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Written by Ruai Pharmaceuticals   
Thursday, 15 September 2011 16:58

Marijuana

  • Marijuana facts
  • What is marijuana, and how is it abused?
  • What is medical marijuana? How is medical marijuana prescribed?
  • What are other names for marijuana?
  • What is the history and different types of marijuana?
  • Is marijuana addictive?
  • What are the psychological and social effects of abusing marijuana?
  • What are the physical effects of abusing marijuana?
  • What are the treatments for marijuana abuse and addiction?
  • Can marijuana abuse and addiction be prevented?
  • What is the prognosis of marijuana abuse and addiction?
  • Where can people find more information about marijuana abuse and addiction?

Marijuana facts

  • Marijuana's (scientific name is Cannabis sativa) leaves, seeds, stems and/or roots are consumed by marijuana users for the purpose of feeling intoxicated.
  • THC, or tetrahydrocannibinol, is one of the hundreds of compounds within marijuana that has major intoxicating effects.
  • Marijuana that is consumed for medical purposes, like for patients with nausea or poor appetite associated with AIDS or cancer treatment, is legal in a few states of the United States.
  • Possession of marijuana, regardless of its purpose, is illegal in most jurisdictions.
  • Marijuana is the most commonly abused illegal substance worldwide.
  • While the number of people who use marijuana at any one time does not seem to have recently increased, the number of people who have a marijuana-related disorder has risen significantly. This is more or less true depending on age and ethnic group.
  • Medical marijuana, also called marinol (Dronabinol), is a synthetic form of marijuana.
  • There are many ways of referring to marijuana itself, as well as for how it is smoked.
  • The history of marijuana goes back for thousands of years. It was only made illegal in many countries during the 20th century.
  • The use of medical marijuana is currently legal in 15 U.S. states and the District of Columbia. In those jurisdictions, people for whom medical marijuana has been specifically recommended by a physician must carry a (medical) marijuana card that indicates their use of the substance for a clear medical purpose.
  • Attempts to completely legalize the use of marijuana, whether for medicinal purposes or not, remain strongly contested in most jurisdictions.
  • There are a variety of marijuana types, also called strains.
  • Numerous research studies show that marijuana is indeed an addictive substance. The symptoms of addiction to marijuana are similar to those of any other addictive substance.
  • The symptoms of marijuana withdrawal are similar to those of other drugs and include irritability, anger, depression, insomnia, drug craving, and decreased appetite.
  • The negative physical, psychological, and social effects of marijuana are numerous.
  • While most individuals with marijuana abuse or dependence are treated on an outpatient basis, admission to both outpatient and inpatient treatment programs for marijuana addiction has increased over the years.
  • Behavioral and family based treatments have been found to be effective for marijuana abuse and addiction.
  • There is as yet no medication that has yet been shown to be a clearly effective treatment of marijuana-use disorders.

What is marijuana, and how is it abused?

Marijuana is a plant whose scientific name is Cannabis sativa. Its leaves, seeds, stems, and/or roots are consumed by marijuana users for the purpose of feeling intoxicated ("high"). Although the plant contains hundreds of compounds, the one that has major intoxicating effects is called tetrahydrocannibinol (THC). Although medical marijuana is legal in a few states of the United States, it is one of many illegal drugs in most jurisdictions. Specifically, laws in most states deem it illegal to engage in possession of marijuana, either for the purpose of your own use or for the purpose of distributing it to others.

Marijuana is the most commonly abused illegal substance worldwide. While the number of people who use marijuana at any one time does not seem to have increased in the past decade, the number of people who have a marijuana-related disorder has increased significantly. This seems to be particularly true for elderly individuals as well as for young Hispanic and African-American adults. In teens, boys remain more likely than girls to smoke or otherwise use marijuana. Native-American adolescents seem to be the ethnic group most vulnerable to engage in recent marijuana use, and Asian adolescents tend to be the least likely.

What is medical marijuana? How is medical marijuana prescribed?

Medical marijuana, also called marinol (Dronabinol), is a synthetic form of marijuana. It comes in 2.5 mg, 5 mg, and 10 mg capsules and is used for the treatment of poor appetite and food intake (anorexia) with weight loss in people with acquired immune deficiency syndrome (AIDS) and for the nausea and vomiting due to cancer chemotherapy in individuals who have not responded adequately to usual treatments for those symptoms. When used for appetite stimulation, marinol is usually dosed at 2.5 mg once or twice per day before lunch, dinner, and/or bedtime. When it is being prescribed to quell nausea, it is usually prescribed at 5 mg, one to three hours before a chemotherapy treatment and every two to four hours after chemotherapy, up to six doses per day.

The most common physical side effects of marinol include asthenia (lack of energy), stomach upset, nausea, vomiting, racing heart rate, facial flushing, and dizziness. The most common psychological side effects of marinol include anxiety, sleepiness, confusion, hallucinations, and paranoia. This medication should therefore be used with caution in persons who have a mental-health diagnosis, particularly depression, mood swings, schizophrenia, or substance abuse. When prescribed for those people, the individual is usually under the care of a psychiatrist.

What are other names for marijuana?

There are many, many ways of referring to marijuana. The technical term for marijuana is cannabis. Some terms like pot, hemp, herb, reefer, ganja, and weed refer to the substance itself. A higher potency form of marijuana is often called hashish or hash. Other words like joints, blunts, backwoods, buds, or bongs refer to the way that marijuana is smoked. Marijuana is also often smoked in pipes or baked in food, like brownies.

What is the history and different types of marijuana?

The history of marijuana goes back for thousands of years. It was only made illegal in many countries during the 20th century. In the past 20 years in the United States, the legalization pros and cons of medical marijuana have been intensely debated as it has become legal to use it in 15 states and the District of Columbia. In those jurisdictions, people for whom medical marijuana has been specifically recommended by a physician must carry a (medical) marijuana card that indicates their use of the substance for a clear medical purpose. Individuals who do not carry such a card risk prosecution for marijuana possession. Different states that allow for legal use of marijuana have different guidelines for the legality of possessing and using medical marijuana. For example, at least one bans home cultivation, and there are regulations concerning the operations of dispensaries in some states.

Federal laws continue to deem marijuana possession, as well as its distribution, as illegal, whether it is used for medicinal purposes or not. While the prosecution rates of individuals who carry small amounts of the substance along with a medical marijuana card tend to be low, dispensaries in states that have legalized medical marijuana remain criminalized and are therefore often raided by law-enforcement agencies.

Attempts to completely legalize the use of marijuana, whether for medicinal purposes or not, remain strongly contested in most jurisdictions. For example, in 2010, Proposition 19, a measure that would have completely legalized possession and growing marijuana then taxed and regulated its use was defeated in the state of California. However, California already reduced legal sanctions for possessing small amounts of marijuana to the level comparable to the penalty for speeding on a freeway.

There are a variety of marijuana types, also called strains. Strains tend to be based on leaf color as indicated in pictures, as well as the strains' potency and medical purpose. Medical strains of marijuana are specifically grown for a particular health benefit, like pain management or reduction of nausea. Some states place restrictions on the strains of marijuana that may be legally used and sold. Marijuana dispensaries often sell hydroponic marijuana seeds through mail order, which can be grown in nutrient solution, with or without soil.

Is marijuana addictive?

Numerous research studies show that marijuana is indeed an addictive substance. More than 4% of Americans develop a dependency on marijuana. The rate of addiction to marijuana has increased for all age groups. Teens are using the drug at younger ages. About one out of every six adolescents who use marijuana develop addiction to it, and half the people who receive treatment for marijuana use are under the age of 25. While the frequency of use seems to have remained the same over the past several years, adults are becoming dependent on marijuana more often. Theories about potential reasons for that increase include increased access to marijuana that is of higher potency, as well as a lower age at which many individuals first use this drug.

The symptoms of addiction to marijuana are similar to those of any other addictive substance. As with any other drug, in order to qualify for the diagnosis of marijuana addiction, the individual must suffer from a negative pattern of use of this drug that results in significant problems or suffering, with at least three of the following symptoms occurring at the same time in the same one year period:

  • Tolerance (decreased effects of marijuana over time or needing to increase the amount used to achieve the desired effect)
  • Withdrawal (characteristic symptoms that occur when the individual abstains from using marijuana for some days)
  • Often taking marijuana in larger amounts or over a longer period of time than planned
  • Persistent desire to use marijuana or trouble decreasing or controlling its use
  • Spending significant time either obtaining marijuana (for example, buying, growing), using it, or recovering from its effects
  • Significant social, educational, occupational, or leisure activities are either abandoned or significantly decreased as a result of marijuana's use
  • Marijuana use continues despite being aware of or experiencing persistent or repeated physical or psychological problems as a result of its use

The symptoms of marijuana withdrawal are similar to those of other drugs, especially tobacco. Those symptoms usually start one to two days after last using marijuana and include irritability, anger, depression, insomnia, drug craving, and decreased appetite. These symptoms tend to interfere with the individual's attempts to stop using marijuana and can motivate the use of both marijuana and other drugs for relief. The symptoms of withdrawal tend to peak within four to six days and last from one to three weeks.

What are the psychological and social effects of abusing marijuana?

The bad effects of marijuana are numerous. For example, it can impair thinking, as in learning, and memory for several days after each time it is used. That risk seems to be even higher for people who score lower on IQ tests compared to those who score higher.

The social effects of smoking marijuana can be quite detrimental as well. Adolescents who use the substance are at higher risk of pregnancy, dropping out of school, delinquency, legal problems, and achieving less educationally and occupationally. Individuals who become dependent on marijuana tend to be less motivated, less happy, or satisfied with their life. They are also at risk for depression and for using larger amounts of alcohol and other drugs.

What are the physical effects of abusing marijuana?

In terms of how long marijuana tends to stay in your system, it can be detected on drug tests for about two weeks. Like many other chemicals that are ingested, marijuana can affect your body in many ways. It seems to be associated with an increased occurrence of certain cancers. It may also increase the risk of sexual dysfunction; statistics indicate that men who smoke or otherwise consume marijuana regularly are at higher risk of either having premature ejaculation or trouble reaching orgasm. Men and women who use this substance on a regular basis seem to have more sexual partners and to be more at risk for contracting sexually transmitted diseases compared to those who do not use marijuana.

Marijuana's effects on the body and brain of a developing fetus seem to be clearly negative. Exposure to this substance before birth (prenatally) is associated with negative effects on fetal growth and body weight, as well as on the impulse control, focusing ability, learning, memory, and decision making in the child who was exposed to marijuana before birth. These negative effects by no means only affect babies who are exposed to marijuana before birth (in utero). Marijuana tends to negatively affect learning, judgment, and muscle skills in people who use marijuana by their own volition.

What are the treatments for marijuana abuse and addiction?

Most individuals with marijuana abuse or dependence are treated on an outpatient basis. Admission to outpatient and inpatient treatment programs for marijuana addiction has increased over the years to the point that the addiction to this substance is nearly as high as dependence on other illegal drugs, like cocaine or heroin.

Behavioral treatments, like motivational enhancement therapy (MET), cognitive-behavioral therapy (CBT), and contingency management (CM), as well as family based treatments have been found to be effective treatments for marijuana abuse and addiction. MET is designed to lessen the resistance a person who abuses marijuana may have to abstaining from using it. This intervention is also designed to motivate the individual to change. CBT teaches people who abuse marijuana skills to help them stop using the drug and to ways to avoid or manage other problems that might prevent them from marijuana use recovery. CM usually provides marijuana users with vouchers of increasing value as a reward for repeatedly testing negative for (the absence of) drugs over time. Those vouchers are then exchanged for positive items or services that promote the person's participation in more positive (pro-social) activities, like securing employment or advancing their education or health.

In addition to the individual therapies just described, adolescents who abuse or are addicted to marijuana are often treated using one or more family therapies. These include multidimensional therapy, multisystemic therapy, family support network intervention, and brief strategic family therapy. Each of these interventions uses techniques that are designed to enhance the skills of the addicted individual and his or her family members as a way of discouraging marijuana use.

Although there is no medication that has yet been shown to be a clearly effective treatment of marijuana-use disorders, research shows that antidepressant medications like nefazodone (Serzone) and fluoxetine (Prozac) may help some individuals manage marijuana withdrawal and to avoid relapse, respectively. Oral THC (Dronabinol) may also help alleviate symptoms of marijuana withdrawal. Successful psychotherapeutic approaches to treatment of marijuana abuse or addiction include motivational approaches with coping skills development.

Can marijuana abuse and addiction be prevented?

In order to prevent marijuana use, abuse, and addiction, an understanding of the risk factors for those issues is essential. In teens, availability of marijuana in their environment, as well as a tendency to engage in negative behaviors (deviancy) increase the likelihood of marijuana use. For some adolescents, using legal substances like alcohol and tobacco can be gateway drugs for marijuana use, in that the use of those substances increases the likelihood that the teen will use marijuana.

What is the prognosis of marijuana abuse and addiction?

While many people with a marijuana-use disorder successfully stop using it with outpatient psychotherapy that provides motivation and teaches coping skills, the relapse rate is quite high, about 67% after the first year. However, when treatment is provided frequently, that statistic improves. Individuals who begin smoking marijuana before 17 years of age seem to be more than three times more likely to attempt suicide than those who either never use the substance or do so after the age of 17. That risk goes the other way as well, in that people who develop depression or have thoughts of suicide before the age of 17 seem to be at a much higher risk of developing an addiction to marijuana. People who are vulnerable to developing psychosis (for example, having hallucinations like seeing things or hearing voices that aren't there; or delusions, like unfounded beliefs that others are trying to harm him or her) may be more likely to do so if marijuana is used, even on a medicinal basis. Marijuana abuse or addiction is also associated with a much higher risk of developing a dependence on other drugs.

Where can people find more information about marijuana abuse and addiction?

  • Codependents Anonymous: http://www.coda.org
  • Kids Against Drugs: http://www.kidsagainstdrugs.com
  • Marijuana Anonymous World Services: 800-766-6779; This e-mail address is being protected from spambots. You need JavaScript enabled to view it
  • Narcanon: http://www.narcanon.org
  • Narcotics Anonymous: http://www.na.org
  • National Council on Alcoholism and Drug Dependence: 800-NCA-CALL
  • National Institute on Drug Abuse: http://www.nida.nih.gov
  • National Clearinghouse for Alcoholism and Drug Information: 800-729-6686
  • National Resource Center: 866-870-4979
  • Substance Abuse & Mental Health Services Administration (SAMHSA): 1-877-SAMHSA-7
  • http://www.treatmentcenter.com

Masturbation

Your Guide to Masturbation

  • Introduction to masturbation
  • Who masturbates?
  • Why do people masturbate?
  • Is masturbation normal?
  • Is masturbation harmful?

Introduction to Masturbation

Masturbation is the self-stimulation of the genitals to achieve sexual arousal and pleasure, usually to the point of orgasm (sexual climax). It is commonly done by touching, stroking, or massaging the penis or clitoris until an orgasm is achieved. Some women also use stimulation of the vagina to masturbate or use "sex toys," such as a vibrator.

Who Masturbates?

Just about everybody. Masturbation is a very common behavior, even among people who have sexual relations with a partner. In one national study, 95% of males and 89% of females reported that they have masturbated. Masturbation is the first sexual act experienced by most males and females. In young children, masturbation is a normal part of the growing child's exploration of his or her body. Most people continue to masturbate in adulthood, and many do so throughout their lives.

Why Do People Masturbate?

In addition to feeling good, masturbation is a good way of relieving the sexual tension that can build up over time, especially for people without partners or whose partners are not willing or available for sex. Masturbation also is a safe sexual alternative for people who wish to avoid pregnancy and the dangers of sexually transmitted diseases. It also is necessary when a man must give a semen sample for infertility testing or for sperm donation. When sexual dysfunction is present in an adult, masturbation may be prescribed by a sex therapist to allow a person to experience an orgasm (often in women) or to delay its arrival (often in men).

Is Masturbation Normal?

While it once was regarded as a perversion and a sign of a mental problem, masturbation now is regarded as a normal, healthy sexual activity that is pleasant, fulfilling, acceptable and safe. It is a good way to experience sexual pleasure and can be done throughout life.

Masturbation is only considered a problem when it inhibits sexual activity with a partner, is done in public, or causes significant distress to the person. It may cause distress if it is done compulsively and/or interferes with daily life and activities.

Is Masturbation Harmful?

In general, the medical community considers masturbation to be a natural and harmless expression of sexuality for both men and women. It does not cause any physical injury or harm to the body, and can be performed in moderation throughout a person's lifetime as a part of normal sexual behavior. Some cultures and religions oppose the use of masturbation or even label it as sinful. This can lead to guilt or shame about the behavior.

Some experts suggest that masturbation can actually improve sexual health and relationships. By exploring your own body through masturbation, you can determine what is erotically pleasing to you and can share this with your partner. Some partners use mutual masturbation to discover techniques for a more satisfying sexual relationship and to add to their mutual intimacy.

Mixed Connective Tissue Disease
(MCTD)


  • What are connective tissues?
  • What diseases characteristically affect connective tissue?
  • What is mixed connective tissue disease?
  • How is mixed connective tissue disease diagnosed?
  • How is mixed connective tissue disease treated?
  • Mixed Connective Tissue Disease At A Glance
  • Find a local Rheumatologist in your town

What are connective tissues?

The connective tissues are the structural portions of our body that essentially hold the cells of the body together. These tissues form a framework or matrix for the body. The connective tissues are composed of two major structural molecules, collagen and elastin. There are many different collagen proteins that vary in amount in each tissue of the body. Elastin is another protein that has the capability of stretching and returning to original length like a spring. Elastin is the major component of ligaments (tissues which attach bone to bone).

Connective tissue diseases are disorders featuring abnormalities involving the collagen and elastin. Connective tissue diseases are often characterized by a variety of immune abnormalities that are common for each particular type of illness.

What diseases characteristically affect connective tissue?

Diseases of connective tissue that are strictly inheritable (due to genetic inheritance) include Marfan syndrome (can have tissue abnormalities in the heart, aorta, lungs, eyes, and skeleton) and Ehlers-Danlos syndrome (may have loose, fragile skin or loose [hyperextensible] joints). Pseudoxanthoma elasticum is an inherited disorder of elastin.

Other diseases of connective tissue do not have specific gene abnormalities as their sole cause. These connective tissue diseases occur for unknown reasons. They are characterized as a group by the presence of spontaneous over activity of the immune system, which results in the production of unusual antibodies into the blood.

The classic immune-related connective tissue diseases include systemic lupus erythematosus, rheumatoid arthritis, scleroderma, polymyositis, and dermatomyositis. Each of these diseases has a characteristic presentation with typical clinical findings that doctors can recognize during an examination. Each also has characteristic blood test abnormalities and abnormal antibody patterns. However, each of these diseases can evolve slowly or rapidly from very subtle abnormalities before demonstrating the classic features that help in the diagnosis. When these conditions have not developed the classic features of a particular disease, doctors will often refer to the condition as "undifferentiated connective tissue disease." This implies that the characteristic features that are used to define the classic connective tissue disease are not present, but some symptoms or signs of connective disease exist. Individuals with undifferentiated connective tissue disease may never develop a fully definable condition or they may eventually develop a classic connective tissue disease.

What is mixed connective tissue disease?

Mixed connective tissue disease, as first described in 1972, is "classically" considered as an "overlap" of three diseases, systemic lupus erythematosus, scleroderma, and polymyositis. Patients with this pattern illness have features of each of these three diseases. They also typically have very high quantities of antinuclear antibodies (ANAs) and antibodies to ribonucleoprotein (anti-RNP) detectable in their blood. The symptoms of many of these patients eventually evolve to become dominated by features of one of three component illnesses, most commonly scleroderma.

It is now known that overlap syndromes can occur that involve any combination of the connective tissue diseases. Therefore, for example, patients can have a combination of rheumatoid arthritis and systemic lupus erythematosus (hence, the coined name "rhupus").

How is mixed connective tissue disease diagnosed?

Today, true mixed connective tissue disease is diagnosed when patients demonstrate the clinical features (exam findings) of overlap illnesses (as described above) and have high amounts of the antibodies ANA and anti-RNP in their blood. Mixed connective tissue disease patients do not typically have antibodies such as dsDNA, Scl70, which are particularly common in systemic lupus erythematosus and scleroderma respectively.

How is mixed connective tissue disease treated?

The treatment of mixed connective tissue disease is based on which features are causing symptoms. The prognosis (outlook) varies accordingly. Therapies must be targeted for each of the organ systems affected. In general, treatment is often directed at suppressing the inflammation present in the tissues by using anti-inflammatory and immunosuppressive medications. These medications include nonsteroidal anti-inflammatory drugs (NSAIDs), cortisone drugs/steroids (such as prednisone), antimalarial drugs (hydroxychloroquine), and cytotoxic drugs (such as methotrexate, azathioprine, and cyclophosphamide). Organ damage, such as in the kidneys, can require additional treatments directed at high blood pressure, etc.

For the joint and muscle pains of mixed connective tissue disease, treatment options include NSAIDs, low-dose prednisone, hydroxychloroquine, and methotrexate can be helpful. Sometimes TNF blockers infliximab (Remicade), etanercept (Enbrel), or adalimumab (Humira) are considered for inflammatory arthritis. Physical therapy for certain joints is sometimes helpful. For pulmonary hypertension, medications that tend to open the arteries to the lungs are used along with blood thinning drugs and even supplemental oxygen. For interstitial lung disease, prednisone and cyclophosphamide are considered. To prevent damage to the kidneys, angiotensin converting enzyme inhibitors, such as captopril (Capoten), enalapril (Vasotec) are used, especially if blood pressure is elevated. Esophagus irritation and heartburn can be prevented by elevating the head of the bed and relieved with omeprazole (Prilosec) or lansoprazole (Prevacid). Antacids can also be helpful. Constipation, cramping and diarrhea is sometimes caused by bacteria that can be treated with tetracycline or erythromycin.

 

For Raynaud's phenomenon, patients are recommended to use hand- and body-warming techniques while protecting the fingers from injury. Nifedipine (Procardia), losartan (Cozaar, Hyzaar), and nitroglycerin cream are used to dilate the constricted blood vessels. Severe RP can lead to gangrene and the loss of digits. In rare cases of severe disease, nerve surgery called "sympathectomy" is sometimes considered. In order to prevent blood vessel spasming, the nerves that stimulate the constriction of the vessels (sympathetic nerves) are surgically interrupted. Usually, this is performed during an operation that is localized to the sides of the base of the fingers at the hand. Through small incisions the tiny nerves around the blood vessels are stripped away. This procedure is referred to as a digital sympathectomy.

Mixed Connective Tissue Disease At A Glance
  • Connective tissues are the framework of the cells of the body.
  • Mixed connective tissue disease is an "overlap" combination of connective tissue diseases.
  • Diagnosis of mixed connective tissue disease is supported by detecting abnormal antibodies in the blood.
  • Treatment of mixed connective tissue disease is directed at suppressing immune-related inflammation of tissues.
 

For more specific information related to the individual connective tissue diseases, please read the following articles:

  • Systemic Lupus Erythematosus
  • Rheumatoid Arthritis
  • Scleroderma
  • Polymyositis

Measles (Rubeola)



  • What is measles?
  • What is rubeola?
  • What is rubella?
  • What are other names for measles?
  • What is the history of measles?
  • What causes measles?
  • How is measles spread?
  • How does one become immune to measles?
  • Who is at risk for getting measles?
  • Are measles deadly?
  • What is the danger of getting measles while pregnant?
  • If I am exposed, how long does it take to develop symptoms?
  • What are measles symptoms and signs?
  • What are the complications seen with measles?
  • What is atypical measles?
  • What is modified measles?
  • How is the diagnosis of measles made?
  • If it is not measles, what else could it be?
  • What should I do if I have been exposed to measles?
  • Is there any treatment for measles after symptoms and signs develop?
  • If measles only rarely occurs in the United States, why should I get vaccinated?
  • What is the prognosis for measles?
  • How can I prevent contracting measles?
  • Is there any truth to the fear of getting autism from vaccines?
  • Who should not receive measles vaccinations?
  • If a child has an egg allergy, can they still receive the measles vaccine?
  • What adverse reactions can occur to the measles vaccination?
  • Who should be revaccinated?
  • Where can I find more information about measles?
  • Measles At A Glance

What is measles?

Measles is a highly contagious viral disease that can kill you. Although an uncommon disease in the United States of America, in 2008, measles killed 164,000 children worldwide. In most people, the disease produces fever (temperature > 101 F [38.3 C]), a generalized rash that last greater than three days, cough, runny nose (coryza), and red eyes (conjunctivitis). The complications of measles that result in most deaths include pneumonia and inflammation of the brain (encephalitis).

What is rubeola?

Rubeola is the scientific name used for measles. It should not be confused with rubella (German measles).

What is rubella?

Rubella is the scientific name used of German measles, a different viral illness. While German measles is rarely fatal, it is dangerous in that it causes birth defects and can cause miscarriage and fetal death.

What are other names for measles?

Other terms have been used to describe measles. These include (erroneously) rubella, hard measles, red measles, seven-day measles, eight-day measles, nine-day measles, 10-day measles, and morbilli.

What is the history of measles?

Cases of measles were described as early as the seventh century. However, it was not until 1963 that researchers first developed a vaccine to prevent measles. Before the vaccine was made available, almost every child became infected with the virus because it is so easily spread. Before routine vaccination, there were approximately 3-4 million cases of measles and 500 deaths due to measles each year in the United States.

There were initially two types of vaccines developed against measles. One was developed from a virus that had been killed, and the other was developed using a live measles virus that was weakened (attenuated) and could no longer cause the disease. Unfortunately, the killed measles virus (KMV) vaccine was not effective in preventing people from getting the disease, and its use was discontinued in 1967. The live virus vaccine has been modified a number of times to make it safer (further attenuated) and today is extremely effective in preventing the disease. The currently used vaccine is a live attenuated vaccine.

What causes measles?

Measles is caused by the measles virus (a paramyxovirus).

How is measles spread?

Measles is spread through droplet transmission from the nose, throat, and mouth of someone who is infected with the virus. These droplets are sprayed out when the infected person coughs or sneezes. Among unimmunized people exposed to the virus, over 90% will contract the disease. The infected person is highly contagious for four days before the rash appears until four days after the rash appears. The measles virus can remain in the air (and still be able to cause disease) for up to two hours after an infected person has left a room.

How does one become immune to measles?

Anyone who has had measles is believed to be immune for life. People who have received two doses of vaccine after their first birthday have a 98% likelihood of being immune. Infants receive some immunity from their mother. Unfortunately, this immunity is not complete, and infants are at increased risk for infection until they receive the vaccination at 12 to 15 months of age.

Who is at risk for getting measles?

Those people at high risk for measles include:

  • children less than 1 year of age (although they have some immunity passed from their mother, it is not 100% effective);
  • people who have not received the proper vaccination series;
  • people who received immunoglobulin at the time of measles vaccination;
  • people immunized from 1963 until 1967 with an older ineffective killed measles vaccine.

Are measles deadly?

Measles can kill you. In 2008, approximately 164,000 people died of measles in the world. However, measles is rarely fatal in the United States. This is due to the fact that most people are immunized, which results in very infrequent outbreaks. Also, people most likely to have complications (including death) are those who are malnourished or who have weakened immune systems

What is the danger of getting measles while pregnant?

If you contract measles while you are pregnant, you may have a miscarriage, a stillbirth, or a preterm delivery. There appears to be no risk of having birth defects (unlike an infection with the rubella virus, known as German measles).

If I am exposed, how long does it take to develop symptoms?

The typical time from exposure to a person infected with measles to development of the initial symptoms is 10-12 days (the range is seven to 21 days). The rash occurs a few days after the initial symptoms (ranges from seven to 18 days from exposure).

Picture of a child with measles skin rash
Picture of a baby with measles. Source: CDC

 

What are measles symptoms and signs?

The typical case of measles actually starts with a fever, runny nose, hacking cough, and red eyes. After two to four days of these symptoms, the patient may develop spots within the mouth called Koplik's spots. These spots look like little grains of white sand surrounded by a red ring and are usually found inside the cheek toward the back of the mouth (opposite the first and second upper molars).

The skin rash (also known as an exanthem or exanthema) appears three to five days after the onset of the initial symptoms (fever, cough, runny nose, and red eyes). The rash is a flat to slightly raised (maculopapular) red rash that usually last five to six days. It begins at the hairline and then progresses to the face and upper neck. Over the next two to three days, the rash progresses downward to cover the entire body, including the hands and feet. The rash has mostly distinct lesions, but some may overlap (become confluent). Initially, these lesions will turn white when you press on them (blanch). After three to four days, they no longer will blanch. As the rash begins to fade, there will often be a fine flaking of the skin (desquamation). The rash fades in the same order that it appears.

The fever that occurs with measles is called a stepwise fever. The patient starts with a mild fever that progressively gets higher. Fevers often reach temperatures greater than 103 F (39.4 C).

Although not as common as other symptoms, some patients may have a sore throat.

What complications are seen with measles?

Approximately 30% of cases of measles have an associated complication. These complications can include diarrhea (8%), ear infections (7%), pneumonia (6%), blindness (1%), acute brain inflammation (encephalitis) (0.1%), and persistent brain inflammation (subacute sclerosing panencephalitis) (0.0001%).

Blindness associated with measles is due to a combination of poor nutrition (specifically vitamin A deficiency) and the measles infection. Prevention is the most effective treatment. In third-world countries, post-measles blindness is the leading cause of blindness, with up to 60,000 cases occurring annually.

Acute encephalitis, although rare, is extremely dangerous and results in death in approximately 15% of patients who develop it. When it occurs, acute encephalitis generally starts six days after onset of the rash. Symptoms can include fever, headache, vomiting, stiff neck, drowsiness, seizures, and coma.

Subacute sclerosing panencephalitis (SSP) is an extremely rare degenerative condition of the brain and spinal cord (central nervous system). It is believed to be caused by a chronic infection of the central nervous system with the measles virus. Typically, symptoms start years after the patient had measles (average seven years, range one month to 27 years). The patient has a slow and progressive loss of brain function, seizures, and eventually death results. There is no known treatment for SSP.

Most deaths from measles are due to pneumonia in children and encephalitis in adults. There are approximately 2.2 deaths per 1,000 people who get the measles. The people most likely to have complications (including death) are those who are malnourished or who have weakened immune systems (for example, people with AIDS or other conditions that weaken the immune system).

 

What is atypical measles?

Atypical measles occurs in people who received the killed measles vaccine (KMV; only used from 1963 until 1967) and who are exposed to wild-type measles virus. The KMV unfortunately sensitizes the patient to the measles virus but does not offer any protection. The disease is characterized by fever, pleural effusions, pneumonia, and swelling of the extremities. The rash of atypical measles is different from measles in that it may have an urticarial component (hives) and usually appears first on the ankles and wrists.

It is recommended by the U.S. Centers for Disease Control and Prevention (CDC) that people who may have received the KMV should receive revaccination with the live measles vaccine.

The virus can be isolated in tissue culture in the lab. Blood (serologic) tests are also available.

Picture of Koplik's spots
Picture of Koplik spots. Source: CDC

 

What is modified measles?

Modified measles is seen in patients who, because they were unimmunized, received immune globulin after being exposed to a patient with measles. It is also seen occasionally in young infants who have limited immunity from their mothers. The immune globulin prolongs the time from exposure to onset of symptoms (incubation period). When the symptoms do occur, they are much milder than those seen with normal measles and tend to last a shorter period of time.

How is the diagnosis of measles made?

The diagnosis of suspected measles is mostly clinical, meaning that the appearance and history of the patient suggest the diagnosis. In a person with known exposure to someone with measles or travel to a foreign country, measles should always be considered when faced with a patient who has high fever and characteristic rash. Until the rash appears, the presence of Koplik's spots should help to suggest the diagnosis. Most cases of suspected measles in the United States turn out not to be measles (see below). It is recommended that the diagnosis be confirmed using a blood test for IgM, a type of antibody against the virus. If the IgM test is positive, viral cultures should be obtained. The state and local health department should be contacted immediately for any suspected case in order to follow the correct procedures for viral culture and isolation of the patient. Further information on laboratory testing of suspected cases is available from the CDC (http://www.cdc.gov/vaccines/pubs/surv-manual/chpt07-measles.htm).

If it is not measles, what else could it be?

There are a large number of infectious diseases and other conditions that can cause some of the symptoms of measles. These include, but are not limited to, dengue fever, drug rashes, enteroviral infections, fifth disease, German measles (rubella), Kawasaki disease, Rocky Mountain spotted fever, roseola, and toxic shock syndrome. It is important that suspected cases be seen by a medical expert and appropriate laboratory tests be ordered.

 

What should I do if I have been exposed to measles?

People who have been appropriately vaccinated (or who have had the disease) and who are exposed to a patient with measles do not need to do anything. If an unimmunized person is exposed to a patient with measles, they should receive the vaccine as soon as possible. This may prevent the disease if given within 72 hours of exposure. Immune globulin may have some benefit if given within six days of exposure. The CDC recommends that immune globulin be utilized for household contacts of infected people, immunocompromised people, and pregnant women. It is not recommended that immune globulin be utilized to control a measles outbreak.

Is there any treatment for measles after symptoms and signs develop?

The treatment of patients with measles is mostly focused upon symptom relief. Specific complications like pneumonia may require antibiotics. Patients should be on bed rest until the fever has resolved and should remain well hydrated. In malnourished patients, vitamin A supplementation is recommended. Patients should be isolated to prevent spread of the disease.

If measles only rarely occurs in the United States, why should I get vaccinated?

Although measles only rarely occurs in the United States, it still does occur and can be fatal. In the year 2000, almost 1 million children died of the disease. Through a very intensive effort by the World Health Organization, this was decreased to only 164,000 in 2008. When the number of vaccinated individuals starts to decrease, we see the disease start to occur more frequently. This occurred from 1989 until 1991 in the U.S. During that period, there were 55,000 cases and 123 deaths from measles in the U.S. Due to a massive public-health effort, almost all children in the U.S. now receive measles vaccine before they are allowed to enter school. The number of cases of measles in the U.S. dropped to only 37 in 2004. Most cases are now from outside the U.S. (commonly from adopted children from China), although some cases occur as people in this country are exposed to the infected international traveler.

What is the prognosis for measles?

Most people who contract measles will recover completely. Only 2.2 out of 1,000 people who get measles will die. People who are malnourished or immunocompromised are more likely to have complications or die. However, it is possible for any person to die from the measles, which highlights the importance of becoming vaccinated. Almost no one who has been vaccinated has died from the disease.

How can I prevent contracting measles?

The only way to prevent measles is by receiving measles immunization: This is commonly given as a shot containing measles, mumps, and rubella vaccine (MMR) or a shot containing measles, mumps, rubella, and varicella vaccine (MMRV). The MMRV is not recommended for anyone older than 12 years of age. The current recommendation is that everyone receives two doses of the vaccine after 1 year of age. If the vaccine is received before 1 year of age, the person should receive two additional doses.

The measles vaccine is also available as a single vaccine; however, in most cases, there is no reason to utilize the measles vaccine alone without mumps and rubella vaccine. The complete schedule of recommended vaccinations is available from the CDC (http://www.cdc.gov/vaccines/recs/schedules/child-schedule.htm).

Is there any truth to the fear of getting autism from vaccines?

There is no valid scientific evidence that the measles vaccine, or any other vaccine, is the cause of autism. The possibility of an association between the measles vaccine and autism was proposed by Andrew Wakefield and colleagues in 1998. The research published by Wakefield was found to be flawed and actually forged, and the results have not been able to be repeated by other researchers. Since 1998, there have been numerous studies that have examined for such an association. None of these studies have shown any risk of autism associated with the use of the vaccine. A recent study performed in Japan after the MMR vaccine was removed from the market showed that autism continued to increase after the vaccine was no longer being utilized. Although autism is a very serious disease that warrants good research to find out its many causes, not obtaining vaccinations is potentially dangerous and not supported by the best scientific data available today.

Who should not receive measles vaccinations?

The following groups of people should not receive measles vaccinations:

  • People who have suffered a severe allergic reaction to either the measles vaccine or its components (gelatin or neomycin) should not receive the vaccine.
  • Women known to be pregnant should not receive the vaccine. Pregnancy should be avoided for four weeks after vaccination.
  • Severely immunocompromised patients (cancer patients or patients who are receiving large doses of corticosteroids) should not receive the vaccine. However, those leukemia patients who have been in remission for three months may receive the MMR.
  • Patients with severe human immunodeficiency virus (HIV) infections should not receive the vaccine. However, asymptomatic patients with HIV are considered to be safe for vaccination. The CDC has issued guidelines for vaccination based on the CD4+ T-lymphocyte counts.
  • People with a moderate to severe acute illness should wait until their illness resolves before receiving the vaccine.

Patients with history of thrombocytopenic purpura or thrombocytopenia (low platelets) may be at increased risk, and immunization should be decided on a case-by-case basis.

If a child has an egg allergy, can they still receive the measles vaccine?

Although the measles vaccine is made using chick embryos, there is no evidence of increased reactions in people with an egg allergy. Therefore the CDC recommends giving MMR vaccine to egg-allergic children without any prior skin testing or the use of special protocols.

What adverse reactions can occur with the measles vaccination?

Adverse reactions to measles vaccination (as part of the MMR) include fever (5%-15%), rash (5%), joint aches (5%), and low platelet count (thrombocytopenia; one instance per 30,000 doses). In adult women, up to 25% will suffer joint pain that is due to the rubella component of the vaccine. The fever usually occurs seven to 12 days after the vaccination, and the rash occurs seven to 10 days after vaccination.

Who should be revaccinated?

The following group of people should be considered unvaccinated and should receive at least one dose of vaccine:

  • People vaccinated before their first birthday should be revaccinated.
  • Anyone known to have been vaccinated with the killed measles vaccine (KMV) should be revaccinated.
  • Anyone vaccinated with KMV who received their dose of live measles vaccine with four months of their last dose of vaccine should be revaccinated.
  • Anyone vaccinated before 1968 in whom it is not known if the vaccine was KMV or not should be revaccinated.

Where can I find more information about measles?

1. http://wwwn.cdc.gov/travel/yellowBookCh4-Measles.aspx

2. http://www.cdc.gov/vaccines/pubs/
pinkbook/downloads/meas.pdf

3. http://www.cdc.gov/vaccines/pubs/surv-manual/chpt07-measles.htm

4. http://www.who.int/mediacentre/factsheets/fs286/en/

5. http://www.who.int/vaccines-documents/GlobalSummary/GlobalSummary.pdf

6. http://www.immunize.org/catg.d/p2065.pdf (autism)

Melanosis Coli
(Pseudomelanosis Coli)


  • What is melanosis coli?
  • What are the symptoms of melanosis coli?
  • What causes melanosis coli?
  • How is melanosis coli diagnosed?
  • What is the prognosis (outcome) of melanosis coli?
  • Find a local Gastroenterologist in your town

What is melanosis coli?

Melanosis coli is a condition usually associated with chronic laxative use in which dark pigment is deposited in the lamina propria (one of the lining layers) of the large intestine (colon). The pigment deposition results in a characteristic dark brown to black discoloration of the lining of the large intestine. This condition is sometimes called pseudomelanosis coli because the pigment deposits consist of a pigment known as lipofuscin and do not contain melanin as implied by the term "melanosis." Lipofuscin is a cellular pigment that forms when cells are destroyed, often called "wear and tear" pigment that can be found throughout the body.

The dark color of the intestinal lining may be uniform or patterned, and the discoloration may be slight or very pronounced. The intensity and pattern of the discoloration may even vary among different sites in the colon of a patient. The condition may also be reversed upon discontinuation of laxative use. In some cases, the wall of the colon appears normal to the eye, but microscopic evaluation of biopsies by a pathologist reveals areas of pigment in the colon's lining. The pigment in melanosis coli does not accumulate in polyps or tumors of the large intestine.

What are the symptoms of melanosis coli?

Melanosis coli does not cause symptoms.

What causes melanosis coli?

Melanosis coli usually results from chronic use of laxatives of the anthranoid group. Some examples of anthranoid laxatives are senna and rhubarb derivatives. Many of these laxatives have been in use for hundreds of years. In 1997, the U.S. Food and Drug Administration (FDA) banned the use of the popular anthranoid laxative phenolphthalein due to fears that it might be carcinogenic (cancer-causing). Animal studies had shown that extremely high doses of phenolphthalein led to tumors in animals, but it has never been shown to cause cancers in humans.

The anthranoid laxatives pass through the gastrointestinal tract unabsorbed until they reach the large intestine, where they are changed into their active forms. The resulting active compounds cause damage to the cells in the lining of the intestine and leads to apoptosis (a form of cell death). The damaged (apoptotic) cells appear as darkly pigmented bodies that may be taken up by scavenger cells known as macrophages. When enough cells have been damaged, the characteristic pigmentation of the bowel wall develops.

How is melanosis coli diagnosed?

Melanosis coli can be observed during endoscopic procedures that examine the large intestine, such as colonoscopy and sigmoidoscopy . Sometimes the diagnosis is made upon microscopic examination of biopsies taken during endoscopic procedures.

What is the prognosis (outcome) of melanosis coli?

If a person stops using anthranoid laxatives, the changes associated with melanosis coli lessen over time and may disappear.

Early studies suggested that anthranoid laxatives might have carcinogenic or tumor-promoting activities in humans and that the presence of melanosis coli might signal an increased risk for the development of colorectal cancer. However, more recent follow-up studies have failed to show an association between colon cancer and anthranoid laxative use or between colon cancer and the finding of melanosis coli.

MELAS Syndrome


  • What is MELAS?
  • What causes MELAS?
  • What are the symptoms of MELAS?
  • How is MELAS diagnosed?
  • When do people with MELAS develop symptoms?
  • How is MELAS treated?
  • Are there other mitochondrial diseases?

What is MELAS?

MELAS is a rare form of dementia. MELAS is an abbreviation that stands for Mitochondrial Encephalopathy, Lactic Acidosis, and Stroke-like episodes.

What causes MELAS?

MELAS syndrome is caused by mutations in the genetic material (DNA) in the mitochondria. While most of our DNA is in the chromosomes in the cell nucleus, some of our DNA is in another important structure called the mitochondrion (plural: mitochondria).

The mitochondria are located outside the nucleus in the cell's cytoplasm. Each mitochondrion has a chromosome made of DNA that is quite different from the better known chromosomes in the nucleus. The mitochondrial chromosome is much smaller; it is round (whereas the chromosomes in the nucleus are normally shaped like rods); there are many copies of the mitochondrial chromosome in every cell; and no matter whether we are male or female, we inherit all of our mitochondrial chromosome from our mother.

Much of the DNA in our mitochondria is used to manufacture proteins involved in the key function of mitochondria -- to produce energy and power the cells in our body.

What are the symptoms of MELAS?

As a result of the disturbed function of their cells' mitochondria, patients with MELAS develop brain dysfunction (encephalopathy) with seizures and headaches, as well as muscle disease with a build-up of lactic acid in the blood (a condition called lactic acidosis), temporary local paralysis (stroke-like episodes), and abnormal thinking (dementia).

How is MELAS diagnosed?

The diagnosis of MELAS is usually suspected on clinical grounds. However, confirmation of the diagnosis usually requires a muscle or brain biopsy. The muscle biopsy shows characteristic ragged red fibers; a brain biopsy shows stroke-like changes.

When do people with MELAS develop symptoms?

MELAS can affect people at very different times in life, ranging from age 4 to age 40 or more. However, most patients with MELAS syndrome show symptoms before they are 20 years old.

How is MELAS treated?

There is no known treatment for the underlying disease, which is progressive and fatal. Patients are managed according to what areas of the body are affected at a particular time. Antioxidants and vitamins have been used, but there have been no consistent successes reported.

Are there other mitochondrial diseases?

Yes, mutations (genetic changes) in the mitochondrial chromosome are responsible for a number of other disorders aside from MELAS such as:

  • An important eye disease called Leber hereditary optic atrophy ;
  • A type of epilepsy called MERRF which stands for Myoclonus Epilepsy with Ragged Red Fibers; and
  • A neuromuscular disease called the Kearns-Sayre syndrome .

MELAS and all other mitochondrial diseases were entirely enigmatic before it was discovered that they were due to mutations not in regular chromosomes but in the chromosome of the mitochondria.

Melasma


  • What is melasma? What are signs of melasma?
  • What causes melasma?
  • Where is melasma seen on the body?
  • What are the types of melasma?
  • How is melasma diagnosed?
  • What is the treatment for melasma?
  • What melasma treatments can I have at my doctor's office?
  • Do lasers work for melasma?
  • How does hydroquinone work in melasma?
  • Are there non-hydroquinone alternative treatments for melasma?
  • What is Tri-Luma?
  • What SPF is recommended for melasma?
  • Can melasma be prevented?
  • What is the prognosis for melasma?
  • Melasma At A Glance
  • Find a local Dermatologist in your town

What is melasma? What are signs of melasma?

Melasma is a very common patchy brown, tan, or blue-gray facial skin discoloration, almost entirely seen in women in the reproductive years. It typically appears on the upper cheeks, upper lip, forehead, and chin of women 20-50 years of age. Although possible, it is uncommon in males. It is thought to be primarily related to external sun exposure, external hormones like birth control pills, and internal hormonal changes as seen in pregnancy. Most people with melasma have a history of daily or intermittent sun exposure. Melasma is most common among pregnant women, especially those of Latin and Asian descents. People with olive or darker skin, like Hispanic, Asian, and Middle Eastern individuals, have higher incidences of melasma.

An estimated 6 million women are living in the U.S. with melasma and 45-50 million women worldwide live with melasma; over 90% of all cases are women. Prevention is primarily aimed at facial sun protection and sun avoidance. Treatment requires regular sunscreen application and fading creams.

What causes melasma?

The exact cause of melasma remains unknown. Experts believe that the dark patches in melasma could be triggered by several factors, including pregnancy, birth control pills, hormone replacement therapy (HRT and progesterone), family history of melasma, race, antiseizure medications, and other medications that make the skin more prone to pigmentation after exposure to ultraviolet (UV) light. Uncontrolled sunlight exposure is considered the leading cause of melasma, especially in individuals with a genetic predisposition to this condition. Clinical studies have shown that individuals typically develop melasma in the summer months, when the sun is most intense. In the winter, the hyperpigmentation in melasma tends to be less visible or lighter.

When melasma occurs during pregnancy, it is also called chloasma, or "the mask of pregnancy." Pregnant women experience increased estrogen, progesterone, and melanocyte-stimulating hormone (MSH) levels during the second and third trimesters of pregnancy. However, it is thought that pregnancy-related melasma is caused by the presence of increased levels of progesterone and not due to estrogen and MSH. Studies have shown that postmenopausal women who receive progesterone hormone replacement therapy are more likely to develop melasma. Postmenopausal women receiving estrogen alone seem less likely to develop melasma.

In addition, products or treatments that irritate the skin may cause an increase in melanin production and accelerate melasma symptoms.

People with a genetic predisposition or known family history of melasma are at an increased risk of developing melasma. Important prevention methods for these individuals include sun avoidance and application of extra sunblock to avoid stimulating pigment production. These individuals may also consider discussing their concerns with their doctor and avoiding birth control pills and hormone replacement therapy (HRT) if possible.

Where is melasma seen on the body?

Melasma is characterized by discoloration or hyperpigmentation primarily on the face. Three types of common facial patterns have been identified in melasma, including centrofacial (center of the face), malar (cheekbones), and mandibular (jawbone).

The centrofacial pattern is the most prevalent form of melasma and includes the forehead, cheeks, upper lip, nose, and chin. The malar pattern includes the upper cheeks. The mandibular pattern is specific to the jaw.

The upper sides of the neck may less commonly be involved in melasma. Rarely, melasma may occur on other body parts like the forearms. One study confirmed the occurrence of melasma on the forearms of people being given progesterone. This was a unique pattern seen in a Native American study.

What are the types of melasma?

Four types of pigmentation patterns are diagnosed in melasma: epidermal, dermal, mixed, and an unnamed type found in dark-complexioned individuals. The epidermal type is identified by the presence of excess melanin in the superficial layers of skin. Dermal melasma is distinguished by the presence of melanophages (cells that ingest melanin) through out the dermis. The mixed type includes both the epidermal and dermal type. In the fourth type, excess melanocytes are present in the skin of dark-skinned individuals.

 

How is melasma diagnosed?

Melasma is usually readily diagnosed by the typical appearance of brown skin patches on the face. Dermatologists are physicians who specialize in skin disorders and often diagnose melasma by visually examining the skin. A black light or Wood's light (340-400 nm) can assist in diagnosing melasma. In most cases, mixed melasma is diagnosed, which means the discoloration is due to pigment in the dermis and epidermis. Rarely, a skin biopsy may be necessary to help exclude other causes of this local skin hyperpigmentation.

What is the treatment for melasma?

The most common melasma therapies include 2% hydroquinone (HQ) creams like the over-the-counter products Esoterica and Porcelana and prescription 4% creams like Obagi Clear, Glyquin, Tri-Luma, and Solaquin. Products with HQ concentrations above 2% generally require a prescription. Clinical studies show that creams containing 2% HQ can be very effective in lightening the skin and less irritating than higher concentrations of HQ for melasma. These creams are usually applied to the brown patches twice a day. Sunscreen should be applied over the hydroquinone cream every morning. There are treatments for all types of melasma, but the epidermal type responds better to treatment than the others because the pigment is closer to the skin surface.

Melasma may clear spontaneously without treatment. Other times, it may clear with sunscreen usage and sun avoidance. For some people, the discoloration with melasma may disappear following pregnancy or if birth control pills and hormone therapy are discontinued.

In order to treat melasma, combination or specially formulated creams with hydroquinone, a phenolic hypopigmenting agent, azelaic acid, and retinoic acid (tretinoin), nonphenolic bleaching agents, and/or kojic acid may be prescribed. For severe cases of melasma, creams with a higher concentration of HQ or combining HQ with other ingredients such as tretinoin, corticosteroids, or glycolic acid may be effective in lightening the skin.

  • Azelaic acid 15%-20% (Azelex, Finacea)
  • Retinoic acid 0.025%-0.1% (tretinoin)
  • Tazarotene 0.5%-0.1% (Tazorac cream or gel)
  • Adapalene 0.1%-0.3% (Differin gel)
  • Kojic acid
  • Lactic acid lotions 12% (Lac-Hydrin or Am-Lactin)
  • Glycolic acid 10%-20% creams (Citrix cream, NeoStrata)
  • Glycolic acid peels 10%-70%
 

Possible side effects of melasma treatments include temporary skin irritation. People who use HQ treatment in very high concentrations for prolonged periods (usually several months to years) are at risk of developing a side effect called ochronosis. Hydroquinone-induced ochronosis is a permanent skin discoloration that is thought to result from use of hydroquinone concentrations above 4%. Although ochronosis is fairly uncommon in the U.S., it is more common in areas like Africa where hydroquinone concentrations upward of 10%-20% may be used to treat skin discoloration like melasma. Regardless of the potential side effects, HQ remains the most widely used and successful fading cream for treating melasma worldwide. Regular medical follow-up appointments with a doctor are important for people using HQ treatment for melasma. HQ should be discontinued at the first signs of ochronosis.

What melasma treatments can I have at my doctor's office?

In conjunction with home cream applications, in-office treatments include chemical peels (chemical exfoliation), microdermabrasion (mechanical exfoliation), and laser therapy. These additional treatments may be useful for some cases of melasma.

Many types and strengths of chemical peels are available for different skin types. The type of peel should be tailored for each individual and selected by the physician. In treating melasma, 30%-70% glycolic acid peels are very common. Various combinations, including a mix of 10% glycolic acid and 2% HQ, can be used to treat melasma.

Microdermabrasion utilizes vacuum suction and an abrasive material like fine diamond chips or aluminum oxide crystals to exfoliate the top layers of the skin. The vacuum pressure is adjusted depending on the sensitivity and tolerance of the skin. Typical microdermabrasion sessions can last anywhere from a few minutes to one hour. Minimal to no recovery time is needed after microdermabrasion. Microdermabrasion techniques can improve melasma, but dramatic results are not generally seen or expected after one or two treatments. Multiple treatments in combination with sunscreen and other creams yield best results.

There is no guarantee that melasma will be improved with these procedures. In some cases, if treatments are too harsh or abrasive, melasma can be induced or worsen. Additionally, these procedures are almost always considered cosmetic and may not be covered by medical insurance providers.

Do lasers work for melasma?

Lasers may be used in melasma. Laser therapy is not the primary choice to treat melasma as studies reveal little to no improvement in the hyperpigmentation for most patients. Lasers may actually temporarily worsen some types of melasma and should be used with caution. Multiple laser treatments may be necessary to see results, as treatments are most effective when they are repeated.

To ensure that treatment doesn't fail, people must minimize sun exposure. People who treat their melasma report a better quality of life because they feel better about themselves. As with any treatment, people should consult their physician. Pregnant women or mothers breastfeeding may need to wait to treat melasma. Many melasma creams need to be discontinued in pregnancy and breastfeeding because of possible risks to the developing fetus and newborn. These people may consider cosmetics to temporarily conceal the skin discoloration.

How does hydroquinone work in melasma?

Researchers believe that the hydroxyphenolic chemical (HQ) blocks a step in a specific enzymatic pathway that involves tyrosinase. Tyrosinase is the enzyme that converts dopamine to melanin. Melanin gives skin its color.

 

Are there non-hydroquinone alternative treatments for melasma?

Azelaic acid is a non-hydroquinone cream that can be used to treat melasma. Studies have reported that 15%-20% azelaic acid was very effective and safe in melasma. There are no major complications reported with azelaic acid. Possible minor side effects include itching (pruritus), redness (erythema), scaling (dry patches), and a temporary burning sensation that tends to improve after 14-30 days of use.

Tretinoin cream (Retin A, Renova, Retin A Micro) is a non-hydroquinone cream used to treat melasma. Most often, tretinoin is used in combination with other creams like azelaic acid or hydroquinone. Mild localized side effects are fairly common and include peeling, dry skin, and irritation. Overall, melasma may respond slower to treatment with tretinoin alone than with hydroquinone.

Other retinoid creams include tazaratone and adapelene. These are prescription creams used much like tretinoin (Retin A).

What is Tri-Luma?

Tri-Luma is a combination prescription cream containing fluocinolone acetonide 0.01%, hydroquinone 4%, and tretinoin 0.05%. It is used to treat melasma and other skin discoloration. Results may be seen in usually about six to eight weeks from starting treatment. Tri-Luma should not be used for prolonged periods exceeding eight weeks without your doctor's recommendation. It should not be used by pregnant or breastfeeding women unless specifically instructed by your physician.

 

Other combination creams include the Kligman formula which is a triple cream including a retinoid, a hydroquinone, and a topical steroid (for example, fluocinolone acetonide 0.01%, hydroquinone 8%, and tretinoin 0.1%). These triple combination creams may be compounded in different strengths by specialty pharmacists according to a physician's prescription. Triple creams are highly effective for melasma.

What SPF is recommended for melasma?

A daily sun protection factor (SPF) of at least 30 that contains physical blockers, such as zinc oxide and titanium dioxide, is recommended to block UV rays. Chemical blockers may not fully block both types of UV-A and UV-B as effectively as zinc or titanium. The regular use of sun protection enhances the effectiveness of melasma treatments.

Can melasma be prevented?

Sometimes melasma may be preventable by avoiding facial sun exposure. In most cases, prevention is difficult. Individuals who have a family history of melasma must take extra precautions to prevent melasma. The most important way to prevent the onset of melasma and premature aging is to avoid the sun. If exposure to sunlight cannot be avoided, then hats, sunglasses, and sunblock with physical blockers should be worn.

What is the prognosis for melasma?

Although melasma tends to be a chronic disorder with periodic ups and downs, the prognosis for most cases is good. Just as melasma develops slowly, clearance also tends to be slow. The gradual disappearance of dark spots is based on establishing the right treatment combination for each individual skin type. Melasma that does not successfully respond to treatment are because of a lack of avoidance of sun exposure.

Melasma At A Glance
  • Melasma is most common in women 20-50 years of age.
  • Melasma looks like brown, tan, or blue-gray spots on the face (hyperpigmentation).
  • Melasma is characterized by three location patterns (central face, cheekbone, and jawline).
  • Melasma is caused partly by sun, genetic predisposition, and hormonal changes.
  • The most common treatment is topical creams containing hydroquinone.
  • Melasma prevention requires sun avoidance and sun protection with hats and sunscreen.

Melioidosis
(Whitmore's Disease)


  • What is melioidosis? What causes melioidosis?
  • Where does melioidosis occur?
  • What are symptoms of melioidosis?
  • How is melioidosis diagnosed?
  • How is melioidosis treated?
  • Can melioidosis be prevented?
  • What is the prognosis for melioidosis?
  • Melioidosis At A Glance

What is melioidosis? What causes melioidosis?

Melioidosis, also called Whitmore's Disease, is an infectious disease caused by a bacterium called Burkholderia pseudomallei (previously known as Pseudomonas pseudomallei). The bacteria are found in contaminated water and soil and spread to humans and animals through direct contact with the contaminated source. The bacteria are also of some concern as a potential agent for biological warfare and biological terrorism.

Melioidosis is similar to glanders disease, which is passed to humans from infected domestic animals.

Where does melioidosis occur?

Melioidosis is most frequently reported in Southeast Asia and Northern Australia. It also occurs in South Pacific, Africa, India, and the Middle East. The bacterium that causes the disease is found in the soil, rice paddies, and stagnant waters of the area. People acquire the disease by inhaling dust contaminated by the bacteria and when the contaminated soil comes in contact with abraded (scraped) area of the skin. Infection most commonly occurs during the rainy season.

In the United States, confirmed cases range from none to five each year and occur among travelers and immigrants, according to the U.S. Centers for Disease Control and Prevention (CDC).

What are symptoms of melioidosis?

Melioidosis symptoms most commonly stem from lung disease where the infection can form a cavity of pus (abscess). The effects can range from mild bronchitis to severe pneumonia. As a result, patients also may experience fever, headache, loss of appetite, cough, chest pain, and general muscle soreness.

The effects can also be localized to infection on the skin (cellulitis) with associated fever and muscle aches. It can spread from the skin through the blood to become a chronic form of melioidosis affecting the heart, brain, liver, kidneys, joints, and eyes.

Melioidosis can be spread from person to person as well.

How is melioidosis diagnosed?

The diagnosis of melioidosis is made with a microscopic evaluation of a blood, urine, sputum, or skin-lesion sample in the laboratory. A blood test is useful to detect early acute cases of melioidosis, but it can not exclude the illness if it is negative.

How is melioidosis treated?

The treatment of melioidosis involves antibiotics and depends on the location of the disease.

For patients with more mild illness, the CDC recommends antibiotics such as imipenem, penicillin, doxycycline, amoxicillin-clavulanic acid, ceftazidime, ticarcillin-clavulanic acid, ceftriaxone, and aztreonam. Patients who are more severely ill are given a combination of two of the above for up to 12 months.

With pulmonary involvement of melioidosis, if cultures remain positive for six months, surgical removal of the lung abscess with lobectomy is considered.

Can melioidosis be prevented?

In counties where melioidosis occurs, people with compromised immune systems (such as AIDS, cancer, those undergoing chemotherapy, etc.) should avoid contact with soil and contaminated water, especially in farm areas.

What is the prognosis for melioidosis?

Untreated, melioidosis is fatal. When treated with antibiotics, severe forms of the illness have a 50% chance of recovery, but overall the mortality rate is 40%.

Melioidosis At A Glance
  • Melioidosis is an infectious disease caused by a bacterium, Burkholderia pseudomallei.
  • Melioidosis infection commonly involves the lungs.
  • Melioidosis is diagnosed with the help of blood, urine, sputum, or skin-lesion testing.
  • Melioidosis is treated with antibiotics.
  • The overall mortality rate is 40%.

Meniere's Disease

  • What is Meniere's disease?
  • What causes Meniere's disease?
  • What are the symptoms of Meniere's disease?
  • How is Meniere's disease diagnosed?
  • How can Meniere's disease be treated?
  • Meniere's Disease At A Glance
  • Patient Discussions: Meniere's Disease - Treatments
  • Patient Discussions: Meniere Disease - Symptoms Experienced and Effective Treatments
  • Find a local Ear, Nose, & Throat Doctor in your town

What is Meniere's disease?

Meniere's disease is a disorder of the flow of fluids of the inner ear.

