges often are caused by a direct blow sustained when a kick goes awry or from a crush injury when a heavy object is dropped on the foot.
  • The most common causes of foot injuries include falls; crush injuries (including impacts from a heavy object or an automobile accident) missed steps, and stress/overuse injuries.

What are the symptoms of a broken foot?

Broken bones are painful, which is the most common symptom that will prompt a person to seek medical care. Swelling, bruising, and tenderness are the other common symptoms. Because the body tries to protect itself, walking may be too painful or the patient will present with a limp. If the bones are significantly displaced (the bone alignment has been lost or there is an associated joint dislocation) a deformity of the foot may be apparent.

In patients with altered pain sensation due to peripheral neuropathy (persons with diabetes are a classic example), pain may not be present, so a fracture may be missed initially. This may also occur in patients with spinal cord injury. Bruising, swelling, and deformity may be the only clues to a potential fracture.

Infants and toddlers may ignore the pain of injury and they may present to the health care practitioner refusing to bear weight on their leg. The child may sit comfortably on the parent's lap without complaint until asked or made to stand.

When should I call the doctor for foot pain?

Most of the bones in the foot will eventually heal with rest, but some fractures may need surgery to repair.

Often, it is the mechanism of injury associated with the intensity of pain that makes the patient seek care. It is appropriate to seek medical care if the patient cannot walk normally without a limp.

Medical care should be accessed immediately if an injury to the foot also includes a laceration. The term "open fracture", previously named "compound fracture," describes a broken bone that is associated with a break in the skin. In threes cases there is significant risk for major infection of the bone.

Other reasons to seek care include the presence of numbness or tingling in the toes, which may be an indication of nerve damage, or if the foot becomes cool and white, which may signal damage to the blood supply of the foot.

How is a broken foot diagnosed?

The diagnosis begins with the health care practitioner taking a history of how the injury occurred. The mechanism of injury will give clues as to what type of injury may exist and importantly, what other associated injuries may also be potentially present. It is helpful to know how much time has passed from when the injury occurred to when the patient presents for care. Past medical history is important; those with diabetes are at greater risk for infection with foot injuries.

Physical examination may include the following:

  • Inspection of the foot for swelling, bruising, deformities and open wounds.
  • Palpation allows the health care practitioner to feel where the pain is located. This is very helpful if X-rays are taken, since it allows a more careful inspection of the area where the tenderness exists. (This is particularly important in children whose bones may not have yet calcified. Fractures may be easily missed since they occur through cartilage instead of bone.)
  • An exam of the circulatory system, feeling for pulses, and a neurologic exam, assessing sensation such as light touch and pin prick sensation along with motor function, may also be done.

  • A range of motion exam of the foot may be helpful in assessing ligament stability. However, if the fracture is obvious, the health care practitioner may choose to keep the foot immobilized to prevent further pain.

Imaging

X-rays are often taken to evaluate the status of the bones in the foot and check for fracture. Usually three pictures are taken to help the health care practitioner and radiologist adequately view the bones. Special views may be taken if there is concern for a fracture of the calcaneus.

X-rays may not be taken for simple toe injuries, since they may not affect the treatment plan.

For some foot fractures, X-rays may not be adequate to visualize the injury. This is often true for metatarsal stress fractures, where bone scans may be used if the history and physical examination suggest a potential fracture, but the plain X-rays are normal.

Computerized tomography (CT) may be used to assess fractures of the calcaneus and talus, since it may better be able to illustrate the anatomy of the ankle and midfoot joint and potential associated injuries.

The Lisfranc joint describes the connection between the first, second, and third metatarsals and the three cuneiform bones. A Lisfranc fracture dislocation often requires a CT scan to evaluate this region of the foot once plain X-rays delineate the injury.

What is the treatment for a broken foot?

First aid at home may include RICE (rest, ice, elevation, and compression) and weight bearing as tolerated. If the decision is made to seek medical care, this regimen may still be considered once the patient is discharged from the hospital to go home.

The treatment of a foot fracture depends upon what bone is broken, the mechanism of injury, the underlying medical condition of the patient, and whether the fracture is open (the skin is broken) or closed (the skin is intact).

Broken toes are often treated symptomatically, with the injured toe "buddy taped" to an adjacent normal toe. It may be helpful to place cotton balls or other absorbent material between the toes to prevent dampness and skin injury. A stiff-soled shoe and crutches may be needed to help with walking. Healing should occur with in 4 to 6 weeks.

Fractures of the great toe that are displaced may require surgery to allow better healing. An orthopedic surgeon or podiatrist may choose this option, but often that decision is made electively a few days after the injury.

Open fractures of the toe usually require good wound cleansing to prevent infection. At the same time the health care practitioner will often explore the wound, looking for foreign objects and evaluate the condition of deep structures like tendons, looking for lacerations.

Metatarsal fractures often heal nicely with conservative care, meaning no operation is needed. The foot is wrapped for comfort to decrease swelling and placed in an orthopedic post-op or Reese shoe.

  • First metatarsal fractures that are aligned nicely may be treated with a post-op shoe and avoidance of weight bearing. If the fracture is displaced, meaning the bone fragments do not align, an operation to pin or plate the fracture may be considered.
  • Second, third, and fourth metatarsal fractures tend to heal nicely with an ace wrap for support and weight bearing as tolerated. Stress fractures usually involve the second and third metatarsals.
  • Fifth metatarsal fractures are of two types. If the fracture is at the very base of the bone, then treatment is the same as the other metatarsal fractures.
  • Jones fractures of the fifth metatarsal shaft have a non healing (non-union) rate of up to 50% and often require surgery to fix the fracture.
  • Lisfranc fracture dislocation injuries require surgery for repair.
  • The treatment of talus fractures depends upon where in the bone the fracture occurs.
  • The top of the talus is dome-shaped and is part of the ankle joint, fitting into the base of the tibia or shin bone. This fracture may not be easily identified and sometimes can be mistaken for a non-healing ankle sprain. The treatment is rest and avoidance of weight bearing.
  • Talar neck fractures often have difficulty healing because of poor blood supply. Surgery may be required if the bone is displaced, otherwise no weight bearing in a cast for 2-3 months may be required.
  • A Shepherd fracture involves the posterior, or back part, of the talus and is seen in athletes who dance or kick. The treatment is immobilization in a cast.
  • Lateral process fractures of the talus are becoming more common with the increased numbers of snowboarding injuries. Treatment includes no weight bearing in a cast.
  • Calcaneus fractures require significant force to occur and are associated with a marked amount of swelling and pain. An orthopedic surgeon or podiatrist is often consulted emergently to decide whether surgery is needed to stabilize the fracture. The health care practitioner will also look for associated injuries of the ankle, knee, hip, and lumbar spine.

Immobilization of the fractured foot will help with pain control. Ibuprofen (Advil, Motrin) can be helpful with pain control by decreasing inflammation in the area. Narcotic pain medication may also be prescribed if needed.

Rest, ice, and elevation will help limit swelling and decrease pain.

What are the complications of a broken foot?

As with any injury, complications may occur.

  • Broken bones may fail to heal, causing a non-union that may require surgery to repair.
  • If the fracture line enters a joint surface, arthritis may develop, even if the joint surface has been aligned by surgery.
  • Open fractures may be complicated by infection and damage to underlying structures like tendons, arteries, and nerves.
  • Though it is uncommon, crush injuries to the foot may cause significant swelling in the tight spaces of the foot, leading to compartment syndrome. Pressure in the foot rises above the patient's blood pressure, restricting blood supply to the foot. This is a surgical emergency and fasciotomies, incisions into the foot, are performed to allow space for the swelling to occur.

Can a broken foot be prevented?

The foot is placed under considerable stress on a daily basis, absorbing the pounding of walking, running, and jumping. Poorly-constructed and -cushioned shoes and obesity help contribute to stress fractures and general instability of the foot.

High-impact sports that include twisting and direct blows to the feet increase the risk of fracture. Appropriate protective equipment will help decrease the risk of injury.

Certain occupations increase the risk of foot injury. These include the construction trades in which weights may be dropped on a foot, or falls from height may occur.

People with osteoporosis or peripheral neuropathy may have increased risk of foot injury. For these people, it is important to decrease the clutter around the house to prevent injury from falling. It is also helpful to limit the number of throw rugs in a home that can cause a person to trip and fall.

Broken Foot at a Glance
  • The bones in the foot may be broken in many ways including direct blows, crush injuries, falls and overuse or stress.
  • Initial treatment may include RICE (rest, ice, compression, elevation).
  • X-rays often help make the diagnosis but bone scan or computerized tomography may be needed to help visualize the injury.
  • Treatment of foot fractures depend upon which bone is broken but many fractures are treated with a compression dressing, a stiff- soled shoe, and weight bearing as tolerated.
  • Some foot fractures require surgery to repair the damage.
  • Complications of foot fractures include non-union at the fracture site, arthritis if a joint is involved, and infection if the skin is broken.

Broken Finger

 

View Adult Skin Problems Slideshow Pictures

 

Adult Skin Problems Slideshow Pictures View Adult Skin Problems Slideshow Pictures
Gallery of Skin Problems and Image Collection Gallery of Skin Problems and Image Collection
Medical Author:

 

Medical Editor:

 

  • Broken finger introduction
  • What are the causes of a broken finger?
  • What are the symptoms of a broken finger?
  • When should I see a doctor for a broken finger?
  • How is a broken finger diagnosed?
  • What is the treatment for a broken finger?
  • What are the complications of a broken finger?
  • How can a broken finger be prevented?
  • Broken Finger At A Glance
  • Find a local Doctor in your town

Broken finger introduction

Fingers are easily injured, and broken fingers are some of the most common traumatic injuries seen in an emergency room. Finger fractures may account for up to 10% of all bone fractures. Because fingers are used for many everyday activities, they are at higher risk than other parts of the body for traumatic injury, including sports injuries, workplace injuries, and other accidents.

Understanding the basic anatomy of the hand and fingers is useful in understanding different types of finger injuries, broken fingers, and how some treatments differ from others.

The hand is divided into three sections: 1) wrist, 2) palm, and 3) fingers.

  • The wrist has eight bones, which move together to allow the vast ranges of motion of the wrist.
  • The palm or mid-hand is comprised of the metacarpal bones. The metacarpal bones have muscular attachments and bridge the wrist to the individual fingers. These bones frequently are injured with direct trauma such as a crush injury, or most commonly, a punching injury.
  • The fingers are the most frequently injured part of the hand. Fingers are constructed of ligaments (strong supportive tissue connecting bone to bone), tendons (attachment tissue from muscle to bone), and three  phalanges (bones). There are no muscles in the fingers; and fingers move by the pull of forearm muscles on the tendons.

     

    • The three bones in each finger are named according to their relationship to the palm of the hand. The first bone, closest to the palm, is the proximal phalange; the second bone is the middle phalange; and the smallest and farthest from the hand is the distal phalange. The thumb does not have a middle phalange.
  • The knuckles are joints formed by the bones of the fingers and are commonly injured or dislocated with trauma to the hand.

     

    • The first and largest knuckle is the junction between the hand and the fingers - the metacarpophalangeal joint (MCP). This joint commonly is injured in closed-fist activities and is commonly known as a boxer's fracture.
    • The next knuckle out toward the fingernail is the proximal inter-phalangeal joint (PIP). This joint may be dislocated in sporting events when a ball or object directly strikes the finger.
    • The farthest joint of the finger is the distal inter-phalangeal joint (DIP). Injuries to this joint usually involve a fracture or torn tendon (avulsion) injury.

Bones of the Hand

What are the causes of a broken finger?

Traumatic injury is the main cause of broken fingers. Most commonly, traumatic injury to the finger occurs from playing sports, workplace injuries, falls, or other accidents.

What are the symptoms of a broken finger?

The main symptoms of a broken finger are pain immediately after the trauma, and sometimes a deformed finger.

  • A true fracture usually will be painful, but a broken finger may still have some range of motion and dull pain, and the individual may still be able to move it. Depending on the fracture stability, some fractures may be more painful than others.
  • Usually within 5-10 minutes, swelling and bruising of the finger will occur and the finger will stiffen. Swelling may affect the adjacent fingers as well.
  • Numbness of the finger may occur either from the trauma of the injury itself, or because swelling compresses the nerves in the fingers.
  • Fractures to the finger tip (distal phalanx) are common from smashing injuries to the fingernail. The symptoms of this type of injury may be swelling and bruising to the finger pad and purple-colored blood underneath the fingernail (subungual hematoma).
  • If the trauma is severe, broken bones may be exposed (called a compound fracture).

Picture of a Subungual Hematoma

When should I see a doctor for a broken finger?

  • After injury, if pain or swelling limits the motion or use of the fingers, or if the finger becomes numb, seek medical care.
  • If the injury to the finger includes a laceration, crushed tissue, or exposure of bone, the individual should go to an emergency department for immediate medical care.
  • Some fractures of the fingers may be subtle and the pain may be tolerable, so if a person suspects that they may have a finger fracture, seek medical attention.

How is a broken finger diagnosed?

X-ray is the primary tool used to diagnose a broken finger. The doctor will need an X-ray to evaluate the position of the broken finger bones.

With more complex injuries, the doctor may seek the advice of an orthopedic (bone and joint specialist) or hand surgeon (an orthopedic surgeon with post-residency, fellowship level training in hand surgery).

What is the treatment for a broken finger?

Broken fingers should be treated by medical professionals; however, a person can minimize some pain and stabilize the injury on the way to seek medical treatment.

  • To reduce swelling and bruising, apply ice to the injured finger on the way to an emergency department. Do not apply ice directly to the skin; put a towel between the ice and the finger.
  • Make a splint to immobilize the finger. A Popsicle stick or pen may be placed next to the broken finger, and then wrap something around the stick and the finger to hold it in place.
  • Keep the injured finger elevated.

Medical treatment

The doctor will assess the stability of the broken finger. The treatment for a broken finger depends on the type of fracture, and the particular bone in the finger that is injured.

If the fracture is stable (not likely to worsen or cause complications with the movement of the finger), treatment may be as simple as buddy taping (splinting one finger to another by taping them together) for about four weeks, followed by an additional two weeks of limiting use of the finger.

If the fracture is unstable, the injured finger will need to be immobilized. A splint may be applied after reduction (re-aligning of the fractured fragments). If this does not maintain enough stability a surgical procedure may be needed.

A surgeon has many different techniques for surgical immobilization, ranging from pinning the fracture with small wires to procedures with plates and screws.

The patient will most likely leave the hospital in some type of immobilizing splint or dressing. Keep the dressing clean, dry, and elevated. It is best not to use the involved hand until a hand specialist is consulted (about one week after the injury) for another X-ray to evaluate the position of the fracture fragments. If the finger is not aligned correctly, it may affect the healing of the finger and leave a permanent disability.

What are the complications of a broken finger?

After reduction, immobilization, and four to six weeks of healing, the prognosis for healing is excellent for a broken finger.

  • Joint stiffness is the most common problem encountered after treatment of fractures in the fingers due to scar tissue formation and the long immobilization period. Physical therapy may be prescribed (preferably by a hand therapist) to regain range of motion.
  • Rotation can occur when one of the bones in the finger rotates abnormally during the healing process. This can cause deformity and decreased ability to use the injured finger when grasping.
  • Nonunion is a complication of some fractures when the two ends of the bone do not heal together properly, leaving the fractured area unstable.
  • If the skin is injured or if surgery is necessary to fix the fractured bone, infection may result.

How can a broken finger be prevented?

The best medicine for prevention of finger fractures is safety. Most fingers are broken from machines or sporting injuries. Always use safety equipment when doing activities that may injure the hands. Despite all efforts and precautions, injuries do occur and should be evaluated as soon possible.

Broken Finger At A Glance
  • Finger fractures may account for up to 10% of all fractures.
  • The finger bones are named according to their relationship to the palm of the hand. The first bone, closest to the palm, is the proximal phalange. The second bone is the middle phalange. The smallest and farthest from the hand is the distal phalange. The thumb does not have a middle phalange.
  • Traumatic injury is the main cause of broken fingers, and it occurs from playing sports, workplace, falls, or in other accidents.
  • The main symptoms of a broken finger are pain immediately after the trauma, and sometimes a deformed finger. If the trauma is severe, broken bones may be exposed (called a compound fracture).
  • If pain or swelling limits the motion or use of the fingers, if the finger becomes numb, or if the injury includes a laceration, crushed tissue, or exposure of bone, seek medical care.
  • The mainstay of diagnosing finger fractures is an X-ray.
  • Treatment of broken fingers depends on the type of fracture and the particular bone in the finger that is injured.
  • Complications of a broken finger can include join stiffness, rotation, nonunion, and infection.
  • After reduction, immobilization, and four to six weeks of healing, the prognosis for healing is excellent for a broken finger.
  • The best medicine for prevention of finger fractures is safety. Always use safety equipment when doing activities that may injure the hands.

Broken Finger

 

View Adult Skin Problems Slideshow Pictures

 

Adult Skin Problems Slideshow Pictures View Adult Skin Problems Slideshow Pictures
Gallery of Skin Problems and Image Collection Gallery of Skin Problems and Image Collection
Medical Author:

 

Medical Editor:

 

  • Broken finger introduction
  • What are the causes of a broken finger?
  • What are the symptoms of a broken finger?
  • When should I see a doctor for a broken finger?
  • How is a broken finger diagnosed?
  • What is the treatment for a broken finger?
  • What are the complications of a broken finger?
  • How can a broken finger be prevented?
  • Broken Finger At A Glance
  • Find a local Doctor in your town

Broken finger introduction

Fingers are easily injured, and broken fingers are some of the most common traumatic injuries seen in an emergency room. Finger fractures may account for up to 10% of all bone fractures. Because fingers are used for many everyday activities, they are at higher risk than other parts of the body for traumatic injury, including sports injuries, workplace injuries, and other accidents.

Understanding the basic anatomy of the hand and fingers is useful in understanding different types of finger injuries, broken fingers, and how some treatments differ from others.

The hand is divided into three sections: 1) wrist, 2) palm, and 3) fingers.

  • The wrist has eight bones, which move together to allow the vast ranges of motion of the wrist.
  • The palm or mid-hand is comprised of the metacarpal bones. The metacarpal bones have muscular attachments and bridge the wrist to the individual fingers. These bones frequently are injured with direct trauma such as a crush injury, or most commonly, a punching injury.
  • The fingers are the most frequently injured part of the hand. Fingers are constructed of ligaments (strong supportive tissue connecting bone to bone), tendons (attachment tissue from muscle to bone), and three  phalanges (bones). There are no muscles in the fingers; and fingers move by the pull of forearm muscles on the tendons.

     

    • The three bones in each finger are named according to their relationship to the palm of the hand. The first bone, closest to the palm, is the proximal phalange; the second bone is the middle phalange; and the smallest and farthest from the hand is the distal phalange. The thumb does not have a middle phalange.
  • The knuckles are joints formed by the bones of the fingers and are commonly injured or dislocated with trauma to the hand.

     

    • The first and largest knuckle is the junction between the hand and the fingers - the metacarpophalangeal joint (MCP). This joint commonly is injured in closed-fist activities and is commonly known as a boxer's fracture.
    • The next knuckle out toward the fingernail is the proximal inter-phalangeal joint (PIP). This joint may be dislocated in sporting events when a ball or object directly strikes the finger.
    • The farthest joint of the finger is the distal inter-phalangeal joint (DIP). Injuries to this joint usually involve a fracture or torn tendon (avulsion) injury.

Bones of the Hand

What are the causes of a broken finger?

Traumatic injury is the main cause of broken fingers. Most commonly, traumatic injury to the finger occurs from playing sports, workplace injuries, falls, or other accidents.

What are the symptoms of a broken finger?

The main symptoms of a broken finger are pain immediately after the trauma, and sometimes a deformed finger.

  • A true fracture usually will be painful, but a broken finger may still have some range of motion and dull pain, and the individual may still be able to move it. Depending on the fracture stability, some fractures may be more painful than others.
  • Usually within 5-10 minutes, swelling and bruising of the finger will occur and the finger will stiffen. Swelling may affect the adjacent fingers as well.
  • Numbness of the finger may occur either from the trauma of the injury itself, or because swelling compresses the nerves in the fingers.
  • Fractures to the finger tip (distal phalanx) are common from smashing injuries to the fingernail. The symptoms of this type of injury may be swelling and bruising to the finger pad and purple-colored blood underneath the fingernail (subungual hematoma).
  • If the trauma is severe, broken bones may be exposed (called a compound fracture).

Picture of a Subungual Hematoma

When should I see a doctor for a broken finger?

  • After injury, if pain or swelling limits the motion or use of the fingers, or if the finger becomes numb, seek medical care.
  • If the injury to the finger includes a laceration, crushed tissue, or exposure of bone, the individual should go to an emergency department for immediate medical care.
  • Some fractures of the fingers may be subtle and the pain may be tolerable, so if a person suspects that they may have a finger fracture, seek medical attention.

How is a broken finger diagnosed?

X-ray is the primary tool used to diagnose a broken finger. The doctor will need an X-ray to evaluate the position of the broken finger bones.

With more complex injuries, the doctor may seek the advice of an orthopedic (bone and joint specialist) or hand surgeon (an orthopedic surgeon with post-residency, fellowship level training in hand surgery).

What is the treatment for a broken finger?

Broken fingers should be treated by medical professionals; however, a person can minimize some pain and stabilize the injury on the way to seek medical treatment.

  • To reduce swelling and bruising, apply ice to the injured finger on the way to an emergency department. Do not apply ice directly to the skin; put a towel between the ice and the finger.
  • Make a splint to immobilize the finger. A Popsicle stick or pen may be placed next to the broken finger, and then wrap something around the stick and the finger to hold it in place.
  • Keep the injured finger elevated.

Medical treatment

The doctor will assess the stability of the broken finger. The treatment for a broken finger depends on the type of fracture, and the particular bone in the finger that is injured.

If the fracture is stable (not likely to worsen or cause complications with the movement of the finger), treatment may be as simple as buddy taping (splinting one finger to another by taping them together) for about four weeks, followed by an additional two weeks of limiting use of the finger.

If the fracture is unstable, the injured finger will need to be immobilized. A splint may be applied after reduction (re-aligning of the fractured fragments). If this does not maintain enough stability a surgical procedure may be needed.

A surgeon has many different techniques for surgical immobilization, ranging from pinning the fracture with small wires to procedures with plates and screws.

The patient will most likely leave the hospital in some type of immobilizing splint or dressing. Keep the dressing clean, dry, and elevated. It is best not to use the involved hand until a hand specialist is consulted (about one week after the injury) for another X-ray to evaluate the position of the fracture fragments. If the finger is not aligned correctly, it may affect the healing of the finger and leave a permanent disability.

What are the complications of a broken finger?

After reduction, immobilization, and four to six weeks of healing, the prognosis for healing is excellent for a broken finger.

  • Joint stiffness is the most common problem encountered after treatment of fractures in the fingers due to scar tissue formation and the long immobilization period. Physical therapy may be prescribed (preferably by a hand therapist) to regain range of motion.
  • Rotation can occur when one of the bones in the finger rotates abnormally during the healing process. This can cause deformity and decreased ability to use the injured finger when grasping.
  • Nonunion is a complication of some fractures when the two ends of the bone do not heal together properly, leaving the fractured area unstable.
  • If the skin is injured or if surgery is necessary to fix the fractured bone, infection may result.

How can a broken finger be prevented?

The best medicine for prevention of finger fractures is safety. Most fingers are broken from machines or sporting injuries. Always use safety equipment when doing activities that may injure the hands. Despite all efforts and precautions, injuries do occur and should be evaluated as soon possible.

Broken Finger At A Glance
  • Finger fractures may account for up to 10% of all fractures.
  • The finger bones are named according to their relationship to the palm of the hand. The first bone, closest to the palm, is the proximal phalange. The second bone is the middle phalange. The smallest and farthest from the hand is the distal phalange. The thumb does not have a middle phalange.
  • Traumatic injury is the main cause of broken fingers, and it occurs from playing sports, workplace, falls, or in other accidents.
  • The main symptoms of a broken finger are pain immediately after the trauma, and sometimes a deformed finger. If the trauma is severe, broken bones may be exposed (called a compound fracture).
  • If pain or swelling limits the motion or use of the fingers, if the finger becomes numb, or if the injury includes a laceration, crushed tissue, or exposure of bone, seek medical care.
  • The mainstay of diagnosing finger fractures is an X-ray.
  • Treatment of broken fingers depends on the type of fracture and the particular bone in the finger that is injured.
  • Complications of a broken finger can include join stiffness, rotation, nonunion, and infection.
  • After reduction, immobilization, and four to six weeks of healing, the prognosis for healing is excellent for a broken finger.
  • The best medicine for prevention of finger fractures is safety. Always use safety equipment when doing activities that may injure the hands.

 

Broken Toe

 

View Adult Skin Problems Slideshow Pictures

 

Adult Skin Problems Slideshow Pictures View Adult Skin Problems Slideshow Pictures
Gallery of Skin Problems and Image Collection Gallery of Skin Problems and Image Collection
Medical Author:

 

Medical Editor:

 

  • Introduction to broken toe
  • What are the causes of a broken toe?
  • What are the symptoms of a broken toe?
  • What are the possible complications of a broken toe?
  • When should I call a doctor about a broken toe?
  • How is a broken toe diagnosed?
  • What is the treatment for a broken toe?
  • Caring for a broken toe at home
  • Medical treatment
  • Other therapy (reduction, buddy taping, how to tape a broken toe, casting)
  • What is the outlook for a broken toe?
  • Broken Toe At A Glance
  • Patient Discussions: Broken Toe - Treatments
  • Patient Discussions: Broken Toe - Describe Your Experience
  • Find a local Orthopedic Surgeon in your town

Introduction to broken toe

A commonly injured area of the body is the foot, more specifically, the toes (phalanxes). This often causes one or more of the toe bones to break (fracture).

What are the causes of a broken toe?

Trauma or injury such as stubbing the toe (jammed toe) or dropping a heavy object on the toe may cause a broken toe. The location of the toes (in the front part of the feet) make them the most likely part of the foot to be injured.

Prolonged repetitive movements, as in certain sports activities, can cause a type of broken type of broken toe called a stress or hairline fracture.

What are the symptoms of a broken toe?

  • Pain, swelling, or stiffness will occur in a broken toe following injury. It may be difficult to walk due to the pain, especially with a broken big toe. This is because the big toe bears much of the weight of the body when walking or pivoting. A broken little toe may be painful but usually does not limit the ability to walk.
  • Other symptoms include bruising of the skin around the toe and a bent or deformed appearance of the toe if the broken bone is out of place.
  • Other problems may develop as a result of the fractured toe. Complications can occur immediately after the injury (minutes to days), or can develop much later (weeks to years).

What are the possible complications of a broken toe?

  • Nail injury: A collection of blood may develop underneath the toenail called a subungual hematoma. If it is large, it may need to be drained. To drain a subungual hematoma a doctor will make a small hole in the toenail to drain the blood out. If the hematoma is very large or painful, the entire toenail may need to be removed. The injury may also result in a broken toenail that may need to be trimmed or removed.
  • Compound fracture: Rarely, the broken bone in a toe fracture may stick out through the skin. This is called an open or compound fracture. Emergency medical treatment and surgery may be necessary in this case.
  • Arthritis: After the toe fracture heals, the person may still be left with arthritis, pain, stiffness, or even a deformity.
  • Nonunion/malunion: Sometimes, the fractured bone will not heal completely (called a nonunion) or will heal improperly (called a malunion). Rarely, surgery may be necessary to fix this problem.

Picture of subungual hematoma


When should I call a doctor about a broken toe?

Go to a hospital's emergency department if the following signs or symptoms are present:

  • Any symptoms of a possible open (compound) fracture which include open wounds, bleeding, or drainage from near the broken toe;
  • Cold, numb, tingling, or unusual sensation in the toes;
  • Blue or gray colored skin near the injury.

Call a doctor if any of the following occur:

  • If the broken toe pain worsens or new pain is not relieved by pain medication;
  • Sores, redness, or open wounds near the injured toe;
  • A cast or splint is damaged or broken.

How is a broken toe diagnosed?

It is best to seek medical evaluation soon after the injury to ensure proper treatment and healing.

  • A doctor will ask questions to determine how the toe was injured and will examine the injured toe and possibly check for other injuries.
  • A doctor may take an X-ray to evaluate if the toe is broken or fractured. X-rays are not always necessary to diagnose a broken toe, especially if the break is in one of the smaller toes.
  • Stress fractures, due to overuse or repetitive movement, may need an MRI to be diagnosed.

What is the treatment for a broken toe?

Caring for a broken toe at home

A broken toe can be can be treated at home (providing it is not necessary to see a doctor or go to the emergency room for treatment). The following can be done to help decrease pain and swelling from a broken toe and to help the fracture heal properly.

  • Rest: Avoid strenuous exercise, prolonged standing, or walking. Crutches may be needed, or a special shoe to wear when walking to avoid putting weight on the fracture while it heals.
  • Ice: Put ice in a plastic bag and apply it to the injury for 15-20 minutes every 1-2 hours for the first 1-2 days. Place a towel between the skin and the ice to protect the skin. Frozen peas or corn can also be used to ice the broken toe as well. The peas or corn may conform to the fractured area better than ice.
  • Elevation: To decrease swelling and pain, keep the foot raised above the level of the heart as much as possible. Prop the foot up as much as possible (for example use several pillows), especially when sleeping. Reclining in a lounge chair is also helpful.

Medical treatment

Depending on the location and severity of the toe fracture, the fracture may need to be put back into place (reduced) and splinted or casted. If there is an open wound near the injured toe, a tetanus shot and antibiotic medication may also be necessary.

If there is an open (compound) fracture of the toe, surgery may be necessary in some cases, and antibiotics will be given. This type of fracture should be seen by a doctor immediately.

Medications

Usually only acetaminophen (Tylenol) or ibuprofen (Motrin) is needed for pain. For a severe fracture, the doctor may prescribe a stronger pain medication.

 

Other therapy (reduction, buddy taping, how to tape a broken toe, casting)

Reduction

  • If the toe fracture is displaced (the two ends of the broken toe bone are out of place) or rotated (the toe is pointing in the wrong direction), the doctor may need to reduce it, or set the broken toe back into place.
  • Sometimes local anesthesia may be needed to numb the toe before it is put back into place.
  • After a reduction, a splint will be applied to the broken toe to hold it in place while it heals.

Buddy taping

  • If there is a minor or small fracture in a bone of one of the small toes, a doctor may only need to tape the injured toe to the one next to it for support. This treatment is called buddy taping.
  • If the toe is buddy taped, it is usually safe to bathe, and then replace the tape afterward, however, check with the doctor prior to removing the tape to bathe.

How to tape a broken toe

  • Put a small piece of cotton or gauze between the toes that are taped together. This prevents the skin between the toes from developing sores or blisters. Using as little tape as necessary, loosely tape the broken toe to the toe next to it. If the toes are taped too tightly it can cause additional swelling and may cut off circulation to the injured toe.

Casting

  • A cast is usually not required for a simple toe fracture. A hard-soled, sturdy, and supportive shoe should be worn. A doctor may give the patient a special shoe to wear if the foot or toes are very swollen.
  • A cast (or surgery) may be needed if the big toe is broken, a fracture involves a joint, several small toe fractures occur at once, or if a bone in the foot or leg is broken in addition to the toe.

What is the outlook for a broken toe?

  • Talk to the doctor to schedule an appointment to have the broken toe evaluated to make sure it is healing properly. Call a doctor or go to an emergency department if any problems or complications develop before the scheduled appointment.
  • Broken toes usually take about six weeks to heal. If problems last longer than six weeks, another X-ray may be needed, or the injury should be rechecked by the doctor to evaluate how the bone is healing.
  • Simple toe fractures usually heal well with no problems. However, a severe fracture or a fracture that goes into a joint is at risk for developing arthritis, pain, stiffness, and possibly even a deformity.

Broken Toe At-A-Glance
  • Broken toes are often caused by trauma or injury. Prolonged repetitive movements can cause a type of broken toe called a stress or hairline fracture.
  • Symptoms of a broken toe include pain, swelling, or stiffness, bruising, deformity, and difficultly walking if the big toe is broken.
  • Possible complications of a broken toe include nail injury, compound fracture, infection, deformity, or arthritis.
  • Seek immediate medical care if you suspect an open fracture of the toe; if there is bleeding; cold, numb, or tingling sensation; or blue or gray color to the injured area.
  • A broken toe is diagnosed with a medical examination, which may include X-rays.
  • To help decrease pain and swelling in a broken toe, elevate the foot, ice the injury, and stay off the foot.
  • Depending on the severity of the fracture, the toe may need to be put back into place (reduced), and some compound toe fractures may require surgery.
  • Pain from a broken toe can usually be controlled with over-the-counter pain medication.
  • Buddy taping can be used to help splint a fractured toe.
  • Most broken toes heal without complications in six weeks.

Bronchiectasis

 

Hidden Home Hazards That Can Harm Your Lungs
Hidden Home Hazards That Can Harm Your Lungs
Energy-Boosting Foods for COPD Slideshow Pictures Energy-Boosting Foods for COPD
Worst Smog Cities in America Slideshow Worst Smog Cities in America Slideshow
Medical Author:

 

Medical Editor:

 

  • What is bronchiectasis?
  • What causes bronchiectasis?
  • What are the symptoms of bronchiectasis?
  • When should you seek medical care for bronchiectasis?
  • How is bronchiectasis diagnosed?
  • What is the treatment for bronchiectasis?
  • What are the complications of bronchiectasis?
  • What is the prognosis for bronchiectasis?
  • Bronchiectasis At A Glance
  • Find a local Doctor in your town

What is bronchiectasis?

Bronchiectasis is a term that describes damage to the walls of the large airways, or bronchial tubes, of the lung. Inflammation due to infection or other causes destroys the smooth muscles that allow the bronchial tubes to be elastic and prevents secretions that are normally made by lung tissue to be cleared.

Normal branching of the airways of the lung demonstrates a gentle taper that occurs at each branch point, like the branches of a tree. This tapering results in decreased resistance in the larger branches, enabling mucus or other objects to be funneled to the larger airways and eventually, with a cough, ejected out through the mouth. Loss of this normal anatomic tapering of the airways by damage due to inflammation causes the walls of the airways to be irregularly shaped. Secretions tend to pool in the distorted airways rather than be expelled, and these stagnant secretions are a breeding ground for bacterial growth. These bacteria, in turn, cause further irritation and inflammation, airway damage, and hence more secretions, initiating a "vicious cycle" of damage. This increases the risk of infections to spread directly into the airspaces of the lungs resulting in pneumonia.

Bronchiectasis is a form of chronic obstructive pulmonary disease (COPD) which also includes emphysema and chronic bronchitis. Bronchiectasis can be present alone, but usually more than one of the aforementioned components of COPD coexist in the same person.

Congenital bronchiectasis may occur due to a genetic defect such as occurs in cystic fibrosis. Usually, the disease Alpha-1 antiprotease (alpha 1- antitrypsin) deficiency results in emphysema, but bronchiectasis can occur as well in this condition. An embryologic defect in the airway cilia, so-called immotile cilia syndrome, is another cause of bronchiectasis and is often associated with situs inversus, in which the major organs are in a reversed position (for example, the heart is on the right).

Pediatric lung infections may ultimately lead to lung destruction and bronchiectasis later in life. Therefore prevention is an important part of treatment, including adequate immunizations and avoidance of secondhand smoke and other toxic fumes.

Bronchiectasis is characterized by an increased amount of sputum production (mucus produced and coughed up from the lung), recurrent infections, and gradual loss of lung function leading to shortness of breath.

Picture of the lungs

What causes bronchiectasis?

Bronchiectasis is caused by damage to the larger airway walls destroying the muscles and elastic tissue layers that allow normal bronchial tubes to contract. This damage decreases the ability of the lung to move and clear secretions that are normally produced in the lung. These pooled secretions cause increased potential for infection like pneumonia and bronchitis, which causes further damage to the bronchial walls. As mentioned above, this results in a vicious cycle in which increased damage leads to increased infection, leading to further damage.

There are three primary types of bronchiectasis. These types are described by their anatomical appearance.

  1. Cylindrical bronchiectasis is the mildest form and reflects the loss of the normal tapering of the airways. The symptoms may be quite mild, like a chronic cough, and usually are discovered on CT scans of the chest.

     

  2. Saccular bronchiectasis is more severe, with further distortion of the airway wall and symptomatically, affected persons produce more sputum.

     

  3. Cystic bronchiectasis is the most severe form of bronchiectasis, and fortunately it is the least common form. This often occurred in the pre-antibiotic era when an infection would run its course and the patient would survive with residual lung damage. These patients often would have a chronic productive cough, bringing up a cup or more of discolored mucus each day.

Bronchiectasis also may be congenital or acquired.

Congenital causes of bronchiectasis

  • Cystic fibrosis

     

  • Kartagener syndrome

     

  • Young's syndrome

     

  • Alpha-1-antitrypsin deficiency

Acquired causes of bronchiectasis

  • Recurrent infection

     

  • Aspiration of foreign bodies or other materials

     

  • Inhalation of toxic gases like ammonia

     

  • Alcohol and drug abuse

     

  • Tuberculosis

     

  • Inflammatory bowel disease (ulcerative colitis, Crohn's disease)

What are the symptoms of bronchiectasis?

Bronchiectasis develops over a prolonged period of time.

Common symptoms include recurrent cough and sputum production. Usually the mucus is clear, but it may be bloody due to bronchial wall injury or green or yellow if infection is present. Shortness of breath and fatigue develop as lung function decreases. Wheezing may or may not be present.

If the disease progresses or if it is poorly controlled, the amount of work required to breathe increases and weight loss and diminished quality of life may occur.

Bronchiectasis may occur due to another underlying disease. Symptoms of that primary disease may also be present. For example, a patient with tuberculosis may have bloody sputum, fever, chills, and night sweats. A person with Crohn's disease may have abdominal pain and diarrhea.

Congenital bronchiectasis often becomes apparent because of recurrent pneumonia.

When should you seek medical care for bronchiectasis?

Any person with unexplained shortness of breath or chronic cough should seek medical care. Depending upon its severity and the situation, activating the emergency medical response system (call 911) may be appropriate.

Usually, people who develop bronchiectasis do so over a prolonged period of time. They seek medical care because of chronic cough, a progressive increase in sputum production, and/or, shortness of breath at rest or exercise. Recurrent pneumonia is also a reason that people may seek care. The symptoms of pneumonia include fever, cough, and shortness of breath.

Bronchiectasis may cause hemoptysis (coughing up blood). This is never normal, and medical attention is needed if hemoptysis occurs. Other reasons for coughing up blood include pneumonia, congestive heart failure, tuberculosis, pulmonary emboli (blood clots in the vessels of the lung), and lung tumors.

How is bronchiectasis diagnosed?

Diagnosis of bronchiectasis begins with history and physical examination.

The patient will complain of daily cough and sputum production that may or may not be bloody due to damage to the bronchial tubes or from infection. Shortness of breath with activity or at rest, wheezing, fatigue, and chest pain are all common complaints.

Physical examination may be relatively normal, or lung examination may reveal wheezing and crackles. Depending up on the severity of disease and how long it has been present, other findings may include weight loss, cyanosis (a bluish color of the skin and the mucous membranes due to an insufficient level of oxygen), and right heart failure (manifested by shortness of breath, leg swelling, and liver enlargement).