What causes Meniere's disease?

Although the cause of Meniere's disease is unknown, it probably results from an abnormality in the way fluid of the inner ear is regulated. In most cases only one ear is involved, but both ears may be affected in about 10% to 20% of patients. Meniere's disease typically starts between the ages of 20 and 50 years of age (although it has been reported in nearly all age groups). Men and women are equally affected. The symptoms may be only a minor nuisance, or can become disabling, especially if the attacks of vertigo are severe, frequent, and occur without warning. Meniere's disease is also called idiopathic endolymphatic hydrops.

What are the symptoms of Meniere's disease?

The symptoms of Meniere's disease typically include at least several of the following:

  • Episodic rotational vertigo: Attacks of a spinning sensation accompanied by disequilibrium (an off-balanced sensation), nausea, and sometimes vomiting. This is usually the most troublesome symptom. The vertigo usually last 20 minutes to two hours or even longer. During attacks, patients are very disabled, and sleepiness may follow. An off-balanced sensation may last for several days.
  • Tinnitus: A roaring, buzzing, machine-like, or ringing sound in the ear. It may be episodic with an attack of vertigo or it may be constant. Usually the tinnitus gets worse or will appear just before the onset of the vertigo.
  • Hearing loss: It may be intermittent early in the onset of the disease, but overtime it may become a fixed hearing loss. It may involve all frequencies, but most commonly occurs in the lower frequencies. Loud sounds may be uncomfortable and appear distorted in the affected ear.
  • Ear fullness: Usually this full feeling occurs just before the onset of an attack of vertigo.

How is Meniere's disease diagnosed?

The diagnosis of Meniere's disease is primarily made from the history and physical examination. Tinnitus or ear fullness (aural fullness) need to be present to make the diagnosis An audiogram is helpful to show a hearing loss, and to rule-out other abnormalities. It is often helpful, if it can be done safely, to have an audiogram during or immediately following an attack of vertigo. This may show the characteristic low frequency hearing loss. As the disease progresses hearing loss usually worsens.

Other tests such as the auditory brain stem response (ABR), a computerized test of the hearing nerves and brain pathways, computer tomography (CT scan) or, magnetic resonance imaging (MRI) may be needed to rule out a tumor occurring on the hearing or balance nerve. These tumors are rare, but they can cause symptoms similar to Meniere's disease. A full neurological evaluation is performed to exclude other causes of vertigo.

How can Meniere's disease be treated?

  • Medications: A diuretic (water pill) such as triamterene (Dyazide, Maxzide) combined with a low salt diet, is the primary treatment of Meniere's disease. Anti-vertigo medications such as meclizine (Antivert, Bonine, Meni-D, Antrizine) or diazepam (Valium) may provide temporary relief during the attacks of vertigo. Anti-nausea medications [for example, promethazine (Phenergan)]  sometimes also are prescribed. Both anti-vertigo and anti-nausea medications may cause drowsiness.
  • Surgery: If vertigo attacks are not controlled medically and are disabling, one of the following surgical procedures may be recommended depending on the individual patient's situation:

     

    • endolymphatic shunt (A surgical procedure in which a shunt (tube) is placed in the endolymphatic sac that drains excess fluid from the ear.)
    • selective vestibular neurectomy
    • labyrinthectomy (surgical removal of the  labyrinth of the ear) and eighth nerve section.

     

Although there is no real cure for Meniere's disease, the attacks of vertigo can be controlled in nearly all cases. If you have vertigo without warning, you should not drive, because failure to control the vehicle may be hazardous to yourself and to others. Safety may require you to forego ladders, scaffolds, and swimming.

Meniere's Disease At A Glance

  • Meniere's disease is a disorder of the flow of fluids of the inner ear.
  • Symptoms of Meniere's disease include ringing, ear fullness, hearing loss, and poor equilibrium.
  • Diagnosis of Meniere's disease is usually based on history and exam, though other tests can be used.
  • Treatments for Meniere's disease include diet and life style changes, medications, and surgery.

Menopause
(Perimenopause)


  • What is menopause?
  • At what age does a woman typically reach menopause?
  • What conditions can affect the timing of menopause?
  • What are the symptoms of menopause?
  • What are the complications and effects of menopause on chronic medical conditions?
  • Are hormone levels or other blood tests helpful in detecting menopause?
  • What are the treatment options for the symptoms of menopause?
  • Hormone therapy
  • Other medical therapies
  • Alternative therapies
  • Non-hormone therapies
  • Lifestyle factors in managing menopause symptoms
  • Menopause At A Glance
  • Menopause and Perimenopause - Slideshow View Menopause and Perimenopause Slideshow
  • Patient Discussions: Menopause - Experience
  • Patient Discussions: Menopause - Symptoms Experienced
  • Find a local Obstetrician-Gynecologist in your town

What is menopause?

Menopause is defined as the state of an absence of menstrual periods for 12 months. The menopausal transition starts with varying menstrual cycle length and ends with the final menstrual period. Perimenopause means "the time around menopause" and is often used to refer to the menopausal transitional period. It is not officially a medical term, but is sometimes used to explain certain aspects of the menopause transition in lay terms. Postmenopause is the entire period of time that comes after the last menstrual period.

Menopause is the time in a woman's life when the function of the ovaries ceases. The ovary (female gonad), is one of a pair of reproductive glands in women. They are located in the pelvis, one on each side of the uterus. Each ovary is about the size and shape of an almond. The ovaries produce eggs (ova) and female hormones such as estrogen. During each monthly menstrual cycle, an egg is released from one ovary. The egg travels from the ovary through a Fallopian tube to the uterus.

The ovaries are the main source of female hormones, which control the development of female body characteristics such as the breasts, body shape, and body hair. The hormones also regulate the menstrual cycle and pregnancy. Estrogens also protect the bone. Therefore, a woman can develop osteoporosis (thinning of bone) later in life when her ovaries do not produce adequate estrogen.

Perimenopause is different for each woman. Scientists are still trying to identify all the factors that initiate and influence this transition period.

 

At what age does a woman typically reach menopause?

The average age of menopause is 51 years old. But there is no way to predict when an individual woman will enter menopause. The age at which a woman starts having menstrual periods is also not related to the age of menopause onset. Most women reach menopause between the ages of 45 and 55, but menopause may occur as earlier as the 30s or 40s or may not occur until a woman reaches her 60s. As a rough "rule of thumb," women tend to undergo menopause at an age similar to that of their mothers.

Perimenopause, often accompanied by irregularities in the menstrual cycle along with the typical symptoms of early menopause, can begin up to 10 years prior to the last menstrual period.

What conditions can affect the timing of menopause?

Certain medical and surgical conditions can influence the timing of menopause.

Surgical removal of the ovaries

The surgical removal of the ovaries (oophorectomy) in an ovulating woman will result in an immediate menopause, sometimes termed a surgical menopause or induced menopause. In this case, there is no perimenopause, and after surgery, a woman will generally experience the signs and symptoms of menopause. In cases of surgical menopause, women often report that the abrupt onset of menopausal symptoms results in particularly severe symptoms, but this is not always the case.

The ovaries are often removed together with the removal of the uterus (hysterectomy). If a hysterectomy is performed without removal of both ovaries in a woman who has not yet reached menopause, the remaining ovary or ovaries are still capable of normal hormone production. While a woman cannot menstruate after the uterus is removed by a hysterectomy, the ovaries themselves can continue to produce hormones up until the normal time when menopause would naturally occur. At this time a woman could experience the other symptoms of menopause such as hot flashes and mood swings. These symptoms would then not be associated with the cessation of menstruation. Another possibility is that premature ovarian failure will occur earlier than the expected time of menopause, as early as 1-2 years following the hysterectomy. If this happens, a woman may or may not experience symptoms of menopause.

Cancer chemotherapy and radiation therapy

Depending upon the type and location of the cancer and its treatment, these types of cancer therapy (chemotherapy and/or radiation therapy) can result in menopause if given to an ovulating woman. In this case, the symptoms of menopause may begin during the cancer treatment or may develop in the months following the treatment.

Premature ovarian failure

Premature ovarian failure is defined as the occurrence of menopause before the age of 40. This condition occurs in about 1% of all women. The cause of premature ovarian failure is not fully understood, but it may be related to autoimmune diseases or inherited (genetic) factors.

What are the symptoms of menopause?

It is important to remember that each woman's experience is highly individual. Some women may experience few or no symptoms of menopause, while others experience multiple physical and psychological symptoms. The extent and severity of symptoms varies significantly among women. These symptoms of menopause and perimenopause are discussed in detail below.

Irregular vaginal bleeding

Irregular vaginal bleeding may occur during menopause. Some women have minimal problems with abnormal bleeding during perimenopause whereas others have unpredictable, excessive bleeding. Menstrual periods (menses) may occur more frequently (meaning the cycle shortens in duration), or they may get farther and farther apart (meaning the cycle lengthens in duration) before stopping. There is no "normal" pattern of bleeding during the perimenopause, and patterns vary from woman to woman. It is common for women in perimenopause to have a period after going for several months without one. There is also no set length of time it takes for a woman to complete the menopausal transition. It is important to remember that all women who develop irregular menses should be evaluated by her doctor to confirm that the irregular menses are due to perimenopause and not as a sign of another medical condition.

The menstrual abnormalities that begin in the perimenopause are also associated with a decrease in fertility, since ovulation has become irregular. However, women who are perimenopausal may still become pregnant until they have reached true menopause (the absence of periods for one year) and should still use contraception if they do not wish to become pregnant.

Hot flashes & night sweats

Hot flashes are common among women undergoing menopause. A hot flash is a feeling of warmth that spreads over the body and is often most pronounced in the head and chest. A hot flash is sometimes associated with flushing and is sometimes followed by perspiration. Hot flashes usually last from 30 seconds to several minutes. Although the exact cause of hot flashes is not fully understood, hot flashes are likely due to a combination of hormonal and biochemical fluctuations brought on by declining estrogen levels.

There is currently no method to predict when hot flashes will begin and how long they will last. Hot flashes occur in up to 40% of regularly menstruating women in their forties, so they may begin before the menstrual irregularities characteristic of menopause even begin. About 80% of women will be finished having hot flashes after five years. Sometimes (in about 10% of women), hot flashes can last as long as 10 years. There is no way to predict when hot flashes will cease, though they tend to decrease in frequency over time. The average woman who has hot flashes will have them for about five years.

Sometimes hot flashes are accompanied by night sweats (episodes of drenching sweats at nighttime). This may lead to awakening and difficulty falling asleep again, resulting in unrefreshing sleep and daytime tiredness.

Vaginal symptoms

Vaginal symptoms occur as a result of the lining tissues of the vagina becoming thinner, drier, and less elastic as estrogen levels fall. Symptoms may include vaginal dryness, itching, or irritation and/or pain with sexual intercourse (dyspareunia). The vaginal changes also lead to an increased risk of vaginal infections.

Urinary symptoms

The lining of the urethra (the transport tube leading from the bladder to discharge urine outside the body) also undergoes changes similar to the tissues of the vagina, and becomes drier, thinner, and less elastic with declining estrogen levels. This can lead to an increased risk of urinary tract infection, feeling the need to urinate more frequently, or leakage of urine (urinary incontinence). The incontinence can result from a strong, sudden urge to urinate or may occur during straining when coughing, laughing, or lifting heavy objects.

Emotional and cognitive symptoms

Women in perimenopause often report a variety of thinking (cognitive) and/or emotional symptoms, including fatigue, memory problems, irritability, and rapid changes in mood. It is difficult to precisely determine exactly which behavioral symptoms are due directly to the hormonal changes of menopause. Research in this area has been difficult for many reasons.

Emotional and cognitive symptoms are so common that it is sometimes difficult in a given woman to know if they are due to menopause. The night sweats that may occur during perimenopause can also contribute to feelings of tiredness and fatigue, which can have an effect on mood and cognitive performance. Finally, many women may be experiencing other life changes during the time of perimenopause or after menopause, such as stressful life events, that may also cause emotional symptoms.

Other physical changes

Many women report some degree of weight gain along with menopause. The distribution of body fat may change, with body fat being deposited more in the waist and abdominal area than in the hips and thighs. Changes in skin texture, including wrinkles, may develop along with worsening of adult acne in those affected by this condition. Since the body continues to produce small levels of the male hormone testosterone, some women may experience some hair growth on the chin, upper lip, chest, or abdomen.

What are the complications and effects of menopause on chronic medical conditions?

Osteoporosis

Osteoporosis is the deterioration of the quantity and quality of bone that causes an increased risk of fracture. The density of the bone (bone mineral density) normally begins to decrease in women during the fourth decade of life. However, that normal decline in bone density is accelerated during the menopausal transition. As a consequence, both age and the hormonal changes due to the menopause transition act together to cause osteoporosis.

The process leading to osteoporosis can operate silently for decades. Women may not be aware of their osteoporosis until suffering a painful fracture. The symptoms are then related to the location and severity of the fractures.

Treatment of osteoporosis

The goal of osteoporosis treatment is the prevention of bone fractures by slowing bone loss and increasing bone density and strength. Although early detection and timely treatment of osteoporosis can substantially decrease the risk of future fracture, none of the available treatments for osteoporosis are complete cures for the condition. Therefore, the prevention of osteoporosis is as important as treatment.

Osteoporosis treatment and prevention measures are:

  • Lifestyle changes including cessation of cigarette smoking, curtailing alcohol intake, exercising regularly, and consuming a balanced diet with adequate calcium and vitamin D.
  • Calcium and vitamin D supplements may be recommended for women who do not consume sufficient quantities of these nutrients.
  • Medications that stop bone loss and increase bone strength include alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva), zoledronic acid (Reclast), raloxifene (Evista), and calcitonin (Calcimar). Teriparatide (Forteo) is a medication that increases bone formation.
 

Cardiovascular disease

Prior to menopause, women have a decreased risk of heart disease and stroke when compared with men. Around the time of menopause, however, a women's risk of cardiovascular disease increases. Heart disease is the leading cause of death in both men and women in the U.S.

Coronary heart disease rates in postmenopausal women are two to three times higher than in women of the same age who have not reached menopause. This increased risk for cardiovascular disease may be related to declining estrogen levels, but in light of other factors (see Treatment section below), postmenopausal women are not advised to take hormone therapy simply as a preventive measure to decrease their risk of heart attack or stroke.

Are hormone levels or other blood tests helpful in detecting menopause?

Because hormone levels may fluctuate greatly in an individual woman, even from one day to the next, hormone levels are not a reliable method for diagnosing menopause. Even if levels are low one day, they may be high the next day in the same woman. There is no single blood test that reliably predicts when a woman is going through the menopausal transition. Therefore, there is currently no proven role for blood testing regarding menopause except for tests to exclude medical causes of erratic menstrual periods other than menopause. The only way to diagnose menopause is to observe the lack of menstrual periods for 12 months in a woman in the expected age range.

What are the treatment options for menopause?

Menopause itself is a normal part of life and not a disease that requires treatment. However, treatment of associated symptoms is possible if these become substantial or severe.

Hormone therapy

Estrogen and progesterone therapy

Hormone therapy (HT) , also referred to as hormone replacement therapy (HRT) or postmenopausal hormone therapy (PHT), consists of estrogens or a combination of estrogens and progesterone (progestin). Hormone therapy has been used to control the symptoms of menopause related to declining estrogen levels such as hot flashes and vaginal dryness, and HT is still the most effective way to treat these symptoms. But long-term studies (the NIH-sponsored Women's Health Initiative, or WHI) of women receiving combined hormone therapy with both estrogen and progesterone were halted when it was discovered that these women had an increased risk for heart attack, stroke, and breast cancer when compared with women who did not receive HT. Later studies of women taking estrogen therapy alone showed that estrogen was associated with an increased risk for stroke, but not for heart attack or breast cancer. Estrogen therapy alone, however, is associated with an increased risk of developing endometrial cancer (cancer of the lining of the uterus) in postmenopausal women who have not had their uterus surgically removed.

Hormone therapy is available in oral (pill), transdermal form (patch and spray). Transdermal hormone products are already in their active form without the need for "first pass" metabolism in the liver to be converted to an active form. Since transdermal hormone products do not have effects on the liver, this route of administration has become the preferred form for most women. A number of preparations are available for oral and transdermal forms of HT, varying in the both type and amount of hormones in the products.

There has been increasing interest in recent years in the use of so-called "bioidentical" hormone therapy for perimenopausal women. Bioidentical hormone preparations are medications that contain hormones that have the same chemical formula as those made naturally in the body. The hormones are created in a laboratory by altering compounds derived from naturally-occurring plant products. Some of these so-called bioidentical hormone preparations are U.S. FDA-approved and manufactured by drug companies, while others are made at special pharmacies called compounding pharmacies that make the preparations on a case-by-case basis for each patient. These individual preparations are not regulated by the FDA, because compounded products are not standardized.

Like transdermal HT products, bioidentical hormone therapy products are administered transdermally. They are typically applied as cream or gels. Their advocates believe that their use may avoid potentially dangerous side effects of synthetic hormones used in conventional hormone therapy. However, studies to establish the long-term safety and effectiveness of these products have not been carried out.

The decision about hormone therapy, is a very individual decision in which the patient and doctor must take into account the inherent risks and benefits of the treatment along with each woman's own medical history. It is currently recommended that if hormone therapy is used, it should be used at the smallest effective dose for the shortest possible time. The WHI study findings do not support the use of HT for the prevention of chronic disease.

Oral contraceptive pills

Oral contraceptive pills are another form of hormone therapy often prescribed for women in perimenopause to treat irregular vaginal bleeding.

Prior to treatment, a doctor must exclude other causes of erratic vaginal bleeding. Women in the menopausal transition tend to have considerable breakthrough bleeding when given estrogen therapy. Therefore, oral contraceptives are often given to women in the menopause transition to regulate menstrual periods, relieve hot flashes, as well as to provide contraception. The list of contraindications for oral contraceptives in women going through the menopause transition is the same as that for premenopausal women.

Local (vaginal) hormone and non-hormone treatments

There are also local (meaning applied directly to the vagina) hormonal treatments for the symptoms of vaginal estrogen deficiency. Local treatments include the vaginal estrogen ring, vaginal estrogen cream, or vaginal estrogen tablets. Local and oral estrogen treatments are sometimes combined for this purpose.

Vaginal moisturizing agents such as creams or lotions (for example, K-Y Silk-E Vaginal Moisturizer or KY Liquibeads Vaginal Moisturizer) as well as the use of lubricants during intercourse are non-hormonal options for managing the discomfort of vaginal dryness.

Applying Betadine topically on the outer vaginal area, and soaking in a sitz bath or soaking in a bathtub of warm water may be helpful for relieving symptoms of burning and vaginal pain after intercourse.

Other pharmaceutical therapies

Antidepressant medications: The class of drugs known as selective serotonin reuptake inhibitors (SSRIs) and related medications have been shown to be effective in controlling the symptoms of hot flashes in up to 60% of women. Specifically, venlafaxine (Effexor), a drug related to the SSRIs, and the SSRIs fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and citalopram (Celexa) have all been shown to decrease the severity of hot flashes in some women. However, antidepressant medications may be associated with side effects, including decreased libido or sexual dysfunction.

Other medications: Other prescription medications have been shown to provide some relief for hot flashes, although their specific purpose is not the treatment of hot flashes. All of these may have side effects, and their use should be discussed with and monitored by a doctor. Some of these medications that have been shown to help relieve hot flashes include the antiseizure drug gabapentin (Neurontin) and clonidine (Catapres), a drug used to treat high blood pressure.

 

Alternative medical therapies

Plant estrogens (phytoestrogens, isoflavones)

Isoflavones are chemical compounds found in soy and other plants that are phytoestrogens, or plant-derived estrogens. They have a chemical structure that is similar to the estrogens naturally produced by the body, but their effectiveness as an estrogen has been estimated to be much lower than true estrogens. Their estrogen potency has been estimated to be only 1/1000 to 1/100,000 of that of estradiol, a natural estrogen.

Two types of isoflavones, genistein and daidzein, are found in soy beans, chick peas, and lentils, and are considered to be the most potent estrogens of the phytoestrogens.

Some studies have shown that these compounds may help relieve hot flashes and other symptoms of menopause. In particular, women who have had breast cancer and do not want to take hormone therapy (HT) with estrogen sometimes use soy products for relief of menopausal symptoms. However, some phytoestrogens can actually have anti-estrogenic properties in certain situations, and the overall risks of these preparations have not yet been determined. For example, researchers have shown that long-term use of phytoestrogens in postmenopausal women led to an overgrowth of the tissues lining the uterus (endometrial hyperplasia) which can be a precursor to cancer.

There is also a perception among many women that plant estrogens are "natural" and therefore safer than HT, but this has never been proven scientifically. Further research is needed to fully characterize the safety and potential risks of phytoestrogens.

Vitamin E

Some women report that vitamin E supplements can provide relief from mild hot flashes, but scientific studies are lacking to prove the effectiveness of vitamin E in relieving symptoms of menopause. Taking a dosage greater than 400 international units (IU) of vitamin E may not be safe, since some studies have suggested that greater dosages may be associated with cardiovascular disease risk.

Black Cohosh

Black cohosh is an herbal preparation that has been popular in Europe for the relief of hot flashes. This herb has become more and more popular in the U.S., and the North American Menopause Society does support the short-term use of black cohosh for treating menopausal symptoms, for a period of up to six months, because of its relatively low incidence of side effects when used short term. However, there have still been very few scientific studies done to establish the benefits and safety of this product. Research is ongoing to further determine the effectiveness and safety of black cohosh.

A large study known as the Herbal Alternatives for Menopause Trial (HALT) tested the effectiveness of different herbal or alternative ingredients versus estrogen therapy or placebo for the relief of menopausal symptoms. After one year of therapy, there was no significant reduction in the frequency or severity of hot flashes in women receiving any of the herbal preparations (including a group who received black cohosh) when compared to placebo at any of the follow-up times (3, 6, and 12 months).

Other alternative therapies

There are many supplements and substances that have been advertised as "natural" treatments for symptoms of menopause, including licorice, dong quai, chasteberry, and wild yam. Scientific studies have not proven the safety or effectiveness of these products.

Non-pharmaceutical therapies

In women for whom oral or vaginal estrogens are deemed inappropriate, such as breast cancer survivors, or women who do not wish to take oral or vaginal estrogen, there are a variety of over-the-counter vaginal lubricants. However, they are probably not as effective in relieving vaginal symptoms as replacing the estrogen deficiency with oral or local estrogen.

Lifestyle factors in controlling the symptoms and complications of menopause

Many of the symptoms of menopause and the medical complications that may develop in postmenopausal women can be lessened or even avoided by taking steps to lead a healthy lifestyle. Regular exercise can help protect against cardiovascular disease as well as osteoporosis, and exercise also has known mental health benefits. Proper nutrition and smoking cessation will also reduce your risk of cardiovascular disease.

Menopause At A Glance
  • Menopause is defined as the absence of menstrual periods for 12 months. It is the time in a woman's life when the function of the ovaries ceases.
  • The process of menopause does not occur overnight, but rather is a gradual process. This so-called perimenopausal transition period is a different experience for each woman.
  • The average age of menopause onset is 51 years old, but menopause may occur as early as the 30s or as late as the 60s There is no reliable lab test to predict when a woman will experience menopause.
  • The age at which a woman starts having menstrual periods is not related to the age of menopause onset.
  • Symptoms of menopause can include abnormal vaginal bleeding, hot flashes, vaginal and urinary symptoms, and mood changes.
  • Complications that women may develop in the postmenopausal period include osteoporosis and heart disease.
  • Treatments for menopause are customized for each patient.
  • Treatments are directed toward alleviating uncomfortable or distressing symptoms.

Menopause and Sex


Sex And Menopause


  • How does menopause affect your sex drive?
  • Does menopause lower sex Drive in all women?
  • What can I do to treat vaginal dryness during menopause?
  • How Can I Improve My Sex Drive During and After Menopause?
  • What can I do to increase intimacy with my partner?
  • Do I still have to worry about sexually transmitted diseases?
  • How can I protect myself from sexually transmitted diseases?
  • Find a local Obstetrician-Gynecologist in your town

How Does Menopause Affect Your Sex Drive?

The loss of estrogen following menopause can lead to changes in a woman's sexual drive and functioning. Menopausal and postmenopausal women may notice that they are not as easily aroused, and may be less sensitive to touching and stroking -- which can result in decreased interest in sex.

In addition, lower levels of estrogen can cause a decrease in blood supply to the vagina. This decreased blood flow can affect vaginal lubrication, causing the vagina to be too dry for comfortable intercourse.

A lower estrogen level is not the only culprit behind a decreased libido; there are numerous other factors that may influence a woman's interest in sexual activity during menopause and after. These include:

  • Bladder control problems
  • Sleep disturbances
  • Depression or anxiety
  • Stress
  • Medications
  • Health concerns

Does Menopause Lower Sex Drive in all Women?

No. In fact, some post-menopausal women report an increase in sex drive. This may be due to decreased anxiety associated with a fear of pregnancy. In addition, many post-menopausal women often have fewer child-rearing responsibilities, allowing them to relax and enjoy intimacy with their partners.

What Can I Do to Treat Vaginal Dryness During Menopause?

During and after menopause, vaginal dryness can be treated with water-soluble lubricants such as Astroglide or K-Y Jelly. Do not use non-water soluble lubricants such as Vaseline because they can weaken latex (the material used to make condoms, which should continue to be used to avoid pregnancy until your doctor verifies you are not producing anymore eggs and to prevent contracting sexually transmitted diseases). Non-water soluble lubricants can also provide a medium for bacterial growth, particularly in a person whose immune system has been weakened by chemotherapy..

How Can I Improve My Sex Drive During and After Menopause?

Currently, there are not any good drugs to treat sexual problems in women dealing with menopause. Estrogen replacement may work, but research has yielded conflicting results regarding its effectiveness. Estrogen can, however, make intercourse less painful by treating vaginal dryness.

Doctors are also studying whether a combination of estrogen and the male hormones, called androgens, may be helpful in increasing sex drive in women.

Although sexual problems can be difficult to discuss, talk to your doctor; there are options to consider, such as counseling. Your doctor may refer you and your partner to a health professional who specializes in sexual dysfunction. The therapist may advise sexual counseling on an individual basis, with your partner or in a support group. This type of counseling can be very successful, even when it is done on a short-term basis.

 

How Can I Increase Intimacy With My Partner During Menopause?

During menopause, if your sex drive isn't what it once was but you don't think you need counseling, you should still take time for intimacy with your partner. Being intimate does not require having intercourse -- love and affection can be expressed in many ways. Enjoy your time together -- you can take long romantic walks, have candlelit dinners, or give each other back rubs.

To improve your physical intimacy, you may want to try the following approaches:

  • Educate yourself about your anatomy, sexual function, and the normal changes associated with aging, as well as sexual behaviors and responses. This may help you overcome your anxieties about sexual function and performance.
  • Enhance stimulation through the use of erotic materials (videos or books), masturbation, and changes to sexual routines.
  • Use distraction techniques to increase relaxation and eliminate anxiety. These can include erotic or non-erotic fantasies; exercises with intercourse; and music, videos, or television.
  • Practice non-coital behaviors (physically stimulating activity that does not include intercourse), such as sensual massage. These activities can be used to promote comfort and increase communication between you and your partner.
  • Minimize any pain you may be experiencing by using sexual positions that allow you to control the depth of penetration. You may also want to take a warm bath before intercourse to help you relax, and use vaginal lubricants to help reduce pain caused by friction.

Do I Still Have to Worry About Sexually Transmitted Diseases?

Yes. Just as you must use protection if you do not want to become pregnant during perimenopause, you must also take measures to protect yourself against sexually transmitted diseases (STDs) during menopause and postmenopause. It's important to remember that your risk of contracting STDs is a possibility at any point in your life during which you are sexually active, and this risk does not go down with age or with changes in your reproductive system.

Left untreated, some STDs can lead to serious illnesses, while others, like AIDS, cannot be cured and are deadly.

How Can I Protect Myself From STDs?

Here are some basic steps that you can take to help protect yourself from STDs:

  • Consider that not having sex is the only sure way to prevent STDs.
  • Use a latex condom every time you have sex. (If you use a lubricant, make sure it is water-based (not Vaseline.)
  • Limit your number of sexual partners. The more partners you have, the more likely you are to catch an STD.
  • Practice monogamy. This means having sex with only one person. That person must also have sex with only you to reduce your risk.
  • Choose your sex partners with care. Don't have sex with someone whom you suspect may have an STD.
  • Get checked for STDs. Don't risk giving the infection to someone else.
  • If you have more than one sex partner, always use a condom.
  • Don't use alcohol or drugs before you have sex. You may be less likely to practice safe sex if you are drunk or high.
  • Know the signs and symptoms of STDs. Look for them in yourself and your sex partners.
  • Learn about STDs. The more you know about STDs, the better you can protect yourself.
Last Updated on Sunday, 18 December 2011 16:40
 
Antimitochondrial Antibodies (AMA) PDF Print E-mail
Written by Ruai Pharmaceuticals   
Thursday, 15 September 2011 15:51

Antimitochondrial Antibodies
(AMA)


  • What are antimitochondrial antibodies (AMA)?
  • Do AMA cause the destruction of the bile ducts in PBC?
  • How is the blood test for AMA done?
  • What is the value of the AMA blood test?

What are antimitochondrial antibodies (AMA)?

Between 95 and 98% of patients with primary biliary cirrhosis (PBC) have autoantibodies (antibodies to self) in their blood that react with the inner lining of mitochondria. These autoantibodies are called antimitochondrial antibodies (AMA). Mitochondria are the energy factories present inside all of our cells, not just the cells of the liver or bile ducts. (The mitochondria use the oxygen carried in the blood from the lungs as a fuel to generate energy.) AMA actually bind to protein antigens that are contained in multienzyme complexes (packages of enzymes) within the inner lining of the mitochondria. These multienzyme complexes produce key chemical reactions necessary for life. The complexes are referred to as multienzyme because they are made up of multiple enzyme units.

AMA specifically react against a component of this multienzyme complex called E2. In PBC, AMA preferentially react with the E2 component of one of the multienzymes that is called the pyruvate dehydrogenase complex (PDC). Accordingly, the antigen is designated as PDC-E2. The practical importance of all of this is that the PDC-E2 antigen is now used, as discussed below, in a diagnostic test for PBC. The PDC-E2 antigen is also referred to as M2, a term introduced to designate it as the second mitochondrial antigen discovered by researchers interested in PBC.

Do AMA cause the destruction of the bile ducts in PBC?

In as much as the bile ducts are the main targets of destruction in PBC, the question was asked whether the AMA reacts with the epithelial cells that line the bile ducts. So, investigators prepared antibodies to PDC-E2. As expected, they found that these antibodies bound to the mitochondria within the cells. But, sure enough, recent information suggests that these AMA autoantibodies also bind to PDC-E2 that lies outside the mitochondria, yet within the epithelial cells lining the bile ducts.

This accumulation of PDC-E2 within the biliary epithelial cells is observed exclusively in the livers of patients with PBC, and not in normal livers or in livers from patients with any other types of liver disease. Interestingly, it was also observed in the livers of those two to five percent of PBC patients who do not have AMA in their blood (AMA-negative PBC). Furthermore, intense binding of these antibodies to biliary epithelial cells was also found to be the earliest indication of recurrence of PBC in a transplanted liver. (PBC is sometimes treated by liver transplantation.)

Nevertheless, no evidence exists that the AMA itself causes the destruction of the biliary epithelial cells lining the small bile ducts. Neither the presence nor the amount (titer) of AMA in the blood appears to be related to the inflammatory destruction of the bile ducts. Indeed, immunization of animals with PDC-E2 antigen results in production of AMA without any liver or bile duct damage (pathology).

How is the blood test for AMA done?

The most economical test for AMA applies diluted samples of a patient's serum onto tissue sections from rat stomach or kidney in the laboratory. (Remember that mitochondria are present in all cells, not just the cells of the liver and bile ducts.) Serum antibodies that attach (bind) to mitochondrial membranes within the tissue cells can then be observed with a microscope. The most dilute sample of serum showing this binding reaction is reported, using the term titer. The titer indicates the most dilute serum sample that reacts with the tissue mitochondria. A higher titer means there is a greater amount of AMA in the serum.

The antigen recognized by AMA in patients with PBC is now known to be PDC-E2 and is also often referred to as the M2 antigen. So, newly developed tests for antibodies that bind to PDC-E2 are more specific and are now available to confirm the diagnosis of PBC.

What is the value of the AMA blood test?

AMA are detectable in the serum in 95 to 98% of patients with PBC. So, AMA are tremendously important as a diagnostic marker in patients with PBC. The AMA titers in PBC are almost universally greater than or equal to 1 to 40. This means that a serum sample diluted with 40 times its original volume still contains enough antimitochondrial antibodies to be detected in the binding reaction. A positive AMA with a titer of at least 1:40 in an adult with an elevated alkaline phosphatase in the blood is highly specific for a diagnosis of PBC.

Macular Degeneration


  • Macular degeneration facts
  • What is macular degeneration?
  • What is the retina?
  • What is the macula?
  • What is age-related macular degeneration (AMD)?
  • What is wet age-related macular degeneration?
  • What are retinal drusen?
  • What is dry age-related macular degeneration?
  • What causes macular degeneration?
  • What are risk factors for macular degeneration?
  • What are macular degeneration symptoms?
  • What are signs of macular degeneration?
  • How is macular degeneration diagnosed?
  • What is the treatment for wet macular degeneration?
  • What is the treatment for dry macular degeneration?
  • What are complications of macular degeneration?
  • What research is being done on macular degeneration?
  • Find a local Eye Doctor in your town

Macular degeneration facts

  • The macula is in the center of the retina, the light-sensitive layer of tissue at the back of the eye. The macula is responsible for central vision (straight-ahead vision). Degeneration of the macula occurs most often after the age of 60 years and is termed age-related macular generation (AMD).
  • AMD is a painless condition.
  • There are two types of AMD: dry AMD and wet AMD.
  • Smoking, high blood pressure, obesity, a diet high in unsaturated fats and simple carbohydrates and lack of exercise all increase the risk of AMD.
  • Early symptoms of dry AMD include slightly blurred vision, the need for more light for reading, and difficulty recognizing faces until very close to the person. A symptom of more advanced dry AMD is the presence of a blurred spot in the center of vision. An early symptom of wet AMD is the wavy appearance of straight lines.
  • Dry AMD cannot be treated at present, but progression can be slowed through a healthy lifestyle and, in certain cases, through anti-oxidant vitamins. Injections into the eye of anti-angiogenic agents are successfully used in arresting or slowing wet AMD. Because of new therapies for the wet form of AMD, early diagnosis of wet AMD is particularly critical.
Picture of the eye

 

 

What is macular degeneration?

Macular degeneration is a common, painless eye condition in which the central portion of the retina deteriorates and does not function adequately.

What is the retina?

The retina is the light sensitive tissue located in the back of the eye. It is like the film in a camera, recording the images we see and sending them via the optic nerve from the eye to the brain. The retina instantly converts light images into electrical impulses through a chemical reaction. The retina then sends these impulses or signal, to the brain, where we interpret what we see, process the visual information, and relate what we see to the rest of our environment.

What is the macula?

The macula is a small portion of the retina located in the central portion of the retina. The macula is responsible for central vision (straight-ahead vision) and provides the ability to see fine detail in your direct line of sight. We use the macula of each eye to have the clear vision that allows us to read, drive a car, and recognize faces or colors. The non-macular areas of the retina provide us with our side vision and best night vision.

What is age-related macular degeneration (AMD)?

Although there are many types of macular degeneration, age-related macular degeneration (AMD or ARMD) is by far the most common type. AMD is a disease associated with aging that gradually destroys sharp central vision that is needed for seeing objects clearly and for common daily tasks such as reading and driving. In some cases, AMD advances so slowly that people notice little change in their vision. In others, the disease progresses faster and may lead to a loss of vision in both eyes. AMD is the leading cause of vision loss in Americans 60 years of age and older. AMD usually affects both eyes, although the clinical appearance and degree of visual loss may vary a great deal between the two eyes.

AMD occurs in two forms. "Wet" age-related macular degeneration is less common but more aggressive in its progression to severe central vision loss. "Dry" age-related macular degeneration is the more common type and is more slowly progressive in causing visual loss

What is wet age-related macular degeneration?

Wet AMD occurs when abnormal blood vessels grow from the choroid (the layer of blood vessels between the retina and the outer firm coat of the eye called the sclera) under and into the macular portion of the retina. These new blood vessels (known as choroidal neovascularization or CNV) tend to be very fragile and often leak blood and fluid. The blood and fluid raise the macula from its normal place at the back of the eye and interfere with the retina's function and causes the central vision to blur. Under these circumstances, vision loss may be rapid and severe. Some patients, however, do not notice visual changes despite the onset of CNV. Therefore, periodic eye examinations are very important for patients at risk for CNV.

Once CNV has developed in one eye, whether there is a visual loss or not, the other eye is at relatively high risk for the same change.

All wet AMD is described as advanced AMD, whether or not there is serious visual loss. Wet AMD does not have not have stages like dry AMD. The wet form generally leads to significantly more vision loss than the dry form.

All people who have the dry form of AMD are at risk for development of the wet form. All people who have the wet form had the dry form first. The dry form can advance and cause vision loss without turning into the wet form. The dry form also suddenly can turn into the wet form. Currently, there is no certain way to predict if or when the dry form will turn into the wet form.

What are retinal drusen?

Retinal drusen are yellow deposits under the retina. They often are found in people over 60 years of age. Your eye-care professional can detect drusen during a comprehensive dilated eye exam.

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

What is dry age-related macular degeneration?

In dry AMD, the light sensitive cells in the macula slowly break down. With less of the macula functioning, central vision diminishes. Dry AMD often occurs in just one eye at first. Later, the other eye can be affected. The cause of dry AMD is unknown.

Dry AMD has three stages, early, intermediate, or advanced, all of which may occur in one or both eyes. People with early AMD have either several small drusen or a few medium-sized drusen. At this stage, there are no symptoms and no vision loss.

People with intermediate AMD have either many medium-sized drusen or one or more large drusen. Some people see a blurred spot in the center of their vision. More light may be needed for reading and other tasks.

In addition to drusen, people with advanced dry AMD have a breakdown of light-sensitive cells and supporting tissue in the central retinal area. This breakdown can cause a blurred spot in the center of your vision. Over time, the blurred spot may get bigger and darker, taking more of your central vision. You may have difficulty reading or recognizing faces until they are very close to you.

The dry form is much more common than the wet form. In dry AMD, there is no CNV (abnormal new blood vessel formation under the retina) and no fluid or blood leakage into the retina (retinal swelling or bleeding). More than 85% of all people with intermediate and advanced AMD combined have the dry form. However, if only advanced AMD is considered, about two-thirds of patients have the wet form.

Dry AMD can advance and cause vision loss without turning into wet AMD. Dry AMD can also rapidly transform into the wet form by the growth of new blood vessels.

What causes macular degeneration?

We do not know the precise cause for the development of ARMD. However, we do know that there are certain risk factors for the development of age-related macular degeneration.

What are risk factors for macular degeneration?

The greatest risk factor is age. Although AMD may occur during middle age, studies show that people over age 60 are clearly at greater risk than other age groups. Middle-aged people have about a 2% risk of getting AMD while people over age 75 have a nearly 30% risk.

Other risk factors include smoking, obesity, white race, female gender, a family history of macular degeneration, a diet low in fruit and vegetables, high blood pressure, and elevated blood cholesterol.

What are macular degeneration symptoms?

Neither dry nor wet AMD cause any eye pain.

The most common early symptom in dry AMD is blurred vision. As fewer cells in the macula are able to function, people will see details less clearly in front of them, such as faces or words in a book. Often this blurred vision will go away in brighter light. If the loss of these light-sensing cells becomes great, people may see a small black or gray blind spot in the middle of their field of vision.

Dry macular degeneration symptoms usually develop gradually and do not include total blindness. However, the symptoms may worsen the quality of life by making reading, driving, and facial recognition difficult Other symptoms may include decreased night vision, a decrease in the intensity or brightness of colors, increase in the haziness of overall vision.

Dry macular degeneration may affect one eye or both eyes. If only one eye is affected, symptoms may not be noticed because the unaffected eye has no visual symptoms.

All of the above symptoms may also be noticed in the wet form of AMD. In addition, the most common symptom in wet macular degeneration is straight lines appearing crooked or wavy. This results when fluid from the leaking blood vessels gathers within and lifts the macula, distorting vision. Larger areas of gray or black in the central area of vision may also occur. The central vision may decrease over a short period of time.

What are signs of macular degeneration?

In both dry and wet forms of macular degeneration, the ophthalmologist may find decreased visual clarity (acuity) with preservation of peripheral vision and changes in the central retina visible with the ophthalmoscope.

How is macular degeneration diagnosed?

Your ophthalmologist may suspect the diagnosis of AMD if you are over age 60 and have had recent changes in your central vision. To look for signs of the disease, he or she will use eyedrops to dilate, or enlarge, your pupils. Dilating the pupils allows your ophthalmologist to view the back of the eye better.

Early AMD is often diagnosed during a comprehensive eye exam in patients without significant symptoms. This eye exam includes having drops placed in your eyes to enlarge, or dilate, the pupils. Your ophthalmologist will carefully examine the central portion of the retina to determine the presence or absence of AMD using various illuminating and magnifying devices.

During the eye exam, you may be asked to look at a checkerboard pattern called an Amsler grid. When looking at an Amsler grid with one eye, patients with AMD may notice that the straight lines of the checkerboard appear wavy or are missing.

Other diagnostic tests that your ophthalmologist may perform include retinal photography, fluorescein angiography and optical coherence tomography. All of these can help to differentiate between dry and wet forms of AMD and also document the abnormalities so that progression and response to treatment can be better measured.

What is the treatment for wet macular degeneration?

Wet AMD can be treated with laser surgery, photodynamic therapy, and injections into the eye. None of these treatments is a permanent cure for wet AMD. The disease and loss of vision may progress despite treatment.

Laser surgery is used to destroy the fragile, leaky blood vessels. A high energy beam of light is aimed directly onto the new blood vessels to eradicate them, preventing further loss of vision. However, laser treatment may also destroy some surrounding healthy tissue and some vision. Because of this, only eyes with new vessels away from the exact center of the vision can be treated. This represents only a small proportion of patients with AMD. Laser surgery is only effective in halting or slowing visual loss if the leaky blood vessels have developed away from the fovea, the central part of the macula. Even in treated cases, the risk of new blood vessels recurring after treatment is significant and further or other treatment may be necessary.

Photodynamic therapy uses a drug called verteporfin (Visudyne) being injected into a vein of the arm. A light is then directed into the eye to activate the drug adhering to the blood vessels in the eye. The activated drug destroys the new blood vessels and leads to a slower rate of vision decline. Photodynamic therapy may slow the rate of vision loss. It does not stop vision loss or restore vision in eyes already damaged by advanced AMD. Treatment results often are temporary. Retreatment may be necessary.

 

Within the last seven years, injections into the eye with drugs specifically developed to stop the growth of new blood vessels have revolutionized the treatment of wet macular degeneration. We have learned that a specific chemical called vascular endothelial growth factor (VEGF) is necessary for the new blood vessels to grow under the retina. Drugs that counter VEGF (anti-VEGF pharmacotherapy) can be injected into the eye to arrest development of new blood vessels and sometimes cause them to regress. These drugs are injected in the ophthalmologist's office and may need to be given as frequently as monthly. Careful observation of the eye on a monthly basis to determine the drug effect is necessary. With this treatment, visual loss can often be halted or slowed and some patients will even experience some improvement of vision. Newer drugs currently under review may need to be given less frequently.

In patients with far advanced macular degeneration on both eyes, surgery to implant a telescopic lens in one eye is an option. The telescope implant, which surgically replaces the eye's natural lens, magnifies images while reducing the field of vision (peripheral vision). The telescopic lens implant may improve both distance and close-up central vision.

What is the treatment for dry macular degeneration?

There is currently no treatment available to reverse dry macular degeneration. However, dry macular degeneration is usually slowly progressive and most patients with this condition are able to live relatively normal, productive lives. Often one eye is affected more than the other.

Once dry AMD reaches the advanced stage, no form of treatment can prevent further vision loss. However, treatment can delay and possibly prevent intermediate AMD from progressing to the advanced stage of severe vision loss. The National Eye Institute's Age-Related Eye Disease Study (AREDS) found that taking a specific high-dose formulation of antioxidants and zinc significantly reduces the risk of advanced AMD and it's associated vision loss. Slowing AMD's progression from the intermediate stage to the advanced stage is helpful in reducing the progression of visual loss in many people.

In this study, researchers used an antioxidant formulation that included vitamin C, vitamin E, beta carotene (or vitamin A), and zinc. For people with early-stage dry macular degeneration, there is no evidence that these vitamins provide a benefit. It is recommended that people with intermediate-stage dry AMD in one or both eyes or advanced stage AMD (dry or wet) in one eye, but not the other eye, take the AREDS formulation. Patients with increased risk of lung cancer should not take beta carotene. Studies involving other supplements such as lutein and bilberry are currently being performed.

The progression of dry age-related macular degeneration can also be slowed through lifestyle changes. These include changing the diet to include more fruits and vegetable, choosing healthy unsaturated fats, such as olive oil, over unhealthy saturated fats, such as butter, eating whole grains rather than refined grains and adding fish high in omega-3 fatty acids.

What are complications of macular degeneration?

Progression to wet macular degeneration is the main complication of dry age-related macular degeneration. At any time, dry macular degeneration can progress to the more severe form of the disease called wet macular degeneration, which may cause rapid vision loss. There's no accurate way to predict who will eventually develop wet macular degeneration.

Other eye diseases such as cataracts, glaucoma, retinal detachment, or dry eyes are not complications of macular degeneration. Patients with macular degeneration can, however, develop these or other eye diseases.

What is the prognosis for macular degeneration?

Macular degeneration in its advanced form can cause loss of all central vision in both eyes. In the absence of other eye diseases, peripheral vision is maintained. Therefore, patients with advanced macular degeneration are, in most cases, able to see enough to get around in familiar situations.

The use of magnifying devices can often improve vision in macular degeneration to allow for reading or watching of television.

Can macular degeneration be prevented?

Your lifestyle can play a role in reducing your risk of developing AMD. Eating a healthy diet high in green leafy vegetables and fish, not smoking, maintaining blood pressure and weight at normal levels, and engaging in regular moderate exercise can be helpful in prevention of macular degeneration.

What research is being done on macular degeneration?

There is a large amount of research currently being performed to increase our understanding of the basic molecular mechanisms of macular degeneration. These include evaluation of families with a history of AMD to understand genetic and hereditary factors that may cause the disease. There are multiple drugs and devices presently in various phases of clinical trials to both prevent and treat macular degeneration. These include new drugs to prevent new blood vessel formation, certain anti-inflammatory treatments for the wet form of AMD, and drug-delivery systems to reduce the need for frequent injections for the wet form of macular degeneration. The possibility of transplantation of transplanting healthy cells into a diseased retina is also being investigated.

This research should provide better ways to detect, treat, and prevent vision loss in people with AMD.

Mad Cow Disease

  • 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).

Magnetic Resonance Imaging
(MRI Scan)


  • What is an MRI scan?
  • When are MRI scans used?
  • What are the risks of an MRI scan?
  • How does a patient prepare for an MRI scan and how is it performed?
  • How does a patient obtain the results of the MRI scan?
  • Pictures of an MRI of the spine
  • MRI Scan At A Glance
  • Patient Discussions: Magnetic Resonance Imaging (MRI Scan) - Helped With Your Diagnosis
  • Find a local Doctor in your town

What is an MRI scan?

An MRI (or magnetic resonance imaging) scan is a radiology technique that uses magnetism, radio waves, and a computer to produce images of body structures. The MRI scanner is a tube surrounded by a giant circular magnet. The patient is placed on a moveable bed that is inserted into the magnet. The magnet creates a strong magnetic field that aligns the protons of hydrogen atoms, which are then exposed to a beam of radio waves. This spins the various protons of the body, and they produce a faint signal that is detected by the receiver portion of the MRI scanner. The receiver information is processed by a computer, and an image is produced.

The image and resolution produced by MRI is quite detailed and can detect tiny changes of structures within the body. For some procedures, contrast agents, such as gadolinium, are used to increase the accuracy of the images.

 

When are MRI scans used?

An MRI scan can be used as an extremely accurate method of disease detection throughout the body. In the head, trauma to the brain can be seen as bleeding or swelling. Other abnormalities often found include brain aneurysms, stroke, tumors of the brain, as well as tumors or inflammation of the spine.

Neurosurgeons use an MRI scan not only in defining brain anatomy but in evaluating the integrity of the spinal cord after trauma. It is also used when considering problems associated with the vertebrae or intervertebral discs of the spine. An MRI scan can evaluate the structure of the heart and aorta, where it can detect aneurysms or tears.

It provides valuable information on glands and organs within the abdomen, and accurate information about the structure of the joints, soft tissues, and bones of the body. Often, surgery can be deferred or more accurately directed after knowing the results of an MRI scan.

What are the risks of an MRI scan?

An MRI scan is a painless radiology technique that has the advantage of avoiding x-ray radiation exposure. There are no known side effects of an MRI scan. The benefits of an MRI scan relate to its precise accuracy in detecting structural abnormalities of the body.

Patients who have any metallic materials within the body must notify their physician prior to the examination or inform the MRI staff. Metallic chips, materials, surgical clips, or foreign material (artificial joints, metallic bone plates, or prosthetic devices, etc.) can significantly distort the images obtained by the MRI scanner. Patients who have heart pacemakers, metal implants, or metal chips or clips in or around the eyeballs cannot be scanned with an MRI because of the risk that the magnet may move the metal in these areas. Similarly, patients with artificial heart valves, metallic ear implants, bullet fragments, and chemotherapy or insulin pumps should not have MRI scanning.

During the MRI scan, patient lies in a closed area inside the magnetic tube. Some patients can experience a claustrophobic sensation during the procedure. Therefore, patients with any history of claustrophobia should relate this to the practitioner who is requesting the test, as well as the radiology staff. A mild sedative can be given prior to the MRI scan to help alleviate this feeling. It is customary that the MRI staff will be nearby during MRI scan. Furthermore, there is usually a means of communication with the staff (such as a buzzer held by the patient) which can be used for contact if the patient cannot tolerate the scan.

How does a patient prepare for an MRI scan and how is it performed?

All metallic objects on the body are removed prior to obtaining an MRI scan. Occasionally, patients will be given a sedative medication to decrease anxiety and relax the patient during the MRI scan. MRI scanning requires that the patient lie still for best accuracy. Patients lie within a closed environment inside the magnetic machine. Relaxation is important during the procedure and patients are asked to breathe normally. Interaction with the MRI technologist is maintained throughout the test. There are loud, repetitive clicking noises which occur during the test as the scanning proceeds. Occasionally, patients require injections of liquid intravenously to enhance the images which are obtained. The MRI scanning time depends on the exact area of the body studied, but ranges from half an hour to an hour and a half.

How does a patient obtain the results of the MRI scan?

After the MRI scanning is completed, the computer generates visual images of the area of the body that was scanned. These images can be transferred to film (hard copy). A radiologist is a physician who is specially trained to interpret images of the body. The interpretation is transmitted in the form of a report to the practitioner who requested the MRI scan. The practitioner can then discuss the results with the patient and/or family.

Future

Scientists are developing newer MRI scanners that are smaller, portable devices. These new scanners apparently can be most useful in detecting infections and tumors of the soft tissues of the hands, feet, elbows, and knees. The application of these scanners to medical practice is now being tested.

Pictures of an MRI of the spine

This patient had a herniated disc between vertebrae L4 and L5. The resulting surgery was a discectomy

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

 

MRI Scan At A Glance
  • MRI scanning uses magnetism, radio waves, and a computer to produce images of body structures.
  • MRI scanning is painless and does not involve x-ray radiation.
  • Patients with heart pacemakers, metal implants, or metal chips or clips in or around the eyes cannot be scanned with MRI because of the effect of the magnet.
  • Claustrophobic sensation can occur with MRI scanning.

Malaria


  • What is malaria?
  • What are malaria symptoms and signs?
  • How is malaria transmitted?
  • Where is malaria a particular problem?
  • What is the incubation period for malaria?
  • How is malaria diagnosed?
  • What is the treatment for malaria?
  • Is malaria a particular problem during pregnancy?
  • Is malaria a particular problem for children?
  • How do people avoid getting malaria?
  • What is the prognosis (outcome) for people with malaria?
  • Where can people get more information about malaria?
  • Malaria At A Glance
  • Patient Discussions: Malaria - Symptoms and Signs Experienced

What is malaria?

Malaria is an infectious disease caused by a parasite, Plasmodium, which infects red blood cells. Malaria is characterized by cycles of chills, fever, pain, and sweating. Historical records suggest malaria has infected humans since the beginning of mankind. The name "mal aria" (meaning "bad air" in Italian) was first used in English in 1740 by H. Walpole when describing the disease. The term was shortened to "malaria" in the 20th century. C. Laveran in 1880 was the first to identify the parasites in human blood. In 1889, R. Ross discovered that mosquitoes transmitted malaria. Of the four common species that cause malaria, the most serious type is Plasmodium falciparum malaria. It can be life-threatening. However, another relatively new species, Plasmodium knowlesi, is also a dangerous species that is typically found only in long-tailed and pigtail macaque monkeys. Like P. falciparum, P. knowlesi may be deadly to anyone infected. The other three common species of malaria (P. vivax, P. malariae, and P. ovale) are generally less serious and are usually not life-threatening. It is possible to be infected with more than one species of Plasmodium at the same time.

Currently, about 2 million deaths per year worldwide are due to Plasmodium infections. The majority occur in children under 5 years of age in sub-Saharan African countries. There are about 400 million new cases per year worldwide. Most people diagnosed in the U.S. obtained their infection outside of the country, usually while living or traveling through an area where malaria is endemic.

What are malaria symptoms and signs?

The symptoms characteristic of malaria include flulike illness with fever, chills, muscle aches, and headache. Some patients develop nausea, vomiting, cough, and diarrhea. Cycles of chills, fever, and sweating that repeat every one, two, or three days are typical. There can sometimes be vomiting, diarrhea, coughing, and yellowing (jaundice) of the skin and whites of the eyes due to destruction of red blood cells and liver cells.

People with severe P. falciparum malaria can develop bleeding problems, shock, liver or kidney failure, central nervous system problems, coma, and can die from the infection or its complications. Cerebral malaria (coma, or altered mental status or seizures) can occur with severe P. falciparum infection. It is lethal if not treated quickly; even with treatment, about 15%-20% die.

How is malaria transmitted?

The life cycle of the malaria parasite (Plasmodium) is complicated and involves two hosts, humans and Anopheles mosquitoes. The disease is transmitted to humans when an infected Anopheles mosquito bites a person and injects the malaria parasites (sporozoites) into the blood. This is shown in Figure 1, where the illustration shows a mosquito taking a blood meal (circle label 1 in Figure 1).

Figure 1: CDC illustration of the life cycles of malaria parasites, Plasmodium spp.
Figure 1: CDC illustration of the life cycles of malaria parasites, Plasmodium spp. SOURCE: CDC

 

Sporozoites travel through the bloodstream to the liver, mature, and eventually infect the human red blood cells. While in red blood cells, the parasites again develop until a mosquito takes a blood meal from an infected human and ingests human red blood cells containing the parasites. Then the parasites reach the Anopheles mosquito's stomach and eventually invade the mosquito salivary glands. When an Anopheles mosquito bites a human, these sporozoites complete and repeat the complex Plasmodium life cycle. P. ovale and P. vivax can further complicate the cycle by producing dormant stages (hypnozoites) that may not develop for weeks to years.

Where is malaria a particular problem?

Malaria is a particular problem and a major one in areas of Asia, Africa, and Central and South America. Unless precautions are taken, anyone living in or traveling to a country where malaria is present can get the disease. Malaria occurs in about 100 countries; approximately 40% of the world population is at risk for contracting malaria. To get information on countries that have current malaria infection problems, the CDC (Centers for Disease Control) has a constantly updated web site (http://www.cdc.gov/malaria/travelers/
country_table/a.html) that lists the problem areas in detail.

HIV (AIDS) and malaria co-infection is a significant problem across Asia and sub-Saharan Africa. Research suggests that malaria and HIV co-infection can lead to worse clinical outcomes in patients. It seems that co-infections enhance the disease process of both pathogens.

What is the incubation period for malaria?

The period between the mosquito bite and the onset of the malarial illness is usually one to three weeks (seven to 21 days). This initial time period is highly variable as reports suggest that the range of incubation periods may range from four days to one year. The usual incubation period may be increased when a person has taken an inadequate course of malaria prevention medications. Certain types of malaria (P. vivax and P. ovale) parasites can also take much longer, as long as eight to 10 months, to cause symptoms. These parasites remain dormant (inactive or hibernating) in the liver cells during this time. Unfortunately, some of these dormant parasites can remain even after a patient recovers from malaria, so the patient can get sick again. This situation is termed relapsing malaria.

How is malaria diagnosed?

Clinical symptoms associated with travel to countries that have identified malarial risk (listed above) suggest malaria as a diagnosis. Malaria tests are not routinely ordered by most physicians so recognition of travel history is essential. Unfortunately, many diseases can mimic symptoms of malaria (for example, yellow fever, dengue fever, typhoid fever, cholera, filariasis, and even measles and tuberculosis). Consequently, physicians need to order the correct special tests to diagnose malaria, especially in industrialized countries where malaria is seldom seen. Without the travel history, it is likely that other tests will be ordered initially. In addition, the long incubation periods may tend to allow people to forget the initial exposure to infected mosquitoes.

The classic and most used diagnostic test for malaria is the blood smear on a microscope slide that is stained (Giemsa stain) to show the parasites inside red blood cells (see Figure 2).

Figure 2: CDC slide of a Giemsa stained smear of red blood cells showing Plasmodium malariae and Plasmodium falciparum parasites.
Figure 2: CDC slide of a Giemsa stained smear of red blood cells showing Plasmodium malariae and Plasmodium falciparum parasites. SOURCE: CDC/Steven Glenn, Laboratory & Consultation Division

 

Although this test is easily done, correct results are dependent on the technical skill of the lab technician who prepares and examines the slides with a microscope. Other tests based on immunologic principles exist; including RDTs (rapid diagnostic tests) approved for use in the U.S. in 2007 and polymerase chain reaction (PCR) tests. These are not yet widely available and are more expensive than the traditional Giemsa blood smear. Some investigators suggest such immunologic based tests be confirmed with a Giemsa blood smear.

What is the treatment for malaria?

Three main factors determine treatments: the infecting species of Plasmodium parasite, the clinical situation of the patient (for example, adult, child, or pregnant female with either mild or severe malaria), and the drug susceptibility of the infecting parasites. Drug susceptibility is determined by the geographic area where the infection was acquired. Different areas of the world have malaria types that are resistant to certain medications. The correct drugs for each type of malaria must be prescribed by a doctor who is familiar with malaria treatment protocols. Since people infected with P. falciparum malaria can die (often because of delayed treatment), immediate treatment for P. falciparum malaria is necessary.

Mild malaria can be treated with oral medication; severe malaria (one or more symptoms of either impaired consciousness/coma, severe anemia, renal failure, pulmonary edema, acute respiratory distress syndrome, shock, disseminated intravascular coagulation, spontaneous bleeding, acidosis, hemoglobinuria [hemoglobin in the urine], jaundice, repeated generalized convulsions, and/or parasitemia [parasites in the blood] of > 5%) requires intravenous (IV) drug treatment and fluids in the hospital.

Drug treatment of malaria is not always easy. Chloroquine phosphate (Aralen) is the drug of choice for all malarial parasites except for chloroquine-resistant Plasmodium strains. Although almost all strains of P. malariae are susceptible to chloroquine, P. falciparum, P. vivax, and even some P. ovale strains have been reported as resistant to chloroquine. Unfortunately, resistance is usually noted by drug-treatment failure in the individual patient. There are, however, multiple drug-treatment protocols for treatment of drug-resistant Plasmodium strains (for example, quinine sulfate plus doxycycline [Vibramycin, Oracea, Adoxa, Atridox] or tetracycline [Achromycin], or clindamycin [Cleocin], or atovaquone-proguanil [Malarone]). There are specialized labs that can test the patient's parasites for resistance, but this is not done frequently. Consequently, treatment is usually based on the majority of Plasmodium species diagnosed and its general drug-resistance pattern for the country or world region where the patient became infested. For example, P. falciparum acquired in the Middle East countries is usually susceptible to chloroquine, but if it's acquired in sub-Sahara African countries, it's usually resistant to chloroquine. The WHO's treatment policy, recently established in 2006, is to treat all cases of uncomplicated P. falciparum malaria with artemisinin-derived combination therapy (ACTs). ACTs are drug combinations (for example, artesunate-amodiaquine, artesunate-mefloquine, artesunate-pyronaridine, dihydroartemisinin-piperaquine, and chlorproguanil-dapsoneartesunate) used to treat drug-resistant P. falciparum. Unfortunately, as of 2009, a number of P. falciparum-infected individuals have parasites resistant to ACT drugs.

 

New drug treatments of malaria are currently under study because Plasmodium species continue to produce resistant strains that frequently spread to other areas. One promising drug class under investigation is the spiroindolones, which have been effective in stopping P. falciparum experimental infections.

Is malaria a particular problem during pregnancy?

Yes. Malaria may pose a serious threat to a pregnant woman and her fetus. Malaria infection in pregnant women may be more severe than in women who are not pregnant. Malaria may also increase the risk of problems with the pregnancy, including prematurity, abortion, and stillbirth. Statistics indicate that in sub-Saharan Africa, between 75,000-200,000 infants die from malaria per year; worldwide estimates indicate about 2 million children die from malaria each year. Therefore, all pregnant women who are living in or traveling to a malaria risk area should consult a doctor and take prescription drugs (for example, sulfadoxine-pyrimethamine) to avoid contracting malaria. Treatment of malaria in the pregnant female is similar to the usual treatment described above; however, drugs such as primaquine (Primaquine), tetracycline (Achromycin, Sumycin), doxycycline, and halofantrine (Halfan) are not recommended as they may harm the fetus. In addition to monitoring the patient for anemia, an OB/GYN specialist often is consulted for further management.

 

Is malaria a particular problem for children?

Yes. All children, including young infants, living in or traveling to malaria risk areas should take antimalarial drugs (for example, chloroquine and mefloquine [Lariam]). Although the recommendations for most antimalarial drugs are the same as for adults, it is crucial to use the correct dosage for the child. The dosage of drug depends on the age and weight of the child. A specialist in pediatric infectious diseases is recommended for consultation in prophylaxis (prevention) and treatment of children. Since an overdose of an antimalarial drug can be fatal, all antimalarial (and all other) drugs should be stored in childproof containers well out of the child's reach.

 

How do people avoid getting malaria?

If people must travel to an area known to have malaria, they need to find out which medications to take, and take them as prescribed. Current CDC recommendations suggest individuals begin taking antimalarial drugs about one to two weeks before traveling to a malaria infested area and for four weeks after leaving the area (prophylactic or preventative therapy). Doctors, travel clinics, or the health department can advise individuals as to what medicines to take to keep from getting malaria. Currently, there is no vaccine available for malaria, but researchers are trying to develop one.

 

Avoid travel to or through countries where malaria occurs if possible. If people must go to areas where malaria occurs, they should take all of the prescribed preventive medicine. In addition, the 2010 CDC international travel recommendations suggest the following precautions be taken in malaria and other disease-infested areas of the world; the following CDC recommendations are not unique for malaria but are posted by the CDC in their malarial prevention publication.

  • Avoid outbreaks: To the extent possible, travelers should avoid traveling in areas of known malaria outbreaks. The CDC Travelers' Health web page provides alerts and information on regional disease transmission patterns and outbreak alerts (http://www.cdc.gov/travel).
  • Be aware of peak exposure times and places: Exposure to arthropod bites may be reduced if travelers modify their patterns of activity or behavior. Although mosquitoes may bite at any time of day, peak biting activity for vectors of some diseases (for example, dengue, chikungunya) is during daylight hours. Vectors of other diseases (for example, malaria) are most active in twilight periods (for example, dawn and dusk) or in the evening after dark. Avoiding the outdoors or focusing preventive actions during peak hours may reduce risk.
  • Wear appropriate clothing: Travelers can minimize areas of exposed skin by wearing long-sleeved shirts, long pants, boots, and hats. Tucking in shirts and wearing socks and closed shoes instead of sandals may reduce risk. Repellents or insecticides such as permethrin can be applied to clothing and gear for added protection; this measure is discussed in detail below.
  • Check for ticks: Travelers should be advised to inspect themselves and their clothing for ticks during outdoor activity and at the end of the day. Prompt removal of attached ticks can prevent some infections.
  • Bed nets: When accommodations are not adequately screened or air conditioned, bed nets are essential to provide protection and to reduce discomfort caused by biting insects. If bed nets do not reach the floor, they should be tucked under mattresses. Bed nets are most effective when they are treated with an insecticide or repellent such as permethrin. Pretreated, long-lasting bed nets can be purchased prior to traveling, or nets can be treated after purchase. The permethrin will be effective for several months if the bed net is not washed. (Long-lasting pretreated nets may be effective for much longer.)
  • Insecticides: Aerosol insecticides, vaporizing mats, and mosquito coils can help to clear rooms or areas of mosquitoes; however, some products available internationally may contain pesticides that are not registered in the United States. Insecticides should always be used with caution, avoiding direct inhalation of spray or smoke.
  • Optimum protection can be provided by applying repellents. The CDC recommended insect repellent should contain up to 50% DEET (N,N-diethyl-m-toluamide), which is the most effective mosquito repellent for adults and children over 2 months of age.

What is the prognosis (outcome) for people with malaria?

The majority of people who become infected with P. malariae, vivax, or ovale do well and the fevers abate after about 96 hours. However, in endemic areas, reinfection is common. Malaria caused by P. falciparum or P. knowlesi, even when treated, have outcomes ranging from fair to poor, depending on how the parasites react to treatment. Untreated people often die from these infections. In general, patients who are infants, children under the age of 5 (especially in sub-Saharan countries), and those with depressed immune systems (for example, AIDS or cancer patients) have a more guarded prognosis.

Where can people get more information about malaria?

"The History of Malaria, an Ancient Disease," Centers for Disease Control and Prevention

"About Malaria," Centers for Disease Control and Prevention

Traveler's Health - Yellow Book, Centers for Disease Control and Prevention

"Malaria," eMedicine.com

Malaria At A Glance
  • Malaria is a disease caused by Plasmodium spp. parasites that infects about 400 million people per year with about 2 million deaths.
  • Symptoms include recurrent cycles (every one to three days) of fever, chills, muscle aches, headaches; nausea, vomiting, and jaundice also may occur.
  • Anopheles mosquitoes transmit the parasites to humans when they bite. The parasites undergo a complicated life cycle in both mosquitoes and humans; the cycle begins again when the mosquitoes take a blood meal from a human that is contaminated with mature parasites.
  • Africa, Asia, and Central and South America are the areas with high numbers of malarial infections.
  • The incubation period for malaria symptoms is about one to three weeks but may be extended to eight to 10 months after the initial infected mosquito bites occur. Some people may have dormant parasites that may get reactivated years after the initial infection.
  • Malaria is diagnosed by the patient's history of recurrent symptoms and the identification of the parasites in the patient's blood, usually by a Giemsa blood smear.
  • Malaria is usually treated by using combinations of two or more anti-parasite drugs incorporated into pills that are taken before exposure (prophylactic or preventative therapy) or during infection. More serious infections are treated by IV anti-parasitic drugs in the hospital.
  • Infants, children, and pregnant females, along with immunodepressed patients are at higher risk for worse outcomes when infected with malaria parasites.
  • To reduce the chance of getting malaria, people should avoid malaria-endemic areas of the world, use mosquito repellents, cover exposed skin, and use mosquito netting covered areas when sleeping.
  • The prognosis for the majority of malaria patients is good; most recover with no problems, unless infected with P. falciparum or P. knowlesi, which may have fair to poor outcomes unless treated immediately. Infants, children under 5 years of age, pregnant females, and those with depressed immune systems frequently have a fair to poor prognosis unless effectively treated early in the infection.

Male Breast Cancer


  • 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.

Mens Health



  • Introduction to men's health
  • Prostate problems
  • Testosterone
  • Top 10 diseases that kill men
  • Heart disease
  • Cancers
  • Injuries
  • Stroke
  • COPD
  • Diabetes
  • Influenza and pneumonia
  • Suicide
  • Kidney disease
  • Alzheimer's disease
  • The checklist: How to stay healthy
  • Patient Discussions: Mens Health

Introduction to men's health

The average life expectancy of a man born in the United State in 2007 is 75 years and 5 months. The life expectancy for a man has increased dramatically in the past 50 years. How long we live is important; however, the quality of life is equally important. The ability to enjoy life to its fullest requires investing time and effort into health maintenance and disease prevention. This investment pays dividends almost immediately and it is never too late to begin. A person who was 65 years old in 2007 could expect to live to age 82, and a 75 year old could expect 10 more years of life.

Our bodies are incredibly complex machines that require fuel components (food, water, and air) to grow, function, and repair itself. Like any machine, the body requires routine maintenance to make it last a long time and to function well throughout a person's life expectancy. Using the body as it was intended and minimizing abuse also increases its ability to perform. When we buy a car, we expect to routinely change the oil, filters, rotate the tires, and avoid driving too aggressively to keep the car running smoothly and last a certain length of time. As in life, accidents happen and cosmetic injuries occur, but it is the "guts" of a car, the engine, transmission, and brakes that will decide if it will be happily driving down the road or sitting in the junkyard.

Our bodies suffer through illnesses and accidents and many are unavoidable. Taking care of your body also includes scheduled maintenance and screening examinations to detect illnesses at an early stage, which increases the potential for cure and a return to health. Learning to listen to the body's warning signs and symptoms is the same as paying attention to the check engine light in your car, neither should not be ignored.

A healthy lifestyle is not just an absence of disease but an opportunity to enjoy the years of life available to each person. Medical care can help the body maintain its performance as it ages. A longer life expectancy should not be considered a jail sentence to inactivity. But as the body ages, there is an expected and normal physiologic change in some of the hormones in the male body.

Prostate problems

The prostate is a unique male organ. It is located beneath the bladder and connects it to the penis. Its function is to produce part of the seminal fluid that is alkaline, which helps lengthen the life span of semen when it enters the vagina. The prostate also has involuntary muscles that contract to help expel semen during ejaculation.

A common condition in men that is part of the normal aging process is benign prostatic hypertrophy (BPH or enlarged prostate). The urethra is a tube that passes through the prostate and drains the bladder. A man with an enlarged prostate (BPH) often has difficulty emptying the bladder because the urethra is being compressed by prostatic tissue. This compression of the urethra makes it difficult for the bladder to generate enough pressure to overcome the obstruction (enlarged prostate). Over time, the bladder itself begins to weaken making urination even more difficult.

Symptoms of BPH include:

  • Urinary frequency (urinating more often)
  • Urinary urgency (the feeling that he has to empty the bladder urgently or risk wetting himself)
  • Urinary hesitancy (difficulty starting the urine stream)
  • Urinary straining (requiring more pressure or bearing down to empty the bladder)
  • Poor urine stream and dribbling

Treatment of BPH (which may include medications or surgery) depends upon the man, any underlying medical conditions, and the severity of symptoms.

Picture of the prostate gland

 

Testosterone

Sexual health and function are important parts of a healthy lifestyle. The ability to participate in sexual intercourse depends upon the brain, hormones, nerves, and blood vessels that supply the penis. A variety of mechanisms and feedback loops need to work for an erection to occur. There are numerous causes of erectile dysfunction (ED, impotence) including:

  • diabetes,
  • peripheral vascular disease,
  • spinal cord injury, and
  • multiple sclerosis.

Impotence is also a complication of prostate cancer treatment including surgery and radiation.

Smoking is an independent risk factor for developing impotence.

Treatment of erectile dysfunction depends upon the cause but may include medications (for example, tadalafil [Cialis], sildenafil [Viagra], and vardenafil [Levitra, Staxyn], testosterone replacement therapy and, for some men, prosthetic devices surgically inserted into the penis.

 

Testosterone levels that are required for puberty, muscle, and bone development in young adulthood gradually decrease over a man's lifetime (sometimes referred to as Low T). Testosterone levels need to be at a certain level to maintain body and brain function. Numerous theories exist about the use of testosterone therapy routinely in older men, but these theories have not been widely accepted. There are however, a few health care practitioners that use testosterone to "prevent aging."

Top 10 diseases that kill men

"Know your enemy and know yourself and you can fight a hundred battles without disaster."

Sun Tzu. Chinese General. 500BC

Most of the common diseases that affect men are potentially preventable, but one needs to know their enemy. Interestingly, the presence of some diseases increases the likelihood that another will occur. Heart disease, stroke, peripheral vascular disease, and dementia all share the same risk factors:

  • smoking,
  • high blood pressure,
  • high cholesterol, and
  • family history.

1. Heart disease

Heart disease is the number one killer of men in the United States.

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.

Angina

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.

Angina symptoms include:

  • chest pressure with radiation down the arm and to the jaw,
  • shortness of breath,
  • sweating,
  • indigestion,
  • nausea,
  • a decreased ability to do routine activities.

This heart pain is often referred to as "anginal equivalent."

Heart attack

A heart attack (myocardial infarction) occurs when a plaque ruptures, allowing a blood clot to form, which can be life-threatening. The blood clot completely obstructs the artery, stopping blood flow to part of the heart muscle, and that portion of muscle dies.

Abnormal heart rhythms and sudden cardiac arrest

The heart is an electrical pump composed of heart muscle and cells that produce and conduct electrical signals. Heart muscle cells can become irritable because they have lost blood supply and may, in addition, cause electrical abnormalities or short circuits that prevent the heart muscle from pumping which can result in sudden cardiac death.

Heart disease risk factors

The major risk factors for heart disease (and stroke and peripheral vascular disease) include smoking, high blood pressure, high cholesterol, diabetes, and family history. While one cannot control their family history, the other factors can be controlled and the risks minimized. These are life-long obligations to decrease the risk of heart disease.

2. Cancers

Lung cancer is the number one killer among cancers in men, and most are preventable. Smoking causes 90% of all lung cancers and while the number of smokers in the United States has decreased in the past generation, 20% of teenagers smoke and will be the future victims of lung cancer. It is harder to stop smoking than it is to stop many other addictions; nicotine in tobacco is a very addictive drug. Tobacco in its various forms including smokeless or chewing tobacco is related to a variety of other cancers including cancer of the mouth, throat and larynx.

Prostate cancer affects the prostate gland. Prostate cancer is the most common cancer among men, and is a disease of aging and is rarely seen in men younger than 50 years of age. Often prostate cancer causes no symptoms and is diagnosed with routine screening tests including a rectal examination to feel the prostate and a PSA (prostate specific antigen) blood test. The cure rate for prostate cancer has increased since the wide spread use of PSA testing began but it still accounts for 10% of cancer deaths among men.

Colon and rectal cancers tie with prostate cancer as the second most common cause of cancer deaths in men. There are few symptoms in the early stages of colon and rectal cancers, thus the diagnosis is often made by routinely screening the stool for occult blood (blood that is not visible to the naked eye but can be found by testing the stool sample) and undergoing routine screening colonoscopy.

Testicular cancer accounts for only about 1% of cancer in men in the US, but usually occurs in younger men (ages 15 to 39); men can help detect this disease by doing a testicular exam routinely and reporting any testicle abnormalities or symptoms (lumps, swelling, pain) to their health care practitioner.

Living a healthy lifestyle decreases the potential risk of developing cancer. Regular exercise, a healthy diet, and avoiding toxins in the environment (including smoking and secondhand smoke) are positive lifestyle changes that the average person can control during their lifetime.

3. Injuries

Accidents happen and the key to minimizing the risk of death is to use common sense and avoid potentially dangerous situations.

  • Simple actions like wearing a seatbelt while in a car, wearing a helmet when cycling, skiing, skateboarding, or other activities where head injuries occur help decrease risk of death in an accident.
  • Driving while impaired on drugs or alcohol is never acceptable and causes a dangerous situation not only for the driver but for those around him. Impairment driving includes not only alcohol but also medications that can cause sedation, including over-the-counter cold and sleep medications. It also includes driving when tired or sleepy. Many authorities on impaired drivers consider texting and cell phone use impaired driving.
  • Most accidents happen around the house and routine prevention can help decrease those accidents. Easy fixes include making sure that floors aren't slippery or wet, stair railings are secure, and walks and driveways are well maintained and well lit at night. Smoke and carbon monoxide detectors can only work if their batteries are fresh.

4. Stroke (cerebrovascular accident, CVA)

A stroke (cerebrovascular accident [CVA]), occurs when blood supply to part of the brain is disrupted, causing brain cells to die. Blood flow can be compromised by a variety of mechanisms. This can occur because blood supply has been cut off (ischemia) or because there has been bleeding in the brain (hemorrhage). Ischemic strokes occur due to a variety of reasons including the gradual narrowing of a blood vessel in the brain, debris that can break off from the carotid artery in the neck, or from a blood clot that embolizes (or travels) from the heart.

The risk factors for stroke are the same as for heart disease: smoking, high blood pressure, high cholesterol, and family history.

A TIA (transient ischemic attack, mini-stroke) is a stroke that improves, usually quickly. A person develops stroke like symptoms (weakness of one side of the body or face, vision loss, speech difficulty) but it resolves spontaneously within a few minutes or hours. This situation should never be ignored since it is a major warning sign that an impending stroke may occur.

5. COPD (chronic obstructive pulmonary disease)

Emphysema and chronic bronchitis are the two types of chronic obstructive pulmonary disease (COPD) and both are most commonly caused by smoking. Due to the toxins in smoke, the lung tissue is damaged and loses its ability to transfer oxygen from the inhaled air into the blood stream. Symptoms of COPD include shortness of breath and wheezing. COPD increases the risk of lung infection including pneumonia.

6. Diabetes

The pancreas makes insulin to help cells use glucose for energy. Diabetes describes the situation where insulin function in the body is abnormal.

  • Type 1 diabetes usually occurs in people younger than 40 where the body's immune system destroys the insulin producing cells in the pancreas.
  • More than 80% of people with diabetes have type 2 diabetes.

Poorly controlled diabetes increases blood sugar levels in the bloodstream and in the long-term, affects the small blood vessels in the body, which can lead to multi-organ failure. Poorly controlled diabetes can  cause vascular disease leading to heart attacks, strokes, limb amputations, kidney failure, blindness, and nerve damage (diabetic neuropathy).

Diabetes prevention and control include eating a well balanced diet, maintaining a healthy weight, and routinely exercising, and keeping active.

7. Influenza and pneumonia

A healthy lifestyle and healthy body makes for a strong immune system that can fight common infections like influenza (flu). It is important to follow public health recommendations for routine immunizations to reduce the risk of contracting the flu, and its complications such as pneumonia. However, pneumonia is not limited to just viral causes. Bacterial pneumonia is ranked with influenza as one of the major causes of death in men by many researchers. Fortunately, a pneumococcal vaccine has proven effective in preventing one of the most common bacterial causes of pneumonia, Streptococcus pneumoniae.

8. Suicide

Mens sana in copore sano: a healthy mind in a healthy body

Thoughts of self harm are not normal. They should not be ignored by a man, family, or friends, and should be considered an emergency situation. Depression can become overwhelming and potentially life-threatening. Men with depression may be able to function reasonably well on a day to day basis and may be reluctant to seek help. It may take a crisis situation to finally get a man to agree to get medical, psychological, and counseling assistance.

Symptoms of depression may be subtle and arise slowly. They can include:

  • difficulty concentrating or completing projects
  • lack of energy
  • difficulty sleeping or sleeping too much
  • change in appetite (some people stop eating while others overeat)
  • feelings of hopelessness or worthlessness
  • excessive sadness or feelings of emptiness
  • thoughts of suicide or self harm

9. Kidney disease

The kidneys filter impurities from the blood and dispose of them in the urine. They are also important in maintaining electrolyte balance in the blood. Even in healthy people, aging gradually decreases the efficiency of kidney function. Kidney failure is often a result of years of poorly controlled high blood pressure and diabetes.

In the United States, approximately 26 million people have chronic kidney disease.

10. Alzheimer's disease

Dementia and Alzheimer's disease describes a gradual loss of cognition and intellectual ability including language, attention, memory, and problem solving is an otherwise healthy person. The cause is unknown and there is no cure. Recommendations to decrease the risk of dementia include avoiding smoking, and keeping blood pressure, high cholesterol, and diabetes under control. Physical and mental fitness may help prevent dementia; keeping socially active may also help. Recurrent head injuries are associated with dementia.

The checklist: How to stay healthy

Being proactive about your health is an important starting point in maintaining health. Some steps are self-evident but a person may need help in taking the first step. The ability to recognize that living healthy is a life-long commitment is an important key to longevity. Nobody is perfect, and the ultimate goal is to have more good habits than bad. Failing to meet a goal does not give permission to quit trying. Doing well one day is not a license to stray the next.

Here is a checklist to promote a healthier lifestyle and living a longer, healthier life.

  • Stop smoking
  • Maintain a healthy weight
  • Engage in some type of physical activity every day
  • Eat a heart healthy diet
  • Maintain good control of blood pressure, cholesterol, and diabetes
  • Get routine medical care and physical examinations
  • Get recommended screenings for prostate and colon cancer
  • Perform routine home testicle exams
  • Keep mentally active
  • Maintain close relationships with a circle of friends
  • Seek help if you have symptoms of depression

Male Menopause


  • Male menopause introduction
  • What is male menopause?
  • How is male menopause diagnosed?
  • Can male menopause be treated?
  • Find a local Endocrinologist in your town

Male Menopause Introduction

Women may not be the only ones who suffer the effects of changing hormones. Some doctors are noticing that their male patients are reporting some of the same symptoms that women experience in perimenopause and menopause.

The medical community is currently debating whether or not men really do go through a well-defined menopause. Doctors say that male patients receiving hormone therapy with testosterone have reported relief of some of the symptoms associated with so-called male menopause.

What Is Male Menopause?

Since men do not go through a well-defined period referred to as menopause, some doctors refer to this problem as androgen (testosterone) decline in the aging male, or what some people call low testosterone. Men do experience a decline in the production of the male hormone testosterone with aging, but this also occurs with some disease states such as diabetes. Along with the decline in testosterone, some men experience symptoms such as fatigue, weakness, depression, and sexual problems. The relationship of these symptoms to the decreased testosterone levels is still controversial.

Unlike menopause in women which represents a well-defined period in which hormone production stops completely, testosterone decline in men is a slower process. The testes, unlike the ovaries, do not run out of the substance it needs to make testosterone. A healthy male may be able to make sperm well into his eighties or longer.

However, as a result of disease, subtle changes in the function of the testes may occur as early as 45 to 50 years of age, and more dramatically after the age of 70 in some men.

How Is Male Menopause Diagnosed?

To make the diagnosis of male menopause, the doctor will perform a physical exam and ask about symptoms. He or she may order other diagnostic tests to rule out any medical problems that may be contributing to the condition. The doctor will then order a series of blood tests which may include several hormone levels, including a blood testosterone level.

Can Male Menopause Be Treated?

If testosterone levels are low, testosterone replacement therapy may help relieve such symptoms as loss of interest in sex (decreased libido), depression, and fatigue. But, as with hormone replacement therapy in women, testosterone replacement therapy does have some potential risks and side effects. Replacing testosterone may worsen prostate cancer, for example.

If you or a loved one is considering androgen replacement therapy, talk to a doctor to learn more. Your doctor may also recommend certain lifestyle changes, such as a new diet or exercise program, or other medications, such as an antidepressant, to help with some of the symptoms of male menopause.

Melanoma


Melanoma 101: Introduction to a Deadly Skin Cancer


  • Introduction
  • What does melanoma look like? What are the symptoms and signs?
  • What if the skin changes are rapid or dramatic?
  • What are the causes and risk factors for melanoma?
  • How do I know my level of risk for melanoma?
  • What are the types of melanoma?
  • How is melanoma diagnosed?
  • How do doctors determine the prognosis (outlook) of a melanoma?
  • What is the treatment for melanoma?
  • What methods are available to help prevent melanoma?
  • Conclusions
  • Melanoma At A Glance
  • Additional Resources
  • Patient Discussions: Melanoma - Causes
  • Patient Discussions: Melanoma - Diagnosis
  • Patient Discussions: Melanoma - How Was Diagnosis Established
  • Find a local Oncologist in your town

Introduction

Melanoma is a cancer that develops in melanocytes, the pigment cells present in the skin. It can be more serious than the other forms of skin cancer because it may spread to other parts of the body (metastasize) and cause serious illness and death. About 50,000 new cases of melanoma are diagnosed in the United States every year.

Because most melanomas occur on the skin where they can be seen, patients themselves are often the first to detect many melanomas. Early detection and diagnosis are crucial. Caught early, most melanomas can be cured with relatively minor surgery.

This article is written from the standpoint of the patient. In other words, instead of describing the disease in exhaustive detail, I will try to help answer the questions: "How do I know if I have melanoma?" and "Should I should be checked for it?"

Spots on the skin

Guideline # 1: Nobody can diagnose him- or herself. If you see a spot that looks as though it is new or changing, show it to a doctor. When it comes to spots on the skin, it is always better to be safe than sorry.

Everybody gets spots on their skin. The older we are, the more spots we have. Some of these are freckles, others are moles, and still others are made up of collections of tissue, such as blood vessels or pigment cells. Most of these spots are benign. That means they are neither cancerous nor on the way to becoming cancerous.

Moles

Guideline # 2: The vast majority of moles stay as moles and do not turn into anything else.

Some people are born with moles (the medical name is "nevus" plural "nevi"). Almost everyone develops them, starting in childhood. On the average, people have about 25 moles, though some have fewer and others many more. Moles may be flat or raised, and they may range in color from tan to light brown to black.

What does melanoma look like? What are the symptoms and signs?

Guideline # 3: A changing spot may be a problem, but not every change is a problem. A mole may appear and then get bigger or become raised but still be only a mole.

Most public health information about melanoma stresses the so-called ABCDs:

  • Asymmetry: One half of the mole is different from the other half.
  • Border irregularity: The spot has borders which are not smooth and regular but uneven or notched.
  • Color: The spot has several colors in an irregular pattern or is a very different color than the rest of your moles.
  • Diameter: The spot is larger than the size of a pencil eraser.

These guidelines are somewhat helpful, but the problem is that many normal moles are not completely symmetrical in their shape or color. This means that many spots, which seem to have one or more of the ABCDs, are in fact just ordinary moles and not melanomas. Additionally, some melanomas do not fit this description but may still be spotted by your dermatologist.

What if the skin changes are rapid or dramatic?

Guideline # 4: The more rapid and dramatic the change, the less serious the problem.

When changes such as pain, swelling, or even bleeding come on rapidly, within a day or two, they are likely to be caused by minor trauma, often a kind you don't remember (like scratching the spot in your sleep). If a spot changes rapidly and then goes back to the way it was within a couple of weeks, or falls off altogether, it is not likely to represent anything serious. Keep in mind that what may seem like the sudden appearance of a spot or a rapid change in its appearance may just mean that something (or someone) has prompted you to look at an old spot for the first time.

Nevertheless, this would be a good time to say once again: Nobody can diagnose him- or herself. If you see a spot that looks as though it is new or changing, show it to a doctor. When it comes to spots on the skin, it is always better to be safe than sorry.

What are the causes and risk factors for melanoma?

Guideline # 5: Individual sunburns do raise your risk of melanoma. However, slow daily sun exposure, even without burning, may also substantially raise your risk of skin cancer.

Factors that raise your risk for melanoma include:

  • Caucasian (white) ancestry
  • Fair skin, light hair, and light-colored eyes
  • A history of intense, intermittent sun exposure, especially in childhood
  • Many (more than 100) moles
  • Large, irregular, or "funny looking" moles
  • Close blood relatives -- parents, siblings, and children -- with melanoma

The presence of close (first-degree) family with melanoma is a high risk factor, although looking at all of melanoma, only 10% of cases run in families.

 

How do I estimate my level of risk for melanoma?

The best way to know your risk level is to have a dermatologist perform a full body examination. That way you will find out whether the spots you have are moles and, if so, whether they are "funny looking" in the medical sense.

The medical term for such moles is "atypical." This is a somewhat confusing term, because among other things the criteria for defining it are not clear, and it's not certain that an atypical mole is necessarily precancerous. If you have such moles, your doctor may do a biopsy in order to counsel you about the need for surveillance or further testing.

Sometimes, you learn at a routine skin evaluation that you do not necessarily need annual routine checkups. In other situations, your doctor may recommend regular checks at six-month or yearly intervals.

What are the types of melanoma?

The main types of melanoma are:

  1. Superficial spreading melanoma: This type accounts for about 70% of all cases of melanoma. The most common locations are the legs of women and the backs of men, and they occur most commonly between the ages of 30 and 50. (Note: Melanomas can occur in other locations and at other ages as well.) These melanomas are often barely raised and have a variety of colors. Such melanomas evolve over one to five years and can be readily caught at an early stage if they are detected and removed.

  2. Nodular melanoma: About 20% of melanomas begin as deeper, blue-black to purplish lumps. They may evolve faster and may also be more likely to spread.

  3. Lentigo maligna: Unlike other forms of melanoma, lentigo maligna tends to occur on places like the face, which are exposed to the sun constantly rather than intermittently. Lentigo maligna looks like a large, irregularly shaped or colored freckle and develops slowly. It may take many years to evolve into a more dangerous melanoma.

There are also other rarer forms of melanoma that may occur, for example, under the nails, on the palms and soles, in the eye, or sometimes even inside the body.

How is melanoma diagnosed?

Most doctors diagnose melanoma by examining the spot causing concern and doing a biopsy. A skin biopsy refers to removing all or part of the skin spot under local anesthesia and sending the specimen to a pathologist for analysis.

The biopsy report may show any of the following:

  • a totally benign condition requiring no further treatment, such as a regular mole;
  • an atypical mole which, depending on the judgment of the doctor and the pathologist, may need a conservative removal (taking off a little bit of normal skin all around just to make sure that the spot is completely out); or
  • a melanoma requiring surgery.

Some doctors are skilled in a clinical technique called epiluminescence microscopy (also called dermatoscopy). They cover a suspicious spot with oil and examine it with a brightly lit magnifying instrument. The gold standard for a solid diagnosis, however, remains a skin biopsy.

How do doctors determine the prognosis (outlook) of a melanoma?

The most useful criterion for determining prognosis is tumor thickness. Thin melanomas, those measuring less than 1 millimeter, have excellent cure rates. The thicker the melanoma, the less optimistic the prognosis. Early diagnosis and treatment are essential.

What is the treatment for melanoma?

In general, melanoma is treated by surgery alone. Doctors have learned that surgery does not need to be as extensive as was thought years ago. When treating many early melanomas, for instance, surgeons only remove 1 centimeter (less than ½ inch) of the normal tissue around the melanoma. Deeper and more advanced cancers may need more extensive surgery.

Depending on various considerations (tumor thickness, body location, age, etc.), the removal of nearby lymph glands may be recommended. For advanced disease, such as when the melanoma has spread to other parts of the body, treatments like immunotherapy are sometimes recommended.

What methods are available to help prevent melanoma?

  1. Reducing sun exposure: Avoidance of sun exposure is the best means of helping to prevent melanoma, followed by wearing hats and tightly woven clothing, and then followed by broad-spectrum waterproof sunscreens applied liberally and often. There has been some controversy about the extent to which sunscreens protect against melanoma. The consensus among dermatologists is that sunscreens are at least partially helpful and are certainly preferable to unprotected sun exposure. (Despite sensational articles in the popular press, there is no credible evidence that sunscreens can cause melanoma.)
  1. Early detection: Get your skin checked at least once. Then, if it is recommended, have your skin checked on a regular basis. The American Academy of Dermatology sponsors free skin cancer screening clinics every May all over the country. Special "Pigmented Lesion Clinics" have also been established in many medical centers to permit close clinical and photographic follow-up of patients at high risk. In most areas, these clinics are only available to patients who have been referred to them by a concerned dermatologist.
  1. Screening of high-risk individuals: Anyone at high risk, such as anyone with a close relative who has melanoma, should be screened by a doctor for melanoma.

Conclusions

When it comes to spots on the skin, it is always better to be safe than sorry. Melanoma is a potentially serious form of skin cancer. Diagnosed early and treated properly, it can very often be cured. And one more time...

Guideline # 1: Nobody can diagnose him- or herself. If you see a spot that looks as though it is new or changing, show it to a doctor.

What is in the future for melanoma?

Research in melanoma is headed in three directions: prevention, more precise diagnosis, and better treatment for advanced disease.

  • Prevention: Public education and more widely available screening clinics can increase public awareness of the need for sun avoidance, sunscreen use, and early detection of suspicious spots.
  • More precise diagnosis: Newer experimental techniques, such as the confocal scanning laser microscope, may help doctors make more certain calls on borderline or suspicious spots.
  • Better treatment for advanced disease: Because conventional chemotherapy has been disappointing with melanoma, researchers have turned their attention to biologic treatments of advanced melanoma to stimulate the body's own immune response against the tumor. These biologic treatments include interferon, interleukins, monoclonal antibodies, and tumor vaccines.

 

Melanoma At A Glance
  • Melanoma is a cancer that develops in pigment cells called melanocytes.
  • Patients themselves are the first to detect many melanomas.
  • Caught early, most melanomas can be cured with relatively minor surgery.
  • Melanoma can be more serious than the other forms of skin cancer, because it may spread (metastasize) to other parts of the body and cause serious illness and death.
  • Spots suspicious for melanoma show one or more of the following features (the ABCDs): Asymmetry, Border irregularity, Color changes, a Diameter more than the size of a pencil eraser.
  • Elevated risk factors for melanoma include Caucasian (white) ancestry, fair skin, light hair and light-colored eyes, a history of intense sun exposure, close blood relatives with melanoma, and moles that are unusually numerous, large, irregular, or "funny looking."
  • Doctors diagnose melanoma by biopsy (removing a piece of skin for analysis).
  • The most common forms of melanoma are superficial spreading melanoma, nodular melanoma, and lentigo maligna.
  • Treatment of melanoma is primarily by surgical removal.
  • Changing or suspicious spots should be brought to medical attention right away.

Additional resources

  • For additional information read the article on Melanoma.
  • For further information about all aspects of melanoma, please visit MelanomaNet (http://www.skincarephysicians.com/melanomanet/) of the American Academy of Dermatology.
  • You can obtain information about free skin cancer screening clinics held by the American Academy of Dermatology every May all over the country from the American Academy of Dermatology (www.aad.org).

Mammogram


  • What is a mammogram?
  • What are the risks of mammography?
  • How is a mammogram performed?
  • How does a patient receive the results of the mammogram?
  • What if the mammogram is abnormal?
  • Mammograms At A Glance
  • Find a local Doctor in your town

What is a mammogram?

A mammogram is an X-ray test that produces an image of the inner breast tissue on film. This technique, called mammography, is used to visualize normal and abnormal structures within the breasts. Mammography, therefore, can help in identifying cysts, calcifications, and tumors within the breast. It is currently the most efficient screening method to detect early breast cancer. Breast self-examination (BSE) on a monthly basis and examination by a doctor are still important, but physical examinations typically find breast cancers when they are much larger than those detected by mammography.

Mammography can be used to discover a small cancer in a curable stage; however, it is not foolproof. Depending a woman's age and other factors, approximately ten to fifteen percent of breast cancers are not identified by mammography, and these cancers are often found by physical examination. It is essential for a woman to perform monthly BSE and have a breast examination by her doctor in addition to the mammogram in order to most effectively screen for breast cancer. For more information, please see the Breast Cancer article.

The American Cancer Society recommends that a woman obtain her first baseline mammogram between the ages of 35 to 40. After the age of 40, she should receive a yearly mammogram. Women who are at high risk for developing breast cancer may need to obtain mammograms earlier than these recommendations and at more frequent intervals. Medicare, Medicaid, and most private insurance companies cover the cost of mammography.

What are the risks of mammography?

Because x-ray procedures use radiation, there is some small risk of radiation side effects to the body. The amount of radiation that is administered in mammography is exceptionally low and is approved by national and international regulatory agencies as well as the National Department of Health and Human Services. However, patients who are pregnant or may be pregnant are advised to notify their requesting practitioner and radiology staff, because radiation can pose a risk to the developing fetus.

How is a mammogram performed?

A brief medical history and a history of specific problems related to the breast, such as pain or a palpable lump (one that is felt), is obtained prior to the mammogram. A small x-ray marker may be taped on the breast overlying the palpable lump. This will help in determining whether any other special mammogram views need to be done beyond the standard views. All jewelry and clothing in the chest and breast area are removed prior to the mammogram. The patient's breasts are then placed on a firm flat panel and a gentle, but firm pressure is applied to the breast with another panel, resulting in compression of the breast between the two panels. This compression causes a degree of discomfort that lasts only for a few seconds. The compression of the breast is necessary to obtain quality mammograms and spreads the breast tissue out so that the x-ray image displays the inner breast tissue with good resolution. If compression is not used, the mammograms may be blurry, breast tissue may not be well delineated, and small lesions can be overlooked.

Antiperspirants, deodorants, and powders should not be worn during mammography and should be removed prior to the procedure, as these substances may make interpretation of the results more difficult. Antiperspirants can cause the images to appear foggy, and powders can sometimes simulate the appearance of microcalcifications (an abnormal finding that is sometimes associated with breast cancer).

Generally, two x-rays are obtained of each breast. More views may be obtained if the breasts are large, the woman has had a breast augmentation, or there is an area on the initial mammography views that needs to be further examined. Special magnified or localized mammograms of a specific area of the breast can then be done.

A radiology technologist is responsible for performing mammography. Once the x-ray pictures are taken, they are developed and examined by a radiologist (a doctor who specializes in the interpretation of x-rays and other imaging studies). In most mammography centers, these radiologists have also had extra training dedicated to interpreting mammograms.

How does a patient receive the results of the mammogram?

The results of the mammogram can be given to the patient either by the radiologist at the completion of the mammogram or by the patient's doctor who ordered the mammogram. In many cases, it will be by both doctors. In some cases, the patient will receive a card in the mail with the results of the mammogram. The report of the mammogram generally takes a few days to reach the referring doctor by mail. However, when there is a suspicious area on the mammogram, this information is usually relayed directly to the referring doctor by phone so that further evaluation of this area can be done expeditiously. A patient should call the doctor if she has not received the results of a mammogram in a reasonable period of time. The patient should not just assume the mammogram was normal.

What if the mammogram is abnormal?

Do not panic if you are told that your mammogram is abnormal or that there is a "spot" on your mammogram. An abnormal mammogram does not mean you have cancer. The overwhelming majority of abnormal mammograms are caused by benign (harmless) processes. In some cases, it may just be an area of thicker or more dense breast tissue, a cyst, or a benign lump such as a fibroadenoma. When a mammogram detects a suspicious area, the patient may be advised to obtain further mammograms of that area, to have an ultrasound or other imaging study of the breast, to see a specialist in diseases of the breast (this is usually a general surgeon), or to have a biopsy performed of the suspicious area.

A breast biopsy is the removal of a piece of breast tissue for examination under a microscope. The biopsy can be performed surgically, in which an incision is made and the area removed, or it can be done as a stereotactic core biopsy. Stereotactic core biopsy is a technique of removing samples of the suspicious area without the need of traditional surgery. In this technique, the doctor, with the aid of a special mammography machine and a computer, can identify precisely the abnormality in the breast and then obtain very thin core samples of breast tissue with a special needle. This biopsy test is done with only a local anesthetic in the area of the needle puncture and is generally painless.

Fortunately, most breast biopsies give benign results. While mammography is not sufficiently accurate to diagnose or exclude breast cancer alone, it is currently the best method available to screen for breast cancer. Since its more widespread routine use, breast cancers are found when they are significantly smaller and more curable. More women are surviving breast cancer as a result of mammography and early cancer treatment. Continued use of routine mammography should be encouraged until a better alternative in breast cancer detection has been found. For more information, please Breast Cancer Prevention article.

Mammograms At A Glance
  • Mammograms are images of the breast tissue produced on x-ray film.
  • Mammograms are the most efficient screening method to detect early breast cancer.
  • Monthly breast self-examination and regular doctor's examinations are combined with mammography for optimal breast cancer screening.
  • An abnormal mammogram does not necessarily mean that a cancer is present, Other tests, including biopsy, may be performed for further clarification of an abnormal mammogram.
  • A normal mammogram does not exclude the presence of cancer.

Marfan Syndrome

 

  • What is Marfan syndrome?
  • What are the symptoms of Marfan syndrome?
  • What causes Marfan syndrome?
  • How is Marfan syndrome diagnosed?
  • What types of doctors treat Marfan syndrome?
  • What treatment options are available for Marfan syndrome?
  • What are some of the emotional and psychological effects of Marfan syndrome?
  • What research is being conducted to help people with Marfan syndrome?
  • Where can people find additional information about Marfan syndrome?
  • Patient Discussions: Marfan Syndrome - Causes
  • Patient Discussions: Marfan Syndrome - Describe Your Experience

What is Marfan syndrome?

Marfan syndrome is a heritable condition that affects the connective tissue. The primary purpose of connective tissue is to hold the body together and provide a framework for growth and development. In Marfan syndrome, the connective tissue is defective and does not act as it should. Because connective tissue is found throughout the body, Marfan syndrome can affect many body systems, including the skeleton, eyes, heart and blood vessels, nervous system, skin, and lungs.

Marfan syndrome affects men, women, and children, and has been found among people of all races and ethnic backgrounds. It is estimated that at least 1 in 5,000 people in the United States have the disorder.

What are the symptoms of Marfan syndrome?

Marfan syndrome affects different people in different ways. Some people have only mild symptoms, while others are more severely affected. In most cases, the symptoms progress as the person ages. The body systems most often affected by Marfan syndrome are:

  • Skeleton - People with Marfan syndrome are typically very tall, slender, and loose-jointed. Because Marfan syndrome affects the long bones of the skeleton, a person's arms, legs, fingers, and toes may be disproportionately long in relation to the rest of the body. A person with Marfan syndrome often has a long, narrow face, and the roof of the mouth may be arched, causing the teeth to be crowded. Other skeletal problems include a sternum (breastbone) that is either protruding or indented, curvature of the spine (scoliosis), and flat feet.
  • Eyes - More than half of all people with Marfan syndrome experience dislocation of one or both lenses of the eye. The lens may be slightly higher or lower than normal, and may be shifted off to one side. The dislocation may be minimal, or it may be pronounced and obvious. One serious complication that may occur with this disorder is retinal detachment. Many people with Marfan syndrome are also nearsighted (myopic), and some can develop early glaucoma (high pressure within the eye) or cataracts (the eye's lens loses its clearness).
  • Heart and blood vessels (cardiovascular system) - Most people with Marfan syndrome have problems associated with the heart and blood vessels. Because of faulty connective tissue, the wall of the aorta (the large artery that carries blood from the heart to the rest of the body) may be weakened and stretch, a process called aortic dilatation. Aortic dilatation increases the risk that the aorta will tear (aortic dissection) or rupture, causing serious heart problems or sometimes sudden death. Sometimes, defects in heart valves can also cause problems. In some cases, certain valves may leak, creating a "heart murmur," which a doctor can hear with a stethoscope. Small leaks may not result in any symptoms, but larger ones may cause shortness of breath, fatigue, and palpitations (a very fast or irregular heart rate).
  • Nervous system - The brain and spinal cord are surrounded by fluid contained by a membrane called the dura, which is composed of connective tissue. As someone with Marfan syndrome gets older, the dura often weakens and stretches, then begins to weigh on the vertebrae in the lower spine and wear away the bone surrounding the spinal cord. This is called dural ectasia. These changes may cause only mild discomfort; or they may lead to radiated pain in the abdomen; or to pain, numbness, or weakness in the legs.
  • Skin - Many people with Marfan syndrome develop stretch marks on their skin, even without any weight change. These stretch marks can occur at any age and pose no health risk. However, people with Marfan syndrome are also at increased risk for developing an abdominal or inguinal hernia, in which a bulge develops that contains part of the intestines.
  • Lungs - Although connective tissue problems make the tiny air sacs within the lungs less elastic, people with Marfan syndrome generally do not experience noticeable problems with their lungs. If, however, these tiny air sacs become stretched or swollen, the risk of lung collapse may increase. Rarely, people with Marfan syndrome may have sleep-related breathing disorders such as snoring, or sleep apnea (which is characterized by brief periods when breathing stops).

What causes Marfan syndrome?

Marfan syndrome is caused by a defect, or mutation, in the gene that determines the structure of fibrillin-1, a protein that is an important part of connective tissue. A person with Marfan syndrome is born with the disorder, even though it may not be diagnosed until later in life.

The defective gene that causes Marfan syndrome can be inherited: The child of a person who has Marfan syndrome has a 50 percent chance of inheriting the disease. Sometimes a new gene defect occurs during the formation of sperm or egg cells, making it possible for two parents without the disease to have a child with the disease. But this is rare. Two unaffected parents have only a 1 in 10,000 chance of having a child with Marfan syndrome. Possibly 25 percent of cases are due to a spontaneous mutation at the time of conception.

Although everyone with Marfan syndrome has a defect in the same gene, different mutations are found in different families, and not everyone experiences the same characteristics to the same degree. In other words, the defective gene expresses itself in different ways in different people. This phenomena is known as variable expression. Scientists do not yet understand why variable expression occurs in people with Marfan syndrome.

How Marfan syndrome diagnosed?

There is no specific laboratory test, such as a blood test or skin biopsy, to diagnose Marfan syndrome. The doctor and/or geneticist (a doctor with special knowledge about inherited diseases) relies on observation and a complete medical history, including:

  • information about any family members who may have the disorder or who had an early, unexplained, heart-related death
  • a thorough physical examination, including an evaluation of the skeletal frame for the ratio of arm/leg size to trunk size
  • an eye examination, including a "slit lamp" evaluation
  • heart tests such as an echocardiogram (a test that uses ultrasound waves to examine the heart and aorta).

The doctor may diagnose Marfan syndrome if the patient has a family history of the disease, and if there are specific problems in at least two of the body systems known to be affected. For a patient with no family history of the disease, at least three body systems must be affected before a diagnosis is made. Moreover, two of the systems must show clear signs that are relatively specific for Marfan syndrome.

In some cases, a genetic analysis may be useful in making a diagnosis of Marfan syndrome, but such analyses are often time consuming and may not provide any additional helpful information. Family members of a person diagnosed with Marfan syndrome should not assume they are not affected if there is no knowledge that the disorder existed in previous generations of the family. After a clinical diagnosis of a family member, a genetic study might identify the specific mutation for which a test can be performed to determine if other family members are affected.

Recently, doctors discovered a connective tissue disorder known as Loeys-Dietz syndrome, which has several characteristics that overlap with those of Marfan syndrome. When making a diagnosis, it is important to distinguish between the two disorders: Loeys-Dietz is more likely to cause fatal aortic aneurysms, and treatment for the two is different. A diagnostic test for Loeys-Dietz syndrome is available.

What types of doctors treat Marfan syndrome?

Because a number of body systems may be affected, a person with Marfan syndrome should be cared for by several different types of doctors. A general practitioner or pediatrician may oversee routine health care and refer the patient to specialists such as a cardiologist (a doctor who specializes in heart disorders), an orthopaedist (a doctor who specializes in bones), or an ophthalmologist (a doctor who specializes in eye disorders), as needed. Some people with Marfan syndrome also go to a geneticist.

What treatment options are available for Marfan syndrome?

There is no cure for Marfan syndrome. To develop one, scientists may have to identify and change the specific gene responsible for the disorder before birth. However, a range of treatment options can minimize and sometimes prevent complications. The appropriate specialists will develop an individualized treatment program; the approach the doctors use depends on which systems have been affected.

  • Skeletal - Annual evaluations are important to detect any changes in the spine or sternum. This is particularly important in times of rapid growth, such as adolescence. A serious malformation not only can be disfiguring, but also can prevent the heart and lungs from functioning properly. In some cases, an orthopaedic brace or surgery may be recommended to limit damage and disfigurement.
  • Eyes - Early, regular eye examinations are essential for identifying and correcting any vision problems associated with Marfan syndrome. In most cases, eyeglasses or contact lenses can correct the problem, although surgery may be necessary in some cases.
  • Heart and blood vessels - Regular checkups and echocardiograms help the doctor evaluate the size of the aorta and the way the heart is working. The earlier a potential problem is identified and treated, the lower the risk of life-threatening complications. Those with heart problems are encouraged to wear a medical alert bracelet and to go to the emergency room if they experience chest, back, or abdominal pain. Some heart-valve problems can be managed with drugs such as beta-blockers, which may help decrease stress on the aorta. In other cases, surgery to replace a valve or repair the aorta may be necessary.

Surgery should be performed before the aorta reaches a size that puts it at high risk for tear or rupture. Because blood clots can form around artificial heart valves, people who have a valve replaced must take the blood-thinning drug warfarin (Coumadin) for the rest of their lives. They must also take extreme care to prevent endocarditis (inflammation of the lining of the heart cavity and valves). Dentists should be alerted to this risk; they are likely to recommend that the patient be prescribed protective medicines before they perform dental work.

 

Because warfarin carries a risk of some serious side effects, including excessive bleeding, and because it is dangerous to unborn babies, doctors are increasingly opting for a newer aortic root replacement procedure that enables people to keep their own valves. The procedure involves removing and replacing the enlarged part of the aorta with a Dacron tube, and resuspending the natural valve into the tube so that the tube supports the valve. The procedure is often performed at an earlier stage than traditional valve replacement. It may also be offered to women with aortic enlargement who are considering becoming pregnant, because it can prevent the rapid aortic growth and possible tearing that sometimes occur during pregnancy.

  • Nervous system - If dural ectasia (swelling of the covering of the spinal cord) develops, medication may help minimize any associated pain.
  • Lungs - It is especially important that people with Marfan syndrome not smoke, as they are already at increased risk for lung damage. Any problems with breathing during sleep should be assessed by a doctor.

Pregnancy poses a particular concern due to the stress on the body, particularly the heart. A pregnancy should be undertaken only under conditions specified by obstetricians and other specialists familiar with Marfan syndrome. The pregnancy should be monitored as a high-risk condition. Women with an aortic measurement of 4 centimeters or greater may want to discuss the possibility of a valve-sparing aortic root replacement with their doctors before becoming pregnant. Women with Marfan syndrome may also seek genetic counseling concerning the likelihood that they will pass the disease on to their children.

While eating a balanced diet is important for maintaining a healthy lifestyle, no vitamin or dietary supplement has been shown to help slow, cure, or prevent Marfan syndrome.

For most people with Marfan syndrome, engaging in moderate aerobic exercise is important for promoting skeletal and cardiovascular health and a sense of well-being. However, because of the risk of aortic dissection, people with the syndrome should not engage in contact sports, competitive athletics, or isometric exercise.

Brand names included in this information are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.

What are some of the emotional and psychological effects of Marfan syndrome?

Being diagnosed and learning to live with a genetic disorder can cause social, emotional, and financial stress. It often requires a great deal of adjustment in outlook and lifestyle. A person who is an adult when Marfan syndrome is diagnosed may feel angry or afraid. There may also be concerns about passing the disorder to future generations or about its physical, emotional, and financial implications.

The parents and siblings of a child diagnosed with Marfan syndrome may feel sadness, anger, and guilt. It is important for parents to know that nothing that they did caused the fibrillin-1 gene to mutate. Parents may be concerned about the genetic implications for siblings or have questions about the risk to future children.

Some children with Marfan syndrome are advised to restrict their activities. This may require a lifestyle adjustment that is hard for a child to understand or accept.

For both children and adults, appropriate medical care, accurate information, and social support make it easier to live with the disease. Genetic counseling may also be helpful for understanding the disease and its potential impact on future generations.

While Marfan syndrome is a lifelong disorder, the outlook has improved in recent years. As early as the 1970s, the life expectancy of a person with Marfan syndrome was two-thirds that of a person without the disease; however, with improvements in recognition and treatment, people with Marfan syndrome now have a life expectancy similar to that of the average person.

 

What research is being conducted to help people with Marfan syndrome?

Numerous studies are underway that should lead to a better understanding of Marfan syndrome and its treatment. They include a plan to identify the factors responsible for the cardiovascular manifestations of Marfan syndrome, a study to better understand the process that leads to skeletal manifestations, and studies to clarify the role of a chemical messenger called transforming growth factor-beta (TGF-β) in the disorder.

Scientists are conducting research on Marfan syndrome from a variety of perspectives. One approach is to better understand what happens once the genetic defect or mutation occurs. How does it change the way connective tissue develops and functions in the body? Why are people with Marfan syndrome affected differently? Scientists are searching for the answers to these questions both by studying the genes themselves and by studying large family groups affected by the disease. Mouse models that carry mutations in the fibrillin-1 gene may help scientists better understand the disorder. Animal studies that can provide preliminary information for gene therapy are also underway.

Other scientists are focusing on ways to treat some of the complications that arise in people with Marfan syndrome. Clinical studies are being conducted to evaluate the usefulness of certain medications in preventing or reducing problems with the aorta.

For example, research has shown that the blood pressure medication losartan prevents aortic aneurysms in a mouse model of Marfan syndrome. New studies receiving funding from the National Heart, Lung and Blood Institute are now underway to determine whether the drug has the same beneficial effect in people.

Where can people find additional information about Marfan syndrome?

E-mail: This e-mail address is being protected from spambots. You need JavaScript enabled to view it

NIAMS provides information about various forms of arthritis and rheumatic disease and bone, muscle, joint, and skin diseases. It distributes patient and professional education materials and refers people to other sources of information. Additional information and updates can also be found on the NIAMS Web site.

E-mail: This e-mail address is being protected from spambots. You need JavaScript enabled to view it

NHGRI conducts studies involving various aspects of Mar-fan syndrome. To find out if there is a study for which you might qualify, call or e-mail NHGRI using the contact information below, or visit www.clinicaltrials.gov

Phone: 800-411-1222 (free of charge) (for information about entering a clinical study) E-mail: This e-mail address is being protected from spambots. You need JavaScript enabled to view it

E-mail: This e-mail address is being protected from spambots. You need JavaScript enabled to view it

This organization helps people who have Marfan syndrome and related connective tissue disorders. It provides information and materials about the disorder and about how to seek appropriate medical care. It supports research and promotes public awareness of Marfan syndrome. The foundation can also provide the names of doctors who diagnose and treat Marfan syndrome.

E-mail: This e-mail address is being protected from spambots. You need JavaScript enabled to view it

The American Heart Association has a fact sheet on its Web site that describes the blood vessel and heart valve complications of Marfan syndrome. It is also a source of information on precautions doctors and other health professionals must use in treating patients who have heart problems associated with Marfan syndrome.

 


Last Updated on Sunday, 18 December 2011 16:20
 
Liposuction PDF Print E-mail
Written by Ruai Pharmaceuticals   
Thursday, 15 September 2011 06:11

Liposuction

  • Introduction to liposuction
  • Who is a good candidate for liposuction?
  • What do I need to know before undergoing liposuction?
  • How is the liposuction procedure done?
  • What are the types of liposuction
  • How long does recovery after liposuction last?
  • Are the results of liposuction permanent?
  • What are the risks of liposuction?
  • Is liposuction covered by insurance?
  • Find a local Plastic Surgeon in your town

Introduction to Liposuction

"The battle of the bulge." That tiny, five-word phrase has been shoved in our faces for years, thanks to television, newspapers and magazines. But sometimes, no matter how hard you fight, the bulge has a tougher army. The fact is that certain people have fat cells that will not shrink, despite diet and exercise. You can thank heredity for that in some cases.

Liposuction is an option to remove small bulges that won't budge and to improve your body's shape. The areas most commonly treated include the hips, abdomen, thighs and buttocks and face. Liposuction does not remove cellulite, only fat.

Who Is a Good Candidate For Liposuction?

A good candidate for liposuction should have realistic expectations about the results of this procedure as well as these basic qualities:

  • Average or slightly above-average weight
  • Firm, elastic skin
  • In good overall health
  • Concentrated pockets of fat that do not respond well to diet and exercise

Patients with poor skin quality (cellulite) are not good candidates for liposuction because they may develop skin irregularities due to under- or over-correction of localized fat deposits. Age is generally not a major consideration when discussing liposuction; however, older patients often have less elasticity in their skin and thus may not achieve the same benefits of liposuction that a younger patient with tighter skin might achieve.

What Do I Need To Know Before Undergoing Liposuction?

The first step before undergoing liposuction will be to arrange a consultation with your surgeon. During the consultation, your surgeon will discuss which options are best for you, your skin type, the effectiveness and safety of the procedure, the potential financial cost and what your expectations should be. Do not hesitate to ask the surgeon any questions you may have. Now is not the time to be shy.

Once you have decided to undergo liposuction, your surgeon will give you any instructions you will need to prepare for the surgery. This may include dietary or alcohol guidelines restrictions or the taking or avoiding of certain vitamins. Be sure to tell your surgeon of any allergies you have as well as any and all medications you are taking. This includes over-the-counter and prescription medications as well as herbal supplements.

How Is the Liposuction Procedure Done?

Depending on the type of liposuction you are undergoing, the procedure may be performed as an outpatient procedure at the doctor's office or surgery center, or if large amounts of fat are being removed, the procedure will be done in a hospital and may require an overnight stay.

Before the procedure begins you will be given an anesthesia. Again, depending on the degree of fat being removed and the type of liposuction being performed, anesthesia varies and may only be locally applied or it may required a general application in which case the surgery will be done while you are sleeping.

Once the anesthesia has taken effect, the liposuction procedure is performed using a suction device attached to a small, stainless steel instrument called a cannula. Through small incisions, the cannula is inserted into fatty areas between skin and muscle where it removes excess fat either using a suction pump or a large syringe. This results in a smoother, improved body contour. The length of the procedure will vary with the amount of fat needing removed.

Types of Liposuction

Though the basics of liposuction described above remain the same, there are a couple of different techniques that can be used during liposuction. These include:

  • Tumescent liposuction. During this technique, the surgeon will inject a solution is injected into your fatty areas before the fat is removed. It is made up of a saline solution, a mild painkiller and epinephrine, a drug that contracts your blood vessels. The solution not only helps the surgeon removed the fat more easily but it helps reduce blood loss and provides pain relief during and after surgery.
  • Ultrasound-assisted liposuction. During ultrasound-assisted liposuction, ultrasonic energy is used to liquefy the fat, after which it is removed from the body.

How Long Does Recovery After Liposuction Last?

Under most circumstances, when liposuction is an outpatient procedure, recovery is usually quick. Most people can return to work within a few days and to normal activities within about two weeks. You should expect bruising, swelling and soreness for a least a few weeks. However, every person's outcome will vary based on factors such as volume of fat cells removed and area of removal. Your doctor will discuss what results you can expect to achieve and how to best maintain your new body shape.

Are the Results of Liposuction Permanent?

The fat cells are removed permanently, so if you gain weight after the procedure, it usually will not concentrate in the area that was treated. However, it is important to note that liposuction will not prevent you from regaining weight. To keep your new shape and new weight after liposuction, you must follow a proper diet and exercise plan.

What Are the Risks of Liposuction?

All surgical procedures involve some risk. However, liposuction has a good safety record and the risks associated with the procedure are minimized when performed by a specially trained, board-certified plastic surgeon.

Although rare, risks include infection and skin discoloration. As with all surgery, common sense is important. The risk of medical problems can be minimized by avoiding extremely long procedures or excessive removal of fat.

Is Liposuction Covered By Insurance?

Like all cosmetic procedures, liposuction is not covered by health insurance plans. Ask to talk with a representative who can explain the costs of the procedure and payment options.

Lower Back Pain
(Lumbar Back Pain)


  • What is the anatomy of the low back?
  • What is the function of the low back?
  • What are common causes of lower back pain?
  • What are other causes of lower back pain?
  • What are uncommon causes of low back pain?
  • What is the treatment for low back pain?
  • Low Back Pain At A Glance
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  • Slideshow: Good & Bad Exercises for Low Back Pain Slideshow: Good & Bad Exercises for Low Back Pain
  • Take the Back Pain Quiz!
  • Patient Discussions: Lower Back Pain - Exercises
  • Patient Discussions: Lower Back Pain - Effective Treatments
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What is the anatomy of the low back?