The history and physical exam may lead to the suspicion of the diagnosis and the health care practitioner may order a high resolution chest CT scan, which will confirm the diagnosis. The CT may also help in finding the underlying reason why bronchiectasis developed.

Plain chest X-rays may be used in helping make the diagnosis and help track the progression of the disease, but these findings are often much more subtle than those seen by CT scans.

Once the diagnosis of bronchiectasis is made, the underlying cause needs to be found. Blood tests and sputum tests may be indicated depending upon the clinical situation. Often a lung specialist (pulmonologist) will be consulted to help direct the investigation and testing.

Pulmonary function studies or pulmonary function tests (PFTs) may be helpful in assessing what kind and how much lung damage has occurred. Bronchiectasis is a form of chronic obstructive pulmonary disease (COPD), and this testing can help confirm this. These tests can help determine whether the lung tissue will respond to the use of bronchodilator treatment with inhaler medications (please see treatment section). Repeated over time, pulmonary function studies can help document the benefits of treatment or progression of the disease.

Less commonly, bronchoscopy is used to look inside the airways with a fiberoptic camera. This is sometimes done to look for tumors or foreign bodies that may have been seen on CT. In some cases, bronchoscopy can be used therapeutically to remove excessive retained secretions.

Screening for cystic fibrosis occurs for all newborns.

What is the treatment for bronchiectasis?

Bronchiectasis is not a curable disease. Instead, the goal of treatment is control of secretions and preventing infections. In some situations, where the disease is limited to one area of the lung, surgery may be a possibility to remove the area affected by the disease.

Basic lung hygiene is required for all patients with bronchiectasis:

  • Keep immunizations up to date to prevent infections.

     

  • Drink plenty of fluids to make mucous secretions less sticky.

     

  • Stop smoking and avoid secondhand smoke.

     

  • Get adequate nutrition by consuming necessary calories. For some people, breathing requires increased effort and thus and requires increased nutrition.

Chest physical therapy

The basis for bronchiectasis treatment is chest physical therapy to assist in coughing up secretions, and antibiotics to prevent infection.

Since the smooth muscles that surround the bronchial tubes are damaged, mechanical ways to clear secretions are used to increase air flow and decrease the risk of infection. Chest physical therapy uses percussion or clapping on the back to help loosen secretions and then changing positions of the body to allow gravity to help those secretions to be coughed up. Chest clapping may be done by a physical therapist, but family members can be taught to do this routinely at home. Mechanical devices such as chest clappers or vests also may be considered.

Antibiotics may be prescribed to treat an infection that occurs or they may be used as prophylaxis to prevent infection. The choice of antibiotics depend upon the clinical situation and may be guided by blood or sputum cultures that will try to identify the bacteria causing the infection, and the type of antibiotic that will effectively treat the infection. Many patients may be kept on a revolving course of different antibiotics over their lifetime. Recently, inhaled antibiotics have been used in addition to medications taken by mouth. In patients with more severe lung infections, intravenous antibiotics may be required.

Medications may also be used to loosen secretions, dilate bronchial tubes and decrease inflammation, hopefully decreasing the risk of infection.

Routine used of inhaled steroids (for example, fluticasone propionate oral inhaler [Flovent]) using a hand held puffer may decrease production of secretions, allow dilation of bronchial tubes, and prevent progression of bronchiectasis. Inhaled steroids may not have enough anti-inflammatory activity, and in unusual cases, steroids taken by mouth (prednisone) may also be required.

Bronchodilator (for example, albuterol, ProAir, Ventolin HFA, Proventil HFA) and anticholinergic (for example, ipratropium bromide inhaler [Atrovent], tiotropium bromide inhalation powder [Spiriva]) inhaled medications dilate bronchial tubes and increase air flow into the lungs, making it easier for secretions to be cleared. The medication can be inhaled using a hand held puffer or with a nebulizer machine. Often, combination therapy with both a bronchodilator and inhaled corticosteroid (fluticasone and salmeterol oral inhaler [Advair], budesonide and formoterol fumarate dihydrate [Symbicort]) are prescribed.

Home oxygen supplementation may be needed if lung function decreases to the point atmospheric air does not supply enough oxygen to the body.

Some patients have only a small area of bronchiectasis, and surgery may be an option to remove the small segment of affected lung in these individuals. Surgery may be considered in other situations to remove part of a lung where infection cannot be controlled or where excessive bleeding cannot be managed.

What are the complications of bronchiectasis?

Bronchiectasis decreases the ability of the lung to mobilize secretions, leading to recurrent infection, increased sputum production, and difficulty breathing.

Decreased air entry into the lung through the bronchial tubes decreases oxygen availability in the bloodstream, causing shortness of breath with activity and ultimately at rest. This decreased oxygen level over time causes constriction of the pulmonary arteries, resulting in increased pressure in these arteries, referred to as pulmonary hypertension. Overcoming these pressures forces the heart to work harder causing the right ventricle to thicken, a condition called cor pulmonale. Eventually, the right side of the heart (which pumps blood to the vessels of the lung) may fail, resulting in increased fluid accumulation in the legs or abdominal cavity.

Bronchiectasis may result in coughing up blood (hemoptysis).

Hospitalization may be required for pneumonia, massive hemoptysis, respiratory failure (when not enough oxygen is present in the bloodstream), and heart failure. Heart failure and respiratory failure are the common causes of death in patients with bronchiectasis. In some cases, due to prolonged use of antibiotics, infections with antibiotic-resistant bacteria may develop that require special antibiotics that are usually given in the hospital through an intravenous (IV) line.

What is the prognosis (outlook) for bronchiectasis?

Early recognition and adequate treatment can help control bronchiectasis and decrease symptoms. Life- long awareness of the need for treatment may allow people with bronchiectasis to minimize complications and maximize life expectancy.

The outlook depends upon the underlying reason for developing bronchiectasis. Congenital causes of bronchiectasis, like cystic fibrosis, may have a worse prognosis than acquired diseases.

Bronchiectasis At A Glance

  • Bronchiectasis describes damage to the walls of larger bronchial tubes with loss of the smooth muscle and loss of elasticity of segments of the bronchi. The resultant airway distortion prevents secretions from being adequately cleared from the lung.

     

  • Bronchiectasis may be congenital or acquired. Cystic fibrosis is the most common cause of congenital bronchiectasis.

     

  • Symptoms of bronchiectasis include increased sputum production, bloody sputum, shortness of breath, weakness, and fatigue.

     

  • Diagnosis is often made by history and confirmed by CT scan of the chest. Efforts may be made to find the underlying cause of bronchiectasis.

     

  • Complications include recurrent pneumonia, respiratory failure, and eventually heart failure.

     

  • Bronchiectasis is not curable. The goal for treatment is to control secretions and minimize the risk of infections.

Acute Bronchitis

 

Pictures of Bronchitis
Bronchitis Slideshow Pictures Pictures of Bronchitis
Medical Author:

 

Medical Editor:

 

  • What is acute bronchitis?
  • What causes acute bronchitis?
  • What are the risk factors for acute bronchitis?
  • What are the symptoms of acute bronchitis?
  • When does a cold become acute bronchitis?
  • When should I call my doctor about my cough?
  • How is acute bronchitis diagnosed?
  • What are the treatments for acute bronchitis?
  • Can I treat acute bronchitis at home?
  • What are the complications of acute bronchitis?
  • Acute Bronchitis At A Glance
  • Bronchitis - Slideshow View Bronchitis Slideshow
  • Patient Discussions: Bronchitis - Treatments
  • Patient Discussions: Bronchitis - Length Symptoms Lasted
  • Find a local Pulmonologist in your town

What is acute bronchitis?

Air is pulled into the lungs when we breathe, initially passing through the mouth, nose, and larynx (voicebox) into the trachea and continues en route to each lung via either the right or left bronchi (the bronchial tree - bronchi, bronchioles, and alveoli). Bronchi are formed as the lower part of the trachea divides into two tubes that lead to the lungs. As the bronchi get farther away from the trachea, each bronchial tube divides and gets smaller (resembling an inverted tree) to provide the air to lung tissue so that it can transfer oxygen to the blood stream and remove carbon dioxide (the waste product of metabolism).

Bronchitis describes inflammation of the bronchial tubes (inflammation = itis). The inflammation causes swelling of the lining of these breathing tubes, narrowing the tubes and promoting secretion of inflammatory fluid.

Acute bronchitis describes the inflammation of the bronchi usually caused by a viral infection, although bacteria and chemicals also may cause acute bronchitis. Bronchiolitis is a term that describes inflammation of the smaller bronchi referred to as bronchioles. In infants, this is usually caused by respiratory syncytial viruses (RSV), and affects the small bronchi and bronchioles more than the large. In adults, other viruses as well as some bacteria can cause bronchiolitis and often manifest as a persistent cough at times productive of small plugs of mucus.

Acute bronchitis is as mentioned above, is a cough that begins suddenly usually due to a viral infection involving the larger airways. Colds (also known as viral upper airway infections) often involve the throat (pharyngitis) and nasal passages, and at times the larynx (resulting in a diminished hoarse voice, also known as laryngitis). Symptoms can include a runny nose, nasal stuffiness, and sore throat. Croup usually occurs in infants and young children and involves the voice box and upper large airways (the trachea and large bronchi).

Chronic bronchitis for research purposes is defined as a daily cough with sputum production for at least three months, two years in a row. Chronic bronchitis is a diagnosis usually made based on clinical findings of a long term persistent cough usually associated with tobacco abuse. From a pathologic standpoint, characteristic microscopic findings involving inflammatory cells in seen in airway tissue samples make the diagnosis. When referring to pulmonary function testing, a decrease in the ratio of the volume of airflow at 1 second when compared to total airflow is less than 70%. This confirms the presence of obstructive airways disease of which chronic bronchitis is one type. Certain findings can be seen on imaging studies (chest X-ray, and CT or MRI of the lungs) to suggest the presence of chronic bronchitis; usually this involves an appearance of thickened tubes.

 

Picture of the anatomy of the lungs

What causes acute bronchitis?

  • Acute bronchitis occurs most often due to a viral infection that causes the inner lining of the bronchial tubes to become inflamed and undergo the changes that occur with any inflammation in the body. Common viruses include the rhinovirus, respiratory syncytial virus (RSV), and the influenza virus.
  • Bacteria can also cause bronchitis (a few examples include, Mycoplasma, Pneumococcus, Klebsiella, Haemophilus).
  • Chemical irritants (for example, tobacco smoke, gastric reflux, solvents) can cause acute bronchitis.

What are the risk factors for acute bronchitis?

Bronchitis describes inflammation of the bronchial tubes. Smoking is a key risk factor for developing acute bronchitis. Any other illnesses that predispose to similar inflammation also increase that risk (for example, asthma patients and patients allergic to airborne chemicals)

What are the symptoms of acute bronchitis?

Inflammation of the bronchial tubes narrows the inside opening of the bronchial tubes. Narrowing of the bronchial tubes result in increased resistance, this increase makes it more difficult for air to move to and from the lungs. This can cause wheezing, coughing, and shortness of breath. The cough may consist of sputum due to the secretions from the inflamed cells that line the bronchi. By coughing, the body attempts to expel secretions that clog the bronchial tubes. If these secretions contain certain inflammatory cells, discoloration of the mucus may result often in a green or yellow color. Sometimes the severity of the inflammation may result in some bleeding.

As with any other infection, there may be associated fever, chills, aches, soreness and the general sensation of feeling poorly or malaise.

When does a cold become acute bronchitis?

Anatomically, the larynx divides the upper and lower airways. Colds tend to affect the mouth, throat, and nasal passages while bronchitis describes specific inflammation of the bronchial tubes. The two illnesses can exist at the same time and may be caused by the same virus infection. A cold does not necessarily lead to bronchitis.

When should I call my doctor about my cough?

While a cough can be irritating and interfere with activities such as sleep, by itself, it needs little care. Drinking plenty of fluids to prevent dehydration, humidifying the air, and occasionally medication to suppress the cough are appropriate home care treatments.

However, medical care should be accessed immediately should shortness of breath occur. Fever, chills, wheezing, and signs of dehydration (lightheadedness, weakness, rapid heart rate) are also reasons to seek medical care. Most coughs tend to subside after a few days. If the cough persists and mucus tends to be discolored, one should seek medical care.

In patients with asthma, wheezing may increase with acute bronchitis. Use of a prescribed albuterol inhaler (Ventolin HFA, Proventil HFA, ProAir) is reasonable; however, asthma patients should contact their health care practitioner if the symptoms of wheezing and shortness of breath do not resolve promptly.

How is acute bronchitis diagnosed?

Acute bronchitis is usually diagnosed through patient history and physical examination.

Patient history

The health care practitioner may ask the following questions about the symptoms:

  1. What symptoms exist?
  2. When did they start?
  3. Is there a related fever?
  4. Is sputum being brought up by coughing?
  5. Is the sputum or color-tinted?
  6. Is there any blood tinge?
  7. Does the person smoke?
  8. Is there a history of asthma or COPD?
  9. Does the patient take any medications or inhalers that are used to treat underlying illnesses?
  10. What has the patient done to treat the symptoms?
  11. Were these measures successful?

Physical examination

The health care practitioner may examine of the patient's upper airways to look for signs of ear, nose, or throat infection including redness of the tympanic membranes (ear drums), runny nose, and post nasal drip. Redness of the throat or swelling and pus on the tonsils can help distinguish common cold, tonsillitis, and acute bronchitis symptoms. The neck may be palpated or felt to check for swollen lymph nodes. Listening to the lungs may reveal decreased air entry and wheezing.

A chest X-ray may be considered by the health care practitioner if there is a concern that a pneumonia or infection of lung tissue is present.

Blood tests are usually not helpful; occasionally, cultures of sputum are done if a bacterial pathogen is suspected.

What are the treatments for acute bronchitis?

Decreasing inflammation is the goal for treating acute bronchitis.

Albuterol inhalation, either with a hand held device (meter dosed inhaler, MDI) or nebulizer will help dilate the bronchial tubes.

Short-term steroid therapy will help minimize inflammation within the bronchial tubes. Prednisone is a common prescription medication that enhances the anti-inflammatory effects of the steroids produced within the body by the adrenal glands. Topical inhaled steroids may also be of benefit with fewer potential side effects.

It is important to keep the patient comfortable by treating fever with acetaminophen or ibuprofen. Drinking plenty of fluid will keep the patient well hydrated and hydration keeps secretions into the bronchial tubes more liquid and easier to expel.

Antibiotics are not necessarily indicated for the treatment of acute bronchitis. Occasionally they may be prescribed should a bacterial infection be present in addition to the usual virus that causes acute bronchitis. However, most acute bronchitis is caused by viruses and no antibiotics are needed.

Although good hydration will help remove secretions into the bronchi, other treatments (for example, Mucinex, Robitussin and others that contain guaifenesin) can help clear secretions though this is often a highly variable finding.

Cough is a very violent action that results in dynamic collapse of the airways. This collapse results in the walls of the airways banging against one another. This action of cough can cause further inflammation and help perpetuate the problem by sustaining and increasing inflammation. Cough suppression with cough drops or other liquid suppressants (for example, Vicks 44, Halls, and cough syrups that contain dextromethorphan) help to break this vicious cycle. In addition, if the person smokes, they should stop. If the acute bronchitis is being caused by inhaled smoke or chemicals, the patient should be removed from these irritant sources.

Can I treat acute bronchitis at home?

The treatment of acute bronchitis is geared toward prevention, control, and relief of symptoms (supportive care). In some cases, the following is all that is needed:

  • drink plenty of fluids to maintain proper hydration (avoiding dehydration and humidify air); and
  • use of acetaminophen and ibuprofen to treat fever and decrease the inflammatory resposne.

The treatments section above covers those actions that can usually be done at home. However, people with medical conditions such as high blood pressure should be careful to choose those products approved for patients with high blood pressure because some cough/cold formulations may further increase a person's blood pressure to elevated or dangerous levels. People with diabetes should also choose cough and cold products that will not affect their blood glucose levels. If individuals are unsure which products are safe, they should contact their primary health care practitioner for advice.

For patients with underlying lung disease such as asthma or COPD, increased use of albuterol or similar inhaled medications may be indicated. However, the health care practitioner should be contacted when a patient considers altering their medication usage.

What are the complications of acute bronchitis?

Acute bronchitis usually resolves spontaneously (about 2-3 weeks) with supportive care. If wheezing and shortness of breath occurs the patient should seek medical care.

In patients who have underlying lung conditions, the inflammation can cause lung tissue to function improperly. Pneumonia or infection of the lung tissue itself may develop.

Acute Bronchitis at a Glance

  • Acute bronchitis describes an infection and inflammation of the breathing tubes leading to cough and occasional wheezing.
  • Treatment is supportive keeping fever under control and the patient well hydrated.
  • Wheezing is often treated with inhaled albuterol, either by puffer (HFA) or nebulizer.
  • Steroid medication may be used short term to help decrease the inflammation within the bronchial tubes.
  • Patients with underlying lung diseases such as asthma or COPD may be at greater risk of developing acute bronchitis.
  • Antibiotics are not commonly prescribed for acute bronchitis but may be prescribed if specifically indicated.

Emphysema, Chronic Bronchitis, and Colds

 

Hidden Home Hazards That Can Harm Your Lungs
Hidden Home Hazards That Can Harm Your Lungs
Energy-Boosting Foods for COPD Slideshow Pictures Energy-Boosting Foods for COPD
Worst Smog Cities in America Slideshow Worst Smog Cities in America Slideshow

 

  • Introduction
  • What is emphysema and chronic bronchitis?
  • What happens with emphysema and chronic bronchitis and colds?
  • Why should I take colds seriously with emphysema or chronic bronchitis?
  • Which cold treatment should I use with emphysema or chronic bronchitis?
  • Can I prevent colds if I have emphysema or chronic bronchitis?
  • Find a local Pulmonologist in your town

Introduction

If you have emphysema or chronic bronchitis, you know how miserable it feels when you catch a cold. After all, breathing is difficult enough with a chronic obstructive pulmonary disease (COPD). Not only does catching a cold worsen your ability to breathe and be active, but the cold virus increases your chance of getting a more serious respiratory tract infection. Here's what you must know to stay well.

What is emphysema and chronic bronchitis?

Emphysema and chronic bronchitis are chronic (long-term) lung diseases that make it hard to breathe. Both diseases are chronic obstructive pulmonary diseases (COPD), meaning they are conditions that cause a limitation in airflow. Emphysema and chronic bronchitis can occur separately or together and are usually the result of cigarette smoking. In addition, although it happens rarely, a genetic form of emphysema can occur early in adulthood, even if you never smoked.

In the United States, COPD is vastly under diagnosed. While only 15 to 20 percent of smokers are diagnosed with COPD, experts believe the majority of smokers develop some degree of airflow obstruction.

Emphysema comes on gradually after years of exposure to irritants such as cigarette smoke. With emphysema, the tiny air sacs in the lungs become damaged. Because the tiny sacs lose their "stretch," less air gets in and out of the lungs. This causes you to feel short of breath.

With chronic bronchitis, the airways that carry air to the lungs are inflamed and produce a lot of mucus. The mucus and inflammation cause the airways to narrow or become obstructed, making it difficult to breathe. Once the airways are irritated over a long period, the lining of the airways becomes thickened. This thickening of the airways results in an irritating cough, hampered airflow, and lung scarring. The damaged airways then become a breeding place for bacterial infections such as pneumonia.

What happens with emphysema and chronic bronchitis and colds?

A cold is a viral respiratory illness that mainly affects your nose and throat but in some instances can affect your airways. When you have emphysema or chronic bronchitis, you already have some difficulty breathing because of the damaged airways and lungs. Catching a respiratory virus along with COPD can hinder breathing even more and can cause the following changes in your symptoms:

  • An increase in phlegm
  • An increase in the thickness or stickiness of the phlegm
  • A change in phlegm color to yellow or green
  • A presence of blood in the phlegm
  • An increase in the severity of shortness of breath, cough, or wheezing
  • A general feeling of ill health
  • Difficulty sleeping
  • Increased fatigue

Why should I take colds seriously with emphysema or chronic bronchitis?

Catching a cold with emphysema or chronic bronchitis may also lead to bacterial infections such as pneumonia. This occurs because of the airway obstruction and the inability to cough out infected secretions of mucus.

Sometimes, patients with COPD are hospitalized because of a respiratory infection and the worsening of their symptoms. Treatment may include inhaled medications, oxygen, and antibiotics to treat any bacterial infection. Antibiotics do not treat a cold.

To avoid more serious problems with emphysema, chronic bronchitis, and colds, it's important to always alert your doctor if your cold symptoms get worse. Don't wait until you have more serious breathing problems to contact your doctor.

Which cold treatment should I use with emphysema or chronic bronchitis?

First, it is important to stay on your prescribed medications for emphysema and chronic bronchitis. Then, to decide how to treat cold symptoms, it's best to talk with your doctor. You might treat the body aches and fever associated with a cold with acetaminophen or ibuprofen. In addition, you should avoid antihistamines that thicken mucus and make it even more difficult to cough up.

Most over-the-counter cold remedies are generally safe for people with emphysema and chronic bronchitis. However, decongestants raise blood pressure and some of the medications used to treat emphysema and chronic bronchitis also raise heart rate. So, use decongestants with caution. Again, ask your doctor about medications for cold symptoms.

Can I prevent colds if I have emphysema or chronic bronchitis?

The following guidelines can help:

  • Good hygiene can decrease respiratory infections such as colds. Prevent the spread of a cold virus by making sure you and your family members wash your hands regularly.
  • Check with your doctor about a pneumonia and influenza vaccine. You need a flu shot every year. One pneumonia shot is usually enough to protect you from a specific type of bacterial pneumonia.
  • Avoid crowds during cold and flu season, since colds and flu can cause serious problems for people with COPD.
  • Pay attention to healthy lifestyle habits by avoiding cigarette smoke and air pollutants; eating a balanced, healthy diet; and exercising to stay strong.
  • Sinus infections can trigger breathing problems for those with emphysema and chronic bronchitis. Be aware of your sinus symptoms and report them immediately to your doctor to prevent worsening of breathing difficulties.

Acute Bronchitis

 

Pictures of Bronchitis
Bronchitis Slideshow Pictures Pictures of Bronchitis
Medical Author:

 

Medical Editor:

 

  • What is acute bronchitis?
  • What causes acute bronchitis?
  • What are the risk factors for acute bronchitis?
  • What are the symptoms of acute bronchitis?
  • When does a cold become acute bronchitis?
  • When should I call my doctor about my cough?
  • How is acute bronchitis diagnosed?
  • What are the treatments for acute bronchitis?
  • Can I treat acute bronchitis at home?
  • What are the complications of acute bronchitis?
  • Acute Bronchitis At A Glance
  • Bronchitis - Slideshow View Bronchitis Slideshow
  • Patient Discussions: Bronchitis - Treatments
  • Patient Discussions: Bronchitis - Length Symptoms Lasted
  • Find a local Pulmonologist in your town

What is acute bronchitis?

Air is pulled into the lungs when we breathe, initially passing through the mouth, nose, and larynx (voicebox) into the trachea and continues en route to each lung via either the right or left bronchi (the bronchial tree - bronchi, bronchioles, and alveoli). Bronchi are formed as the lower part of the trachea divides into two tubes that lead to the lungs. As the bronchi get farther away from the trachea, each bronchial tube divides and gets smaller (resembling an inverted tree) to provide the air to lung tissue so that it can transfer oxygen to the blood stream and remove carbon dioxide (the waste product of metabolism).

Bronchitis describes inflammation of the bronchial tubes (inflammation = itis). The inflammation causes swelling of the lining of these breathing tubes, narrowing the tubes and promoting secretion of inflammatory fluid.

Acute bronchitis describes the inflammation of the bronchi usually caused by a viral infection, although bacteria and chemicals also may cause acute bronchitis. Bronchiolitis is a term that describes inflammation of the smaller bronchi referred to as bronchioles. In infants, this is usually caused by respiratory syncytial viruses (RSV), and affects the small bronchi and bronchioles more than the large. In adults, other viruses as well as some bacteria can cause bronchiolitis and often manifest as a persistent cough at times productive of small plugs of mucus.

Acute bronchitis is as mentioned above, is a cough that begins suddenly usually due to a viral infection involving the larger airways. Colds (also known as viral upper airway infections) often involve the throat (pharyngitis) and nasal passages, and at times the larynx (resulting in a diminished hoarse voice, also known as laryngitis). Symptoms can include a runny nose, nasal stuffiness, and sore throat. Croup usually occurs in infants and young children and involves the voice box and upper large airways (the trachea and large bronchi).

Chronic bronchitis for research purposes is defined as a daily cough with sputum production for at least three months, two years in a row. Chronic bronchitis is a diagnosis usually made based on clinical findings of a long term persistent cough usually associated with tobacco abuse. From a pathologic standpoint, characteristic microscopic findings involving inflammatory cells in seen in airway tissue samples make the diagnosis. When referring to pulmonary function testing, a decrease in the ratio of the volume of airflow at 1 second when compared to total airflow is less than 70%. This confirms the presence of obstructive airways disease of which chronic bronchitis is one type. Certain findings can be seen on imaging studies (chest X-ray, and CT or MRI of the lungs) to suggest the presence of chronic bronchitis; usually this involves an appearance of thickened tubes.

 

Picture of the anatomy of the lungs

What causes acute bronchitis?

  • Acute bronchitis occurs most often due to a viral infection that causes the inner lining of the bronchial tubes to become inflamed and undergo the changes that occur with any inflammation in the body. Common viruses include the rhinovirus, respiratory syncytial virus (RSV), and the influenza virus.
  • Bacteria can also cause bronchitis (a few examples include, Mycoplasma, Pneumococcus, Klebsiella, Haemophilus).
  • Chemical irritants (for example, tobacco smoke, gastric reflux, solvents) can cause acute bronchitis.

What are the risk factors for acute bronchitis?

Bronchitis describes inflammation of the bronchial tubes. Smoking is a key risk factor for developing acute bronchitis. Any other illnesses that predispose to similar inflammation also increase that risk (for example, asthma patients and patients allergic to airborne chemicals).

What are the symptoms of acute bronchitis?

Inflammation of the bronchial tubes narrows the inside opening of the bronchial tubes. Narrowing of the bronchial tubes result in increased resistance, this increase makes it more difficult for air to move to and from the lungs. This can cause wheezing, coughing, and shortness of breath. The cough may consist of sputum due to the secretions from the inflamed cells that line the bronchi. By coughing, the body attempts to expel secretions that clog the bronchial tubes. If these secretions contain certain inflammatory cells, discoloration of the mucus may result often in a green or yellow color. Sometimes the severity of the inflammation may result in some bleeding.

As with any other infection, there may be associated fever, chills, aches, soreness and the general sensation of feeling poorly or malaise.

When does a cold become acute bronchitis?

Anatomically, the larynx divides the upper and lower airways. Colds tend to affect the mouth, throat, and nasal passages while bronchitis describes specific inflammation of the bronchial tubes. The two illnesses can exist at the same time and may be caused by the same virus infection. A cold does not necessarily lead to bronchitis.

When should I call my doctor about my cough?

While a cough can be irritating and interfere with activities such as sleep, by itself, it needs little care. Drinking plenty of fluids to prevent dehydration, humidifying the air, and occasionally medication to suppress the cough are appropriate home care treatments.

However, medical care should be accessed immediately should shortness of breath occur. Fever, chills, wheezing, and signs of dehydration (lightheadedness, weakness, rapid heart rate) are also reasons to seek medical care. Most coughs tend to subside after a few days. If the cough persists and mucus tends to be discolored, one should seek medical care.

In patients with asthma, wheezing may increase with acute bronchitis. Use of a prescribed albuterol inhaler (Ventolin HFA, Proventil HFA, ProAir) is reasonable; however, asthma patients should contact their health care practitioner if the symptoms of wheezing and shortness of breath do not resolve promptly.

How is acute bronchitis diagnosed?

Acute bronchitis is usually diagnosed through patient history and physical examination.

Patient history

The health care practitioner may ask the following questions about the symptoms:

  1. What symptoms exist?
  2. When did they start?
  3. Is there a related fever?
  4. Is sputum being brought up by coughing?
  5. Is the sputum or color-tinted?
  6. Is there any blood tinge?
  7. Does the person smoke?
  8. Is there a history of asthma or COPD?
  9. Does the patient take any medications or inhalers that are used to treat underlying illnesses?
  10. What has the patient done to treat the symptoms?
  11. Were these measures successful?

Physical examination

The health care practitioner may examine of the patient's upper airways to look for signs of ear, nose, or throat infection including redness of the tympanic membranes (ear drums), runny nose, and post nasal drip. Redness of the throat or swelling and pus on the tonsils can help distinguish common cold, tonsillitis, and acute bronchitis symptoms. The neck may be palpated or felt to check for swollen lymph nodes. Listening to the lungs may reveal decreased air entry and wheezing.

A chest X-ray may be considered by the health care practitioner if there is a concern that a pneumonia or infection of lung tissue is present.

Blood tests are usually not helpful; occasionally, cultures of sputum are done if a bacterial pathogen is suspected.

What are the treatments for acute bronchitis?

Decreasing inflammation is the goal for treating acute bronchitis.

Albuterol inhalation, either with a hand held device (meter dosed inhaler, MDI) or nebulizer will help dilate the bronchial tubes.

Short-term steroid therapy will help minimize inflammation within the bronchial tubes. Prednisone is a common prescription medication that enhances the anti-inflammatory effects of the steroids produced within the body by the adrenal glands. Topical inhaled steroids may also be of benefit with fewer potential side effects.

It is important to keep the patient comfortable by treating fever with acetaminophen or ibuprofen. Drinking plenty of fluid will keep the patient well hydrated and hydration keeps secretions into the bronchial tubes more liquid and easier to expel.

Antibiotics are not necessarily indicated for the treatment of acute bronchitis. Occasionally they may be prescribed should a bacterial infection be present in addition to the usual virus that causes acute bronchitis. However, most acute bronchitis is caused by viruses and no antibiotics are needed.

Although good hydration will help remove secretions into the bronchi, other treatments (for example, Mucinex, Robitussin and others that contain guaifenesin) can help clear secretions though this is often a highly variable finding.

Cough is a very violent action that results in dynamic collapse of the airways. This collapse results in the walls of the airways banging against one another. This action of cough can cause further inflammation and help perpetuate the problem by sustaining and increasing inflammation. Cough suppression with cough drops or other liquid suppressants (for example, Vicks 44, Halls, and cough syrups that contain dextromethorphan) help to break this vicious cycle. In addition, if the person smokes, they should stop. If the acute bronchitis is being caused by inhaled smoke or chemicals, the patient should be removed from these irritant sources

Can I treat acute bronchitis at home?

The treatment of acute bronchitis is geared toward prevention, control, and relief of symptoms (supportive care). In some cases, the following is all that is needed:

  • drink plenty of fluids to maintain proper hydration (avoiding dehydration and humidify air); and
  • use of acetaminophen and ibuprofen to treat fever and decrease the inflammatory resposne.

The treatments section above covers those actions that can usually be done at home. However, people with medical conditions such as high blood pressure should be careful to choose those products approved for patients with high blood pressure because some cough/cold formulations may further increase a person's blood pressure to elevated or dangerous levels. People with diabetes should also choose cough and cold products that will not affect their blood glucose levels. If individuals are unsure which products are safe, they should contact their primary health care practitioner for advice.

For patients with underlying lung disease such as asthma or COPD, increased use of albuterol or similar inhaled medications may be indicated. However, the health care practitioner should be contacted when a patient considers altering their medication usage.

What are the complications of acute bronchitis?

Acute bronchitis usually resolves spontaneously (about 2-3 weeks) with supportive care. If wheezing and shortness of breath occurs the patient should seek medical care.

In patients who have underlying lung conditions, the inflammation can cause lung tissue to function improperly. Pneumonia or infection of the lung tissue itself may develop.

Acute Bronchitis at a Glance

  • Acute bronchitis describes an infection and inflammation of the breathing tubes leading to cough and occasional wheezing.
  • Treatment is supportive keeping fever under control and the patient well hydrated.
  • Wheezing is often treated with inhaled albuterol, either by puffer (HFA) or nebulizer.
  • Steroid medication may be used short term to help decrease the inflammation within the bronchial tubes.
  • Patients with underlying lung diseases such as asthma or COPD may be at greater risk of developing acute bronchitis.
  • Antibiotics are not commonly prescribed for acute bronchitis but may be prescribed if specifically indicated.

Chronic Bronchitis

 

Hidden Home Hazards That Can Harm Your Lungs
Hidden Home Hazards That Can Harm Your Lungs
Energy-Boosting Foods for COPD Slideshow Pictures Energy-Boosting Foods for COPD
Worst Smog Cities in America Slideshow Worst Smog Cities in America Slideshow
  • Chronic Bronchitis Facts
  • What is bronchitis?
  • What is acute bronchitis?
  • What are the symptoms of acute bronchitis?
  • What is chronic bronchitis?
  • What are the causes of chronic bronchitis?
  • What are the risk factors for chronic bronchitis?
  • What are the symptoms of chronic bronchitis?
  • When should an individual seek medical care for chronic bronchitis?
  • How is chronic bronchitis diagnosed?
  • What is the treatment for chronic bronchitis?
  • What are the complications of chronic bronchitis?
  • Can chronic bronchitis be prevented?
  • What is the outlook (prognosis) for chronic bronchitis?
  • Patient Discussions: Chronic Bronchitis
  • Find a local Pulmonologist in your town

Chronic Bronchitis Facts

  • Bronchitis is a term that describes inflammation of the bronchial tubes (bronchi and the smaller branches termed bronchioles) that results in excessive secretions of mucus into the tubes with tissue swelling that may narrow or close off bronchial tubes.
  • Chronic bronchitis is defined as a cough that occurs every day with sputum production that lasts for at least 3 months, 2 years in a row.
  • The major cause of chronic bronchitis is cigarette smoking; other causes are bronchial irritants, usually inhaled repeatedly by the affected person.
  • Ideally, people should seek medical care before chronic bronchitis develops. People should seek care for tobacco addiction and the occasional chronic cough (less than daily for 3 months) to potentially avoid developing chronic bronchitis. Those with chronic bronchitis should seek care for severe dyspnea, cyanosis, and fever immediately.
  • Diagnosis for chronic bronchitis is done by clinical history and physical exam, while other tests such as chest X-rays, pulmonary function tests, and CT imaging studies may also be used.
  • Treatment of most people with chronic bronchitis is to quit cigarette smoking and avoid air-borne bronchial irritants; medical treatments include bronchodilators, steroids, and oxygen therapy.
  • The major complications of chronic bronchitis are severe shortness of breath, COPD, respiratory failure, and a high mortality rate.
  • Risk factors for chronic bronchitis include smoking, exposure to airborne chemicals and secondhand smoke, dust, and other bronchial irritants.
  • A majority of cases of chronic bronchitis can be prevented by not smoking and avoiding secondhand smoke. Avoidance of air-borne bronchial irritants, vaccinations, and asthma prevention may help prevent bouts of chronic bronchitis.
  • Although the disease is chronic and progressive, patients that are diagnosed early before much bronchial damage occurs and who stop smoking (or avoid airborne dust, chemicals or other situations that lead to bronchial irritation) often have a good prognosis for many years.

 

What is bronchitis?

Bronchitis is a term that describes inflammation of the bronchial tubes (bronchi and the smaller branches termed bronchioles) that results in excessive secretions of mucus into the tubes, leading to tissue swelling that can narrow or close off bronchial tubes. Bronchial tubes extend from the trachea and terminate at the alveoli in the lungs; the bronchial system resembles an inverted tree and is sometimes termed the "bronchial tree." A few authors include the trachea and upper airway in the definition. There are two major types of bronchitis, acute and chronic. Many investigators conclude that recurrent incidences of acute bronchitis are the first steps that can lead to developing chronic bronchitis.

What is acute bronchitis?

Acute bronchitis is bronchitis that is short-lived; the bronchitis lasts about two weeks and usually people recover with no permanent damage to the bronchial tree. Viruses such as influenza, respiratory syncytial virus (RSV), and rhinoviruses cause the majority (about 90%) of cases of acute bronchitis, while the remainder are caused by bacteria (for example, Mycoplasma, Pneumococcus) or short-term exposure to chemical irritants (for example, tobacco smoke, gastric reflux contents, inhaled solvents).

What are the symptoms of acute bronchitis?

Symptoms of acute bronchitis may include:

  • a cough,
  • mild wheezing,
  • fever,
  • chills and malaise, and
  • shortness of breath especially with exertion.

Some people may cough up phlegm. Chronic bronchitis differs from acute bronchitis in several ways described below (for example, pathology, progression of disease, major causes, treatments, and outcomes).

What is chronic bronchitis?

Chronic bronchitis is defined as a cough that occurs every day with sputum production that lasts for at least 3 months, two years in a row. This definition was developed to help select uniform patient populations for research purposes, for example, to study medication therapies for treatment of chronic bronchitis.

Many of the bronchi develop chronic inflammation with swelling and excess mucus production. The inflammation causes a change in the lining cells of the airways to varying degrees. Many cells that line the airway lose the function of their cilia (hair-like appendages that are capable of beating rapidly), and eventually the ciliated cells are lost. Cilia perform the function of moving particles and fluid (usually mucus) over the lining surface in such structures as the trachea, bronchial tubes, and nasal cavities to keep these hollow structures clear of particles and fluids. These ciliated cells that help in clearance of secretions are often replaced by so-called goblet cells. This group of cells secretes mucus into the airway. The warm moist environment of the airway along with the nutrients in the mucus is an excellent medium for growing bacteria. The mucus often becomes infected and discolored from the bacterial overgrowth and the body's inflammatory response to it. The inflammation, swelling, and mucus frequently and significantly inhibit the airflow to and from the lung alveoli by narrowing and partially obstructing the bronchi and bronchioles.

The muscles that surround the some of the airways can be stimulated by this airway irritation. This muscular spasm also known as bronchospasm can result in further airway narrowing. With long standing inflammation, as can be seen in chronic bronchitis, this muscular spasm and inflammation results in a fixed, nonreversible narrowing of the airway and the condition is termed chronic obstructive pulmonary disease (COPD). Chronic coughing develops as the body attempts to open and clear the bronchial airways of particles and mucus or as an overreaction to ongoing inflammation. Chronic bronchitis can be a progressive disease; symptoms (listed below) increase over time. Some NIH investigators consider chronic bronchitis a type of COPD.

COPD also includes the entities of emphysema, chronic bronchitis, and chronic asthma. These conditions are not always separable and patients often have components of each. In the case of chronic bronchitis, the fixed airway obstruction, airway inflammation and retained secretions can result in a mismatch of blood flow and airflow in the lungs. This can impair oxygenation of the blood as well as removal of the waste product, carbon dioxide.

Although people of any age can develop chronic bronchitis, the majority of people diagnosed with the disease are 45 years of age or older.

Picture of the structures of the lungs

 

 

What are the causes of chronic bronchitis?