The first step to understanding the various causes of low back pain is learning about the normal design (anatomy) of the tissues of this area. Important structures of the low back that can be related to symptoms there include the bony lumbar spine (vertebrae, singular = vertebra), discs between the vertebrae, ligaments around the spine and discs, spinal cord and nerves, muscles of the low back, internal organs of the pelvis and abdomen, and the skin covering the lumbar area.

The bony lumbar spine is designed so that vertebrae "stacked" together can provide a movable support structure while also protecting the spinal cord from injury. The spinal cord is composed of nervous tissue that extends down the spinal column from the brain. Each vertebra has a spinous process, a bony prominence behind the spinal cord, which shields the cord's nervous tissue from impact trauma. Vertebrae also have a strong bony "body" (vertebral body) in front of the spinal cord to provide a platform suitable for weight bearing of all tissues above the buttocks. The lumbar vertebrae stack immediately atop the sacrum bone that is situated in between the buttocks. On each side, the sacrum meets the iliac bone of the pelvis to form the sacroiliac joint of the buttocks.

The discs are pads that serve as "cushions" between the individual vertebral bodies. They help to minimize the impact of stress forces on the spinal column. Each disc is designed like a jelly donut with a central softer component (nucleus pulposus) and a surrounding outer ring (annulus fibrosus). The central portion of the disc is capable of rupturing (herniating) through the outer ring, causing irritation of adjacent nervous tissue and sciatica as described below.

Ligaments are strong fibrous soft tissues that firmly attach bones to bones. Ligaments attach each of the vertebrae to each other and surround each of the discs.

The nerves that provide sensation and stimulate the muscles of the low back as well as the lower extremities (the thighs, legs, feet, and toes) exit the lumbar spinal column through bony portals, each of which is called a "foramen."

Many muscle groups that are responsible for flexing, extending, and rotating the waist, as well as moving the lower extremities, attach to the lumbar spine through tendon insertions.

The aorta and blood vessels that transport blood to and from the lower extremities pass in front of the lumbar spine in the abdomen and pelvis. Surrounding these blood vessels are lymph nodes (lymph glands) and tissues of the involuntary nervous system that are important in maintaining bladder and bowel control.

The uterus and ovaries are important pelvic structures in front of the pelvic area of women. The prostate gland is a significant pelvic structure in men. The kidneys are on either side of the back of the lower abdomen, in front of the lumbar spine.

The skin over the lumbar area is supplied by nerves that come from nerve roots that exit from the lumbar spine.

What is the function of the low back?

The low back, or lumbar area, serves a number of important functions for the human body. These functions include structural support, movement, and protection of certain body tissues.

When we stand, the lower back is functioning to support the weight of the upper body. When we bend, extend, or rotate at the waist, the lower back is involved in the movement. Therefore, injury to the structures important for weight bearing, such as the bony spine, muscles, tendons, and ligaments, often can be detected when the body is standing erect or used in various movements.

Protecting the soft tissues of the nervous system and spinal cord as well as nearby organs of the pelvis and abdomen is a critical function the lumbar spine and its adjacent muscles.

What are common causes of lower back pain?

Common causes of low back pain (lumbar backache) include lumbar strain, nerve irritation, lumbar radiculopathy, bony encroachment, and conditions of the bone and joints. Each of these is reviewed below.

  1. Lumbar strain (acute, chronic)

    A lumbar strain is a stretch injury to the ligaments, tendons, and/or muscles of the low back. The stretching incident results in microscopic tears of varying degrees in these tissues. Lumbar strain is considered one of the most common causes of low back pain. The injury can occur because of overuse, improper use, or trauma. Soft-tissue injury is commonly classified as "acute" if it has been present for days to weeks. If the strain lasts longer than three months, it is referred to as "chronic."

    Lumbar strain most often occurs in people in their 40s, but it can happen at any age. The condition is characterized by localized discomfort in the low back area with onset after an event that mechanically stressed the lumbar tissues. The severity of the injury ranges from mild to severe, depending on the degree of strain and resulting spasm of the muscles of the low back.

    The diagnosis of lumbar strain is based on the history of injury, the location of the pain, and exclusion of nervous system injury. Usually, X-ray testing is only helpful to exclude bone abnormalities.

    The treatment of lumbar strain consists of resting the back (to avoid reinjury), medications to relieve pain and muscle spasm, local heat applications, massage, and eventual (after the acute episode resolves) reconditioning exercises to strengthen the low back and abdominal muscles. Initial treatment at home might include heat application, acetaminophen (Tylenol) or ibuprofen (Advil, Motrin), and avoiding reinjury and heavy lifting. Long periods of inactivity in bed are no longer recommended, as this treatment may actually slow recovery. Spinal manipulation for periods of up to one month has been found to be helpful in some patients who do not have signs of nerve irritation. Future injury is avoided by using back-protection techniques during activities and support devices as needed at home or work.

  2. Nerve irritation

    The nerves of the lumbar spine can be irritated by mechanical pressure (impingement) by bone or other tissues, or from disease, anywhere along their paths -- from their roots at the spinal cord to the skin surface. These conditions include lumbar disc disease (radiculopathy), bony encroachment, and inflammation of the nerves caused by a viral infection (shingles). See discussions of these conditions below.

  3. Lumbar radiculopathy

    Lumbar radiculopathy is nerve irritation that is caused by damage to the discs between the vertebrae. Damage to the disc occurs because of degeneration ("wear and tear") of the outer ring of the disc, traumatic injury, or both. As a result, the central softer portion of the disc can rupture (herniate) through the outer ring of the disc and abut the spinal cord or its nerves as they exit the bony spinal column. This rupture is what causes the commonly recognized "sciatica" pain of a herniated disc that shoots from the low back and buttock down the leg. Sciatica can be preceded by a history of localized low-back aching or it can follow a "popping" sensation 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, sciatica can be accompanied by incontinence of the bladder and/or bowels. The sciatica of lumbar radiculopathy typically affects only one side of the body, such as the left side or right side, and not both.

    Lumbar radiculopathy is suspected based on the above symptoms. Increased radiating pain when the lower extremity is lifted supports the diagnosis. Nerve testing (EMG/electromyogram and NCV/nerve conduction velocity) of the lower extremities can be used to detect nerve irritation. The actual disc herniation can be detected with imaging tests, such as CAT or MRI scanning.

    Treatment of lumbar radiculopathy ranges from medical management to surgery. Medical management includes patient education, medications to relieve pain and muscle spasms, cortisone injection around the spinal cord (epidural injection), physical therapy (heat, massage by a therapist, ultrasound, electrical stimulation), and rest (not strict bed rest but avoiding reinjury). 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 (a small hole in the bone of the lumbar spine surrounding the spinal cord), laminectomy (removal of the bony wall), by needle technique (percutaneous discectomy), disc-dissolving procedures (chemonucleolysis), and others.

    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

  4. Bony encroachment

    Any condition that results in movement or growth of the vertebrae of the lumbar spine can limit the space (encroachment) for the adjacent spinal cord and nerves. Causes of bony encroachment of the spinal nerves include foraminal narrowing (narrowing of the portal through which the spinal nerve passes from the spinal column, out of the spinal canal to the body, commonly as a result of arthritis), spondylolisthesis (slippage of one vertebra relative to another), and spinal stenosis (compression of the nerve roots or spinal cord by bony spurs or other soft tissues in the spinal canal). Spinal-nerve compression in these conditions can lead to sciatica pain that radiates down the lower extremities. Spinal stenosis can cause lower-extremity pains that worsen with walking and are relieved by resting (mimicking the pains of poor circulation). Treatment of these afflictions varies, depending on their severity, and ranges from rest to surgical decompression by removing the bone that is compressing the nervous tissue.

  5. Bone and joint conditions

    Bone and joint conditions that lead to low back pain include those existing from birth (congenital), those that result from wear and tear (degenerative) or injury, and those that are due to inflammation of the joints (arthritis).

      Congenital bone conditions -- Congenital causes (existing from birth) of low back pain include scoliosis and spina bifida. Scoliosis is a sideways (lateral) curvature of the spine that can be caused when one lower extremity is shorter than the other (functional scoliosis) or because of an abnormal architecture of the spine (structural scoliosis). Children who are significantly affected by structural scoliosis may require treatment with bracing and/or surgery to the spine. Adults infrequently are treated surgically but often benefit by support bracing.

      Spina bifida is a birth defect in the bony vertebral arch over the spinal canal, often with absence of the spinous process. This birth defect most commonly affects the lowest lumbar vertebra and the top of the sacrum. Occasionally, there are abnormal tufts of hair on the skin of the involved area. Spina bifida can be a minor bony abnormality without symptoms. However, the condition can also be accompanied by serious nervous abnormalities of the lower extremities.

      Degenerative bone and joint conditions -- As we age, the water and protein content of the body's cartilage changes. This change results in weaker, thinner, and more fragile 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). Degeneration of the disc is called spondylosis. Spondylosis can be noted on X-rays of the spine as a narrowing of the normal "disc space" between the vertebrae. It is the deterioration of the disc tissue that predisposes the disc to herniation and localized lumbar pain ("lumbago") in older patients. Degenerative arthritis (osteoarthritis) of the facet joints is also a cause of localized lumbar pain that can be detected with plain X-ray testing. These causes of degenerative back pain are usually treated conservatively with intermittent heat, rest, rehabilitative exercises, and medications to relieve pain, muscle spasm, and inflammation.

      Injury to the bones and joints -- Fractures (breakage of bone) of the lumbar spine and sacrum bone most commonly affect elderly people with osteoporosis, especially those who have taken long-term cortisone medication. For these individuals, occasionally even minimal stresses on the spine (such as bending to tie shoes) can lead to bone fracture. In this setting, the vertebra can collapse (vertebral compression fracture). The fracture causes an immediate onset of severe localized pain that can radiate around the waist in a band-like fashion and is made intensely worse with body motions. This pain generally does not radiate down the lower extremities. Vertebral fractures in younger patients occur only after severe trauma, such as from motor-vehicle accidents or a convulsive seizure.

      In both younger and older patients, vertebral fractures take weeks to heal with rest and pain relievers. Compression fractures of vertebrae associated with osteoporosis can also be treated with a procedure called vertebroplasty, which can help to reduce pain. In this procedure, a balloon is inflated in the compressed vertebra, often returning some of its lost height. Subsequently, a "cement" (methymethacrylate) is injected into the balloon and remains to retain the structure and height of the body of the vertebra.

      Arthritis -- The spondyloarthropathies are inflammatory types of arthritis that can affect the lower back and sacroiliac joints. Examples of spondyloarthropathies include reactive arthritis (Reiter's disease), ankylosing spondylitis, psoriatic arthritis, and the arthritis of inflammatory bowel disease. Each of these diseases can lead to low back pain and stiffness, which is typically worse in the morning. These conditions usually begin in the second and third decades of life. They are treated with medications directed toward decreasing the inflammation. Newer biologic medications have been greatly successful in both quieting the disease and stopping its progression.

What are other causes of lower back pain?

Other causes of low back pain include kidney problems, pregnancy, ovary problems, and tumors.

Kidney problems

Kidney infections, stones, and traumatic bleeding of the kidney (hematoma) are frequently associated with low back pain. Diagnosis can involve urine analysis, sound-wave tests (ultrasound), or other imaging studies of the abdomen.

Pregnancy

Pregnancy commonly leads to low back pain by mechanically stressing the lumbar spine (changing the normal lumbar curvature) and by the positioning of the baby inside of the abdomen. Additionally, the effects of the female hormone estrogen and the ligament-loosening hormone relaxin may contribute to loosening of the ligaments and structures of the back. Pelvic-tilt exercises and stretches are often recommended for relieving this pain. Women are also recommended to maintain physical conditioning during pregnancy according to their doctors' advice.

Ovary problems

Ovarian cysts, uterine fibroids, and endometriosis not infrequently cause low back pain. Precise diagnosis can require gynecologic examination and testing.

Tumors

Low back pain can be caused by tumors, either benign or malignant, that originate in the bone of the spine or pelvis and spinal cord (primary tumors) and those which originate elsewhere and spread to these areas (metastatic tumors). Symptoms range from localized pain to radiating severe pain and loss of nerve and muscle function (even incontinence of urine and stool) depending on whether or not the tumors affect the nervous tissue. Tumors of these areas are detected using imaging tests, such as plain X-rays, nuclear bone scanning, and CAT and MRI scanning.

What are uncommon causes of low back pain?

Uncommon causes of low back pain include Paget's disease of bone, bleeding or infection in the pelvis, infection of the cartilage and/or bone of the spine, aneurysm of the aorta, and shingles.

Paget's disease of bone

Paget's disease of the bone is a condition of unknown cause in which the bone formation is out of synchrony with normal bone remodeling. This condition results in abnormally weakened bone and deformity and can cause localized bone pain, though it often causes no symptoms. Paget's disease is more common in people over the age of 50. Heredity (genetic background) and certain unusual virus infections have been suggested as causes. Thickening of involved bony areas of the lumbar spine can cause the radiating lower extremity pain of sciatica.

Paget's disease can be diagnosed on plain X-rays. However, a bone biopsy is occasionally necessary to ensure the accuracy of the diagnosis. Bone scanning is helpful to determine the extent of the disease, which can involve more than one bone area. A blood test, alkaline phosphatase, is useful for diagnosis and monitoring response to therapy. Treatment options include aspirin, other anti-inflammatory medicines, pain medications, and medications that slow the rate of bone turnover, such as calcitonin (Calcimar, Miacalcin), etidronate (Didronel), alendronate (Fosamax), risedronate (Actonel), and pamidronate (Aredia).

 

Bleeding or infection in the pelvis

Bleeding in the pelvis is rare without significant trauma and is usually seen in patients who are taking blood-thinning medications, such as warfarin (Coumadin). In these patients, a rapid-onset sciatica pain can be a sign of bleeding in the back of the pelvis and abdomen that is compressing the spinal nerves as they exit to the lower extremities. Infection of the pelvis is infrequent but can be a complication of conditions such as diverticulosis, Crohn's disease, ulcerative colitis, pelvic inflammatory disease with infection of the Fallopian tubes or uterus, and even appendicitis. Pelvic infection is a serious complication of these conditions and is often associated with fever, lowering of blood pressure, and a life-threatening state.

 

Infection of the cartilage and/or bone of the spine

Infection of the discs (septic discitis) and bone (osteomyelitis) is extremely rare. These conditions lead to localized pain associated with fever. The bacteria found when these tissues are tested with laboratory cultures include Staphylococcus aureus and Mycobacterium tuberculosis (TB bacteria). TB infection in the spine is called Pott's disease. These are each very serious conditions requiring long courses of antibiotics. The sacroiliac joints rarely become infected with bacteria. Brucellosis is a bacterial infection that can involve the sacroiliac joints and is usually transmitted in goat's milk.

Aneurysm of the aorta

In the elderly, atherosclerosis can cause weakening of the wall of the large arterial blood vessel (aorta) in the abdomen. This weakening can lead to a bulging (aneurysm) of the aorta wall. While most aneurysms cause no symptoms, some cause a pulsating low back pain. Aneurysms of certain size, especially when enlarging over time, can require surgical repair with a grafting procedure to repair the abnormal portion of the artery.

Shingles

Shingles (herpes zoster) is an acute infection of the nerves that supply sensation to the skin, generally at one or several spinal levels and on one side of the body (right or left). Patients with shingles usually have had chickenpox earlier in life. The herpes virus that causes chickenpox is believed to exist in a dormant state within the spinal nerve roots long after the chickenpox resolves. In people with shingles, this virus reactivates to cause infection along the sensory nerve, leading to nerve pain and usually an outbreak of shingles (tiny blisters on the same side of the body and at the same nerve level). The back pain in patients with shingles of the lumbar area can precede the skin rash by days. Successive crops of tiny blisters can appear for several days and clear with crusty inflammation in one to two weeks. Patients occasionally are left with a more chronic nerve pain (postherpetic neuralgia). Treatment can involve symptomatic relief with lotions, such as calamine, or medications, such as acyclovir (Zovirax) for the infection and pregabalin (Lyrica) or lidocaine (Lidoderm) patches for the pain.

What is the treatment for low back pain?

So, how is low back pain treated? Well, as described above, the treatment very much depends on the precise cause of the low back pain. Moreover, each patient must be individually evaluated and managed in the context of the underlying background health status and activity level.

As has been highlighted by research presented at the national meeting of the American College of Rheumatology, a very important aspect of the individual evaluation is the patient's own perception of their particular situation. British researchers found that those who believed that their symptoms had serious consequences on their lives and that they had, or treatments had, little control over their symptoms were more likely to have a poor outcome. This research points out to physicians the importance of addressing the concerns and perceptions that patients have about their condition during the initial evaluations.

Finally, it should be noted that the conditions listed above are intended for general review. There are many other causes of back pain, including upper back pain, that have not been discussed.

Low Back Pain At A Glance
  • Functions of the low back, or lumbar area, include structural support, movement, and protection of certain body tissues.
  • Symptoms in the low back can relate to the bony lumbar spine, discs between the vertebrae, ligaments around the spine and discs, spinal cord and nerves, muscles of the low back, internal organs of the pelvis and abdomen, and the skin covering the lumbar area.
  • Treatment of low back pain is optimally directed toward a diagnosed or suspected specific cause. For acute lumbar strain, use of a home remedy initially can be beneficial.

Low Blood Pressure
(Hypotension)


  • What is low blood pressure?
  • How is blood pressure generated?
  • How does the body maintain normal blood pressure?
  • Is low blood pressure bad for your health?
  • What are low blood pressure signs and symptoms?
  • What are the causes of low blood pressure?
  • How is low blood pressure diagnosed and evaluated?
  • How is low blood pressure treated?
  • Low Blood Pressure At A Glance
  • Patient Discussions: Low Blood Pressure - Treatments
  • Patient Discussions: Low Blood Pressure - Causes

What is low blood pressure?

Blood pressure is the force exerted by circulating blood on the walls of blood vessels. It constitutes one of the critically important signs of life or vital signs which include heart beat, breathing, and temperature. Blood pressure is generated by the heart pumping blood into the arteries modified by the response of the arteries to the flow of blood.

An individual's blood pressure is expressed as systolic/diastolic blood pressure, for example, 120/80.The systolic blood pressure (the top number) represents the pressure in the arteries as the muscle of the heart contracts and pumps blood into them. The diastolic blood pressure (the bottom number) represents the pressure in the arteries as the muscle of the heart relaxes following its contraction. Blood pressure always is higher when the heart is pumping (squeezing) than when it is relaxing.

The range of systolic blood pressure for most healthy adults falls between 90 and 120 millimeters of mercury (mm Hg). Normal diastolic blood pressure ranges between 60 and 80 mm Hg. Current guidelines define normal blood pressure range as lower than 120/80. Blood pressures over 130/80 are considered high. High blood pressure increases the risk of developing:

  • heart disease,
  • kidney disease,
  • hardening of the arteries (atherosclerosis or arteriosclerosis),
  • eye damage, and
  • stroke.

Low blood pressure (hypotension) is pressure so low it causes symptoms or signs due to the low flow of blood through the arteries and veins. When the flow of blood is too low to deliver enough oxygen and nutrients to vital organs such as the brain, heart, and kidney, the organs do not function normally and may be temporarily or permanently damaged.

Unlike high blood pressure, low blood pressure is defined primarily by signs and symptoms of low blood flow and not by a specific blood pressure number. Some individuals routinely may have blood pressures of 90/50 with no symptoms and therefore do not have low blood pressure. However, others who normally have higher blood pressures may develop symptoms of low blood pressure if their blood pressure drops to 100/60.


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How is blood pressure generated?

During relaxation of the heart (diastole) the left ventricle of the heart fills with blood returning from the lungs. The left ventricle then contracts and pumps blood into the arteries (systole). The blood pressure in the arteries during contraction of the ventricle (systolic pressure) is higher because blood is being actively ejected into the arteries. It is lower during relaxation of the ventricle (diastolic pressure) when no blood is being ejected into the arteries. The pulse that we can feel when we place our fingers over an artery is caused by the contraction of the left ventricle and the ejection of blood.

Blood pressure is determined by two factors: 1) The amount of blood pumped by the left ventricle of the heart into the arteries, and 2) the resistance to the flow of blood caused by the walls of the arterioles (smaller arteries).

Generally, blood pressure tends to be higher if more blood is pumped into the arteries or if the arterioles are narrow and/or stiff. (Narrow and/or stiff arterioles, by resisting the flow of blood, increase blood pressure.) Arterioles may become narrower when the muscles surrounding them contract. Arterioles may become stiff and narrow when older patients develop atherosclerosis.

Blood pressure tends to be lower if less blood is being pumped into the arteries or if the arterioles are larger and more flexible and, therefore, have less resistance to the flow of blood.

How does the body maintain normal blood pressure?

The body has mechanisms to alter or maintain blood pressure and blood flow. There are sensors that sense blood pressure in the walls of the arteries and send signals to the heart, the arterioles, the veins, and the kidneys that cause them to make changes that lower or increase blood pressure. There are several ways in which blood pressure can be adjusted - by adjusting the amount of blood pumped by the heart into the arteries (cardiac output), the amount of blood contained in the veins, the arteriolar resistance, and the volume of blood.

  • The heart can speed up and contract more frequently and it can eject more blood with each contraction. Both of these responses increase the flow of blood into the arteries and increase blood pressure.
  • The veins can expand and narrow. When veins expand, more blood can be stored in the veins and less blood returns to the heart for pumping into the arteries. As a result, the heart pumps less blood, and blood pressure is lower. On the other hand, when veins narrow, less blood is stored in the veins, more blood returns to the heart for pumping into the arteries, and blood pressure is higher.
  • The arterioles can expand and narrow. Expanded arterioles create less resistance to the flow of blood and decrease blood pressure, while narrowed arterioles create more resistance and raise blood pressure.
  • The kidney can respond to changes in blood pressure by increasing or decreasing the amount of urine that is produced. Urine is primarily water that is removed from the blood. When the kidney makes more urine, the amount (volume) of blood that fills the arteries and veins decreases, and this lowers blood pressure. If the kidneys make less urine, the amount of blood that fills the arteries and veins increases and this increases blood pressure. Compared with the other mechanisms for adjusting blood pressure, changes in the production of urine affect blood pressure slowly over hours and days. (The other mechanisms are effective in seconds.)

For example, low blood volume due to bleeding (such as a bleeding ulcer in the stomach or from a severe laceration from an injury) can cause low blood pressure. The body quickly responds to the low blood volume and pressure by the following adjustments which all increase blood pressure:

  • The heart rate increases and the forcefulness of the heart's contractions increase thus pumping more blood through the heart.
  • Veins narrow to return more blood to the heart for pumping.
  • Blood flow to the kidneys decreases to reduce the formation of urine and thereby increases the volume of blood in the arteries and veins.
  • Arterioles narrow to increase resistance to blood flow

These adaptive responses will keep the blood pressure in the normal range unless blood loss becomes so severe that the responses are overwhelmed.

Is low blood pressure bad for your health?

People who have lower blood pressures have a lower risk of stroke, kidney disease, and heart disease. Athletes, people who exercise regularly, people who maintain ideal body weight, and non-smokers tend to have lower blood pressures. Therefore, low blood pressure is desirable as long as it is not low enough to cause symptoms and damage to the organs in the body.

What are low blood pressure signs and symptoms?

When blood pressure is not sufficient to deliver enough blood to the organs of the body, the organs do not work properly and can be temporarily or permanently damaged. For example, if insufficient blood flows to the brain, brain cells do not receive enough oxygen and nutrients, and a person can feel lightheaded, dizzy, or even faint.

Going from a sitting or lying position to a standing position often brings out symptoms of low blood pressure. This occurs because standing causes blood to "settle" in the veins of the lower body, and this can lower the blood pressure. If the blood pressure is already low, standing can make the low pressure worse, to the point of causing symptoms. The development of lightheadedness, dizziness, or fainting upon standing caused by low blood pressure is called orthostatic hypotension. Normal individuals are able to compensate rapidly for the low pressure created by standing with the responses discussed previously and do not develop orthostatic hypotension.

When there is insufficient blood pressure to deliver blood to the coronary arteries (the arteries that supply blood to the heart's muscle), a person may develop chest pain (a symptom of angina) or even a heart attack.

When insufficient blood is delivered to the kidneys, the kidneys fail to eliminate wastes from the body, for example, urea (BUN) and creatinine, and increases in their levels in the blood occur.

Shock is a life-threatening condition where persistently low blood pressure causes organs such as kidney(s), liver, heart, lung, and brain to fail rapidly.

What are the causes of low blood pressure?

Conditions that reduce the volume of blood, reduce cardiac output (the amount of blood pumped by the heart), and medications are frequent reasons for low blood pressure.

  • Dehydration is common among patients with prolonged nausea, vomiting, and diarrhea. Large amounts of water are lost when vomiting and with diarrhea, especially if the person does not drink adequate amounts of fluid to replace the depleted water.

Other causes of dehydration include exercise, sweating, fever, and heat exhaustion, or heat stroke. Individuals with mild dehydration may experience only thirst and dry mouth. Moderate to severe dehydration may cause orthostatic hypotension (manifested by lightheadedness, dizziness, or fainting upon standing). Prolonged and severe dehydration can lead to shock, kidney failure, confusion, acidosis (too much acid in the blood), coma, and even death.

  • Moderate or severe bleeding can quickly deplete an individual's body of blood, leading to low blood pressure or orthostatic hypotension. Bleeding can result from trauma, surgical complications, or from gastrointestinal abnormalities such as ulcers, tumors, or diverticulosis. Occasionally, the bleeding may be so severe and rapid (for example, bleeding from a ruptured aortic aneurysm) that it causes shock and death rapidly.
  • Severe inflammation of organs inside the body such as acute pancreatitis can cause low blood pressure. In acute pancreatitis, fluid leaves the blood vessels to enter the inflamed tissues around the pancreas as well as the abdominal cavity, concentrating blood and reducing its volume.

Causes of low blood pressure due to heart disease

  • Weakened heart muscle can cause the heart to fail and reduce the amount of blood it pumps. One common cause of weakened heart muscle is the death of a large portion of the heart's muscle due to a single, large heart attack or repeated smaller heart attacks. Other examples of conditions that can weaken the ability of the heart to pump blood include medications that are toxic to the heart, infections of the muscle of the heart by viruses (myocarditis), and diseases of the heart's valves such as aortic stenosis.
  • Pericarditis is an inflammation of the pericardium (the sac surrounding the heart). Pericarditis can cause fluid to accumulate within the pericardium and compress the heart, restricting the ability of the heart to fill and pump blood.
  • Pulmonary embolism is a condition in which a blood clot in a vein (deep vein thrombosis) breaks off and travels to the heart and eventually the lung. A large blood clot can block the flow of blood into the left ventricle from the lungs and severely diminish the blood returning to the heart for pumping. Pulmonary embolism is a life-threatening emergency.
  • A slow heart rate (bradycardia) can decrease the amount of blood pumped by the heart. The resting heart rate for a healthy adult is between 60 and 100 beats/minute. Bradycardia (resting heart rates slower than 60 beats/minute) does not always cause low blood pressure. In fact, some highly trained athletes can have resting heart rates in the 40s and 50s (beats per minute) without any symptoms. (The slow heart rates are offset by more forceful contractions of the heart that pump more blood than in non-athletes.) But in many patients bradycardia can lead to low blood pressure, lightheadedness, dizziness, and even fainting.

Several common reasons for bradycardia include: 1) sick sinus syndrome, 2) heart block, and 3) drug toxicity. Many of these conditions occur in the elderly.

  1. Sick sinus syndrome: Sick sinus syndrome occurs when the diseased electrical system of the heart cannot generate signals fast enough to maintain a normal heart rate.
  2. Heart block: Heart block occurs when the specialized tissues that transmit electrical current in the heart are damaged by heart attacks, degeneration from atherosclerosis, and medications. Heart block prevents some or all of the electrical signals from reaching parts of the heart, and this prevents the heart from contracting as well as it otherwise would.
  3. Drug toxicity: Drugs such as digoxin (Lanoxin) or beta blockers for high blood pressure, can slow the transmission of electricity in the heart chemically and can cause bradycardia and hypotension (see section below "Medications that cause low blood pressure").
  • An abnormally fast heart rate (tachycardia) also can cause low blood pressure. The most common example of tachycardia causing low blood pressure is atrial fibrillation. Atrial fibrillation is a disorder of the heart characterized by rapid and irregular electrical discharges from the muscle of the heart causing the ventricles to contract irregularly and (usually) rapidly. The rapidly contracting ventricles do not have enough time to fill maximally with blood before the each contraction, and the amount of blood that is pumped decreases in spite of the faster heart rate. Other abnormally rapid heart rhythms such as ventricular tachycardia also can produce low blood pressure, sometimes even life-threatening shock.

Medications that cause low blood pressure

  • Medications such as calcium channel blockers, beta blockers, and digoxin (Lanoxin) can slow the rate at which the heart contracts. Some elderly people are extremely sensitive to these medications since they are more likely to have diseased hearts and electrical conduction tissues. In some individuals, the heart rate can become dangerously slow even with small doses of these medications.
  • Medications used in treating high blood pressure (such as ACE inhibitors, angiotensin receptor blockers, beta blockers, calcium channel blockers, and alpha-blockers) can excessively lower blood pressure and result in symptomatic low blood pressure especially among the elderly.
  • Water pills (diuretics) such as hydrochlorothiazide furosemide (Lasix) can decrease blood volume by causing excessive urination.

 

  • Medications used for treating depression, such as amitriptyline (Elavil), Parkinson's disease, such as levodopa-carbidopa (Sinemet), erectile dysfunction (impotence), such as sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis) when used in combination with nitroglycerine, can cause low blood pressure.

 

  • Alcohol and narcotics also can cause low blood pressure.

Other conditions that cause low blood pressure

  • Vasovagal reaction is a common condition in which a healthy person temporarily develops low blood pressure, slow heart rate, and sometimes fainting. A vasovagal reaction typically is brought on by emotions of fear or pain such as having blood drawn, starting an intravenous infusion, or by gastrointestinal upset. Vasovagal reactions are caused by activity of the involuntary (autonomic) nervous system, especially the vagus nerve, which releases hormones that slow the heart and widen the blood vessels. The vagus nerve also controls digestive tract function and senses activity in the digestive system. Thus, some people can have a vasovagal reaction from straining at a bowel movement or vomiting.
  • Postural (orthostatic) hypotension is a sudden drop in blood pressure when an individual stands up from a sitting, squatting, or supine (lying) position. When a person stands up, gravity causes blood to settle in the veins in the legs so that less blood returns to the heart for pumping, and, as a result, the blood pressure drops. The body normally responds automatically to the drop in blood pressure by increasing the rate at which the heart beats and by narrowing the veins to return more blood to the heart. In patients with postural hypotension, this compensating reflex fails to occur, resulting low blood pressure and its symptoms. Postural hypotension can occur in persons of all ages but is much more common among the elderly, especially in those on medications for high blood pressure and/or diuretics. Other causes of postural hypotension include dehydration, adrenal insufficiency (discussed later), prolonged bed rest, diabetes that has caused damage to the autonomic nerves, alcoholism with damage to the autonomic nerves, and certain rare neurological syndromes (for example, Shy-Drager syndrome) that damage the autonomic nerves.
  • Another form of postural hypotension occurs typically in young healthy individuals. After prolonged standing, the individual's heart rate and blood pressure drop, causing dizziness, nausea, and often fainting. In these individuals, the autonomic nervous system wrongly responds to prolonged standing by directing the heart to slow down and the veins to dilate.
  • Micturition syncope is a temporary drop in blood pressure and loss of consciousness brought about by urinating. This condition typically occurs in elderly patients and may be due to the release by the autonomic nerves of hormones that lower blood pressure.
  • Adrenal insufficiency, for example, due to Addison's disease, can cause low blood pressure. Addison's disease is a disorder in which the adrenal glands (small glands next to the kidneys) are destroyed. The destroyed adrenal glands can no longer produce sufficient adrenal hormones (specifically cortisol) necessary to maintain normal bodily functions. Cortisol has many functions, one of which is to maintain blood pressure and the function of the heart. Addison's disease is characterized by weight loss, muscle weakness, fatigue, low blood pressure, and, sometimes, darkening of the skin.

  • Septicemia is a severe infection in which bacteria (or other infectious organisms such as fungi) enter the blood. The infection typically originates in the lungs (as pneumonia), bladder, or in the abdomen due to diverticulitis or gallstones. The bacteria then enter the blood where they release toxins and cause life-threatening and profound low blood pressure (septic shock), often with damage to several organs.
  • Anaphylaxis (anaphylactic shock) is a potentially fatal allergic reaction to medications such as penicillin, intravenous iodine used in some X-ray studies, foods such as peanuts, or bee stings (insect stings). In addition to a severe drop in blood pressure, individuals may also experience hives as well as wheezing due to constriction of the airways, and a swollen throat which cause difficulty breathing. The shock is caused by enlargement of blood-containing blood vessels and escape of water from the blood into the tissues.

How is low blood pressure diagnosed and evaluated?

In some individuals, particularly relatively healthy ones, symptoms of weakness, dizziness, and fainting raise the suspicion of low blood pressure. In others, an event often associated with low blood pressure, for example a heart attack has occurred to cause the symptoms.

Measuring blood pressure, in both the lying (supine) and standing positions usually is the first step in diagnosing low blood pressure. In patients with symptomatic low blood pressure, there often is a marked drop in blood pressure upon standing, and patients may even develop orthostatic symptoms. The heart rate often increases greatly. Once low blood pressure has been identified as the cause of symptoms, the goal is to identify the cause of the low blood pressure. Sometimes the causes are readily apparent (such as loss of blood due to trauma, or sudden shock after receiving x-ray dyes containing iodine). At other times, the cause may be identified by testing:

  • CBC (complete blood count). CBC may reveal anemia from blood loss or elevated white blood cells due to infection.
  • Blood electrolyte measurements may show dehydration and mineral depletion, renal failure (kidney failure), or acidosis (excess acid in the blood).
  • Cortisol levels can be measured to diagnose adrenal insufficiency and Addison's disease.
  • Blood and urine cultures can be performed to diagnose septicemia and bladder infections, respectively.
  • Radiology studies, such as chest x-rays, abdominal ultrasounds, and computerized tomography (CT or CAT) scans may detect pneumonia, heart failure, gallstones, pancreatitis, and diverticulitis.
  • Electrocardiograms (EKG) can detect abnormally slow or rapid heart beats, pericarditis, and heart muscle damage from either previous heart attacks or a reduced supply of blood to the heart muscle that has not yet caused a heart attack.
  • Holter monitor recordings are used to diagnose intermittent episodes of abnormal heart rhythms. If abnormal rhythms occur intermittently, a standard EKG performed at the time of a visit to the doctor's office may not show the abnormal rhythm. A Holter monitor is a continuous recording of the heart's rhythm for 24 hours that often is used to chart and diagnose intermittent episodes of bradycardia or tachycardia.
  • Patient-activated event recorder. If the episodes of bradycardia or tachycardia are infrequent, a 24-hour Holter recording may not capture these sporadic episodes. In this situation, a patient can wear a patient-activated event recorder for up to four weeks. The patient presses a button to start the recording when he or she senses the onset of an abnormal heart rhythm or symptoms possibly caused by low blood pressure. The doctor then analyzes the recordings at a later date to identify the abnormal episodes.
  • Echocardiograms are examinations of the structures and motion of the heart using ultrasound. Echocardiograms can detect pericardial fluid due to pericarditis, the extent of heart muscle damage from heart attacks, diseases of the heart valves, and rare tumors of the heart.
  • Ultrasound examinations of the leg veins and CT scans of the chest can detect deep vein thrombosis and pulmonary embolism.
  • Tilt-Table tests are used to evaluate patients suspected of having postural hypotension or syncope due to abnormal function of the autonomic nerves. During a tilt-table test, the patient lies on an examining table with an intravenous infusion administered while the heart rate and blood pressure are monitored. The table then is tilted upright for 15 minutes to 45 minutes. Heart rate and blood pressure are monitored every few minutes. The purpose of the test is to try to reproduce postural hypotension.  Sometimes a doctor may administer epinephrine (Adrenalin, Isuprel) intravenously to induce postural hypotension.

How is low blood pressure treated?

Low blood pressure in healthy subjects without symptoms or organ damage needs no treatment. However, all patients with symptoms possibly due to low blood pressure should be evaluated by a doctor. (Patients who have had a major drop in blood pressure from their usual levels even without the development of symptoms also should be evaluated.) The doctor needs to identify the cause of the low blood pressure; remedies will depend on the cause. For example, if a medication is causing the low blood pressure, the dose of medication may have to be reduced or the medication stopped, though only after consulting the doctor. Self-adjustment of medication should not be done.

  • Dehydration is treated with fluids and minerals (electrolytes). Mild dehydration without nausea and vomiting can be treated with oral fluids and electrolytes. Moderate to severe dehydration usually is treated in the hospital or emergency room with intravenous fluids and electrolytes.
  • Blood loss can be treated with intravenous fluids and blood transfusions. Continuous and severe bleeding needs to be treated immediately.
  • Septic shock is an emergency and is treated with intravenous fluids and antibiotics.
  • Blood pressure medications or diuretics are adjusted, changed, or stopped by the doctor if they are causing low blood pressure symptoms.
  • Bradycardia may be due to a medication. The doctor may reduce, change or stop the medication. Bradycardia due to sick sinus syndrome or heart block is treated with an implantable pacemaker.
  • Tachycardia is treated depending on the nature of the tachycardia. Atrial fibrillation can be treated with oral medications, electrical cardioversion, or a catheterization procedure called pulmonary vein isolation. Ventricular tachycardia can be controlled with medications or with an implantable defibrillator.
  • Pulmonary embolism and deep vein thrombosis is treated with blood thinners, intravenous initially with heparin, and oral warfarin (Coumadin) later.

 

  • Pericardial fluid can be removed by a procedure called pericardiocentesis.
  • Postural hypotension can be treated with changes in diet such as increasing water and salt intake*, increasing intake of caffeinated beverages (because caffeine constricts blood vessels), using compression stockings to compress the leg veins and reduce the pooling of blood in the leg veins, and in some patients, the use of a medication called midodrine (ProAmatine). The problem with ProAmatine is that while it increases blood pressure in the upright position, the supine blood pressure may become too high, thus increasing the risk of strokes. Mayo Clinic researchers found that a medication used to treat muscle weakness in myasthenia gravis called pyridostigmine (Mestinon) increases upright blood pressure but not supine blood pressure. Mestinon, an anticholinesterase medication, works on the autonomic nervous system, especially when a person is standing up. Side effects include minor abdominal cramping or increased frequency of bowel movements. *Note: Increasing salt intake can lead to heart failure in patients with existing heart disease and should not be undertaken without consulting a doctor.

 

  • Postprandial hypotension refers to low blood pressure occurring after meals. Ibuprofen (Motrin) or indomethacin (Indocin) may be beneficial.

 

  • Vasovagal Syncope can be treated with several types of drugs such as beta blockers [for example, propanolol (Inderal, Inderal LA)], selective serotonin reuptake inhibitors [fluoxetine (Prozac), escitalopram oxalate (Lexapro), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), fluvoxamine (Luvox)], fludrocortisone (Florinef) (a drug that prevents dehydration by causing the kidney(s) to retaining water). A pacemaker can also be helpful when a patient fails drug therapy.
Low Blood Pressure At A Glance
  • Low blood pressure, also called hypotension, is blood pressure that is low enough that the flow of blood to the organs of the body is inadequate and symptoms and/or signs of low blood flow develop.
  • Low pressure alone, without symptoms or signs, usually is not unhealthy.
  • The symptoms of low blood pressure include lightheadedness, dizziness, and fainting. These symptoms are most prominent when individuals go from the lying or sitting position to the standing position (orthostatic hypotension).
  • Low blood pressure that causes an inadequate flow of blood to the body's organs can cause strokes, heart attacks, and kidney failure. It's most severe form is shock.
  • Common causes of low blood pressure include a reduced volume of blood, heart disease, and medications.
  • The cause of low blood pressure can be determined with blood tests, radiologic studies, and cardiac testing to look for arrhythmias.
  • Treatment of low blood pressure is determined by the cause of the low pressure.

Additional resources from WebMD Boots UK on Low Blood Pressure

Low Potassium
(Hypokalemia)


  • What is is potassium?
  • What are the causes of low potassium  (hypokalemia)?
  • What are the symptoms of low potassium?
  • How is low potassium diagnosed?
  • What is the treatment for low potassium?
  • How can low potassium be prevented?
  • Patient Discussions: Low Potassium (Hypokalemia) - Symptoms and Signs
  • Patient Discussions: Low Potassium (Hypokalemia) - How Was Diagnosis Established
  • Find a local Internist in your town

What is is potassium?

Small chemicals in the body known as electrolytes are crucial for cells to function. Potassium is one of the main electrolytes, and is concentrated within the cells of the body. Only 2% of the body's total potassium is available in the serum (the fluid part of the bloodstream that is not red or white blood cells or platelets). Small changes in the serum levels of potassium can affect body function. One of the important functions of potassium is maintenance of the cell electrical potential. The serum bathes the cells, and if the serum potassium level falls, cells with high electrical activity (for example, muscles and nerves) are particularly affected.

Normal potassium levels measured in the serum range from 3.5 to 5.0 mEq/liter. Normal daily intake of potassium is 70-100 mEq (270 to 390 mg/dl), and requires the kidneys to remove that same amount each day. If more is removed, the body's total potassium store will be decreased, and the result is hypokalemia (hypo=low + kal=potassium +emia= in the blood) occurs.

Potassium enters the body through dietary intake. Examples of potassium rich foods include:

  • Fresh fruits: bananas, cantaloupe, oranges, strawberries, kiwi, avocados, apricots
  • Fresh vegetables: greens, mushrooms, peas, beets, tomatoes
  • Meats: beef, fish, turkey,
  • Juices: Orange, prune, apricot, grapefruit

What are the causes of low potassium?

Hypokalemia is not commonly caused by poor dietary intake.

Excessive loss is the most common reason that potassium levels are low. Loss of potassium may occur from both the gastrointestinal (GI) tract and from the kidney.

Potassium loss from the intestines may be caused by:

  • Vomiting
  • Diarrhea
  • Ileostomy: In some patients who have had bowel surgery and an ileotomy formed, significant potassium loss can occur.
  • Villous adenoma (a type of colon polyp that can cause the colon to leak potassium)
  • Laxative use

Causes of potassium loss from the kidney:

  • Diuretic medications (water pills) like hydrochlorothiazide (HCTZ) or furosemide (Lasix)
  • Elevated corticosteroid levels, either from medication like prednisone or from Cushing's Syndrome
  • Elevated levels of aldosterone, a hormone that can increase with renal artery stenosis or adrenal tumors
  • Renal tubular acidosis
  • Low body magnesium levels

Low potassium levels may result from side effects of some medications:

Aminoglycosides like gentamicin (Garamycin) or tobramycin (Nebcin)

What are the symptoms of low potassium?

Potassium affects the way neuromuscular cells discharge energy (depolarize) and then regenerate (repolarize) that energy to be able to fire again. When potassium levels are low, the cells cannot repolarize and are unable to fire repeatedly, as is needed for the function of muscles and nerves. It is understandable then that the effects of low potassium include:

  • muscle weakness,
  • muscle aches, and
  • muscle cramps.

Since the heart is also a muscle, there can be some changes in the electrocardiogram (EKG or ECG) that are associated with hypokalemia, especially in the repolarization section of the EKG tracing. Palpitations (irregular heartbeats) may be perceived by the patient. In severe cases, hypokalemia can lead to dangerous disturbances in heart rhythm (arrhythmias).

How is low potassium diagnosed?

Hypokalemia is usually a secondary problem that is considered by the healthcare provider as part of the evaluation of the underlying disease. For example, patients with high blood pressure who are being treated with diuretics such as hydrochlorothiazide (Hydrodiuril) or furosemide (Lasix) often have their potassium levels monitored. Patients who present with vomiting and diarrhea, dehydration and weakness may have their electrolytes tested in order to determine whether body potassium losses may need to be replaced.

Blood tests and electrocardiograms are used to diagnose hypokalemia. Other testing may be done to define the underlying disease or illness that lead to the low potassium levels.

What is the treatment for low potassium?

Serum potassium levels above 3.0 mEq/liter are not considered dangerous or of great concern; they can be treated with potassium replacement by mouth. Levels lower than 3.0 mEq/liter may require intravenous replacement. Decisions are patient-specific and depend upon the diagnosis, the circumstances of the illness, and the patient's ability to tolerate fluid and medication by mouth.

Over the short term, with self-limited illnesses like gastroenteritis with vomiting and diarrhea, the body is able to regulate and restore potassium levels on its own. However, if the hypokalemia is severe, or the losses of potassium are predicted to be ongoing, potassium replacement or supplementation may be required.

In those patients taking diuretics, often a small amount of oral potassium may be prescribed since the loss will continue as long as the medication is prescribed. Oral supplements may be in pill or liquid form, and the dosages are measured in mEq. Common doses are 10-20mEq per day. Alternatively, consumption of foods high in potassium may be suggested for replacement. Bananas, apricots, oranges, and tomatoes are high in potassium content. Since potassium is excreted in the kidney, blood tests that monitor kidney function may be ordered to predict and prevent potassium levels from rising too high.

When potassium needs to be given intravenously, it must be given slowly. Potassium is irritating to the vein and must be given at a rate of approximately 10 mEq per hour. As well, infusing potassium too quickly can cause heart irritation and promote potentially dangerous rhythms like ventricular tachycardia.

A Special Situation: Periodic Paralysis

Rarely, a special situation will occur when all the potassium in the body shifts from the serum into the cells of the body. This drops the serum potassium levels to 1.0 mEq/liter or lower. This causes immediate muscle weakness to the point that the patient cannot move. Arms and legs are most affected. Rarely, breathing and swallowing muscles can be involved.

Periodic paralysis may be hereditary and may be precipitated by excessive exercise, a high carbohydrate or high salt meal, or may occur without apparent cause.

Treatment by potassium replacement intravenously is effective, and recovery occurs within 24 hours.

How can low potassium be prevented?

Eating a well-balanced diet will prevent low potassium conditions. It is difficult to predict if hypokalemia will occur with vomiting and diarrhea or with diuretic use. Appreciating the potential for hypokalemia will allow the healthcare provide and the patient to work together to monitor serum potassium levels and initiate replacement therapy if needed.

Low Testosterone
(Low T)


  • What is testosterone?
  • What is low testosterone?
  • What are the causes of low testosterone?
  • What are the symptoms of low testosterone?
  • When should I seek medical care for low testosterone?
  • How is low testosterone diagnosed?
  • What is the treatment for low testosterone?
  • What are the complications of low testosterone?
  • Can low testosterone be prevented?
  • What is the outlook for a patient with low testosterone?
  • Low Testosterone At A Glance
  • Patient Discussions: Low Testosterone
  • Find a local Endocrinologist in your town

What is testosterone?

Testosterone is a steroid hormone which is made in the testes in males and in the ovaries in women (a minimal amount is also made in the adrenal glands). Testosterone has two major functions in the human body.

  1. Testosterone is needed to form and maintain the male sex organs and promote secondary male sex characteristics (in both men and women) such as voice deepening and hair growth patterns. This function is related to its androgenic properties.
  2. Testosterone is the facilitation of muscle growth as well as bone development and maintenance. This is a result of its anabolic properties.

Testosterone production is regulated by hormones released from the brain. The hypothalamus and pituitary gland located in the brain produce hormonal signals that ultimately result in the production of testosterone. The hypothalamus is located just above the brain stem, and among its many functions, it produces gonadotrophin releasing hormone (GRH). GRH then travels a short distance to the pituitary gland, which is located in the base of the brain, and stimulates this gland to release FSH (follicle stimulating hormone) and LH (luteinizing hormone). These hormones travel through the bloodstream to activate the sex organs in both men and women. Subsequently, these hormones have a role in regulating testosterone levels in the bloodstream.

The majority of testosterone circulates in the blood bound to a carrier protein (many hormones that are produced in one area and affect another area have a carrier protein that helps their travel through the bloodstream). In this case the carrier protein is called "sex hormone binding globulin," or SHBG. When testosterone is being carried by SHBG, it is considered "bound". Bound testosterone does not play an active role in the body; only the unbound or "free" testosterone is able to enter the different cells of the body and exert its androgenic and anabolic effects. Thus, anything that affects the function or the amount of SHBG can also affect the total circulating amount of active testosterone.

Picture of the endocrine system including the testes and ovaries

What is low testosterone?

The human body functions within a relatively narrow range of normal. When chemicals such as hormones fall outside those normal levels, there can be consequences that affect the body at a cellular, organ, or systemic (body-wide) level.

Blood tests used to measure testosterone are usually performed in the morning. Testosterone sampling is difficult since the levels normally tend to bounce around a fair bit during the course of the day. The normal value for total testosterone in males is 270-1070 ng/dl. However, this depends to some extent on the individual laboratory being used, and the range can vary as a result. In women, there is debate about the accuracy of testosterone measurements, because the circulating values are so much lower than in males and are harder to accurately measure.

With advancing age, in both men and women, the amount of testosterone the body produces gradually falls. Free testosterone levels can be measured and normal levels depend upon an individual's age. Interestingly, menopause itself does not seem to play a role in a reduction of testosterone levels in women beyond that of advancing age.

What are the causes of low testosterone?

Low testosterone levels may be caused by a number of factors. For example – there may be a problem at the level of the hypothalamus or pituitary to produce appropriate amounts of LH and FSH to stimulate testosterone production. Another possibility is that the organs that make testosterone do not function normally or are not able to respond to stimulation by the brain. Also, as mentioned, changes in SHBG can account for the amount of testosterone that is available to exert its effects.

  • When the problem is in the organs that produce testosterone (the ovaries or testes, for the most part), it is called a "primary" problem". In medical terminology, the decrease in normal testosterone production is called "hypogonadism."
  • When the problem is related to the pituitary and its ability to regulate testosterone, it is called "secondary hypogonadism," and
  • If the problem is thought to be at the level of the hypothalamus, it is called "tertiary hypogonadism."

Some common causes of primary hypogonadism or failure of the gonads (the medical term for the sex organs, or testes and ovaries) may include the following:

  • Undescended testicles: If the testes fail to migrate from inside the abdomen into the scrotum during fetal development or in the first year or two of life, the testes may become damaged and unable to produce adequate amounts of testosterone.
  • Injury to the scrotum: If the testes are injured, they may not be able to produce adequate testosterone. Damage to one testicle does not often to lead to low levels if the other testis remains normal.
  • Cancer therapy: Chemotherapy and radiation therapy can damage the interstitial cells in the testes responsible for testosterone production. This decrease in testosterone production may be temporary as the cells recover, or it may be permanent.
  • Aging: Testosterone levels decrease with aging. Usually, enough testosterone is manufactured to allow for adequate bodily functions.
  • Mumps orchitis: The mumps virus can cause inflammation of the testes in males, and if the illness occurs in puberty or adulthood, the damage to the testes may lead to low testosterone production. Immunization against the mumps has significantly decreased the incidence of this illness.
  • Chromosomal abnormalities: A normal male has one X and one Y chromosome (a normal female has two X chromosomes). In Klinefelter's syndrome, in males, an extra X chromosome is present and among other anatomic issues, there is abnormal development of the testes and decreased ability to manufacture testosterone.
  • Ovary conditions in women: Premature ovarian failure and surgical removal of both ovaries (bilateral oophorectomy) are conditions associated with lower circulating testosterone levels.

Secondary and tertiary hypogonadism may be due to damage of the hypothalamus or pituitary and/or the failure of the production of hormones (GRH, TSH and/or LH) to stimulate the gonads.

Causes of secondary and tertiary hypogonadism include:

  • Damage to the pituitary gland may occur because of tumors of the gland itself or because of damage caused by the side effects of treatment of nearby brain tumors.
  • Hypothalamus malformations can prevent normal function. Kallman's syndrome is one example.
  • Compromised blood flow to these glands from other conditions such as excessive systemic blood loss.
  • Inflammation caused by tuberculosis and sarcoidosis may affect the pituitary gland.
  • HIV and AIDS may also cause inflammation of both the hypothalamus and pituitary.
  • Illegal use of anabolic steroids, for example in body building, can cause hypogonadism and low testosterone levels.

It should be noted that obesity also can be a cause of low testosterone. While it can be associated with other causes, obesity specifically enhances the conversion of testosterone to estrogen. This is a naturally occurring process in both men and women, and this conversion occurs predominantly in fat cells. In the case of obesity, the large amount of fat cells enhances this process, and testosterone levels may fall due to excessive conversion to estrogen.

There are rarer causes of hypogonadism that can occur, dealing with cellular mechanisms and receptor binding. These are beyond the scope of this discussion.

What are the symptoms of low testosterone?

Low testosterone symptoms in males

In males, symptoms of decreased testosterone depend upon when the low levels occur.

If there is inadequate testosterone in the fetus, genital development may be affected. There may be poor development of the penis and scrotum, with an appearance of female genitalia or ambiguous genitalia that are neither male nor female. Remember that the definition of male is based upon the type of chromosomes present and not necessarily upon the outward appearance.

If low testosterone occurs before or during puberty, there may be a lack of sexual maturation. Signs may include failure to develop muscle mass, failure of the voice to deepen, poor growth of body hair, enlarged breasts (gynecomastia), and failure of the penis and testes to enlarge.

In adulthood, low testosterone may lead to decreased sexual function and desire, infertility, and erectile dysfunction. Loss of hair, decreased muscle mass, and osteoporosis or decreased bone density may occur.

Low testosterone symptoms in females

While low testosterone is usually thought of as a male disease, low levels may occur in women and cause significant issues. Symptoms may include hot flashes, irritability, loss of sexual desire (decreased libido), and sleep disturbances. Loss of muscle mass, decreased bone density (osteoporosis), and loss of body hair may also be seen.

When should I contact the doctor for low testosterone?

For infants, routine screening examination is useful in checking for normal placement of the testes within the scrotum.

As puberty approaches in males, it is important that parents and health care practitioners look for the development of secondary sex characteristics such as lowering of voice, development of characteristic hair growth, and increased muscle mass.

In adults, most males will seek help with erectile dysfunction and decreased libido.

In women, a loss of sexual desire and libido are often the presenting complaints.

How is low testosterone diagnosed?

Many of the symptoms that lead to the diagnosis of low testosterone are nonspecific, and the health care practitioner may want to take a history of symptoms and perform a physical examination prior to ordering blood tests to assess for low testosterone levels in the body.

The diagnosis also depends upon at what age the concern occurs. Many times the diagnosis in the pediatric age group occurs because of the ability of the parent and health care practitioner to observe abnormalities in physical development that may occur.

If the diagnosis of low testosterone or hypogonadism is considered, blood tests to measure testosterone levels may be ordered. The level of testosterone varies depending upon the time of day, and most often, early morning testosterone levels are measured.

Based upon the clinical situation, further tests may be considered to determine whether the low testosterone is due to primary or secondary hypogonadism.

What is the treatment for low testosterone?

The initial consideration for treating low testosterone is to find the underlying cause and address that issue.

Treatment of low testosterone in men

In men, low testosterone levels in the body can be supplemented by hormone replacement with testosterone. Testosterone replacement therapy can be prescribed as an intramuscular injection usually given on a biweekly basis, as a patch or gel placed on the skin, or as putty that is applied to the gums of the mouth. Each of the treatments has its risks and benefits. The decision as to which form of testosterone to use depends upon the clinical situation. Discussions between the patient and health care practitioner often helps decide which medication to use.

Treatment of low testosterone in women

In women, in the United States there are currently no preparations that are FDA approved for testosterone replacement. Esterified estrogens and methyltestosterone (Estratest), manufactured by Solvay Pharmaceuticals, a combination of estrogen and methyltestosterone that was formerly available, was discontinued by the manufacturer in the spring of 2009.

 

Some doctors will advise women to cut the patches for men into smaller sizes, or to use the gel in smaller doses; however, the accuracy of these methods is questionable, as is the safety.

What are the complications of low testosterone?

Complications of low testosterone levels depend upon when in life the situation occurs. Low testosterone levels in infants can lead to poor development of sexual organs. Near puberty, it can lead to failure of development of secondary sexual characteristics. In adulthood, osteoporosis, loss of muscle mass, and decreased sexual function including erectile dysfunction and decreased libido may occur.

Can low testosterone be prevented?

Low testosterone is due to the failure of at least one part of the hypothalamus-pituitary- gonadal axis. Many illnesses and diseases that affect these organs are inherited and cannot be prevented. Other causes are unavoidable consequences such as cancer therapy and infection. However, some causes are preventable including obesity and drug abuse.

What is the outlook (prognosis) for a patient with low testosterone?

The ability to treat the condition depends upon recognizing symptoms and seeking medical care. Once the cause for the low testosterone levels is diagnosed, testosterone replacement therapy may be helpful in reversing the symptoms related to those low levels.

Maintaining adequate testosterone levels within the body may minimize future risk of muscle and bone loss.

Low Testosterone At A Glance

  • Testosterone is produced by the testes in males and ovaries in females. The testes are under the hormonal control of the hypothalamus and pituitary in the brain and make testosterone in response to stimulation by FSH and LH.
  • Primary hypogonadism occurs because of the inability of the testes to produce testosterone.
  • Causes of secondary and tertiary hypogonadism are due to a variety of illnesses or diseases that affect the hypothalamus-pituitary-gonadal axis.
  • Symptoms of low testosterone depend upon when in the life cycle it occurs.
  • Osteoporosis is a significant complication of low testosterone.
  • In the United States testosterone replacement therapy is available as an FDA-approved treatment in men only. It may be administered by injection, patch or gel, or gum and cheek putty.

Lumbar Puncture (LP)


  • What is a lumbar puncture (LP)?
  • Why is a lumbar puncture done?
  • How is the LP performed?
  • What is done next?
  • What is the cerebrospinal fluid (CSF)?
  • What is normal CSF?
  • What diseases are diagnosed by examination of the CSF?
  • What are the risks of an LP?
  • What are the benefits of an LP?

 

What is a lumbar puncture (LP)?

A lumbar puncture (an LP) is the insertion of a needle into the fluid within the spinal canal. It is termed a "lumbar puncture" because the needle goes into the lumbar portion (the "small") of the back.

Other names for a lumbar puncture (an LP) include spinal tap, spinal puncture, thecal puncture, and rachiocentesis.

Why is a lumbar puncture done?

An LP is most commonly peformed to diagnose a disease, namely to obtain a sample of the fluid in the spinal canal (the cerebrospinal fluid) for examination.

An LP can also be done to treat diseases. For example, as a way of administering antibiotics, cancer drugs, or anesthetic agents into the spinal canal. Spinal fluid is sometimes removed by LP for the purpose of decreasing spinal fluid pressure in patients with uncommon conditions (such as, for examples, normal-pressure hydrocephalus and benign intracranial hypertension).

How is the LP performed?

The patient is typically lying down sideways for the procedure. Less often, the procedure is performed while the patient is sitting up. LPs in infants are often done upright.

After local anesthesia is injected into the small of the back (the lumbar area), a needle is inserted in between the nearby bony building blocks (vertebrae) into the spinal canal. (The needle is usually placed between the 3rd and 4th lumbar vertebrae).

What is done next?

Spinal fluid pressure can then be measured and cerebrospinal fluid (CSF) removed for testing.

What is the cerebrospinal fluid (CSF)?

The CSF circulates around the brain and spinal cord (the central nervous system). This "water bath" acts as a support of buoyancy for the brain and spinal cord. The support of the CSF helps to protect the brain from injury.

The normal CSF contains various chemicals, such as protein and sugar (glucose), and few if any cells. The spinal fluid also has a normal pressure when first removed.

What is normal CSF?

Normal values for spinal fluid examination are as follows:

  • Protein (15-45 mg/dl)
  • Glucose (50-75 mg/dl)
  • Cell count (0-5 mononuclear cells)
  • Initial pressure (70-180 mm)

These normal values can be altered by injury or disease of the brain, spinal cord or adjacent tissues. The values are routinely evaluated during examination of the spinal fluid obtained from the lumbar puncture. Additionally, spinal fluid is tested for infection in the microbiology laboratory.

What diseases are diagnosed by examination of the CSF?