There can be many causes of chronic bronchitis, but the main cause is cigarette smoke. Statistics from the US Centers for Disease Control and Prevention (CDC) suggest that about 49% of smokers develop chronic bronchitis and 24% develop emphysema/COPD. Some researchers suggest that about 90% of cases of chronic bronchitis are directly or indirectly caused by exposure to tobacco smoke.

Many other inhaled irritants (for example, smog, industrial pollutants, and solvents) can also result in chronic bronchitis.

Viral and bacterial infections that result in acute bronchitis may lead to chronic bronchitis if people have repeated bouts with infectious agents.

Also, underlying disease processes (for example, asthma, cystic fibrosis, immunodeficiency, congestive heart failure, familial genetic predisposition to bronchitis, and congenital or acquired dilation of the bronchioles, known as bronchiectasis) may cause chronic bronchitis to develop, but these are infrequent causes compared to cigarette smoking.

What are the risk factors for chronic bronchitis?

The major risk factor for individuals to develop chronic bronchitis is tobacco smoking and second-hand tobacco smoke exposure. However, there are others, such as repeated exposure to pollutants (especially airborne materials such as ammonia, sulfur dioxide, chlorine, bromine, hydrogen sulfide), dust, repeated bouts of acute bronchitis or pneumonia, and gastric reflux (by inhalation of gastric contents).

What are the symptoms of chronic bronchitis?

The major symptoms of chronic bronchitis are as follows:

  • Cough and sputum production are the most common symptoms; they usually last for at least 3 months and occur daily. The intensity of coughing and the amount and frequency of sputum production vary from patient to patient. Sputum may be clear, yellowish, greenish, or occasionally, blood-tinged. Since cigarette smoke is the most common cause for chronic bronchitis, it should not be surprising that the most common presentation is so called smoker's cough. This is characterized by a cough that tends to be worse upon arising and is often productive of discolored mucus in the early part of the day. As the day progresses, less mucus is produced.
  • Dyspnea (shortness of breath) gradually increases with the severity of the disease. Usually, people with chronic bronchitis get short of breath with activity and begin coughing; dyspnea at rest usually signals that COPD or emphysema has developed.
  • Wheezing (a coarse whistling sound produced when airways are partially obstructed) often occurs.

In addition, symptoms of fatigue, sore throat, muscle aches, nasal congestion, and headaches can accompany the major symptoms. Severe coughing may cause chest pain; cyanosis (bluish/grayish skin coloration) may develop in people with advanced COPD. Fever may indicate a secondary viral or bacterial lung infection. When symptoms worsen or become more frequent, this is often referred to as an exacerbation of chronic bronchitis. These exacerbations often require antibiotics, and may need steroid medication and an increase in respiratory inhaled medications.

When should an individual seek medical care for chronic bronchitis?

Ideally, a person should seek medical care before chronic bronchitis develops. It is reasonable for people to seek care for tobacco addiction and the occasional chronic cough (occurring less than daily for 3 months) and to get medical help to potentially avoid developing chronic bronchitis. However, any daily cough that lasts for at least 3 months in a person should be investigated by a physician.

If a person develops chronic (3 months or longer) cough, difficulty breathing, sputum production, and other symptoms, it may represent the first bout of chronic bronchitis, so seeking medical care may help slow or prevent the usual progression of the disease.

If a person with diagnosed chronic bronchitis (or COPD or emphysema) develops severe problems with breathing, cyanosis or fever, they should seek medical care immediately.

How is chronic bronchitis diagnosed?

Health care practitioner's diagnose chronic bronchitis by using a combination of a person's medical history, physical exam, and diagnostic tests. A history of a daily productive (sputum production) cough that lasts at least 3 months, especially if has occurred two years in a row, fits the criteria for a clinical diagnosis of chronic bronchitis. The physical examination often allows health care practitioners to hear wheezes and a prolongation of the exhalation of breathing, which are signs of airflow obstruction.

A chest X-ray is often performed to help rule out other lung problems (for example, pneumonia, bronchial obstructions). Additional tests such as a complete blood count (CBC), arterial blood gas measurements, CT scan of the chest, and pulmonary function tests are often done to characterize the structure and function of the lungs and to help exclude other conditions (for example, lung cancer, tuberculosis, lung infections). Often a pulmonologist (a physician with specialized training in the management of lung diseases) can help diagnose and treat chronic bronchitis.

What is the treatment for chronic bronchitis?

For the majority of cases, the initial treatment is simple to prescribe but frequently ignored or rejected by the patient – stop smoking cigarettes and avoid second-hand tobacco smoke. People should be encouraged in every way to cease smoking, as continuation will only cause further lung damage. Similarly, blocking or removing other underlying causes of repeated bronchial irritation (for example, exposure to chemical fumes) is a treatment goal. Fifty percent of patients with chronic bronchitis who smoke will no longer cough after 1 month of smoking cessation. The number increases to 80% after 2 months.

Two major classes of medications are used to treat chronic bronchitis, bronchodilators and steroids.

  • Bronchodilators (for example, albuterol [Ventolin, Proventil, AccuNeb, Vospire, ProAir], metaproterenol [Alupent], formoterol [Foradil], salmeterol [Serevent]) work by relaxing the smooth muscles that encircle the bronchi, which allows the inner airways to expand. Anticholinergic drugs also can act as bronchodilators, including tiotropium (Spiriva) and ipratropium (Atrovent).
  • Steroids (for example, prednisone, methylprednisolone [Medrol, Depo-Medrol]) reduce the inflammatory reaction and thus decrease the bronchial swelling and secretions that in turn allows better airflow because of reduced airway obstruction. Often inhaled steroids are administered since they have fewer side effects than systemic (oral) steroids. Examples include budesonide (Pulmicort), fluticasone (Flovent), beclomethasone (Qvar), and mometasone (Asmanex). Combination therapy with both steroids and bronchodilators is often utilized. These include fluticasone/salmeterol (Advair), budesonide/formoterol (Symbicort), and mometasone/formoterol (Dulera).
  • PDE4 inhibitors are a new class of anti-inflammatory agents for exacerbations of COPD that has recently been approved by the FDA. It is primarily for exacerbations that involve excessive bronchitis and mucus production. There is currently only one agent available called roflumilast (Daliresp), a pill taken once per day.
 

Occasionally, antibiotics are used to treat chronic bronchitis exacerbations caused by bacterial infections. Broad spectrum antibiotics are often the choice. Examples include:

  • Fluoroquinolones (levofloxacin [Levaquin])
  • Macrolides (clarithromycin [Biaxin], azithromycin [Zithromax, Zmax])
  • Sulfonamides (sulfamethoxazole and trimethoprim [Bactrim])
  • Tetracyclines (doxycycline [Vibramycin])
 

Of course, if a culture is obtained, directed therapy at the specific offending organism is always best.

Pulmonary rehabilitation is another treatment method that combines education and graded physical exercise. The education portion often includes smoking cessation techniques and the relationship of tobacco use to symptoms. Breathing techniques can be very helpful in overcoming the anxiety and discomfort of exacerbations. When chronic bronchitis is severe, airflow and blood flow may not move appropriately through the lungs. It is crucial for lung function that airflow and blood flow to the lung are precisely matched. When they are not, drops in oxygen and increases in carbon dioxide can result with profound negative consequences.

Supplemental oxygen therapy may be an integral part of treatment. Often it is required with activity and sleep. Patients with severe disease can often benefit from purchasing a small finger oximeter (around $100) for monitoring blood oxygen levels at rest and with activity.

Certain "home remedies" may ease the symptoms of chronic bronchitis. Cold air often aggravates coughing and dyspnea, so avoiding cold air or wearing a cold-air mask (such as a ski mask or face scarf) may help when in cold environments. Dry air also aggravates coughing so warm, humidified air may help by reducing coughing and also may allow mucus to flow more freely, which may result in better clearing of the bronchial airways and less blockage by viscous mucus. One of the lessons of pulmonary rehabilitation is to instruct patients on the proper path for air to follow. This involves breathing in through the nose so that the air is moistened, cleansed, and warmed by the function of the upper airways (sinuses). Air is than expelled through the mouth and in some cases with pursed lips to help optimize the lung's function.

Over-the-counter (OTC) cough suppressants such as dextromethorphan (for example, Pertussin, Vicks 44 or Benylin) may be helpful in reducing cough symptoms. OTC preparations with guaifenesin (for example, Robitussin or Mucinex) may make patients feel more comfortable but there is no scientific evidence that it helps mucus to become less viscous.

Alternative treatments have been suggested by some individuals with little or no evidence of any benefit; and some may even be harmful (for example, herbal teas, high doses of vitamin C, South African geranium herb, eucalyptus oil inhalation therapy, and many others); it is advisable to check with the health care practitioner before using any of these remedies or products.

What are the complications of chronic bronchitis?

The major complications of chronic bronchitis are as follows:

  • dyspnea, sometimes severe,
  • respiratory failure,
  • pneumonia,
  • cor pulmonale (enlargement and weakness of right heart ventricle due to lung disease),
  • pneumothorax (collection of air or gas in lung causing lung collapse),
  • polycythemia (abnormally high concentration of red blood cells needed to carry oxygen),
  • COPD (some NIH investigators consider chronic bronchitis a type of COPD),
  • emphysema,
  • chronic advancement of the disease, and
  • high mortality (death) rate (COPD is the 4th leading cause of death in the United States).

Can chronic bronchitis be prevented?

The majority of instances of chronic bronchitis can be prevented by not smoking and avoiding second-hand smoke. Flu and pneumococcal vaccines can help prevent repeated infections that may lead to the disease.

Certain industries (for example, chemical, textile, and farm workers) are often associated with air-borne chemicals and dust; avoiding air-borne chemicals and dust with appropriate masks may prevent or reduce the individual's chance of developing chronic bronchitis.

Good control of asthma may prevent chronic bronchitis from developing. The genetic predisposition to chronic bronchitis is not currently preventable.

What is the outlook (prognosis) for chronic bronchitis?

Although the disease is chronic and progressive, affected individuals that are diagnosed early before much bronchial damage occurs stop smoking (or avoid airborne dust, chemicals, or other situations that lead to bronchial irritation), they often have a good prognosis for many years.

Approximately 50% of smokers with chronic bronchitis will stop coughing after 1 month of smoking cessation. This number increases to 80% after 2 months of abstinence. If airflow obstruction has occurred, this can improve but the improvement level depends on the duration of injury and the compliance with therapy. Obviously, the more impaired patients will have a lesser recovery of lung function.

Conversely, those individuals that have continued bronchial irritation have only a fair to poor prognosis, since repeated bouts with the disease usually get worse, with affected individuals having more frequent incidents of coughing and dyspnea over time and further progression of lung function abnormalities.

 

Bronchoscopy

 

Hidden Home Hazards That Can Harm Your Lungs
Hidden Home Hazards That Can Harm Your Lungs
Energy-Boosting Foods for COPD Slideshow Pictures Energy-Boosting Foods for COPD
Worst Smog Cities in America Slideshow Worst Smog Cities in America Slideshow
Revising Medical Author:

 

Revising Medical Editor:

 

  • What is bronchoscopy?
  • What are the indications for bronchoscopy?
  • What are the potential complications of bronchoscopy?
  • How does a patient prepare for bronchoscopy?
  • What should a patient expect during bronchoscopy?
  • What can a patient expect after a bronchoscopy?
  • What's new in bronchoscopy?
  • Bronchoscopy At A Glance
  • Find a local Pulmonologist in your town

What is bronchoscopy?

Bronchoscopy is a procedure during which an examiner uses a viewing tube to evaluate a patient's lung and airways including the voice box and vocal cord, trachea, and many branches of bronchi. Bronchoscopy is usually performed by a pulmonologist or a thoracic surgeon. Although a bronchoscope does not allow for direct viewing and inspection of the lung tissue itself, samples of the lung tissue can be biopsied through the bronchoscope for examination in the laboratory.

There are two types of bronchoscopes - a flexible fiberoptic bronchoscope and a rigid bronchoscope. Since the 1960s, the fiberoptic bronchoscope has progressively supplanted the rigid bronchoscope because of overall ease of use. In some patients, flexible fiberoptic bronchoscopy can be performed without anesthesia, but in most cases, conscious sedation "twilight sleep") is utilized. However, rigid bronchoscopy requires general anesthesia and the services of an anesthesiologist. During the bronchoscopy, the examiner can see the tissues of the airways either directly by looking through the instrument or by viewing on a TV monitor.

Depending on the indication the examiner will choose between the flexible fiber optic bronchoscope or the rigid bronchoscope. For example, if a patient were coughing up large amounts of blood, a rigid bronchoscope is used since it has a large suction channel and allows for the use of instruments that can better control bleeding. The vast majority of bronchoscopies are performed using the flexible fiberoptic scope because of the improved patient comfort and reduced use of anesthesia.

 

What are the indications for bronchoscopy?

Bronchoscopy can be used for diagnosis or treatment. (The lists below are not meant to be all-inclusive, but are intended to provide a greater awareness and knowledge regarding the indications for bronchoscopy.)

Bronchoscopy is used to make a diagnosis most commonly for these conditions:

  1. persistent or unexplained cough;
  1. blood in the sputum (coughed up mucus material from the lungs);
  1. abnormal chest x-ray such as a mass, nodule, or inflammation in the lung; or
  1. evaluation of a possible lung infection.

Bronchoscopy is used for treatment:

  1. to remove foreign bodies in the airway;
  1. to place a stent (a tiny tube) to open a collapsed airway due to pressure by a mass or tumor; or
  1. to remove a mass or growth that is blocking the airway.

What are the potential complications of bronchoscopy?

Complications of bronchoscopy are relatively rare and most often minor. It is important to realize that all procedures may involve risk or complications from both known and unforeseen causes, because individual patients vary in their anatomy and response to medications. Therefore, there is no guarantee that a procedure can be free of complications. The following is a list of potential complications:

  • Nose bleeding (epistaxis)
  • Vocal cord injury
  • Irregular heart beats
  • Lack of oxygen to the body's tissues
  • Heart injury due to medications or lack of oxygen
  • Bleeding from the site of biopsy
  • Punctured lung (pneumothorax)
  • Damage to teeth (from rigid bronchoscopy)
  • Complications from pre-medications or general anesthesia

(This list is not meant to be inclusive of all possible complications, but to provide information for your greater awareness concerning bronchoscopy.)

How does a patient prepare for bronchoscopy?

Usually, patients undergoing bronchoscopy should take nothing by mouth after midnight prior to the procedure. Routine medications should be taken with sips of water except for those drugs that can enhance the risk of bleeding. These medications are aspirin products, blood thinners such as warfarin (Coumadin™), and non-steroidal anti-inflammatory products such as ibuprofen. (These drugs must be discontinued at varying numbers of days before the procedure, depending on the medication. Patients must consult their doctors for the appropriate schedule in their particular situation.) The doctor will also want to know of any drug allergies or major drug reactions that the patient may have experienced.

What should a patient expect during bronchoscopy?

As the patient arrives in the bronchoscopy suite (or if the patient is already in the hospital), an intravenous catheter (IV) will be started for administration of medication and fluid. The patient is then connected to a monitor for continuous monitoring of the heart rate, blood pressure, and oxygen level in the blood. If needed, supplemental oxygen will be supplied either through a ½ inch tube inserted into the nostrils (cannula) or a facemask. Medication is then given through the IV to make the patient feel relaxed and sleepy for the flexible fiber optic bronchoscopy. If rigid bronchoscopy is to be performed, an anesthesiologist will be present to induce and monitor the general anesthesia.

Patients will be lying on their back with oxygen supplemented through the mouth or the nose. Prior to the insertion of the flexible bronchoscope, a local anesthesia with topical lidocaine is given in the nose and to the back of the throat. The flexible bronchoscope can be introduced either through the mouth or the nose. Some patients may require a special tube called an endotracheal tube to be inserted through the mouth, passing the vocal cord, and into the trachea to protect and secure the airway. Once the bronchoscope is in the airway, an additional topical anesthetic will be sprayed into the airway for local anesthesia to minimize discomfort and coughing spells. The rigid bronchoscope is inserted by mouth only. This is usually done after the patient is under general anesthesia.

Flexible bronchoscopy rarely causes any discomfort or pain. Patients may feel the urge to cough because of the sensation of a foreign object in the "windpipe." Again, this feeling can be minimized by pre-procedural medication given for relaxation and local anesthesia with lidocaine. The procedure usually takes between 15 to 60 minutes. If a specific area needs to be more thoroughly evaluated or an abnormality is detected during the procedure, samples can be collected by several methods listed below:

  1. Washing - Squirts of salt water (saline) are injected through the bronchoscope into the area of interest and the fluid is then suctioned back. This process is repeated several times to obtain adequate samples, which are then submitted to the laboratory for analysis. Brushing - A soft brush is inserted through the bronchoscope to the area of interest. Cells around the airway are collected by brushing up and down the airway. The samples are also sent to the laboratory for analysis.
  1. Needle aspiration - A small needle is inserted into the airway and through the wall of the airway to obtain samples outside of the airway for analysis under a microscope.
  1. Forceps biopsy - Forceps may be used to biopsy either a visible lesion in the airway or a lung lesion. Abnormal tissue that is visible in the airway is usually easily biopsied. However, a mass that is in the lung tissue is deep within the lung and usually requires a biopsy using special x-ray guidance (fluoroscopy). Specimens obtained are sent to a pathologist for inspection under a microscope.

What can a patient expect after a bronchoscopy?

Patients are taken to an observation area for monitoring for one to two hours until any medication given adequately wears off and patients are able to swallow safely. A family member or a friend must take the patient home after the outpatient procedure. Patients are not allowed to drive or operate heavy machinery for the rest of the day because their reflexes and judgment may be impaired. Some patients may cough up dark-brown blood for the next one to two days after the procedure. This is expected and should not be alarming. However, if there is persistent bright red blood in the sputum, the doctor must be consulted immediately. A follow-up visit with the doctor is scheduled to review the laboratory results, which are typically available within one week.

What's new in bronchoscopy?

The bronchoscope is now being used with lasers to help remove and destroy tumor in the lungs. Sometimes, probes can be passed through the scope to freeze bleeding sites or to shrink tumors. Some newer technologies are on the horizon and may play a future role in the management of asthma and emphysema. There is data to suggest that warming the linings of the airways can reduce asthma attacks. Studies are also now underway investigating one-way valves placed in the upper lobe airways in patients with emphysema. The hope is that this investigational therapy will simulate the benefits seen in emphysema patients that receive lung volume reduction surgery.

Bronchoscopy At A Glance
  • Bronchoscopy is a procedure that is performed by lung specialists (pulmonologists or thoracic surgeons) to diagnose or treat a variety of lung-related diseases.
  • There are two types of bronchoscopes - flexible fiber optic and rigid.
  • Bronchoscopy is relatively safe.
  • Bronchoscopy is performed in various settings, including same-day outpatient bronchoscopy suite, operating room, hospital ward, and/or intensive care unit.

Hereditary Hemochromatosis
(Iron Overload)

 

View Birth Control Slideshow Pictures
Take the Blood and Bleeding Disorders Quiz! Take the Blood and Bleeding Disorders Quiz!

 

Medical Author:

 

Medical Editor:

 

  • What is hereditary hemochromatosis?
  • How is hemochromatosis inherited?
  • What are the symptoms of hemochromatosis?
  • How is hemochromatosis diagnosed?
  • How is hemochromatosis treated?
  • What are dietary recommendations in hemochromatosis
  • What are recommendations for screening for liver cancer in hemochromatosis?
  • Related iron overload article:
    Hemochromatosis (Iron Overload) - on eMedicineHealth
  • Patient Discussions: Iron Overload

What is hereditary hemochromatosis?

Hereditary hemochromatosis is an inherited (genetic) disorder in which there is excessive accumulation of iron in the body (iron overload). It is a common genetic disorder among Caucasians in the United States, affecting approximately one in 240 to 300 Caucasians. Individuals affected with hereditary hemochromatosis may have no symptoms or signs (and have normal longevity), or they can have severe symptoms and signs of iron overload that include sexual dysfunction, heart failure, joint pains, liver cirrhosis , diabetes mellitus, fatigue, and darkening of skin.

The normal iron content of the body is three to four grams. The total amount of iron in the body is carefully controlled. The body loses one mg of iron daily from sweat and cells that are shed from the skin and the inner lining of the intestines. Women also lose one mg of iron daily on average from. In normal adults the intestines absorb one mg of iron daily from food to replace the lost iron, and therefore, there is no excess accumulation of iron in the body. When iron losses are greater, more iron is absorbed from food.

In individuals with hereditary hemochromatosis, the daily absorption of iron from the intestines is greater than the amount needed to replace losses. Since the normal body cannot increase iron excretion, the absorbed iron accumulates in the body. At this rate of iron accumulation, a man with hemochromatosis can accumulate 20 gram of total body iron by age 40 to 50. This excess iron deposits in the joints, liver, testicles, and heart, which causes damage to these organs, and causes signs and symptoms of hemochromatosis. Women with hemochromatosis accumulate iron at a slower rate than men because they lose more iron than men due to iron loss from menstruation and breastfeeding. Therefore, they typically develop signs and symptoms of organ damage due to excess iron 10 years later then men.

How is hereditary hemachromatosis inherited?

Hereditary hemochromatosis is an autosomal recessive disorder, which means an individual has the possibility of developing iron overload only if he/she inherits abnormal genes from both parents. (An autosomal recessive disorder is different from autosomal dominant disorder in which individuals can develop disease by inheriting an abnormal chromosome from only one parent.)

The human body is composed of trillions of cells. Inside the inner core (nucleus) of each cell are chromosomes. Every human cell has two sets of 23 chromosomes (total of 46 chromosomes). Each set is inherited from one parent. Chromosomes contain DNA that carries genes that govern all bodily functions including cell metabolism, appearance, height, intelligence, hair and eye color, and other physical traits. Defects in DNA (also called mutations) are passed from one generation to the next, and sometimes can cause diseases.

There are primarily two mutations associated with hereditary hemochromatosis; C282Y and H63D. The numbers 282 and 63 designate the location of the defects on the HFE gene located on chromosome number 6. An individual who inherits two C282Y mutations (one from each parent) are called C282Y homozygotes, and he/she has a significant chance of developing hemochromatosis. In fact, C282Y homozygotes account for 95% of cases of hereditary hemochromatosis. Patients who inherit one C282Y mutation from one parent and another H63D mutation from another parent are called compound heterozygotes. They account for another three percent of the cases of hereditary hemochromatosis.

What are the symptoms and signs of hemochromatosis?

Patients with early hemochromatosis have no symptoms and are unaware of their condition. The disease may then be discovered when elevated iron blood levels are noted by routine blood testing. In men, symptoms may not appear until 40-50 years of age. Iron deposits in the skin cause darkening of the skin. Since females lose iron through menstrual blood loss, they develop organ damage from iron accumulation 15 to 20 years later than men on average.

Iron deposits in the pituitary gland and testicles cause shrinkage of the testicles and impotence. Iron deposits in the pancreas cause a decrease in insulin production resulting in diabetes mellitus (please read the Diabetes Mellitus article). Iron deposits in the heart muscle can cause heart failure as well as abnormal heart rhythms. Iron accumulation in the liver causes scarring of the liver (cirrhosis) and an increased risk of developing liver cancer. For further information on the consequences of cirrhosis, please read the Cirrhosis article.

How is hemochromatosis diagnosed?

Most patients with hemochromatosis are diagnosed early and have no symptoms. Their hemochromatosis is discovered when elevated levels of iron in the blood are found as part of routine blood testing; or when blood iron levels are measured as in screening studies in family members of patients with hereditary hemochromatosis. Some patients are diagnosed as having hemochromatosis when their doctors perform blood iron levels as part of the evaluation for abnormal elevations in blood levels of liver enzymes AST and ALT.

Blood iron tests

There are several blood tests that reflect the amount of iron in the body; ferritin level, iron level, total iron binding capacity (TIBC), and transferrin saturation.

Ferritin is a blood protein whose levels correlate with the amount of iron stored in the body. Blood ferritin levels usually are low in patients with iron deficiency anemia, and are high in patients with hemochromatosis and other conditions that cause an increase in body iron levels. Since ferritin also can be elevated in certain infections such as viral hepatitis and other inflammatory conditions in the body, an elevated ferritin level alone is not sufficient to accurately diagnose hemochromatosis.

Serum iron, TIBC, and transferrin saturation are often performed together. Serum iron is the measure of the amount of iron in serum (the liquid portion of the blood). TIBC is a measure of the total amount of iron that can be carried in serum by transferrin, a protein that carries iron in serum from one part of the body to another. Transferrin saturation is a number calculated by dividing serum iron by TIBC—it is a number that reflects what percentage of the transferrin that is being used to transport iron. In healthy individuals the transferrin saturation is between 20 and 50 percent. In patients with iron deficiency anemia, the serum iron and transferrin saturation are abnormally low; and in patients with hereditary hemochromatosis the serum iron and transferrin saturation are abnormally high.

Since serum iron can be elevated by eating and can fluctuate during the day, serum iron measurements should be done fasting, usually in the morning before breakfast.

Liver biopsy

The most accurate test for diagnosing hemochromatosis is measurement of the iron content of liver tissue obtained by a biopsy. A liver biopsy involves the removal of a sample of liver tissue for analysis and is usually performed with a needle under local anesthesia. After numbing the skin and the underlying tissues, the doctor inserts the needle into the liver through the right lower rib cage, sometimes under ultrasound guidance. The tissue obtained by the needle is studied under a microscope for signs of active liver disease, fibrosis and cirrhosis (permanent scarring), and iron content (usually significantly elevated in hemochromatosis).

The liver biopsy also has prognostic value because it determines whether the patient already has irreversible advanced cirrhosis. Patients with hemochromatosis but an otherwise normal liver biopsy have longevity similar to other healthy adults if adequately treated, while patients with cirrhosis as a result of hemochromatosis have significantly reduced longevity. Furthermore, the risks of cirrhotic patients developing liver cancer (hepatocellular carcinoma) are substantially higher than normal subjects even with adequate treatment of the iron overload with phlebotomy (see below).

Genetic Tests

The gene for hereditary hemochromatosis was identified in 1996. The gene is referred to as the HFE gene. Hereditary hemochromatosis is associated in most patients with two mutations of the HFE gene; C282Y and H63D.

A C282Y homozygote is a person who has inherited one mutated C282Y gene from each parent. A C282Y homozygote is considered at risk of developing iron overload. In fact, C282Y homozygotes account for 95% of all hereditary hemochromatosis. Conversely, not every C282Y homozygote develops iron overload. Studies have shown that an estimated 50% of C282Y homozygotes may not develop iron overload or its complications.

A C282Y/H63D compound heterozygote is a person who has inherited one mutated C282Y gene from one parent and a second mutated H63D gene from the other parent. Most compound heterozygotes have normal iron levels though some can develop mild to moderate iron overload.

A C282Y heterozygote is a person who has inherited one mutated C282Y gene from one parent but a second normal HFE gene from the other parent. Children born of two C282Y heterozygotes have a 25% chance of being a C282Y homozygote and, therefore, will be at risk of developing hemochromatosis. A C282Y heterozygote does not develop iron overload.

An algorithm for diagnosing hereditary hemochromatosis is as follows:

  1. Adults suspected of having hereditary hemochromatosis (for example, adult, first-degree relatives of a patient with hereditary hemochromatosis) are subjected to measurements of fasting serum iron, TIBC, transferrin saturation and ferritin.

  2. Patients with elevated serum iron, ferritin, and transferrin saturation of greater than 45% are subjected to genetic testing

  3. Patients with transferrin saturation greater than 45% who are C282Y homozygotes have hemochromatosis and, therefore, should be treated with therapeutic phlebotomy (see below).

Who should undergo liver biopsy?

Not all patients with hemochromatosis need to undergo liver biopsy. The purpose of liver biopsy is to identify those patients with cirrhosis and to exclude other possible liver diseases. (Patients with hemochromatosis and cirrhosis are at increased risk of complications, especially liver cancer.)

Young patients (<40 years of age) who are C282Y homozygotes with normal liver blood levels and serum ferritin levels <1000 ng/ml have a very low risk of having cirrhosis of the liver. Therefore, these patients can be treated with therapeutic phlebotomy without a liver biopsy. Their prognosis is excellent with adequate treatment.

Older patients (>40 years of age) who have serum ferritin levels >1000 ng/ml, and have abnormally elevated liver blood levels may already have developed cirrhosis. Doctors may recommend liver biopsies in these patients provided that it is safe for them to undergo liver biopsy.

How is hemochromatosis treated?

The most effective treatment for hemochromatosis is to reduce iron in the body by phlebotomy (withdrawal of blood from the arm veins). One unit of blood, which contains 250 mg of iron, usually is withdrawn every one to two weeks. Serum ferritin and transferrin saturation are checked every two to three months. Once ferritin levels are below 50 ng/ml and transferrin saturations are below 50%, the frequency of phlebotomies are reduced to every two to three months. When hemochromatosis is diagnosed early and is treated effectively, damage to the liver, heart, testicles, pancreas and joints can be prevented completely, and patients maintain normal health. In patients with established cirrhosis, effective treatment can improve the function of the heart, skin color, and diabetes; however, the cirrhosis is irreversible and the risk of developing liver cancer remains.

The benefits of therapeutic phlebotomy in hemochromatosis are as follows:

  • It prevents the development of liver cirrhosis and liver cancer if the disease is discovered and treated early.
  • It improves liver function partially in patients who have already developed advanced cirrhosis.
  • It improves and/or completely resolves symptoms of weakness, liver pain, joint pain, and fatigue.
  • It improves function of the heart in patients with mild and early heart disease.

What are dietary recommendations in hemochromatosis?

  • A normal balanced diet is recommended without avoidance of iron containing foods provided patients are undergoing effective therapeutic phlebotomy.
  • Alcohol should be avoided since alcohol consumption increases the risk of developing cirrhosis and liver cancer.
  • Ingestion of high doses of vitamin C in patients with iron overload may lead to fatal abnormal heart rhythms. Therefore, it is reasonable to avoid vitamin C supplementation until patients are adequately treated.
  • Raw seafood should be avoided since patients with hemochromatosis are at risk of acquiring bacterial infections that flourish in iron rich environment.

What are the recommendations for screening for liver cancer in hemochromatosis?

Liver cancers (hepatoma or hepatocellular cancer) mainly occur in patients with cirrhosis. Therefore, patients with hemochromatosis and cirrhosis should have abdominal ultrasound examinations and blood tests for alpha-fetal protein (a protein produced by liver cancer) every six months.

Cosmetic Procedures and the Brow Lift

 

View the Antiaging Tips & Secrets Slideshow Pictures

 

Antiaging Tips & Secrets Slideshow Pictures Antiaging Tips & Secrets Slideshow Pictures
Cosmetic Surgery Slideshow Pictures Cosmetic Surgery Slideshow Pictures
Take the Quiz: Skin - An Incredible Organ Take the Quiz: Skin - An Incredible Organ

 

  • What is a brow lift?
  • Does my health insurance cover this procedure?
  • What can I expect during a brow lift consultation?
  • How do I prepare for brow lift surgery?
  • What will I need at home after brow lift surgery?
  • What can I expect the day of surgery?
  • What should I expect after brow lift surgery?
  • When should I call my doctor after a brow lift?
  • Find a local Plastic Surgeon in your town

Introduction

Are you frustrated with sagging skin in your forehead region? Then the forehead lift and eyebrow lift, also called "the brow lift," may be just what you're seeking. This popular procedure is used to help reverse the aging process (think deep wrinkles and creases across your forehead caused by years of facial expressions and environmental effects). But don't be fooled. Younger people are also candidates if they have inherited traits, such as lowbrow or other problems.

What Is a Brow Lift?

A forehead lift can be performed using one of three common procedures: an endobrow lift performed through an endoscope, an open brow lift, or a temporal lift. The procedure cosmetically corrects sagging in the forehead skin, upper eyelids, and eyebrows.

Here's how:

Your surgeon will maneuver tissues and remove segments of muscles and skin that are responsible for wrinkles or deep frown. Sometimes, this procedure is performed in conjunction with a face-lift or reshaping of the nose.

Think about it. You want your facial features to have the same contoured appearance. If you only have the work done on your forehead, other areas will appear more aged. If you are interested in learning about other procedures, you can discuss the options with your surgeon.

There are two methods to lift your forehead and eyebrow areas:

  • the classic lift
  • endoscopic lift.
The classic lift involves one continuous incision, beginning at the level of your ears and going up around your hair line. Depending on where your hair line is, the surgeon will move the incision line to avoid a visible scar. For instance, if you are a man who is balding, the surgeon can make the incision mid-scalp, so the scar can be hidden in the remaining hair.

Here's how the endoscopic lift differs: Instead of making one continuous incision, your surgeon will make a few shorter incisions in the scalp. He or she will insert a scope (small camera on the end of a thin tube) into one of the incisions in order to view the tissues and muscles from a screen. At the same time, he or she will use another device inserted in another incision to make the necessary alterations.

In this procedure, small anchors are used to secure the offending tissue once it's altered appropriately. Those anchors are tiny, but mighty. They'll keep your tissue under control for years. Because the incisions are smaller, this procedure is less invasive. You will experience minimal scarring and shortened recovery time.

Does My Health Insurance Cover This Procedure?

A forehead lift is a cosmetic procedure and is not covered under health insurance plans unless you have severe visual field loss. It's important that you receive price quotes in writing from your surgeon's office and that you understand charges for any follow-up care.

Your Brow Lift Consultation

You've selected the surgeon, now it's time for the consultation about your brow lift.

You should prepare by having your medical history handy (for instance, have you previously undergone facial surgeries to correct aging or wrinkling?), current medical conditions and any medications. This will all affect how your surgeon analyzes your case and determines how to approach your surgery. Also, you should know exactly what you want to correct about the current appearance of your forehead.

Your surgeon will evaluate your entire forehead region, including your upper eyelids, paying attention to the muscles. The surgeon may have you make a variety of facial expressions so he or she can evaluate exactly how to help you.

How to Prepare for Your Brow Lift

There might be some lifestyle adjustments you have to make before you can undergo a brow lift. For instance, do you smoke? Then you may have to quit, or at least curtail your habit for a few days. But this is up to your surgeon, and he or she will provide you with specific pre-operative instructions.

You may also have to avoid alcohol and certain medications. If you regularly take an aspirin or other anti-inflammatory drug, your surgeon will ask you to stop taking these for a certain period of time before the surgery. These drugs can cause increased bleeding and should be avoided.

 

Also, be advised: if your hair is long and will get in the way of the procedure, you may have to trim it. If your hair is shorter, you may seek to grow it out to cover any scars. You will be able to discuss all this with your surgeon and how you should prepare.

What You'll Need at Home After a Brow Lift

You should make sure your house is stocked with plenty of gauze and clean towels once you've arrived home after your brow lift. Also make sure to have the following on hand:

  • Plenty of ice
  • Container to use for ice or cold water
  • Plastic freezer bags to hold the ice OR you can also keep bags of frozen corn or peas on hand
  • Pillows (you'll have to keep your head elevated for a period of time)
  • Ointment for the incision area (which your surgeon can recommend or prescribe, if necessary)

The Day of Your Brow Lift

Typically, you can undergo a brow lift at your surgeon's office, in a hospital, or outpatient surgery facility. Your surgery should be completed within two hours and you will not normally need to stay overnight. However, you will need to bring someone along who can drive you home and, if you live alone, stay with you the first night or two.

Your surgeon will use local anesthesia. But, if it makes you more comfortable, you can request an anesthesia that will put you to sleep during the operation (general anesthesia). Once the operation has ended, your surgeon will close the incision areas with stitches or staples. Then he or she will cleanse the area to remove blood and cover the wound area with a soft, sterilized bandage that will surround your face.

It's very important to follow the instructions on how to care for the bandage and how frequently you should change it.

What to Expect After a Brow Lift

Your recovery is going to vary depending upon which procedure you had: a classic or endoscopic brow lift.

In either case, you will have stitches or staples in the incisions which will need to be removed in about a week. If you have temporary fixation screws, these will be removed in about two weeks (these fixtures are installed beneath the hairline to hold the elevated brow in place).

You will probably experience swelling and bruising, which can also affect other parts of your face, including your cheeks and eyes. The swelling should be gone in about a week. For at least two days following surgery, you should keep your head elevated to help alleviate the swelling, and you can gently apply ice packs to the affected region.

For those who undergo surgery via the classic method, you will most likely experience more pain during your recovery. Your doctor will give you a prescription for a painkiller. You may also experience more itching, which can last for a few months.

Those patients who undergo surgery via endoscopic method will also receive a prescription painkiller. Itching can also be a side effect for those who have undergone the endoscopic method, though it is much more mild than with the classic method.

In either case, you may also experience numbness or tingling. This will subside over time. Those who underwent the classic procedure may experience more numbing.

Most patients can return to work or school within 10 days, some sooner, depending on which procedure you underwent and your own personal rate of recovery.

You should be sure to avoid heavy lifting, vigorous exercise or other activity for the first few weeks after surgery.

Though the side effects are minimal, possible complications can include infection, scars, complications with eyebrow movement or the loss of sensation around the incision site. It's important to remember that these occur rarely.

After a Brow Lift, Call Your Doctor Immediately If:

You experience any of the following:

  • fever that climbs over 100 degrees Fahrenheit
  • excessive swelling or bleeding.

Brucellosis

 

Take the MRSA Quiz!

 

 

 

Take the MRSA Quiz! Take the MRSA Quiz!
Strep or Sore Throat Slideshow Pictures Strep or Sore Throat
Infectious Mononucleosis Slideshow Pictures Strep or Sore Throat

 

Medical Author:
Medical Editor:
  • What is brucellosis?
  • What is the history of brucellosis?
  • What causes brucellosis?
  • How is brucellosis transmitted?
  • What are the symptoms and signs of brucellosis?
  • How is brucellosis diagnosed?
  • What is the treatment for brucellosis?
  • What are the complications of brucellosis?
  • How can brucellosis be prevented?
  • Brucellosis At A Glance

What is brucellosis?

Brucellosis is an infectious disease caused by bacteria from the genus Brucella. It is an infection that affects mainly animals, including goats, sheep, camels, pigs, elk, deer, cattle, and dogs. Humans develop brucellosis when they come in contact with contaminated animals or animal products. The symptoms of brucellosis often resemble a flu-like illness.

Human brucellosis is a disease that is found worldwide, and it has an annual occurrence rate of more than 500,000 cases. Brucellosis tends to occur more commonly in regions with less established animal-disease-control programs and in areas where public-health initiatives may be less effective. High-risk areas include the Mediterranean Basin (Portugal, Spain, Southern France, Italy, Greece, Turkey, and North Africa), South and Central America, Eastern Europe, Africa, Asia, the Caribbean, and the Middle East. In the United States, brucellosis is much less common, with only 100-200 human cases reported each year. This decrease in cases in the United States is felt to be due to effective animal vaccination programs and milk pasteurization.

What is the history of brucellosis?

Brucellosis is a disease that is thought to have existed since ancient times, as it was first described more than 2,000 years ago by the Romans and Hippocrates. It was not until 1887 that a British physician, Dr .David Bruce, isolated the organism that causes brucellosis from several deceased patients from the island of Malta. This disease has had several names throughout its history, including Mediterranean fever, Malta fever, Crimean fever, Bang's disease, and undulant fever (because of the relapsing nature of the fever associated with the disease).