Spinal fluid obtained from the lumbar puncture can be used to diagnose many important diseases such as bleeding around the brain; increased pressure from hydrocephalus; inflammation of the brain, spinal cord, or adjacent tissues (encephalitis, meningitis); tumors of brain or spinal cord, etc. Sometimes spinal fluid can indicate diseases of the immune system, such as multiple sclerosis.

What are the risks of an LP? When spinal fluid is removed during an LP, the risks include headache, brain herniation, bleeding, and infection. Each of these complications are uncommon with the exception of headache, which can appear from hours to up to a day after LP. Headaches occur less frequently when the patient remains lying flat 1-3 hours after the procedure.

What are the benefits of an LP?

The benefits of the LP depend upon the exact situation for which it is performed, but an LP can provide lifesaving information.

Radiculopathy


  • What is radiculopathy?
  • What are the risk factors for radiculopathy?
  • What are the causes of radiculopathy?
  • What are the symptoms of radiculopathy?
  • How is radiculopathy diagnosed?
  • What is the treatment for radiculopathy?
  • Can radiculopathy be prevented?
  • What is the outlook for radiculopathy?
  • Radiculopathy At A Glance
  • Patient Discussions: Radiculopathy
  • Patient Discussions: Radiculopathy
  • Find a local Neurologist in your town

What is radiculopathy?

Radiculopathy is a condition due to a compressed nerve in the spine that can cause pain, numbness, tingling, or weakness along the course of the nerve. Radiculopathy can occur in any part of the spine, but it is most common in the lower back (lumbar radiculopathy) and in the neck (cervical radiculopathy). It is less commonly found in the middle portion of the spine (thoracic radiculopathy).

What are the risk factors for radiculopathy?

Risk factors for radiculopathy are activities that place an excessive or repetitive load on the spine. Patients involved in heavy labor or contact sports are more prone to develop radiculopathy than those with a more sedentary lifestyle. A family history of radiculopathy or other spine disorders also increase the risk of developing radiculopathy.

What are the causes of radiculopathy?

Radiculopathy is caused by compression or irritation of the nerves as they exit the spine. This can be due to mechanical compression of the nerve by a disk herniation, a bone spur (osteophytes) from osteoarthritis, or from thickening of surrounding ligaments.

Other less common causes of mechanical compression of the nerves is from a tumor or infection. Either of these can reduce the amount of space in the spinal canal and compress the exiting nerve.

Scoliosis can cause the nerves on one side of the spine to become compressed by the abnormal curve of the spine.

Other causes of radiculopathy include diabetes which can decrease the normal blood flow to the spinal nerves. Inflammation from trauma or degeneration can lead to radiculopathy from direct irritation of the nerves.

What are the symptoms of radiculopathy?

The symptoms of radiculopathy depend on which nerves are affected. The nerves exiting from the neck (cervical spine) control the muscles of the neck and arms and supply sensation there. The nerves from the middle portion of the back (thoracic spine) control the muscles of the chest and abdomen and supply sensation there. The nerves from the lower back (lumbar spine) control the muscles of the buttocks and legs and supply sensation there.

The most common symptoms of radiculopathy are pain, numbness and tingling in the arms or legs. It is common for patients to also have localized neck or back pain as well. Lumbar radiculopathy that causes pain that radiates down a lower extremity is commonly referred to as sciatica. Thoracic radiculopathy causes pain from the middle back that travels around to the chest. It is often mistaken for shingles.

Some patients develop a hypersensitivity to light touch that feels painful in the area involved. Less commonly, patients can develop weakness in the muscles controlled by the affected nerves. This is can indicate nerve damage.

How is radiculopathy diagnosed?

The diagnosis of radiculopathy begins with a medical history and physical examination by the physician. During the medical history, the doctor will ask questions about the type and location of symptoms, how long they have been present, what makes them better and worse, and what other medical problems present. By knowing the exact location of the patient's symptoms, the doctor can help localize the nerve that is responsible. The physical examination will focus on the extremity involved. The doctor will check the patient's muscle strength, sensation, and reflexes to see if there are any abnormalities.

The patient may then be asked to obtain imaging studies to look for a source of the radiculopathy. Plain X-rays are often obtained first. These can often identify the presence of trauma or osteoarthritis and early signs of tumor or infection. An MRI scan may then be obtained. This study provides the best look at the soft tissues around the spine including the nerves, the disk and the ligaments. If the patient is unable to obtain an MRI, they may obtain a CT scan instead to explore possible compression of the nerves.

In some cases the doctor may order a nerve conduction study or electromyogram (EMG). These studies look at the electrical activity along the nerve and can show if there is damage to the nerve.

What is the treatment for radiculopathy?

Fortunately, most people can obtain good relief of their symptoms of radiculopathy with conservative treatment. This may include anti-inflammatory medications, physical therapy or chiropractic treatment, and avoiding activity that strains the neck or back. The majority of radiculopathy patients respond well to this conservative treatment, and symptoms often improve within six weeks to three months.

If patients do not improve with the treatments listed above they may benefit from an epidural steroid injection. With the help of an X-ray machine, a physician injects steroid medication between the bones of the spine adjacent to the involved nerves. This can help to rapidly reduce the inflammation and irritation of the nerve and help reduce the symptoms of radiculopathy.

In some cases the symptoms continue despite all of the above treatment options. If this occurs and the symptoms are severe, surgery may be an option. The goal of the surgery is to remove the compression from the affected nerve. Depending on the cause of the radiculopathy, this can be done by a laminectomy or a discectomy. A laminectomy removes a small portion of the bone covering the nerve to allow it to have additional space. A discectomy removes the portion of the disk that has herniated out and is compressing a nerve.

Can radiculopathy be prevented?

There is no specific prevention for radiculopathy. Maintaining a reasonable weight, good muscle conditioning, and avoiding excessive strain on the neck and back can reduce the chances of developing radiculopathy.

What is the outlook for radiculopathy?

The outlook for radiculopathy is good. The majority of patients respond well to conservative treatment options. Those patients that need surgical procedures typically obtain good results as well with no long-term restrictions.

Radiculopathy At A Glance
  • Radiculopathy is caused by compression or irritation of a nerve as it exits the spinal column.
  • Symptoms of radiculopathy include pain, numbness, tingling or weakness in the arms or legs.
  • Most patients with radiculopathy respond well to conservative treatment including medications, physical therapy or chiropractic.
  • Often radiculopathy can resolve within six weeks to three months.

Lumbar Spinal Stenosis


  • What is lumbar spinal stenosis?
  • What causes lumbar spinal stenosis?
  • What are the symptoms of lumbar spinal stenosis?
  • How is lumbar spinal stenosis diagnosed?
  • What is the treatment for lumbar spinal stenosis?
  • What can be done to prevent lumbar spinal stenosis?
  • Lumbar Spinal Stenosis At A Glance
  • Patient Discussions: Lumbar Spinal Stenosis - Symptoms
  • Patient Discussions: Lumbar Spinal Stenosis - Describe Your Experience

What is lumbar spinal stenosis?

The lumbar spine is made up of five vertebral bodies in the lower back. Nerves coming off the spinal cord travel though the spinal canal and exit the canal through small openings on the sides of the vertebral called foramen. Lumbar stenosis (spinal stenosis) is a condition whereby either the spinal canal (central stenosis) or vertebral foramen (foraminal stenosis) becomes narrowed. If the narrowing is substantial, it causes compression of the nerves, which causes the painful symptoms of lumbar spinal stenosis.

What causes lumbar spinal stenosis?

The most common cause of lumbar spinal stenosis is degenerative arthritis. As with other joints in the body arthritis commonly occurs in the spine as part of the normal ageing process. This can lead to loss of the cartilage between the bones at the joints, formation of bone spurs (osteophytes), loss of the normal height of the discs between the vertebrae of the spine (degenerative disc disease), and overgrowth (hypertrophy) of the ligamentous structures. Each of these processes reduces the normal space available for the nerves and can directly press on nerve tissues to cause lumbar spinal stenosis.

Lumbar spinal stenosis can also be caused by other conditions that decrease the space of the spinal canal or vertebral foramen. These can include:

  • tumor,
  • infection, and
  • various metabolic bone disorders, such as Paget's disease of bone.

These causes are much less common than degenerative arthritis.

What are the symptoms of lumbar spinal stenosis?

Lumbar spinal stenosis can cause:

  • low back pain,
  • weakness, numbness, pain, and loss of sensation in the legs.

In most cases the symptoms improve when the patient is sitting or leaning forward. Typically, painful sensations shoot down the legs with continued walking, and diminish with resting. Standing and bending backwards can make the symptoms worse. This is because bending forward increases the space in the spinal canal and vertebral foramen, while bending backward decrease the space. It more comfortable for patients to sit or lean forward and are unable to walk for long distances. Patients often state their symptoms are improved when bending forward while walking with the support of a walker or shopping cart.

In most cases the symptoms gradually worsen with time. This is because degenerative arthritis is a progressive disease that gradually becomes more severe with time. If left untreated the compression on the nerves from lumbar spinal stenosis can lead to increasing weakness and loss of function of the legs. It can also lead to loss of bowel and bladder control and loss of sexual function.

Your doctor can help determine if your symptoms are from lumbar spinal stenosis or a different condition. Many other disorders can cause similar symptoms including:

  • diabetic neuropathy,
  • peripheral vascular disease, and
  • vascular claudication.

How is lumbar spinal stenosis diagnosed?

The patient's physician will start with a complete medical history and physical examination. During the medical history the patient will be asked questions regarding symptoms including how long they have been present, what make it better or worse, what prior treatment the patient has had, and what other medical conditions they have. These questions can help the doctor distinguish lumbar spinal stenosis from other disorders.

The physical examination can consist of testing the range of motion in the back and feeling for areas of tenderness in the back. The legs may be examined for range of motion, strength, sensation, reflexes, and pulses. The hips and knees may also be examined because problems with these joints can often causes symptoms similar to lumbar spinal stenosis.

After the examination the physician may order imaging studies. This often begins with plain x-rays of the back. The doctors may also order an x-ray of the patient's hips depending on findings from the physical examination. The x-rays can show the doctor various signs associated with spinal stenosis including loss of the normal intervertebral disc height, bone spurs (osteophytes), and spinal instability (abnormal motion between the vertebrae. The ultimate diagnosis of lumbar spinal stenosis is made with by MRI scan (magnetic resonance imagining scan) or CT scan. These are more advanced tests that show the nerves in the lower back and can show if they are being compressed from lumbar spinal stenosis.

In some cases special nerve tests including electromyogram (EMG) or nerve conduction studies may be ordered. These tests can identify damage to or irritation of the nerves caused by long-term compression from lumbar spinal stenosis. These tests can also help determine exactly which nerves are involved.

What is the treatment for lumbar spinal stenosis?

In most cases the treatment for lumbar spinal stenosis begins with conservative (non-operative) treatment. This can include medications to reduce inflammation, even short courses of oral cortisone medication, and pain medications. There are also several medications directed specifically at nerve pain that are helpful in lumbar spinal stenosis, including gabapentin (Neurontin) and pregabalin (Lyrica). Physical therapy can help in some cases. Cortisone (steroid) injections in the lumbar spine can also reduce the symptoms by decreasing inflammation and swelling around the nerve tissue. These can be repeated up to three times per year.

 

Surgery

Surgery may be indicated for patients that do not improve with the above treatments, or if there is severe or progressive weakness or loss of bowel or bladder function (cauda equina syndrome). Depending on the examination findings and imaging studies there are various operations available for lumbar spinal stenosis.

The main goal of surgery is to remove the structures that are compressing the nerves in the spinal canal or vertebral foramen. This is a lumbar decompression surgery (laminectomy, laminotomy, foraminotomy). In some cases this can be performed alone, but in other cases it must be combined with lumbar fusion. If too much of the compressive structures need to be removed to free the nerve, the vertebrae may become unstable (spinal instability). This leaves the vertebrae with abnormal motion. If this occurs, a spinal fusion can be performed to make the vertebrae attached together and eliminate the motion at that level.

Surgery for lumbar spinal stenosis can be very successful in most cases for the leg symptoms. However, depending on the severity of the nerve compression and the length of time the nerve have been compressed, there may be some permanent damage that is not relieved with surgery. The success for back pain relief is less reliable with surgery than the relief of leg symptoms.

What can be done to prevent lumbar spinal stenosis?

Unfortunately, the degenerative changes responsible for lumbar spinal stenosis can occur as part of the normal ageing process. There is little that can be done to prevent lumbar spinal stenosis.

Lumbar Spinal Stenosis At A Glance
  • Lumbar spinal stenosis is typically caused be degenerative arthritis.
  • Patients can develop low back pain as well as pain, weakness, numbness or decreased sensation in the legs.
  • Surgery is recommended for failure of other treatments and for patients with increasing weakness of the legs or loss of bowel or bladder function.
  • Surgery includes a lumbar decompression with or without a lumbar fusion.
  • Surgery is most reliable for the relief of leg symptoms and less reliable for the relief of back pain.

Lung Cancer

  • What is lung cancer?
  • How common is lung cancer?
  • What causes lung cancer?
  • What are the types of lung cancer?
  • What are lung cancer symptoms and signs?
  • How is lung cancer diagnosed?
  • What is staging of lung cancer?
  • What is the treatment for lung cancer?
  • What is the prognosis (outcome) of lung cancer?
  • How can lung cancer be prevented?
  • Lung Cancer At A Glance
  • Patient Discussions: Lung Cancer - Treatments
  • Patient Discussions: Lung Cancer - Describe Your Experience
  • Find a local Oncologist in your town

What is lung cancer?

Cancer of the lung, like all cancers, results from an abnormality in the body's basic unit of life, the cell. Normally, the body maintains a system of checks and balances on cell growth so that cells divide to produce new cells only when new cells are needed. Disruption of this system of checks and balances on cell growth results in an uncontrolled division and proliferation of cells that eventually forms a mass known as a tumor.

Tumors can be benign or malignant; when we speak of "cancer," we are referring to those tumors that are malignant. Benign tumors usually can be removed and do not spread to other parts of the body. Malignant tumors, on the other hand, grow aggressively and invade other tissues of the body, allowing entry of tumor cells into the bloodstream or lymphatic system and then to other sites in the body. This process of spread is termed metastasis; the areas of tumor growth at these distant sites are called metastases. Since lung cancer tends to spread or metastasize very early after it forms, it is a very life-threatening cancer and one of the most difficult cancers to treat. While lung cancer can spread to any organ in the body, certain organs -- particularly the adrenal glands, liver, brain, and bone -- are the most common sites for lung cancer metastasis.

The lung also is a very common site for metastasis from tumors in other parts of the body. Tumor metastases are made up of the same type of cells as the original (primary) tumor. For example, if prostate cancer spreads via the bloodstream to the lungs, it is metastatic prostate cancer in the lung and is not lung cancer.

 

The principal function of the lungs is to exchange gases between the air we breathe and the blood. Through the lung, carbon dioxide is removed from the bloodstream and oxygen from inspired air enters the bloodstream. The right lung has three lobes, while the left lung is divided into two lobes and a small structure called the lingula that is the equivalent of the middle lobe on the right. The major airways entering the lungs are the bronchi, which arise from the trachea. The bronchi branch into progressively smaller airways called bronchioles that end in tiny sacs known as alveoli where gas exchange occurs. The lungs and chest wall are covered with a thin layer of tissue called the pleura.

Lung cancer picture

Picture of lung cancer

Lung cancers can arise in any part of the lung, but 90%-95% of cancers of the lung are thought to arise from the epithelial cells, the cells lining the larger and smaller airways (bronchi and bronchioles); for this reason, lung cancers are sometimes called bronchogenic cancers or bronchogenic carcinomas. (Carcinoma is another term for cancer.) Cancers also can arise from the pleura (called mesotheliomas) or rarely from supporting tissues within the lungs, for example, the blood vessels.

 

How common is lung cancer?

Lung cancer is the most common cause of death due to cancer in both men and women throughout the world. The American Cancer Society estimated that 222,520 new cases of lung cancer in the U.S. will be diagnosed and 157,300 deaths due to lung cancer would occur in 2010. According to the U.S. National Cancer Institute, approximately one out of every 14 men and women in the U.S. will be diagnosed with cancer of the lung at some point in their lifetime.

Lung cancer is predominantly a disease of the elderly; almost 70% of people diagnosed with lung cancer are over 65 years of age, while less than 3% of lung cancers occur in people under 45 years of age.

Lung cancer was not common prior to the 1930s but increased dramatically over the following decades as tobacco smoking increased. In many developing countries, the incidence of lung cancer is beginning to fall following public education about the dangers of cigarette smoking and the introduction of effective smoking-cessation programs. Nevertheless, lung cancer remains among the most common types of cancers in both men and women worldwide. In the U.S., lung cancer has surpassed breast cancer as the most common cause of cancer-related deaths in women.

 

What causes lung cancer?

Smoking

The incidence of lung cancer is strongly correlated with cigarette smoking, with about 90% of lung cancers arising as a result of tobacco use. The risk of lung cancer increases with the number of cigarettes smoked and the time over which smoking has occurred; doctors refer to this risk in terms of pack-years of smoking history (the number of packs of cigarettes smoked per day multiplied by the number of years smoked). For example, a person who has smoked two packs of cigarettes per day for 10 years has a 20 pack-year smoking history. While the risk of lung cancer is increased with even a 10-pack-year smoking history, those with 30-pack-year histories or more are considered to have the greatest risk for the development of lung cancer. Among those who smoke two or more packs of cigarettes per day, one in seven will die of lung cancer.

Pipe and cigar smoking also can cause lung cancer, although the risk is not as high as with cigarette smoking. Thus, while someone who smokes one pack of cigarettes per day has a risk for the development of lung cancer that is 25 times higher than a nonsmoker, pipe and cigar smokers have a risk of lung cancer that is about five times that of a nonsmoker.

Tobacco smoke contains over 4,000 chemical compounds, many of which have been shown to be cancer-causing or carcinogenic. The two primary carcinogens in tobacco smoke are chemicals known as nitrosamines and polycyclic aromatic hydrocarbons. The risk of developing lung cancer decreases each year following smoking cessation as normal cells grow and replace damaged cells in the lung. In former smokers, the risk of developing lung cancer begins to approach that of a nonsmoker about 15 years after cessation of smoking.

Passive smoking

Passive smoking or the inhalation of tobacco smoke by nonsmokers who share living or working quarters with smokers, also is an established risk factor for the development of lung cancer. Research has shown that nonsmokers who reside with a smoker have a 24% increase in risk for developing lung cancer when compared with nonsmokers who do not reside with a smoker. An estimated 3,000 lung cancer deaths that occur each year in the U.S. are attributable to passive smoking.

Asbestos fibers

Asbestos fibers are silicate fibers that can persist for a lifetime in lung tissue following exposure to asbestos. The workplace is a common source of exposure to asbestos fibers, as asbestos was widely used in the past as both thermal and acoustic insulation. Today, asbestos use is limited or banned in many countries, including the U.S. Both lung cancer and mesothelioma (cancer of the pleura of the lung as well as of the lining of the abdominal cavity called the peritoneum) are associated with exposure to asbestos. Cigarette smoking drastically increases the chance of developing an asbestos-related lung cancer in workers exposed to asbestos. Asbestos workers who do not smoke have a fivefold greater risk of developing lung cancer than nonsmokers, but asbestos workers who smoke have a risk that is fifty- to ninetyfold greater than nonsmokers.

Radon gas

Radon gas is a natural, chemically inert gas that is a natural decay product of uranium. Uranium decays to form products, including radon, that emit a type of ionizing radiation. Radon gas is a known cause of lung cancer, with an estimated 12% of lung-cancer deaths attributable to radon gas, or about 20,000 lung-cancer-related deaths annually in the U.S., making radon the second leading cause of lung cancer in the U.S. As with asbestos exposure, concomitant smoking greatly increases the risk of lung cancer with radon exposure. Radon gas can travel up through soil and enter homes through gaps in the foundation, pipes, drains, or other openings. The U.S. Environmental Protection Agency estimates that one out of every 15 homes in the U.S. contains dangerous levels of radon gas. Radon gas is invisible and odorless, but it can be detected with simple test kits.

 

Familial predisposition

While the majority of lung cancers are associated with tobacco smoking, the fact that not all smokers eventually develop lung cancer suggests that other factors, such as individual genetic susceptibility, may play a role in the causation of lung cancer. Numerous studies have shown that lung cancer is more likely to occur in both smoking and nonsmoking relatives of those who have had lung cancer than in the general population. Recently, the largest genetic study of lung cancer ever conducted, involving over 10,000 people from 18 countries and led by the International Agency for Research on Cancer (IARC), identified a small region in the genome (DNA) that contains genes that appear to confer an increased susceptibility to lung cancer in smokers. The specific genes, located the q arm of chromosome 15, code for proteins that interact with nicotine and other tobacco toxins (nicotinic acetylcholine receptor genes).

Lung diseases

The presence of certain diseases of the lung, notably chronic obstructive pulmonary disease (COPD), is associated with an increased risk (four- to sixfold the risk of a nonsmoker) for the development of lung cancer even after the effects of concomitant cigarette smoking are excluded.

Prior history of lung cancer

Survivors of lung cancer have a greater risk of developing a second lung cancer than the general population has of developing a first lung cancer. Survivors of non-small cell lung cancers (NSCLCs, see below) have an additive risk of 1%-2% per year for developing a second lung cancer. In survivors of small cell lung cancers (SCLCs, see below), the risk for development of second lung cancers approaches 6% per year.

Air pollution

Air pollution from vehicles, industry, and power plants can raise the likelihood of developing lung cancer in exposed individuals. Up to 1% of lung cancer deaths are attributable to breathing polluted air, and experts believe that prolonged exposure to highly polluted air can carry a risk for the development of lung cancer similar to that of passive smoking.

What are the types of lung cancer?

Lung cancers, also known as bronchogenic carcinomas, are broadly classified into two types: small cell lung cancers (SCLC) and non-small cell lung cancers (NSCLC). This classification is based upon the microscopic appearance of the tumor cells themselves. These two types of cancers grow and spread in different ways and may have different treatment options, so a distinction between these two types is important.

SCLC comprise about 20% of lung cancers and are the most aggressive and rapidly growing of all lung cancers. SCLC are strongly related to cigarette smoking, with only 1% of these tumors occurring in nonsmokers. SCLC metastasize rapidly to many sites within the body and are most often discovered after they have spread extensively. Referring to a specific cell appearance often seen when examining samples of SCLC under the microscope, these cancers are sometimes called oat cell carcinomas.

NSCLC are the most common lung cancers, accounting for about 80% of all lung cancers. NSCLC can be divided into three main types that are named based upon the type of cells found in the tumor:

  • Adenocarcinomas are the most commonly seen type of NSCLC in the U.S. and comprise up to 50% of NSCLC. While adenocarcinomas are associated with smoking, like other lung cancers, this type is observed as well in nonsmokers who develop lung cancer. Most adenocarcinomas arise in the outer, or peripheral, areas of the lungs. Bronchioloalveolar carcinoma is a subtype of adenocarcinoma that frequently develops at multiple sites in the lungs and spreads along the preexisting alveolar walls.
  • Squamous cell carcinomas were formerly more common than adenocarcinomas; at present, they account for about 30% of NSCLC. Also known as epidermoid carcinomas, squamous cell cancers arise most frequently in the central chest area in the bronchi.
  • Large cell carcinomas, sometimes referred to as undifferentiated carcinomas, are the least common type of NSCLC.
  • Mixtures of different types of NSCLC are also seen.

Other types of cancers can arise in the lung; these types are much less common than NSCLC and SCLC and together comprise only 5%-10% of lung cancers:

  • Bronchial carcinoids account for up to 5% of lung cancers. These tumors are generally small (3 cm-4 cm or less) when diagnosed and occur most commonly in people under 40 years of age. Unrelated to cigarette smoking, carcinoid tumors can metastasize, and a small proportion of these tumors secrete hormone-like substances that may cause specific symptoms related to the hormone being produced. Carcinoids generally grow and spread more slowly than bronchogenic cancers, and many are detected early enough to be amenable to surgical resection.
  • Cancers of supporting lung tissue such as smooth muscle, blood vessels, or cells involved in the immune response can rarely occur in the lung.

As discussed previously, metastatic cancers from other primary tumors in the body are often found in the lung. Tumors from anywhere in the body may spread to the lungs either through the bloodstream, through the lymphatic system, or directly from nearby organs. Metastatic tumors are most often multiple, scattered throughout the lung, and concentrated in the peripheral rather than central areas of the lung.

What are lung cancer symptoms and signs?

Symptoms of lung cancer are varied depending upon where and how widespread the tumor is. Warning signs of lung cancer are not always present or easy to identify. A person with lung cancer may have the following kinds of symptoms:

  • No symptoms: In up to 25% of people who get lung cancer, the cancer is first discovered on a routine chest X-ray or CT scan as a solitary small mass sometimes called a coin lesion, since on a two-dimensional X-ray or CT scan, the round tumor looks like a coin. These patients with small, single masses often report no symptoms at the time the cancer is discovered.
  • Symptoms related to the cancer: The growth of the cancer and invasion of lung tissues and surrounding tissue may interfere with breathing, leading to symptoms such as cough, shortness of breath, wheezing, chest pain, and coughing up blood (hemoptysis). If the cancer has invaded nerves, for example, it may cause shoulder pain that travels down the outside of the arm (called Pancoast's syndrome) or paralysis of the vocal cords leading to hoarseness. Invasion of the esophagus may lead to difficulty swallowing (dysphagia). If a large airway is obstructed, collapse of a portion of the lung may occur and cause infections (abscesses, pneumonia) in the obstructed area.
  • Symptoms related to metastasis: Lung cancer that has spread to the bones may produce excruciating pain at the sites of bone involvement. Cancer that has spread to the brain may cause a number of neurologic symptoms that may include blurred vision, headaches, seizures, or symptoms of stroke such as weakness or loss of sensation in parts of the body.
  • Paraneoplastic symptoms: Lung cancers frequently are accompanied by symptoms that result from production of hormone-like substances by the tumor cells. These paraneoplastic syndromes occur most commonly with SCLC but may be seen with any tumor type. A common paraneoplastic syndrome associated with SCLC is the production of a hormone called adrenocorticotrophic hormone (ACTH) by the cancer cells, leading to oversecretion of the hormone cortisol by the adrenal glands (Cushing's syndrome). The most frequent paraneoplastic syndrome seen with NSCLC is the production of a substance similar to parathyroid hormone, resulting in elevated levels of calcium in the bloodstream.
  • Nonspecific symptoms: Nonspecific symptoms seen with many cancers, including lung cancers, include weight loss, weakness, and fatigue. Psychological symptoms such as depression and mood changes are also common.

When should one consult a doctor?

One should consult a health-care provider if he or she develops the symptoms associated with lung cancer, in particular, if they have

  • a new persistent cough or worsening of an existing chronic cough
  • ,
  • blood in the sputum,
  • persistent bronchitis or repeated respiratory infections
  • ,
  • chest pain
  • ,
  • unexplained weight loss and/or fatigue
  • ,
  • breathing difficulties such as shortness of breath or wheezing.

How is lung cancer diagnosed?

Doctors use a wide range of diagnostic procedures and tests to diagnose lung cancer. These include the following:

  • The history and physical examination may reveal the presence of symptoms or signs that are suspicious for lung cancer. In addition to asking about symptoms and risk factors for cancer development such as smoking, doctors may detect signs of breathing difficulties, airway obstruction, or infections in the lungs. Cyanosis, a bluish color of the skin and the mucous membranes due to insufficient oxygen in the blood, suggests compromised function due to chronic disease of the lung. Likewise, changes in the tissue of the nail beds, known as clubbing, also may indicate chronic lung disease.
  • The chest X-ray is the most common first diagnostic step when any new symptoms of lung cancer are present. The chest X-ray procedure often involves a view from the back to the front of the chest as well as a view from the side. Like any X-ray procedure, chest X-rays expose the patient briefly to a small amount of radiation. Chest X-rays may reveal suspicious areas in the lungs but are unable to determine if these areas are cancerous. In particular, calcified nodules in the lungs or benign tumors called hamartomas may be identified on a chest X-ray and mimic lung cancer.
  • CT (computerized tomography, computerized axial tomography, or CAT) scans may be performed on the chest, abdomen, and/or brain to examine for both metastatic and lung tumors. A CT scan of the chest may be ordered when X-rays do not show an abnormality or do not yield sufficient information about the extent or location of a tumor. CT scans are X-ray procedures that combine multiple images with the aid of a computer to generate cross-sectional views of the body. The images are taken by a large donut-shaped X-ray machine at different angles around the body. One advantage of CT scans is that they are more sensitive than standard chest X-rays in the detection of lung nodules, that is, they will demonstrate more nodules. Sometimes intravenous contrast material is given prior to the scan to help delineate the organs and their positions. A CT scan exposes the patient to a minimal amount of radiation. The most common side effect is an adverse reaction to intravenous contrast material that may have been given prior to the procedure. This may result in itching, a rash, or hives that generally disappear rather quickly. Severe anaphylactic reactions (life-threatening allergic reactions with breathing difficulties) to contrast material are rare. CT scans of the abdomen may identify metastatic cancer in the liver or adrenal glands, and CT scans of the head may be ordered to reveal the presence and extent of metastatic cancer in the brain.
  • A technique called a low-dose helical CT scan (or spiral CT scan) is sometimes used in screening for lung cancers. This procedure requires a special type of CT scanner and has been shown to be an effective tool for the identification of small lung cancers in smokers and former smokers. However, it has not yet been proven whether the use of this technique actually saves lives or lowers the risk of death from lung cancer. The heightened sensitivity of this method is actually one of the sources of its drawbacks, since lung nodules requiring further evaluation will be seen in approximately 20% of people with this technique. Of the nodules identified by low-dose helical screening CTs, 90% are not cancerous but require up to two years of costly and often uncomfortable follow-up and testing. Trials are underway to further determine the utility of spiral CT scans in screening for lung cancer.
  • Magnetic resonance imaging (MRI) scans may be appropriate when precise detail about a tumor's location is required. The MRI technique uses magnetism, radio waves, and a computer to produce images of body structures. As with CT scanning, the patient is placed on a moveable bed which is inserted into the MRI scanner. There are no known side effects of MRI scanning, and there is no exposure to radiation. The image and resolution produced by MRI is quite detailed and can detect tiny changes of structures within the body. People with heart pacemakers, metal implants, artificial heart valves, and other surgically implanted structures cannot be scanned with an MRI because of the risk that the magnet may move the metal parts of these structures.
  • Positron emission tomography (PET) scanning is a specialized imaging technique that uses short-lived radioactive drugs to produce three-dimensional colored images of those substances in the tissues within the body. While CT scans and MRI scans look at anatomical structures, PET scans measure metabolic activity and the function of tissues. PET scans can determine whether a tumor tissue is actively growing and can aid in determining the type of cells within a particular tumor. In PET scanning, the patient receives a short half-lived radioactive drug, receiving approximately the amount of radiation exposure as two chest X-rays. The drug accumulates in certain tissues more than others, depending on the drug that is injected. The drug discharges particles known as positrons from whatever tissues take them up. As the positrons encounter electrons within the body, a reaction producing gamma rays occurs. A scanner records these gamma rays and maps the area where the radioactive drug has accumulated. For example, combining glucose (a common energy source in the body) with a radioactive substance will show where glucose is rapidly being used, for example, in a growing tumor. PET scanning may also be integrated with CT scanning in a technique known as PET-CT scanning. Integrated PET-CT has been shown to improve the accuracy of staging (see below) over PET scanning alone.
  • Bone scans are used to create images of bones on a computer screen or on film. Doctors may order a bone scan to determine whether a lung cancer has metastasized to the bones. In a bone scan, a small amount of radioactive material is injected into the bloodstream and collects in the bones, especially in abnormal areas such as those involved by metastatic tumors. The radioactive material is detected by a scanner, and the image of the bones is recorded on a special film for permanent viewing.
  • Sputum cytology: The diagnosis of lung cancer always requires confirmation of malignant cells by a pathologist, even when symptoms and X-ray studies are suspicious for lung cancer. The simplest method to establish the diagnosis is the examination of sputum under a microscope. If a tumor is centrally located and has invaded the airways, this procedure, known as a sputum cytology examination, may allow visualization of tumor cells for diagnosis. This is the most risk-free and inexpensive tissue diagnostic procedure, but its value is limited since tumor cells will not always be present in sputum even if a cancer is present. Also, noncancerous cells may occasionally undergo changes in reaction to inflammation or injury that makes them look like cancer cells.
  • Bronchoscopy: Examination of the airways by bronchoscopy (visualizing the airways through a thin, fiberoptic probe inserted through the nose or mouth) may reveal areas of tumor that can be sampled (biopsied) for diagnosis by a pathologist. A tumor in the central areas of the lung or arising from the larger airways is accessible to sampling using this technique. Bronchoscopy may be performed using a rigid or a flexible fiberoptic bronchoscope and can be performed in a same-day outpatient bronchoscopy suite, an operating room, or on a hospital ward. The procedure can be uncomfortable, and it requires sedation or anesthesia. While bronchoscopy is relatively safe, it must be carried out by a lung specialist (pulmonologist or surgeon) experienced in the procedure. When a tumor is visualized and adequately sampled, an accurate cancer diagnosis usually is possible. Some patients may cough up dark-brown blood for one to two days after the procedure. More serious but rare complications include a greater amount of bleeding, decreased levels of oxygen in the blood, and heart arrhythmias as well as complications from sedative medications and anesthesia.
  • Needle biopsy: Fine needle aspiration (FNA) through the skin, most commonly performed with radiological imaging for guidance, may be useful in retrieving cells for diagnosis from tumor nodules in the lungs. Needle biopsies are particularly useful when the lung tumor is peripherally located in the lung and not accessible to sampling by bronchoscopy. A small amount of local anesthetic is given prior to insertion of a thin needle through the chest wall into the abnormal area in the lung. Cells are suctioned into the syringe and are examined under the microscope for tumor cells. This procedure is generally accurate when the tissue from the affected area is adequately sampled, but in some cases, adjacent or uninvolved areas of the lung may be mistakenly sampled. A small risk (3%-5%) of an air leak from the lungs (called a pneumothorax, which can easily be treated) accompanies the procedure.
  • Thoracentesis: Sometimes lung cancers involve the lining tissue of the lungs (pleura) and lead to an accumulation of fluid in the space between the lungs and chest wall (called a pleural effusion). Aspiration of a sample of this fluid with a thin needle (thoracentesis) may reveal the cancer cells and establish the diagnosis. As with the needle biopsy, a small risk of a pneumothorax is associated with this procedure.
  • Major surgical procedures: If none of the aforementioned methods yields a diagnosis, surgical methods must be employed to obtain tumor tissue for diagnosis. These can include mediastinoscopy (examining the chest cavity between the lungs through a surgically inserted probe with biopsy of tumor masses or lymph nodes that may contain metastases) or thoracotomy (surgical opening of the chest wall for removal or biopsy of a tumor). With a thoracotomy, it is rare to be able to completely remove a lung cancer, and both mediastinoscopy and thoracotomy carry the risks of major surgical procedures (complications such as bleeding, infection, and risks from anesthesia and medications). These procedures are performed in an operating room, and the patient must be hospitalized.
  • Blood tests: While routine blood tests alone cannot diagnose lung cancer, they may reveal biochemical or metabolic abnormalities in the body that accompany cancer. For example, elevated levels of calcium or of the enzyme alkaline phosphatase may accompany cancer that is metastatic to the bones. Likewise, elevated levels of certain enzymes normally present within liver cells, including aspartate aminotransferase (AST or SGOT) and alanine aminotransferase (ALT or SGPT), signal liver damage, possibly through the presence of tumor metastatic to the liver. One current focus of research in the area of lung cancer is the development of a blood test to aid in the diagnosis of lung cancer. Researchers have preliminary data that has identified specific proteins, or biomarkers, that are in the blood and may signal that lung cancer is present in someone with a suspicious area seen on a chest X-ray or other imaging study.

Illustration of a lung cancer located in the right upper lobe of the lung

Schematic illustration of a lung cancer located in the right upper lobe of the lung.

What is staging of lung cancer?

The stage of a cancer is a measure of the extent to which a cancer has spread in the body. Staging involves evaluation of a cancer's size and its penetration into surrounding tissue as well as the presence or absence of metastases in the lymph nodes or other organs. Staging is important for determining how a particular cancer should be treated, since lung-cancer therapies are geared toward specific stages. Staging of a cancer also is critical in estimating the prognosis of a given patient, with higher-stage cancers generally having a worse prognosis than lower-stage cancers.

Doctors may use several tests to accurately stage a lung cancer, including laboratory (blood chemistry) tests, X-rays, CT scans, bone scans, MRI scans, and PET scans. Abnormal blood chemistry tests may signal the presence of metastases in bone or liver, and radiological procedures can document the size of a cancer as well as its spread.

NSCLC are assigned a stage from I to IV in order of severity:

  • In stage I, the cancer is confined to the lung.
  • In stages II and III, the cancer is confined to the chest (with larger and more invasive tumors classified as stage III).
  • Stage IV cancer has spread from the chest to other parts of the body.

SCLC are staged using a two-tiered system:

  • Limited-stage (LS) SCLC refers to cancer that is confined to its area of origin in the chest.
  • In extensive-stage (ES) SCLC, the cancer has spread beyond the chest to other parts of the body.

What is the treatment for lung cancer?

Treatment for lung cancer can involve surgical removal of the cancer, chemotherapy, or radiation therapy, as well as combinations of these treatments. The decision about which treatments will be appropriate for a given individual must take into account the location and extent of the tumor as well as the overall health status of the patient.

As with other cancers, therapy may be prescribed that is intended to be curative (removal or eradication of a cancer) or palliative (measures that are unable to cure a cancer but can reduce pain and suffering). More than one type of therapy may be prescribed. In such cases, the therapy that is added to enhance the effects of the primary therapy is referred to as adjuvant therapy. An example of adjuvant therapy is chemotherapy or radiotherapy administered after surgical removal of a tumor in an attempt to kill any tumor cells that remain following surgery.

Surgery: Surgical removal of the tumor is generally performed for limited-stage (stage I or sometimes stage II) NSCLC and is the treatment of choice for cancer that has not spread beyond the lung. About 10%-35% of lung cancers can be removed surgically, but removal does not always result in a cure, since the tumors may already have spread and can recur at a later time. Among people who have an isolated, slow-growing lung cancer removed, 25%-40% are still alive five years after diagnosis. It is important to note that although a tumor may be anatomically suitable for resection, surgery may not be possible if the person has other serious conditions (such as severe heart or lung disease) that would limit their ability to survive an operation. Surgery is less often performed with SCLC than with NSCLC because these tumors are less likely to be localized to one area that can be removed.

The surgical procedure chosen depends upon the size and location of the tumor. Surgeons must open the chest wall and may perform a wedge resection of the lung (removal of a portion of one lobe), a lobectomy (removal of one lobe), or a pneumonectomy (removal of an entire lung). Sometimes lymph nodes in the region of the lungs also are removed (lymphadenectomy). Surgery for lung cancer is a major surgical procedure that requires general anesthesia, hospitalization, and follow-up care for weeks to months. Following the surgical procedure, patients may experience difficulty breathing, shortness of breath, pain, and weakness. The risks of surgery include complications due to bleeding, infection, and complications of general anesthesia.

Radiation: Radiation therapy may be employed as a treatment for both NSCLC and SCLC. Radiation therapy uses high-energy X-rays or other types of radiation to kill dividing cancer cells. Radiation therapy may be given as curative therapy, palliative therapy (using lower doses of radiation than with curative therapy), or as adjuvant therapy in combination with surgery or chemotherapy. The radiation is either delivered externally, by using a machine that directs radiation toward the cancer, or internally through placement of radioactive substances in sealed containers within the area of the body where the tumor is localized. Brachytherapy is a term used to describe the use of a small pellet of radioactive material placed directly into the cancer or into the airway next to the cancer. This is usually done through a bronchoscope.

Radiation therapy can be given if a person refuses surgery, if a tumor has spread to areas such as the lymph nodes or trachea making surgical removal impossible, or if a person has other conditions that make them too ill to undergo major surgery. Radiation therapy generally only shrinks a tumor or limits its growth when given as a sole therapy, yet in 10%-15% of people it leads to long-term remission and palliation of the cancer. Combining radiation therapy with chemotherapy can further prolong survival when chemotherapy is administered. External radiation therapy can generally be carried out on an outpatient basis, while internal radiation therapy requires a brief hospitalization. A person who has severe lung disease in addition to a lung cancer may not be able to receive radiotherapy to the lung since the radiation can further decrease function of the lungs. A type of external radiation therapy called the "gamma knife" is sometimes used to treat single brain metastases. In this procedure, multiple beams of radiation coming from different directions are focused on the tumor over a few minutes to hours while the head is held in place by a rigid frame. This reduces the dose of radiation that is received by noncancerous tissues.

For external radiation therapy, a process called simulation is necessary prior to treatment. Using CT scans, computers, and precise measurements, simulation maps out the exact location where the radiation will be delivered, called the treatment field or port. This process usually takes 30 minutes to two hours. The external radiation treatment itself generally is done four or five days a week for several weeks.

Radiation therapy does not carry the risks of major surgery, but it can have unpleasant side effects, including fatigue and lack of energy. A reduced white blood cell count (rendering a person more susceptible to infection) and low blood platelet levels (making blood clotting more difficult and resulting in excessive bleeding) also can occur with radiation therapy. If the digestive organs are in the field exposed to radiation, patients may experience nausea, vomiting, or diarrhea. Radiation therapy can irritate the skin in the area that is treated, but this irritation generally improves with time after treatment has ended.

Chemotherapy: Both NSCLC and SCLC may be treated with chemotherapy. Chemotherapy refers to the administration of drugs that stop the growth of cancer cells by killing them or preventing them from dividing. Chemotherapy may be given alone, as an adjuvant to surgical therapy, or in combination with radiotherapy. While a number of chemotherapeutic drugs have been developed, the class of drugs known as the platinum-based drugs have been the most effective in treatment of lung cancers.

Chemotherapy is the treatment of choice for most SCLC, since these tumors are generally widespread in the body when they are diagnosed. Only half of people who have SCLC survive for four months without chemotherapy. With chemotherapy, their survival time is increased up to four- to fivefold. Chemotherapy alone is not particularly effective in treating NSCLC, but when NSCLC has metastasized, it can prolong survival in many cases.

Chemotherapy may be given as pills, as an intravenous infusion, or as a combination of the two. Chemotherapy treatments usually are given in an outpatient setting. A combination of drugs is given in a series of treatments, called cycles, over a period of weeks to months, with breaks in between cycles. Unfortunately, the drugs used in chemotherapy also kill normally dividing cells in the body, resulting in unpleasant side effects. Damage to blood cells can result in increased susceptibility to infections and difficulties with blood clotting (bleeding or bruising easily). Other side effects include fatigue, weight loss, hair loss, nausea, vomiting, diarrhea, and mouth sores. The side effects of chemotherapy vary according to the dosage and combination of drugs used and may also vary from individual to individual. Medications have been developed that can treat or prevent many of the side effects of chemotherapy. The side effects generally disappear during the recovery phase of the treatment or after its completion.

Prophylactic brain radiation: SCLC often spreads to the brain. Sometimes people with SCLC that is responding well to treatment are treated with radiation therapy to the head to treat very early spread to the brain (called micrometastasis) that is not yet detectable with CT or MRI scans and has not yet produced symptoms. Brain radiation therapy can cause short-term memory problems, fatigue, nausea, and other side effects.

Treatment of recurrence: Lung cancer that has returned following treatment with surgery, chemotherapy, and/or radiation therapy is referred to as recurrent or relapsed. If a recurrent cancer is confined to one site in the lung, it may be treated with surgery. Recurrent tumors generally do not respond to the chemotherapeutic drugs that were previously administered. Since platinum-based drugs are generally used in initial chemotherapy of lung cancers, these agents are not useful in most cases of recurrence. A type of chemotherapy referred to as second-line chemotherapy is used to treat recurrent cancers that have previously been treated with chemotherapy, and a number of second-line chemotherapeutic regimens have been proven effective at prolonging survival. People with recurrent lung cancer who are well enough to tolerate therapy also are good candidates for experimental therapies (see below), including clinical trials.

Targeted therapy: The drugs erlotinib (Tarceva) and gefitinib (Iressa) are so-called targeted drugs, which may be used in certain patients with NSCLC who are no longer responding to chemotherapy. Targeted therapy drugs more specifically target cancer cells, resulting in less damage to normal cells than general chemotherapeutic agents. Erlotinib and gefitinib target a protein called the epidermal growth factor receptor (EGFR) that is important in promoting the division of cells. This protein is found at abnormally high levels on the surface of some types of cancer cells, including many cases of non-small cell lung cancer.

 

Other attempts at targeted therapy include drugs known as antiangiogenesis drugs, which block the development of new blood vessels within a cancer. Without adequate blood vessels to supply oxygen-carrying blood, the cancer cells will die. The antiangiogenic drug bevacizumab (Avastin) has also been found to prolong survival in advanced lung cancer when it is added to the standard chemotherapy regimen. Bevacizumab is given intravenously every two to three weeks. However, since this drug may cause bleeding, it is not appropriate for use in patients who are coughing up blood, if the lung cancer has spread to the brain, or in people who are receiving anticoagulation therapy ("blood thinner" medications). Bevacizumab also is not used in cases of squamous cell cancer because it leads to bleeding from this type of lung cancer.

 

Cetuximab is an antibody that binds to the epidermal growth factor receptor (EGFR).. In patients with NSCLC whose tumors have been shown to express the EGFR by immunohistochemical analysis, the addition of cetuximab may be considered for some patients.

Photodynamic therapy (PDT): One newer therapy used for different types and stages of lung cancer (as well as some other cancers) is photodynamic therapy. In photodynamic treatment, a photosynthesizing agent (such as a porphyrin, a naturally occurring substance in the body) is injected into the bloodstream a few hours prior to surgery. During this time, the agent is taken up in rapidly growing cells such as cancer cells. A procedure then follows in which the physician applies a certain wavelength of light through a handheld wand directly to the site of the cancer and surrounding tissues. The energy from the light activates the photosensitizing agent, causing the production of a toxin that destroys the tumor cells. PDT has the advantages that it can precisely target the location of the cancer, is less invasive than surgery, and can be repeated at the same site if necessary. The drawbacks of PDT are that it is only useful in treating cancers that can be reached with a light source and is not suitable for treatment of extensive cancers. The U.S. Food and Drug Administration (FDA) has approved the photosensitizing agent called porfimer sodium (Photofrin) for use in PDT to treat or relieve the symptoms of esophageal cancer and non-small cell lung cancer. Further research is ongoing to determine the effectiveness of PDT in other types of lung cancer.

 

Radiofrequency ablation (RFA): Radiofrequency ablation is being studied as an alternative to surgery, particularly in cases of early stage lung cancer. In this type of treatment, a needle is inserted through the skin into the cancer, usually under guidance by CT scanning. Radiofrequency (electrical) energy is then transmitted to the tip of the needle where it produces heat in the tissues, killing the cancerous tissue and closing small blood vessels that supply the cancer. RFA usually is not painful and has been approved by the U.S. Food and Drug Administration for the treatment of certain cancers, including lung cancers. Studies have shown that this treatment can prolong survival similarly to surgery when used to treat early stages of lung cancer but without the risks of major surgery and the prolonged recovery time associated with major surgical procedures.

Experimental therapies: Since no therapy is currently available that is absolutely effective in treating lung cancer, patients may be offered a number of new therapies that are still in the experimental stage, meaning that doctors do not yet have enough information to decide whether these therapies should become accepted forms of treatment for lung cancer. New drugs or new combinations of drugs are tested in so-called clinical trials, which are studies that evaluate the effectiveness of new medications in comparison with those treatments already in widespread use. Experimental treatments known as immunotherapies are being studied that involve the use of vaccine-related therapies or other therapies that attempt to utilize the body's immune system to fight cancer cells.

What is the prognosis (outcome) of lung cancer?

The prognosis of lung cancer refers to the chance for cure or prolongation of life (survival) and is dependent upon where the cancer is located, the size of the cancer, the presence of symptoms, the type of lung cancer, and the overall health status of the patient.

SCLC has the most aggressive growth of all lung cancers, with a median survival time of only two to four months after diagnosis when untreated. (That is, by two to four months, half of all patients have died.) However, SCLC is also the type of lung cancer most responsive to radiation therapy and chemotherapy. Because SCLC spreads rapidly and is usually disseminated at the time of diagnosis, methods such as surgical removal or localized radiation therapy are less effective in treating this type of lung cancer. When chemotherapy is used alone or in combination with other methods, survival time can be prolonged four- to fivefold; however, of all patients with SCLC, only 5%-10% are still alive five years after diagnosis. Most of those who survive have limited-stage SCLC.

In non-small cell lung cancer (NSCLC), the most important prognostic factor is the stage (extent of spread) of the tumor at the time of diagnosis. Results of standard treatment are generally poor in all but the most smallest of cancers that can be surgically removed. However, in stage I cancers that can be completely removed surgically, five-year survival approaches 75%. Radiation therapy can produce a cure in a small minority of patients with NSCLC and leads to relief of symptoms in most patients. In advanced-stage disease, chemotherapy offers modest improvements in survival although rates of overall survival are poor.

The overall prognosis for lung cancer is poor when compared with some other cancers. Survival rates for lung cancer are generally lower than those for most cancers, with an overall five-year survival rate for lung cancer of about 16% compared to 65% for colon cancer, 89% for breast cancer, and over 99% for prostate cancer.

How can lung cancer be prevented?

Cessation of smoking and eliminating exposure to tobacco smoke is the most important measure that can prevent lung cancer. Many products, such as nicotine gum, nicotine sprays, or nicotine inhalers, may be helpful to people trying to quit smoking. Minimizing exposure to passive smoking also is an effective preventive measure. Using a home radon test kit can identify and allow correction of increased radon levels in the home. Methods that allow early detection of cancers, such as the helical low-dose CT scan, also may be of value in the identification of small cancers that can be cured by surgical resection and prevented from becoming widespread, incurable, metastatic cancer.

Lung Cancer At A Glance
  • Lung cancer is the number-one cause of cancer deaths in both men and women in the U.S. and worldwide.
  • Cigarette smoking is the principal risk factor for development of lung cancer.
  • Passive exposure to tobacco smoke also can cause lung cancer.
  • The two types of lung cancer, which grow and spread differently, are the small cell lung cancers (SCLC) and non-small cell lung cancers (NSCLC).
  • The stage of lung cancer refers to the extent to which the cancer has spread in the body.
  • Treatment of lung cancer can involve a combination of surgery, chemotherapy, and radiation therapy as well as newer experimental methods.
  • The general prognosis of lung cancer is poor, with overall survival rates of about 16% at five years.
  • Smoking cessation is the most important measure that can prevent the development of lung cancer.

Additional resources from WebMD Boots UK on Lung Cancer

REFERENCES:

Hung, R.J., et al. A Susceptibility Locus for Lung Cancer Maps to Nicotinic Acetylcholine Receptor Subunit Genes on 15q25." Nature 452.7187 Apr. 3, 2008: 633-637.

McKeage, Mark J., et al. "Phase II Study of ASA404 (vadimezan, 5,6-dimethylxanthenone-4-acetic acid/DMXAA) 1800 mg/m2 Combined With Carboplatin and Paclitaxel in Previously Untreated Advanced Non-Small Cell Lung Cancer." Lung Cancer 65.2 Aug. 2009: 192-197.

United States. National Cancer Institute (NCI). "Lung Cancer." July 26, 2007. <http://www.cancer.gov/cancertopics/types/lung>.

"What Are the Key Statistics About Lung Cancer?" American Cancer Society. Oct. 20, 2009. <http://www.cancer.org/docroot/CRI/content/CRI_2_4_1x_What_Are_the_Key_Statistics_About _Lung_Cancer_15.asp?sitearea=>.

"What You Need to Know About Lung Cancer." National Cancer Institute, U.S. National Institutes of Health. July 26, 2007. <http://www.cancer.gov/cancertopics/types/lung>

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Lungs Design And Purpose


  • 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.

Lyme Disease

  • What is Lyme disease? What causes Lyme disease?
  • What is the history of Lyme disease?
  • What are symptoms and signs of Lyme disease?
  • How is Lyme disease diagnosed?
  • What is the treatment for Lyme disease?
  • How can Lyme disease be prevented? Is there a vaccine?
  • Lyme Disease At A Glance
  • Lyme Disease - Slideshow View Lyme Disease Slideshow
  • Take the Lyme Disease Quiz Take the Lyme Disease Quiz
  • Lyme Disease Medical Pictures - Image Collection View Lyme Disease Medical Pictures - Image Collection
  • Patient Discussions: Lyme Disease - Treatments
  • Patient Discussions: Lyme Disease - How Was Diagnosis Established

What is Lyme disease? What causes Lyme disease?

Lyme disease is a bacterial illness caused by a bacterium called a "spirochete." In the United States, the actual name of the bacterium is Borrelia burgdorferi. In Europe, another bacterium, Borrelia afzelii, also causes Lyme disease. Certain ticks found on deer harbor the bacterium in their stomachs. Lyme disease is spread by these ticks when they bite the skin, which permits the bacterium to infect the body. Lyme disease is not contagious from an affected person to someone else. Lyme disease can cause abnormalities in the skin, joints, heart, and nervous system.

What is the history of Lyme disease?

Interestingly, the disease only became apparent in 1975 when mothers of a group of children who lived near each other in Lyme, Connecticut, made researchers aware that their children had all been diagnosed with rheumatoid arthritis. This unusual grouping of illness that appeared "rheumatoid" eventually led researchers to the identification of the bacterial cause of the children's condition, what was then called "Lyme disease" in 1982.

Ticks are carriers of the Lyme bacterium in their stomachs. The ticks then are vectors that can transmit the bacterium to humans with a tick bite. The number of cases of the disease in an area depends on the number of ticks present and how often the ticks are infected with the bacteria. In certain areas of New York, where Lyme disease is common, over half of the ticks are infected. Lyme disease has been reported most often in the northeastern United States, but it has been reported in all 50 states, as well as China, Europe, Japan, Australia, and parts of the former Soviet Union. In the United States, it is primarily contracted in the Northeast from the states of Maine to Maryland, in the Midwest in Minnesota and Wisconsin, and in the West in Oregon and Northern California.

Picture of a deer tick
Picture of a deer tick

What are symptoms and signs of Lyme disease?

Lyme disease affects different areas of the body in varying degrees as it progresses. The site where the tick bites the body is where the bacteria enter through the skin. As the bacteria spread in the skin away from the initial tick bite, the infection causes an expanding reddish rash that is often associated with "flu-like" symptoms. Later, it can produce abnormalities in the joints, heart, and nervous system.

Lyme disease is medically described in three phases as: (1) early localized disease with skin inflammation; (2) early disseminated disease with heart and nervous system involvement, including palsies and meningitis; and (3) late disease featuring motor and sensory nerve damage and brain inflammation as well as arthritis.

In the early phase of the illness, within days to weeks of the tick bite, the skin around the bite develops an expanding ring of unraised redness. There may be an outer ring of brighter redness and a central area of clearing, leading to a "bull's-eye" appearance. This classic initial rash is called "erythema migrans" (formerly called erythema chronicum migrans). Patients often can't recall the tick bite (the ticks can be as small as the periods in this paragraph). Also, they may not have the identifying rash to signal the doctor. More than one in four patients never even develop a rash. The redness of the skin is often accompanied by generalized fatigue, muscle and joint stiffness, swollen lymph nodes ("swollen glands"), and headache, resembling symptoms of a virus infection.

The redness resolves, without treatment, in about a month. Weeks to months after the initial redness of the skin the bacteria and their effects spread throughout the body. Subsequently, disease in the joints, heart, and nervous system can occur.

The later phases of Lyme disease can affect the heart, causing inflammation of the heart muscle. This can result in abnormal heart rhythms and heart failure. The nervous system can develop facial muscle paralysis (Bell's palsy), abnormal sensation due to disease of peripheral nerves (peripheral neuropathy), meningitis, and confusion. Arthritis, or inflammation in the joints, begins with swelling, stiffness, and pain. Usually, only one or a few joints become affected, most commonly the knees. The arthritis of Lyme disease can look like many other types of inflammatory arthritis and can become chronic.

Researchers have also found that anxiety and depression occur with an increased rate in people with Lyme disease. This is another important aspect of the evaluation and management of this condition.

 

How is Lyme disease diagnosed?

In early Lyme disease, doctors can sometimes make a diagnosis simply by finding the classic red rash (described above), particularly in people who have recently been in regions in which Lyme disease is common. The doctor might review the patient's history and examine the patient in order to exclude diseases with similar findings in the joints, heart, and nervous system. Blood testing for antibodies to Lyme bacteria is generally not necessary or helpful in early stage disease, but it can help in diagnosis in later stages. (Antibodies are produced by the body to attack the bacteria and can be evidence of exposure to the bacteria. These antibodies can be detected using a laboratory method called an enzyme-linked immunosorbent assay [ELISA].) Antibodies, however, can be false indicators of disease, since they can persist for years after the disease is cured. Moreover, false-positive tests in patients with nonspecific findings (those that are not specifically suggestive of Lyme disease) can lead to confusion. Currently, the confirmatory test that is most reliable is the Western Blot assay antibody test. More accurate tests are being developed.

Generally, Lyme blood testing is helpful in a patient who has symptoms compatible with Lyme disease, who has a history of a tick bite at least a month prior, or who has unexplained disorders of the heart, joints, or nervous system that are characteristic of Lyme disease.

What is the treatment for Lyme disease?

Most cases of Lyme disease are curable with antibiotics. This is so true that some authors of Lyme disease research have stated that the most common cause of lack of response of Lyme disease to antibiotics is a lack of Lyme disease to begin with! The type of antibiotic depends on the stage of the disease (early or late) and what areas of the body are affected. Early illness is usually treated with medicines taken by mouth, for example, doxycycline (Vibramycin), amoxicillin (Amoxil), or cefuroxime axetil (Ceftin). Of note, doxycycline should not be used in pregnancy. Therefore, if a person finds a typical bull's-eye skin rash (described above) developing in an area of a tick bite, they should seek medical attention as soon as possible. Generally, antibiotic treatment resolves the rash within one or two weeks with no long-term consequences. Later illness such as nervous-system disease might require intravenous drugs; examples are ceftriaxone (Rocephin) and penicillin G.

 

For the relief of symptoms, pain-relieving medicines might be added. Swollen joints can be reduced by the doctor removing fluid from them (arthrocentesis). An arthrocentesis is a procedure whereby fluid is removed from a joint using a needle and syringe under sterile conditions. It is usually performed in a doctor's office. Rarely, even with appropriate antibiotics, the arthritis continues. It has been suggested by researchers that sometimes joint inflammation can persist even after eradication of the Lyme bacteria. This has been explained as an ongoing autoimmune response causing inflammation of the joint that was initially stimulated by the original bacterial infection. The doctor also can use oral medications such as ibuprofen (Motrin, Nuprin) to reduce inflammation and improve function.

How is Lyme disease diagnosed?

In early Lyme disease, doctors can sometimes make a diagnosis simply by finding the classic red rash (described above), particularly in people who have recently been in regions in which Lyme disease is common. The doctor might review the patient's history and examine the patient in order to exclude diseases with similar findings in the joints, heart, and nervous system. Blood testing for antibodies to Lyme bacteria is generally not necessary or helpful in early stage disease, but it can help in diagnosis in later stages. (Antibodies are produced by the body to attack the bacteria and can be evidence of exposure to the bacteria. These antibodies can be detected using a laboratory method called an enzyme-linked immunosorbent assay [ELISA].) Antibodies, however, can be false indicators of disease, since they can persist for years after the disease is cured. Moreover, false-positive tests in patients with nonspecific findings (those that are not specifically suggestive of Lyme disease) can lead to confusion. Currently, the confirmatory test that is most reliable is the Western Blot assay antibody test. More accurate tests are being developed.

Generally, Lyme blood testing is helpful in a patient who has symptoms compatible with Lyme disease, who has a history of a tick bite at least a month prior, or who has unexplained disorders of the heart, joints, or nervous system that are characteristic of Lyme disease.

What is the treatment for Lyme disease?