In the mid-20th century, the Brucella bacteria was also developed for use as a biological weapon by the United States. The use of brucellosis for biological warfare purposes was later banned in 1969 by President Nixon.

What causes brucellosis?

Brucellosis is a systemic infectious disease transmitted from certain animals to humans (zoonotic disease). Brucellosis in humans is predominantly caused by four different species of Brucella bacteria: Brucella melitensis (goats, sheep, camels), Brucella suis (pigs), Brucella abortus (cows, buffalo, elk, camels, yaks), and Brucella canis (dogs). Though all of these species can cause human brucellosis, Brucella melitensis is the most prevalent worldwide, and it is felt to cause the most severe cases of brucellosis.

How is brucellosis transmitted?

Brucellosis is transmitted from animals to humans in several ways. The most common route of transmission occurs when humans consume raw milk or cheese from infected sheep and goats. Infected animals shed the organism into their milk, and if humans eat or drink unpasteurized dairy products from these affected animals, they can develop brucellosis.

Brucellosis can also be transmitted to humans via inhalation of the organism or by direct contact with infected animal secretions. The bacteria can gain entry into the body through the inhalation of aerosolized secretions, through breaks in the skin, or through exposure of the mucous membranes/conjunctiva from the splashing of infected secretions. With these routes of entry, brucellosis is an occupational disease that can affect veterinarians, slaughterhouse workers, butchers, hunters, laboratory personnel, and those individuals who work closely with livestock (for example, farmers and shepherds).

Finally, an accidental injection with the livestock vaccine used against Brucella abortus can also lead to brucellosis in humans. Human-to-human transmission is very rare (via sexual contact and breastfeeding).

What are the symptoms and signs of brucellosis?

The symptoms and signs of brucellosis may develop from days to months after the initial exposure to the organism (incubation period). While some individuals may develop mild symptoms, others may go on to develop long-term chronic symptoms.

The signs and symptoms of brucellosis are extensive and they can be similar to many other febrile illnesses. They include

  • fever (the most common finding, and it may be intermittent and relapsing),
  • sweating,
  • body aches,
  • joint pain,
  • fatigue,
  • weakness,
  • dizziness,
  • headache,
  • depression,
  • irritability,
  • loss of appetite,
  • weight loss,
  • cough,
  • difficulty breathing,
  • chest pain,
  • abdominal pain,
  • enlarged liver and/or spleen.

Other symptoms and signs may also be present with brucellosis. Certain variables such as the severity of illness, the chronicity of illness, and the development of complications can all impact the clinical findings associated with the disease.

How is brucellosis diagnosed?

Making the diagnosis of brucellosis can sometimes be difficult because of the similar symptoms and signs shared with other febrile illnesses. An accurate history obtained by your health-care provider (including travel history, occupation, animal exposure, etc.) may be very helpful in raising the suspicion of brucellosis as a possible diagnosis.

In general, blood tests and blood/tissue cultures are necessary for making the diagnosis of brucellosis. Common blood tests used to make the diagnosis include testing for antibodies against the bacteria and isolating the organism from blood cultures. A biopsy of body tissue (from the bone marrow or the liver, for example) can also assist in making the diagnosis. Additional blood tests may demonstrate anemia, low platelets, a low white blood cell count, and elevated liver function tests.

Other imaging studies and procedures may also be performed initially depending on the individual's signs and symptoms. These tests may include CT scan, MRI, X-ray, ultrasound, lumbar puncture (spinal tap), joint aspiration, or an electrocardiogram (ECG).

What is the treatment for brucellosis?

The cornerstone of treatment for brucellosis is antibiotics. Because of the high relapse rate associated with the disease, the use of a multidrug (two or more) antibiotic regimen is recommended. The antimicrobials most commonly used include doxycycline (Vibramycin), streptomycin, rifampin (Rifadin), gentamicin (Garamycin), and trimethoprim-sulfamethoxazole (Bactrim, Septra). The combination of antibiotics used will vary based on disease severity, age and pregnancy.

 

In general, a full six-week course of antibiotics is recommended, and prompt treatment can lead to an improvement in symptoms and may also prevent the complications associated with brucellosis. However, relapse rates of the disease are still about 5%-10%, even with treatment. Depending on the severity of illness, the associated complications (if any) and the timing of treatment, recovery may take from a few weeks to a few months.

Rarely, surgical intervention may be needed for certain complications associated with brucellosis, such as abscess formation or heart-valve infection. Your health-care provider may need to consult other physicians, including surgeons, infectious disease specialists, or a neurologist

What are the complications of brucellosis?

In general, if treated appropriately with antibiotics in a timely manner after the onset of symptoms, the prognosis for patients with brucellosis is excellent. The mortality rate is low (<2%). However, several potential complications can develop and may include involvement of the following organ systems:

  • Bones and joints
    • Sacroiliitis, spondylitis, and osteomyelitis
  • Cardiovascular
    • Endocarditis (a primary cause of death), myocarditis, and pericarditis
  • Central nervous system (neurobrucellosis)
    • Meningoencephalitis
  • Gastrointestinal
    • Hepatitis, hepatic abscess, colitis, and spontaneous peritonitis
  • Genitourinary
    • Orchitis
  • Pulmonary
    • Pneumonia
  • Ocular
    • Optic neuritis and uveitis

How can brucellosis be prevented?

The prevention of brucellosis can be achieved through various measures. The most important step in preventing brucellosis in humans begins with the control and/or eradication of the infection in animals who serve as a reservoir. This requires a coordinated effort between local public-health organizations and animal-disease-control entities. The most effective measures to achieve this objective include animal vaccination programs, animal testing, and the elimination of infected animals. There is no human vaccine currently available.

In areas where eradication of the disease may not be possible, preventive measures are aimed at reducing the risk of transmission to humans. These measures may include

  • pasteurization of dairy products;
  • avoiding the consumption of unpasteurized dairy products, including milk and cheese;
  • avoiding the consumption of undercooked meat;
  • using appropriate barrier precautions (goggles, gloves, masks, etc) to avoid exposure to aerosols and body fluids for those with an occupational risk for brucellosis;
  • warning laboratory workers about potentially infected specimens so that appropriate biosafety level III precautions can be taken.
Brucellosis At A Glance
  • Brucellosis is an infectious disease caused by bacteria from the genus Brucella.
  • Brucellosis is an infection of certain animals that is transmitted to humans.
  • Humans acquire brucellosis when they come in contact with contaminated animals or animal products, most commonly from the ingestion of raw milk or cheese.
  • The symptoms of brucellosis may include fever, sweating, body aches, and joint pain.
  • Brucellosis is typically diagnosed through blood tests and by isolating the organism from blood and other body tissues.
  • A multidrug antibiotic regimen is the cornerstone of treatment for brucellosis.
  • The complications of brucellosis may involve various organ systems.
  • Brucellosis can be prevented by animal-disease-control measures, avoidance of unpasteurized dairy products, and occupational protective measures.

Black Eye

 

View the Eye Diseases and Conditions Slideshow Pictures

 

 

 

 

Eye Diseases and Conditions Slideshow Pictures Eye Diseases and Conditions Slideshow Pictures
Pink Eye Slideshow Pictures Pink Eye Slideshow Pictures
Cataracts Slideshow Pictures Cataracts Slideshow Pictures

 

Medical Author:
Medical Editor:
  • Black eye introduction
  • What causes a black eye?
  • What are the signs and symptoms of a black eye?
  • When should I call the doctor for a black eye?
  • How is a black eye diagnosed?
  • What is the treatment for a black eye?
  • What are the complications of black eye?
  • How can I prevent a black eye?
  • Black Eye At A Glance
  • Find a local Doctor in your town

Black eye introduction

A black eye often results from injury to the face or the head, and is caused when blood and other fluids collect in the space around the eye. Swelling and dark discoloration result in a "black eye" – sometimes called a "shiner."

Most black eyes are relatively minor injuries. Many heal on their own in a few days, but they may signify a more serious injury.

Despite the name, "black eye," the eye itself is not usually injured. The tissues around the eye may be significantly discolored and swollen without any injury to the eye itself, like a bruise (ecchymosis) around the eye.

The skin around the eye is very loose, with mostly fat underneath it and fluid accumulates easily in this area. The skin around the eye is one of the first places to swell when the facial area is injured. Depending on the location and type of injury, one or both eyes may be affected. Injuries to the eye brow and forehead area often result in black eyes because gravity pulls the blood and inflammatory fluid into the soft tissues under and around the eyes.

As a black eye heals, the swelling around the eye decreases, and the bruise gradually fades away. The bruising will usually start out a very dark purple, and as it fades, it may change to light purple, then greenish, then yellow before disappearing.

What causes a black eye?

The most common cause of a black eye is a blow to the eye, nose, or forehead. Depending on where the blow lands, one or both eyes may be affected.

A blow to the nose often causes both eyes to swell because the swelling from the nasal injury causes fluid to collect in the loose tissues of the eyelids.

Other causes of black eye include:

  • surgical procedures to the face, such as a facelift, jaw surgery, or nose surgery;
  • a certain type of head injury, called a basilar skull fracture, causes both eyes to swell and blacken; this condition is typically described as "raccoon eyes;"

Other causes of swelling around the eye include (these conditions do not make the skin turn black and blue around the eye):

  • allergic reactions,
  • bites,
  • cellulitis (skin infection around the eye),
  • angioedema (swelling, usually around both eyes), and
  • dental infections.

What are the signs and symptoms of a black eye?

Edema (swelling) and pain are the most common signs and symptoms of a black eye.

Initially, the swelling and discoloration may be mild. The eye often starts off slightly reddened, and then progresses to a darker shade and swelling increases. Some blurry vision or difficulty opening the eye may occur, but more serious visual problems are less common. Over the course of a few days, the area becomes lighter and the swelling decreases.

Signs of a more serious injury are double vision, loss of sight, or inability to move the eye. Loss of consciousness, blood or clear fluid coming out of the nose or the ears, blood on the surface of the eye itself, or persistent headache can also indicate a severe injury.

When should I call the doctor for a black eye?

Most black eyes are minor injuries that heal on their own in a few days with ice and pain medications. Depending on the mechanism of injury and accompanying symptoms, an ophthalmologist might have to examine the injured eye to make sure that no significant injury to the eye has occurred.

Call a doctor if the patient:

  • experiences changes in vision;
  • has severe pain or swelling that does not go away;
  • has swelling around the eyes that is not related to an injury;
  • has signs of infection (for example, fever, warmth, redness, pus-like drainage), or
  • has behavioral changes, forgetfulness or lethargy, or nausea, vomiting and/or dizziness.

The individual should consult a health care practitioner any time he/she is unsure about treatment or concerned about symptoms.

Some conditions require immediate medical care. Call 9-1-1 or get to an emergency department immediately in the following situations:

  • the patient experiences changes in or loss of vision (especially double vision);
  • an inability to move the eye itself (i.e., unable to look in different directions);
  • any injury in which an object may have pierced the eye or may be inside the eyeball;
  • if there is obvious blood in the eye itself;
  • if there is deformity to the eye;
  • fluid leaking from the eyeball;
  • there are any lacerations (cuts) to the eye area, face, or head;
  • the patient has signs of a serious head or facial injury;
  • if the black eye is accompanied by broken bones or teeth;
  • loss of consciousness;
  • changes in behavior;
  • nausea, vomiting and/or dizziness;
  • inability to walk;
  • blood or clear fluids coming out of the nose or the ears;
  • patients who take blood thinners, such as warfarin (Coumadin), or those with a history of bleeding problems such as hemophilia;
  • swelling after a bee sting near the eye; or
  • from a suspected infection of the eye

How is a black eye diagnosed?

For most black eyes, a doctor will perform a basic physical exam. He or she will ask about the injury and look for any associated injuries or symptoms.

The physician will shine a light into the patient's eyes to look at the pupils and inside the eye itself for any injury, and to check for foreign bodies or abrasions on the eye. They will test the motion of the patient's eye (following the doctor's finger with his/her eyes), and examine the facial bones around the eye.

Depending on what is found, the doctor may perform additional testing. An X-ray or a CT scan may be performed if the doctor suspects a fracture to the bones of the face or around the eye (the orbit) or that something is inside the eye.

If there are any special concerns, the doctor may refer the patient to a specialist, such as an ophthalmologist (a medical doctor who specializes in eye care and surgery), for follow-up care.

What is the treatment for a black eye?

Home remedies

Home remedies for black eye include rest and ice applied early after the injury help to decrease swelling and pain.

Ice helps decrease swelling by constricting blood vessels, by decreasing fluid accumulation, and by cooling and numbing the area.

  • Apply ice for 20 minutes every hour while awake, for the first 24 hours (a package of frozen vegetables such as peas or corn can be used as it will conform to the shape of the face better than ice cubes).
  • To avoid potential cold injury to the site, wrap the ice or frozen object in a cloth or use a commercial ice pack.
  • Do not use raw meat on a black eye as putting potentially bacteria-laden meat on a mucous membrane or an open skin injury can be dangerous.

Medical care

For simple, uncomplicated black eyes, the treatment prescribed by health care practitioners is similar to home treatment:

  • ice;
  • pain medications [avoid taking aspirin (unless prescribed by your doctor or cardiologist for your heart) because this may increase bleeding];
  • rest; and
  • protection of the injured area.

Avoid possibly injurious activities until after the eye has healed

For more complicated injuries, the patient may be referred to an appropriate specialist; such as an ophthalmologist, who can treat the patient's injuries to the eye itself, or an otorhinolaryngologist [ear, nose, and throat (ENT)] for fractures to the face.

What are the complications of black eye?

Black eye in itself usually is a minor condition that resolves on its own. Severe injuries, especially forceful blunt trauma to the eye area may result in complications.

Traumatic uveitis and iritis (iritis is a type of uveitis) results from blunt trauma to the eye. A black eye may be the first sign of this condition. Iritis generally affects only one eye. Signs and symptoms of uveitis (and iritis) may include:

  • reddened eye (especially around the iris, the colored part of the eyeball);
  • pain that increases with exposure to bright light;
  • a small or irregularly shaped pupil;
  • floating spots before the eyes; or
  • blurred vision.

Any of these symptoms should be brought to the attention of a physician.

Hyphema is an accumulation of blood in the front (anterior) chamber of the eye following injury and can cause damage to the interior tissues of the eye. The amount of blood may be too small to see with the naked eye, or the entire front of the eye may fill with blood.

Glaucoma may also result from blunt trauma to the eye, and can occur immediately or years later. The force of the trauma can cause bleeding inside the eye which leads to an increase in eye pressure, and damages the optic nerve. Delayed onset glaucoma (angle recession glaucoma) can occur as scar tissue from the injury builds in the eye.

Orbital floor fracture (blowout fracture) may also occur as a result of the forceful blunt trauma to the eye. The force of the blow pushes the eyeball further into the eye socket, fracturing the very thin walls of bone that make up the eye socket. This can lead to pinching (entrapment) of the optic nerve and the muscles that move the eye. Loss of vision or double vision can result and must be treated emergently.

Retinal detachment can result in permanent vision loss. Trauma to the eye can lift or pull the retina from its normal position, lining the back of the eyeball. Symptoms include partial or total loss of vision or flashing lights or spots in the field of vision and must be treated immediately.

 


Picture of the anatomy of the eye


How can I prevent a black eye?

Black eye injury can be avoided with basic injury prevention.

  • Check the home for items that might cause a fall, such as throw rugs or objects on the floor (such as toys).
  • Wear the appropriate protective gear for any athletic or work-related activity.
  • Wear goggles or other eye protection when working, doing yard work, or other hobbies and sports that may be injurious to the eyes.
  • Wear seat belts while driving and wear helmets when riding a motorcycle.

Black Eye At A Glance

  • A black eye often results from injury to the face or the head, and is caused when blood and other fluids collect in the space around the eye. Swelling and dark discoloration result in a "black eye."
  • Most black eyes are relatively minor injuries. Many heal on their own in a few days, but they may signify a more serious injury.
  • The most common cause of a black eye is a blow to the eye, nose, or forehead.
  • Pain and swelling are the most common signs and symptoms of a black eye.
  • Call a doctor if the injured individual has changes in vision, severe pain, or swelling that does not go away, the swelling around the eyes is not related to an injury, there are signs of infection (for example, fever, warmth, redness, pus-like drainage), if the person has behavioral changes, forgetfulness or lethargy, nausea, vomiting and/or dizziness, loss of vision (especially double vision), or an inability to move the eye itself (i.e., unable to look in different directions).
  • Home remedies for black eye include rest and ice applied early after the injury help to decrease swelling and pain. Do not use raw meat on an eye injury, this creates potential for infection.
  • Avoid a black eye with basic injury prevention. Wear the appropriate protective gear for any athletic or work-related activity.
  • Complications include traumatic iritis and uveitis, hyphema, glaucoma, orbital floor fracture (blowout fracture), and retinal detachment.

Bumps & Bruises
(Contusions & Ecchymoses)

 

View the Bad Bugs Slideshow Pictures

 

Bad Bugs Slideshow Pictures Bad Bugs Slideshow Pictures
Take the Bed Bugs Quiz! Take the Bed Bugs Quiz!

 

Medical Author:

 

  • What is a bruise?
  • Why do bruises occur more frequently in some people than in others?
  • What does a bruise look like, and why does it change color?
  • What if the bruise doesn't get better or the area stays swollen?
  • What are some less common causes of bruising, and what do they indicate?
  • What is the treatment for bruising?
  • Bumps & Bruises At A Glance
  • Patient Discussions: Bumps And Bruises - Effective Treatments

What is a bruise?

You fall off your bike, bang your shin on the coffee table (that you swore you would move months ago) or run into a wall and wake up with a wallop of a bruise. What is a bruise, and what can you do about it? A bruise (medically referred to as a contusion) is caused when tiny blood vessels are damaged or broken as the result of a blow to the skin (be it bumping against something or hitting yourself with a hammer). The raised area of a bump or bruise results from blood leaking from these injured blood vessels into the tissues as well as from the body's response to the injury. A purplish, flat bruise that occurs when blood leaks out into the top layers of skin is referred to as an ecchymosis.

Why do bruises occur more frequently in some people than in others?

The injury required to produce a bruise varies with age. While it may take quite a bit of force to cause a bruise in a young child, even minor bumps and scrapes may cause extensive bruising or ecchymosis in an elderly person. Blood vessels become more fragile as we age, and bruising may even occur without prior injury in the elderly.

The amount of bruising may also be affected by medications which interfere with blood clotting (and thus cause more bleeding into the skin or tissues). These drugs include many prescription arthritis medications called nonsteroidal antiinflammatories (for example, ibuprofen [Advil, Nuprin] and naproxen [Aleve]) as well as over-the-counter medications, such as aspirin. Warfarin (Coumadin) is often prescribed by doctors specifically to prevent clotting in patients who have had blood clots in their legs or heart. Warfarin can cause particularly severe bruising, especially if the level of the medication becomes too high. Cortisone medications, such as prednisone, promote bruising by increasing the fragility of the tiny blood vessels in the skin. In addition, patients with inherited clotting problems (such as in hemophilia) or acquired clotting problems (such as in patients with liver diseases like cirrhosis), can develop extensive bruising or even life-threatening bleeding.

What does a bruise look like, and why does it change color?

Bruises change in appearance over time, and it is possible to tell by looking at a bruise how old it is. When it first appears, a bruise will be reddish looking, reflecting the color of the blood in the skin. By one to two days, the reddish iron from the blood undergoes a change and the bruise will appear blue or purple. By day six, the color changes to green and by day eight to nine, the bruise will appear yellowish-brown. In general, the bruised area will be repaired by the body in two to three weeks after which the skin will return to normal.

What if the bruise doesn't get better or the area stays swollen?

On occasion, instead of going away, the area of a bruise will become firm and may actually start increasing in size. It may also continue to be painful. There are two major causes for this. First, if a large collection of blood is formed under the skin or in the muscle, instead of trying to clean up the area, the body may wall the blood off causing what is called a hematoma. A hematoma is nothing more than a small pool of blood that is walled off. This may need to be drained by your health-care practitioner.

A second and much less common problem occurs when the body deposits calcium, the material that makes up the majority of bone, in the area of injury. The area becomes tender and firm. This process is called heterotopic ossification or myositis ossificans.

This condition is diagnosed by x-ray and requires a trip to your health-care practitioner.

What are some less common causes of bruising, and what do they indicate?

The terminology describing different types of bruising often refers to not only their appearance but also to their cause. Petechiae refer to very small, 1- to 3-millimeter accumulations of blood beneath the skin. These can appear like multiple tiny red dots on any part of the body (most commonly the legs). Most often these are multiple, and they can suggest that there is serious health problem present. Examples of these are an infection of the valves of the heart (endocarditis) or abnormal function of the blood-clotting elements (platelets). Bruising around the navel (belly button) can be a result of bleeding within the abdomen. Bruising behind the ear (Battle's sign) can indicate that there is a skull fracture. Lastly, bruises that are raised, firm, multiple, and occur without any injury can be a sign of various types of "autoimmune" diseases (diseases in which the body attacks its own blood vessels). Each of these should be evaluated by a health-care practitioner.

What is the treatment for bruising?

There are a couple of things that you can do to prevent or minimize bruising after an injury. First, try a cold compress. Put ice in a plastic bag, wrap the bag in a towel (applying the ice directly to the skin can cause frostbite), and place it on the injured area. Commercial ice packs are also available, but a bag of frozen peas makes an excellent substitute. It molds to the shape of the injured area and can then be re-frozen and used again (but don't eat them!). The cold reduces the blood flow to the area and therefore limits bleeding into the skin and reduces the size of the bruise. The cold also decreases the inflammation in the area of the injury and limits swelling in this way as well. If possible, elevate the area above the level of the heart. The lower an extremity is below the heart, the more blood will flow to the area and increase the bleeding and swelling.

Avoid taking the medications listed above that can contribute to bruising. If you have any questions about whether or not your medication can contribute to bruising, ask your health-care practitioner or pharmacist. Do not stop any prescription medications without first contacting your health-care practitioner.

Finally, pressure applied to the area (by hand, not with tourniquets) can reduce bleeding.

People who take medicines that reduce clotting ("blood thinners") or have clotting abnormalities should seek the advice of a physician or other health-care provider immediately, as should the elderly or those who have experienced significantly severe trauma.

Bumps & Bruises At A Glance
  • A bruise is medically referred to as a contusion.
  • Bruises occur when tiny blood vessels are damaged or broken.
  • The injury required to produce a bruise varies with age and certain medications.
  • Individual bruises change in appearance over time.
  • Spontaneous bruising can indicate a serious bleeding tendency.
Last Updated on Sunday, 06 November 2011 15:14
 
Breast Cancer: Breast Self-Exam PDF Print E-mail
Written by Ruai Pharmaceuticals   
Saturday, 20 August 2011 18:59

Breast Cancer: Breast Self-Exam

 

View Breast Cancer Slideshow Pictures

 

 

Breast Cancer Slideshow Pictures Breast Cancer Slideshow Pictures
Take the Breast Cancer Quiz Take the Breast Cancer Quiz
Disease Prevention in Women Slideshow Pictures Disease Prevention in Women Slideshow Pictures
  • How do I know there is a recurrence?
  • What factors determine the likelihood of a recurrence?
  • How will my prognosis affect my treatment?
  • How would a recurrence be treated?

Breast cancer can recur at any time, but most recurrences occur in the first three to five years after initial treatment. Breast cancer can come back as a local recurrence (in the treated breast or near the mastectomy scar) or as a distant recurrence somewhere else in the body. The most common sites of recurrence include the lymph nodes, the bones, liver, or lungs.

How Do I Know There Is A Recurrence?

If you've been treated for breast cancer, you should continue to practice breast self-examination, checking both the treated area and your other breast each month. You should report any changes to your doctor right away. Breast changes that might indicate a recurrence include:

  • An area that is distinctly different from any other area on either breast
  • Lump or thickening in or near the breast or in the underarm that persists through the menstrual cycle
  • A change in the size, shape, or contour of the breast
  • A mass or lump, which may feel as small as a pea
  • A marble-like area under the skin
  • A change in the feel or appearance of the skin on the breast or nipple, including skin that is dimpled, puckered, scaly, or inflamed (red, warm or swollen)
  • Bloody or clear fluid discharge from the nipples
  • Redness of the skin on the breast or nipple

In addition to performing monthly breast self-exams, keep your scheduled follow-up appointments with your healthcare provider. During these appointments, your healthcare provider will perform a breast exam, order lab or imaging tests as needed, and ask you about any symptoms you might have. Initially, these follow-up appointments may be scheduled every three to four months. The longer you are cancer-free, the less often you will need to see your healthcare provider. Continue to follow your healthcare provider's recommendations on screening mammograms (usually recommended once a year).

What Factors Determine The Likelihood Of A Recurrence?

Prognostic indicators are characteristics of a patient and her tumor that may help a physician predict a cancer recurrence. These are some common indicators:

  • Lymph node involvement. Women who have lymph node involvement are more likely to have a recurrence.
  • Tumor size. In general, the larger the tumor, the greater the chance of recurrence.
  • Hormone receptors. About two-thirds of all breast cancers contain significant levels of estrogen receptors, which means the tumors are estrogen receptor positive (ER+). ER-positive tumors tend to grow less aggressively and may respond favorably to treatment with hormones.
  • Histologic grade. This term refers to how much the tumor cells resemble normal cells when viewed under the microscope; the grading scale is 1 to 4. Grade 4 tumors contain very abnormal and rapidly growing cancer cells. The higher the histologic grade, the greater chance of recurrence.
  • Nuclear grade. This is the rate at which cancer cells in the tumor divide to form more cells. Cancer cells with a high nuclear grade (also called proliferative capacity) are usually more aggressive (faster growing).
  • Oncogene expression. An oncogene is a gene that causes or promotes cancerous changes within the cell. Tumors that contain certain oncogenes may increase a patient's chance of recurrence.

How Will My Prognosis Affect My Treatment?

Following surgery or radiation, your treatment team will determine the likelihood that the cancer will recur outside the breast. This team usually includes a medical oncologist, a specialist trained in using medicines to treat breast cancer. The medical oncologist, who works with your surgeon, may advise the use of tamoxifen (tamoxifen citrate, Nolvadex) or possibly chemotherapy. These treatments are used in addition to, but not in place of, local breast cancer treatment with surgery and/or radiation therapy.

 

How Would A Recurrence Be Treated?

The type of treatment for local breast cancer recurrences depends on your initial treatment. If you had a lumpectomy, local recurrence is usually treated with mastectomy, since radiation therapy cannot be delivered twice to the same area. If the initial treatment was mastectomy, recurrence near the mastectomy site is treated by removing the tumor whenever possible, usually followed by radiation therapy.

In either case, hormone therapy and/or chemotherapy may be used after surgery and/or radiation therapy. If breast cancer is found in the other breast, it may be a new tumor unrelated to the first breast cancer. Treatment would include a lumpectomy or mastectomy and possibly systemic therapy (chemotherapy and/or hormonal therapy).

Women with distant recurrence involving organs such as the bones, lungs, brain, or other organs are treated with systemic therapy. Radiation therapy or surgery may also be recommended to relieve certain symptoms.

Immunotherapy with trastuzumab (Herceptin) alone or with chemotherapy may be recommended for women whose cancer cells have high levels of the HER2/neu protein. Immunotherapy is generally started after hormonal or chemotherapy are no longer effective.

What Are the Potential Problems With Genetic Testing?

Genetic testing is not 100% accurate. If a test is negative, a person still has a chance of developing breast cancer. If the test is positive, there is still a 15% to 20% chance of not developing breast cancer.

Genetic testing is costly, ranging from about $200 to more than $2,000, depending on the type of test. Insurance policies vary in providing coverage for genetic testing.

The results of genetic tests won't be available for several weeks. The length of time it takes to get results depends on the tests performed and under what circumstances they are done.

Genetic testing is highly controversial in society today, and legislation has been enacted to protect individuals who may have a genetic risk of developing cancer from employment and insurance problems. The best course of action a person can take is to become involved with an established genetic registry that can counsel individuals with a genetic risk for cancer.

What Are the Benefits of Genetic Testing?

For some women, the benefits of genetic testing include the ability to make informed medical and lifestyle decisions while reducing the anxiety of not knowing their genetic background. Another benefit is the ability to make a proactive decision regarding prophylactic surgery. In addition, many women are able to participate in medical research that may in the long run decrease their risk of death from breast cancer.

What About My Privacy?

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 prevents insurance companies from denying health insurance based on genetic information, and prevents them from using genetic information to demonstrate that a health condition existed before application was made for insurance. In addition, many states have passed laws or have legislation pending to address insurance concerns.

Should I Be Tested for Genetic Mutations?

You may want to discuss genetic testing with your doctor if any of the following scenarios apply to you:

  • You have two or more blood relatives -- mother, sister, aunt, cousin, or daughter -- with premenopausal breast cancer or ovarian cancer diagnosed at any age.
  • You have been diagnosed with breast cancer, especially if it was diagnosed before you reached menopause, you have a blood relative with breast or ovarian cancer, or if you cancer in both breasts.
  • You have been diagnosed with ovarian cancer and you have blood relatives who have had ovarian or breast cancer.
  • You are related to someone (male or female) who has a BRCA1 or BRCA2 mutation.
  • You are of Ashkenazi Jewish descent and you have blood relatives who have had breast or ovarian cancer, or you have had breast or ovarian cancer.

What Are my Options if I Have a "Cancer Gene?"

Women in high-risk categories (first-degree relative with breast cancer, personal history of breast cancer, prior abnormal breast biopsy results with atypical ductal hyperplasia or lobular carcinoma in situ) and carriers of the genes associated with breast cancer may want to consider starting regular breast cancer screening at age 25 or 10 years earlier than the age of the youngest person with breast cancer at the time of their diagnosis.

Some women choose preventive (prophylactic) mastectomy to decrease the chances of developing breast cancer, although this doesn't offer complete protection.

Another approach includes using the anti-estrogen drug tamoxifen or raloxifene (also known as Evista), a drug used to treat osteoporosis, to help prevent development of breast cancer

What Are the Potential Problems With Genetic Testing?

Genetic testing is not 100% accurate. If a test is negative, a person still has a chance of developing breast cancer. If the test is positive, there is still a 15% to 20% chance of not developing breast cancer.

Genetic testing is costly, ranging from about $200 to more than $2,000, depending on the type of test. Insurance policies vary in providing coverage for genetic testing.

The results of genetic tests won't be available for several weeks. The length of time it takes to get results depends on the tests performed and under what circumstances they are done.

Genetic testing is highly controversial in society today, and legislation has been enacted to protect individuals who may have a genetic risk of developing cancer from employment and insurance problems. The best course of action a person can take is to become involved with an established genetic registry that can counsel individuals with a genetic risk for cancer.

What Are the Benefits of Genetic Testing?

For some women, the benefits of genetic testing include the ability to make informed medical and lifestyle decisions while reducing the anxiety of not knowing their genetic background. Another benefit is the ability to make a proactive decision regarding prophylactic surgery. In addition, many women are able to participate in medical research that may in the long run decrease their risk of death from breast cancer.

What About My Privacy?

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 prevents insurance companies from denying health insurance based on genetic information, and prevents them from using genetic information to demonstrate that a health condition existed before application was made for insurance. In addition, many states have passed laws or have legislation pending to address insurance concerns.

Male Breast Cancer

 

View Breast Cancer Slideshow Pictures

 

 

Breast Cancer Slideshow Pictures Breast Cancer Slideshow Pictures
Take the Breast Cancer Quiz Take the Breast Cancer Quiz
Disease Prevention in Women Slideshow Pictures Disease Prevention in Women Slideshow Pictures

 

Medical Author:

 

Medical Editor:

 

Medical Editor:

 

  • What is male breast cancer?
  • How common is male breast cancer?
  • What are causes and risk factors of male breast cancer?
  • What are the different types of male breast cancer?
  • What are male breast cancer symptoms and signs?
  • How is male breast cancer diagnosed?
  • What is staging of male breast cancer?
  • What is the treatment for male breast cancer?
  • What is the outcome (prognosis) of male breast cancer?
  • Male Breast Cancer At A Glance
  • Patient Discussions: Male Breast Cancer
  • Find a local Oncologist in your town

What is male breast cancer?

Men possess a small amount of nonfunctioning breast tissue (breast tissue that cannot produce milk) that is concentrated in the area directly behind the nipple on the chest wall. Like breast cancer in women, cancer of the male breast is the uncontrolled growth of the abnormal cells of this breast tissue.

Breast tissue in both young boys and girls consists of tubular structures known as ducts. At puberty, a girl's ovaries produce female hormones (estrogen) that cause the ducts to grow and milk glands (lobules) to develop at the ends of the ducts. The amount of fat and connective tissue in the breast also increases as girls reach puberty. On the other hand, male hormones (such as testosterone) secreted by the testes suppress the growth of breast tissue and the development of lobules. The male breast, therefore, is made up of predominantly small, undeveloped ducts and a small amount of fat and connective tissue.

How common is male breast cancer?

Male breast cancer is a rare condition, accounting for only about 1% of all breast cancers. The American Cancer Society estimates that in 2010, about 1,970 new cases of breast cancer in men would be diagnosed and that breast cancer would cause approximately 390 deaths in men (in comparison, almost 40,000 women die of breast cancer each year). Breast cancer is 100 times more common in women than in men. Most cases of male breast cancer are detected in men between the ages of 60 and 70, although the condition can develop in men of any age. A man's lifetime risk of developing breast cancer is about 1/10 of 1%, or one in 1,000.

What are causes and risk factors of male breast cancer?

As with cancer of the female breast, the cause of cancer of the male breast has not been fully characterized, but both environmental influences and genetic (inherited) factors likely play a role in its development. The following risk factors for the development of male breast cancer have been identified.

Radiation exposure

Exposure to ionizing radiation has been associated with an increased risk of developing male breast cancer. Men who have previously undergone radiation therapy to treat malignancies in the chest area (for example, Hodgkin's lymphoma) have an increased risk for the development of breast cancer.

Hyperestrogenism (high levels of estrogen)

Men normally produce small amounts of the female hormone estrogen, but certain conditions result in abnormally high levels of estrogen in men. The term gynecomastia refers to the condition in which the male breasts become abnormally enlarged in response to elevated levels of estrogen. High levels of estrogens also can increase the risk for development of male breast cancer. The majority of breast cancers in men are estrogen receptor-positive (meaning that they grow in response to stimulation with estrogen). Two conditions in which men have abnormally high levels of estrogen that are commonly associated with breast enlargement are Klinefelter's syndrome and cirrhosis of the liver. Obesity is also associated with elevated estrogen levels and breast enlargement in men.

Klinefelter's syndrome is an inherited condition affecting about one in 1,000 men. A normal man has two sex chromosomes (X and Y). He inherited the female X chromosome from his mother and the male Y chromosome from his father. Men with Klinefelter's syndrome have inherited an extra female X chromosome, resulting in an abnormal sex chromosome makeup of XXY rather than the normal male XY. Affected Klinefelter's patients produce high levels of estrogen and develop enlarged breasts, sparse facial and body hair, small testes, and the inability to produce sperm. Some studies have shown an increase in the risk of developing breast cancer in men with this condition. Their risk for development of breast cancer is markedly increased, up to 50 times that of normal men.

Cirrhosis (scarring) of the liver can result from chronic alcohol abuse, chronic viral hepatitis, or rare genetic conditions that result in accumulation of toxic substances within the liver. The liver produces important binding proteins that affect the transport and delivery of male and female hormones via the bloodstream. With cirrhosis, liver function is compromised, and the levels of male and female hormones in the bloodstream are altered. Men with cirrhosis of the liver have higher blood levels of estrogen and have an increased risk of developing breast cancer.

Familial predisposition

Epidemiologic studies have shown that men who have several female relatives with breast cancer also have an increased risk for development of the disease. In particular, men who have inherited mutations in the breast cancer-associated BRCA-2 gene have a dramatically increased (about eightyfold) risk for developing breast cancer, with a lifetime risk of about 5%-10% for development of breast cancer. BRCA-2 is a gene on chromosome 13 that normally functions in suppression of cell growth. Mutations in this gene lead to an increased risk for development of breast, ovarian, and prostate cancers. About 15% of breast cancers in men are thought to be attributable to BRCA-2 mutation. The role of the BRCA-1 gene, which has been associated with inherited breast cancers in women, is not as clearly defined for male breast cancers.

Finasteride use

Finasteride (Propecia, Proscar), a drug that has been used to treat benign prostatic hyperplasia and to prevent prostate cancer, may be associated with an increased risk for male breast cancer. During clinical trials for the drug, no increased risk was shown. However, over 50 cases of male breast cancer have been reported worldwide in men taking the drug. Further studies are needed to clarify whether a causal relationship between the drug and the disease actually exists

What are the different types of male breast cancer?

The most common type of male breast cancer is infiltrating ductal carcinoma, which is also a common type of breast cancer in women. Ductal carcinoma refers to cancers with origins in the ducts (tubular structures) of the breast, and the term infiltrating means that the cancer cells have spread beyond the ducts into the surrounding tissue. On the other hand, lobular cancers (cancers of the milk glands), common in women, are extremely rare in men since male breast tissue does not normally contain lobules.

Other uncommon types of cancers of the breast that have been reported in men include ductal carcinoma in situ (cancer in the ducts that has not spread beyond the ducts themselves), cystosarcoma phylloides (a type of cancer of the connective tissue surrounding the ducts), and Paget's disease of the breast (a cancer involving the skin of the nipple). Some other types of breast cancer that occur in men are named for their growth patterns and microscopic appearance of the cancer cells, including papillary carcinoma, inflammatory carcinoma, and medullary carcinoma.

About 85% of breast cancers in men have estrogen receptors on their cell membranes. Estrogen receptors on the cell membranes allow estrogen molecules to bind to the cancer cells. Estrogen binding to the cancer cells stimulates cell growth and multiplication.

What are male breast cancer symptoms and signs?

The most common sign of breast cancer in men is a firm, nonpainful mass located just below the nipple. There may not be other associated symptoms. The average size of breast cancer in men when first discovered is about 2.5 cm in diameter. The cancer may cause skin changes in the area of the nipple. These changes can include ulceration of the skin, puckering or dimpling, redness or scaling of the nipple, or retraction (turning inward) of the nipple. Bloody or opaque discharge from the nipple may also occur. Less than 1% of cases are bilateral (occurring on both sides).

Breast cancer that has spread (metastasized) to the bones may also produce bone pain at the sites of metastases. Advanced breast cancer can also produce symptoms typical of many cancers, including malaise, weakness, and weight loss.

How is male breast cancer diagnosed?

Diagnosis of breast cancer requires identifying cancer cells in tissue specimens obtained by biopsy. Since men have little breast tissue, cancers in male breasts are easily palpable (located by feel) and, therefore, are easily accessible to biopsy. Fine needle aspiration or needle biopsy of a suspicious mass can usually establish a diagnosis. A needle is inserted into the mass and tissue from the suspicious area is withdrawn. Microscopic examination of the tissue by a pathologist establishes the diagnosis.

Other techniques that may be used to diagnose breast cancer in men include incisional (removing a portion of the suspicious tissue) or excisional (removing the mass in its entirety) biopsy of a breast mass. If nipple discharge is present, microscopic examination of a smear of the discharge can sometimes establish the diagnosis.

Imaging studies such as X-rays, CAT scans (CT scans), magnetic resonance imaging (MRI), ultrasound, and bone scans may be performed to evaluate the presence and extent of metastatic disease once the initial diagnosis of breast cancer has been made.

What is staging of male breast cancer?

Staging is carried out to determine the extent to which a cancer has spread within the body. Staging of breast cancer in men is carried out identically to the staging of breast cancer in women. The American Joint Committee on Cancer (AJCC) TNM system takes into account the tumor size, lymph node involvement by cancer, and presence of metastasis:

  • T: tumor size and extent of local spread
  • N: extent of tumor involvement of lymph nodes in the axillary (underarm) region. Since the nipple area is rich in lymphatic vessels, male breast cancer commonly spreads via the lymphatic channels to the axillary lymph nodes. (When the tumor has spread to the lymph nodes, doctors sometimes use the term "lymph node-positive" cancer.)

     

  • M: presence of distant metastases (spread to other parts of the body through the bloodstream or lymphatic vessels)

Stage 0

Stage 0 refers to intraductal carcinoma, in which the cancer cells have not spread beyond the boundaries of the ducts themselves.

Stage I

In Stage I breast cancer, the tumor is 2 cm or less in greatest diameter and has not spread to the lymph nodes or to other sites in the body.

Stage II

Stage II cancers are divided into two groups. Stage IIA cancer is either less than 2 cm in diameter with spread to the axillary lymph nodes, or the tumor is between 2 cm-5 cm but has not spread to the axillary lymph nodes. Stage IIB tumors are either larger than 5 cm without spread to the lymph nodes or are between 2 cm-5 cm in size and have spread to the axillary lymph nodes.

Stage III

Stage III is considered to be locally advanced cancer. Stage IIIA means the tumor is smaller than 5 cm but has spread to the axillary lymph nodes, and the axillary lymph nodes are attached to each other or to other structures; or the tumor is greater than 5 cm in diameter with spread to the axillary lymph nodes, which may be attached to each other or to other structures. Stage IIIB tumors have spread to surrounding tissues such as skin, chest wall, and ribs, or to the lymph nodes inside the chest wall.

Stage IV

Stage IV cancer refers to metastatic cancer, meaning it has spread to other parts of the body. With breast cancer, metastases (sites of tumor elsewhere in the body) are most often found in the bones, lungs, liver, or brain. Stage IV cancer is also diagnosed when the tumor can be found in the lymph nodes of the neck.

What is the treatment for male breast cancer?

Like breast cancer in women, treatment depends upon the stage of the cancer and the overall physical condition of the patient. Treatments are the same as for breast cancer in women.

Most men diagnosed with breast cancer are initially treated by surgery. A modified radical mastectomy (removal of the breast, lining over the chest muscles, and portions of the axillary lymph nodes) is the most common surgical treatment of male breast cancer. Sometimes portions of the muscles of the chest wall are also removed.

After surgery, adjuvant therapies are often prescribed. These are recommended especially if the cancer has spread to the lymph nodes (node-positive cancer). Adjuvant therapies include chemotherapy, radiation therapy, targeted therapy, and hormone therapy. In cases of metastatic cancer, chemotherapy, hormone therapy, or a combination of both, are generally recommended.

Chemotherapy refers to the administration of toxic drugs that stop the growth of cancer cells. Chemotherapy may be given as pills, as an injection, or via an intravenous infusion, depending upon the types of drugs chosen. Combinations of different drugs are usually given, and treatment is administered in cycles with a recovery period following each treatment. Some of the most common chemotherapeutic agents for treating breast cancer are cyclophosphamide (Cytoxan), methotrexate (Rheumatrex, Trexall), fluorouracil, and doxorubicin (Adriamycin). In most cases, chemotherapy is administered on an outpatient basis. Chemotherapy may be associated with unpleasant side effects including hair loss, nausea and vomiting, and diarrhea.

 

Radiation therapy uses high-energy radiation to kill tumor cells. Radiation therapy may be delivered either externally (using a machine to send radiation toward the tumor) or internally (radioactive substances placed in needles or catheters and inserted into the body).

Hormonal therapy prevents hormones from stimulating growth of cancer cells and is useful when the cancer cells have binding sites (receptors) for hormones. Over 90% of male breast cancers express estrogen receptors and are most commonly treated with the drug tamoxifen (Nolvadex), which blocks the action of estrogen on the cancer cells. Side effects of tamoxifen treatment can include hot flashes, weight gain, mood changes, and impotence.

 

While estrogen is the most common target of hormonal therapy, studies have also shown that treatments directed against the actions of male hormones (anti-androgens) can also reduce the size of male breast cancer metastases. The reasons why anti-androgens are effective in widespread disease are not fully understood. Orchiectomy (removal of the testes) was formerly performed to lower androgen levels, but newer nonsurgical methods are currently favored. Drugs known as luteinizing hormone-releasing hormone (LHRH) analogs affect the pituitary gland and result in lowered production of male hormones by the testes.

Targeted therapy involves agents that are designed to specifically target one of the cancer-specific changes in cells. An example of targeted therapy is trastuzumab (Herceptin), a monoclonal antibody that blocks the activity the protein known as HER-2-neu that is made by some breast cancers. This treatment is only used in breast cancers whose cells express the HER-2-neu protein and is given intravenously. Trastuzumab has been shown to be effective in women with breast cancer but has not been extensively tested in men with breast cancer. Similarly, lapatinib (Tykerb) is a drug taken in pill form that also targets the HER2/neu protein. It is used in combination with other agents to treat HER2-positive breast cancer that is no longer responsive to trastuzumab.

 

If a cancer that has been surgically removed regrows at the original site, this is referred to as local recurrence. Locally recurrent cancers are usually treated by surgery along with chemotherapy or radiation therapy combined with chemotherapy.

What is the outcome (prognosis) of male breast cancer?

The prognosis of a patient with male breast cancer is considered similarly to breast cancer in a woman. As in women, the size and extent (stage) of tumor are the most important factors in the prognosis for male breast cancer. Overall survival rates for each tumor stage are similar for men and women. Since men have less breast tissue than women, it is more common for breast cancers in men to have spread beyond the breast when they are identified, resulting in a more advanced tumor stage at diagnosis.

Disease-specific five-year survival rates (meaning the percentage of patients who do not die of the disease for at least five years following diagnosis) reported for male breast cancer by stage are as follows:

  • Stage 0 - 100%
  • Stage I - 96%
  • Stage II - 88%
  • Stage III - 60%
  • Stage IV - 23%

These survival rates were calculated using historical data, and it is likely that current treatments will lead to even greater survival rates for those recently diagnosed.

Male Breast Cancer at a Glance
  • Male breast cancer is rare and accounts for only about 1% of all breast cancers.
  • Breast cancer risk in men is increased by elevated levels of estrogen, previous radiation exposure, and a family history of breast cancer.
  • Infiltrating ductal carcinoma is the most common type of male breast cancer.
  • A lump beneath the nipple is the most common symptom of male breast cancer.
  • Male breast cancer is staged (reflecting the extent of tumor spread) identically to breast cancer in women.
  • Surgery is the most common initial treatment for male breast cancer; chemotherapy, radiation therapy, and hormonal therapy are also administered.
  • The prognosis of male breast cancer, like breast cancer in women, is predominantly influenced by tumor stage.

Breast Cancer: Breast Cancer in Young Women

 

View Breast Cancer Slideshow Pictures

 

 

Breast Cancer Slideshow Pictures Breast Cancer Slideshow Pictures
Take the Breast Cancer Quiz Take the Breast Cancer Quiz
Disease Prevention in Women Slideshow Pictures Disease Prevention in Women Slideshow Pictures
  • Introduction
  • What is different about breast cancer in young women?
  • Can breast cancer in younger women be prevented?
  • Should women under age 40 get mammograms?
  • What's the best way for younger women to screen for breast cancer?
  • How is breast cancer treated in young women?
  • Find a local Oncologist in your town

Introduction

Younger women generally do not consider themselves to be at risk for breast cancer. Only 5 percent of all breast cancer cases occur in women under 40 years old. However, breast cancer can strike at any age, and all women should be aware of their personal risk factors for breast cancer. (A risk factor is a condition or behavior that puts a person at risk for developing a disease.)

There are several factors that put a woman at high risk for developing breast cancer, including:

Risk factors include:

  • A personal history of breast cancer or non-cancerous breast disease
  • A family history of breast cancer, particularly in a mother, daughter or sister
  • History of radiation therapy Evidence of a specific genetic defect (BRCA1/BRCA2 mutation). Women who carry defects on either of these genes are at greater risk for developing breast cancer.
  • A Gail Index score of at least 1.7% (The Gail Index uses risk factors such as age, family history of breast cancer, age of first menstrual period and first pregnancy, and number of breast biopsies to calculate a woman's risk of developing breast cancer within the next five years.)

An extended use of oral contraceptives (the Pill) later in life is also sometimes considered a factor for developing breast cancer. However, this is still subject to much debate in the medical community.

What Is Different About Breast Cancer in Younger Women?

Diagnosing breast cancer in younger women (under 40 years old) is more difficult because their breast tissue is generally more dense than the breast tissue in older women. By the time a lump in a younger woman's breast can be felt, the cancer often is advanced.

In addition, breast cancer in younger women may be aggressive and less likely to respond to treatment . Women who are diagnosed with breast cancer at a younger age are more likely to have a mutated (altered) BRCA1 or BRCA2 gene.

Delays in diagnosing breast cancer also are a problem. Many younger women who have breast cancer ignore the warning signs -- such as a breast lump or unusual discharge -- because they believe they are too young to get breast cancer.

Many women assume they are too young to get breast cancer and tend to assume a lump is a harmless cyst or other growth. Some health care providers also dismiss breast lumps in young women as cysts and adopt a "wait and see" approach.

Can Breast Cancer in Younger Women Be Prevented?

Although breast cancer may not be prevented, early detection and prompt treatment can significantly improve a woman's chances of surviving breast cancer. More than 90% of women whose breast cancer is found in an early stage will survive.

When women learn at a young age about the risks and benefits of detecting breast cancer early, they are more likely to following the recommendations regarding clinical exams and mammograms . Young women also need to understand their risk factors and be able to discuss breast health with their health care providers.

Should Women Under Age 40 Get Mammograms?

In general, regular mammograms are not recommended for women under 40 years old, in part, because breast tissue tends to be more dense in young women, making mammograms less effective as a screening tool. In addition, most experts believe the low risk of developing breast cancer at a young age does not justify the radiation exposure or the cost of mammography. However, screening mammograms may be recommended for younger women with a family history of breast cancer and other risk factors.

What's the Best Way for Younger Women to Screen for Breast Cancer?

The American Cancer Society (ACS) recommends that all women 20 years of age or older should perform monthly breast self-examinations . The best time to perform BSE is the day after your monthly period ends. Becoming familiar with the look and feel of their breasts offers the best chance for a young woman to notice and change.

In addition to monthly BSE, annual clinical breast exams performed by your doctor are recommended for all women beginning at age 20. Annual screening mammograms also are recommended at age 40. Women younger than 40 who have a family history or other risk factors for breast cancer should discuss their risk and an appropriate screening schedule with their health care providers.

How Is Breast Cancer Treated in Younger Women?

The course of treatment for breast cancer at any age is based on the extent of the person's disease (whether or not it has spread beyond the breast), as well as the woman's general health and personal circumstances.

Treatment options include surgery: either a lumpectomy, which involves removing the lump and some surrounding tissue, or a mastectomy, which is the removal of a breast.

Radiation therapy is generally used following a lumpectomy, and chemotherapy and/or hormone therapy often are recommended after surgery to help destroy any remaining cancer cells and prevent recurrence.

Breast cancer poses other challenges for younger women, as well, such as sexuality, fertility and pregnancy after breast cancer treatment.

Breast Cancer Prevention

 

View Breast Cancer Slideshow Pictures

 

 

Breast Cancer Slideshow Pictures Breast Cancer Slideshow Pictures
Take the Breast Cancer Quiz Take the Breast Cancer Quiz
Disease Prevention in Women Slideshow Pictures Disease Prevention in Women Slideshow Pictures

 

Medical Author:

 

Medical Editor:

 

  • Introduction to breast cancer prevention
  • What are the biological causes of breast cancer?
  • What are the risk factors for developing breast cancer?
  • What is the importance of early breast cancer detection?
  • What are the advantages and limitations of mammography?
  • How frequently should women undergo mammography and breast examinations?
  • What is the risk of radiation with repeated mammography screening over the years?
  • Are there any controversies in the area of breast cancer screening?
  • How helpful are BRCA1 and BRCA2 genetic tests in identifying women at risk?
  • What is the link between estrogen and breast cancer?
  • What are breast cancer prevention treatments?
  • Are there other breast cancer prevention measures?
  • Conclusion

Introduction to breast cancer prevention

For so many women, there is no more dreaded disease than breast cancer. Breast cancer elicits fears related to loss of body image and sexuality, surgery, and death. As is the case for most cancers, the exact cause of breast cancer is not clearly known. Furthermore, there is currently no cure for advanced disease, and there is no definitive way of preventing it.

Breast cancer also affects men. Male breast cancer accounts for about 1% of all breast cancers. Over 200,000 new cases of breast cancer are diagnosed each year in women in the U.S., while about 2,000 cases are diagnosed in men.

Our knowledge of how breast cancer develops is expanding rapidly. As a result, new medications are being developed to reduce the risk of breast cancer among those at high risk of contracting this disease. For the majority of women, lifestyle changes, a healthy diet, cautious use of selected antioxidants, exercise, and weight reduction can also help reduce the chance of developing breast cancer. To date, the most important strategy in improving survival is still breast cancer screening and early detection. Breast cancer is the second leading cause of cancer deaths among women in the United States. The leading cause is lung cancer. One in every eight women in the United States develops breast cancer. The risk is even higher for women with previous breast cancer, those who have first-degree relatives with breast cancer, those with multiple family members with cancer, and those who have inherited "cancer genes."

What are the biological causes of breast cancer?

Breast cancer cells, like all cancers, initially develop because of defects in the genetic material deoxyribonucleic acid (DNA) of a single cell. The human body is composed of trillions of cells. Inside the inner core (nucleus) of each cell is our DNA located on chromosomes. Every human cell has two sets of 23 chromosomes. Each set is inherited from one parent. DNA exists as long, spiraled strands on these chromosomes. Different segments along the DNA strands contain information for various genes. Genes are blueprints that provide genetic instructions for the growth, development, and behavior of every cell. Human DNA is thought to contain approximately 50,000 to 100,000 genes. Most genes carry instructions for the types and the amount of proteins, enzymes, and other substances produced by the cells. Genes also govern the sizes and the shapes of the organs by controlling the rate of division of the cells within these organs. (During cell division, a cell makes a duplicate copy of its chromosomes and then divides into two cells.) Some genes restrict cell division and limit tissue growth.

Defects on the DNA strands can lead to gene coding errors, which in turn can cause diseases. When genes that normally restrict cell growth and divisions are absent or defective, the affected cells can divide and multiply without restraint. The cells that divide and multiply without restraint enlarge (forming a tumor) and can also invade adjacent tissues and organs. These cells can further break away and migrate to distant parts of the body in a process called metastasis. The ability to multiply without restraint, the tendency to invade other organs, and the ability to metastasize to other parts of the body are the key characteristics of cancers -- characteristics that are due to DNA defects.

The cancer-causing DNA defects can be acquired at birth (inherited) or may develop during adult life. The inherited DNA defects are present in every cell of the body. On the other hand, DNA defects that develop during adult life are confined to the descendants (products of cell divisions) of the single affected cell. Generally, inherited DNA defects have a greater tendency to cause cancers and cancers that occur earlier in life than DNA defects that develop during adult life.

Research has shown that 5%-10% of breast cancers are associated with mutations (defects) in two genes known as breast cancer-associated (BRCA) genes, BRCA1 and BRCA2. These genes function to prevent abnormal cell growth that could lead to cancer. Every cell in the body has two BRCA1 or BRCA2 genes, one inherited from each parent. A woman who has received one defective BRCA1 or BRCA2 gene from one parent and a healthy gene from the other is called a carrier of the defective BRCA gene. Even though only one healthy BRCA1 or BRCA2 gene is needed to help prevent cancerous growth of cells, the one remaining healthy BRCA gene is vulnerable to damage during adult life by environmental factors such as toxins, radiation, and other chemicals such as free radicals. Therefore, women bearing a defective BRCA1 or BRCA2 gene are at an increased risk of developing breast and ovarian cancers. Women carrying defective BRCA1 or BRCA2 genes also tend to develop these cancers earlier in life.

Other rare genetic mutations are also associated with an increased risk for the development of breast cancer, including mutations of the tumor suppressor gene p53, the CHEK-2 gene, and the ATM (ataxia-telangiectasia mutation) gene.

Since inherited DNA defects account for only 5%-10% of breast cancers, the majority of breast cancers are due to DNA damages that develop during adult life. Environmental factors that can cause DNA damage include free radicals, chemicals, radiation, and certain toxins. But even among individuals without inherited cancer-causing DNA defects, their vulnerability to DNA damage, their ability to repair DNA damage, and their ability to destroy cells with DNA damage, are likely to be genetically inherited. This is probably why the risk of cancer is higher among first-degree relatives of breast cancer patients, even among families that do not carry the defective BRCA1 and BRCA2 tumor-suppressing genes.

Some of the errors in the normal control mechanisms allow the accumulation of additional errors in other parts of the system. These errors may lead to gene silencing of critical control genes or the overactivity of other growth-stimulating genes by activation of promoter sites adjacent to these otherwise normal genes.

Other substances such as estrogen (a female hormone) and certain fatty acids may also increase the risk of breast cancer by stimulating the growth and division of cells of the breast tissue.

What are the risk factors for developing breast cancer?

The most significant risk factors for breast cancer are gender and age. Men can develop breast cancer, but women are 100 times more likely to develop breast cancer than men. Breast cancer is 400 times more common in women who are 50 years old as compared to those who are 20 years old.

Family history

Another important risk factor is having first-degree relatives (mother, sister, or daughter) with breast cancer or male relatives with prostate cancer. The risk is especially higher if both the mother and sister have had breast cancers, if the cancers in first-degree relatives occurred early in life (before age 50), or if the cancers in these relatives were found in both breasts. Having a male relative with breast cancer and having both relatives with breast and ovarian cancers also increase a woman's risk of developing breast cancer. Families with multiple members with other cancers may have a genetic defect leading to a higher risk of breast cancer.

Women who have inherited defective BRCA1, BRCA2, p53, and DNA repair genes have an increased risk of developing breast cancer, sometimes at early ages, as discussed previously. But even in the absence of one of the known predisposing genetic defects, a strong family history may signify an increased risk because of genetic or environmental factors that are specific to that particular family. For example, increased risk in families could be due to exposure to similar environmental toxins in some cases.

Previous breast cancer

A woman with a history of breast cancer can develop a recurrence of the same breast cancer years later if the cancer cells had already spread to the lymph nodes or other parts of the body. A woman with previous breast cancer also has a three- to fourfold greater chance of developing another breast cancer in the opposite breast. In women who have been treated for breast cancer with breast conservation therapy (BCT), recurrence of cancer within the treated breast may also occur.

Other breast conditions

Even though most women with fibrocystic breasts and its related breast symptoms do not have increased risk of developing breast cancer, the lumpy texture and density of the breasts may hamper early cancer detection by breast examination or by mammography. Sometimes, women with fibrocystic breast changes have to undergo breast biopsies (obtaining small tissue samples from the breast for examination under a microscope) to make certain that palpable lumps are not cancerous.

Breast biopsies sometimes may reveal abnormal, though not yet cancerous, cell changes (called atypical hyperplasia). Women with atypical hyperplasia of the breast tissue have about a four- to fivefold enhanced likelihood of developing breast cancer. Some other benign cell changes in breast tissue are also associated with a slight increase (one and a half to two times normal) in risk. These are termed hyperplasia of breast tissue without atypia, sclerosing adenosis, fibroadenoma with complex features, and solitary papilloma.

The common benign breast tumor known as a fibroadenoma, unless it has unusual features under the microscope, does not confer an increased cancer risk.

Breast cancer risks can be additive. For example, women who have first-degree relatives with breast cancer and who also have atypical hyperplasia of the breast tissue have a much higher risk of developing breast cancer than women without these risk factors.

Radiation therapy

Women with a history of radiation therapy to the chest area as treatment for another cancer (such as Hodgkin's disease or non-Hodgkin's lymphoma) have a significantly increased risk for breast cancer, particularly if the radiation treatment was received at a young age.

Hormonal factors

Women who started their menstrual periods before age 12, those who have late menopause (after age 55), and those who had their first pregnancy after age 30, or who have never had children have a mildly increased risk of developing breast cancer (less than two times the normal risk). Early onset of menses, late arrival of menopause, and late or no pregnancies are all factors that increase a woman's lifetime level of estrogen exposure.

Studies have confirmed that long-term use (several years or more) of hormone therapy (HT) after menopause, particularly estrogens and progesterone combined, leads to an increase in risk for development of breast cancer. This risk appears to return to normal if a woman has not used hormone therapy for five years or more. Similarly, some studies show birth control pills cause a small increased risk of breast cancer, but this risk also returns to normal after 10 years of nonuse. The decision whether to use hormone therapy or birth control pills involves weighing the risks versus the benefits and should be individualized after consulting one's doctor.

Lifestyle factors

Dietary factors such as high-fat diets and alcohol consumption have also been implicated as factors that increase the risk for breast cancer. Cigarette smoking, caffeine intake, antiperspirant use, bras, breast implants, miscarriages or abortions, and stress do not appear to increase the risk of breast cancer. It is important to remember that 75% of women who develop breast cancer have no risk factors other than age. Thus, screening and early detection are important to every woman regardless of the presence of risk factors.

Alcohol

The consumption of alcohol is associated with an increased risk of developing breast cancer, and this risk increases with the amount of alcohol consumed. Compared with nondrinkers, women who consume one alcoholic drink a day have a very small increase in risk. However, those who have two to five drinks daily have about one and a half times the risk of women who drink no alcohol.

What is the importance of early breast cancer detection?

The various types of cancers behave differently, with distinct rates of growth and patterns of spreading (metastasis) to other areas of the body. Some cancers are "favorable" and treatable, while others are so aggressive and malignant that almost nothing in modern medicine's arsenal can help.

Compared to other cancers, breast cancer is on the more treatable end of the spectrum if diagnosed early. It is considered a "favorable" cancer because it can be detected early by breast examination or by mammography. Pancreatic cancer, for example, is on the lethal end of the spectrum of cancers. Pancreatic cancer is often difficult to detect until it is very far advanced.

Studies have clearly shown that the smaller the size of the breast cancer when detected, the better the chance of a surgical cure and long-term survival. The likelihood of a cure is also higher if the cancer is removed before it has spread to lymph nodes and other organs such as the lungs, liver, bones, and brain.

Currently, mammography and breast examinations serve as the foundation for screening for breast cancer. It is extremely important for a woman to have regular breast examinations as well as mammograms to detect early breast cancer.

What are the advantages and limitations of mammography?

Mammography is an X-ray examination of the breast that has the ability to detect a cancer in the breast when it is quite small, long before it may be felt by breast examination. Approximately 85%-90% of all breast cancers are detectable by mammography. Early detection by mammography has reduced the mortality rate from breast cancer by 20%-30% in women over 50 years of age.

However, some 10%-15% of breast cancers are not visible on mammography but can be felt on physical examination of the breast. Therefore, a normal mammogram does not exclude the possibility of breast cancer. Breast examination by your health-care professional by palpation and visual inspection is also important. During a routine physical checkup, a doctor can conduct an examination of the breast.

How frequently should women undergo mammography and breast examinations?

The American Cancer Society (ACS) recommends a baseline mammogram for all women by age 40 and annual mammograms for women 40 and older for as long as they are in good health.

In women with "lumpy breasts" or breast symptoms, and also in women with a high risk of developing breast cancer, sometimes a baseline mammogram at 35 years of age is recommended. This recommendation is somewhat controversial, and there are other viewpoints.

However, the U.S. Preventive Services Task Force (USPSTF) issued new breast cancer screening guidelines in 2009, which recommend against routine mammography screening for women before 50 years of age and suggests that screening end at 74 years of age.

The new USPSTF recommendations are in opposition to other existing breast cancer screening guidelines from organizations such as the American Cancer Society as described above. The USPSTF guidelines also recommend changing the screening interval from one year to two years and suggest that women 40 to 49 years old who are at high risk for breast cancer consult with their doctor regarding the time to begin regular screening mammography.

It is important for women who are concerned about when to begin mammography to discuss the situation with their health-care professional. He or she can help you make an informed decision about breast cancer screening that is appropriate for your individual situation.

Mammograms and young women

There is a special issue regarding mammograms in young women. Since young women have dense glandular breast tissue, routine mammograms have difficulty "seeing through" the dense breast tissue. Therefore mammograms may not be able to detect cancer in the breast because the dense breast tissue around the cancer obscures it. However, this problem can be partly offset by the use of special breast ultrasound, which is now an extremely important additional imaging technique used to supplement mammography in difficult cases. Ultrasound can make visible a lump hidden within dense breast tissue. It may also detect lumps and early breast cancers when mammograms fail to identify a problem. Ultrasound can also help doctors locate specific areas in the breast for biopsy (obtain small samples of tissue to study under a microscope). Sometimes doctors also suggest the use of magnetic resonance imaging (MRI) screening (see below) in younger women with dense breast tissue.

Magnetic resonance imaging (MRI) scanning

Recent research has shown that MRI scanning may be a useful screening tool for breast cancer in certain high-risk populations. In 2004, a team of Dutch researchers published a study of over 1,900 women at high risk for breast cancer in the New England Journal of Medicine. These women underwent breast cancer screening that included physical exams every six months along with yearly mammograms and MRI scans of the breasts. While conventional mammography did detect many cancers at an early stage, some tumors were identified by MRI that were not detected by mammography. Overall, MRI led to the identification of 32 tumors, of which 22 were not seen on the corresponding mammogram. Likewise, some tumors appeared on mammograms that were not visible on the MRI scan. Mammography detected a total of 18 tumors, of which eight were not identified by MRI.

The routine use of MRI, however, has many limitations. While it enabled the detection of some tumors in high-risk women, it also detected more noncancerous lesions (false-positives), which lead to many more follow-up examinations and potentially unnecessary medical procedures. In fact, MRI led to twice as many unnecessary examinations and three times as many unneeded surgical biopsies of the breast than screening by mammography alone. MRI is also approximately 10 times more costly (average cost $1000-$1500) than mammography.

Because of these limitations, experts believe that screening with MRI is impractical for women who do not have an elevated risk of developing breast cancer. However, its benefits appear to outweigh its limitations in certain high-risk populations.

In March 2007, the American Cancer Society Breast Cancer Advisory Group issued new breast-cancer-screening recommendations that include MRI scanning along with mammography for women 30-69 years of age who are considered to have an estimated lifetime risk of developing breast cancer of 20%-25%.

The previous screening recommendations regarding breast self-examinations, clinical breast exams, and mammograms were not altered in the 2007 screening recommendations. Adding a yearly breast MRI was recommended for women who

  • have a BRCA1 or BRCA2 mutation, indicative of a strong inherited risk of breast cancer;
  • have a first-degree relative with a BRCA1 or BRCA2 mutation but have not been tested for the mutation; or
  • received chest radiation -- to treat Hodgkin's disease or other cancers, for example -- between 10 and 30 years of age.

The guidelines state that there is at present insufficient evidence to recommend the use of routine MRI screening in women with other risk factors, including a personal history of breast cancer, a history of carcinoma in situ or atypical hyperplasia, or dense breast tissue that makes the interpretation of mammograms difficult. Women with these risk factors may want to discuss their screening program with their physician to better determine whether MRI may be useful in their own case.

It is important to note that MRI should not be considered a substitute for regular mammography, and mammography is the only screening tool for which a reduction in mortality (death rate) from breast cancer has been proved.

Breast self-examination and breast examinations by your doctor

Both the American Cancer Society and the USPSTF do not call for regular self-examination of the breasts in their guidelines. The ACS states that breast self-exam is optional, while the USPSTF states that doctors should not teach women to do breast self-examination. The ACS further recommends a clinical breast exam (CBE) by a health-care professional about every three years for women in their 20s and 30s and every year for women 40 years of age and over.

The following technique describes the procedure for breast self-examination for women who choose this option.

 

How to perform a breast self-examination

Breast self-examination is best performed when the hormone stimulation of the breast is the least. This typically occurs seven to 10 days after the start of a menstrual cycle (or three days after a period). At that point, the fluid retention of the breast and the cellular proliferation are the lowest. An ideal setting in which to conduct the exam is the bath or shower.

  1. With the hand and breast wet with soap, begin with the fingers flat together and work sweeping from the outer part to the center of the breast. It helps to mentally divide the area to be examined into quadrants and work around the quadrants sequentially. The upper outer quadrant should be mentally extended into the armpit along the chest wall. This area should be carefully included in the examination.
  2. The process is repeated in the same sequence with the fingers moving in a fluttering motion. These different motions, flat fingered stroking and fluttering fingertips, allow detection of somewhat different tissue abnormalities.
  3. This examination by feeling the breast (palpation) should be accompanied by a brief visual exam. With the arms at the side looking in a mirror, note the symmetry. Then raise the arms slowly overhead, checking for any areas of pulling in of the skin or visible lumps or distortion.

The entire examination process can be done in a few minutes' time.

Any detected change from the usual appearance or feel should be reported to the doctor. If there are any areas of concern that can be felt (palpable) and the mammogram does not show an abnormality, then a specialized breast ultrasound can be extremely helpful.

For women who are concerned that they have lumpy breasts and can't make any sense of their exam, it is best to do a careful exam after a physician's examination. This serves as the baseline for normal "lumps." The aim is to maintain an appropriate degree of alertness without creating continuous anxiety.

What is the risk of radiation with repeated mammography screening over the years?

With modern mammography equipment, the amount of radiation exposure is extremely small. Although there is no level of radiation without some theoretical risk, there is no evidence of increased breast cancer risks from mammography performed in the recommended manner. Furthermore, the benefits of early detection far outweigh these theoretical concerns.

Are there any controversies in the area of breast cancer screening?

The screening guidelines described above from the ACS and the USPSTF differ in their recommendations for when screening mammograms should begin. The ACS recommends yearly mammograms starting at age 40, while the USPSTF recommends mammograms every two years beginning at age 50.

There is further debate over the issue of mammography screening in young women, as discussed previously. There is also the issue of the emotional trauma of receiving false positive mammogram reports (mammograms that show abnormal changes in the breast that subsequently prove to be noncancerous). However, after evaluating women who have gone through this process, there does not appear to be a lasting problem.

There is no agreement about the practice or importance of breast self-examination, which in the past was recommended for all women. The ACS now states that this practice is optional, while the USPSTF recommends that the practice not be taught to patients.

There is also no standard recommendation for screening women with high risks such as women with a positive family history of breast cancer or those who have inherited defective BRCA1 or BRCA2 genes. After careful counseling, some patients with BRCA mutations may eventually elect to undergo preventive mastectomy to reduce the risks of breast cancer. For those patients who elect monitoring, it is generally accepted that more frequent breast clinical examinations and perhaps, periodically, more involved imaging (ultrasound and MRI) are the minimum measures.

How helpful are BRCA1 and BRCA2 genetic tests in identifying women at risk?

In special circumstances, genetic tests can be very helpful both in identifying exceptionally high-risk patients and reducing the level of concern for others. We also now know that the presence of one of these genetic defects does not cause cancer in every patient. The cancers that do occur may also behave somewhat differently than non-BRCA-associated tumors. There is some evidence that they have a better outcome.

Before genetic tests are conducted, individuals being tested must have thorough counseling. A clear understanding of the limitations of the tests and the problems they may pose must precede the testing. The patient must know the meaning of the possible results, whichever way they may turn out, before testing. They should also have settled on a plan for each possible outcome of the test results. Often, the best way to evaluate a potential genetic risk is to test a relative who has already been diagnosed with breast cancer. If the relative's genetic testing (which must cover a large number of possible mutations) proves negative, then there is no need to perform genetic testing on the concerned individual. But the concerned individual should still undergo close monitoring with breast examinations and mammograms. If the test is positive on the relative, then that specific mutation is the only one that needs to be checked in the concerned individual and the other family members.

What is the link between estrogen and breast cancer?

Estrogen is a female hormone that is produced by the ovaries. During the reproductive years, a woman's body is exposed to high levels of estrogen. After menopause, the production of estrogen by the ovaries decreases. Estrogen is sometimes prescribed to treat some of the problems often associated with menopause, such as hot flashes, night sweats, sleeplessness, and vaginal dryness. Estrogen has the additional benefit of prevention of bone thinning (osteoporosis). However, results from a large clinical trial of postmenopausal women receiving hormone therapy (HT) released in 2002 showed that the overall risks of estrogen plus progestin therapy outweighed the benefits of hormone therapy. Combined hormone therapy with estrogen and progestin was shown to increase the risk of heart disease, stroke, and blood clots.

High levels of estrogen over long periods also increase the risk of developing breast and uterine cancers. Estrogen stimulates the cells of the breast and the uterine lining to grow and divide. Breast cells that are actively dividing are believed to have a greater chance of DNA damage as well as a higher number of cells that already have DNA damage. A higher number of cells with DNA damage elevate the risk of cancer development.

Women who have an early onset of their menstrual period (or menses) and late menopause are more likely to develop breast cancer than women with late menses onset and early menopause. This difference is believed to be attributable to the longer period of estrogen exposure in the first group.

What are breast cancer prevention treatments?

Selective estrogen receptor modulator (SERM) and its effect of estrogen on breast cell growth

A selective estrogen receptor modulator (SERM) is a chemical that is designed to act like estrogen in certain tissue such as the bones and not like estrogen in other tissue such as the breast. The use of SERMs takes advantage of the benefits of estrogen while trying to avoid the risks associated with estrogen. Two SERMs, tamoxifen (Nolvadex) and raloxifene (Evista), have been used as preventive treatment. The advantages and disadvantages of each are discussed in more detail below.

Tamoxifen

Tamoxifen is the first SERM to receive approval by the United States Food and Drug Administration in the treatment of breast cancer. Some breast cancer cells are "estrogen sensitive," meaning they possess so-called estrogen receptors and need estrogen to grow and divide. But estrogen has to bind to the receptors of these cancer cells in order to stimulate them. Binding of estrogen to the receptors is analogous to fitting a key into a lock. Tamoxifen blocks the action of estrogen on the cancer cells by occupying the receptors (the locks), thus preventing estrogen (the keys) from fitting into the receptors. Blocking estrogen from the estrogen-sensitive cancer cells stops the growth and multiplication of these cells. Tamoxifen (in higher than usual doses) may also possess other properties that cause the death of breast cancer cells that are not estrogen sensitive.

Tamoxifen has been used to treat both advanced and early stage breast cancers. This drug has also proven valuable to women who have had cancer in one breast in reducing the chances of developing cancer in the second breast.

Even though tamoxifen behaves like an anti-estrogen agent in breast tissue, it acts like a weak estrogen in the bones. Thus, tamoxifen may have some benefit in preventing osteoporosis fractures in postmenopausal women.

Tamoxifen also decreases cysts and lumps in the breasts, especially among younger women. Fewer cysts and lumps make early detection by breast examinations and mammograms easier. This use of the drug would only be in extreme situations and is not an approved use.

 

Primary prevention of breast cancer with tamoxifen

The term "primary prevention" means trying to reduce the risks of developing breast cancer in women without a prior history of breast cancer. Tamoxifen not only blocks the action of estrogen on estrogen-sensitive cancer cells, but it also blocks estrogen from acting on cells that are not cancerous. Therefore, by reducing the growth and division of normal breast cells, tamoxifen decreases the population of cells that can develop cancer-causing DNA damage.

In the National Surgical Adjuvant Breast and Bowel Project (NSABP) P-1, more than 13,000 women considered at high risk for developing breast cancer were given either tamoxifen or a placebo for five years. The women receiving tamoxifen developed 49% fewer breast cancers than women receiving the placebo. A further study, the International Breast Cancer Intervention Study (IBIS-I) in Europe, also confirmed a reduction in the rate of breast cancer development in high-risk women.

The United States Food and Drug Administration (FDA) has approved the use of tamoxifen for primary prevention in women at high risk for developing breast cancer. There is no evidence to suggest that tamoxifen can reduce breast cancer incidence in women considered to have a normal risk for the development of breast cancer.

Risks and side effects of tamoxifen

The risk of tamoxifen is the development of uterine cancer. Although the overall risk of developing uterine cancer is small (probably less than 1%), in the NSABP-P1 trial, more women on tamoxifen developed uterine cancer than women taking the placebo.

Additionally, women over 50 years of age on tamoxifen have a slightly heightened chance of developing blood clots in the veins of the lower extremities. These blood clots can occasionally break off and travel to cause blockage of blood vessels in the lungs (a process called pulmonary embolism). Symptoms of pulmonary embolism include shortness of breath, chest pain, and sometimes shock. Some studies have also reported an increased risk of stroke in patients taking tamoxifen.

The other side effects of tamoxifen include weight gain, hot flashes, irregular periods, vaginal dryness or discharge, and a slightly enhanced risk of cataracts.

Many of these side effects also depend on the age group being studied.

Raloxifene

Raloxifene is the second SERM to be approved by the FDA. It has been approved for use in preventing osteoporosis in postmenopausal women. Data suggest that raloxifene, like tamoxifen, can reduce the chance of developing breast cancer in high-risk women. Unlike tamoxifen, raloxifene does not stimulate cells of the uterus and is not believed to increase the risk of uterine cancer.

Studies that examined the effects of both tamoxifen and raloxifene (including the STAR trial, which studied over 19,000 postmenopausal women at high risk for developing breast cancer) showed that both drugs lowered the incidence of breast cancer in a similar manner. While both tamoxifen and raloxifene increased a woman's risk of blood clots, the observed increase was smaller with raloxifene. Raloxifene was also associated with a lower risk of uterine cancer and hysterectomy for noncancerous reasons than tamoxifen. However, some data suggested that raloxifene might not be as effective in preventing the development of early, noninvasive cancers as tamoxifen.

Data are not available on the effects of raloxifene in premenopausal women, and it is a potential teratogen, meaning that it may cause harm to the developing fetus. Therefore, raloxifene is limited to use by postmenopausal women and not used in women of childbearing age.

Controversies or other concerns about the use of tamoxifen or raloxifene as a primary prevention for patients at high risk

The data from studies of raloxifene and tamoxifen are encouraging. But there are still unresolved issues:

  1. Do women treated with tamoxifen or raloxifene for primary prevention have a higher long-term survival rate than women who received the placebo do?
  2. Does tamoxifen or raloxifene really prevent breast cancer, or do they only suppress the growth of existing breast cancer, thus delaying detection?
  3. If tamoxifen is offered to healthy, young women, what are the long-term side effects? Does breast-cancer reduction translate into better long-term survival and quality of life?
  4. How many years should patients be kept on the medication?

Select groups of high-risk women for whom a preventive medication such as tamoxifen or raloxifene should considered for use as primary prevention.