Most cases of Lyme disease are curable with antibiotics. This is so true that some authors of Lyme disease research have stated that the most common cause of lack of response of Lyme disease to antibiotics is a lack of Lyme disease to begin with! The type of antibiotic depends on the stage of the disease (early or late) and what areas of the body are affected. Early illness is usually treated with medicines taken by mouth, for example, doxycycline (Vibramycin), amoxicillin (Amoxil), or cefuroxime axetil (Ceftin). Of note, doxycycline should not be used in pregnancy. Therefore, if a person finds a typical bull's-eye skin rash (described above) developing in an area of a tick bite, they should seek medical attention as soon as possible. Generally, antibiotic treatment resolves the rash within one or two weeks with no long-term consequences. Later illness such as nervous-system disease might require intravenous drugs; examples are ceftriaxone (Rocephin) and penicillin G.

 

For the relief of symptoms, pain-relieving medicines might be added. Swollen joints can be reduced by the doctor removing fluid from them (arthrocentesis). An arthrocentesis is a procedure whereby fluid is removed from a joint using a needle and syringe under sterile conditions. It is usually performed in a doctor's office. Rarely, even with appropriate antibiotics, the arthritis continues. It has been suggested by researchers that sometimes joint inflammation can persist even after eradication of the Lyme bacteria. This has been explained as an ongoing autoimmune response causing inflammation of the joint that was initially stimulated by the original bacterial infection. The doctor also can use oral medications such as ibuprofen (Motrin, Nuprin) to reduce inflammation and improve function.

How can Lyme disease be prevented? Is there a vaccine?

Because Lyme disease is transmitted by ticks attaching to the body, it is important to use tick-bite avoidance techniques when visiting known tick-infested areas. Spraying insect repellant containing DEET onto exposed skin can help. Wearing long pants tucked into boots and long sleeves can protect the skin. Clothing, children, and pets should be examined for ticks. Ticks can be removed gently with tweezers and saved in a jar for later identification. Bathing the skin and scalp and washing clothing upon returning home might prevent the bite and transmission of the disease.

If a person is bitten by the classic tick (Ixodes) that has been attached for at least 36 hours, a single dose of doxycycline (200 mg) can be helpful for prevention of Lyme disease. This therapy is not recommended if the tick is acquired in an area where these ticks are not commonly infested (infection rate less than 20%) with the bacterium (Borrelia) that causes Lyme disease. Also, doxycycline should not be used in pregnancy.

Vaccines were formerly on the market; however, as of Feb. 25, 2002, the manufacturer announced that the LYMErix Lyme disease vaccine would no longer be commercially available. Further studies of vaccines are needed. For now, ideal prevention focuses on the recommendations of the preceding paragraph.

Lyme Disease At A Glance
  • Lyme disease is a bacterial illness that is spread by tick bites.
  • Lyme disease can affect the skin, joints, heart, and the nervous system.
  • Lyme disease occurs in phases -- the early phase beginning at the site of the tick bite with an expanding ring of redness.
  • Lyme disease is diagnosed based on the patient's clinical signs of illness and the detection of Lyme antibodies in the blood.
  • Lyme disease is treated with antibiotics.

Microscopic Colitis

(Lymphocytic Colitis and Collagenous Colitis)


  • What is colitis?
  • What diseases are not colitis?
  • What is microscopic colitis?
  • What causes microscopic colitis?
  • What are the symptoms of microscopic colitis?
  • How common is microscopic colitis and who is at risk?
  • When should I seek medical care for microscopic colitis?
  • How is microscopic colitis diagnosed?
  • What is the treatment for microscopic colitis?
  • What is the prognosis of microscopic colitis?
  • Can microscopic colitis be prevented?
  • Patient Discussions: Lymphocytic Colitis - Treatments
  • Patient Discussions: Lymphocytic Colitis - Cause
  • Find a local Gastroenterologist in your town

What is colitis?

Colitis means inflammation of the colon. The colon, also known as the large intestine or large bowel, constitutes the last part of the digestive tract. The colon is a long, muscular tube that receives undigested food from the small intestine. It removes water from the undigested food, stores the undigested food, and then eliminates it from the body through bowel movements. The rectum is the last part of the colon adjacent to the anus. The common symptoms of colitis include:

  • abdominal pain,
  • diarrhea, and
  • sometimes, rectal bleeding.

There are many different types of colitis with different causes. Some examples of colitis include:

  • infectious colitis caused by bacteria (such as shigella, Campylobacter, E. coli, and C. difficile)
  • infectious colitis caused by a virus (such as cytomegalovirus [CMV])
  • radiation colitis (such as following treatment with radiation for prostate cancer)
  • ischemic colitis (such as blockage of an artery in the colon by a blood clot. If the blood clot interrupts the flow of blood to a segment of the colon, the result is inflammation of that segment and, sometimes, even death [gangrene] of the segment)
  • Crohn's disease and ulcerative colitis (two related conditions that are caused by abnormalities of the body's immune system in which the body is inappropriately making antibodies and chemicals that attack the colon). Crohn's disease and ulcerative colitis are also referred to as inflammatory bowel disease (IBD).

Infectious, radiation, ischemic, ulcerative, and Crohn's colitis all have visible abnormalities of the inner lining of the colon. These abnormalities include edema (swelling of the lining), redness, bleeding from the lining with gentle rubbing (friability), and ulcers. These abnormalities can be seen during either colonoscopy (examination of the entire colon using a long flexible viewing tube) or flexible sigmoidoscopy (examination of the rectum and the sigmoid colon - the segment of the colon closest to the rectum).

Edema and inflammation of the colon's lining interferes with the absorption of water from the undigested food, and the unabsorbed water exits the rectum as diarrhea. Pus and fluid also are secreted into the colon and add to the diarrhea. The redness, bleeding from the lining with gentle rubbing (friability), and ulcerations in the lining of the colon contribute to rectal bleeding.

Picture of Large Intestine (Colon) Anatomy

 

What diseases are not colitis?

Individuals with irritable bowel syndrome (IBS) do not have colitis, even though this condition is sometimes referred to as having "spastic colitis." These individuals may have symptoms that mimic colitis such as diarrhea, abdominal pain, and mucous in stool. Nevertheless, there is no inflammation of the colon (not even microscopic colitis) in patients with IBS. The cause of symptoms in IBS is not clearly known; it may be caused by either abnormal motility (abnormal contractions) of the intestinal muscles or abnormally sensitive nerves in the intestines (visceral hypersensitivity).

What is microscopic colitis?

Microscopic colitis refers to inflammation of the colon that is only visible when the colon's lining is examined under a microscope. The appearance of the inner colon lining in microscopic colitis is normal by visual inspection during colonoscopy or flexible sigmoidoscopy. The diagnosis of microscopic colitis is made when a doctor, while performing colonoscopy or flexible sigmoidoscopy, takes biopsies (small samples of tissue) of the normal-appearing lining, and then examines the biopsies under a microscope.

There are two types of microscopic colitis: 1) lymphocytic colitis and 2) collagenous colitis.

  1. In lymphocytic colitis, there is an accumulation of lymphocytes (a type of white blood cell) within the lining of the colon.
  2. In collagenous colitis, there is an additional layer of collagen (scar tissue) just below the lining.

Some experts believe that lymphocytic colitis and collagenous colitis represent different stages of the same disease.

The inflammation and the collagen probably interfere with absorption of water from the colon, and cause the diarrhea.

What causes microscopic colitis?

The cause(s) of microscopic colitis is unknown. Some doctors suspect that microscopic colitis is an autoimmune disorder similar to the autoimmune disorders that cause chronic ulcerative colitis and Crohn's disease.

One study has implicated long term (longer than 6 months) use of nonsteroidal antiinflammatory drugs (NSAIDs) as a cause of microscopic colitis. Some individuals' diarrhea improves after stopping the NSAIDs.

What are the symptoms of microscopic colitis?

The primary symptom of microscopic colitis is chronic, watery diarrhea. Individuals with microscopic colitis can have diarrhea for months or years before the diagnosis is made. Typically, the symptoms begin very gradually and are intermittent in nature with periods when the person feels well, followed by bouts of chronic diarrhea. This chronic diarrhea of microscopic colitis is different from the acute diarrhea of infectious colitis, which typically lasts only days to weeks. Some individuals with microscopic colitis also may experience mild abdominal cramps and pain. Blood in the stool is unusual.

How common is microscopic colitis and who is at risk?

The prevalence of microscopic colitis in the U.S. is not clearly known. It is estimated that 10% to 20% of persons with chronic diarrhea may have microscopic colitis. It is this author's experience, that the condition is becoming more common in recent years. It is not clear, however, whether there is an actual increase in the frequency of microscopic colitis or whether doctors are just better at diagnosing it.

Microscopic colitis most commonly occurs in middle aged to elderly patients and is more common among women than men.

When should I seek medical care for microscopic colitis?

A person should seek medical care if the diarrhea lasts for more than 2 weeks or is accompanied with symptoms such as weight loss, fatigue, and abdominal pain.

How is microscopic colitis diagnosed?

The diagnosis of microscopic colitis is made by performing biopsies from different regions of the colon during colonoscopy or sigmoidoscopy.

The abnormalities of the colon's lining in microscopic colitis occur in a patchy distribution (areas of normal lining may coexist adjacent to areas of abnormal lining). For this reason, multiple biopsies should be taken from several different regions of the colon in order to accurately make a diagnosis.

The patchy nature of microscopic colitis also is the reason why flexible sigmoidoscopy often is inadequate in diagnosing the condition because the abnormalities of microscopic colitis may be absent from the sigmoid colon (the colonic segment that is closest to the rectum and is within the reach of a sigmoidoscope) in 30% to 40% of the patients with microscopic colitis.

Thus, biopsies of other regions of the colon accessible only with colonoscopy may be necessary for diagnosing microscopic colitis.

What is the treatment for microscopic colitis?

The treatment of microscopic colitis has not been standardized because there have not been adequate large scale, prospective, placebo controlled treatment trials. The following strategies are safe and may relieve diarrhea in some patients:

  • Avoid nonsteroidal antiinflammatory drugs (NSAIDs)
  • Trial of lactose elimination (just to eliminate the possibility that intolerance to lactose in milk is aggravating the diarrhea)
  • Antidiarrhea agents such as loperamide (Imodium) or diphenoxylate and atropine (Lomotil)
  • Bismuth subsalicylate such as Pepto-Bismol
  • budesonide (Entocort EC)
  • 5-ASA (mesalamine) compounds such as Asacol, Pentasa, or Colazal
 

Controlled trials showed that budesonide (Entocort, a poorly absorbed steroid) is effective in controlling diarrhea in more than 75% of the patients with collagenous colitis, but the diarrhea tends to recur soon after stopping Entocort.

Though data supporting their use is lacking, some doctors may use medications that potently suppress the immune system such as azathioprine (Imuran, Azasan) and 6-mercaptopurine in patients with severe microscopic colitis that is unresponsive to other treatments.

 

Can microscopic colitis be prevented?

Since the cause of microscopic colitis is not known, no advice can be provided about preventing this disease.

What is the prognosis of microscopic colitis?

The long term prognosis (course) of microscopic colitis is not clear. In approximately two-thirds of the patients with microscopic colitis, the diarrhea resolves spontaneously after several years. The remaining one-third of the patients experience persistent or intermittent diarrhea for many years (possibly indefinitely).

 

 

Last Updated on Sunday, 18 December 2011 15:58
 
Leprosy (Hansen's Disease) PDF Print E-mail
Written by Ruai Pharmaceuticals   
Wednesday, 14 September 2011 18:47

Leprosy (Hansen's Disease)


  • What is leprosy?
  • What is the history of leprosy (Hansen's disease)?
  • What causes leprosy?
  • What are leprosy symptoms and signs?
  • Are there different forms (classifications) of leprosy?
  • How is leprosy transmitted?
  • How is leprosy diagnosed?
  • What is the treatment for leprosy?
  • How is leprosy prevented?
  • Where can I find more information on leprosy?
  • Leprosy (Hansen's Disease) At A Glance

What is leprosy?

Leprosy is a disease caused by the bacteria Mycobacterium leprae, which causes damage to the skin and the peripheral nervous system. The disease develops slowly (from six months to 40 years!) and results in skin lesions and deformities, most often affecting the cooler places on the body (for example, eyes, nose, earlobes, hands, feet, and testicles). The skin lesions and deformities can be very disfiguring and are the reason that infected individuals historically were considered outcasts in many cultures. Although human-to-human transmission is the primary source of infection, three other species can carry and (rarely) transfer M. leprae to humans: chimpanzees, mangabey monkeys, and nine-banded armadillos. The disease is termed a chronic granulomatous disease, similar to tuberculosis, because it produces inflammatory nodules (granulomas) in the skin and nerves over time.

What is the history of leprosy (Hansen's disease)?

Unfortunately, the history of leprosy and its interaction with man is one of suffering and misunderstanding. The newest research suggests that at least as early as 4000 B.C. individuals had been infected with M. leprae, while the first known written reference to the disease was found on Egyptian papyrus in about 1550 B.C. The disease was well recognized in ancient China, Egypt, and India, and there are several references to the disease in the Bible. Because the disease was poorly understood, very disfiguring, slow to show symptoms, and had no known treatment, many cultures thought the disease was a curse or punishment from the gods. Consequently, leprosy was left to be "treated" by priests or holy men, not physicians.

 

Picture of a person with leprosy (Hansen's disease)
Picture of a person with leprosy (Hansen's disease)

 

Since the disease often appeared in family members, some people thought it was hereditary; other people noted that if there was little or no contact with infected individuals, the disease did not infect others. Consequently, some cultures considered infected people (and occasionally their close relatives) as "unclean" or as "lepers" and ruled they could not associate with uninfected people. Often infected people had to wear special clothing and ring bells so uninfected people could avoid them.

The Romans and the Crusaders brought the disease to Europe, and the Europeans brought it to the Americas. In 1873, Dr. Hansen discovered bacteria in leprosy lesions, suggesting leprosy was an infectious disease, not a hereditary disease or a punishment from the gods. However, patients with the disease were still ostracized by many societies and cared for only at missions by religious personnel. Patients with leprosy were encouraged or forced to live in seclusion up to the 1940s, even in the U.S. (for example, the leper colony on Molokai, Hawaii, and at Carville, La.), often because no effective treatments were available.

Because of Hansen's discovery of M. leprae, efforts were made to find treatments that would stop or eliminate M. leprae; in the early 1900s to about 1940, oil from Chaulmoogra nuts was used with questionable efficacy by injecting it into patients' skin. At Carville in 1941, promin, a sulfone drug, showed efficacy but required many painful injections. Dapsone pills were found to be effective in the 1950s, but soon (1960s-1970s), M. leprae developed resistance to dapsone. Fortunately, drug trials on the island of Malta in the 1970s showed that a three-drug combination (dapsone, rifampicin [Rifadin], and clofazimine [Lamprene]) was very effective in killing M. leprae. This multi-drug treatment (MDT) was recommended by the WHO in 1981 and remains, with minor changes, the therapy of choice. MDT, however, does not alter the damage done to an individual by M. leprae before MDT is started.

Currently, there are several areas (India, East Timor) of the world where the WHO and other agencies (for example, the Leprosy Mission) are working to decrease the number of clinical cases of leprosy and other diseases such as rabies and schistosomiasis that occur in remote regions. Although researchers hope to eliminate leprosy like smallpox, endemic (meaning prevalent or embedded in a region) leprosy makes complete eradication unlikely. In the U.S., leprosy has occurred infrequently but is considered endemic in Texas, Louisiana, Hawaii, and the U.S. Virgin Islands by some investigators.

Leprosy is often termed "Hansen's disease" by many clinicians in an attempt to have patients forgo the stigmas attached to being diagnosed with leprosy.

What causes leprosy?

Leprosy is caused mainly by Mycobacterium leprae, a rod-shaped bacillus that is an obligate intracellular (only grows inside of certain human and animal cells) bacterium. M. leprae is termed an "acid fast" bacterium because of its chemical characteristics. When special stains are used for microscopic analysis, it stains red on a blue background due to mycolic acid content in its cell walls. The Ziehl-Neelsen stain is an example of the special staining techniques used to view the acid-fast organisms under the microscope.

Currently, the organisms cannot be cultured on artificial media. The bacteria take an extremely long time to reproduce inside of cells (about 12-14 days as compared to minutes to hours for most bacteria). The bacteria grow best at 80.9 F-86 F, so cooler areas of the body tend to develop the infection. The bacteria grow very well in the body's macrophages and Schwann cells (cells that cover and protect nerve axons). M. leprae is genetically related to M. tuberculosis (the type of bacteria that cause tuberculosis) and other mycobacteria that infect humans. As with malaria, patients with leprosy produce anti-endothelial antibodies (antibodies against the lining tissues of blood vessels), but the role of these antibodies in these diseases is still under investigation.

In 2009, investigators discovered a new Mycobacterium species, M. lepromatosis, which causes diffuse disease (lepromatous leprosy). This new species (determined by genetic analysis) was found in patients located in Mexico and the Caribbean islands.

What are leprosy symptoms and signs?

Unfortunately, the early signs and symptoms of leprosy are very subtle and occur slowly (usually over years). The symptoms are similar to those that may occur with syphilis, tetanus, and leptospirosis. Numbness and loss of temperature sensation (cannot sense very hot or cold temperatures) are some of the first symptoms that patients experience. As the disease progresses, the sensations of touch, then pain, and eventually deep pressure are decreased or lost. Signs that occur, such as relatively painless ulcers, skin lesions of hypopigmented macules (flat, pale areas of skin), and eye damage (dryness, reduced blinking) are experienced before the large ulcerations, loss of digits, and facial disfigurement develop. This long-term developing sequence of events begins and continues on the cooler areas of the body (for example, hands, feet, face, and knees).

Are there different forms (classifications) of leprosy?

There are multiple forms of leprosy described in the literature. The forms of leprosy are based on the person's immune response to M. leprae. A good immune response can produce the so-called tuberculoid form of the disease, with limited skin lesions and some asymmetric nerve involvement. A poor immune response can result in the lepromatous form, characterized by extensive skin and symmetric nerve involvement. Some patients may have aspects of both forms. Currently, two classification systems exist in the medical literature: the WHO system and the Ridley-Jopling system. The Ridley-Jopling system is composed of six forms or classifications, listed below according to increasing severity of symptoms:

  • Indeterminate leprosy: a few hypopigmented macules; can heal spontaneously, persists or advances to other forms
  • Tuberculoid leprosy: a few hypopigmented macules, some are large and some become anesthetic (lose pain sensation); some neural involvement in which nerves become enlarged; spontaneous resolution in a few years, persists or advances to other forms
  • Borderline tuberculoid leprosy: lesions like tuberculoid leprosy but smaller and more numerous with less nerve enlargement; this form may persist, revert to tuberculoid leprosy, or advance to other forms
  • Mid-borderline leprosy: many reddish plaques that are asymmetrically distributed, moderately anesthetic, with regional adenopathy (swollen lymph nodes); the form may persist, regress to another form, or progress
  • Borderline lepromatous leprosy: many skin lesions with macules (flat lesions) papules (raised bumps), plaques, and nodules, sometimes with or without anesthesia; the form may persist, regress or progress to lepromatous leprosy
  • Lepromatous leprosy: Early lesions are pale macules (flat areas) that are diffuse and symmetric; later many M. leprae organisms can be found in them. Alopecia (hair loss) occurs; often patients have no eyebrows or eyelashes. As the disease progresses, nerve involvement leads to anesthetic areas and limb weakness; progression leads to aseptic necrosis (tissue death from lack of blood to area), lepromas (skin nodules), and disfigurement of many areas including the face. The lepromatous form does not regress to the other less severe forms. Histoid leprosy is a clinical variant of lepromatous leprosy that presents with clusters of histiocytes (a type of cell involved in the inflammatory response) and a grenz zone (an area of collagen separating the lesion from normal tissue) seen in microscopic tissue sections.

The Ridley-Jopling classification is used globally in evaluating patients in clinical studies. However, the WHO classification system is more widely used; it has only two forms or classifications of leprosy. The 2009 WHO classifications are simply based on the number of skin lesions as follows:

  • Paucibacillary leprosy: skin lesions with no bacilli (M. leprae) seen in a skin smear
  • Multibacillary leprosy: skin lesions with bacilli (M. leprae) seen in a skin smear

However, the WHO further modifies these two classifications with clinical criteria because "of the non-availability or non-dependability of the skin-smear services. The clinical system of classification for the purpose of treatment includes the use of number of skin lesions and nerves involved as the basis for grouping leprosy patients into multibacillary (MB) and paucibacillary (PB) leprosy." Investigators state that up to about four to five skin lesions constitutes paucibacillary leprosy, while about five or more constitutes multibacillary leprosy.

Multidrug therapy (MDT) with three antibiotics (dapsone, rifampicin, and clofazimine) is used for multibacillary leprosy, while a modified MDT with two antibiotics (dapsone and rifampicin) is recommended for paucibacillary leprosy and composes most current treatments today (see treatment section below). Paucibacillary leprosy usually includes indeterminate, tuberculoid, and borderline tuberculoid leprosy from the Ridley-Jopling classification, while multibacillary leprosy usually includes the double (mid-) borderline, borderline lepromatous, and lepromatous leprosy.


In this Article

  • What is leprosy?
  • What is the history of leprosy (Hansen's disease)?
  • What causes leprosy?
  • What are leprosy symptoms and signs?
  • Are there different forms (classifications) of leprosy?
  • How is leprosy transmitted?
  • How is leprosy diagnosed?
  • What is the treatment for leprosy?
  • How is leprosy prevented?
  • Where can I find more information on leprosy?
  • Leprosy (Hansen's Disease) At A Glance

How is leprosy transmitted?

Researchers suggest that M. leprae are spread person to person by nasal secretions or droplets. They speculate that infected droplets reach other peoples' nasal passages and begin the infection there. Some investigators suggest the infected droplets can infect others by entering breaks in the skin. M. leprae apparently cannot infect intact skin. Rarely, humans get leprosy from the few animal species mentioned above. Occurrence in animals makes it difficult to eradicate leprosy from these endemic sources. Routes of transmission are still being researched for leprosy. Recent genetic studies have demonstrated that several genes (about seven) are associated with an increased susceptibility to leprosy; some researchers now conclude that susceptibility to leprosy may be partially inheritable.

How is leprosy diagnosed?

The majority of cases of leprosy are diagnosed by clinical findings, especially since most current cases are diagnosed in areas that have limited or no laboratory equipment available. Hypopigmented patches of skin or reddish skin patches with loss of sensation, thickened peripheral nerves, or both clinical findings together often comprise the clinical diagnosis. Skin smears or biopsy material that show acid-fast bacilli with the Ziehl-Neelsen stain or the Fite stain (biopsy) can diagnose multibacillary leprosy, or if bacteria are absent, diagnose paucibacillary leprosy. Other tests can be done, but most of these are done by specialized labs and may help a clinician to place the patient in the more detailed Ridley-Jopling classification and are not routinely done (lepromin test, phenolic glycolipid-1 test, PCR, lymphocyte migration inhibition test or LMIT). Other tests such as CBC test, liver function tests, creatinine test, or a nerve biopsy may be done to help determine if other organ systems have been affected.

What is the treatment for leprosy?

The majority of cases (mainly clinically diagnosed) are treated with antibiotics. The recommended antibiotics, their dosages, and length of time of administration are based on the form or classification of the disease and whether or not the patient is supervised by a medical professional. In general, paucibacillary leprosy is treated with two antibiotics, dapsone and rifampicin, while multibacillary leprosy is treated with the same two plus a third antibiotic, clofazimine. Usually, the antibiotics are given for at least six to 12 months or more.

Antibiotics can treat paucibacillary leprosy with little or no residual effects on the patient. Multibacillary leprosy can be kept from advancing, and living M. leprae can be essentially eliminated from the person by antibiotics, but the damage done before antibiotics are administered is usually not reversible. Recently, the WHO suggested that single-dose treatment of patients with only one skin lesion with rifampicin, minocycline (Minocin), or ofloxacin (Floxin) is effective. Studies of other antibiotics are ongoing. Each patient, depending on the above criteria, has a schedule for their individual treatment, so treatment schedules should be planned by a clinician knowledgeable about that patient's initial diagnostic classification.

The role for surgery in the treatment of leprosy occurs after medical treatment (antibiotics) has been completed with negative skin smears (no detectable acid-fast bacilli) and is often only needed in advanced cases. Surgery is individualized for each patient with the goal to attempt cosmetic improvements and, if possible, to restore limb function and some neural functions that were lost to the disease.

How is leprosy prevented?

Prevention of contact with droplets from nasal and other secretions from patients with untreated M. leprae infection currently is a way recommended to avoid the disease. Treatment of patients with appropriate antibiotics stops the person from spreading the disease. People who live with individuals who have untreated leprosy are about eight times as likely to develop the disease, because investigators speculate that family members have close proximity to infectious droplets. Leprosy is not hereditary, but recent findings suggest susceptibility to the disease may have a genetic basis.

Many people get exposed to leprosy throughout the world, but the disease in not highly contagious; researchers suggest that over 95% of exposures result in no disease, and further studies suggest that susceptibility may be based,  in part, by a person's genetic makeup. In the U.S., there are about 200-300 new cases diagnosed per year, with most coming from exposures during foreign travel. The majority of worldwide cases are found in the tropics or subtropics (for example, Brazil, India, and Indonesia). The WHO reports about 500,000 to 700,000 new cases per year worldwide, with curing of about 14 million cases since 1985.

There is no commercially available vaccine available to prevent leprosy. However, there are reports of using BCG vaccine, the BCG vaccine along with heat-killed M. leprae organisms, and other preparations that may be protective or help to clear the infection or to shorten treatment. Except for BCG in some countries, these preparations are not readily available.

Animals (chimpanzees, mangabey monkeys, and nine-banded armadillos) rarely transfer M. leprae to humans; nonetheless, handling such animals in the wild is not advised. These animals are a source for endemic infections.

Where can I find more information on leprosy?

 

"Leprosy Elimination," World Health Organization
http://www.who.int/lep/mdt/en/

"Leprosy," eMedicine.com
http://emedicine.medscape.com/article/
1104977-overview

"Hansen's Disease," Centers for Disease Control and Prevention
http://www.cdc.gov/nczved/divisions/dfbmd/
diseases/hansens_disease/technical.html

Leprosy (Hansen's Disease) At A Glance
  • Leprosy is a slowly developing, progressive disease that damages the skin and nervous system.
  • Leprosy is caused by an infection with Mycobacterium leprae or M. lepromatosis bacteria.
  • Early symptoms begin in cooler areas of the body and include loss of sensation.
  • Signs of leprosy are painless ulcers, skin lesions of hypopigmented macules (flat, pale areas of skin), and eye damage (dryness, reduced blinking). Later, large ulcerations, loss of digits, skin nodules, and facial disfigurement may develop.
  • The infection is thought to be spread person to person by nasal secretions or droplets. Leprosy is rarely transmitted from chimpanzees, mangabey monkeys, and nine-banded armadillos to humans by droplets or direct contact.
  • Susceptibility to getting leprosy may be due to certain human genes.
  • Antibiotics are used in the treatment of leprosy.

Leptospirosis


  • What is leptospirosis?
  • What are leptospirosis symptoms and signs?
  • How is leptospirosis diagnosed?
  • What is the treatment for leptospirosis? What is the prognosis for leptospirosis?
  • Can leptospirosis be prevented with a vaccine?
  • Can my pets get leptospirosis?
  • Leptospirosis At A Glance

What is leptospirosis?

Leptospirosis is an infectious disease caused by a type of bacteria called a spirochete. Leptospirosis can be transmitted by many animals such as rats, skunks, opossums, raccoons, foxes, and other vermin. It is transmitted though contact with infected soil or water. The soil or water is contaminated with the waste products of an infected animal. People contract the disease by either ingesting contaminated food or water or by broken skin and mucous membrane (eyes, nose, sinuses, mouth) contact with the contaminated water or soil.

Leptospirosis occurs worldwide, but it is most commonly acquired in the tropics. The U.S. Centers for Disease Control and Prevention states 100-200 cases of leptospirosis are reported each year in the United States, with about 50% of cases occurring in Hawaii. Although the incidence in the United States is relatively low, leptospirosis is considered the most widespread disease that is transmitted by animals in the world.

A 2010 outbreak in Michigan caused serious illness in numerous pets, raising concern for the local human population. In 2009, typhoons hit the Philippines, causing a leptospirosis outbreak. The Philippines Department of Health then reported 1,887 cases of leptospirosis, which resulted in 138 deaths.

What are leptospirosis symptoms and signs?

Leptospirosis symptoms begin from two to 25 days after initial direct exposure to the urine or tissue of an infected animal. This can even occur via contaminated soil or water. Veterinarians, pet shop owners, sewage workers, and farm employees are at particularly high risk. People participating in outdoor sporting activities like canoeing, rafting, hiking, and camping can also come into contact with contaminated water or soil.

The illness typically progresses through two phases:

  • The first phase of nonspecific flu-like symptoms includes headaches, muscle aches, eye pain with bright lights, followed by chills and fever. Watering and redness of the eyes occurs and symptoms seem to improve by the fifth to ninth day.
  • The second phase begins after a few days of feeling well. The initial symptoms recur with fever and aching with stiffness of the neck. Some patients develop serious inflammation of the nerves to the eyes, brain, spinal column (meningitis), or other nerves. Right upper area abdominal pain may occur. Less common symptoms relate to disease of the liver, lungs, kidneys, and heart.

Leptospirosis associated with liver and kidney disease is called Weil's syndrome and is characterized by yellowing of the eyes (jaundice). Patients with Weil's syndrome can also develop kidney disease and have more serious involvement of the organs affected.

How is leptospirosis diagnosed?

The diagnosis of leptospirosis is made by culture of the bacterial organism Leptospira from infected blood, spinal fluid, or urine. However, many doctors must rely upon rising Leptospira antibody levels in the blood in order to make the diagnosis, as the technique required to perform the culturing is delicate and difficult.

How is the treatment for leptospirosis? What is the prognosis for leptospirosis?

The treatment of leptospirosis involves high doses of antibiotics. Antibiotic treatment (doxycycline [Vibramycin, Oracea, Adoxa, Atridox], penicillin) is most effective when initiated early in the course of the illness. Severely ill patients may need hospitalization for IV fluid and antibiotic treatment. Severe liver and kidney manifestations of the infection may require intensive medical care and sometimes dialysis treatment. However, even in severe cases, liver and kidney function often does return after recovery from the illness.

Mortality rates for severe illness with leptospirosis can range from 5%-40%, depending on the severity of organ dysfunction and the patient's general health prior to infection. Most previously healthy patients have a good prognosis and will make a full recovery.

Can leptospirosis be prevented with a vaccine?

A vaccine for leptospirosis is available and used in some countries in Europe and Asia. It must be given every year like a flu shot. A longer-acting vaccine is being investigated in Cuba. It is not currently available in the United States.

Travelers who are going to an area where leptospirosis is common and who will be engaged in activities that increase likelihood of exposure can take 200 mg of doxycycline per week by mouth starting before and during the time period of potential exposure. According to the Leptospirosis Information Center, there are no drug-resistant strains of the bacteria at this time.

Leptospirosis was a reportable disease in the United States, but it was removed from the national CDC list of reportable diseases. It is, however, still reportable in some states, most notably Hawaii.

Can my pets get leptospirosis?

According to information from the CDC, your pets (especially dogs, less commonly cats) can contract leptospirosis. Your pet can contract it in the same ways you can (ingesting contaminated soil, water, or through skin wounds). Your pet may exhibit vomiting, refusal to eat, weight loss, decreased activity, muscle pains, or stiffness.

If you suspect your pet is ill, take them to a veterinarian for testing and treatment. Early antibiotic treatment often can limit or prevent organ damage.

If your pet is diagnosed with leptospirosis, you must be careful to try to prevent exposure to yourself or other household members. Remember to wash your hands frequently with soap and water after cleaning up waste from your pet. If possible, use latex or rubber gloves to do the job of cleanup. Use a diluted (1:10 parts) bleach solution to clean surfaces where pet wastes may have contaminated. And make sure your pet receives the full course of antibiotic treatment that is prescribed by your vet. Discuss other pet-care issues directly with your vet should you have any other questions regarding the disease.

Leptospirosis At A Glance
  • Leptospirosis is an infectious disease caused by a bacterium.
  • Leptospirosis is transmitted to humans by direct exposure to urine or tissue of an infected animal.
  • Leptospirosis typically progresses through two phases of nonspecific symptoms.
  • Leptospirosis can be diagnosed by culture of infected blood, urine, or spinal fluid, as well as using antibody testing.
  • Your pets may also be at risk for contracting leptospirosis.
  • Leptospirosis is treated with antibiotics and is rarely fatal.

Lesionectomy

Epilepsy and Lesionectomy


  • What is a lesionectomy?
  • Who is a candidate for lesionectomy?
  • What happens before a lesionectomy?
  • What happens during a lesionectomy?
  • What happens after a lesionectomy?
  • How effective is a lesionectomy?
  • What are the side effects of a lesionectomy?
  • What risks are associated with a lesionectomy?

 

What Is a Lesionectomy?

 

A lesionectomy is an operation to remove a lesion -- a damaged or abnormally functioning area -- in the brain. Brain lesions include tumors, scars from a head injury or infection, abnormal blood vessels, and hematomas (a swollen area filled with blood).

A lesion causes seizures -- also called the seizure focus -- in about 20% to 30% of people with epilepsy that do not improve after taking medication (intractable or refractory epilepsy). It is not known for certain if the lesion itself triggers the seizures, or if the seizures result from irritation to the brain tissue surrounding the lesion. For this reason, surgery may also include the removal of a small rim of brain tissue around the lesion, called lesionectomy plus corticectomy.

Who Is a Candidate for Lesionectomy?

 

Lesionectomy may be an option for people whose epilepsy is linked to a defined lesion and whose seizures are not controlled by medication. In addition, it must be possible to remove the lesion and surrounding brain tissue without causing damage to areas of the brain responsible for vital functions, such as movement, sensation, language, and memory. There also must be a reasonable chance that the person will benefit from surgery.

What Happens Before a Lesionectomy?

 

Candidates for lesionectomy undergo an extensive pre-surgery evaluation-including seizure monitoring, electroencephalography (EEG) and magnetic resonance imaging (MRI). These tests help to pinpoint the location of the lesion and confirm that the lesion is the source of the seizures. Another test to assess electrical activity in the brain is EEG-video monitoring, in which video cameras are used to record seizures while the EEG monitors the brain's activity. In some cases, invasive monitoring -- in which electrodes are placed inside the skull over a specific area of the brain -- is also used to further identify the tissue responsible for seizures.

What Happens During a Lesionectomy?

 

A lesionectomy requires exposing an area of the brain using a procedure called a craniotomy. ("Crani" refers to the skull and "otomy" means "to cut into.") After the patient is put to sleep with general anesthesia, the surgeon makes an incision (cut) in the scalp, removes a piece of bone and pulls back a section of the dura, the tough membrane that covers the brain. This creates a "window" in which the surgeon inserts special instruments for removing the brain tissue. Surgical microscopes are used to give the surgeon a magnified view of the lesion and surrounding brain tissue. The surgeon utilizes information gathered during pre-surgical brain imaging to help identify abnormal brain tissue and avoid areas of the brain responsible for vital functions.

In some cases, a portion of the surgery is performed while the patient is awake, using medication to keep the person relaxed and pain-free. This is done so that the patient can help the surgeon find and avoid vital areas of the brain. While the patient is awake, the doctor uses special probes to stimulate different areas of the brain. At the same time, the patient is asked to count, identify pictures, or perform other tasks. The surgeon can then identify the area of the brain associated with each task. After the brain tissue is removed, the dura and bone are fixed back into place, and the scalp is closed using stitches or staples.

What Happens After a Lesionectomy?

 

After a lesionectomy, the patient generally stays in an intensive care unit for 24 to 48 hours after surgery and then stays in a regular hospital room for three to four days. Most people who have a lesionectomy will be able to return to their normal activities, including work or school, in six to eight weeks after surgery. Most patients will need to continue taking anti-seizure medication. Once seizure control is established, medications may be reduced or eliminated.

How Effective Is a Lesionectomy?

 

Lesionectomy results are excellent in patients whose seizures are clearly associated with a defined lesion. Seizures usually stop once the lesion is removed.

What Are the Side Effects of a Lesionectomy?

 

Side effects of a lesionectomy vary, depending on the location and extent of the lesion and the tissue removed. The following side effects may occur after surgery, although they generally go away on their own:

  • Scalp numbness.
  • Nausea.
  • Feeling tired or depressed.
  • Headaches.
  • Difficulty speaking, remembering, or finding words.

What Risks Are Associated With a Lesionectomy?

 

The risks associated with lesionectomy include:

  • Risks associated with surgery, including infection, bleeding, and an allergic reaction to anesthesia.
  • Failure to relieve seizures.
  • Swelling in the brain.
  • Damage to healthy brain tissue.

Leukemia


  • Leukemia facts
  • What is leukemia?
  • What are the types of leukemia?
  • Who is at risk for leukemia?
  • What are symptoms of leukemia?
  • How is leukemia diagnosed?
  • How is leukemia treated?
  • How does someone get a second opinion about leukemia treatment?
  • What happens after treatment for leukemia?
  • What research is being done for leukemia?
  • What resources are available to patients with leukemia?
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  • Patient Discussions: Leukemia - Treatments
  • Patient Discussions: Leukemia - Symptoms Experienced
  • Find a local Oncologist in your town

Leukemia facts

  • Leukemia is a cancer of the blood cells.
  • While the exact cause(s) of leukemia is not known, risk factors have been identified.
  • Leukemias are grouped by how quickly the disease develops (acute or chronic) as well as by the type of blood cell that is affected (lymphocytes or myelocytes). The four main types of leukemia include acute lymphocytic leukemia (ALL), chronic lymphocytic leukemia (CLL), acute myelocytic leukemia (AML), and chronic myelocytic leukemia (CML).
  • People with leukemia are at significantly increased risk for developing infections, anemia, and bleeding. Other symptoms and signs include easy bruising, weight loss, night sweats, and unexplained fevers.
  • The diagnosis of leukemia is supported by findings of the medical history and examination, and examining blood and bone marrow samples under a microscope.

     

  • Treatment of leukemia depends on the type of leukemia, certain features of the leukemia cells, the extent of the disease, and prior history of treatment, as well as the age and health of the patient.
  • Most patients with leukemia are treated with chemotherapy. Some patients also may have radiation therapy and/or bone marrow transplantation.
  • There is no known way to prevent leukemia.
  • The prognosis of leukemia depends upon several factors, including the patient's age, the type of leukemia, and the extent to which the cancer has spread.

What is leukemia?

Leukemia is cancer that starts in the tissue that forms blood. To understand cancer, it helps to know how normal blood cells form.

Normal Blood Cells

Most blood cells develop from cells in the bone marrow called stem cells. Bone marrow is the soft material in the center of most bones.

Stem cells mature into different kinds of blood cells. Each kind has a special job:

White Blood Cells
White blood cells help fight infection. There are several types of white blood cells.

Red Blood Cells
Red blood cells carry oxygen to tissues throughout the body.

Platelets
Platelets help form blood clots that control bleeding.

White blood cells, red blood cells, and platelets are made from stem cells as the body needs them. When cells grow old or get damaged, they die, and new cells take their place.

The picture below shows how stem cells can mature into different types of white blood cells. First, a stem cell matures into either a myeloid stem cell or a lymphoid stem cell:

  • A myeloid stem cell matures into a myeloid blast. The blast can form a red blood cell, platelets, or one of several types of white blood cells.
  • A lymphoid stem cell matures into a lymphoid blast. The blast can form one of several types of white blood cells, such as B cells or T cells.

The white blood cells that form from myeloid blasts are different from the white blood cells that form from lymphoid blasts.

Picture of Leukemia

Leukemia Cells

In a person with leukemia, the bone marrow makes abnormal white blood cells. The abnormal cells are leukemia cells.

Unlike normal blood cells, leukemia cells don't die when they should. They may crowd out normal white blood cells, red blood cells, and platelets. This makes it hard for normal blood cells to do their work.

Types of Leukemia

The types of leukemia can be grouped based on how quickly the disease develops and gets worse. Leukemia is either chronic (which usually gets worse slowly) or acute (which usually gets worse quickly):

  • Chronic leukemia: Early in the disease, the leukemia cells can still do some of the work of normal white blood cells. People may not have any symptoms at first. Doctors often find chronic leukemia during a routine checkup - before there are any symptoms.

    Slowly, chronic leukemia gets worse. As the number of leukemia cells in the blood increases, people get symptoms, such as swollen lymph nodes or infections. When symptoms do appear, they are usually mild at first and get worse gradually.

     

  • Acute leukemia: The leukemia cells can't do any of the work of normal white blood cells. The number of leukemia cells increases rapidly. Acute leukemia usually worsens quickly.

The types of leukemia also can be grouped based on the type of white blood cell that is affected. Leukemia can start in lymphoid cells or myeloid cells. See the picture of these cells. Leukemia that affects lymphoid cells is called lymphoid, lymphocytic, or lymphoblastic leukemia. Leukemia that affects myeloid cells is called myeloid, myelogenous, or myeloblastic leukemia.

There are four common types of leukemia:

  • Chronic lymphocytic leukemia (CLL): CLL affects lymphoid cells and usually grows slowly. It accounts for more than 15,000 new cases of leukemia each year. Most often, people diagnosed with the disease are over age 55. It almost never affects children.
  • Chronic myeloid leukemia (CML): CML affects myeloid cells and usually grows slowly at first. It accounts for nearly 5,000 new cases of leukemia each year. It mainly affects adults.
  • Acute lymphocytic (lymphoblastic) leukemia (ALL): ALL affects lymphoid cells and grows quickly. It accounts for more than 5,000 new cases of leukemia each year. ALL is the most common type of leukemia in young children. It also affects adults.
  • Acute myeloid leukemia (AML): AML affects myeloid cells and grows quickly. It accounts for more than 13,000 new cases of leukemia each year. It occurs in both adults and children.

Hairy cell leukemia is a rare type of chronic leukemia.

Risk Factors

When you're told that you have cancer, it's natural to wonder what may have caused the disease. No one knows the exact causes of leukemia. Doctors seldom know why one person gets leukemia and another doesn't. However, research shows that certain risk factors increase the chance that a person will get this disease.

The risk factors may be different for the different types of leukemia:

  • Radiation: People exposed to very high levels of radiation are much more likely than others to get acute myeloid leukemia, chronic myeloid leukemia, or acute lymphocytic leukemia.
    • Atomic bomb explosions: Very high levels of radiation have been caused by atomic bomb explosions (such as those in Japan during World War II). People, especially children, who survive atomic bomb explosions are at increased risk of leukemia.
    • Radiation therapy: Another source of exposure to high levels of radiation is medical treatment for cancer and other conditions. Radiation therapy can increase the risk of leukemia.
    • Diagnostic x-rays: Dental x-rays and other diagnostic x-rays (such as CT scans) expose people to much lower levels of radiation. It's not known yet whether this low level of radiation to children or adults is linked to leukemia. Researchers are studying whether having many x-rays may increase the risk of leukemia. They are also studying whether CT scans during childhood are linked with increased risk of developing leukemia.
  • Smoking: Smoking cigarettes increases the risk of acute myeloid leukemia.
  • Benzene: Exposure to benzene in the workplace can cause acute myeloid leukemia. It may also cause chronic myeloid leukemia or acute lymphocytic leukemia. Benzene is used widely in the chemical industry. It's also found in cigarette smoke and gasoline.
  • Chemotherapy: Cancer patients treated with certain types of cancer-fighting drugs sometimes later get acute myeloid leukemia or acute lymphocytic leukemia. For example, being treated with drugs known as alkylating agents or topoisomerase inhibitors is linked with a small chance of later developing acute leukemia.
  • Down syndrome and certain other inherited diseases: Down syndrome and certain other inherited diseases increase the risk of developing acute leukemia.
  • Myelodysplastic syndrome and certain other blood disorders: People with certain blood disorders are at increased risk of acute myeloid leukemia.
  • Human T-cell leukemia virus type I (HTLV-I): People with HTLV-I infection are at increased risk of a rare type of leukemia known as adult T-cell leukemia. Although the HTLV-I virus may cause this rare disease, adult T-cell leukemia and other types of leukemia are not contagious.
  • Family history of leukemia: It's rare for more than one person in a family to have leukemia. When it does happen, it's most likely to involve chronic lymphocytic leukemia. However, only a few people with chronic lymphocytic leukemia have a father, mother, brother, sister, or child who also has the disease.

Having one or more risk factors does not mean that a person will get leukemia. Most people who have risk factors never develop the disease.

Symptoms

Like all blood cells, leukemia cells travel through the body. The symptoms of leukemia depend on the number of leukemia cells and where these cells collect in the body.

People with chronic leukemia may not have symptoms. The doctor may find the disease during a routine blood test.

People with acute leukemia usually go to their doctor because they feel sick. If the brain is affected, they may have headaches, vomiting, confusion, loss of muscle control, or seizures. Leukemia also can affect other parts of the body such as the digestive tract, kidneys, lungs, heart, or testes.

Common symptoms of chronic or acute leukemia may include:

  • Swollen lymph nodes that usually don't hurt (especially lymph nodes in the neck or armpit)
  • Fevers or night sweats
  • Frequent infections
  • Feeling weak or tired
  • Bleeding and bruising easily (bleeding gums, purplish patches in the skin, or tiny red spots under the skin)
  • Swelling or discomfort in the abdomen (from a swollen spleen or liver)
  • Weight loss for no known reason
  • Pain in the bones or joints

Most often, these symptoms are not due to cancer. An infection or other health problems may also cause these symptoms. Only a doctor can tell for sure.

Anyone with these symptoms should tell the doctor so that problems can be diagnosed and treated as early as possible.

Diagnosis

Doctors sometimes find leukemia after a routine blood test. If you have symptoms that suggest leukemia, your doctor will try to find out what's causing the problems. Your doctor may ask about your personal and family medical history.

You may have one or more of the following tests:

  • Physical exam: Your doctor checks for swollen lymph nodes, spleen, or liver.
  • Blood tests: The lab does a complete blood count to check the number of white blood cells, red blood cells, and platelets. Leukemia causes a very high level of white blood cells. It may also cause low levels of platelets and hemoglobin, which is found inside red blood cells.
  • Biopsy: Your doctor removes tissue to look for cancer cells. A biopsy is the only sure way to know whether leukemia cells are in your bone marrow. Before the sample is taken, local anesthesia is used to numb the area. This helps reduce the pain. Your doctor removes some bone marrow from your hipbone or another large bone. A pathologist uses a microscope to check the tissue for leukemia cells.

    There are two ways your doctor can obtain bone marrow. Some people will have both procedures during the same visit:

    • Bone marrow aspiration: The doctor uses a thick, hollow needle to remove samples of bone marrow.
    • Bone marrow biopsy: The doctor uses a very thick, hollow needle to remove a small piece of bone and bone marrow.

Other Tests

The tests that your doctor orders for you depend on your symptoms and type of leukemia. You may have other tests:

  • Cytogenetics: The lab looks at the chromosomes of cells from samples of blood, bone marrow, or lymph nodes. If abnormal chromosomes are found, the test can show what type of leukemia you have. For example, people with CML have an abnormal chromosome called the Philadelphia chromosome.
  • Spinal tap: Your doctor may remove some of the cerebrospinal fluid (the fluid that fills the spaces in and around the brain and spinal cord). The doctor uses a long, thin needle to remove fluid from the lower spine. The procedure takes about 30 minutes and is performed with local anesthesia. You must lie flat for several hours afterward to keep from getting a headache. The lab checks the fluid for leukemia cells or other signs of problems.
  • Chest x-ray: An x-ray can show swollen lymph nodes or other signs of disease in your chest.

You may want to ask your doctor these questions before having a bone marrow aspiration or biopsy:

  • Will you remove the sample of bone marrow from the hip or from another bone?
  • Where will I go for this procedure?
  • Will I have to do anything to prepare for it?
  • How long will it take? Will I be awake?
  • Will it hurt? What will you do to prevent or control the pain?
  • Are there any risks? What are the chances of infection or bleeding after the procedure?
  • How long will it take me to recover?
  • How soon will I know the results? Who will explain them to me?
  • If I do have leukemia, who will talk to me about next steps? When?

Treatment

People with leukemia have many treatment options. The options are watchful waiting, chemotherapy, targeted therapy, biological therapy, radiation therapy, and stem cell transplant. If your spleen is enlarged, your doctor may suggest surgery to remove it. Sometimes a combination of these treatments is used.

The choice of treatment depends mainly on the following:

  • The type of leukemia (acute or chronic)
  • Your age
  • Whether leukemia cells were found in your cerebrospinal fluid

It also may depend on certain features of the leukemia cells. Your doctor also considers your symptoms and general health.

People with acute leukemia need to be treated right away. The goal of treatment is to destroy signs of leukemia in the body and make symptoms go away. This is called a remission. After people go into remission, more therapy may be given to prevent a relapse. This type of therapy is called consolidation therapy or maintenance therapy. Many people with acute leukemia can be cured.

If you have chronic leukemia without symptoms, you may not need cancer treatment right away. Your doctor will watch your health closely so that treatment can start when you begin to have symptoms. Not getting cancer treatment right away is called watchful waiting.

When treatment for chronic leukemia is needed, it can often control the disease and its symptoms. People may receive maintenance therapy to help keep the cancer in remission, but chronic leukemia can seldom be cured with chemotherapy. However, stem cell transplants offer some people with chronic leukemia the chance for cure.

Your doctor can describe your treatment choices, the expected results, and the possible side effects. You and your doctor can work together to develop a treatment plan that meets your medical and personal needs.

You may want to talk with your doctor about taking part in a clinical trial, a research study of new treatment methods.

Your doctor may refer you to a specialist, or you may ask for a referral. Specialists who treat leukemia include hematologists, medical oncologists, and radiation oncologists. Pediatric oncologists and hematologists treat childhood leukemia. Your health care team may also include an oncology nurse and a registered dietitian.

Whenever possible, people should be treated at a medical center that has doctors experienced in treating leukemia. If this isn't possible, your doctor may discuss the treatment plan with a specialist at such a center.

Before treatment starts, ask your health care team to explain possible side effects and how treatment may change your normal activities. Because cancer treatments often damage healthy cells and tissues, side effects are common. Side effects may not be the same for each person, and they may change from one treatment session to the next.

You may want to ask your doctor these questions before you begin treatment:

  • What type of leukemia do I have? How do I get a copy of the report from the pathologist?
  • What are my treatment choices? Which do you recommend for me? Why?
  • Will I have more than one kind of treatment? How will my treatment change over time?
  • What are the expected benefits of each kind of treatment?
  • What are the risks and possible side effects of each treatment? What can we do to control the side effects?
  • What can I do to prepare for treatment?
  • Will I need to stay in the hospital? If so, for how long?
  • What is the treatment likely to cost? Will my insurance cover the cost?
  • How will treatment affect my normal activities?
  • Would a clinical trial be right for me? Can you help me find one?
  • How often should I have checkups?

 

 

Watchful Waiting

People with chronic lymphocytic leukemia who do not have symptoms may be able to put off having cancer treatment. By delaying treatment, they can avoid the side effects of treatment until they have symptoms.

If you and your doctor agree that watchful waiting is a good idea, you'll have regular checkups (such as every 3 months). You can start treatment if symptoms occur.

Although watchful waiting avoids or delays the side effects of cancer treatment, this choice has risks. It may reduce the chance to control leukemia before it gets worse.

You may decide against watchful waiting if you don't want to live with an untreated leukemia. Some people choose to treat the cancer right away.

If you choose watchful waiting but grow concerned later, you should discuss your feelings with your doctor. A different approach is nearly always available.

You may want to ask your doctor these questions before choosing watchful waiting: If I choose watchful waiting, can I change my mind later on?

  • If I choose watchful waiting, can I change my mind later on?
  • Will the leukemia be harder to treat later?
  • How often will I have checkups?
  • Between checkups, what problems should I report?

Chemotherapy

Many people with leukemia are treated with chemotherapy. Chemotherapy uses drugs to destroy leukemia cells.

Depending on the type of leukemia, you may receive a single drug or a combination of two or more drugs.

You may receive chemotherapy in several different ways:

  • By mouth: Some drugs are pills that you can swallow.
  • Into a vein (IV): The drug is given through a needle or tube inserted into a vein.
  • Through a catheter (a thin, flexible tube): The tube is placed in a large vein, often in the upper chest. A tube that stays in place is useful for patients who need many IV treatments. The health care professional injects drugs into the catheter, rather than directly into a vein. This method avoids the need for many injections, which can cause discomfort and injure the veins and skin.
  • Into the cerebrospinal fluid: If the pathologist finds leukemia cells in the fluid that fills the spaces in and around the brain and spinal cord, the doctor may order intrathecal chemotherapy. The doctor injects drugs directly into the cerebrospinal fluid. Intrathecal chemotherapy is given in two ways:
    • Into the spinal fluid: The doctor injects the drugs into the spinal fluid.
    • Under the scalp: Children and some adult patients receive chemotherapy through a special catheter called an Ommaya reservoir. The doctor places the catheter under the scalp. The doctor injects the drugs into the catheter. This method avoids the pain of injections into the spinal fluid.
  • Intrathecal chemotherapy is used because many drugs given by IV or taken by mouth can't pass through the tightly packed blood vessel walls found in the brain and spinal cord. This network of blood vessels is known as the blood-brain barrier.

Chemotherapy is usually given in cycles. Each cycle has a treatment period followed by a rest period.

You may have your treatment in a clinic, at the doctor's office, or at home. Some people may need to stay in the hospital for treatment.

The side effects depend mainly on which drugs are given and how much. Chemotherapy kills fast-growing leukemia cells, but the drug can also harm normal cells that divide rapidly:

  • Blood cells: When chemotherapy lowers the levels of healthy blood cells, you're more likely to get infections, bruise or bleed easily, and feel very weak and tired. You'll get blood tests to check for low levels of blood cells. If your levels are low, your health care team may stop the chemotherapy for a while or reduce the dose of drug. There also are medicines that can help your body make new blood cells. Or, you may need a blood transfusion.
  • Cells in hair roots: Chemotherapy may cause hair loss. If you lose your hair, it will grow back, but it may be 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. Ask your health care team about medicines and other ways to help you cope with these problems.
  • Sperm or egg cells: Some types of chemotherapy can cause infertility.
    • Children: Most children treated for leukemia appear to have normal fertility when they grow up. However, depending on the drugs and doses used and the age of the patient, some boys and girls may be infertile as adults.
    • Adult men: Chemotherapy may damage sperm cells. Men may stop making sperm. Because these changes to sperm may be permanent, some men have their sperm frozen and stored before treatment (sperm banking).
    • Adult women: Chemotherapy may damage the ovaries. Women may have irregular menstrual periods or periods may stop altogether. Women may have symptoms of menopause, such as hot flashes and vaginal dryness. Women who may want to get pregnant in the future should ask their health care team about ways to preserve their eggs before treatment starts.

Targeted Therapy

People with chronic myeloid leukemia and some with acute lymphoblastic leukemia may receive drugs called targeted therapy. Imatinib (Gleevec) tablets were the first targeted therapy approved for chronic myeloid leukemia. Other targeted therapy drugs are now used too.

Targeted therapies use drugs that block the growth of leukemia cells. For example, a targeted therapy may block the action of an abnormal protein that stimulates the growth of leukemia cells.

Side effects include swelling, bloating, and sudden weight gain. Targeted therapy can also cause anemia, nausea, vomiting, diarrhea, muscle cramps, or a rash. Your health care team will monitor you for signs of problems.

Biological Therapy

Some people with leukemia receive drugs called biological therapy. Biological therapy for leukemia is treatment that improves the body's natural defenses against the disease.

One type of biological therapy is a substance called a monoclonal antibody. It's given by IV infusion. This substance binds to the leukemia cells. One kind of monoclonal antibody carries a toxin that kills the leukemia cells. Another kind helps the immune system destroy leukemia cells.

For some people with chronic myeloid leukemia, the biological therapy is a drug called interferon. It is injected under the skin or into a muscle. It can slow the growth of leukemia cells.

You may have your treatment in a clinic, at the doctor's office, or in the hospital. Other drugs may be given at the same time to prevent side effects.

The side effects of biological therapy differ with the types of substances used, and from person to person. Biological therapies commonly cause a rash or swelling where the drug is injected. They also may cause a headache, muscle aches, a fever, or weakness. Your health care team may check your blood for signs of anemia and other problems.

You may want to ask your doctor these questions before having chemotherapy, targeted therapy, or biological therapy:

  • Which drugs will I get? What will the treatment do?
  • Should I see my dentist before treatment begins?
  • When will treatment start? When will it end? How often will I have treatments?
  • Where will I go for treatment? Will I have to stay in the hospital?
  • What can I do to take care of myself during treatment?
  • How will we know the treatment is working?
  • Will I have side effects during treatment? What side effects should I tell you about? Can I prevent or treat any of these side effects?
  • Can these drugs cause side effects later on?
  • How often will I need checkups?

Radiation Therapy

Radiation therapy (also called radiotherapy) uses high-energy rays to kill leukemia cells. People receive radiation therapy at a hospital or clinic.

Some people receive radiation from a large machine that is aimed at the spleen, the brain, or other parts of the body where leukemia cells have collected. This type of therapy takes place 5 days a week for several weeks. Others may receive radiation that is directed to the whole body. The radiation treatments are given once or twice a day for a few days, usually before a stem cell transplant.

The side effects of radiation therapy depend mainly on the dose of radiation and the part of the body that is treated. For example, radiation to your abdomen can cause nausea, vomiting, and diarrhea. In addition, your skin in the area being treated may become red, dry, and tender. You also may lose your hair in the treated area.

You are likely to be very tired during radiation therapy, especially after several weeks of treatment. Resting is important, but doctors usually advise patients to try to stay as active as they can.

Although the side effects of radiation therapy can be distressing, they can usually be treated or controlled. You can talk with your doctor about ways to ease these problems.

It may also help to know that, in most cases, the side effects are not permanent. However, you may want to discuss with your doctor the possible long-term effects of radiation treatment.

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

  • Why do I need this treatment?
  • When will the treatments begin? How often will they be given? When will they end?
  • How will I feel during treatment? Will I be able to continue my normal activities during treatment?
  • Will there be side effects? How long will they last?
  • Can radiation therapy cause side effects later on?
  • What can I do to take care of myself during treatment?
  • How will we know if the radiation treatment is working?
  • How often will I need checkups?

 

Stem Cell Transplant

Some people with leukemia receive a stem cell transplant. A stem cell transplant allows you to be treated with high doses of drugs, radiation, or both. The high doses destroy both leukemia cells and normal blood cells in the bone marrow. After you receive high-dose chemotherapy, radiation therapy, or both, you receive healthy stem cells through a large vein. (It's like getting a blood transfusion.) New blood cells develop from the transplanted stem cells. The new blood cells replace the ones that were destroyed by treatment.

Stem cell transplants take place in the hospital. Stem cells may come from you or from someone who donates their stem cells to you:

  • From you: An autologous stem cell transplant uses your own stem cells. Before you get the high-dose chemotherapy or radiation therapy, your stem cells are removed. The cells may be treated to kill any leukemia cells present. Your stem cells are frozen and stored. After you receive high-dose chemotherapy or radiation therapy, the stored stem cells are thawed and returned to you.
  • From a family member or other donor: An allogeneic stem cell transplant uses healthy stem cells from a donor. Your brother, sister, or parent may be the donor. Sometimes the stem cells come from a donor who isn't related. Doctors use blood tests to learn how closely a donor's cells match your cells.
  • From your identical twin: If you have an identical twin, a syngeneic stem cell transplant uses stem cells from your healthy twin.

Stem cells come from a few sources. The stem cells usually come from the blood (peripheral stem cell transplant). Or they can come from the bone marrow (bone marrow transplant). Another source of stem cells is umbilical cord blood. Cord blood is taken from a newborn baby and stored in a freezer. When a person gets cord blood, it's called an umbilical cord blood transplant.

After a stem cell transplant, you may stay in the hospital for several weeks or months. You'll be at risk for infections and bleeding because of the large doses of chemotherapy or radiation you received. In time, the transplanted stem cells will begin to produce healthy blood cells.

Another problem is that graft-versus-host disease (GVHD) may occur in people who receive donated stem cells. In GVHD, the donated white blood cells in the stem cell graft react against the patient's normal tissues. Most often, the liver, skin, or digestive tract is affected. GVHD can be mild or very severe. It can occur any time after the transplant, even years later. Steroids or other drugs may help.