A specific model has been developed to assist doctors in predicting breast cancer risks for their patients. This model was used in the NSABP tamoxifen trial and is available to help evaluate patients considering this question. Some doctors would consider recommending tamoxifen to perimenopausal (the years around menopause) or raloxifene to postmenopausal patients with several first-degree relatives who have had breast cancer if the patient has had biopsies with abnormal but not yet cancerous cell changes (atypical hyperplasia) or a type of localized breast cancer (lobular carcinoma in situ). This recommendation would be even stronger if the patient has had a hysterectomy.

Studies are also ongoing to determine whether tamoxifen or raloxifene are effective in preventing breast cancer in women with inherited BRCA1 or BRCA2 genes.

Aromatase inhibitors

Other medications, known collectively as aromatase inhibitors, are also used to block the effects of estrogen. Examples of aromatase inhibitors include anastrozole (Arimidex), letrozole (Femara), and exemestane (Aromasin). Their main activity is to inhibit (block) the action of a particular enzyme (aromatase) that creates estrogen from other normally circulating hormones. Tamoxifen and aromatase inhibitors, therefore, act differently and have different side effects. Studies are under way to compare their use as breast cancer preventive drugs together and in sequence.

 

Surgical measures to prevent breast cancer

Preventive or prophylactic mastectomy is the surgical removal of one or both breasts in women who have moderate to high risk of developing breast cancer. Studies have shown that this technique reduces a woman's chance of developing breast cancer by up to 90%. Since small amounts of breast tissue can remain on the chest wall, in the underarm, or even in the abdomen following a mastectomy, it is impossible to completely prevent development of breast cancer by prophylactic mastectomy. Women often choose to have surgical reconstruction of the breasts at the time of surgery.

It is very important for a woman considering preventive mastectomy to have a frank discussion with her physician concerning her cancer risk, other available treatments, and the potential complications and implications of the surgery before making a decision.

Are there other breast cancer prevention measures?

Free radicals

Free radicals are electrically charged chemicals that can attack and damage proteins and DNA, thereby altering genetic information. If enough damage occurs to the DNA segments of a cell that controls cell division and growth, cancer can develop from that single cell.

Free radicals can be formed by the normal metabolic activity in the body. The cells in the body chemically transform nutrients (sugars, fats, and proteins) into substances that the muscles, brain, and other organs can use as energy. Such transformations involve many chemical reactions and multiple energy transfers between chemicals. During this metabolic process, free radicals can be formed.

Free radicals also occur when cells are exposed to radiation. The body is regularly exposed to low levels of radiation in the atmosphere. The body also receives radiation during mammography and other X-ray tests. Theoretically, these low levels of radiation can lead to the formation of free radicals. (The amount of radiation in the atmosphere and in carefully performed X-rays tests is generally considered safe.)

Fortunately, a healthy body is well equipped to destroy free radicals and prevent cells with damaged DNA from becoming cancerous. The body is capable of quickly recognizing and destroying free radicals. For example, the body has an enzyme called superoxide dismutase that regularly cleans up free radicals and prevents them from damaging cells and proteins. The body can repair DNA damage caused by radiation or free radicals. The body is also capable of quickly destroying cells that have irreparable DNA damage to prevent them from turning cancerous. The immune system also seeks out cells with DNA damage and destroys them.

However, an overload of free radicals can cause damage to the system that destroys free radicals and damage to DNA repair systems. This damage or a weakened immune system can contribute to cancer development.

Antioxidants

Antioxidants are chemicals that prevent a type of chemical reaction called oxidation. Oxidation is a major source of free radical formation. Antioxidants also mop up the free radicals that are formed. Superoxide dismutase is one example of an enzyme that acts like an antioxidant. Other naturally occurring antioxidants include beta carotene, vitamin E, and vitamin C. Fruits and vegetables are safe and rich sources of antioxidants. A somewhat controversial substance is caffeine. In several laboratory studies, caffeine acted like an antioxidant that cleans up free radicals. At present, there is no evidence that caffeine or coffee affects breast cancer risk. Also, some caffeine-containing substances, such as tea, have apparently been shown to decrease cancer risks.

The relationship between meats, fats, and breast cancer

Early epidemiological studies suggested that high-fat diets might be associated with increased risks of breast cancer. But this relationship has not been confirmed, and it is clear that some fats may be protective rather than harmful. There are, however, some theoretical concerns about eating overcooked meats and fats.

From person to person, there are many "normal" variations in individual metabolic systems (sequences of enzymes and proteins). Some of these variations lead to different risks from potential cancer-causing exposures. Examples of systems with the potential for individual variation in management of these potential toxins are:

  • NAT-2 is a well-studied enzyme in the body that converts substances from overcooked meats into active agents that can damage DNA. There are two forms of NAT-2 enzyme: fast or slow acting. When an individual with the fast-acting NAT-2 enzyme consumes overcooked meat, the agents that damage DNA can accumulate rapidly.
  • Another enzyme in the body is lipoxygenase. Fats in the diet are converted into fatty acids, linoleic acid, and arachidonic acid. Lipoxygenase further converts linoleic and arachidonic acids into chemicals that are potent stimulators of cell growth. These chemicals not only increase the risk of developing cancers, they also promote the growth of cancers and encourage cancer cells to metastasize.
  • Even though we cannot change our individual NAT-2 or lipoxygenase enzyme activities, we can reduce the consumption of fats and overcooked meats.
  • There also appear to be certain types of fats such as omega-3 fatty acids that protect against the formation and activation of injurious fatty products. These are found in higher concentration in many fish. There are both epidemiological and laboratory studies which show these benefits.

Diet and lifestyle measures to reduce breast cancer risk

Theoretically, there are dietary and lifestyle measures that can decrease free-radical formation and reduce the risk of developing breast and other types of cancer. These measures include

  • diets rich in vegetables and fruits;
  • diets low in fats, and red and overcooked meats;

     

  • reasonable intake of anti-oxidants such as vitamins E and C;

     

  • regular exercise and weight reduction; and
  • avoiding cigarettes.

Evidence that these measures reduce the chances of developing breast cancer is largely based on epidemiological data. Epidemiological evidence is derived from comparing two large populations with similar characteristics that have different diets or levels of exercise. Epidemiological evidence can only be suggestive, not conclusive. In fact, concrete proof that diet and exercise actually reduce the risk of developing breast cancer will be difficult to attain.

When firm scientific data is lacking and is unlikely to be available for the foreseeable future, the doctor has to weigh the risks of his/her recommendations against the potential benefits. Long-term risk and benefit considerations are especially important in advising young, healthy women about preventing a disease that they may or may not develop.

In the case of diets low in fat and overcooked meats, diets high in vegetables and fruits, avoiding smoking, and regular exercise, there is enough known benefit and very little known risk, which makes it easy for doctors to recommend them to their patients.

Doctors are also comfortable with recommending one multivitamin a day. However, there is no clinical evidence that taking megadoses of vitamins are of any benefit. Megadoses of certain vitamins can have adverse side effects.

Exercise

There is epidemiological data which show that women who exercise regularly have a lower incidence of breast cancer than women who do not exercise. The reason for such a benefit is unknown, but it may be related to the fact that obese individuals have higher levels of estrogen in the body than nonobese people. The higher levels of estrogen may increase the risk of breast cancer in obese women.

Conclusion

There are two important aspects in breast cancer prevention: early detection and risk reduction. Screening may identify early noninvasive cancers and allow treatment before they become invasive or identify invasive cancers at an early treatable stage. But screening does not, per se, prevent cancer. Breast cancer prevention really must be understood as risk reduction. In extremely high-risk patients, such as those who have BRCA mutations, risk reduction may involve prophylactic surgical removal of the breasts and ovaries. For the average patient, lifestyle modifications (diet, exercise, weight loss, etc.) may be easily recommended and have many other benefits. For patients who have an increased risk based on other factors, the use of hormone-blocking agents, in addition to the usual lifestyle recommendations, may also be considered.

Breast Cancer: Checking for Cancer Recurrence

 

View Breast Cancer Slideshow Pictures

 

 

Breast Cancer Slideshow Pictures Breast Cancer Slideshow Pictures
Take the Breast Cancer Quiz Take the Breast Cancer Quiz
Disease Prevention in Women Slideshow Pictures Disease Prevention in Women Slideshow Pictures
  • Introduction to breast cancer recurrence
  • How do I know there is a recurrence of breast cancer?
  • What factors determine the likelihood of a cancer recurrence?
  • How will my prognosis affect my treatment?
  • How would a recurrence be treated?
  • Find a local Oncologist in your town

Introduction to Breast Cancer Recurrence

Breast cancer can recur at any time, but most recurrences occur in the first three to five years after initial treatment. Breast cancer can come back as a local recurrence (in the treated breast or near the mastectomy scar) or as a distant recurrence somewhere else in the body. The most common sites of recurrence include the lymph nodes, the bones, liver, or lungs.

How Do I Know There Is A Recurrence?

If you've been treated for breast cancer, you should continue to practice breast self-examination, checking both the treated area and your other breast each month. You should report any changes to your doctor right away. Breast changes that might indicate a recurrence include:

  • An area that is distinctly different from any other area on either breast
  • Lump or thickening in or near the breast or in the underarm that persists through the menstrual cycle
  • A change in the size, shape, or contour of the breast
  • A mass or lump, which may feel as small as a pea
  • A marble-like area under the skin
  • A change in the feel or appearance of the skin on the breast or nipple, including skin that is dimpled, puckered, scaly, or inflamed (red, warm or swollen)
  • Bloody or clear fluid discharge from the nipples
  • Redness of the skin on the breast or nipple

In addition to performing monthly breast self-exams, keep your scheduled follow-up appointments with your healthcare provider. During these appointments, your healthcare provider will perform a breast exam, order lab or imaging tests as needed, and ask you about any symptoms you might have. Initially, these follow-up appointments may be scheduled every three to four months. The longer you are cancer-free, the less often you will need to see your healthcare provider. Continue to follow your healthcare provider's recommendations on screening mammograms (usually recommended once a year).

What Factors Determine The Likelihood Of A Recurrence?

Prognostic indicators are characteristics of a patient and her tumor that may help a physician predict a cancer recurrence. These are some common indicators:

  • Lymph node involvement. Women who have lymph node involvement are more likely to have a recurrence.
  • Tumor size. In general, the larger the tumor, the greater the chance of recurrence.
  • Hormone receptors. About two-thirds of all breast cancers contain significant levels of estrogen receptors, which means the tumors are estrogen receptor positive (ER+). ER-positive tumors tend to grow less aggressively and may respond favorably to treatment with hormones.
  • Histologic grade. This term refers to how much the tumor cells resemble normal cells when viewed under the microscope; the grading scale is 1 to 4. Grade 4 tumors contain very abnormal and rapidly growing cancer cells. The higher the histologic grade, the greater chance of recurrence.
  • Nuclear grade. This is the rate at which cancer cells in the tumor divide to form more cells. Cancer cells with a high nuclear grade (also called proliferative capacity) are usually more aggressive (faster growing).
  • Oncogene expression. An oncogene is a gene that causes or promotes cancerous changes within the cell. Tumors that contain certain oncogenes may increase a patient's chance of recurrence.

How Will My Prognosis Affect My Treatment?

Following surgery or radiation, your treatment team will determine the likelihood that the cancer will recur outside the breast. This team usually includes a medical oncologist, a specialist trained in using medicines to treat breast cancer. The medical oncologist, who works with your surgeon, may advise the use of tamoxifen (tamoxifen citrate, Nolvadex) or possibly chemotherapy. These treatments are used in addition to, but not in place of, local breast cancer treatment with surgery and/or radiation therapy.

How Would A Recurrence Be Treated?

The type of treatment for local breast cancer recurrences depends on your initial treatment. If you had a lumpectomy, local recurrence is usually treated with mastectomy, since radiation therapy cannot be delivered twice to the same area. If the initial treatment was mastectomy, recurrence near the mastectomy site is treated by removing the tumor whenever possible, usually followed by radiation therapy.

In either case, hormone therapy and/or chemotherapy may be used after surgery and/or radiation therapy. If breast cancer is found in the other breast, it may be a new tumor unrelated to the first breast cancer. Treatment would include a lumpectomy or mastectomy and possibly systemic therapy (chemotherapy and/or hormonal therapy).

Women with distant recurrence involving organs such as the bones, lungs, brain, or other organs are treated with systemic therapy. Radiation therapy or surgery may also be recommended to relieve certain symptoms.

Immunotherapy with trastuzumab (Herceptin) alone or with chemotherapy may be recommended for women whose cancer cells have high levels of the HER2/neu protein. Immunotherapy is generally started after hormonal or chemotherapy are no longer effective.

Breast Augmentation

 

View the Antiaging Tips & Secrets Slideshow Pictures

 

Antiaging Tips & Secrets Slideshow Pictures Antiaging Tips & Secrets Slideshow Pictures
Cosmetic Surgery Slideshow Pictures Cosmetic Surgery Slideshow Pictures
Take the Quiz: Skin - An Incredible Organ Take the Quiz: Skin - An Incredible Organ

 

  • What is breast augmentation?
  • How is the incision made?
  • What are smooth and textured implants?
  • What are the options for implant size?
  • What are risks and complications of breast augmentation?
  • How long do implants last?
  • Breast Augmentation At A Glance
  • Find a local Plastic Surgeon in your town

What is breast augmentation?

Augmentation of the breast consists of insertion of a silicone bag (prosthesis) under the breast (submammary) or under the breast and chest muscle (subpectoral) and then filling the bag with saline (salt water). This prosthesis expands the breast area to give a fuller breast (increased cup size), give a better contour, and give more cleavage.

How is the incision made?

The incision (cut) may be placed at various locations such as: under the breast at the breast fold; periareolar which is at the edge of the areola (brown area consisting of nipple and areola); within the areola; in the armpit (axillary); or in the umbilical area.

The thinnest scar is usually in the areola. The umbilical incision approach is used with an endoscope (tube with a light for visualization and placement of the breast implant).

What are smooth and textured implants?

The smooth surface implant requires a large pocket and is associated with a 10% incidence of capsule contracture (tightening of the scar around the implant causing firmness or hardness). The smooth implant has only an occasional occurrence of rippling or wrinkling which gives the overlying skin a wavy appearance.

A textured (roughened surface) implant is associated with a 3% incidence of capsule contracture but has a 7-9% occurrence of rippling.

What are the choices of implant positions? The easiest surgical placement of the implant is under the breast tissue (submammary).

A slightly more difficult surgical placement is under the chest muscle (submuscular or subpectoral) but this position is associated with a lower incidence of capsule contracture and slightly less occurrence of rippling. There is more pain postoperatively than with a submammary placement.

What are the options for implant size?

The ultimate size of the breast is mainly a personal decision by the patient. Cup size is an inexact estimate of the final size since cup sizes vary with the bra manufacturer and how tight or loose the patient wears her bra as well as how much breast tissue is already present. Describing the preferred cup size does aid the surgeon, but it also helps to look at pictures or photos to show the physician the desired final look.

The most accurate method of estimating the implant size (in ounces) is to fill a plastic bag with measured amounts of water and place in a bra with the patient's estimated cup size. One can see with the bra on and covered by a sweater what the final result will approximate.

Patients most often comment that, "I wish I had gone larger," although there is a rare patient who feels she is too large.

What are risks and complications of breast augmentation?

1. Infection

Although infection is rare (1-3%) it can be a very distressing problem. Signs of infection are fever, redness, swelling, and discomfort. If the infection does not respond rapidly to antibiotic treatment, the implant must be removed and the implant can be replaced three (3) months after the wound is completely healed.

2. Bleeding

If bleeding occurs into the implant pocket after surgery, the implant must be surgically removed, the bleeding controlled, the wound washed out, and the implant replaced. Signs of bleeding include marked swelling, increasing pain, and bruising.

3. Capsule contracture

Hardening of the breast with distortion and sometime pain may require surgical incision of the fibrous scar capsule around the implant (capsulotomy) or partial or total removal of the scar capsule (capsulectomy). The implant can be immediately placed back in the new packet. About 30-35% of patients have recurrent capsule contracture.

Other means of treating the contracture is replacement of a smooth implant with a textured one or placing the implant in a new pocket either under the breast or under the muscle.

If capsule contracture occurs multiple times, the patient may decide to remove the implants permanently.

4. Asymmetry

Sometimes the implant will slip out of the position in which it was initially placed and appear too high, too low, or to one side. Most of the time this requires surgical repair.

5. Problems with Mammography

The implant will block some areas of the breast from being visualized on mammography. This is usually less if the implant is placed under the muscle.

Because breast implants might affect the clarity of the mammogram, patients who have multiple close family members with breast cancer probably should not have breast implants.

6. Autoimmune Disease

With all the confusion in the newspaper, magazines and on the T.V. or radio, there has been a fear that silicone implants may cause autoimmune disease. At this time there is no scientific evidence that silicone causes autoimmune disease.

7. Cancer

There is no evidence that silicone implants cause cancer.

8. Calcifications

Implants that have been in a patient for many years may cause calcifications in the scar capsule around the implant. These calcifications can almost always be distinguished from the calcifications which may indicate breast cancer.

9. Deflation

An implant may leak from weakness in the patch or valve area, a hole from incomplete inflation, or other factors. The more modern saline implants have been estimated to leak in 1-5% of cases.

How long do implants last?

It is not known how long implants will last. In the body, the wall of the implant may weaken and become disrupted. This is more likely when there is an impact injury, such as from the steering wheel of a car or fall. The implant may or may not last a lifetime and depends upon the manufacturing process and other, as yet, unknown factors.

FINAL RESULTS

Most patients are extremely happy with breast augmentation. There is a certain amount of increased self esteem and self confidence which may result.

The patient who desires augmentation should not be influenced by family or friends as to whether or not the surgery should be performed and what size is most desirable. This is a very personal matter to most patients and satisfaction is best when the patient makes the decisions.

Breast Augmentation At A Glance
  • Smooth implants have less chance of rippling (waviness of skin) than textured (roughened) implants.
  • Smooth implants have a higher incidence of capsule contracture (hardening of the implant) than textured implants.
  • Implants placed under the muscle result in more pain postoperatively but have a lower incidence of capsule contracture and rippling.
  • Infection and bleeding are rare but must be treated promptly.
  • A certain number of patients may need another surgery to correct a problem.
  • The aesthetic results of breast implants are best appreciated by the patient who feels the need for larger breasts.

How long do implants last?

It is not known how long implants will last. In the body, the wall of the implant may weaken and become disrupted. This is more likely when there is an impact injury, such as from the steering wheel of a car or fall. The implant may or may not last a lifetime and depends upon the manufacturing process and other, as yet, unknown factors.

FINAL RESULTS

Most patients are extremely happy with breast augmentation. There is a certain amount of increased self esteem and self confidence which may result.

The patient who desires augmentation should not be influenced by family or friends as to whether or not the surgery should be performed and what size is most desirable. This is a very personal matter to most patients and satisfaction is best when the patient makes the decisions.

Breast Augmentation At A Glance
  • Smooth implants have less chance of rippling (waviness of skin) than textured (roughened) implants.
  • Smooth implants have a higher incidence of capsule contracture (hardening of the implant) than textured implants.
  • Implants placed under the muscle result in more pain postoperatively but have a lower incidence of capsule contracture and rippling.
  • Infection and bleeding are rare but must be treated promptly.
  • A certain number of patients may need another surgery to correct a problem.
  • The aesthetic results of breast implants are best appreciated by the patient who feels the need for larger breasts.

Breast Lumps In Women

 

 

 

 

 

What's Causing Your Pelvic Pain Slideshow View What's Causing Your Pelvic Pain Slideshow Pictures
Disease Prevention in Women Slideshow Pictures Disease Prevention in Women Slideshow Pictures
Take the Quiz: Puberty In Girls Take the Quiz: Puberty In Girls

 

Medical Author:

 

Medical Editor:

 

  • What are causes of breast lumps?
  • Infections that cause breast lumps
  • Injuries that cause breast lumps
  • Non-cancerous growths that cause breast lumps
  • Symptoms of breast cancer
  • What determines breast cancer risk?
  • How are breast lumps evaluated?
  • How can a woman be certain that a lump is not cancer?
  • How are breast lumps treated?
  • Breast Lumps At A Glance
  • Patient Discussions: Breast Lumps
  • Patient Discussions: Breast Lumps In Women - How Was Diagnosis Established
  • Find a local Obstetrician-Gynecologist in your town

What are causes of breast lumps?

There are many causes of breast lumps. Some of these causes are harmless, while others can be painful and/or dangerous. Causes of breast lumps include infections, injuries, non-cancerous growths, and cancer.

Breast cancer is the second leading cause of cancer-related deaths in women in the United States. Currently, death rates from breast cancer are declining. The decline in death rates may be due to a combination of earlier detection and better screening as well as improved treatments. While most breast lumps are harmless (benign), every breast lump should be evaluated by a doctor to exclude or establish a diagnosis of cancer.

Picture of the anatomy of the breast
Picture of the anatomy of the breast

Infections that cause breast lumps

Infections of the breast are known as mastitis. Mastitis is especially common in women who are breastfeeding a baby (lactating). When the skin of the nipple (areola) is injured or cracked, such as occurs with nursing, bacteria can enter the wound and cause infections. In a breastfeeding woman, a hard area commonly thought of a "clogged milk duct" can form. Sometimes, certain treatments (see below) can prevent the painful, hard area from developing into an actual breast infection (mastitis). Infections can either be a deep pocket of pus, in which the infection looks like it is growing down into the breast (an abscess), or a wider area of skin redness that spreads out (cellulitis). Body piercing in the nipple area increases the risk of breast infections that may be particularly difficult to treat.

Injuries that cause breast lumps

If a breast is injured by trauma, tiny blood vessels can rupture to cause an area of localized bleeding (hematoma that can be felt as a lump. Trauma to the breast can damage the fat cells in the breast tissue, a condition called fat necrosis. The injury can also form a lump in the breast. These types of lumps that follow a significant trauma are not cancerous.

Non-cancerous growths that cause breast lumps

  • Fibroadenomas are benign (not cancerous) growths and are very common. These growths most commonly occur in women 30 to 35 years old. Fibroadenomas are solid, firm tumors that are usually painless or only slightly tender. They sometimes grow quickly in teenagers or during pregnancy.
  • Breast cysts are fluid-filled, tiny sacs within the breast tissue and are benign. They are very common, especially over the age of 35. These cysts often vary in size during the menstrual cycle and may be tender.
  • Fibrocystic changes are characterized by breasts that are lumpy with many irregularities in the breast that feel almost grainy. Fibrocystic breasts seem to occur because a woman's breasts are extra sensitive to fluctuating hormone levels. Women with fibrocystic changes may have pain and/or lumps.

What are the symptoms of breast cancer?

The symptoms of breast cancer include painless breast lumps, nipple discharge, and inflammation of the skin of the breast.

Breast cancer usually causes no pain in the breast. Although women often worry about breast pain, most women with breast pain do not have breast cancer. Only about 6% of women with breast cancer have breast pain as their first sign of cancer.

Nipple discharge that occurs without the nipple being touched can be caused by benign (non-cancerous) growths. Examples of these growths are intraductal papillomas (non-cancerous growths that protrude into the milk ducts) and dilated areas of milk ducts (ductal ectasia). Nipple discharge can also be caused by cancer of the breast tissue. Because nipple discharge can be a sign of cancer, it needs to be evaluated by a doctor.

Skin changes on the breast, including redness and warmth, can sometimes be a sign of breast cancer. A form of breast cancer that commonly causes these signs of inflammation is Paget's disease of the breast. Most inflammation or rashes on the breast are not due to cancer. They may be caused by benign problems such as nipple eczema or a fungus infection. Still, any breast rashes should be evaluated by a doctor. Areas that are especially scaly and red, particularly if they are persistent, or if there is also nipple discharge, are often sampled (biopsied) to rule out cancer.


What determines breast cancer risk?

The chances that a particular breast lump could be cancerous depends on many factors, including a woman's past medical history, physical examination, and mammogram and ultrasound results. Some of the most important risk factors are outlined below. For more information on risk factors and prevention of breast cancer, read the article on Breast Cancer Prevention.

History

Age is the biggest risk factor for breast cancer. In other words, most cases of breast cancer occur due to the fact that the risk of breast cancer increases with age. Most women with breast cancer do not have a history of breast cancer. A woman who has had a prior breast cancer or who has a family history of breast cancer is certainly at risk herself, especially if multiple family members are involved, the cases occurred at a young age, or if the cancer involved both breasts of a single family member.

Women who have received radiation therapy to the chest area as treatment for another cancer have a significantly increased risk for breast cancer.

Genetic factors

About 5% to 10% of breast cancer cases have been shown to be related to inherited gene changes (mutations). The most common mutations are those of the BRCA1 and BRCA2 genes, although other genetic mutations may also lead to breast cancers. For more, please read the Genetic Testing for Breast Cancer article.

Abnormal findings on previous breast biopsies

The finding of certain conditions on previous breast biopsies can also increase the risk for developing breast cancer. Pre-cancerous growths and growths noted on a breast biopsy that represent an increased risk for the development of breast cancer include the following:

  • Ductal carcinoma-in-situ (DCIS) is an uncontrolled growth of cells that has not spread beyond the milk duct where it is located. DCIS consists of cancer cells that have not invaded other tissues. Therefore, DCIS is an early stage of breast cancer and is the most common type of noninvasive breast cancer. DCIS is not life-threatening, but must be treated. Women with DCIS have an increased risk for developing a recurrence of the cancer or for development of a new cancer in either breast.
  • Lobular carcinoma-in-situ (LCIS) is considered to be a condition in which abnormal cells are confined to the lobules in the breast (the glands that produce milk). Unlike DCIS, LCIS is not considered to have a high probability of becoming a cancer, but it is a sign of risk for that breast or the opposite breast for developing a cancer. Therefore, women with LCIS have a greater chance of developing breast cancer in either breast.
  • Proliferative disease of the breast is a benign condition, but it can be a signal that breast cancer may develop in the future. Ductal hyperplasia (the excessive growth of normal cells within the breast ducts) and atypical hyperplasia (overgrowth of abnormal cells in the ducts or lobules that is not serious or extensive enough to qualify as DCIS or LCIS) are examples of conditions that increase the overall risk for developing breast cancer. Not surprisingly, women with atypical hyperplasia have a higher risk than do those with usual ductal hyperplasia (without atypia, or abnormal cells).

Women with DCIS, LCIS, atypical hyperplasia, or proliferative disease are at even higher risk of developing breast cancer if they have a history of breast cancer in the family.

How are breast lumps evaluated?

Physical Examination

A manual examination of the breast is an important screening method for detecting cancer and is the first step in the evaluation of a breast lump. Unfortunately, the manual examination of the breast is not perfect. However, if a mass can be felt manually, it is important to estimate the location of the mass so that the mammogram and/or other diagnostic examinations can focus on the particular area. A doctor also inspects any suspicious skin changes that may be a sign of breast cancer. Since the manual examination can miss breast cancer, mammography is also important as a screening tool.

Mammogram

Women with a breast lump need to have a mammogram of both breasts. A mammogram is estimated to be able to detect about 90% of breast cancers. This means that about 10% of breast cancers are missed by mammography. Therefore, if a woman or her physician feels a lump and the mammogram is normal, further studies or biopsies are carried out to rule out cancer. Sometimes, a certain pattern of calcium deposits appears on the mammogram that makes the doctor suspicious of cancer. In these cases, it is often recommended that a biopsy be taken that is guided by a mammography technician to be sure the correct area is sampled.

Ultrasound

Ultrasound is useful in the evaluation of breast lumps. It can distinguish between a cyst (such as a benign cyst, which is filled with fluid) and a solid lump (which may or may not be cancerous). The first step in the evaluation of a breast lump is to determine whether it is a cyst or solid mass, and this is what an ultrasound can do best. Especially in young women, in whom a benign cyst may be suspected, if the woman's ultrasound confirms a typical cyst, she may not require any procedures or biopsies. If it is unclear on the ultrasound whether the lump is completely a cyst, a further evaluation is usually recommended.

MRI

Magnetic resonance imaging (MRI) is becoming more widely used in the evaluation of breast lumps. MRI is a special radiology technique designed to image internal structures of the body using magnetism, radio waves, and a computer to produce the images of body structures. Cancers require a greater blood supply than non-cancerous growths, and the images obtained from an MRI may help determine whether a particular area is cancerous because the MRI shows greater contrast in those areas with an increased blood supply. In most cases, MRI is performed if results of mammography and ultrasound evaluations are not conclusive.

MRI also has limitations. For example, MRI cannot detect the presence of calcium deposits, which can be identified by mammography and may be a sign of cancer.

How can a woman be certain that a lump is not cancer?

 

There is only one way to be certain that a lump is not cancerous is to have a tissue sampling (biopsy). There are several ways to do the biopsy.

Sometimes, a fine needle aspiration (FNA) is done. FNA is like a blood test in that a needle is inserted and fluid is withdrawn.  A hollow needle is inserted into the suspicious area, and a core of tissue is removed via the needle. To determine the correct location to sample, the lump can either be felt, or if it cannot be felt, the FNA may be done during an ultrasound or mammogram. FNA of a benign cyst may remove the fluid contents of the cyst and cause the mass to disappear or markedly decrease in size. If no fluid can be aspirated, the mass is solid, and a direct tissue sampling must be performed.

Depending upon the location and size of the breast lump and the medical history, the doctor may also recommend a surgical biopsy (using either local anesthesia or general anesthesia in an operating room) to remove a sample of the lump for analysis.

How are breast lumps treated?

  • A breast infection (mastitis) in a breastfeeding woman is treated with warm compresses and antibiotics.
    • A convenient and effective way of applying heat treatment is to wet some washcloths and put them in the microwave briefly to warm them.
    • Hot showers are also helpful.
    • During heat treatment, the infected area can be massaged.
    • After heat treatment, which helps open up the milk ducts, either nursing the baby or using a breast pump can help relieve the swelling and pain. Contrary to common myth, nursing the baby or using a breast pump is a critical part of the treatment because it helps decrease the chance of the infection progressing.

If the area actually looks red or fails to get better with heat, massage, and nursing, a doctor should be consulted for consideration of antibiotics, because mastitis can progress quickly and develop into a severe infection. Whether a woman is pregnant or not, she needs to see a doctor if the area does not return completely to normal with treatment in order to rule out more unusual types of infections. Cellulitis needs to be treated with antibiotics and frequent follow-ups with the doctor.

  • An abscess of the breast often needs to be drained by a doctor because antibiotics alone cannot adequately treat an abscess.
  • Fibroadenomas are usually removed because they are difficult to distinguish from cancer until they are removed.
  • Breast pain (mastodynia) is a common problem. As long as no mass can be felt by the doctor or patient, and no breast lump is seen on a mammogram or ultrasound, breast pain is often concluded to be a normal condition. It is often thought that this pain is caused by natural hormonal fluctuations. If the discomfort is particularly acute and interferes excessively with a woman's life, oral contraceptives or other medications can be helpful, especially if the pain is worse around the time of the menstrual cycles.
  • Fibrocystic changes do not require medication or surgery. Often, a baseline mammogram is done. Then, no further treatment is needed unless a new lump arises, in which case an evaluation with a mammogram and possibly ultrasound is necessary.
  • Breast cancer requires urgent treatment. Treatment depends on the type of cancer detected, its size, and its location. For more information, read the article on Breast Cancer.
Breast Lumps At A Glance
  • Breast lumps can be caused by infections, injuries, non-cancerous growths, and cancer.
  • Breast cancer usually causes no pain in the breast. The symptoms of breast cancer include painless breast lumps, nipple discharge, and inflammation of the skin of the breast.
  • The chances that a particular breast lump could be cancerous depends on many factors, including past medical history, physical examination, and genetic and other risk factors.
  • There only one way to be certain that a lump is not cancerous is to have a tissue sampling (biopsy). There are several ways to do the biopsy. The treatment of a breast lump depends on its cause.

Breast Reconstruction

 

View Breast Cancer Slideshow Pictures

 

 

Breast Cancer Slideshow Pictures Breast Cancer Slideshow Pictures
Take the Breast Cancer Quiz Take the Breast Cancer Quiz
Disease Prevention in Women Slideshow Pictures Disease Prevention in Women Slideshow Pictures

 

  • Why breast reconstruction?
  • Breast reconstruction: A personal decision
  • Why should I consider breast reconstruction?
  • When should breast reconstruction be performed?
  • What are the different breast reconstruction options?
  • How long does breast reconstruction surgery take?
  • What about recovery from breast reconstruction surgery?
  • What follow-up care is needed after breast reconstruction?
  • Does insurance cover breast reconstruction?
  • Find a local Plastic Surgeon in your town

Why Have Breast Reconstruction?

Reconstructive plastic surgery for breast cancer is performed to replace skin, breast tissue and the nipple removed during a mastectomy. The amount of missing tissue varies with each mastectomy. Factors contributing to the amount of tissue removed include the width, size and location of the original tumor and its proximity to the axilla, where the lymph glands are removed.

The ultimate goal of reconstruction is to restore symmetry between the two breasts.

Choosing Breast Reconstruction

When it comes to breast reconstruction, the choices that are right for one woman won't necessarily be right for another. That's because the long-term prospects of living without a breast or part of a breast affect every woman differently.

After your mastectomy, you may choose to wear external breast forms or pads or make no attempt to alter your appearance. Or you may choose breast reconstruction, using either breast implants or your own tissue.

Continual improvements in plastic surgery techniques offer better results today than ever before and make breast reconstruction an option for most women facing a mastectomy.

The decision, however, is a personal one and often not easy to make.

Why Should I Consider Breast Reconstruction?

Restoring the breast is not considered cosmetic surgery. Operations performed to restore anatomy and symmetry, like breast reconstruction after a mastectomy, are considered reconstructive surgery. Since breast reconstruction after mastectomy is considered part of the treatment of a disease, The Women's Health and Cancer Rights Act mandates that insurers provide coverage for breast reconstruction following mastectomy surgery.

Breast reconstruction not only changes your physical appearance, but has psychological benefits as well. It can help promote a sense of wellness for you and your family

When Should Breast Reconstruction Be Performed?

Timing of reconstructive surgery is based on the patient's desires, medical conditions and cancer treatment. Whenever possible, plastic surgeons encourage women to begin breast reconstruction at the same time they are having their mastectomy. For many women, immediate reconstruction reduces the trauma of having a breast removed as well as the expense and discomfort of two major operations.

It is also possible to do breast reconstruction months or years after a mastectomy. If any chemotherapy or radiation treatments have already been started, reconstruction is usually postponed until those treatments are completed. Your surgical team can help you decide the appropriate timing for reconstruction.

What Are the Different Breast Reconstruction Options?

A variety of breast reconstructive techniques are available that offer cosmetically-appealing results. Multiple factors, such as the patient's goals, medical condition and previous surgery, are considered when choosing between reconstruction using breast implants or flaps of tissue moved from other parts of the body.

One procedure to consider after breast reconstruction is nipple reconstruction. Usually, the nipple and areola (the dark area around the nipple) is removed during mastectomy operation because it is breast tissue and is at risk for cancer recurrence.

Nipple/areola reconstruction is usually done at a later date after reconstruction of the breast is complete. This allows new breast tissue to heal and settle into place so minor adjustments in size and position can be carried out when the nipple and areola are reconstructed.

The nipple/areola reconstruction is typically an outpatient procedure performed under local anesthesia. Tissue for the nipple/areola is often taken from the newly constructed breast. To match the color of the nipple of the other breast and to create the areola, medical tattooing may be done.

The prosthetic nipple is another option that may be temporary or permanent. The plastic surgeon makes a copy of your natural nipple and colors the areola. It can be adhered to the breast using prosthetic glue and re-glued every week or so.

How Long Does Breast Reconstruction Surgery Take?

Preparation for breast reconstruction surgery, including administering anesthesia and any work done to treat the breast cancer may take two hours. Once the plastic surgery team takes over, the reconstructive portion of the procedure is completed within an additional one to six hours.

Following surgery, the patient spends approximately two to three hours in the recovery room before being transferred to a hospital room.

Recovery From Breast Reconstruction Surgery?

For the first few days after surgery, you may experience some discomfort, but you will be given pain medication as needed. Throughout your hospital stay, your recovery will be closely monitored.

Soon after surgery you will be encouraged to move your arms, but not for any forceful activity such as pulling yourself up, getting out of bed or lifting heavy objects. Nurses will help you in and out of bed. The day after surgery, you will normally be able to sit in a chair beside the bed. On the second day, most patients are walking without assistance.

Intravenous fluids will probably continue for a day or two, but you will gradually progress to a regular diet. You may have a urinary catheter in overnight or until you can walk to the bathroom. You will also have drains at the incision sites. If you go home with these drains in place, you will be given instructions on how to care for them.

The length of your hospital stay depends on the type of operation and how your recovery progresses. If you've gotten implants, the average length of hospitalization is one to two days. Flap procedures require a stay of five to six days.

Follow-up Care for Breast Reconstruction

Most women return to normal activities within six weeks after surgery. It may be several weeks before you can do strenuous exercise.

After you go home, you can expect some soreness, swelling and bruising for two to three weeks. You may be asked to apply medications to the suture area or change bandages at home. Your plastic surgeon will advise you about showering, bathing, and wound care.

The mastectomy and breast reconstruction will leave areas of numbness where the surgery was performed. Instead of feeling pain where the tissue was taken, a patient may feel numbness and tightness. In time, some feeling may return in your breasts. Most scars will fade over time.

The shape of your reconstructed breast will gradually improve over the months following the reconstruction.

You'll be asked to return for regular checkups at first. If you have a temporary expander implanted, it will be expanded with saline once a week, on average, until the desired size is obtained (usually within six to 10 office visits).

After breast reconstruction, you should continue to examine your breasts every month. You should continue to have regular screening exams, such as an annual mammogram.

Breast reconstruction has no bearing on cancer recurrence or surveillance, and generally does not interfere with chemotherapy or radiation treatment. A recurrence can still be treated by any of the standard treatment methods, which include surgery, radiation and chemotherapy. In addition, reconstruction rarely, if at all, hides or obscures a local recurrence.

Does Insurance Cover Breast Reconstruction?

Insurance coverage may vary on your personal situation and your insurance carrier. Make sure to speak with someone at your insurance company who knows the policy. In most cases, insurance companies will cover the first breast reconstruction operation, but there are many gray areas in insurance coverage.

For instance, insurance coverage for re-operation procedures or follow-up visits to your doctor may not be covered, but this depends on your carrier's policy. Additionally, if you are seeking breast reconstruction after a mastectomy, there is an Federal law established in 1998 that requires health insurance plans to cover reconstruction associated with a mastectomy.

Breast Reconstruction Without Implants

 

View Breast Cancer Slideshow Pictures

 

 

Breast Cancer Slideshow Pictures Breast Cancer Slideshow Pictures
Take the Breast Cancer Quiz Take the Breast Cancer Quiz
Disease Prevention in Women Slideshow Pictures Disease Prevention in Women Slideshow Pictures

 

  • Where does the tissue come from?
  • What are the benefits of a getting a breast reconstruction without implants?
  • What are the challenges of a flap procedure?
  • What follow-up care is needed after breast reconstruction without implants?
  • What side effects can I expect with breast reconstruction without implants?
  • What complications may I experience after breast reconstruction without implants?
  • Does insurance cover breast reconstruction without implants?
  • Find a local Plastic Surgeon in your town

Women who have had breast cancer and a mastectomy have a number of options in breast reconstruction. If the woman does not want implants, she may choose to have her breast reconstructed using her own body tissue through what is commonly known as a flap procedure. This operation involves moving healthy tissue from one area of the body to the chest using one of two methods, tunneling or free-flap.