 

You may want to ask your doctor these questions before having a stem cell transplant:

  • What kind of stem cell transplant will I have? If I need a donor, how will we find one?
  • How long will I be in the hospital? Will I need special care? How will I be protected from germs? Will my visitors have to wear a mask? Will I?
  • What care will I need when I leave the hospital?
  • How will we know if the treatment is working?
  • What are the risks and the side effects? What can we do about them?
  • What changes in normal activities will be necessary?
  • What is my chance of a full recovery? How long will that take?
  • How often will I need checkups?

In this Article

  • Leukemia facts
  • What is leukemia?
  • What are the types of leukemia?
  • Who is at risk for leukemia?
  • What are symptoms of leukemia?
  • How is leukemia diagnosed?
  • How is leukemia treated?
  • How does someone get a second opinion about leukemia treatment?
  • What happens after treatment for leukemia?
  • What research is being done for leukemia?
  • What resources are available to patients with leukemia?
  • Pictures of Skin Cancer Signs - Slideshow View Skin Cancer Signs Slideshow
  • Pictures of Breast Cancer - SlideshowView Breast Cancer Slideshow
  • Pictures of Colorectal Cancer (Cancer of the Colon) - Slideshow View Colorectal Cancer (Cancer of the Colon) Slideshow
  • Find a local Oncologist in your town

Second Opinion

Before starting treatment, you might want a second opinion about your diagnosis and treatment plan. Some people worry that the doctor will be offended if they ask for a second opinion. Usually the opposite is true. Most doctors welcome a second opinion. And many health insurance companies will pay for a second opinion if you or your doctor requests it.

If you get a second opinion, the doctor may agree with your first doctor's diagnosis and treatment plan. Or the second doctor may suggest another approach. Either way, you have more information and perhaps a greater sense of control. You can feel more confident about the decisions you make, knowing that you've looked at your options.

It may take some time and effort to gather your medical records and see another doctor. In most cases, it's not a problem to take several weeks to get a second opinion. The delay in starting treatment usually won't make treatment less effective. To make sure, you should discuss this delay with your doctor. Some people with leukemia need treatment right away.

There are many ways to find a doctor for a second opinion. You can ask your doctor, a local or state medical society, a nearby hospital, or a medical school for names of specialists. NCI's Cancer Information Service at 1-800-4-CANCER can tell you about nearby treatment centers.

Nonprofit groups with an interest in leukemia may be of help.

Supportive Care

Leukemia and its treatment can lead to other health problems. You can have supportive care before, during, or after cancer treatment.

Supportive care is treatment to prevent or fight infections, to control pain and other symptoms, to relieve the side effects of therapy, and to help you cope with the feelings that a diagnosis of cancer can bring. You may receive supportive care to prevent or control these problems and to improve your comfort and quality of life during treatment.

Infections: Because people with leukemia get infections very easily, you may receive antibiotics and other drugs. Some people receive vaccines against the flu and pneumonia. The health care team may advise you to stay away from crowds and from people with colds and other contagious diseases. If an infection develops, it can be serious and should be treated promptly. You may need to stay in the hospital for treatment.

Anemia and bleeding: Anemia and bleeding are other problems that often require supportive care. You may need a transfusion of red blood cells or platelets. Transfusions help treat anemia and reduce the risk of serious bleeding.

Dental problems: Leukemia and chemotherapy can make the mouth sensitive, easily infected, and likely to bleed. Doctors often advise patients to have a complete dental exam and, if possible, undergo needed dental care before chemotherapy begins. Dentists show patients how to keep their mouth clean and healthy during treatment. You can get information about supportive care on NCI's Web site at http://www.cancer.gov/cancerinfo/coping and from NCI's Cancer Information Service at 1-800-4-CANCER or LiveHelp (http://www.cancer.gov/help).

Nutrition and Physical Activity

It's important for you to take care of yourself by eating well and staying as active as you can.

You need the right amount of calories to maintain a good weight. You also need enough protein to keep up your strength. Eating well may help you feel better and have more energy.

Sometimes, especially during or soon after treatment, you may not feel like eating. You may be uncomfortable or tired. You may find that foods do not taste as good as they used to. In addition, the side effects of treatment (such as poor appetite, nausea, vomiting, or mouth sores) can make it hard to eat well. Your doctor, a registered dietitian, or another health care provider can suggest ways to deal with these problems.

Research shows that people with cancer feel better when they are active. Walking, yoga, and other activities can keep you strong and increase your energy. Exercise may reduce nausea and pain and make treatment easier to handle. It also can help relieve stress. Whatever physical activity you choose, be sure to talk to your doctor before you start. Also, if your activity causes you pain or other problems, be sure to let your doctor or nurse know about it.

Follow-up Care

You'll need regular checkups after treatment for leukemia. Checkups help ensure that any changes in your health are noted and treated if needed. If you have any health problems between checkups, you should contact your doctor.

Your doctor will check for return of the cancer. Even when the cancer seems to be completely destroyed, the disease sometimes returns because undetected leukemia cells remained somewhere in your body after treatment. Also, checkups help detect health problems that can result from cancer treatment.

Checkups may include a careful physical exam, blood tests, cytogenetics, x-rays, bone marrow aspiration, or spinal tap.

 

You may want to ask your doctor these questions after you have finished treatment:

  • How often will I need checkups?
  • Which follow-up tests do you suggest for me?
  • Between checkups, what health problems or symptoms should I tell you about?

Sources of Support

Learning you have leukemia can change your life and the lives of those close to you. These changes can be hard to handle. It's normal for you, your family, and your friends to have new and confusing feelings to work through.

Concerns about treatments and managing side effects, hospital stays, and medical bills are common. You may also worry about caring for your family, keeping your job, or continuing daily activities.

Here's where you can go for support:

  • Doctors, nurses, and other members of your health care team can answer many of your questions about treatment, working, or other activities.
  • Social workers, counselors, or members of the clergy can be helpful if you want to talk about your feelings or concerns. Often, social workers can suggest resources for financial aid, transportation, home care, or emotional support.
  • Support groups can also 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.
  • Information specialists at 1-800-4-CANCER and at LiveHelp (http://www.cancer.gov/help) can help you locate programs, services, and publications. They can give you names of national organizations that offer services to people with cancer and their families.

 

Taking Part in Cancer Research

Cancer research has led to real progress in leukemia treatment. Because of research, adults and children with leukemia can look forward to a better quality of life and less chance of dying from the disease. Continuing research offers hope that, in the future, even more people with this disease will be treated successfully.

Doctors all over the country are conducting many types of clinical trials (research studies in which people volunteer to take part). Clinical trials are designed to answer important questions and to find out whether new approaches are safe and effective.

Doctors are studying methods of new and better ways to treat leukemia, and ways to improve quality of life. They are testing new targeted therapy, biological therapy, and chemotherapy. They also are working with various combinations of treatments.

Even if people in a trial do not benefit directly, they still make an important contribution by helping doctors learn more about leukemia and how to control it. Although clinical trials may pose some risks, doctors do all they can to protect their patients.

If you are interested in being part of a clinical trial, talk with your doctor.

. It has general information about clinical trials as well as detailed information about specific ongoing studies of leukemia. Information specialists at 1-800-4-CANCER or at LiveHelp at http://www.cancer.gov/help can answer questions and provide information about clinical trials.

National Cancer Institute Information Resources

You may want more information for yourself, your family, and your doctor. The following NCI services are available to help you.

Telephone

NCI's Cancer Information Service (CIS) provides accurate, up-to-date information about cancer to patients and their families, health professionals, and the general public. Information specialists translate the latest scientific information into plain language, and they will respond in English or Spanish, as well as through TRS providers for the hearing or speech impaired. Calls to the CIS are confidential and free.

    Telephone: 1-800-4-CANCER (1-800-422-6237)

Internet

NCI's Web site provides information from numerous NCI sources. It offers current information about cancer prevention, screening, diagnosis, treatment, genetics, supportive care, and ongoing clinical trials. It has information about NCI's research programs, funding opportunities, and cancer statistics.

    Web site: http://www.cancer.gov

    Spanish Web site: http://www.cancer.gov/espanol

Leukoplakia

  • What causes leukoplakia?
  • What are the symptoms?
  • How is leukoplakia diagnosed?
  • How is leukoplakia treated?
  • Find a local Doctor in your town

Introduction

Leukoplakia is a white or gray patch that develops on the tongue or the inside of the cheek. It is the mouth's reaction to chronic irritation of the mucous membranes of the mouth. Leukoplakia patches can also develop on the female genital area; however, the cause of this is unknown.

The growth can occur at any time in your life, but it is most common in the elderly.

"Hairy" leukoplakia of the mouth is an unusual form of leukoplakia that is seen only in people who are infected with HIV, have AIDS, or AIDS-related complex. It consists of fuzzy, hence the name "hairy," white patches on the tongue and less frequently elsewhere in the mouth. It may resemble thrush, an infection caused by the fungus Candida which, in adults, usually occurs if your immune system is not working properly, and may be one of the first signs of infection with the HIV virus.

What Causes Leukoplakia?

  • Irritation from rough teeth, fillings, or crowns, or ill-fitting dentures that rub against your cheek or gum
  • Chronic smoking, pipe smoking, or other tobacco use
  • Sun exposure to the lips
  • Oral cancer, although rare
  • HIV or AIDS

What Are the Symptoms?

The presence of white or gray colored patches on your tongue, gums, roof of your mouth, or the inside of the cheeks of your mouth may be a sign of leukoplakia. The patch may have developed slowly over weeks to months and be thick, slightly raised, and may eventually take on a hardened and rough texture. It usually is painless, but may be sensitive to touch, heat, spicy foods, or other irritation.

How Is Leukoplakia Diagnosed?

Your dentist may suspect leukoplakia upon examination; however, a biopsy will likely be taken to rule out other causes, such as oral cancer. During the biopsy, a small piece of tissue from the lesion will be removed to be examined in a lab. A numbing agent will be used so that you will not feel any pain.

How Is Leukoplakia Treated?

Treatment, if needed, involves removing the source of irritation. For example, if leukoplakia is caused by a rough tooth or an irregular surface on a denture or filling the tooth will be smoothed and dental appliances repaired. If leukoplakia is caused by smoking, you will be asked to minimize or stop smoking or using other tobacco products.

Leukoplakia is usually harmless, and lesions usually clear in a few weeks or months after the source of irritation is removed. If eliminating the source of irritation is ineffective in reducing leukoplakia, the lesion may need to be surgically removed. The lesion can be removed either by your general dentist or by an oral surgeon in their office under local anesthesia.

Hairy leukoplakia requires treatment with an antiviral medication.

Lichen Planus


  • What is lichen planus?
  • How is the rash of lichen planus different from that of most other common rashes?
  • What are the symptoms of lichen planus?
  • What does lichen planus look like?
  • How is lichen planus diagnosed?
  • What causes lichen planus?
  • What is the treatment for lichen planus?
  • What is the long-term outlook for patients with lichen planus?
  • Patient Discussions: Lichen Planus - Symptoms and Signs
  • Patient Discussions: Lichen Planus - Describe Your Experience
  • Find a local Dermatologist in your town

What is lichen planus?

Lichen planus is a recurrent rash that is due to inflammation. The rash is characterized by small, flat-topped, many-sided (polygonal) bumps that can grow together into rough, scaly patches on the skin. There may also be a rash in the lining (mucous membranes) of the mouth or vagina.

Lichen planus is a very curious skin condition, the effects of which are localized to the areas of involvement. (Lichen refers to a tree moss while planus is Latin for flat = like a flat tree moss.)

How is the rash of lichen planus different from that of most other common rashes?

The major point of distinction of lichen planus from eczema, psoriasis, and other common rashes is its color -- lilac or violet. The textbooks call it "violaceous."

What are the symptoms of lichen planus?

Lichen planus itches with an intensity that varies in different people from mild to severe.

The onset of lichen planus can be sudden or gradual. The first attack may last for weeks or months, and recurrences may happen for years. Children are not often affected by lichen planus. The bumps at first are 2 to 4 mm in diameter, with angular borders, and a violaceous color. At the onset of the disease, new bumps may appear at sites of minor skin injury, such as a superficial scratch. An excess of pigment (hyperpigmentation) may develop in the affected skin as the lesions persist. Rarely, a patchy scarring balding (alopecia) of the scalp occurs.

What does lichen planus look like?

The appearance of lichen planus depends on whether the skin or the lining (mucous membranes) inside the mouth or vagina are affected:

  • Skin involvement: The usual skin involvement with lichen planus consists of flat-topped lilac or violet spots a few millimeters in diameter on the skin. These spots tend to be located on the inner wrists, forearms, the lower legs just above the ankles, and the lower part of the back.

    A variant of this disease is called hypertrophic lichen planus. This condition appears as thick, reddish-brown lesions that are covered with scales. These spots tend to be on the shins, but they can occur anywhere on the body. This is an especially itchy and persistent (chronic) variant of lichen planus.

  • Mucous membranes: Lichen planus of the mucous membranes is common. Dentists often come across it as a white, lacy rash on the inside of the cheeks of people who are unaware of the condition. About half of the people affected with lichen planus have the rash inside of their mouths (oral mucosa). The oral rash often occurs prior to any skin involvement.

    More troublesome, although rare, is erosive lichen planus, which can be quite sore and uncomfortable. This erosive form typically causes the patient to complain of the shallow and often quite painful, recurrent ulcers in the mouth.

    Lichen planus can affect the female genitals, including the vagina. This condition can be confused with sexually transmitted diseases (STDs), although lichen planus is neither sexually transmitted nor contagious.

Sometimes, lichen planus produces pits and grooves in the nails as well.

How is lichen planus diagnosed?

Usually, lichen planus is relatively straightforward to diagnose. Physicians can make the diagnosis in typical cases simply by looking at the rash. If necessary, a skin biopsy may be done to help confirm the diagnosis. Under the microscope, lichen planus is distinctive in appearance.

This tell-tale appearance under the microscope can be valuable in ensuring that the rash or spots are lichen planus. Persistent oral or vaginal lichen planus, with spots that thicken and grow together, can sometimes be difficult to distinguish clinically from whitish precancerous plaques called leukoplakia. A biopsy can be helpful in this situation.

Widespread lichen planus with erosions in the mouth can also be confusing. A biopsy may be required to distinguish this from other conditions such as candidiasis (yeast infection), carcinoma (cancer), and ulcers in the mouth (aphthous ulcers).

 

What causes lichen planus?

In most cases, the cause of lichen planus is unknown.

Some drugs, such as those containing arsenic, bismuth, or gold can cause a reaction that is indistinguishable from the rash of lichen planus. Exposure to certain chemicals used in the development of color photographs can also produce a similar rash. The long-term use of the drugs quinacrine or quinidine (used for malaria, certain microscopic organisms, and worms) may produce hypertrophic lichen planus of the lower legs and other skin and body- wide (systemic) disturbances. Other unusual causes of lichen planus include liver disease and what is called graft-versus-host disease in people who have received a transplant.

What is the treatment for lichen planus?

Most cases of lichen planus are relatively mild. Affected individuals who do not have symptoms do not need treatment.

If the itch or appearance of the rash are unpleasant, topical corticosteroid creams may be of help. Topical steroid creams that, for example, are under wrapping or taped at bedtime may also be useful. For localized, itchy, thick lesions, injections of corticosteroids may be given. Antihistamines may blunt the itch, particularly if it is only moderate. This effect is in part due to the sedative effect of antihistamines.

In more severe cases, physicians may recommend oral medications or therapy with ultraviolet light. Orally taken medications may include a course of oral corticosteroids such as prednisone. However, the itching may return after the drug has been discontinued. A low-dose oral corticosteroid every other morning may be also prescribed. With continued itching, ultraviolet light (PUVA) treatment may help. For painful lesions within the mouth, the use of special mouthwashes containing a painkiller (such as lidocaine) before meals may provide some relief. Any drug or chemical suspected of being the cause of the lichen planus should of course also be halted.

What is the long-term outlook for patients with lichen planus?

Lichen planus usually goes away by itself in time. Some drugs can produce rashes that are similar in appearance to lichen planus. These rashes can be distinguished from lichen planus in that they go away when the offending drug is stopped.

Lichen planus, by contrast, usually persists quite a while before resolving. The average duration of the condition is 4 years. Even after going away, lichen planus may recur. The disease is thus paradoxical in that it tends to be self-limiting but may recur after years. It is usually not associated with any body-wide (systemic) diseases or problems.

Lichen Sclerosus

  • What is lichen sclerosus?
  • Who gets lichen sclerosus?
  • What are the symptoms of lichen sclerosus?
  • What causes lichen sclerosus?
  • How is it diagnosed?
  • How is it treated?
  • Can people with lichen sclerosus have sex?
  • Is lichen sclerosus related to cancer?
  • What kind of doctor treats lichen sclerosus?
  • Where can I find more information about lichen sclerosus?
  • Find a local Dermatologist in your town

What is lichen sclerosus?

Lichen sclerosus is a long-term problem of the skin. It mostly affects the genital and anal areas. Sometimes, lichen sclerosus appears on the upper body, breasts, and upper arms.

Who gets lichen sclerosus?

Lichen sclerosus appears in:

  • Women (often after menopause)
  • Men (uncommon)
  • Children (rare).

What are the symptoms?

Early in the disease, small white spots appear on the skin. The spots are usually shiny and smooth. Later, the spots grow into bigger patches. The skin on the patches becomes thin and crinkled. Then the skin tears easily, and bright red or purple bruises are common. Sometimes, the skin becomes scarred. If the disease is a mild case, there may be no symptoms.

Other symptoms are:

  • Itching (very common)
  • Discomfort or pain
  • Bleeding
  • Blisters.

What causes lichen sclerosus?

Doctors don't know the exact cause of lichen sclerosus. Some doctors think a too active immune system and hormone problems may play a role. It is also thought that people inherit the likelihood of getting the disease. Sometimes, lichen sclerosus appears on skin that has been damaged or scarred from some other previous injury.

Lichen sclerosus is not contagious (it can't be caught from another person).

How is it diagnosed?

Doctors can look at severe lichen sclerosus and know what it is. But usually, a doctor takes a small piece of the skin patch (biopsy) and looks at it under a microscope. This allows doctors to make sure that it is not a different disease.

 

How is it treated?

If you have patches on the arms or upper body, they usually don't need treatment. The patches go away over time.

Lichen sclerosus of the genital skin should be treated. Even if it isn't painful or itchy, the patches can scar. This can cause problems with urination or sex. There is also a very small chance that skin cancer may develop in the patches.

Surgery is normally a good option for men. Circumcision (removing the foreskin on the penis) is the most widely used therapy for men with lichen sclerosus. The disease usually does not come back. Surgery is normally not a good option for women. When the lichen sclerosus patches are removed from the genitals of women and girls, they usually come back.

Treatment also includes using very strong cortisone cream or ointment on the skin. You put these creams on the patches every day for several weeks. This stops the itching. Then you use the cream or ointment two times a week for a long time to keep the disease from coming back. Treatment does not fix the scarring that may have already occurred.

You need regular followup by a doctor because using these creams and ointments for a long time can cause:

  • Thinning and redness of the skin
  • Stretch marks where the cream is applied
  • Genital yeast infections.

Sometimes, you don't get better when using the cortisone creams. Some things that can keep symptoms from clearing up are:

  • Low estrogen levels
  • Infection
  • Allergy to the medication.

When creams and ointments don't work, your doctor may suggest:

  • Retinoids, or vitamin A-like drugs
  • Tacrolimus ointment
  • Ultraviolet light treatments (not used on skin of the genitals).

If you need medicine, ask your doctor:

  • How does the medicine work?
  • What are its side effects?
  • Why is it the best treatment for my lichen sclerosus?

If a young girl gets lichen sclerosis, she may not require lifelong treatment. Lichen sclerosus sometimes goes away at puberty. Scarring and changes in skin color may remain.

Can people with lichen sclerosus have sex?

Women with severe lichen sclerosus in the genitals may not be able to have sex. The disease can cause scars that narrow the vagina. Also, sex can hurt and cause the patches to bleed. However, treatment with creams or ointments can help. Women with severe scarring in the vagina may need surgery, but only after lichen sclerosus is controlled with medication.

Is lichen sclerosus related to cancer?

Lichen sclerosus does not cause skin cancer. However, skin that is scarred by lichen sclerosus is more likely to develop skin cancer. If you have the disease, see the doctor every 6 to 12 months. The doctor can look at and treat any changes in the skin.

What kind of doctor treats lichen sclerosus?

Lichen sclerosus is treated by:

  • Dermatologists (doctors who treat the skin)
  • Gynecologists (doctors who treat the female reproductive system)
  • Urologists (doctors who treat the urinary or urogenital tract)
  • Primary health care providers.

For more information about lichen sclerosus and other related conditions:

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
National Institutes of Health
1 AMS Circle Bethesda, MD 20892-3675
Phone: 301-495-4484 or 877-22-NIAMS (226-4267) (free of charge)
TTY: 301-565-2966
Fax: 301-718-6366
E-mail: This e-mail address is being protected from spambots. You need JavaScript enabled to view it
www.niams.nih.gov

Can people with lichen sclerosus have sex?

Women with severe lichen sclerosus in the genitals may not be able to have sex. The disease can cause scars that narrow the vagina. Also, sex can hurt and cause the patches to bleed. However, treatment with creams or ointments can help. Women with severe scarring in the vagina may need surgery, but only after lichen sclerosus is controlled with medication.

Is lichen sclerosus related to cancer?

Lichen sclerosus does not cause skin cancer. However, skin that is scarred by lichen sclerosus is more likely to develop skin cancer. If you have the disease, see the doctor every 6 to 12 months. The doctor can look at and treat any changes in the skin.

What kind of doctor treats lichen sclerosus?

Lichen sclerosus is treated by:

  • Dermatologists (doctors who treat the skin)
  • Gynecologists (doctors who treat the female reproductive system)
  • Urologists (doctors who treat the urinary or urogenital tract)
  • Primary health care providers.

For more information about lichen sclerosus and other related conditions:

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
National Institutes of Health
1 AMS Circle Bethesda, MD 20892-3675
Phone: 301-495-4484 or 877-22-NIAMS (226-4267) (free of charge)
TTY: 301-565-2966
Fax: 301-718-6366
E-mail: This e-mail address is being protected from spambots. You need JavaScript enabled to view it
www.niams.nih.gov

Fainting
(Syncope)


  • Introduction to fainting (syncope)
  • What causes fainting (syncope)?
  • Heart rhythm changes
  • Heart structural conditions
  • Heart valve conditions
  • Sudden cardiac death
  • Postural hypotension
  • Vasovagal syncope
  • Anemia
  • Dehydration
  • Orthostatic hypotension
  • Vertebrobasilar system
  • Electrolyte imbalance
  • Other medications and drugs
  • Pregnancy
  • What are the signs and symptoms of fainting (syncope)?
  • How is fainting (syncope) diagnosed?
  • What is the treatment for fainting (syncope)?
  • Can fainting (syncope) be prevented?
  • Fainting (Syncope) At A Glance
  • Patient Discussions: Fainting (Syncope) - Treatments
  • Patient Discussions: Fainting - Describe Your Experience

Introduction to fainting (syncope)

Fainting, "blacking out," or syncope is the temporary loss of consciousness followed by the return to full wakefulness. This loss of consciousness may be accompanied by loss of muscle tone that can result in falling or slumping over. To better understand why fainting can occur; it is helpful to explain why somebody is awake.

The brain has multiple parts, including two hemispheres, the cerebellum, and the brain stem. The brain requires blood flow to provide oxygen and glucose (sugar) to its cells to sustain life. For the body to be awake, an area known as the reticular activating system located in the brain stem needs to be turned on, and at least one brain hemisphere needs to be functioning. For fainting or syncope to occur, either the reticular activating system needs to lose its blood supply, or both hemispheres of the brain need to be deprived of blood, oxygen, or glucose. If blood sugar levels are normal blood flow must be briefly disrupted to the whole brain or to the reticular activating system.

Fainting is not caused by head trauma, since loss of consciousness after a head injury is considered a concussion. However, fainting can cause injury if the person falls and hurts themselves, or if the faint occurs while participating in an activity like driving a car.

What causes fainting (syncope)?

Decreased blood flow to the brain can occur because 1) the heart fails to pump the blood; 2) the blood vessels don't have enough tone to maintain blood pressure to deliver the blood to the brain; 3) there is not enough blood or fluid within the blood vessels; or 4) a combination of reasons one, two, or three above.

Heart rhythm changes

Heart rhythm changes are the most common causes of passing out, fainting, or syncope. While this may sound ominous, frequently the faint is due to a temporary change in normal body function.

Sometimes, the heart rhythm change is more dangerous and potentially life-threatening. The heart is an electrical pump, and if an electrical system problem exists, the heart may on occasion be unable to adequately pump blood, causing short term drops in blood pressure. The electrical issues may cause the heart to beat too quickly, too slowly, or erratically.

A rapid heart rate or tachycardia (tachy = fast + cardia = heart) is an abnormal rhythm generated in either the upper or lower chambers of the heart and may be life-threatening. Should the heart beat too quickly, there may not be enough time for it to fill with blood in between each heart beat, which then decreases the amount of blood the heart can deliver to the body. Tachycardias can occur at any age and may not be related to atherosclerotic heart disease.

With bradycardia, or a slow heart rate (brady = slow + cardia = heart), the heart's ability to pump blood may be compromised. As the heart ages, the electrical system can become fragile and heart blocks, or disruptions of the electrical system, can occur, causing the heart rate to slow down.

Aside from structural electrical problems with the heart, medications may be the culprit. When taking prescribed medications for blood pressure control [for example, beta blockers such as metoprolol (Lopressor, Toprol XL), propranolol (Inderal, Inderal LA), atenolol (Tenormin), or calcium channel blockers such as diltiazem (Cardizem, Dilacor, Tiazac), verapamil (Calan, Verelan and others), amlodipine (Norvasc)], the heart can on occasion become more sensitive to the effects of these drugs and beat abnormally slow and decrease blood output from the heart.

Heart structural conditions

Structural problems with the heart can cause fainting or syncope, either because there is a problem with the ability of the heart to adequately pump blood or because of valve problems. When the heart muscle becomes damaged or inflamed it may not have the ability to pump blood to meet the body's needs. Examples include a heart attack (myocardial infarction) or cardiomyopathy, in which the heart muscle weakens.

Heart valve conditions

Abnormalities with the heart valves can also cause fainting or syncope. The valves allow blood to go in the proper direction when the heart pumps. Valve diseases may include abnormal narrowing (stenosis) or leakage (insufficiency or regurgitation). Either situation can cause issues with maintaining adequate blood flow to the body.

Sudden cardiac death

In young people, especially athletes, fainting or syncope can occur because of abnormal thickening of parts of the heart muscle (hypertrophic cardiomyopathy). This may obstruct blood when it tries to leave the heart, especially when the heart is asked to beat harder during exercise. Sudden death in athletes may be foreshadowed by episodes of syncope.

Postural hypotension

Loss of intravascular fluid, that is the blood and water within the blood vessels, can also cause fainting or syncope. Usually, fainting will occur when a person stands up quickly from a lying or sitting position and there isn't enough time for the body to compensate by making the heart beat quicker, or having the blood vessels constrict to maintain the body's blood pressure and blood flow to the brain. This is referred to as postural hypotension.

Vasovagal syncope

Vasovagal syncope is one of the most common causes of fainting. In this situation, the balance between the chemicals adrenaline and acetylcholine is disrupted. Adrenaline stimulates the body, including making the heart beat faster and blood vessels narrower, thereby increasing blood pressure. Acetylcholine does the opposite. When the vagus nerve is stimulated, excess acetylcholine is released, the heart rate slows and the blood vessels dilate, making it harder for blood to defeat gravity and be pumped to the brain. This temporary decrease in blood flow to the brain causes the syncopal (fainting) episode.

Pain can stimulate the vagus nerve and is a common cause of vasovagal syncope. Other noxious stimuli can do the same thing, including situational stressors. It is common for medical and nursing students to faint when observing their first operation or autopsy. Some people pass out when they hear bad news; others pass out when they experience the sight of blood or needles. In the Victorian age this was known as a "swoon."

Other situations commonly cause the heart rate to temporarily slow and cause a faint. Straining with urination, bowel movement, or coughing can cause a vagal response, increase acetylcholine levels and decrease blood flow to the brain.

Anemia

Anemia (low red blood cell count), whether it occurs acutely from bleeding or gradually for a variety of reasons, can cause fainting because there aren't enough red blood cells to deliver oxygen to the brain.

Dehydration

Dehydration, or lack of water in the body can similarly cause fainting or syncope. This can be caused by excessive loss of water from vomiting, diarrhea, sweating, or by inadequate fluid intake. Some illnesses like diabetes can cause dehydration by excess loss of water in the urine.

Orthostatic hypotension

Blood vessels need to maintain their tone so that the body can withstand the effects of gravity with changes in position. When the body position changes from lying down to standing, the autonomic nervous system (the part of the brain not under conscious control), increases tone in the blood vessel walls, making them constrict, and at the same time increases the heart rate so that blood can be pumped upward to the brain. As people age, blood vessels may become less resilient, and orthostatic hypotension (relative low blood pressure with standing) may occur and cause syncope.

Vertebrobasilar system

Blood vessels to the brain are no different than any other blood vessels in the body and are at risk for narrowing with age, smoking, high blood pressure, high cholesterol, and diabetes. While most people are aware of the carotid arteries that supply the thinking parts of the brain, another set of arteries supply the base of the brain. This vertebrobasilar system is also at risk for narrowing, and should there be a temporary disruption in the blood flow to the midbrain and the reticular activating system, fainting or syncope may occur. The vertebral arteries run to the brain in the back of the neck and are encased in bony tunnels. If blood flow in these arteries is disrupted, the brain stem and reticular activating system may turn off, causing syncope.

Electrolyte imbalance

Electrolyte and hormone abnormalities may also be responsible for syncope; however, these causes are due to their effects on the heart and blood vessels.

Other medications and drugs

Other medications or drugs may also be potential causes of fainting or syncope including those for high blood pressure that can dilate blood vessels, antidepressants that can affect heart electrical activity, and those that affect mental status like pain medications, alcohol, and cocaine.

Pregnancy

Syncope is also related to pregnancy. Likely explanations include compression of the inferior vena cava (the large vein that returns blood to the heart) by the enlarging uterus and by orthostatic hypotension.

 

What are the signs and symptoms of fainting (syncope)?

With fainting (syncope), the patient is unaware that they have passed out and fallen to the ground. It is only afterward that they understand what has happened.

There may be symptoms or signs before the syncopal episode, which may include:

  • The person may feel lightheaded, nauseated, sweaty, or weak. There may be a feeling of dizziness or vertigo (with the room spinning), vision may fade or blur, and there may be muffled hearing and tingling sensations in the body.
  • With pre-syncope or a near-faint, the same symptoms will occur, but the person doesn't quite lose consciousness.

During the episode, when the person is unconscious, there may a few twitches of the body which may be confused with seizure activity.

The person may have some confusion after wakening but it should resolve within a few seconds.

After a syncopal episode, there should be a quick return to normal mental function, though there may be other signs and symptoms depending upon the underlying cause of the faint. For example, if the individual is in the midst of a heart attack, he or she may complain of chest pain or pressure.

How is fainting (syncope) diagnosed?

As with most medical conditions, the history is the key in finding out why a patient faints. Since most episodes of syncope do not occur while the patient is wearing a heart monitor in front of a medical provider, it is the description of how the patient felt and what bystanders or family members witnessed that will give clues to the diagnosis.

Physical examination will try to look for signs that will give direction to the potential diagnosis. Heart monitoring may be done to look for heart rhythm disturbances. Blood pressure may be checked both lying and standing to uncover orthostatic hypotension. Examination of the heart, lung, and neurologic system may uncover a potential cause if these are abnormal.

Initial diagnostic tests may include an electrocardiogram (EKG) and screening blood tests like a complete blood count (CBC), electrolytes, glucose, and kidney function tests. Thyroid blood tests may be performed.

Heart rhythm disturbances may be transient and not always evident at time of the examination. On occasion, a heart monitor (Holter monitor) can be worn as an outpatient for 24 or 48 hours or for up to 30 days (event monitor). Abnormal heart rhythms and rates may be uncovered as the potential cause of syncope.

A tilt-table test can be used to uncover orthostatic hypotension and is usually done on an outpatient basis. The patient is placed at an angle on a table for 30-45 minutes (every institution has its own protocol) and blood pressure and pulse rate are measured with the patient in different positions.

Depending upon the suspicions of the health care provider, imaging may be done of the brain using computerized tomography (CT scan) or magnetic resonance imaging (MRI).

Often these tests are normal and a presumptive diagnosis is made of a non life-threatening event. However, the medical care provider may decide, in consultation with the patient, whether further testing is required and whether testing should occur in the hospital or as an outpatient. It may be reasonable in some cases to take a watchful waiting approach and not proceed with any further evaluation.

What is the treatment for fainting (syncope)?

Fainting is not normal, although the cause may not be serious. When in doubt, calling 911, activating the emergency medical system, and seeking medical care is appropriate. It is always appropriate to seek medical care.

If the episode is short-lived and the person returns to normal function with no evidence of injury, it may be appropriate to contact the primary care practitioner to discuss care options.

If the person is not breathing and no pulse can be felt, 911 should be activated, an AED placed, and bystander CPR should be initiated.

In the ambulance, hospital, or doctor's office, because the potential life-threatening causes of syncope need to be initially considered; often a patient who complains of fainting (syncope) will be placed on a heart monitor, have an intravenous line placed, and oxygen supplied. A fingerstick blood sugar may be checked to look for hypoglycemia (low blood sugar).

Further treatment will be tailored to the specific cause of the fainting or syncope based upon the patient's evaluation.

Can fainting (syncope) be prevented?

Depending upon the cause, there may be opportunity to prevent fainting spells. For example:

  • Patients who have had a vasovagal episode may be aware of the warning signs and be able to sit or lie down before passing out and avert the fainting episode.
  • For older patients with orthostatic hypotension, waiting for a second after changing positions may be all that is needed to allow the body's reflexes to react.
  • Medications may be adjusted if they are thought to be the potential cause of fainting or syncope.
  • Adequate fluid intake may be enough to prevent dehydration as the cause for syncope.
  • There is an increased awareness of syncope and sudden death in younger athletes due to hypertrophic cardiomyopathy. A variety of screening tests are available to assess potential risk for sudden death, but no consensus yet as to who and when to screen athletes has emerged.
Fainting (Syncope) At A Glance
  • Being unconscious is not normal; those affected should seek medical care.
  • Syncope may be caused by a variety of mechanisms.
  • Some causes of syncope can be a warning of a life-threatening situation. Most times, syncope is a relatively benign situation.
  • While most episodes of syncope can be easily explained, some patients never receive a diagnosis or know the specific cause.

Listeriosis (Listeria monocytogenes Infection)


  • What is listeriosis?
  • What are listeriosis symptoms and signs?
  • What are the risk factors for listeriosis?
  • How is listeriosis diagnosed?
  • What is the treatment for listeriosis?
  • How does a person get listeriosis?
  • Can listeriosis be prevented?
  • What is the prognosis (outcome) for Listeria infections?
  • If a person has eaten recalled food potentially contaminated with Listeria, what should they do?
  • What is the government doing about listeriosis?
  • Listeriosis (Listeria monocytogenes Infection) At A Glance
  • Find a local Doctor in your town

What is listeriosis?

Listeriosis is an infection caused by a gram-positive motile bacterium named Listeria monocytogenes that produces fever, muscle aches, and in many people, diarrhea. Severe infections can cause headaches, meningitis, convulsions, and death. Most healthy people exposed to the bacteria have minor or no symptoms, but a few people, especially the elderly, pregnant females and their fetus, newborns, and anyone with a compromised immune system are especially susceptible to these organisms. Listeria bacteria are widespread throughout the world and are frequently associated with farm animals that infrequently show no signs of infection. Research shows that many animals are uninfected carriers; in addition, they suggest that about 5%-10% of all humans carry these organisms as part of the human bowel flora. About 2,500 infections are diagnosed per year in the U.S. with about 500 deaths per year. Except for pregnant females and their fetus or newborn, there is no direct transfer of Listeria from human to human.

The organisms (Listeria monocytogenes) that cause listeriosis probably have been infecting humans for centuries; Listeria was first isolated from an infected WWI soldier in 1918 and had many different names until 1940, when the genus and species names were firmly established. The bacteria were first recognized as a food-borne pathogen in 1979. The bacteria can penetrate human cells and can multiply inside them. People with altered or impaired immune systems have cells that are less able to control the spread of these organisms into the blood or into other cells. In 2010, a known species, Listeria ivanovii, thought only to infect cattle, was found to infect humans.

There have been many outbreaks of the disease over the world; the most recent occurred in Texas in October 2010, tentatively related to locally processed celery; 10 people were diagnosed with listeriosis and five died. Most people infected had underlying medical problems or conditions.

What are listeriosis symptoms and signs?

Fever, muscle aches, and occasionally, nausea or diarrhea (or both) are the usual symptoms associated with listeriosis. These symptoms usually last up to one week and spontaneously resolve. However, in some people, the organisms can spread to the brain. The symptoms of meningitis (stiff neck, headache, and fever), altered mental status (confusion, reduced mental activity), balance problems, and seizures develop in brain infections. Brain abscesses may also occur and cause similar symptoms.

Pregnant women who are otherwise healthy usually have only minor symptoms develop. However, Listeria organisms in pregnant females often cause miscarriage, stillbirth, premature birth, or cause infection and, potentially, death of the newborn. About 30% of all listeriosis infections reported in the U.S. occur in pregnant females.

Occasionally, localized skin infections may occur, especially in people who handle animals that are infected with Listeria. These skin infections rarely lead to further complications such as brain infection.

What are the risk factors for listeriosis?

The major risk factor for getting listeriosis is eating or drinking foods and liquids contaminated with Listeria bacteria. Foods and liquids that have been contaminated with animal feces or soil are the most frequently identified sources for these organisms. Drinking inadequately treated or non-pasteurized liquids is another source of infection.

Some individuals have an increased risk for getting listeriosis. In general, people with an altered or damaged immune system have a higher risk of getting listeriosis and its more severe complications. Specifically, people at higher risk include pregnant females, newborns, the elderly, diabetics, cancer patients, AIDS patients, patients with kidney diseases, and those patients undergoing any immune-suppression therapy.

How is listeriosis diagnosed?

Preliminary diagnosis is usually based on the patient's history and physical exam, especially after the patient gives a history of likely exposure to a contaminated food source during a Listeria outbreak. Without this information, the diagnosis is difficult to sort out from many other diseases; this situation may result in a delay of treatment as the physician may do other tests to rule out other diseases. Definitive diagnosis of listeriosis is by culturing Listeria monocytogenes bacteria from the patient's blood, cerebrospinal fluid or amniotic fluid, usually on a medium that is selective for Listeria (for example, RAPID'L mono agar). Currently, no reliable tests are available to detect the bacteria in the stool; also, there are no serological tests available.

What is the treatment for listeriosis?

The majority of people with Listeria infections spontaneously clear the infection in about seven days. However, those patients at increased risk, especially pregnant patients, usually require immediate IV antibiotic treatment to prevent, halt, or slow the development of more severe disease. For example, early effective antibiotic treatment of pregnant females may be lifesaving for the fetus.

In general, length of antibiotic treatment increases with the severity of the infection. Meningitis is treated for three weeks while brain abscesses are treated for six weeks. The initial choice of antibiotics is usually IV ampicillin. Bactrim (trimethoprim-sulfamethoxazole) also has been used successfully. However, each patient's treatment should be individualized for optimal results; many clinicians recommend an infectious-disease consultant be involved and if the patient is pregnant, her obstetrician and a pediatric specialist should help manage the treatment plan.

 

How does a person get listeriosis?

The majority of people (over 95%) who get listeriosis have consumed Listeria-contaminated foods. Because the bacteria are often found in both soil and water, cultivated foods like vegetables can easily become contaminated, especially from fertilizer or animal waste. Listeria has been found in many types of raw food (even seafood) but especially in meats, vegetables and cheeses. It has even been found in processed foods because of contamination during or after the processing. After the contaminated food or fluid has been ingested, it may take up to three weeks for the organisms to cause symptoms.

The fetus may become infected after the mother ingests the organisms; the bacteria apparently reach the fetus via the bloodstream. Newborn infants can acquire the bacteria during a Caesarian procedure or be exposed to them while traversing the vagina.

Can listeriosis be prevented?

Yes, listeriosis can be prevented. The CDC recommends the following measures:

General recommendations:

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

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

  • Do not eat hot dogs, luncheon meats, or deli meats, unless they are reheated until steaming hot.
  • Avoid getting fluid from hot-dog packages on other foods, utensils, and food preparation surfaces, and wash hands after handling hot dogs, luncheon meats, and deli meats.
  • Do not eat refrigerated pâtés or meat spreads. Canned or shelf-stable pâtés and meat spreads may be eaten.
  • Do not eat refrigerated smoked seafood, unless it is contained in a cooked dish, such as a casserole. Refrigerated smoked seafood, such as salmon, trout, whitefish, cod, tuna or mackerel, is most often labeled as "nova-style," "lox," "kippered," "smoked," or "jerky." The fish is found in the refrigerator section or sold at deli counters of grocery stores and delicatessens. Canned or shelf-stable smoked seafood may be eaten.
  • Avoid cross-contaminating other foods, utensils, and food-preparation surfaces with fluid from hot-dog packages, and wash hands after handling hot dogs.
  • Do not eat soft cheeses such as feta, Brie, and Camembert, blue-veined cheeses, or Mexican-style cheeses such as queso blanco, queso fresco, and Panela, unless they have labels that clearly state they are made from pasteurized milk. Cheeses that may be eaten include hard cheeses, semi-soft cheeses such as mozzarella, pasteurized processed cheeses such as slices and spreads, cream cheese, and cottage cheese.
  • Do not eat refrigerated pâtés or meat spreads. Canned or shelf-stable pâtés and meat spreads may be eaten.
  • Do not eat refrigerated smoked seafood, unless it is contained in a cooked dish, such as a casserole. Canned or shelf-stable smoked seafood may be eaten.
  • Do not drink raw (unpasteurized) milk or eat foods that contain unpasteurized milk.

There is no commercially available vaccine to protect against infection by Listeria.

What is the prognosis (outcome) for Listeria infections?

Since most infections go unnoticed or have minor symptoms, the prognosis is excellent. However, the prognosis for people with altered or impaired immune systems range from good (with early appropriate therapy) to poor, depending on how debilitated the patient is when first infected.

The pregnant female usually has a good prognosis. However, her fetus or newborn has a good to guarded prognosis, again depending how quickly the mother or newborn is effectively treated.

If a person has eaten recalled food potentially contaminated with Listeria, what should they do?

The CDC recommends the following to all people. If the person has no symptoms, they recommend no tests or treatment is done. However, if the person is in a high-risk group (see risk factor section above), they recommend contacting the person's physician only if the person develops fever or signs of serious illness within two months of eating the food. The CDC makes these conservative suggestions based on the fact that the chance of developing Listeria infection, even after ingestion of a contaminated product, is very small.

However, people in the high-risk groups should have no delays in contacting their doctor if they suspect symptoms of listeriosis are developing.

What is the government doing about listeriosis?

The following is taken directly from the CDC in response to the above question.

Government agencies and the food industry have taken steps to reduce contamination of food by the Listeria bacterium. The Food and Drug Administration and the U.S. Department of Agriculture monitor food regularly. When a processed food is found to be contaminated, food monitoring and plant inspection are intensified, and if necessary, the implicated food is recalled.

The Coordinating Center for Infectious Diseases (CCID) is studying listeriosis in several states to help measure the impact of prevention activities and recognize trends in disease occurrence. CCID also assists local health departments in investigating outbreaks. Early detection and reporting of outbreaks of listeriosis to local and state health departments can help identify sources of infection and prevent more cases of the disease.

In addition, the FDA publishes its list of product recalls on the Internet and the site is frequently updated. The following web site http://www.fda.gov/Safety/Recalls/default.htm will allow individuals to check on specific products and describe how to identify them.

 

Listeriosis (Listeria monocytogenes Infection) At A Glance
  • Listeriosis is a disease caused by a gram-positive bacterium named Listeria that can penetrate and replicate inside human cells.
  • Most people that are infected have few or no symptoms; when symptoms are present, they usually consist of fever, muscle aches, nausea, or diarrhea. Some people may develop more severe symptoms such as meningitis, mental changes, brain abscesses, or death.
  • Although most people have self-limited disease, people with risk factors such as an altered or depressed immune response (for example, pregnant females and their fetus or newborn, cancer patients, AIDS patients) are at higher risk for getting the disease and some are more likely to have more severe disease.
  • Listeriosis is usually diagnosed by discovering that a person was associated with an outbreak of Listeria-contaminated food or fluid, or identified as a person associated with the source of a known listeriosis outbreak. Definitive diagnosis is done when Listeria bacteria are isolated from the patient's blood, cerebral spinal fluid, or other body fluid.
  • Most normal people spontaneously clear the infection and require no treatment. In contrast, people with risk factors should be treated quickly with IV antibiotics.
  • People are exposed to Listeria bacteria if they ingest contaminated food or fluid. Foods that are not cooked or fluids that are not treated or pasteurized are frequently the sources of infection. Pregnant females can transmit Listeria organisms to their fetus or to their newborn.
  • Cooking foods, treating or pasteurizing fluids, and avoiding food and fluids that may be contaminated with animal or human waste may prevent infection.
  • The prognosis for most Listeria infections is excellent even if people have consumed contaminated foods or fluid; however, the prognosis rapidly declines in patients with risk factors if they are not quickly diagnosed and treated.
  • U.S. government agencies are responsible for maintaining safe foods and fluids for the U.S. population and may enforce regulations to ensure contaminated products are reported, removed, recalled, and production and sales stopped until processing meets acceptable standards of safety.

Hepatocellular Carcinoma
(Liver Cancer)


  • What is liver cancer (hepatocellular carcinoma, HCC)?
  • What is the scope of the liver cancer problem?
  • What are the population characteristics (epidemiology) of liver cancer?
  • What are liver cancer causes and risk factors?
  • What are liver cancer symptoms and signs?
  • How is liver cancer diagnosed?
  • Blood tests
  • Imaging studies
  • Liver biopsy or aspiration
  • What is the natural history of liver cancer?
  • What are the treatment options for liver cancer?
  • Chemotherapy and biotherapy
  • Chemoembolization (trans-arterial chemoembolization or TACE)
  • Radioembolization
  • Ablation techniques
  • Cryoablation
  • Stereotactic radiosurgery
  • Proton beam therapy
  • Surgery
  • Is there a role for routine screening for liver cancer?
  • What is fibrolamellar carcinoma?
  • What's in the future for the prevention and treatment of liver cancer?
  • Liver Cancer At a Glance
  • Patient Discussions: Liver Cancer - Diagnosis
  • Patient Discussions: Liver Cancer - Describe Your Experience
  • Find a local Oncologist in your town

What is liver cancer (hepatocellular carcinoma, HCC)?

Liver cancer (hepatocellular carcinoma) is a cancer arising from the liver. It is also known as primary liver cancer or hepatoma. The liver is made up of different cell types (for example, bile ducts, blood vessels, and fat-storing cells). However, liver cells (hepatocytes) make up 80% of the liver tissue. Thus, the majority of primary liver cancers (over 90%-95%) arises from liver cells and is called hepatocellular cancer or carcinoma.

When patients or physicians speak of liver cancer, however, they are often referring to cancer that has spread to the liver, having originated in other organs (such as the colon, stomach, pancreas, breast, and lung). More specifically, this type of liver cancer is called metastatic liver disease (cancer) or secondary liver cancer. This is a much more common problem around the world than primary liver cancer and frequently leads to confusion, because the term liver cancer actually can refer to either metastatic liver cancer or hepatocellular cancer. The subject of this article is hepatocellular carcinoma, which I will refer to as liver cancer.

What is the scope of the liver cancer problem?

Liver cancer is the third most common cancer in the world. A deadly cancer, liver cancer will kill almost all patients who have it within a year. In 2000, it was estimated that there were about 564,000 new cases of liver cancer worldwide, and a similar number of patients died as a result of this disease. About three-quarters of the cases of liver cancer are found in Southeast Asia (China, Hong Kong, Taiwan, Korea, and Japan). Liver cancer is also very common in sub-Saharan Africa (Mozambique and South Africa).

The frequency of liver cancer in Southeast Asia and sub-Saharan Africa is greater than 100 cases per 100,000 population. In contrast, the frequency of liver cancer in North America and Western Europe is much lower, less than five per 100,000 population. However, the frequency of liver cancer among native Alaskans is comparable to that seen in Southeast Asia. This reflects the prevalence of hepatitis B infection, which is the most common cause of this cancer worldwide. Recent data show, however, that the frequency of liver cancer in the U.S. overall is rising. This increase is due primarily to rising obesity and diabetes rates, and to chronic hepatitis C, another infection of the liver that causes liver cancer.

What are the population characteristics (epidemiology) of liver cancer?

In the U.S., the highest frequency of liver cancer occurs in immigrants from Asian countries, where liver cancer is common. The frequency of liver cancer among Caucasians is the lowest, whereas among African-Americans and Hispanics, it is intermediate. The frequency of liver cancer is high among Asians because liver cancer is closely linked to chronic hepatitis B infection. This is especially so in individuals who have been infected with chronic hepatitis B for most of their lives (it is usually a childhood disease in Asia). If you take a world map depicting the frequency of chronic hepatitis B infection, you can easily superimpose that map on a map showing the frequency of liver cancer. On the other hand, in Japan, North America and Europe, hepatitis C infection is a much more common cause; alcohol abuse is also an important contributing factor. All of these diseases cause continual damage to the liver, which can result in severe scarring (cirrhosis) that then can lead to cancer.

In areas where liver cancer is more common and associated with hepatitis B, the cancer usually develops in people in their 30s and 40s, as opposed to other areas of the world, where they are in their 60s and 70s. This is because it generally takes about 30 years of chronic damage to the liver before the cancer grows large enough to become obvious. Men are much more likely than women to have liver cancer, especially if they have hepatitis and cirrhosis. Regardless of the cause, patients with a history of alcohol abuse as well are much sicker when they initially develop the cancer. In North America, up to one-quarter of people with liver cancer have no obvious risk factors; they are generally healthier and do much better with treatment.

What are liver cancer causes and risk factors?

Hepatitis B infection

Hepatitis B can be caught from contaminated blood products or used needles or sexual contact but is frequent among Asian children from contamination at birth or even biting among children at play. The role of hepatitis B virus (HBV) infection in causing liver cancer is well established. Several lines of evidence point to this strong association. As noted earlier, the frequency of liver cancer relates to (correlates with) the frequency of chronic hepatitis B virus infection. In addition, the patients with hepatitis B virus who are at greatest risk for liver cancer are men with hepatitis B virus cirrhosis (scarring of the liver) and a family history of liver cancer. Perhaps the most convincing evidence, however, comes from a prospective (looking forward in time) study done in the 1970s in Taiwan involving male government employees over the age of 40. In this study, the investigators found that the risk of developing liver cancer was 200 times higher among employees who had chronic hepatitis B virus as compared to employees without chronic hepatitis B virus infection.

Studies in animals also have provided evidence that hepatitis B virus can cause liver cancer. For example, we have learned that liver cancer develops in other mammals that are naturally infected with viruses related to the hepatitis B virus. Finally, by infecting transgenic mice with certain parts of the hepatitis B virus, scientists caused liver cancer to develop in mice that do not usually develop liver cancer. (Transgenic mice are mice that have been injected with new or foreign genetic material.)

How does chronic hepatitis B virus cause liver cancer? In patients with both chronic hepatitis B virus and liver cancer, the genetic material of hepatitis B virus is frequently found to be part of the genetic material of the cancer cells. It is thought, therefore, that specific regions of the hepatitis B virus genome (genetic code) enter the genetic material of the liver cells. This hepatitis B virus genetic material may then disrupt the normal genetic material in the liver cells, thereby causing the liver cells to become cancerous.

The vast majority of liver cancer that is associated with chronic hepatitis B virus occurs in individuals who have been infected most of their lives. In areas where hepatitis B virus is not always present (endemic) in the community (for example, the U.S.), liver cancer is relatively uncommon. The reason for this is that most of the people with chronic hepatitis B virus in these areas acquired the infection as adults, and very few develop an ongoing (chronic active) infection, which happens as often as 15% of the time in Asia.

Hepatitis C infection

Hepatitis C virus (HCV) infection is more difficult to get than hepatitis B. It usually requires direct contact with infected blood, either from contaminated blood products or needles. HCV is also associated with the development of liver cancer. In fact, in Japan, hepatitis C virus is present in up to 75% of cases of liver cancer. As with hepatitis B virus, the majority of hepatitis C virus patients with liver cancer have associated cirrhosis (liver scarring). In several retrospective-prospective studies (looking backward and forward in time) of the natural history of hepatitis C, the average time to develop liver cancer after exposure to hepatitis C virus was about 28 years. The liver cancer occurred about eight to 10 years after the development of cirrhosis in these patients with hepatitis C. Several prospective European studies report that the annual incidence (occurrence over time) of liver cancer in cirrhotic hepatitis C virus patients ranges from 1.4%-2.5% per year.

In hepatitis C virus patients, the risk factors for developing liver cancer include the presence of cirrhosis, older age, male gender, elevated baseline alpha-fetoprotein level (a blood tumor marker), alcohol use, and co-infection with hepatitis B virus. Some earlier studies suggested that hepatitis C virus genotype 1b (a common genotype in the U.S.) may be a risk factor, but more recent studies do not support this finding.

The way in which hepatitis C virus causes liver cancer is not well understood. Unlike hepatitis B virus, the genetic material of hepatitis C virus is not inserted directly into the genetic material of the liver cells. It is known, however, that cirrhosis from any cause is a risk factor for the development of liver cancer. Therefore, it has been argued that hepatitis C virus, which causes cirrhosis of the liver, is an indirect cause of liver cancer.

On the other hand, there are some chronic hepatitis C virus-infected individuals who have liver cancer without cirrhosis. So, it has been suggested that the core (central) protein of hepatitis C virus is the culprit in the development of liver cancer. The core protein itself (a part of the hepatitis C virus) is thought to impede the natural process of cell death or interfere with the function of a normal tumor suppressor (inhibitor) gene (the p53 gene). The result of these actions is that the liver cells go on living and reproducing without the normal restraints, which is what happens in cancer.

Alcohol

Cirrhosis caused by chronic alcohol consumption is the most common association of liver cancer in the developed world. In fact, at autopsy, as many as half of alcoholics previously unsuspected to have cancer will have early evidence of cancer hidden within the liver. Many of these people are also infected with chronic hepatitis C virus. The usual setting is an individual with alcoholic cirrhosis who has stopped drinking for 10 years and then develops liver cancer. It is somewhat unusual for an actively drinking alcoholic to develop liver cancer. What happens is that when the drinking is stopped, the liver cells try to heal by regenerating (reproducing). It is during this active regeneration that a cancer-producing genetic change (mutation) can occur, which explains the occurrence of liver cancer after the drinking has been stopped.

More importantly, if an alcoholic does not stop drinking, he or she is unlikely to live long enough to develop the cancer. Alcoholics who are actively drinking are more likely to die from non-cancer related complications of alcoholic liver disease (for example, liver failure). Indeed, patients with alcoholic cirrhosis who die of liver cancer are about 10 years older than patients who die of non-cancer causes. Finally, as noted above, alcohol adds to the risk of developing liver cancer in patients with chronic hepatitis C virus or hepatitis B virus infections.

Aflatoxin B1

Aflatoxin B1 is the most potent liver cancer-forming chemical known. It is a product of a mold called Aspergillus flavus, which is found in food that has been stored in a hot and humid environment. This mold is found in such foods as peanuts, rice, soybeans, corn, and wheat. Aflatoxin B1 has been implicated in the development of liver cancer in Southern China and sub-Saharan Africa. It is thought to cause cancer by producing changes (mutations) in the p53 gene. These mutations work by interfering with the gene's important tumor suppressing (inhibiting) functions.

Drugs, medications, and chemicals

There are no medications that cause liver cancer, but female hormones (estrogens) and protein-building (anabolic) steroids are associated with the development of hepatic adenomas. These are benign liver tumors that may have the potential to become malignant (cancerous). Thus, in some individuals, hepatic adenoma can evolve into cancer.

Certain chemicals are associated with other types of cancers found in the liver. For example, thorotrast, a previously used contrast agent for diagnostic imaging studies, caused a cancer of the blood vessels in the liver called hepatic angiosarcoma. Also, vinyl chloride, a compound used in the plastics industry, can cause hepatic angiosarcomas that appear many years after the exposure.

Hemochromatosis

Liver cancer will develop in up to 30% of patients with hereditary hemochromatosis (a disorder in which there is too much iron stored in the body, including in the liver). Patients at the greatest risk are those who develop cirrhosis with their hemochromatosis. Unfortunately, once cirrhosis is established, effective removal of excess iron (the treatment for hemochromatosis) will not reduce the risk of developing liver cancer.

Diabetes and obesity

Over the past decade, the incidence of liver cancer in the United States has risen significantly, paralleling the rise in obesity. Although it is hard to separate the effects of diabetes from obesity on the liver, both conditions can cause chronic damage and accumulation of fat within the liver.. This is a disease called NASH (non-alcoholic steatohepatitis), which is present in up to 5% of North Americans. Fatty liver disease like this causes damage to the individual liver cells and may lead to cirrhosis in some people, thereby increasing the risk of liver cancer. Not only is the chance of developing the cancer enhanced, but patients with diabetes who undergo surgical removal of liver cancer have a higher chance of the cancer returning than do those without diabetes.

 

Cirrhosis

Individuals with most types of cirrhosis of the liver are at an increased risk of developing liver cancer. In addition to the conditions described above (hepatitis B, hepatitis C, alcohol, and hemochromatosis), alpha 1 anti-trypsin deficiency, a hereditary condition that can cause emphysema and cirrhosis, may lead to liver cancer. Liver cancer is also strongly associated with hereditary tyrosinemia, a childhood biochemical abnormality that results in early cirrhosis.

Certain causes of cirrhosis are less frequently associated with liver cancer than are other causes. For example, liver cancer is rarely seen with the cirrhosis in Wilson's disease (abnormal copper metabolism) or primary sclerosing cholangitis (chronic scarring and narrowing of the bile ducts). It used to be thought that liver cancer is rarely found in primary biliary cirrhosis (PBC) as well. Recent studies, however, show that the frequency of liver cancer in PBC is comparable to that in other forms of cirrhosis.

What are liver cancer symptoms and signs?

The initial symptoms (the clinical presentations) of liver cancer are variable. It is becoming much more common for patients to be identified by screening people at high risk for the cancer and finding the cancer before there are any symptoms at all. In countries where liver cancer is very common, the cancer generally is discovered at a very advanced stage of disease for several reasons. For one thing, areas where there is a high frequency of liver cancer are generally developing countries where access to health care is limited. For another, screening examinations for patients at risk for developing liver cancer are not available in these areas. In addition, patients from these regions may actually have more aggressive liver cancer disease. In other words, the tumor usually reaches an advanced stage and causes symptoms more rapidly. In contrast, patients in areas of low liver cancer frequency tend to have liver cancer tumors that progress more slowly and, therefore, remain without symptoms longer.

There are no specific symptoms of liver cancer, and in fact, the earliest signs are usually subtle and can be mistaken for simple worsening of cirrhosis and liver function. Abdominal pain is uncommon with liver cancer and usually signifies a very large tumor or widespread involvement of the liver. Additionally, unexplained weight loss or unexplained fevers are warning signs of liver cancer in patients with cirrhosis. These symptoms are less common in individuals with liver cancer in the U.S. because these patients are usually diagnosed at an earlier stage. However, whenever the overall health of a patient with cirrhosis deteriorates, every effort should be made to look for liver cancer.

A common initial presentation of liver cancer in a patient with compensated cirrhosis (meaning that there are no complications of liver disease) is the sudden onset of a complication. For example, the sudden appearance of ascites (abdominal fluid and swelling), jaundice (yellow color of the skin), or muscle wasting without causative (precipitating) factors (for example, alcohol consumption) suggests the possibility of liver cancer. What's more, the cancer can invade and block the portal vein (a large vein that brings blood to the liver from the intestine and spleen). When this happens, the blood will travel paths of less resistance, such as through esophageal veins. This causes increased pressure in these veins, which results in dilated (widened) veins called esophageal varices. The patient then is at risk for hemorrhage from the rupture of the varices into the gastrointestinal tract. Rarely, the cancer itself can rupture and bleed into the abdominal cavity, resulting in bloody ascites.