  • Tunneling procedure. Using this technique, the transplanted section of tissue remains attached to its original blood supply. The surgeon tunnels the section of tissue under the skin and places it at the reconstruction site.
  • Free-flap procedure. Using this technique, the tissue is disconnected from its original blood supply and then reconnected, using microsurgical techniques, to an existing blood supply in the chest area.

Where Does the Tissue Come From?

While tissue from the back or buttocks may be used, the most common flap procedure uses muscle and skin taken from the abdomen. Using either the tunneling or free-flap technique, muscle, skin and fat are transplanted from the abdomen to the chest area. After the flap of tissue has been transferred, the surgeon shapes it into the contour of a breast.

When the abdominal flap is not an option, the surgeon may use tissue from the back -- and, less often, the buttocks -- in making the new breast.

What Are the Benefits of a Getting a Breast Reconstruction Without Implants?

Using one's own tissue and muscle results in a more natural looking breast that is not vulnerable to the problems that sometimes occur with implants. The shape, feel and contour of a breast reconstructed from a woman's own tissue more closely resemble the characteristics of a natural breast.

Transferring tissue from the abdomen also results in tightening of the stomach resembling a tummy tuck.

What Are the Challenges of These Procedures?

Flap surgery is more involved than implant surgery. And, like all major surgical procedures, it carries the risk of complications, such as bleeding, infection or poor healing. However, these complications, should they occur, can be treated at the hospital.

Flap procedures also leave additional scars on the abdomen, back or buttocks and require a longer hospital stay than implant surgery; on average five to six days versus one or two days for implant recipients. Generally, the additional scars resulting from the flap procedure are well concealed.

Follow-up Care

Most women return to normal activities within six weeks after surgery. It may be several weeks before you can do strenuous exercise. After you go home, you can expect some soreness, swelling and bruising for two to three weeks. You may be asked to apply medications to the suture area or change bandages at home. Your plastic surgeon will advise you about showering, bathing and wound care.

Mastectomy and breast reconstruction surgery will leave areas of numbness where the surgery was performed. Instead of feeling pain where the tissue was taken, a patient may feel numbness and tightness. The same is true of the reconstruction site. In time, some feeling may return in your breasts. Most scars will fade over time.

The shape of your reconstructed breast will gradually improve over the months following the reconstruction.

You'll be asked to return for regular checkups at first. If you have a temporary expander implanted, it will be expanded with saline on average once a week until the desired size is obtained (usually within six to ten office visits).

After breast reconstruction, you should continue to examine your breasts every month. You should continue to have regular screening examinations, such as an annual mammogram.

Breast reconstruction has no bearing on cancer recurrence or surveillance, and generally does not interfere with chemotherapy or radiation treatment. A recurrence can still be treated by any of the standard treatment methods, which include surgery, radiation and chemotherapy. In addition, reconstruction rarely, if at all, hides or obscures a local recurrence.

What Side Effects Can I Expect?

  • Infection at surgery site. As with any surgery, infection is a risk. Typically, an antibiotic will get rid of the infection.
  • Pain and discomfort. Your doctor will advise you on a pain relief medication. The level of pain and discomfort will vary from person to person.
  • Itching. As the wound heals, you will experience itching. No matter how much the area may itch, you should avoid scratching it. Your doctor can recommend an ointment or cream to use at the site to reduce this effect.
  • Numbness or tingling sensations. You may experience these sensations because the nerves have been affected. This side effect can last up to 12 months after surgery.
  • Fluid collection under the wound. Sometimes, one of two types of fluid may collect under the wound: seroma (fluid under flap) or hematoma (blood). This may happen even after your drainage tubes are removed several days after your operation. If the fluid collection is small, it may go away by itself. However, if the fluid collection is large, your surgeon may have to drain the site using a needle and syringe.

After Your Surgery, Contact Your Doctor Immediately Should You Experience Any of the Following:

  • A fever above 100 degrees
  • Fluid leaking from incision sites
  • Any change in color in the breast or scar area

Does Insurance Cover Breast Reconstruction Without Implants?

Reconstructing the breast is not considered a cosmetic procedure. Rather, it's part of the treatment for a disease and the Women's Health and Cancer Rights Act mandates that insurers provide coverage for breast reconstruction.

However, each carrier will vary in its coverage, so it's important that you familiarize yourself with the details of your plan

Breast Self-Exam

 

 

 

 

 

What's Causing Your Pelvic Pain Slideshow View What's Causing Your Pelvic Pain Slideshow Pictures
Disease Prevention in Women Slideshow Pictures Disease Prevention in Women Slideshow Pictures
Take the Quiz: Puberty In Girls Take the Quiz: Puberty In Girls

 

  • Introduction to breast self exam
  • What is a breast self exam?
  • How do I perform a breast self exam?
  • What do I do if I find a lump in my breast?

Introduction To Breast Self Exam

The most effective way to detect breast cancer is by mammography, and a clinical breast exam can complement mammography screening. But medical organizations don't agree on the recommendation for breast self-exams. Doctors should discuss the benefits and limitations of breast self-exams with their patients.

What Is a Breast Self-Exam?

The breast self-exam is a way that you can check your breasts for changes (such as lumps or thickenings). It includes looking at and feeling your breast. Any unusual changes should be reported to your doctor. When breast cancer is detected in its early stages, your chances for surviving the disease are greatly improved.

How Do I Perform A Breast Self-Exam?

To perform a breast self-exam, follow the steps described below.

In the mirror

  1. Stand undressed from the waist up in front of a mirror in a well-lit room. Look at your breasts. Don't be alarmed if they do not look equal in size or shape. Most women's breasts aren't. With your arms relaxed by your sides, look for any changes in size, shape, texture, or skin. Look for skin puckering, dimpling, sores, or discoloration. Inspect your nipples and look for any sores, peeling, or change in the direction of the nipples.
  2. Next, place your hands on your hips and press down firmly to tighten the chest muscles beneath your breasts. Turn from side to side so you can inspect the outer part of your breasts.
  3. Then bend forward toward the mirror. Roll your shoulders and elbows forward to tighten your chest muscles. Your breasts will fall forward. Look for any changes in the shape or contour of your breasts.
  4. Now, clasp your hands behind your head and press your hands forward. Again, turn from side to side to inspect your breasts' outer portions. Remember to inspect the border underneath your breasts. You may need to lift your breasts with your hand to see this area.
  5. Check your nipples for discharge (fluid). Place your thumb and forefinger on the tissue surrounding the nipple and pull outward toward the end of the nipple. Look for any discharge. Repeat on your other breast.

In the shower


  1. Now it's time to feel for changes. It is helpful to have your hands slippery with soap and water. Check for any lumps or thickening in your underarm area. Place your left hand on your hip and reach with your right hand to feel in the left armpit. Repeat on the other side.
  2. Check both sides for lumps or thickenings above and below your collarbone.
  3. With hands soapy, raise one arm behind your head to spread out your breast tissue. Use the flat part of your fingers from the other hand to press gently into the breast. Follow an up-and-down pattern along the breast, moving from bra line to collarbone. Continue the pattern until you have covered the entire breast. Repeat on the other side. the circle is complete, move in one inch toward the nipple and complete another circle around the clock. Continue in this pattern until you've felt the entire breast. Make sure to feel the upper outer areas that extend into your armpit.
  4. Lying down
  5. Next, lie down and place a small pillow or folded towel under your right shoulder. Put your right hand behind your head. Place your left hand on the upper portion of your right breast with fingers together and flat. Body lotion may help to make this part of the exam easier.
  6. Think of your breast as a face on a clock. Start at 12 o'clock and move toward 1 o'clock in small circular motions. Continue around the entire circle until you reach 12 o'clock again. Keep your fingers flat and in constant contact with your breast. When the circle is complete, move in one inch toward the nipple and complete another circle around the clock. Continue in this pattern until you've felt the entire breast. Make sure to feel the upper outer areas that extend into your armpit.
  7. Place your fingers flat and directly on top of your nipple. Feel beneath the nipple for any changes. Gently press your nipple inward. It should move easily.

Repeat these steps on your other breast.

What Do I Do If I Find a Lump in My Breast?

See your health care provider if you discover any new breast changes. Conditions that should be checked by a doctor include:

  • An area that is distinctly different from any other area on either breast
  • A lump or thickening in or near the breast or in the underarm that persists through the menstrual cycle
  • A change in the size, shape, or contour of the breast
  • A mass or lump, which may feel as small as a pea
  • A marble-like area under the skin
  • A change in the feel or appearance of the skin on the breast or nipple (dimpled, puckered, scaly, or inflamed)
  • Bloody or clear fluid discharge from the nipples
  • Redness of the skin on the breast or nipple

Breastfeeding and Formula Feeding

 

Take the Quiz: Baby's First Year

 

Take the Quiz: Baby's First Year Take the Quiz: Baby's First Year
10 Mistakes New Parents Make Slideshow Pictures 10 Mistakes New Parents Make Slideshow Pictures
Parenting and Healthy Eating Slideshow Pictures Parenting and Healthy Eating Slideshow Pictures

 

Medical Author:

 

Medical Editor:

 

  • When should we decide about breastfeeding?
  • Why is the choice so important?
  • What are the advantages and disadvantages of breastfeeding?
  • What are the advantages and disadvantages of formula feeding?
  • Can we use both forms of feedings for our baby?
  • Is there any special preparation required for breastfeeding?
  • When can breastfeeding begin?
  • What is the proper technique for breastfeeding?
  • When should breast pumps be used?
  • Should certain foods be avoided while breastfeeding?
  • How can one manage minor discomforts related to breastfeeding?
  • Clogged milk ducts
  • Sore nipples
  • When should one seek medical care for problems with breastfeeding?
  • Can supplements or medications increase a low milk supply?
  • Is it possible to breastfeed while pregnant?
  • Is smoking harmful when breastfeeding?
  • Do breast implants, surgeries, or reductions affect breastfeeding?
  • How should one wean a baby from breastfeeding?
  • Breastfeeding and Formula Feeding At A Glance
  • Patient Discussions: Breastfeeding

A flood of questions and concerns arises upon confirmation of pregnancy. Certainly one of the important ones is "How will we feed our baby?" In this article, we will review advantages and disadvantages of breast and formula feeding and helpful concepts in preparation for breastfeeding. This article is intended to help parents feel comfortable in making an educated decision about feeding their child based on scientific information.

When should we decide about breastfeeding?

Generally, it is a good idea to meet with the baby's doctor prior to the birth in order for all to get to know each other in a controlled, non-rushed, quiet environment. This is a perfect opportunity to discuss your concerns and wishes about feeding your baby. One important reason to have the decision to breastfeed made before the delivery is that it can be very difficult or even impossible to start using formula and then later try to switch to breastfeeding. This is because the ability of the breasts to produce milk diminishes soon after childbirth without the stimulation of breastfeeding.

Why is the choice so important?

During your baby's first year of life, he/she will more than triple his/her total body weight, and the vast majority of this weight gain will come from the milk that he/she drinks. According to the American Academy of Pediatrics, human milk is the preferred feeding for all infants. This includes premature and sick newborns, with rare exceptions. Of course, breast milk would appear to be the most ideal food for your newborn. It is the food least likely to cause allergic reactions, it is inexpensive, it is readily available at any hour of the day or night; babies accept the taste readily; and the immunity factors in breast milk can help the baby fight off some infections.

Although breast milk is the ideal food for human infants, because of medical or other reasons, some women opt for formula feeding. Infant formulas have been developed to artificially duplicate human milk, although no formulas have been developed that are an exact replacement for human milk.

What are the advantages and disadvantages of breastfeeding?

The nutritional advantages of breast milk are certainly numerous. The amino acids in breast milk, the building blocks of proteins, are well balanced for the human baby, as are the sugars (primarily lactose) and fats. The baby's intestinal tract is best aided in its digestion by the vitamins, enzymes, and minerals found in breast milk. Breast milk also contains infection-fighting antibodies from the mother, and breastfed babies are believed to be at a reduced risk for many acute and chronic infections early in life. The cholesterol content is also high in human milk and very low in formulas. Cholesterol promotes brain growth and provides the building blocks of hormones, vitamin D, and intestinal bile.

Breast milk is also the least expensive way to feed an infant. However, the mother must maintain good nutrition and continue taking any vitamin/mineral supplements her doctor recommended during the pregnancy.

Formula-fed babies also have the risk of developing an allergy to a particular formula. When a baby develops an allergy to formula, he or she may have symptoms that include irritability, crying after feedings, nausea, vomiting, diarrhea, or a skin rash.

Nursing helps most women lose weight (though not fluid) after delivery, as 500 calories or more are used by breastfeeding each day.

There is a well-accepted extra closeness that breastfeeding mothers experience that is both hormonal and emotional in nature.

The only disadvantages for the baby in breastfeeding occur when things are not going well, for example, if there's an inadequate supply of breast milk or an inefficient suck reflex in the baby. However, it is unusual for a mother not to produce enough milk for her baby unless she is not breastfeeding correctly or frequently enough. The disadvantages that most commonly arise involve the rest of the family. Siblings and dad often feel "left out" of baby care since mom is the only one who can do the nursing. However, other family members can be involved in helping with different aspects of the baby's care, and this gives them a valuable feeling of importance and allows mom a chance to rest.

Breastfed babies eat more often than formula-fed babies since breast milk is more quickly digested and leaves the stomach empty more frequently. This puts a little more stress on the mother because of the potential necessity for more frequent feedings. If the mother develops certain medical conditions, whether or not to continue breastfeeding may need to be reassessed. These conditions should always be discussed with the doctor. However, it is rare that breastfeeding would need to be discontinued completely. In any interaction, the mother's doctor and/or pharmacist should be informed that she is breastfeeding. Some medicines should be avoided during breastfeeding. Numerous other medications have not yet been adequately studied in the context of breastfeeding and the possible effects on the baby. If a breastfeeding mother is required to take a medication which has not been fully studied, she may want to consider discussing this matter with her doctor.

What are the advantages and disadvantages of formula feeding?

For some parents, or when the baby has certain medical conditions, it is very important to know exactly how much their baby is receiving at each feeding, and formula/bottle-feeding allows exact measurement. Foods, medications, or physical conditions in the mother are no longer a concern for the baby who is receiving formula. The entire family can immediately become intimately involved in all aspects of the baby's care, including feedings, allowing the mother to get more rest. Formula-fed babies actually need to eat somewhat less often since formula is less readily digested by the baby than human milk. The disadvantages of formulas are primarily their expense, the lack of maternal infection-fighting antibodies that are in breast milk, and the fact that no formula can exactly duplicate the ideal composition of breast milk.

Can we use both forms of feedings for our baby?

According to the American Academy of Pediatrics, exclusive breastfeeding is ideal nutrition and sufficient to support optimal growth and development for approximately the first six months after birth. Furthermore, it is recommended that breastfeeding continue for at least 12 months, and thereafter for as long as mutually desired. Infants weaned before 12 months of age should not receive cow's milk feedings but should receive iron-fortified infant formula.

Supplementing breastfeeding with formula is usually discouraged, although it may be helpful in cases where the mother is not producing an adequate supply of milk or the baby is not able to breastfeed well.

Lactation aids are also available as an option to avoid using a bottle when supplementation is necessary.

Is there any special preparation required for breastfeeding?

Education about the benefits and practice of breastfeeding are keys to optimal preparation. Your local hospital may offer breastfeeding classes as part of the childbirth class, or you can join your local La Leche League or other breastfeeding support group. These classes can put you in touch with a lactation specialist who may later be your personal breastfeeding consultant. These classes can also help you to learn proper positioning and latch-on techniques.

Contrary to some popular beliefs, it is not necessary to stimulate or prepare the nipples in advance for breastfeeding. Moreover, some techniques of stimulating the nipples may actually be harmful.

No specific physical preparation is necessary for optimal breastfeeding. General good health measures and adequate hydration are helpful measures. Most doctors recommend continuing basic prenatal vitamins while breastfeeding.

When can breastfeeding begin?

Breastfeeding can begin within minutes after birth for most babies. Most babies take a few licks or sucks and then pause at the beginning. Frequent bursts of sucking interrupted by pauses is the usual pattern for the first few hours and sometimes even the first few days.

The first milk the mother produces, called colostrum, is the best food for a newborn. The nipple stimulation that occurs during breastfeeding also helps the uterus contract and can help stop uterine bleeding.

When a baby begins to open its eyes, look around, and put his or her fist into his or her mouth, then it is time to offer your breast. Breastfeeding experts recommend that the baby not be given sugar water or other types of bottle feedings in the hospital unless specifically prescribed by the doctor.

What is the proper technique for breastfeeding?

Observing other breastfeeding mothers and talking with breastfeeding support organizations can help new breastfeeding mothers learn techniques for optimal breastfeeding that can help reduce the likelihood of any discomfort or complications. These techniques are briefly outlined below.

After the mother has assumed a position comfortable for her, she can nestle the baby in a cradle hold (cradling the baby with the mother's arm on the same side as the breast being presented). The baby's body should be on its side, so that the baby does not have to turn his or her head to reach the nipple.

1. First, manually express a few drops of milk to moisten the nipple.

2. Cup the breast with your hand and using the milk-moistened nipple, gently massage baby's lips, encouraging the baby to open its mouth.

3. When the baby's mouth is opened, the nipple is inserted into the center of the baby's mouth while pulling the baby in very close. The baby's gums should take in at least a 1-inch radius of the areola.

4. The mother may have to make adjustments for the baby's breathing by changing the angle of baby's position slightly or using the thumb to press gently on the breast to uncover the baby's nose.

5. Hold the breast throughout the feeding so the weight of your breast does not tire your newborn's mouth.

6. When feeding is over, to avoid trauma to your nipples, do not pull your nipple from baby's mouth without first breaking the suction by inserting your finger into the corner of baby's mouth

When should breast pumps be used?

Many women find the convenience of a breast pump to be an invaluable aid in breastfeeding. Basically, breast pumps allow the nursing mother to expel (and store, if desired) breast milk at times when she is not available to nurse the baby.

There are different types of breast pumps. Large, dual-action pumps are typically used in the hospital setting and may be rented for home use. The options for personal use and purchase include automatic models that are comparable to hospital-grade pumps, small electric or battery-operated units that double- or single-pump, and one-handed manual pumps.

Breast pumps may be useful for working mothers who wish to provide a supply of breast milk for their newborn and keep up their own milk production. Sometimes, women must stop breastfeeding on a temporary basis due to an infection or need to take certain medications. In these cases, use of a breast pump can keep milk production active during the breastfeeding hiatus.

 

Should certain foods be avoided while breastfeeding?

Some babies appear to be sensitive to certain foods in the mother's diet, while other babies never appear to have negative reactions to foods. A baby may become fussy, may have trouble sleeping, or may develop gas after the mother eats certain types of foods with strong flavors. Some of the most common triggers of fussiness in babies include chocolate, spices, citrus fruits, and gas-causing vegetables like cauliflower, cabbage, and broccoli. However, not all babies will have a reaction to particular foods.

Most experts recommend limiting consumption of caffeine while breastfeeding, since high levels of caffeine can make the baby fussy or disturb the baby's sleep patterns. Having more than one alcoholic beverage is also not recommended, since two or more alcoholic beverages at one time can increase blood alcohol levels to a point where the alcohol enters the breast milk. If a nursing mother consumes more than two drinks, she should wait at least two hours until nursing the baby to allow for elimination of alcohol from the body. If the breasts become engorged, it is fine to pump and discard breast milk while waiting. Studies have also shown that alcohol can interfere with the body's ability to "let down" (enable the free flow of breast milk) during breastfeeding.

Symptoms of allergy in a nursing baby may or may not be due to something eaten by the mother. If an allergic reaction to mother's food is present in the baby, it usually develops two to six hours after the mother consumed the offending food.

Because of concerns about mercury poisoning, the U.S. Food and Drug Administration (FDA) and Environmental Protection Agency (EPA) recommend that nursing mothers limit their exposure to mercury in fish. The FDA and EPA advise eating no more than 6 oz. (about one serving) of canned albacore or "white" tuna a week and limiting intake of canned "light" tuna and other cooked fish to about 12 oz. (about two servings) per week. Nursing mothers should completely avoid eating shark, swordfish, king mackerel, and tilefish (also called golden or white snapper) because of potentially high levels of mercury.

How can one manage minor discomforts related to breastfeeding?

Clogged milk ducts

Clogged milk ducts may appear as small, red, tender lumps within the breast. Milk ducts may become clogged with dried milk or other material. The goal of treatment is opening these blocked ducts. This can be aided by increasing the breastfeeding frequency and offering the affected breast first, as well as pumping the breast after breastfeeding if the baby is not emptying the breast.

Moist heat packs can be applied to the affected area to increase blood flow and healing. A warm shower and massaging of the area may also enhance resolution of this problem.

Sometimes, the baby will refuse the affected breast because the milk develops a sour taste. Pump the breast and empty it as well as possible. Continue to offer that breast to the baby until he/she accepts the affected breast again.

Sore nipples

Sore nipples can be relieved by exposing the nipples to the air as much as possible. Using a hair dryer on a low setting to dry nipples after breastfeeding may also provide relief. Nipples should be washed only with water, never with soap, alcohol, benzoin, or premoistened towelettes. Petroleum-based ointments and other cosmetic preparations should not be used, but unmedicated lanolin may help alleviate nipple cracking.

When should one seek medical care for problems with breastfeeding?

It is important to call your health-care provider if the above techniques do not alleviate the problem or if you develop serious symptoms such as fever or signs of mastitis (a breast inflammation that may be caused by an infection). Symptoms of mastitis include increasing pain in the breast, fever, chills, sweats, breast swelling and/or hardness, and redness of the skin over the affected area. A delay in treating mastitis could lead to a more severe infection and possible breast abscess.

Can supplements or medications increase a low milk supply?

Most experts agree that increasing the number of feedings and receiving coaching and assistance on proper breastfeeding technique can help increase what is perceived to be a low milk supply. Some women find that using breast pumps after each feeding stimulates milk production because of the increased degrees of emptying of the breast.

Medications that are reported to increase milk production are known as galactogogues. The most common examples are dopamine receptor antagonists (such as metoclopramide [Reglan, Reglan ODT, Metozol ODT, Octamide] and domperidone). However, there have been no data to demonstrate that these drugs are more effective than interventions that focus on improving breastfeeding technique and increasing breastfeeding frequency. Most doctors do not support the use of these medications to augment milk supply.

Likewise, a number of dietary supplements and/or herbal preparations have been claimed to stimulate milk production, including alfalfa, fenugreek, or blessed thistle. There is no scientific data to support the claims that any herbal or dietary supplement can increase milk production.

Is it possible to breastfeed while pregnant?

While breastfeeding typically is associated with a decrease in fertility, it is possible to become pregnant while breastfeeding, and breastfeeding does not afford 100% protection from pregnancy. For most women, it is safe to continue breastfeeding if they desire, provided they ensure that they are receiving adequate nutrition and fluid intake. While breast milk from a pregnant mother is still nutritionally strong, the hormonal changes of pregnancy will result in some changes in the content of the breast milk and the way the breast milk tastes.

Some women who have had premature labor in previous pregnancies may be advised to stop breastfeeding if they become pregnant. This is because the stimulation of the nipples that occurs during breastfeeding may trigger contractions of the uterus. In a woman prone to preterm labor, these weak uterine contractions might increase her risk of developing preterm labor. Both pregnancy and breastfeeding place high demands on the body in terms of nutritional support and rest. Other women may be advised to stop breastfeeding during pregnancy if their nutritional status is poor or if they are suffering from extreme fatigue due to the pregnancy.

Is smoking harmful when breastfeeding?

Tobacco smoking is always harmful, and all mothers should be encouraged to quit smoking prior to pregnancy and breastfeeding. However, smoking cigarettes is not considered to be a reason for not breastfeeding, since breastfeeding is the optimal nutrition for newborns. According to the American Academy of Pediatrics' policy statement on breastfeeding, "tobacco smoking by mothers is not a contraindication to breastfeeding, but health-care professionals should advise all tobacco-using mothers to avoid smoking within the home and to make every effort to wean themselves from tobacco as rapidly as possible."

Nursing mothers should understand that nicotine is passed to the baby in breast milk, and they should never nurse their baby immediately after smoking or while smoking. Babies exposed to secondhand smoke also are at risk for a number of health issues, so if a woman smokes, she should nurse her baby after smoking, in a room away from cigarette smoke. Of course, the safest policy for both mother and baby is to abstain from tobacco use while breastfeeding and forever thereafter.

Do breast implants, surgeries, or reductions affect breastfeeding?

Strictly speaking, neither breast augmentation surgery nor breast reduction surgery are indications that a woman should not breastfeed. However, all types of breast surgery can interfere with milk production. In women who have received implants, the location of the implant and the type of incision used in the procedure will determine the extent, if any, to which the implant may affect breast milk production or nursing ability. In some cases, operations on a woman's breast may have involved incisions in the nipple area (such as surgeries for biopsies), and in these cases, the milk ducts may have been disrupted. Surgical disruption of milk ducts and scar tissue may also predispose women to plugged ducts, mastitis, or milk retention cysts during breastfeeding.

Concerns have been expressed in the past that the content of breast implants (particularly with silicone implants) could leak out and be absorbed into breast milk, but studies have failed to show that this is a risk. Ideally, a woman who is planning breast surgery should discuss in advance with her surgeon the risks that the procedure may pose to future breastfeeding.

How should one wean a baby from breastfeeding?

Weaning is the process of transitioning from breastfeeding to other sources of nourishment. There are no established standards on when to wean a baby, although the American Academy of Pediatrics recommends that babies receive only breast milk for the first six months of life and a combination of solid foods and breast milk until the baby is at least 1 year old.

Sometimes babies will signal their mothers that it is time to begin weaning; they may nurse for shorter periods of time or appear indifferent, fussy, or distractible when nursing. Other babies may even be resistant to weaning even when the mother is ready. As babies begin to eat more solid foods, their consumption of breast milk may decrease, making breast engorgement less of a problem for the mother.

Weaning does not have to take place all at once. For example, a woman may choose to continue breastfeeding only in the evening, and to wean during the day. Weaning is also easier when the baby has been exposed to another source of milk, such as taking breast milk from a bottle.

No matter when weaning occurs, experts suggest that the process take place gradually. Many women wean by dropping one breastfeeding session a week. Slowing down the process can also help milk production gradually decrease, making engorgement less of a problem. Some mothers prefer to leave the weaning process up to the child; when a child is eating solid foods at every meal, there is often a decreased interest in breastfeeding.

Breastfeeding At A Glance
  • The ability of the breasts to produce milk diminishes soon after childbirth without the stimulation of breastfeeding.
  • Infants triple their total body weight during their first year of life.
  • The immunity factors in breast milk can help the baby to fight off infections.
  • Breast milk contains vitamins, minerals, and enzymes which aid the baby's digestion.
  • Breast milk is the ideal form of nutrition for infants.

Hydrogen Breath Test

 

Take the Tummy Trouble Digestive Quiz

 

Take the Tummy Trouble Digestive Quiz Take the Tummy Trouble Digestive Quiz
Digestive Disease Myths Slideshow Pictures Digestive Disease Myths Slideshow Pictures
Diverticulitis (Diverticulosis) Slideshow Pictures Diverticulitis (Diverticulosis) Slideshow Pictures

 

Medical Author:

 

Medical Editor:

 

  • What is the hydrogen breath test?
  • When is hydrogen breath testing used?
  • How does hydrogen breath testing work?
  • How is hydrogen breath testing performed?
  • How are the results of hydrogen breath testing interpreted?
  • What are the limitations of hydrogen breath testing?
  • Are there other ways in which hydrogen breath testing can be used?
  • What are the side effects of hydrogen breath testing?
  • What are the alternatives to hydrogen breath testing?
  • Find a local Gastroenterologist in your town

What is the hydrogen breath test?

The hydrogen breath test is a test that uses the measurement of hydrogen in the breath to diagnose several conditions that cause gastrointestinal symptoms. In humans, only bacteria - specifically, anaerobic bacteria in the colon - are capable of producing hydrogen. The bacteria produce hydrogen when they are exposed to unabsorbed food, particularly sugars and carbohydrates, not proteins or fats. Although limited hydrogen is produced from the small amounts of unabsorbed food that normally reach the colon, large amounts of hydrogen may be produced when there is a problem with the digestion or absorption of food in the small intestine, that allows more unabsorbed food to reach the colon.

Large amounts of hydrogen also may be produced when the colon bacteria move back into the small intestine, a condition called bacterial overgrowth of the small bowel. In this latter instance, the bacteria are exposed to unabsorbed food that has not had a chance to completely traverse the small intestine to be fully digested and absorbed. Some of the hydrogen produced by the bacteria, whether in the small intestine or the colon, is absorbed into the blood flowing through the wall of the small intestine and colon. The hydrogen-containing blood travels to the lungs where the hydrogen is released and exhaled in the breath where it can be measured.

When is hydrogen breath testing used?

Hydrogen breath testing is used in the diagnosis of three conditions.

  • The first is a condition in which dietary sugars are not digested normally. The most common sugar that is poorly digested is lactose, the sugar in milk. Individuals who are unable to properly digest lactose are referred to as lactose intolerant. Testing also may be used to diagnose problems with the digestion of other sugars such as sucrose, fructose and sorbitol.
  • The second condition for which hydrogen breath testing is used is for diagnosing bacterial overgrowth of the small bowel, a condition in which larger-than-normal numbers of colonic bacteria are present in the small intestine.
  • The third condition for which hydrogen breath testing is used is for diagnosing rapid passage of food through the small intestine. All three of these conditions may cause abdominal pain, abdominal bloating and distention, flatulence (passing gas in large amounts), and diarrhea.

How does hydrogen breath testing work?

The bacteria in the colon, including the anaerobic bacteria, are able to digest and use sugars and carbohydrates as food. When the anaerobic bacteria digest sugars and carbohydrates, they convert some of the sugars and carbohydrates into gases, most commonly hydrogen. They also may produce and release into the colon other substances, for example, chemicals that cause the colon to secrete water and cause diarrhea.

As previously discussed, some of the hydrogen gas is absorbed by the colon into the blood and is eliminated in the breath where it can be measured. As long as little sugar or carbohydrate reaches the colon, the small amounts of gas and other substances that are produced do not cause a problem. When larger amounts of sugar or carbohydrate reach the colon because they are not digested and absorbed in the small intestine, larger amounts of gas and substances are formed in the colon.

For example, if an individual digests and absorbs the sugar in milk (lactose) normally, then none of the lactose that is given for the lactose hydrogen breath test reaches the colon, and no increase in the concentration of hydrogen in the breath is seen during the breath test. On the other hand, if the individual does not digest and absorb the lactose completely, that is, he or she is lactose intolerant, the lactose travels through the small intestine and enters the colon where the bacteria digest it and produce hydrogen. An increase in hydrogen in the breath then is seen. Other sugars for which poor digestion can be diagnosed by breath testing include sucrose and fructose (found in corn syrup), and sorbitol (a sugar that is used as a low-calorie sweetener).

There are ways other than abnormal digestion of dietary sugars by which the bacteria can cause problems. Unlike in the colon, the number of hydrogen-producing, anaerobic bacteria in the small intestine is small. If, however, large numbers of hydrogen-producing bacteria move into the small intestine from the colon, a condition called bacterial overgrowth of the small bowel, the bacteria may digest the sugars and carbohydrates before the small bowel has had a chance to digest and absorb them and produce large amounts of hydrogen.

Finally, if individuals have abnormally rapid passage of food through the small intestine, there may not be enough time for the small intestine to digest and absorb sugars and carbohydrates. This results in the entry of larger amounts of sugar and carbohydrate into the colon where the bacteria can digest and convert them to gas.

To diagnose bacterial overgrowth and rapid transit through the small intestine, a sugar that is not digested and absorbed by man, such as lactulose, usually is used for the test. In the case of rapid passage through the small intestine, the sugar passes quickly through the small intestine and into the colon so that hydrogen is found in the breath very soon after ingestion of the sugar. In the case of bacterial overgrowth, production of hydrogen occurs twice during the test. Once as the sugar passes the bacteria in the small intestine and again when the sugar enters the colon.

How is hydrogen breath testing performed?

Prior to hydrogen breath testing, the patient fasts for at least 12 hours. At the start of the test, the patient blows into and fills a balloon with a breath of air. The concentration of hydrogen is measured in a sample of breath removed from the balloon. The patient then ingests a small amount of the test sugar (lactose, sucrose, sorbitol, fructose, lactulose, etc. depending on the purpose of the test). Additional samples of breath are collected and analyzed for hydrogen every 15 minutes for three and up to five hours.

How are the results of hydrogen breath testing interpreted?

The interpretation of the results of hydrogen breath testing depends on the sugar that is used for testing, and the pattern of hydrogen production after the sugar is ingested.

After ingestion of test doses of the dietary sugars lactose, sucrose, fructose or sorbitol, any production of hydrogen means that there has been a problem with digestion or absorption of the test sugar and that some of the sugar has reached the colon.

When rapid intestinal transit is present, the test dose of non-digestible lactulose reaches the colon more quickly than normally, and, therefore, hydrogen is produced by the colonic bacteria soon after the sugar is ingested.

When bacterial overgrowth of the small bowel is present, ingestion of lactulose results in two separate periods during the test in which hydrogen is produced, an earlier period caused by the bacteria in the small intestine and a later one caused by the bacteria in the colon.

What are the limitations of hydrogen breath testing?

There are several limitations to hydrogen breath testing. For unclear reasons, testing for bacterial overgrowth of the small bowel with lactulose can diagnose only 60% of cases. (This insensitivity of the test may be due in part to the strict criteria that are used for interpreting a test as abnormal. Less strict criteria may diagnose overgrowth more often.) In addition, with bacterial overgrowth there may be an overlap of the early and later periods of hydrogen production that can be misinterpreted as a single period characteristic of rapid intestinal transit. Finally, some normal individuals may have slow transit through the small intestine making prolonged testing - up to 5 hours - necessary, and many individuals are unwilling to undergo such prolonged testing.

Some individuals do not have bacteria that produce hydrogen, and in these individuals hydrogen breath testing is not possible. Most of these individuals have bacteria that produce a different gas, methane. (There also are individuals who produce both hydrogen and methane.) Methane can be measured in the breath just like hydrogen, and the production of methane can be used for diagnosis in the same way as hydrogen. There is much less experience with methane, however, and the production of methane is more complex than the production of hydrogen. Therefore, it is not clear if the pattern of methane production after ingestion of sugars can be interpreted in the same way as hydrogen production, particularly for the diagnosis of bacterial overgrowth.

A pattern of hydrogen production that is typical for bacterial overgrowth does not necessarily mean that an individual's symptoms are caused by the overgrowth. For example, there may be anatomic abnormalities of the small intestine such as narrowing or functional abnormalities in the way the muscle of the small intestine works. These abnormalities can cause symptoms of bloating, distention, pain, and diarrhea themselves, but they also can lead to bacterial overgrowth with its similar symptoms. Therefore, it may be an underlying abnormality that is responsible for the symptoms and not the bacterial overgrowth. The only way to differentiate between the two causes of symptoms-an underlying problem or bacterial overgrowth - is to treat and eradicate the bacteria. If the symptoms disappear, then it is more likely that it is the overgrowth rather than the underlying abnormality that is responsible for the symptoms.

Any condition that results in the delivery of undigested or unabsorbed food to the colon may result in abnormal breath tests when dietary sugars are used for testing. Both pancreatic insufficiency and celiac sprue can cause abnormal breath tests, in the former instance because pancreatic enzymes that are necessary for the digestion of carbohydrates are missing, and in the latter instance because the lining of the small intestine is destroyed, and digested food cannot be absorbed. It may be necessary to exclude these causes of abnormal breath tests by additional tests-pancreatic function tests and small intestinal biopsy.

Are there other ways in which hydrogen breath testing can be used?

Antibiotics are used for treating bacterial overgrowth of the small bowel; however, any one antibiotic may be effective at eliminating the overgrowing bacteria only 50%-60% of the time. Therefore, if symptoms do not disappear in an individual following treatment with antibiotics, it may be useful to repeat the breath test to determine if the antibiotics have eliminated the bacteria. If not, a different antibiotic or non-antibiotic treatment can be tried.

What are the side effects of hydrogen breath testing?

The side effects of hydrogen breath testing are exactly what one would expect to see in individuals who poorly digest and absorb sugars and carbohydrates, for example, bloating, distention, pain, and diarrhea. When lactulose is used these symptoms are unlikely to occur or are mild because the dose of lactulose used for testing is small.

What are the alternatives to hydrogen breath testing?

For diagnosing lactose intolerance, an alternative procedure to breath testing requires blood samples to be taken after the ingestion of lactose. If the digestion and absorption of lactose is normal, the levels of glucose in the blood should rise. The elevation of blood glucose occurs because the lactose is broken down into its two component sugars, galactose and glucose, as it is absorbed into the blood. A second alternative is to give a dose of lactose (or other dietary sugar) and observe an individual for symptoms. If the individual is intolerant, bloating, distention, pain, flatulence, and diarrhea are likely to occur. A third alternative is a trial of a diet in which the potentially-offending sugar is strictly eliminated. All of these alternatives, however, have limitations and problems.

Bacterial overgrowth can be diagnosed by culturing (growing) the bacteria from a sample of fluid from the small intestine and counting the numbers of colonic bacteria that are present. This procedure requires a tube to be passed through the nose, throat, esophagus and stomach under X-ray guidance so that fluid can be obtained from the small intestine. It is an uncomfortable and expensive procedure, and most laboratories are not able to accurately culture the samples.

An alternative method for diagnosing rapid transit through the small intestine involves eating food that is labeled with a radioactive marker and determining the time it takes for the marker to reach the colon. Progress of the marker through the bowel is assessed with a scanner that acts somewhat like a Geiger counter.

Urea Breath Test
(UBT)

 

Take the Tummy Trouble Digestive Quiz

 

Take the Tummy Trouble Digestive Quiz Take the Tummy Trouble Digestive Quiz
Digestive Disease Myths Slideshow Pictures Digestive Disease Myths Slideshow Pictures
Diverticulitis (Diverticulosis) Slideshow Pictures Diverticulitis (Diverticulosis) Slideshow Pictures

 

Medical Author:

 

Medical Editor:

 

  • What is the urea breath test?
  • What is the basis of this test?
  • How is this breath test done?
  • How are the results of the urea breath test interpreted?
  • Are there any risks or complications of the urea breath test?
  • Find a local Gastroenterologist in your town

What is the urea breath test?

The urea breath test (UBT) is a test for diagnosing the presence of a bacterium, Helicobacter pylori (H. pylori) in the stomach. H. pylori causes inflammation, ulcers, and atrophy of the stomach. The test also may be used to demonstrate that H. pylori has been eliminated by treatment with antibiotics.

What is the basis of this test?

The urea breath test is based on the ability of H. pylori to break down urea, a chemical made up of nitrogen and carbon, into carbon dioxide which then is absorbed from the stomach and eliminated in the breath. (Urea normally is produced by the body from excess or "waste" nitrogen-containing chemicals and then eliminated in the urine.)

How is this breath test done?

For the test, patients swallow a capsule containing urea made from an isotope of carbon. (Isotopes of carbon occur in minuscule amounts in nature, and can be measured with special testing machines.) If H. pylori is present in the stomach, the urea is broken up and turned into carbon dioxide. The carbon dioxide is absorbed across the lining of the stomach and into the blood. It then travels in the blood to the lungs where it is excreted in the breath. Samples of exhaled breath are collected, and the isotopic carbon in the exhaled carbon dioxide is measured.

How are the results of the urea breath test interpreted?

If the isotope is detected in the breath, it means that H. pylori is present in the stomach. If the isotope is not found, H. pylori is not present. When the H. pylori is effectively treated (eradicated) by antibiotics, the test changes from positive (isotope present) to negative (isotope absent).

Are there any risks or complications of the urea breath test?

There are no risks or complications of the urea breath test.

Lungs Design And Purpose

 

Hidden Home Hazards That Can Harm Your Lungs
Hidden Home Hazards That Can Harm Your Lungs
Energy-Boosting Foods for COPD Slideshow Pictures Energy-Boosting Foods for COPD
Worst Smog Cities in America Slideshow Worst Smog Cities in America Slideshow
Medical Reviewer:

 

  • What are the lungs?
  • What does breathing accomplish?
  • What is the structure of the respiratory system?
  • How is air moved into and out of the lungs during respiration?
  • How does gas exchange occur?
  • What are other important events during the breathing cycle?
  • Lungs Design And Purpose At A Glance

 

What are the lungs?

Picture of the lungsThe lungs are a pair of organs in the chest, which are primarily responsible for the exchange of oxygen and carbon dioxide between the air we breathe and the blood.

 

What does breathing accomplish?

The cells in the body constantly need a new supply of oxygen to produce energy. With lack of oxygen, cellular function is impaired and damage or cell death may occur. As energy is utilized, waste products are created, one of which is the gas carbon dioxide. Eliminating carbon dioxide from the body is just as important as breathing in oxygen from the air. If carbon dioxide builds up in the blood it will lead to headaches, drowsiness, coma, and eventually even death.

 

What is the structure of the respiratory system?

Air enters the body via the nose (preferably) or the mouth. The air enters the main windpipe, called the trachea, and continues en route to each lung via either the right or left bronchi. The lungs are separated into sections called lobes, two on the left and three on the right. The air passages continue to divide into ever smaller tubes, which finally connect with tiny air sacs called alveoli. This gradually branching array of tubes is referred to as the tracheobronchial "tree" because of the remarkable similarity to the branching pattern of a tree.

The other half of the respiratory system involves blood circulation. Venous blood from the body is returned to the right side of the heart and then pumped out via the pulmonary artery. This artery splits in two for the left and right lungs and then continues to branch much like the tracheobronchial tree. These vessels branch into a fine network of very tiny tubes called capillaries. The capillaries are situated adjacent to the alveoli and are so small that only one red blood cell at a time can pass through their openings. It is during this passage that gases are exchanged between the blood and the air in the nearby alveoli. After passing the alveoli, capillaries then join together to begin forming the pulmonary veins, which carry the blood back to the left side of the heart.

Lungs Design And Purpose - Illustration

 


How is air moved into and out of the lungs during respiration?

Respiration is divided into two components, inhalation and exhalation.

Inhalation is active, because it requires muscle contraction. The major muscle of respiration is a sheet-like dome shaped muscle called the diaphragm. The diaphragm separates the chest and abdominal cavities. As the diaphragm contracts, it flattens out, moving toward the abdominal cavity. This action causes an increase in the size of the chest cavity, thus creating a vacuum. Air is then sucked in through the mouth. When physical activity increases dramatically, or with some lung conditions, other muscles like those of the neck and those between the ribs also assist in the increase in size of the chest cavity. These muscles are referred to as accessory muscles.

Exhalation is passive because it does not require muscle contraction. During this phase, the expanded lung acts like a stretched rubber band and simply contracts to its resting position. This contraction forces air out of the lungs and through the mouth.

How does gas exchange occur?

As energy is utilized by cells, one of the waste products is the gas carbon dioxide. Oxygen-enriched red blood cells release oxygen to the cells of the body and then pick up the waste carbon dioxide. This oxygen- deprived, dark blue blood is then delivered to the blood vessels of the lungs. Carbon dioxide is released by the red cell, easily passes through the capillary wall into the space in the air sac of the adjacent alveoli, and is then eliminated with each breath out of the mouth (exhalation). Oxygen present in the air sac easily passes into the capillaries and into the red blood cells. The capillary network carrying this oxygen-rich, bright red blood empties into the left side of the heart where it is pumped to all the tissues of the body. Thus, the cycle or circle of blood is complete; hence, the name circulation.

What are other important events during the breathing cycle?

Outside air needs to be heated and moistened to match the body's temperature and humidity. As air passes down the tracheobronchial tree, it is warmed and water is added. Contaminants must also be removed. Nose hairs and tiny microscopic hairs called cilia, along with sticky mucus produced by the lining membrane help cleanse the air of impurities. Cilia beat in a synchronized fashion brushing any collected dirt and mucus up toward the mouth. The accumulated material is then coughed out or swallowed. By the time the air reaches the alveoli, it is virtually sterile. Amazingly, all of the above is occurring naturally while you are reading this information!

Lungs Design And Purpose At A Glance
  • The lungs exchange oxygen and carbon dioxide between the air we breathe and the blood.
  • The tracheobronchial tree is the passage way from the mouth to the interior of the lung.
  • Gas exchange occurs in the alveoli deep in the lungs.
  • Breathing air in (inhalation) requires muscular effort.
  • Air is warmed, humidified, and cleaned by the nose and lungs.

Sleep Related Breathing Disorders

 

Causes of Fatigue Slideshow Pictures
Causes of Fatigue Slideshow Pictures Depression Tips for Exercise, Diet and Stress Reduction
Is Sleepiness Hurting You?
Take the Sleep Quiz Take the Sleep Quiz

Medical Author: Andrew Verneuil, MD
Medical Editor: Melissa Stoppler, MD

  • What are sleep related breathing disorders?
  • Why do we sleep?
  • What are the stages of sleep?
  • Find a local Ear, Nose, & Throat Doctor in your town

What are sleep related breathing disorders?

Sleep related breathing disorders are a group of disorders that affect our breathing while we are asleep, and are characterized by disruptions of normal breathing patterns that only occur during sleep. Therefore, the person with the disorder may be the last to know he or she has a problem. Sleep related breathing disorders constitute a subset of the broad group of sleep disorders that include many other disorders such as insomnia (difficulty sleeping), hypersomnias (inappropriately falling asleep, for example, narcolepsy), parasomnias (activities during sleep, for example, sleepwalking and sleep terrors), and sleep related movement disorders (for example, restless leg syndrome). The most common sleep related breathing disorders are snoring and sleep apnea.

Why do we sleep?

This is a complex topic that we only partially understand. Mammals, reptiles, birds, and even fruit flies have been observed sleeping. A manatee can sleep with one side of its brain while the other side is awake and alert. Sleeping in this way avoids a long period of unconsciousness, during which it would be very vulnerable. Humans typically need 6-8 hours of sleep every night, but individuals vary in their need for sleep. During sleep, we rest and repair our muscles and organize our thoughts and memories. Therefore, if we become sleep deprived, we feel both physically fatigued and mentally exhausted. Many studies show that sleep deprivation causes a decrease in problem solving ability, attention, and manual reflex times.

What are the stages of sleep?

Sleep stages can be measured by monitoring the electrical impulses within the brain, often termed brain waves. These electrical impulses, or brain waves can be monitored with an electroencephalogram (EEG). Sleep can be broken up into four stages and REM (rapid eye movement) sleep. Stage 1 sleep is the most superficial and stage 4 is the deepest. Stage 1 and 2 sleep are both considered to be light sleep, while stage 3 and 4 sleep are both deeper, more restorative sleep. These stages are important for the body to feel well. REM sleep is the sleep stage in which we typically dream. During REM, the brain sends signals to the muscles to relax, so we do not "act out" our dreams. The relaxation of muscles in REM sleep can sometimes worsen sleep related breathing disorders like snoring and sleep apnea. We typically spend about 50% of our sleep in stages 1 and 2, 25% in stages 3 and 4, and 25% in REM sleep.

Endotracheal Intubation

 

Causes of Fatigue Slideshow Pictures

 

Causes of Fatigue Slideshow Pictures Causes of Fatigue Slideshow Pictures
Take the Quiz: The Human Body Take the Human Body Quiz
Is Sleepiness Hurting You?

 

Revising Medical Author:

 

Revising Medical Editor:

 

  • What is endotracheal intubation?
  • What kind of tube is used?
  • How do they put the tube down into the trachea?
  • What is the purpose of endotracheal intubation?
  • What are the complications of endotracheal intubation?

What is endotracheal intubation?

Endotracheal intubation is a procedure by which a tube is inserted through the mouth down into the trachea (the large airway from the mouth to the lungs). Before surgery, this is often done under deep sedation. In emergency situations, the patient is often unconscious at the time of this procedure.

What kind of tube is used?

The tube that is used today is usually a flexible plastic tube. It is called an endotracheal tube because it is slipped within the trachea.

How do they put the tube down into the trachea?

The doctor often inserts the tube with the help of a laryngoscope, an instrument that permits the doctor to see the upper portion of the trachea, just below the vocal cords. During the procedure the laryngoscope is used to hold the tongue aside while inserting the tube into the trachea. It is important that the head be positioned in the appropriate manner to allow for proper visualization. Pressure is often applied to the thyroid cartilage (Adam's apple) to help with visualization and prevent possible aspiration of stomach contents.

What is the purpose of endotracheal intubation?

The endotracheal tube serves as an open passage through the upper airway. The purpose of endotracheal intubation is to permit air to pass freely to and from the lungs in order to ventilate the lungs. Endotracheal tubes can be connected to ventilator machines to provide artificial respiration. This can help when a patient is unconscious and by maintaining a patent airway, especially during surgery. It is often used when patients are critically ill and cannot maintain adequate respiratory function to meet their needs. The endotracheal tube facilitates the use of a mechanical ventilator in these critical situations.

What are the complications of endotracheal intubation?

If the tube is inadvertently placed in the esophagus (right behind the trachea), adequate respirations will not occur. Brain damage, cardiac arrest, and death can occur. Aspiration of stomach contents can result in pneumonia and ARDS. Placement of the tube too deep can result in only one lung being ventilated and can result in a pneumothorax as well as inadequate ventilation. During endotracheal tube placement, damage can also occur to the teeth, the soft tissues in the back of the throat, as well as the vocal cords.

It is no wonder that this procedure should be performed by a physician with experience in intubation. In the vast majority of cases of intubation, no significant complications occur.

Dental Health: Bridges

 

View Cosmetic Dentistry: Before and After Slideshow Pictures
Cosmetic Dentistry: Before and After Slideshow Pictures View Before and After Pictures of Cosmetic Dentistry Slideshow Pictures
Teeth Whitening Secrets Slideshow Pictures View Secrets to Brighter, Whiter Teeth Slideshow Pictures
Take the Dental (Oral) Health Quiz! Take the Dental (Oral) Health Quiz!

 

  • What are the benefits of dental bridges?
  • What types of dental bridges are available?
  • What is the process for obtaining a dental bridge?
  • How much do dental bridges cost?
  • How long do dental bridges last?
  • Will it be difficult to eat with a dental bridge?
  • Will the dental bridge change how I speak?
  • How do I care for my bridges?

Dental bridges literally bridge the gap created by one or more missing teeth.

A bridge is made up of two crowns for the teeth on either side of the gap -- these two anchoring teeth are called abutment teeth -- and a false tooth/teeth in between. These false teeth are called pontics and can be made from gold, alloys, porcelain or a combination of these materials. Dental bridges are supported by natural teeth or implants.

What Are the Benefits of Dental Bridges?

Bridges:

  • Restore your smile
  • Restore your ability to properly chew and speak
  • Maintain the shape of your face
  • Distribute the forces in your bite properly by replacing missing teeth
  • Prevent remaining teeth from drifting out of position

What Types of Dental Bridges Are Available?

There are three main types of bridges:

 

  • Traditional bridges involve creating a crown for the tooth or implant on either side of the missing tooth, with a pontic in between. Traditional bridges are the most common type of bridge and are made of either porcelain fused to metal or ceramics.
  • Cantilever bridges are used when there are adjacent teeth on only one side of the missing tooth or teeth.
  • Maryland bonded bridges (also called a resin-bonded bridge or a Maryland bridge) are made of plastic teeth and gums supported by a metal framework. Metal wings on each side of the bridge are bonded to your existing teeth.

Bridge

What Is the Process for Obtaining a Dental Bridge?

During the first visit, the abutment teeth are prepared. Preparation involves recontouring these teeth by removing a portion of enamel to allow room for a crown to be placed over them. Next, impressions of your teeth are made, which serve as a model from which the bridge, pontic, and crowns will be made by a dental laboratory. Your dentist will make a temporary bridge for you to wear to protect the exposed teeth and gums while your bridge is being made.

During the second visit, your temporary bridge will be removed and the new permanent bridge will be checked and adjusted, as necessary, to achieve a proper fit. Multiple visits may be required to check the fit of the metal framework and bite. This is dependent on each individual's case. If the dental bridge is a fixed (permanent) bridge, your dentist may temporarily cement it in place for a couple of weeks to make sure it is fitting properly. After a couple weeks, the bridge is permanently cemented into place.

How Much Do Dental Bridges Cost?

The cost of dental bridges varies depending on the type of bridge selected and the area of the country in which the procedure is performed. Dental insurance will typically pay a percentage of the fee depending on the individual dental plan.

How Long Do Dental Bridges Last?

Dental bridges can last 5 to 15 years and even longer. With good oral hygiene and regular prophylaxis, it is not unusual for the life span of a fixed bridge to be over 10 years.

Will It Be Difficult to Eat with a Dental Bridge?

Replacing missing teeth should actually make eating easier. Until you become accustomed to the bridge, eat soft foods that have been cut into small pieces.

Will the Dental Bridge Change How I Speak?

It can be difficult to speak clearly when teeth are missing in the front or anterior areas. Wearing a dental bridge with the anterior teeth in their proper relationship will help you speak properly.

How Do I Care for My Bridges?

It is important to keep your remaining teeth healthy and strong as the success of the bridge (depending on the type selected) depends on the solid foundation offered by the surrounding teeth. Brushing twice a day and flossing daily helps prevent tooth decay and gum disease that can lead to tooth loss. Your dentist or dental hygienist can demonstrate how to properly brush and floss your teeth. Keeping a regular cleaning schedule will help diagnose problems at an early stage when treatment has a better prognosis. Selecting a balanced diet for proper nutrition is also important.

Brief Psychotic Disorder

 

View the Phobias Slideshow Pictures
Phobias Slideshow Pictures Phobias Slideshow Pictures
Depression Tips Slideshow Pictures Tips on how to cope with Depression Slideshow Pictures
Bipolar Disorder: Do You Have Extreme Mood Shifts? Bipolar Disorder Slideshow Pictures
  • What are the symptoms of brief psychotic disorder?
  • What causes brief psychotic disorder?
  • How common is brief psychotic disorder?
  • How is brief psychotic disorder diagnosed?
  • How is brief psychotic disorder treated?
  • What is the outlook for people with brief psychotic disorder?
  • Can brief psychotic disorder be prevented?
  • Find a local Psychiatrist in your town

As the name suggests, brief psychotic disorder is a short-term illness with psychotic symptoms. The symptoms often come on suddenly, but last for less than one month, after which the person usually recovers completely. There are three basic forms of brief psychotic disorder:

  • Brief psychotic disorder with obvious stressor (also called brief reactive psychosis): This type, also called brief reactive psychosis, occurs shortly after and often in response to a trauma or major stress, such as the death of a love one, an accident or assault, or a natural disaster. Most cases of brief psychotic disorder occur as a reaction to a very disturbing event.
  • Brief psychotic disorder without obvious stressor: With this type, there is no apparent trauma or stress that triggers the illness.
  • Brief psychotic disorder with postpartum onset: This type occurs in women, usually within 4 weeks of having a baby.

What Are the Symptoms of Brief Psychotic Disorder?

The most obvious symptoms include:

  • Hallucinations: Hallucinations are sensory perceptions of things that aren't actually present, such as hearing voices, seeing things that aren't there or feeling sensations on your skin even though nothing is touching your body.
  • Delusions: These are false beliefs that the person refuses to give up, even in the face of contradictory facts.

Other symptoms of brief psychotic disorder include:

  • Disorganized thinking
  • Speech or language that doesn't make sense
  • Unusual behavior and dress
  • Problems with memory
  • Disorientation or confusion
  • Changes in eating or sleeping habits, energy level, or weight
  • Inability to make decisions

What Causes Brief Psychotic Disorder?

The exact cause of brief psychotic disorder is not known. One theory suggests a genetic link. This is based on the fact that the disorder is more common in people who have family members with mood disorders, such as bipolar disorder. Another theory suggests that the disorder is caused by poor coping skills, as a defense against or escape from a particularly frightening or stressful situation. These factors may create a vulnerability to develop brief psychotic disorder. In most cases, the disorder is then triggered by a major stress or traumatic event. Childbirth may trigger the disorder in some women.

How Common Is Brief Psychotic Disorder?

Brief psychotic disorder is uncommon. It generally first occurs in early adulthood (20's and 30's), and is more common in women than in men. People who have a personality disorder—such as antisocial personality disorder or paranoid personality disorder—are more prone to developing brief psychotic disorder.

How Is Brief Psychotic Disorder Diagnosed?

If symptoms are present, the doctor will perform a complete medical history and physical examination. Although there are no laboratory tests to specifically diagnose brief psychotic disorder, the doctor may use various tests—such as x-rays or blood tests—to rule out physical illness as the cause of the symptoms.

If the doctor finds no physical reason for the symptoms, he or she may refer the person to a psychiatrist or psychologist, mental health professionals who are specially trained to diagnose and treat mental illnesses. Psychiatrists and psychologists use specially designed interview and assessment tools to evaluate a person for a psychotic disorder. Brief psychotic disorder occurs when a person has psychotic symptoms, such as delusions, hallucinations and disorganized thinking, for less than one month, after which time the symptoms go away completely.

How Is Brief Psychotic Disorder Treated?

Treatment for brief psychotic disorder typically includes psychotherapy (a type of counseling) and/or medication. Hospitalization may be necessary if the symptoms are severe or if there is a risk that the person may harm him or herself, or others.

  • Medication: Antipsychotic drugs may be prescribed to decrease or eliminate the symptoms and end the brief psychotic disorder. Conventional antipsychotics include: Thorazine, Prolixin, Haldol, Navane, Stelazine, Trilafon and Mellaril. Newer medications, called atypical antipsychotic drugs, include: Risperdal, Clozaril, Seroquel, Geodon and Zyprexa. Tranquilizers such as Ativan or Valium may be used if the person has a very high level of anxiety (nervousness) and/or problems sleeping.
  • Psychotherapy: Psychotherapy helps the person identify and cope with the situation or event that triggered the disorder

What Is the Outlook for People with Brief Psychotic Disorder?

Brief psychotic disorder, by definition, lasts for less than one month, after which most people recover fully. Some people, however, may have recurrent episodes of psychotic symptoms, but this is rare.

Can Brief Psychotic Disorder Be Prevented?

There is no known way to prevent brief psychotic disorder. However, early diagnosis and treatment can help decrease the disruption to the person's life, family and friendships.

Subconjunctival Hemorrhage

 

View the Eye Diseases and Conditions Slideshow Pictures

 

 

 

 

Eye Diseases and Conditions Slideshow Pictures Eye Diseases and Conditions Slideshow Pictures
Pink Eye Slideshow Pictures Pink Eye Slideshow Pictures
Cataracts Slideshow Pictures Cataracts Slideshow Pictures

 

Medical Author:

 

Medical Editor:

 

  • What is a subconjunctival hemorrhage?
  • What causes a subconjunctival hemorrhage?
  • What are symptoms and signs of a subconjunctival hemorrhage?
  • How is a subconjunctival hemorrhage diagnosed?
  • What is the treatment for a subconjunctival hemorrhage?
  • Can a subconjunctival hemorrhage be prevented?
  • Subconjunctival Hemorrhage At A Glance
  • Find a local Eye Doctor in your town

What is a subconjunctival hemorrhage?

The conjunctiva is a clear tissue that covers the white of the eye (the sclera) and lines the inside of both eyelids. A subconjunctival hemorrhage is blood that is located between the conjunctiva and the underlying sclera.

What causes a subconjunctival hemorrhage?

The conjunctiva contains nerves and many small blood vessels. These blood vessels are usually barely visible but become larger and more visible if the eye is inflamed. These blood vessels are somewhat fragile and their walls may break easily, resulting in a subconjunctival hemorrhage (bleeding under the conjunctiva). A subconjunctival hemorrhage appears as a bright red or dark red patch on the sclera. Most subconjunctival hemorrhages are spontaneous without an obvious cause for the bleeding from normal conjunctival blood vessels. Since most subconjunctival hemorrhages are painless, a person may discover a subconjunctival hemorrhage only by looking in the mirror. Many spontaneous subconjunctival hemorrhages are first noticed by another person seeing a red spot on the white of your eye. Rarely there may be an abnormally large or angulated blood vessel as the source of the hemorrhage.

The following can occasionally result in a spontaneous subconjunctival hemorrhage:

  • Sneezing
  • Coughing
  • Straining/vomiting
  • Increasing the pressure in the veins of the head, as in weight lifting
  • Eye rubbing or inserting contact lenses
  • Certain infections of the outside of the eye (conjunctivitis) where a virus or a bacteria weaken the walls of small blood vessels under the conjunctiva
  • Medical disorder causing bleeding or inhibiting normal clotting.

Subconjunctival hemorrhage can also be non-spontaneous and result from a severe eye infection, trauma to the head or eye or after eye or eyelid surgery.

What are symptoms and signs of a subconjunctival hemorrhage?

Most of the time, no symptoms are associated with a subconjunctival hemorrhage other than seeing blood over the white part of the eye.

  • Very rarely people experience pain when the hemorrhage begins. When the bleeding first occurs, you may notice a sense of fullness in the eye or under the lid. As the hemorrhage resolves, some people may feel very mild irritation of the eye or merely a sense of awareness of the eye.
  • The hemorrhage itself is an obvious, sharply outlined bright red area overlying the sclera. The entire white part of the eye may occasionally be covered by blood.
  • In a spontaneous subconjunctival hemorrhage, no blood will exit from the eye. If you blot the eye with a tissue, there should be no blood on the tissue.
  • The hemorrhage will appear larger within the first 24 hours after its onset and then will slowly decrease in size as the blood is absorbed.

Call your ophthalmologist (a medical doctor who specializes in eye care and surgery) if the subconjunctival hemorrhage does not get better within two weeks or if it has happened multiple times.

Also, call your ophthalmologist if you have a hemorrhage in both eyes at the same time or if the subconjunctival hemorrhage coincides with a new onset of easy bruising or bleeding gums.

Go to your ophthalmologist immediately if the subconjunctival hemorrhage is associated with

  • pain,
  • changes in vision (for example, blurry vision, double vision, difficulty seeing),
  • a history of recent injury or trauma,
  • a history of bleeding disorder, or
  • a history of high blood pressure.

How is a subconjunctival hemorrhage diagnosed?

Your ophthalmologist will take a medical, eye, and medication history to determine what events were leading up to the subconjunctival hemorrhage and will also perform an examination. Your blood pressure may also be checked.

If trauma was the cause, a more thorough examination will usually be performed. Once the diagnosis of subconjunctival hemorrhage is made, your ophthalmologist might be able to tell you the cause and if there is any sign of damage to the eye.

In newborn infants, subconjunctival hemorrhage can occasionally be found as a result of the birth process. Shaken baby syndrome should be considered in young children with subconjunctival hemorrhages in both eyes.

What is the treatment for a subconjunctival hemorrhage?

Usually, no treatment is needed. Over-the-counter artificial tears can be applied to the eye if mild irritation is present. The eye does not require a patch.

The use of aspirin or other medication that inhibits clotting should be avoided. If you are taking aspirin or an anticoagulant for a medical condition, check with your physician to determine whether the medication should be stopped or continued.

If the subconjunctival hemorrhage is trauma-related, your ophthalmologist will determine what other treatment is necessary to promote healing of the injury.

If the subconjunctival hemorrhage is a result of an external infection, your ophthalmologist may prescribe antibiotic drops or an ointment.

This condition clears by itself within one to two weeks. Recovery is usually complete, without any long-term problems, similar to a mild bruise under the skin. Like a bruise, a subconjunctival hemorrhage changes colors (often red to orange to yellow) as it heals. A skin bruise changes to various shades of green, black, and blue as it heals, because the blood is being seen through skin. Because the conjunctiva is transparent, a subconjunctival hemorrhage never has these color characteristics.

Can a subconjunctival hemorrhage be prevented?

If you are having frequent subconjunctival hemorrhages or your subconjunctival hemorrhage is associated with easy bruising or bleeding elsewhere, you should have a medical evaluation for an underlying bleeding or clotting problem. Treatment of such an underlying condition may prevent future hemorrhages.

Subconjunctival Hemorrhage At A Glance
  • The conjunctiva is the thin, moist, transparent membrane that covers the white part of the eye (called the sclera) and the inside of the eyelids. The conjunctiva is the outermost protective coating of the eyeball.
  • The conjunctiva contains nerves and many small blood vessels. These blood vessels are usually barely visible but become larger and more visible if the eye is inflamed. These blood vessels are somewhat fragile and their walls may break easily, resulting in a subconjunctival hemorrhage (bleeding under the conjunctiva). A subconjunctival hemorrhage appears as a bright red or dark red patch on the sclera.

Fracture

 

View Adult Skin Problems Slideshow Pictures

 

Adult Skin Problems Slideshow Pictures View Adult Skin Problems Slideshow Pictures
Gallery of Skin Problems and Image Collection Gallery of Skin Problems and Image Collection
Medical Author:

 

Medical Editor:

 

  • Fracture facts
  • Introduction to fracture
  • What causes a fracture?
  • What are common types of fractures?
  • Stress fracture
  • Compression fracture
  • Rib fracture
  • Skull fracture
  • Fracture in children
  • How is a fracture diagnosed?
  • What is the treatment for a fracture?
  • Patient Discussions: Fracture - Causes
  • Patient Discussions: Fracture - Describe Your Experience
  • Find a local Doctor in your town

Fracture facts

  • Bone fracture, broken bone, bone crack all mean he same thing. The bone has been damaged such that. None of these terms indicate the severity of the bone damage.
  • Bones are the body's storage place for calcium. Under hormone control, calcium content of bone is constantly increasing or decreasing.
  • Bones break when they cannot withstand a force or trauma applied to them. Sometimes the bones are so weak that force may be just gravity, like compression fractures of the back in the elderly.
  • Fracture descriptions help explain how the breakage appears. For examples, whether or not the fragments are aligned (displaced fracture) and whether or not there is skin overlying the injury is damaged (compound fracture).
  • Fractures may be complicated by damage to nearby blood vessels, nerves and muscles and joints.
  • Children's fractures may be more difficult to diagnose because their bones lack enough calcium to be seen on X-ray and because growth plates in the bones may disguise or hide the fracture.
  • Diagnosis of a fracture includes a history and physical examination. X-rays are often taken. Occasionally, CT or MRI is used to find an occult or hidden fracture or provide more information regarding the damage to the bone and adjacent tissues.
  • Fractures of the skull, spine and ribs have their own unique diagnosis and treatment issues.

Introduction to fracture

Bones form the skeleton of the body and allow the body to be supported against gravity and to move and function in the world. Bones also protect some body parts, and bone marrow is the production center for blood products.

Bone is not a stagnant organ. It is the body's reservoir of calcium and is always undergoing change under the influence of hormones. Parathyroid hormone increases blood calcium levels by leeching calcium from bone, while calcitonin has the opposite effect, allowing bone to accept calcium from the blood.

What causes a fracture?

When outside forces are applied to bone it has the potential to fail. Fractures occur when bone cannot withstand those outside forces. Fracture, break, or crack all mean the same thing. One term is not better or worse than another. The integrity of the bone has been damaged and the bone structure fails and a fracture occurs.

Broken bones hurt for a variety of reasons including:

  • The nerve endings that surround bones contain pain fiber. These fibers may become irritated when the bone is broken or bruised.
  • Broken bones bleed, and the blood and associated swelling (edema) causes pain.
  • Muscles that surround the injured area may go into spasm when they try to hold the broken bone fragments in place, and these spasms may cause further pain.

Often a fracture is easy to detect because there is obvious deformity. However, at times it is not easily diagnosed. It is important for the physician to take a history of the injury to decide what potential problems might exist. Moreover, fractures don't always occur in isolation, and there may be associated injuries that need to be addressed.

Fractures can occur because of direct blows, twisting injuries, or falls. The type of forces or trauma applied to the bone may determine what type of injury that occurs. Some fractures occur without any obvious trauma due to osteoporosis, the loss of calcium in bone (for example a compression fracture of the vertebrae of the back).

Descriptions of fractures can be confusing. They are based on:

 

  • Where in the bone the break has occurred
  • How the bone fragments are aligned
  • Whether any complications exist
  • Whether the skin is intact

The first step in describing a fracture is to decide if it is open or closed. If the skin over the break is disrupted, then an open fracture exists. The skin can be cut, torn, or abraded (scraped), but if the skin's integrity is damaged, the potential for an infection to get into the bone exists. Since the fracture site in the bone communicates with the outside world, these injuries often need to be cleaned out aggressively and many times require anesthesia in the operating room to do the job effectively. Compound fracture was the previous term used to describe an open fracture.

Next, there needs to be a description of the fracture line. Does the fracture line go across the bone (transverse), at an angle (oblique) or does it spiral? Is the fracture in two pieces or is it comminuted, in multiple pieces?

A greenstick fracture describes the situation when the bone partially breaks. This often occurs in infants and children where the bone hasn't completely calcified and has the potential to bend instead of breaking completely through. It is similar to trying to break off a young branch or shoot from a tree (a green stick). Other fracture terms include torus or buckle fracture, again when only part of a bone breaks, but this may occur in adults as well.

Bone Fractures Illustration - Fracture of Bone

Finally, the fracture's alignment is described as to whether the fracture fragments are displaced or in their normal anatomic position. If the bones fragments aren't in the right place, they need to be reduced or placed back into their normal alignment.

What are common types of fractures?

Stress fracture

A stress fracture is an overuse injury. Because of repeated micro-trauma, the bone can fail to absorb the shock that is being put upon it and become weakened. Often it is seen in the lower leg, the shin bone (tibia), or foot. Athletes are at risk the most, because they have repeated footfalls on hard surfaces. Tennis players, basketball players, jumpers, and gymnasts are typically at risk. A March fracture is the name given to a stress fracture of the metatarsal or long bones of the foot. (It is named because it often occurs in soldiers who are required to march long distances.)

Diagnosis is made by history and physical exam, though on occasion a bone scan, CT scan, or MRI may be done to confirm the diagnosis.

Treatment is conservative, rest, ice, and anti-inflammatory medication like ibuprofen. These fractures can take six to eight weeks to heal. Trying to return too quickly may cause re-injury, and may also allow the stress fracture to extend through the entire bone and displace. Surgery is not commonly performed for routine stress fractures.

Shin splints may have very similar symptoms as a stress fracture of the tibia but they are due to inflammation of the lining of the bone, called the periosteum. Shin splints are caused by overuse, especially in runners, walkers, dancers, including those who do aerobics. Muscles that run through the periosteum and the bone itself may also become inflamed.

Treatment is similar to a stress fracture and physical therapy can be helpful.

Compression fracture

As people age, there is a potential for the bones to develop osteoporosis, a condition where bones lose their calcium content. This makes bone more susceptible to breaking. One such type of injury is a compression fracture to the spine, most often the thoracic or lumbar spine. Since we are an upright animal, if the bones of the back cannot withstand the force of gravity these bones can crumple. Pain is the major complaint, especially with movement.

Compression injuries of the back may or may not be associated with nerve or spinal cord injury. An X-ray of the back can reveal the bone injury, however, sometimes a CT scan or MRI will be used to insure that no damage is done to the spinal cord.

Treatment includes pain medication and often a back brace. Some compression fractures can also be treated with vertebroplasty. Vertebroplasty involves inserting a glue-like material into the center of the collapsed spinal vertebra in order to stabilize and strengthen the crushed bone. The glue (methylmethacrylate) is inserted with a needle and syringe through anesthetized skin into the midportion of the vertebra under the guidance of specialized X-ray equipment. Once inserted, the glue soon hardens, forming a cast-like structure within the compressed vertebra.

Rib fracture

The ribs are especially vulnerable to injury and are prone to breaking due to a direct blow. Rib X-rays are rarely taken as it doesn't matter if the rib is broken or just bruised. A chest X-ray is usually taken to make certain there is no collapse or bruising of the lung.

As we breathe, our rubs and lungs expand like a bellows. Air is sucked into our lungs when the ribs move out and the diaphragm moves down as we inhale. When a person has a rib injury, the pain associated with that injury, be it a fracture or contusion (bruise), it makes breathing difficult and the person has a tendency to not take deep breaths. If the lung underlying the injury does not expand, it is at risk for infection. The person is then susceptible to pneumonia (lung infection), which is characterized by fever, cough, and shortness of breath.

As opposed to other parts of the body that can rest when they are injured, it is very important to take deep breaths to prevent pneumonia when rib fractures are present. The treatment for bruised and broken ribs is the same: ice to the chest wall, ibuprofen as an anti-inflammatory, deep breaths and pain medication. Even if all goes well, there will be significant pain for four to six weeks.

With lower rib fractures, there may be concern about organs in the abdomen that the ribs protect. The liver is located under the ribs on the right side of the chest, and the spleen under the ribs on the left side of the chest. Many times your doctor may be more worried about abdominal injury than about the broken rib itself. Ultrasound or CT scan may help diagnosis intra-abdominal injuries.

Skull fracture

With the wide availability of CT scans, skull X-rays are rarely taken to diagnose head injury. If a head injury exists, the health care practitioner will feel or palpate the scalp and skull to determine if there may be a skull fracture. A nervous system exam may be done assessing brain function. Fractures of the base of the skull may cause hemotympanum (blood behind the ear drum), Battle's sign (bruising behind the ear) ,or raccoon eyes (bruising surrounding the orbits of th eyes).

The skull is a flat, compact bone and it takes significant force to break it. If a skull fracture exists, there is an increased likelihood of bleeding in the brain, especially in children. There are guidelines that are available to decide whether a CT scan is indicated (needed).

Minor head injury is defined as witnessed loss of consciousness, definite amnesia, or witnessed disorientation in patients with a GCS (Glasgow Coma Score) score of 15. With minor head injury, the following risk groups are considered when evaluating need for CT brain scan:

High risk for potential neurosurgical operation

  • Abnormal neurologic exam within two hours after injury
  • Suspected open or depressed skull fracture
  • Any sign of basal skull fracture (blood behind the ear drum, blackened eyes, clear fluid running from the ears, or bruising behind the ear)
  • Vomiting - two episodes
  • 65 years of age or older

Medium risk (for brain injury on CT)

  • Amnesia before impact - more than 30 minutes
  • Dangerous mechanism (pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from height greater than 3 feet or five stairs)

Fracture in children

Children can break bones and yet have normal X-rays. Fractures appear as clear lines through the bone on an X-ray through the bone. If calcium hasn't yet accumulated in the repairing bone, the break may not be apparent. This lack of calcification happens in two ways.

  1. Bones mature at different times in a child's development and while the bony structure is there, it may have more cartilage than calcium.

  2. The second situation is associated with growth plates. Each bone has an area where cell activity is maximal and where the bone grows. These areas appear as lucent lines on X-ray. It may be one of the weaker points in the bone as well, and a fracture through the growth plate may not be seen.

The doctor needs to match the history and physical exam with what is seen on X-ray to make to a diagnosis. Sometimes, the child is placed in a cast for a period of time to protect the broken limb. As fractures heal, the body lays down extra calcium as building material and then remodels it to normal shape. After 7-10 days, there may be evidence on X-ray of the healing calcium to confirm the fracture.

Growth plate fractures are classified by Salter-Harris category. When a break occurs through the growth plate, it can involve different parts of the bone on each side of the plate. It is important that these fractures are aligned properly so that the bone grows properly as the child ages.

Children are more flexible than adults until the calcium completely solidifies their bone. If you think of an arm or leg bone as tubular, sometimes only one side of the bone breaks, just like an immature branch on a tree. This is referred to as a greenstick fracture, and may need to be "set" so that it heals properly. Sometimes the bones can bend but not break because they are so pliable. This is called a plastic deformity or bow fracture and will need to be set or aligned to allow proper healing.

How is a fracture diagnosed?

The health care practitioner will first assess the history of the injury. Where, when, and why did the injury occur? Did the person trip and fall, or did they pass out before the fall? Are there other injuries that take precedence over the fracture? For example, a person who falls and hurts their wrist because they had a stroke or heart attack will have their fracture care delayed to allow care for the life threatening illness. The injured area will be examined and a search will happen for potential associated injuries. These include damage to skin, arteries and nerves.

Pain control is a priority and many times, pain medication will be prescribed before the diagnosis is made. If the health care practitioner believes that an operation is likely, pain medication will be given through an intravenous (IV) line or by an injection into the muscle. This allows the stomach to remain empty for potential anesthesia.

A decision will be made whether X-rays are required, and which type of X-ray should be taken to make the diagnosis and better assess the injury. There are guidelines in place to help health care practitioners decide if an X-ray is necessary. Some include the Ottawa ankle and knee X-ray rules.

The body is three dimensional, and plain film X-rays are only two dimensional. Therefore, two or three X-rays of the injured areas may be taken in different positions and planes to give a true picture of the injury. Sometimes the fracture will not be seen in one position, but is easily seen in another.

There are areas of the body where one bone fracture is associated with another fracture at a more distant part. For example, the bones of the forearm make a circle and it is difficult to break just one bone in that circle. Think of trying to break a pretzel in just one place, it is difficult to do. Therefore broken bones at the wrist may be associated with an elbow injury. Similarly, an ankle injury can be accompanied by a knee fracture. The health care practitioner may X-ray areas of the body that don't initially appear to be injured.

Occasionally, the broken bone isn't easily seen, but there may be other signs that a fracture exists. In elbow injuries, fluid seen in the joint on X-ray (sail sign) is an indicator of a subtle fracture. And in wrist injuries, fractures of the scaphoid or navicular bone may not show up on X-ray for one to two weeks, and diagnosis is made solely on physical examination with swelling and tenderness over the snuffbox at the base of the thumb.

In children, bones may have numerous growth plates that can cause confusion when reading an X-ray. Sometimes, the health care professional will to X-ray the opposite arm, leg or joint for comparison to determine what normal is for the child before deciding whether a fracture exists.

What is the treatment of a fracture?

Initial treatment for fractures of the arms, legs, hands and feet in the field include splinting the extremity in the position it is found, elevation and ice. Immobilizati