On physical examination, an enlarged, sometimes tender, liver is the most common finding. Liver cancers are very vascular (containing many blood vessels) tumors. Thus, increased amounts of blood feed into the hepatic artery (artery to the liver) and cause turbulent blood flow in the artery. The turbulence results in a distinct sound in the liver (hepatic bruit) that can be heard with a stethoscope in about one-quarter to one-half of patients with liver cancer. Any sign of advanced liver disease (for example, ascites, jaundice, or muscle wasting) means a poor prognosis. Rarely, a patient with liver cancer can become suddenly jaundiced when the tumor erodes into the bile duct. The jaundice occurs in this situation because both sloughing of the tumor into the duct and bleeding that clots in the duct can block the duct.

In advanced liver cancer, the tumor can spread locally to neighboring tissues or, through the blood vessels, elsewhere in the body (distant metastasis). Locally, liver cancer can invade the veins that drain the liver (hepatic veins). The tumor can then block these veins, which results in congestion of the liver. The congestion occurs because the blocked veins cannot drain the blood out of the liver. (Normally, the blood in the hepatic veins leaving the liver flows through the inferior vena cava, which is the largest vein that drains into the heart.) In African patients, the tumor frequently blocks the inferior vena cava. Blockage of either the hepatic veins or the inferior vena cava results in a very swollen liver and massive formation of ascites. In some patients, as previously mentioned, the tumor can invade the portal vein and lead to the rupture of esophageal varices.

Regarding distant metastases, liver cancer frequently spreads to the lungs, presumably by way of the bloodstream. Usually, patients do not have symptoms from the lung metastases, which are diagnosed by radiologic (X-ray) studies. Rarely, in very advanced cases, liver cancer can spread to the bone or brain. These are an infrequent problem in many patients who do not live long enough to develop these complications.

How is liver cancer diagnosed?

Blood tests

Liver cancer is not diagnosed by routine blood tests, including a standard panel of liver tests. This is why the diagnosis of liver cancer depends so much on the vigilance of the physician screening with a tumor marker (alpha-fetoprotein) in the blood and radiological imaging studies. Since most patients with liver cancer have associated liver disease (cirrhosis), their liver blood tests may not be normal to begin with. If these blood tests become abnormal or worsen due to liver cancer, this usually signifies extensive cancerous involvement of the liver. At that time, any medical or surgical treatment may be too late.

Sometimes, however, other abnormal blood tests can indicate the presence of liver cancer. Remember that each cell type in the body contains the full complement of genetic information. What differentiates one cell type from another is the particular set of genes that are turned on or off in that cell. When cells become cancerous, certain of the cell's genes that were turned off may become turned on. Thus, in liver cancer, the cancerous liver cells may take on the characteristics of other types of cells. For example, liver cancer cells sometimes can produce hormones that are ordinarily produced in other body systems. These hormones then can cause certain abnormal blood tests, such as a high red blood count (erythrocytosis), low blood sugar (hypoglycemia) and high blood calcium (hypercalcemia).

Another abnormal blood test, high serum cholesterol (hypercholesterolemia), is seen in up to 10% of patients from Africa with liver cancer. The high cholesterol occurs because the liver cancer cells are not able to turn off (inhibit) their production of cholesterol. (Normal cells are able to turn off their production of cholesterol.)

There is no reliable or accurate screening blood test for liver cancer. The most widely used biochemical blood test is alpha-fetoprotein (AFP), which is a protein normally made by the immature liver cells in the fetus. At birth, infants have relatively high levels of AFP, which fall to normal adult levels by the first year of life. Also, pregnant women carrying babies with neural tube defects may have high levels of AFP. (A neural tube defect is an abnormal fetal brain or spinal cord that is caused by folic acid deficiency during pregnancy.)

In adults, high blood levels (over 500 nanograms/milliliter) of AFP are seen in only three situations:

  • Liver cancer
  • Germ cell tumors (cancer of the testes and ovaries)
  • Metastatic cancer in the liver (originating in other organs)

Several assays (tests) for measuring AFP are available. Generally, normal levels of AFP are below 10 ng/ml. Moderate levels of AFP (even almost up to 500 ng/ml) can be seen in patients with chronic hepatitis. Moreover, many patients with various types of acute and chronic liver diseases without documentable liver cancer can have mild or even moderate elevations of AFP.

The sensitivity of AFP for liver cancer is about 60%. In other words, an elevated AFP blood test is seen in about 60% of liver cancer patients. That leaves 40% of patients with liver cancer who have normal AFP levels. Therefore, a normal AFP does not exclude liver cancer. Also, as noted above, an abnormal AFP does not mean that a patient has liver cancer. It is important to note, however, that patients with cirrhosis and an abnormal AFP, despite having no documentable liver cancer, still are at very high risk of developing liver cancer. Thus, any patient with cirrhosis and an elevated AFP, particularly with steadily rising blood levels, will either most likely develop liver cancer or actually already have an undiscovered liver cancer.

An AFP greater than 500 ng/ml is very suggestive of liver cancer. In fact, the blood level of AFP loosely relates to (correlates with) the aggressiveness of the liver cancer. Finally, in patients with liver cancer and abnormal AFP levels, the AFP may be used as a marker of response to treatment. For example, an elevated AFP is expected to fall to normal in a patient whose liver cancer is successfully removed surgically (resected). People with higher AFP levels generally do not live as long as those with lower AFP levels.

There are a number of other liver cancer tumor markers that currently are research tools and not generally available. These include des-gamma-carboxyprothrombin (DCP), a variant of the gamma-glutamyltransferase enzymes, and variants of other enzymes (for example, alpha-L-fucosidase), which are produced by normal liver cells. (Enzymes are proteins that speed up biochemical reactions.) Potentially, these blood tests, used in conjunction with AFP, could be very helpful in diagnosing more cases of liver cancer than with AFP alone.

Imaging studies

Imaging studies play a very important role in the diagnosis of liver cancer. A good study can provide information as to the size of the tumor, the number of tumors, and whether the tumor has involved major blood vessels locally or spread outside of the liver. There are several types of studies, each having its merits and disadvantages. In practice, several studies combined often complement each other. On the other hand, a plain X-ray is not very helpful, and therefore, is not routinely done in the diagnostic work-up of liver cancer. Further, there is no practical role for nuclear medicine scans of the liver and spleen in the workup for liver cancer. Such scans are not very sensitive and they provide no additional information beyond that provided by the other (ultrasound, CT, and MRI) scans.

Ultrasound examination is usually the first study ordered if liver cancer is suspected in a patient. The accuracy of an ultrasound depends very much on the technician and radiologist who perform the study (operator dependent). Studies from Japan and Taiwan report that ultrasound is the most sensitive imaging study for diagnosing and characterizing liver cancer. But in these studies, highly experienced individuals performed the scans and spent up to one hour scanning each patient suspected of having liver cancer. An ultrasound has the advantages of not requiring intravenous contrast material and not involving radiation. Moreover, the price of an ultrasound is quite low as compared to the other types of scans.

Computerized axial tomography (CT scan) is a very common study used in the U.S. for the workup of tumors in the liver. The ideal CT study is a multi-phase, spiral CT scan using oral and intravenous contrast material. Pictures are taken in three phases:

  • Without intravenous contrast
  • With intravenous contrast (enhanced imaging) that highlights the arterial system (arterial phase)
  • When the contrast is in the venous phase

The pictures are taken at very frequent intervals (thin slices) as the body is moved through the CT scanner. Many radiologists use a specific protocol that determines how the contrast is infused in relation to how the pictures are taken. Therefore, CT is much less operator-dependent than is ultrasound. However, CT is considerably more expensive. Furthermore, CT requires the use of contrast material, which has the potential risks of an allergic reaction and adverse effects on kidney function.

There are several variations to CT scanning. For example, in a CT angiogram, which is a highly invasive (enters a part of the body) study, intravenous contrast is selectively infused through the hepatic artery (artery to the liver). The purpose is to highlight the vessels for better visualization of them by the CT scan. Also, in Japan, an oily contrast material called Lipiodol, which is selectively taken up by liver cancer cells, has been used with CT. The purpose of this approach is to improve the sensitivity of the scan. That is to say, the goal is to increase the percentage of abnormal CT scans in patients who have liver cancer.

Magnetic resonance imaging (MRI) can provide very clear images of the body. Its advantage over CT is that MRI can provide sectional views of the body in different planes. The technology has evolved to the point that the newer MRIs can actually reconstruct images of the biliary tree (bile ducts and gallbladder) and of the arteries and veins of the liver. (The biliary tree transports bile from the liver to the duodenum, the first part of the intestine.) MRI studies can be made even more sensitive by using intravenous contrast material (for example, gadolinium).

MRI scans are expensive and there is tremendous variability in the quality of the images. The quality depends on the age of the machine and the ability of the patients to hold their breath for up to 15 to 20 seconds at a time. Furthermore, many patients, because of claustrophobia, cannot tolerate being in the MRI scanner. However, the current open MRI scanners generally do not provide as high quality images as the closed scanners do. MRI sometimes finds lesions that are smaller than can be seen on a CT scan and can tell the radiologist more about the blood vessel (vascular) characteristics of the tumor; more importantly, there is no radiation risk, which becomes important if the screening test is to be repeated many times over a person's lifetime.

Advances in ultrasound, CT, and MRI technology have almost eliminated the need for angiography. An angiography procedure involves inserting a catheter into the femoral artery (in the groin) through the aorta, and into the hepatic artery, the artery that supplies blood to the liver. Contrast material is then injected, and X-ray pictures of the arterial blood supply to the liver are taken. An angiogram of liver cancer shows a characteristic blush that is produced by newly formed abnormal small arteries that feed the tumor (neovascularization).

Another potential test used for many other cancers is a PET (positron emission tomography) scan, which involves the injection of radioactive sugar to light up actively growing cells, as in cancers. However, this is not very useful in liver cancer.

What, then, is the best imaging study for diagnosing liver cancer? There is no simple answer. Many factors need to be taken into consideration. For example, is the diagnosis of liver cancer known or is the scan being done for screening? What is the expertise of doctors in the patient's area? What is the quality of the different scanners at a particular facility? Are there economic considerations? Does the patient have any other conditions that need to be considered, such as claustrophobia or kidney impairment? Does the patient have any hardware, for example, a pacemaker or metal prosthetic device? (The hardware would make doing an MRI impossible.)

If you live in Japan or Taiwan and have access to a radiologist or hepatologist with expertise in ultrasound, then it may be as good as a CT scan. Ultrasound is also the most practical (easier and cheaper) for regular screening (surveillance). In North America, a multiphase spiral CT scan is probably the most accurate type of scan. However, for patients with impaired renal function or who have access to a state-of-the-art MRI scanner, the MRI may be the diagnostic scan of choice. Finally, keep in mind that the technology of ultrasound, CT, and MRI is ever evolving with the development of better machines and the use of special contrast materials to further characterize the tumors.

What are the population characteristics (epidemiology) of liver cancer?

In the U.S., the highest frequency of liver cancer occurs in immigrants from Asian countries, where liver cancer is common. The frequency of liver cancer among Caucasians is the lowest, whereas among African-Americans and Hispanics, it is intermediate. The frequency of liver cancer is high among Asians because liver cancer is closely linked to chronic hepatitis B infection. This is especially so in individuals who have been infected with chronic hepatitis B for most of their lives (it is usually a childhood disease in Asia). If you take a world map depicting the frequency of chronic hepatitis B infection, you can easily superimpose that map on a map showing the frequency of liver cancer. On the other hand, in Japan, North America and Europe, hepatitis C infection is a much more common cause; alcohol abuse is also an important contributing factor. All of these diseases cause continual damage to the liver, which can result in severe scarring (cirrhosis) that then can lead to cancer.

In areas where liver cancer is more common and associated with hepatitis B, the cancer usually develops in people in their 30s and 40s, as opposed to other areas of the world, where they are in their 60s and 70s. This is because it generally takes about 30 years of chronic damage to the liver before the cancer grows large enough to become obvious. Men are much more likely than women to have liver cancer, especially if they have hepatitis and cirrhosis. Regardless of the cause, patients with a history of alcohol abuse as well are much sicker when they initially develop the cancer. In North America, up to one-quarter of people with liver cancer have no obvious risk factors; they are generally healthier and do much better with treatment.

What are liver cancer causes and risk factors?

Hepatitis B infection

Hepatitis B can be caught from contaminated blood products or used needles or sexual contact but is frequent among Asian children from contamination at birth or even biting among children at play. The role of hepatitis B virus (HBV) infection in causing liver cancer is well established. Several lines of evidence point to this strong association. As noted earlier, the frequency of liver cancer relates to (correlates with) the frequency of chronic hepatitis B virus infection. In addition, the patients with hepatitis B virus who are at greatest risk for liver cancer are men with hepatitis B virus cirrhosis (scarring of the liver) and a family history of liver cancer. Perhaps the most convincing evidence, however, comes from a prospective (looking forward in time) study done in the 1970s in Taiwan involving male government employees over the age of 40. In this study, the investigators found that the risk of developing liver cancer was 200 times higher among employees who had chronic hepatitis B virus as compared to employees without chronic hepatitis B virus infection.

Studies in animals also have provided evidence that hepatitis B virus can cause liver cancer. For example, we have learned that liver cancer develops in other mammals that are naturally infected with viruses related to the hepatitis B virus. Finally, by infecting transgenic mice with certain parts of the hepatitis B virus, scientists caused liver cancer to develop in mice that do not usually develop liver cancer. (Transgenic mice are mice that have been injected with new or foreign genetic material.)

How does chronic hepatitis B virus cause liver cancer? In patients with both chronic hepatitis B virus and liver cancer, the genetic material of hepatitis B virus is frequently found to be part of the genetic material of the cancer cells. It is thought, therefore, that specific regions of the hepatitis B virus genome (genetic code) enter the genetic material of the liver cells. This hepatitis B virus genetic material may then disrupt the normal genetic material in the liver cells, thereby causing the liver cells to become cancerous.

The vast majority of liver cancer that is associated with chronic hepatitis B virus occurs in individuals who have been infected most of their lives. In areas where hepatitis B virus is not always present (endemic) in the community (for example, the U.S.), liver cancer is relatively uncommon. The reason for this is that most of the people with chronic hepatitis B virus in these areas acquired the infection as adults, and very few develop an ongoing (chronic active) infection, which happens as often as 15% of the time in Asia.

Hepatitis C infection

Hepatitis C virus (HCV) infection is more difficult to get than hepatitis B. It usually requires direct contact with infected blood, either from contaminated blood products or needles. HCV is also associated with the development of liver cancer. In fact, in Japan, hepatitis C virus is present in up to 75% of cases of liver cancer. As with hepatitis B virus, the majority of hepatitis C virus patients with liver cancer have associated cirrhosis (liver scarring). In several retrospective-prospective studies (looking backward and forward in time) of the natural history of hepatitis C, the average time to develop liver cancer after exposure to hepatitis C virus was about 28 years. The liver cancer occurred about eight to 10 years after the development of cirrhosis in these patients with hepatitis C. Several prospective European studies report that the annual incidence (occurrence over time) of liver cancer in cirrhotic hepatitis C virus patients ranges from 1.4%-2.5% per year.

In hepatitis C virus patients, the risk factors for developing liver cancer include the presence of cirrhosis, older age, male gender, elevated baseline alpha-fetoprotein level (a blood tumor marker), alcohol use, and co-infection with hepatitis B virus. Some earlier studies suggested that hepatitis C virus genotype 1b (a common genotype in the U.S.) may be a risk factor, but more recent studies do not support this finding.

The way in which hepatitis C virus causes liver cancer is not well understood. Unlike hepatitis B virus, the genetic material of hepatitis C virus is not inserted directly into the genetic material of the liver cells. It is known, however, that cirrhosis from any cause is a risk factor for the development of liver cancer. Therefore, it has been argued that hepatitis C virus, which causes cirrhosis of the liver, is an indirect cause of liver cancer.

On the other hand, there are some chronic hepatitis C virus-infected individuals who have liver cancer without cirrhosis. So, it has been suggested that the core (central) protein of hepatitis C virus is the culprit in the development of liver cancer. The core protein itself (a part of the hepatitis C virus) is thought to impede the natural process of cell death or interfere with the function of a normal tumor suppressor (inhibitor) gene (the p53 gene). The result of these actions is that the liver cells go on living and reproducing without the normal restraints, which is what happens in cancer.

Alcohol

Cirrhosis caused by chronic alcohol consumption is the most common association of liver cancer in the developed world. In fact, at autopsy, as many as half of alcoholics previously unsuspected to have cancer will have early evidence of cancer hidden within the liver. Many of these people are also infected with chronic hepatitis C virus. The usual setting is an individual with alcoholic cirrhosis who has stopped drinking for 10 years and then develops liver cancer. It is somewhat unusual for an actively drinking alcoholic to develop liver cancer. What happens is that when the drinking is stopped, the liver cells try to heal by regenerating (reproducing). It is during this active regeneration that a cancer-producing genetic change (mutation) can occur, which explains the occurrence of liver cancer after the drinking has been stopped.

More importantly, if an alcoholic does not stop drinking, he or she is unlikely to live long enough to develop the cancer. Alcoholics who are actively drinking are more likely to die from non-cancer related complications of alcoholic liver disease (for example, liver failure). Indeed, patients with alcoholic cirrhosis who die of liver cancer are about 10 years older than patients who die of non-cancer causes. Finally, as noted above, alcohol adds to the risk of developing liver cancer in patients with chronic hepatitis C virus or hepatitis B virus infections.

Aflatoxin B1

Aflatoxin B1 is the most potent liver cancer-forming chemical known. It is a product of a mold called Aspergillus flavus, which is found in food that has been stored in a hot and humid environment. This mold is found in such foods as peanuts, rice, soybeans, corn, and wheat. Aflatoxin B1 has been implicated in the development of liver cancer in Southern China and sub-Saharan Africa. It is thought to cause cancer by producing changes (mutations) in the p53 gene. These mutations work by interfering with the gene's important tumor suppressing (inhibiting) functions.

Drugs, medications, and chemicals

There are no medications that cause liver cancer, but female hormones (estrogens) and protein-building (anabolic) steroids are associated with the development of hepatic adenomas. These are benign liver tumors that may have the potential to become malignant (cancerous). Thus, in some individuals, hepatic adenoma can evolve into cancer.

Certain chemicals are associated with other types of cancers found in the liver. For example, thorotrast, a previously used contrast agent for diagnostic imaging studies, caused a cancer of the blood vessels in the liver called hepatic angiosarcoma. Also, vinyl chloride, a compound used in the plastics industry, can cause hepatic angiosarcomas that appear many years after the exposure.

Hemochromatosis

Liver cancer will develop in up to 30% of patients with hereditary hemochromatosis (a disorder in which there is too much iron stored in the body, including in the liver). Patients at the greatest risk are those who develop cirrhosis with their hemochromatosis. Unfortunately, once cirrhosis is established, effective removal of excess iron (the treatment for hemochromatosis) will not reduce the risk of developing liver cancer.

Diabetes and obesity

Over the past decade, the incidence of liver cancer in the United States has risen significantly, paralleling the rise in obesity. Although it is hard to separate the effects of diabetes from obesity on the liver, both conditions can cause chronic damage and accumulation of fat within the liver.. This is a disease called NASH (non-alcoholic steatohepatitis), which is present in up to 5% of North Americans. Fatty liver disease like this causes damage to the individual liver cells and may lead to cirrhosis in some people, thereby increasing the risk of liver cancer. Not only is the chance of developing the cancer enhanced, but patients with diabetes who undergo surgical removal of liver cancer have a higher chance of the cancer returning than do those without diabetes.

 

Cirrhosis

Individuals with most types of cirrhosis of the liver are at an increased risk of developing liver cancer. In addition to the conditions described above (hepatitis B, hepatitis C, alcohol, and hemochromatosis), alpha 1 anti-trypsin deficiency, a hereditary condition that can cause emphysema and cirrhosis, may lead to liver cancer. Liver cancer is also strongly associated with hereditary tyrosinemia, a childhood biochemical abnormality that results in early cirrhosis.

Certain causes of cirrhosis are less frequently associated with liver cancer than are other causes. For example, liver cancer is rarely seen with the cirrhosis in Wilson's disease (abnormal copper metabolism) or primary sclerosing cholangitis (chronic scarring and narrowing of the bile ducts). It used to be thought that liver cancer is rarely found in primary biliary cirrhosis (PBC) as well. Recent studies, however, show that the frequency of liver cancer in PBC is comparable to that in other forms of cirrhosis.

What are liver cancer symptoms and signs?

The initial symptoms (the clinical presentations) of liver cancer are variable. It is becoming much more common for patients to be identified by screening people at high risk for the cancer and finding the cancer before there are any symptoms at all. In countries where liver cancer is very common, the cancer generally is discovered at a very advanced stage of disease for several reasons. For one thing, areas where there is a high frequency of liver cancer are generally developing countries where access to health care is limited. For another, screening examinations for patients at risk for developing liver cancer are not available in these areas. In addition, patients from these regions may actually have more aggressive liver cancer disease. In other words, the tumor usually reaches an advanced stage and causes symptoms more rapidly. In contrast, patients in areas of low liver cancer frequency tend to have liver cancer tumors that progress more slowly and, therefore, remain without symptoms longer.

There are no specific symptoms of liver cancer, and in fact, the earliest signs are usually subtle and can be mistaken for simple worsening of cirrhosis and liver function. Abdominal pain is uncommon with liver cancer and usually signifies a very large tumor or widespread involvement of the liver. Additionally, unexplained weight loss or unexplained fevers are warning signs of liver cancer in patients with cirrhosis. These symptoms are less common in individuals with liver cancer in the U.S. because these patients are usually diagnosed at an earlier stage. However, whenever the overall health of a patient with cirrhosis deteriorates, every effort should be made to look for liver cancer.

A common initial presentation of liver cancer in a patient with compensated cirrhosis (meaning that there are no complications of liver disease) is the sudden onset of a complication. For example, the sudden appearance of ascites (abdominal fluid and swelling), jaundice (yellow color of the skin), or muscle wasting without causative (precipitating) factors (for example, alcohol consumption) suggests the possibility of liver cancer. What's more, the cancer can invade and block the portal vein (a large vein that brings blood to the liver from the intestine and spleen). When this happens, the blood will travel paths of less resistance, such as through esophageal veins. This causes increased pressure in these veins, which results in dilated (widened) veins called esophageal varices. The patient then is at risk for hemorrhage from the rupture of the varices into the gastrointestinal tract. Rarely, the cancer itself can rupture and bleed into the abdominal cavity, resulting in bloody ascites.

On physical examination, an enlarged, sometimes tender, liver is the most common finding. Liver cancers are very vascular (containing many blood vessels) tumors. Thus, increased amounts of blood feed into the hepatic artery (artery to the liver) and cause turbulent blood flow in the artery. The turbulence results in a distinct sound in the liver (hepatic bruit) that can be heard with a stethoscope in about one-quarter to one-half of patients with liver cancer. Any sign of advanced liver disease (for example, ascites, jaundice, or muscle wasting) means a poor prognosis. Rarely, a patient with liver cancer can become suddenly jaundiced when the tumor erodes into the bile duct. The jaundice occurs in this situation because both sloughing of the tumor into the duct and bleeding that clots in the duct can block the duct.

In advanced liver cancer, the tumor can spread locally to neighboring tissues or, through the blood vessels, elsewhere in the body (distant metastasis). Locally, liver cancer can invade the veins that drain the liver (hepatic veins). The tumor can then block these veins, which results in congestion of the liver. The congestion occurs because the blocked veins cannot drain the blood out of the liver. (Normally, the blood in the hepatic veins leaving the liver flows through the inferior vena cava, which is the largest vein that drains into the heart.) In African patients, the tumor frequently blocks the inferior vena cava. Blockage of either the hepatic veins or the inferior vena cava results in a very swollen liver and massive formation of ascites. In some patients, as previously mentioned, the tumor can invade the portal vein and lead to the rupture of esophageal varices.

Regarding distant metastases, liver cancer frequently spreads to the lungs, presumably by way of the bloodstream. Usually, patients do not have symptoms from the lung metastases, which are diagnosed by radiologic (X-ray) studies. Rarely, in very advanced cases, liver cancer can spread to the bone or brain. These are an infrequent problem in many patients who do not live long enough to develop these complications.

What are liver cancer symptoms and signs?

The initial symptoms (the clinical presentations) of liver cancer are variable. It is becoming much more common for patients to be identified by screening people at high risk for the cancer and finding the cancer before there are any symptoms at all. In countries where liver cancer is very common, the cancer generally is discovered at a very advanced stage of disease for several reasons. For one thing, areas where there is a high frequency of liver cancer are generally developing countries where access to health care is limited. For another, screening examinations for patients at risk for developing liver cancer are not available in these areas. In addition, patients from these regions may actually have more aggressive liver cancer disease. In other words, the tumor usually reaches an advanced stage and causes symptoms more rapidly. In contrast, patients in areas of low liver cancer frequency tend to have liver cancer tumors that progress more slowly and, therefore, remain without symptoms longer.

There are no specific symptoms of liver cancer, and in fact, the earliest signs are usually subtle and can be mistaken for simple worsening of cirrhosis and liver function. Abdominal pain is uncommon with liver cancer and usually signifies a very large tumor or widespread involvement of the liver. Additionally, unexplained weight loss or unexplained fevers are warning signs of liver cancer in patients with cirrhosis. These symptoms are less common in individuals with liver cancer in the U.S. because these patients are usually diagnosed at an earlier stage. However, whenever the overall health of a patient with cirrhosis deteriorates, every effort should be made to look for liver cancer.

A common initial presentation of liver cancer in a patient with compensated cirrhosis (meaning that there are no complications of liver disease) is the sudden onset of a complication. For example, the sudden appearance of ascites (abdominal fluid and swelling), jaundice (yellow color of the skin), or muscle wasting without causative (precipitating) factors (for example, alcohol consumption) suggests the possibility of liver cancer. What's more, the cancer can invade and block the portal vein (a large vein that brings blood to the liver from the intestine and spleen). When this happens, the blood will travel paths of less resistance, such as through esophageal veins. This causes increased pressure in these veins, which results in dilated (widened) veins called esophageal varices. The patient then is at risk for hemorrhage from the rupture of the varices into the gastrointestinal tract. Rarely, the cancer itself can rupture and bleed into the abdominal cavity, resulting in bloody ascites.

On physical examination, an enlarged, sometimes tender, liver is the most common finding. Liver cancers are very vascular (containing many blood vessels) tumors. Thus, increased amounts of blood feed into the hepatic artery (artery to the liver) and cause turbulent blood flow in the artery. The turbulence results in a distinct sound in the liver (hepatic bruit) that can be heard with a stethoscope in about one-quarter to one-half of patients with liver cancer. Any sign of advanced liver disease (for example, ascites, jaundice, or muscle wasting) means a poor prognosis. Rarely, a patient with liver cancer can become suddenly jaundiced when the tumor erodes into the bile duct. The jaundice occurs in this situation because both sloughing of the tumor into the duct and bleeding that clots in the duct can block the duct.

In advanced liver cancer, the tumor can spread locally to neighboring tissues or, through the blood vessels, elsewhere in the body (distant metastasis). Locally, liver cancer can invade the veins that drain the liver (hepatic veins). The tumor can then block these veins, which results in congestion of the liver. The congestion occurs because the blocked veins cannot drain the blood out of the liver. (Normally, the blood in the hepatic veins leaving the liver flows through the inferior vena cava, which is the largest vein that drains into the heart.) In African patients, the tumor frequently blocks the inferior vena cava. Blockage of either the hepatic veins or the inferior vena cava results in a very swollen liver and massive formation of ascites. In some patients, as previously mentioned, the tumor can invade the portal vein and lead to the rupture of esophageal varices.

Regarding distant metastases, liver cancer frequently spreads to the lungs, presumably by way of the bloodstream. Usually, patients do not have symptoms from the lung metastases, which are diagnosed by radiologic (X-ray) studies. Rarely, in very advanced cases, liver cancer can spread to the bone or brain. These are an infrequent problem in many patients who do not live long enough to develop these complications.

How is liver cancer diagnosed?

Blood tests

Liver cancer is not diagnosed by routine blood tests, including a standard panel of liver tests. This is why the diagnosis of liver cancer depends so much on the vigilance of the physician screening with a tumor marker (alpha-fetoprotein) in the blood and radiological imaging studies. Since most patients with liver cancer have associated liver disease (cirrhosis), their liver blood tests may not be normal to begin with. If these blood tests become abnormal or worsen due to liver cancer, this usually signifies extensive cancerous involvement of the liver. At that time, any medical or surgical treatment may be too late.

Sometimes, however, other abnormal blood tests can indicate the presence of liver cancer. Remember that each cell type in the body contains the full complement of genetic information. What differentiates one cell type from another is the particular set of genes that are turned on or off in that cell. When cells become cancerous, certain of the cell's genes that were turned off may become turned on. Thus, in liver cancer, the cancerous liver cells may take on the characteristics of other types of cells. For example, liver cancer cells sometimes can produce hormones that are ordinarily produced in other body systems. These hormones then can cause certain abnormal blood tests, such as a high red blood count (erythrocytosis), low blood sugar (hypoglycemia) and high blood calcium (hypercalcemia).

Another abnormal blood test, high serum cholesterol (hypercholesterolemia), is seen in up to 10% of patients from Africa with liver cancer. The high cholesterol occurs because the liver cancer cells are not able to turn off (inhibit) their production of cholesterol. (Normal cells are able to turn off their production of cholesterol.)

There is no reliable or accurate screening blood test for liver cancer. The most widely used biochemical blood test is alpha-fetoprotein (AFP), which is a protein normally made by the immature liver cells in the fetus. At birth, infants have relatively high levels of AFP, which fall to normal adult levels by the first year of life. Also, pregnant women carrying babies with neural tube defects may have high levels of AFP. (A neural tube defect is an abnormal fetal brain or spinal cord that is caused by folic acid deficiency during pregnancy.)

In adults, high blood levels (over 500 nanograms/milliliter) of AFP are seen in only three situations:

  • Liver cancer
  • Germ cell tumors (cancer of the testes and ovaries)
  • Metastatic cancer in the liver (originating in other organs)

Several assays (tests) for measuring AFP are available. Generally, normal levels of AFP are below 10 ng/ml. Moderate levels of AFP (even almost up to 500 ng/ml) can be seen in patients with chronic hepatitis. Moreover, many patients with various types of acute and chronic liver diseases without documentable liver cancer can have mild or even moderate elevations of AFP.

The sensitivity of AFP for liver cancer is about 60%. In other words, an elevated AFP blood test is seen in about 60% of liver cancer patients. That leaves 40% of patients with liver cancer who have normal AFP levels. Therefore, a normal AFP does not exclude liver cancer. Also, as noted above, an abnormal AFP does not mean that a patient has liver cancer. It is important to note, however, that patients with cirrhosis and an abnormal AFP, despite having no documentable liver cancer, still are at very high risk of developing liver cancer. Thus, any patient with cirrhosis and an elevated AFP, particularly with steadily rising blood levels, will either most likely develop liver cancer or actually already have an undiscovered liver cancer.

An AFP greater than 500 ng/ml is very suggestive of liver cancer. In fact, the blood level of AFP loosely relates to (correlates with) the aggressiveness of the liver cancer. Finally, in patients with liver cancer and abnormal AFP levels, the AFP may be used as a marker of response to treatment. For example, an elevated AFP is expected to fall to normal in a patient whose liver cancer is successfully removed surgically (resected). People with higher AFP levels generally do not live as long as those with lower AFP levels.

There are a number of other liver cancer tumor markers that currently are research tools and not generally available. These include des-gamma-carboxyprothrombin (DCP), a variant of the gamma-glutamyltransferase enzymes, and variants of other enzymes (for example, alpha-L-fucosidase), which are produced by normal liver cells. (Enzymes are proteins that speed up biochemical reactions.) Potentially, these blood tests, used in conjunction with AFP, could be very helpful in diagnosing more cases of liver cancer than with AFP alone.

Imaging studies

Imaging studies play a very important role in the diagnosis of liver cancer. A good study can provide information as to the size of the tumor, the number of tumors, and whether the tumor has involved major blood vessels locally or spread outside of the liver. There are several types of studies, each having its merits and disadvantages. In practice, several studies combined often complement each other. On the other hand, a plain X-ray is not very helpful, and therefore, is not routinely done in the diagnostic work-up of liver cancer. Further, there is no practical role for nuclear medicine scans of the liver and spleen in the workup for liver cancer. Such scans are not very sensitive and they provide no additional information beyond that provided by the other (ultrasound, CT, and MRI) scans.

Ultrasound examination is usually the first study ordered if liver cancer is suspected in a patient. The accuracy of an ultrasound depends very much on the technician and radiologist who perform the study (operator dependent). Studies from Japan and Taiwan report that ultrasound is the most sensitive imaging study for diagnosing and characterizing liver cancer. But in these studies, highly experienced individuals performed the scans and spent up to one hour scanning each patient suspected of having liver cancer. An ultrasound has the advantages of not requiring intravenous contrast material and not involving radiation. Moreover, the price of an ultrasound is quite low as compared to the other types of scans.

Computerized axial tomography (CT scan) is a very common study used in the U.S. for the workup of tumors in the liver. The ideal CT study is a multi-phase, spiral CT scan using oral and intravenous contrast material. Pictures are taken in three phases:

  • Without intravenous contrast
  • With intravenous contrast (enhanced imaging) that highlights the arterial system (arterial phase)
  • When the contrast is in the venous phase

The pictures are taken at very frequent intervals (thin slices) as the body is moved through the CT scanner. Many radiologists use a specific protocol that determines how the contrast is infused in relation to how the pictures are taken. Therefore, CT is much less operator-dependent than is ultrasound. However, CT is considerably more expensive. Furthermore, CT requires the use of contrast material, which has the potential risks of an allergic reaction and adverse effects on kidney function.

There are several variations to CT scanning. For example, in a CT angiogram, which is a highly invasive (enters a part of the body) study, intravenous contrast is selectively infused through the hepatic artery (artery to the liver). The purpose is to highlight the vessels for better visualization of them by the CT scan. Also, in Japan, an oily contrast material called Lipiodol, which is selectively taken up by liver cancer cells, has been used with CT. The purpose of this approach is to improve the sensitivity of the scan. That is to say, the goal is to increase the percentage of abnormal CT scans in patients who have liver cancer.

Magnetic resonance imaging (MRI) can provide very clear images of the body. Its advantage over CT is that MRI can provide sectional views of the body in different planes. The technology has evolved to the point that the newer MRIs can actually reconstruct images of the biliary tree (bile ducts and gallbladder) and of the arteries and veins of the liver. (The biliary tree transports bile from the liver to the duodenum, the first part of the intestine.) MRI studies can be made even more sensitive by using intravenous contrast material (for example, gadolinium).

MRI scans are expensive and there is tremendous variability in the quality of the images. The quality depends on the age of the machine and the ability of the patients to hold their breath for up to 15 to 20 seconds at a time. Furthermore, many patients, because of claustrophobia, cannot tolerate being in the MRI scanner. However, the current open MRI scanners generally do not provide as high quality images as the closed scanners do. MRI sometimes finds lesions that are smaller than can be seen on a CT scan and can tell the radiologist more about the blood vessel (vascular) characteristics of the tumor; more importantly, there is no radiation risk, which becomes important if the screening test is to be repeated many times over a person's lifetime.

Advances in ultrasound, CT, and MRI technology have almost eliminated the need for angiography. An angiography procedure involves inserting a catheter into the femoral artery (in the groin) through the aorta, and into the hepatic artery, the artery that supplies blood to the liver. Contrast material is then injected, and X-ray pictures of the arterial blood supply to the liver are taken. An angiogram of liver cancer shows a characteristic blush that is produced by newly formed abnormal small arteries that feed the tumor (neovascularization).

Another potential test used for many other cancers is a PET (positron emission tomography) scan, which involves the injection of radioactive sugar to light up actively growing cells, as in cancers. However, this is not very useful in liver cancer.

What, then, is the best imaging study for diagnosing liver cancer? There is no simple answer. Many factors need to be taken into consideration. For example, is the diagnosis of liver cancer known or is the scan being done for screening? What is the expertise of doctors in the patient's area? What is the quality of the different scanners at a particular facility? Are there economic considerations? Does the patient have any other conditions that need to be considered, such as claustrophobia or kidney impairment? Does the patient have any hardware, for example, a pacemaker or metal prosthetic device? (The hardware would make doing an MRI impossible.)

If you live in Japan or Taiwan and have access to a radiologist or hepatologist with expertise in ultrasound, then it may be as good as a CT scan. Ultrasound is also the most practical (easier and cheaper) for regular screening (surveillance). In North America, a multiphase spiral CT scan is probably the most accurate type of scan. However, for patients with impaired renal function or who have access to a state-of-the-art MRI scanner, the MRI may be the diagnostic scan of choice. Finally, keep in mind that the technology of ultrasound, CT, and MRI is ever evolving with the development of better machines and the use of special contrast materials to further characterize the tumors.

Liver biopsy or aspiration

In theory, a definitive diagnosis of liver cancer is always based on microscopic (histological) confirmation. However, some liver cancers are well differentiated, which means they are made up of nearly fully developed, mature liver cells (hepatocytes). Therefore, these cancers can look very similar to non-cancerous liver tissue under a microscope. Moreover, not all pathologists are trained to recognize the subtle differences between well-differentiated liver cancer and normal liver tissue. Also, some pathologists can mistake liver cancer for adenocarcinoma in the liver. An adenocarcinoma is a different type of cancer, and as previously mentioned, it originates from outside of the liver. Most importantly, a metastatic adenocarcinoma would be treated differently from a primary liver cancer (liver cancer). Therefore, all of this considered, it is important that an expert liver pathologist review the tissue slides of liver tumors in questionable situations. New advances in immunohistochemistry (staining the microscopic cells with proteins that identify cell types very specifically) have helped to be able to tell the difference among cell and cancer types more reliably.

Tissue can be sampled with a very thin needle. This technique is called fine needle aspiration. When a larger needle is used to obtain a core of tissue, the technique is called a biopsy. Generally, radiologists, using ultrasound or CT scans to guide the placement of the needle, perform the biopsies or fine needle aspirations. The most common risk of the aspiration or biopsy is bleeding, especially because liver cancer is a tumor that is very vascular (contains many blood vessels). Extremely rarely, new foci (small areas) of tumor can be seeded (planted) from the tumor by the needle into the liver along the needle track.

The aspiration procedure is safer than a biopsy with less risk for bleeding. However, interpretation of the specimen obtained by aspiration is more difficult because often only a cluster of cells is available for evaluation. Thus, a fine needle aspiration is not generally recommended. Moreover, a core of tissue obtained with a biopsy needle is more ideal for a definitive diagnosis because the architecture of the tissue is preserved. The point is that sometimes a precise diagnosis can be important clinically. For example, some studies have shown that the degree of differentiation of the tumor may predict the patient's outcome (prognosis). That is to say, the more differentiated (resembling normal liver cells) the tumor is, the better the prognosis.

All of that said, in many instances, there is probably no need for a tissue diagnosis by biopsy or aspiration. If a patient has a risk factor for liver cancer (for example, cirrhosis, chronic hepatitis B, or chronic hepatitis C) and a significantly elevated alpha-fetoprotein blood level, the doctor can be almost certain that the patient has liver cancer without doing a biopsy. Moreover, recent advances in MRI interpretation can identify small liver cancers as such with an extremely high degree of probability. However, recent understanding of gene variations in some liver cancers is beginning to be useful in helping to decide what kind of therapy might be best for an individual patient. Therefore, the patient and physician should always ask two questions before deciding on doing a liver biopsy:

    1. Is this tumor most likely a liver cancer?

    2. Will the biopsy findings change the management of the patient?

If the answer to both questions is yes, then the biopsy should be done. Finally, there are two other situations related to liver cancer in which a biopsy may be considered. The first is to characterize a liver abnormality (for example, a possible tumor) seen by imaging in the absence of risk factors for liver cancer or elevated alpha-fetoprotein. The second is to determine the extent of disease when there are multiple areas of abnormalities (possibly tumors) seen by imaging in the liver.

Overall, no blanket recommendation can be given regarding the need for liver biopsy or aspiration. The decision has to be made on an individual basis, depending on the treatment options and the expertise of the medical and surgical teams. The truth is, biopsies are not always definitive; people with cirrhosis have many small nodules in their livers, and while one might be cancerous, others are not. Occasionally, people have to undergo several biopsies over many months before a definite diagnosis can be made.

What is the natural history of liver cancer?

The natural history of liver cancer depends on the stage of the tumor and the severity of associated liver disease (for example, cirrhosis) at the time of diagnosis. For example, a patient with a 1 cm tumor with no cirrhosis has a greater than 50% chance of surviving three years, even without treatment. In contrast, a patient with multiple tumors involving both lobes of the liver (multicentric tumors) with decompensated cirrhosis (signs of liver failure) is unlikely to survive more than six months, even with treatment.

What are the predictors of a poor outcome? Our knowledge of the prognosis is based on studying many patients with liver cancer, separating out their clinical characteristics, and relating them to the outcome. Grouped in various categories, the unfavorable clinical findings include the following:

  • Population characteristics (demographics): male gender, older age, or alcohol consumption

     

  • Symptoms: weight loss or decreased appetite
  • Signs of impaired liver function: jaundice, ascites, or encephalopathy (altered mental state)

     

  • Blood tests: elevated liver tests (bilirubin or transaminase), reduced albumin, elevated AFP, elevated blood urea nitrogen (BUN), or low serum sodium
  • Staging of tumor (based on imaging or surgical findings): more than one tumor, tumor over 3 cm (almost 1¼ inches), tumor invasion of local blood vessels (portal and/or hepatic vein), tumor spread outside of the liver (to lymph nodes or other organs)

There are various systems for staging liver cancer. Some systems look at clinical findings while others rely solely on pathological (tumor) characteristics. It makes the most sense to use a system that incorporates a combination of clinical and pathological elements. In any event, it is important to stage the cancer because staging can provide guidelines not only for predicting outcome (prognosis) but also for decisions regarding treatment.

The doubling time for a cancer is the time it takes for the tumor to double in size. For liver cancer, the doubling time is quite variable, ranging from one month to 18 months. This kind of variability tells us that every patient with liver cancer is unique. Therefore, an assessment of the natural history and the evaluation of different treatments are very difficult. Nevertheless, in patients with a solitary liver cancer that is less than 3 cm, with no treatment, we can expect that 90% of the patients will survive (live) for one year, 50% for three years, and 20% for five years. In patients with more advanced disease, we can expect that 30% will survive for one year, 8% for three years, and none for five years.

What are the treatment options for liver cancer?

The treatment options are dictated by the stage of liver cancer and the overall condition of the patient. The only proven cure for liver cancer is liver transplantation for a solitary, small (<3cm) tumor. Now, many physicians may dispute this statement. They would argue that a small tumor can be surgically removed (partial hepatic resection) without the need for a liver transplantation. Moreover, they may claim that the one- and three-year survival rates for resection are perhaps comparable to those for liver transplantation.

However, most patients with liver cancer also have cirrhosis of the liver and would not tolerate liver resection surgery. In fact, in the United States, only 8% of people with liver cancer are able to undergo surgery. But, they probably could tolerate the transplantation operation, which involves removal of the patient's entire diseased liver just prior to transplanting a donor liver. Furthermore, many patients who undergo hepatic resections will develop a recurrence of liver cancer elsewhere in the liver within several years. In fact, some experts believe that once a liver develops liver cancer, there is a tendency for that liver to develop other tumors at the same time (synchronous multicentric occurrence) or at a later time (metachronous multicentric occurrence). This makes sense, since whatever in the liver caused the cancer to develop in the first place is still there. Realistically, though, donor livers are a very limited resource, so many patients who need a transplantation will never receive one.

The results of the various medical treatments available (see below; chemotherapy, chemoembolization, ablation, and proton beam therapy) remain disappointing. Moreover, for reasons noted earlier (primarily the variability in natural history), there have been no systematic study comparisons of the different treatments. As a result, individual patients will find that the various treatment options available to them depend largely on the local expertise.

How do we know if a particular treatment worked for a particular patient? Well, hopefully, the patient will feel better. However, a clinical response to treatment is usually defined more objectively. Thus, a response is defined as a decrease in the size of the tumor on imaging studies along with a reduction of the alpha-fetoprotein in the blood if the level was elevated prior to treatment.

One thing to keep in mind is that in a relatively healthy patient there is never just one answer to this question. Usually, people go through multiple different treatments sequentially. Something is chosen as the best place to start, and then other treatments are tried once the previous one stops working. The idea is to make sure someone is healthy enough to be able to try another therapy if they still desire it.

Chemotherapy and biotherapy

Systemic (entire body) chemotherapy

The most commonly used systemic chemotherapeutic agents are doxorubicin (Adriamycin) and 5-fluorouracil (5 FU). These drugs are used together or in combination with new experimental agents. These drugs are quite toxic and results have been disappointing. A few studies suggest some benefit with tamoxifen (Nolvadex) but more studies show no advantage at all. Octreotide (Sandostatin) given as an injection was shown in one study to slow down the progression of large liver cancer tumors, but so far, no other studies have confirmed this benefit. Recent studies suggest that combinations of drugs such as gemcitabine, cisplatin, or oxaliplatin can shrink the tumors in some people.

 

Biotherapy

One of the most important recent advances in the filed of treating liver cancer has been the understanding of the genetic makeup of these tumors, as well as the cancer cells' reliance upon blood vessels and molecules produced in the body that can help them grow. Many cancers grow by causing the development and recruitment of tiny new blood vessels to feed the tumor and enable it to spread to other parts of the body. This is called angiogenesis, and this has become a very hot field in oncology and pharmaceutical development over the past decade. One drug, bevacizumab, has been approved for use in many cancers such as colon, lung, and breast, and is known to help standard chemotherapy shrink and control other types of cancer. It might be helpful in liver cancer as well, and similar drugs are still being investigated.

The best success so far has been with the oral drug sorafenib (Nexavar). This is a pill designed to block several components of the angiogenesis pathway, as well as other growth signals for individual cancer cells. Large studies have shown that patients taking this drug for advanced liver cancer live significantly longer than those taking a placebo pill. Although the difference was not very long (three months) and is shorter in sicker patients, this is still the first study in decades to show that there is a reliable way to slow down this cancer's growth and to prolong patients' lives. Sorafenib is thus the first, and so far, only, drug to be approved by the U.S. FDA to treat liver cancer. Current studies are under way to see if the drug works better when combined with other types of chemotherapy.

 

Hepatic arterial infusion of chemotherapy

The normal liver gets its blood supply from two sources: the portal vein (about 70%) and the hepatic artery (30%). However, liver cancer gets its blood exclusively from the hepatic artery. Making use of this fact, investigators have delivered chemotherapy agents selectively through the hepatic artery directly to the tumor. The theoretical advantage is that higher concentrations of the agents can be delivered to the tumors without subjecting the patients to the systemic toxicity of the agents.

In reality, however, much of the chemotherapeutic agents does end up in the rest of the body. Therefore, selective intra-arterial chemotherapy can cause the usual systemic (body-wide) side effects. In addition, this treatment can result in some regional side effects, such as inflammation of the gallbladder (cholecystitis), intestinal and stomach ulcers, and inflammation of the pancreas (pancreatitis). Liver cancer patients with advanced cirrhosis may develop liver failure after this treatment. Well then, what is the benefit of intra-arterial chemotherapy? The bottom line is that fewer than 50% of patients will experience a reduction in tumor size.

An interventional radiologist (one who does therapeutic procedures) usually carries out this procedure. The radiologist must work closely with an oncologist (cancer specialist), who determines the amount of chemotherapy that the patient receives at each session. Some patients may undergo repeat sessions at six- to 12-week intervals. This procedure is done with the help of fluoroscopy (a type of X-ray) imaging. A catheter (long, narrow tube) is inserted into the femoral artery in the groin and is threaded into the aorta (the main artery of the body). From the aorta, the catheter is advanced into the hepatic artery. Once the branches of the hepatic artery that feed the liver cancer are identified, the chemotherapy is infused. The whole procedure takes one to two hours, and then the catheter is removed.

The patient generally stays in the hospital overnight for observation. A sandbag is placed over the groin to compress the area where the catheter was inserted into the femoral artery. The nurses periodically check for signs of bleeding from the femoral artery puncture. They also check for the pulse in the foot on the side of the catheter insertion to be sure that the femoral artery is not blocked as a result of the procedure. (Blockage would be signaled by the absence of a pulse.)

Generally, the liver enzyme tests increase (get worse) during the two to three days after the procedure. This worsening of the liver tests is actually due to death of the tumor (and some non-tumor) cells. The patient may experience some post-procedure abdominal pain and low-grade fever. However, severe abdominal pain and vomiting suggest that a more serious complication has developed. Imaging studies of the liver are repeated in six to 12 weeks to assess the size of the tumor in response to the treatment. For more, please read the chemotherapy article.

Chemoembolization (trans-arterial chemoembolization or TACE)

This technique takes advantage of the fact that liver cancer is a very vascular (contains many blood vessels) tumor and gets its blood supply exclusively from the branches of the hepatic artery. This procedure is similar to intra-arterial infusion of chemotherapy. But in TACE, there is the additional step of blocking (embolizing) the small blood vessels with different types of compounds, such as gel foam or even small metal coils. Thus, TACE has the advantages of exposing the tumor to high concentrations of chemotherapy and confining the agents locally since they are not carried away by the bloodstream. At the same time, this technique deprives the tumor of its needed blood supply, which can result in the damage or death of the tumor cells. In fact, TACE originally grew out of the observation that patients undergoing intraarterial chemotherapy who accidentally had their catheters clotted off did better!

By relying upon blocking blood flow to the tumor, TACE will also cause some damage to the surrounding liver, and this is its primary limitation. Although the tumor may shrink up to 70% of the time, the associated liver damage can cause pain, fever, nausea, infection, fluid accumulation, and rarely, death. Nonetheless, TACE has been shown to be better than no treatment in several studies. There are newer techniques for delivering chemotherapy intra-arterially and blocking the blood vessels at the same time (microscopic drug-eluting beads); while the side effects seem to be less, it is not clear whether this method is more effective.

While TACE is not suitable for people with very sick livers or who are otherwise medically compromised, it is one of the most widely used techniques to control liver cancer around the world. It is important to realize, though, that it is not a cure and can only control the cancer for a limited time. However, in many individual patients appropriately chosen by their physicians, TACE can help to keep them alive longer.

Radioembolization

Radioembolization (also known as SIRT, or selective internal radiotherapy) involves attaching a radioactive molecule (called Yttrium) to tiny glass beads. These are then injected directly into the blood vessels feeding the cancers (as in TACE). The radiation particles can then kill tumor cells within a distance of 2.5 mm from them, so that any part of the cancer fed by tiny blood vessels will be exposed to the radiation. It seems to have fewer complications than TACE, although severe liver damage is still possible. The effectiveness is probably comparable to chemoembolization.

Ablation techniques

Ablation refers to any method that physically destroys a tumor, and is generally only applicable to situations in which there is only one, two, or sometimes three individual cancers in a liver. When there are more than that, it is not possible to reach every one on its own, so a different method such as systemic chemotherapy or TACE must be used.

Radiofrequency ablation (RFA) therapy

In the U.S., RFA therapy has become the ablation (tissue destruction) therapy of choice among surgeons. The surgeon can perform this procedure laparoscopically (through small holes in the abdomen) or during open exploration of the abdomen. More commonly, the procedure is done without opening the abdomen by just using ultrasound or CT scan for visual guidance.

In RFA, heat is generated locally by high frequency radio waves that are channeled into metal electrodes. A probe is inserted into the center of the tumor and the non-insulated electrodes, which are shaped like prongs, are projected into the tumor. The local heat that is generated melts the tissue (coagulative necrosis) that is adjacent to the probe. The probe is left in place for about 10-15 minutes. The whole procedure is monitored visually by ultrasound scanning. The ideal size of a liver cancer tumor for RFA is less than 5 cm. Larger tumors may require more than one session. This treatment should be viewed as palliative (providing some relief), not curative.

Percutaneous ethanol (alcohol) injection

In this technique, which has been generally replaced by RFA, pure alcohol is injected into the tumor through a very thin needle with the help of ultrasound or CT visual guidance. Alcohol induces tumor destruction by drawing water out of tumor cells (dehydrating them) and thereby altering (denaturing) the structure of cellular proteins. It may take up to five or six sessions of injections to completely destroy the cancer.

The most common side effect of alcohol injection is leakage of alcohol onto the surface of the liver and into the abdominal cavity, thereby causing pain and fever. It is important that the location of the tumor relative to the adjacent blood vessels and bile ducts is clearly identified. The reason for needing to locate these structures is to avoid injuring them during the procedure and causing bleeding, bile duct inflammation, or bile leakage.

Cryoablation

Cryoablation is similar to RFA in that a single tumor is identified and then targeted by a radiologist with a needle inserted through the skin directly into the cancer. However, instead of using heat, cryoablation sues a probe filled with liquid nitrogen to freeze the tumor and kill it that way. This is probably as effective as RFA but can be used in some tumor locations where heat might accidentally damage adjacent organs (like when the gallbladder or colon is too close to the tumor).

Stereotactic radiosurgery

Stereotactic radiosurgery (SRS) is a new technique directing radiation (high-powered X-ray beams) directly to the tumor. Previously, radiation could not generally be used for liver cancer, because the normal liver was more sensitive to dying from radiation than the cancer was. SRS uses computer planning and CT scans to model the exact size, shape, and location of the cancer. It then directs the radiation machine, which can move around the patient in all three dimensions, to give many individual beams of radiation designed to converge just on the tumor, thus sparing much of the normal liver from the cumulative high doses. This appears to be very effective against solitary tumors.

 

Proton beam therapy

This technique is able to deliver high doses of radiation to a defined local area. Proton beam therapy is used in the treatment of other solid tumors as well. There are not much data yet regarding the efficacy of this treatment in liver cancer. The ideal patient is one with only a small (<5 cm) solitary lesion. To have this procedure done, the patient actually is fitted with a body cast so that he or she can be placed in the identical position for each session. Therapy is conducted daily for 15 days. Preliminary data from the U.S. suggest similar effectiveness as seen with TACE or ablation therapy. It is not known, however, whether this type of radiation treatment prolongs the life of the patient.

How do these various medical treatment procedures compare to each other?

We really don't know because there are no head-to-head studies comparing chemotherapy, chemoembolization, ablation techniques, and proton beam therapy to each other. Most reports deal with a heterogeneous group of patients who have undergone only one specific treatment procedure or another. Therefore, selection of a treatment option for a particular patient will depend primarily on the expertise of the doctors in the patient's area. Studies are also needed to evaluate combinations of these procedures (for example, proton beam and TACE). Decisions are generally made by a multidisciplinary team of liver cancer specialists who are knowledgeable and expert in all of these techniques, so that the team can choose the best method for an individual patient depending upon overall health and liver function as well as the size, number, and location of the tumors.

Surgery

Surgical options are limited to individuals whose tumors are less than 5 cm and confined to the liver, with no invasion of the blood vessels.

Liver resection

The goal of liver resection is to completely remove the tumor and the appropriate surrounding liver tissue without leaving any tumor behind. This option is limited to patients with one or two small (3 cm or less) tumors and excellent liver function, ideally without associated cirrhosis. As a result of these strict guidelines, in practice, very few patients with liver cancer can undergo liver resection. The biggest concern about resection is that following the operation, the patient can develop liver failure. The liver failure can occur if the remaining portion of the liver is inadequate to provide the necessary support for life. Even in carefully selected patients, about 10% of them are expected to die shortly after surgery, usually as a result of liver failure.

When a portion of a normal liver is removed, the remaining liver can grow back (regenerate) to the original size within one to two weeks. A cirrhotic liver, however, cannot grow back. Therefore, before resection is performed for liver cancer, the non-tumor portion of the liver should be biopsied to determine whether there is associated cirrhosis.

For patients whose tumors are successfully resected, the five-year survival rate is up to 60%. This means that 60% of patients who actually undergo liver resection for liver cancer are expected to live five years. Many of these patients, however, will have a recurrence of liver cancer elsewhere in the liver. Still, this is the procedure of choice for patients without cirrhosis and a solitary tumor who are felt to be medically able to undergo surgery.

Liver transplantation

Liver transplantation has become an accepted treatment for patients with end-stage (advanced) liver disease of various types (for example, chronic hepatitis B and C, alcoholic cirrhosis, primary biliary cirrhosis, and sclerosing cholangitis). Survival rates for these patients without liver cancer are 90% at one year, 80% at three years, and 75% at five years. Moreover, liver transplantation is the best option for patients with tumors that are less than 5 cm in size who also have signs of liver failure. In fact, as one would expect, patients with small cancers (less than 3 cm) and no involvement of the blood vessels do very well. These patients have a less than 10% risk of recurrent liver cancer after transplant. On the other hand, there is a very high risk of recurrence in patients with tumors greater than 5 cm or with involvement of blood vessels. For these reasons, when patients are being evaluated for treatment of liver cancer, every effort should be made to characterize the tumor and look for signs of spread beyond the liver.

There is a severe shortage of organ donors in the U.S. Currently, there are about 18,000 patients on the waiting list for liver transplantation. About 4,000 donated cadaver livers (taken at the time of death) are available per year for patients with the highest priority. This priority goes to patients on the transplant waiting list who have the most severe liver failure. A recent change in distribution rules made liver cancer of under 5 cm a priority, so these people can spend less time on the waiting list. A newer, growing option is live donor transplantation.

The use of a partial liver from a healthy, live donor may provide patients with liver cancer an opportunity to undergo liver transplantation before the tumor becomes too large. This innovation is a very exciting development in the field of liver transplantation.

As a precaution, doing a biopsy or aspiration of liver cancer should probably be avoided in patients considering liver transplantation. The reason to avoid needling the liver is that there is about a 1%-4% risk of seeding (planting) cancer cells from the tumor by the needle into the liver along the needle track. You see, after liver transplantation, patients take powerful anti-rejection medications to prevent the patient's immune system from rejecting the new liver. However, the suppressed immune system can allow new foci (small areas) of cancer cells to multiply rapidly. These new foci of cancer cells would normally be kept at bay by the immune cells of an intact immune system. It now appears that people who do undergo transplantation for liver cancer have a lower chance of having the cancer return if they are first treated with a local method such as chemoembolization. This also helps them to be treated while they are spending time on the transplant waiting list, so that the cancer does not grow while they are waiting.

In summary, liver resection should be reserved for patients with small tumors and normal liver function (no evidence of cirrhosis). Patients with multiple or large tumors should receive palliative therapy with systemic chemotherapy or TACE, provided they do not have signs of severe liver failure. Patients with an early stage of cancer and signs of chronic liver disease should receive palliative treatment with RFA, cryoablation, or TACE and undergo evaluation for liver transplantation.

Is there a role for routine screening for liver cancer?

It makes sense to screen for liver cancer just as we do for colon, cervical, breast, and prostate cancer. However, the difference is that there is, as yet, no cost-effective way of screening for liver cancer. Blood levels of alpha-fetoprotein are normal in up to 50% of patients with small liver cancer; among native Alaskan women who have a high risk of liver cancer, the most common cause of an elevated AFP was pregnancy. Ultrasound scanning, which is noninvasive and very safe, is, as mentioned before, operator-dependent. Therefore, the effectiveness of a screening ultrasound that is done at a small facility can be very suspect.

Even more disappointing is the fact that no study outside of Asia has shown, on a large scale, that early detection of liver cancer saved lives. Why is that? It is because, as already noted, the treatment for liver cancer, except for liver transplantation, is not very effective. Also, keep in mind that patients found with small tumors on screening live longer than patients with larger tumors only because of what is called a "lead time bias." In other words, they seem to liver longer (the bias) only because the cancer was discovered earlier (the lead time), not because of any treatment given.

Nevertheless, strong arguments can be made for routine screening. For example, the discovery of a liver cancer in the early stages allows for the most options for treatment, including liver resection and liver transplantation. Therefore, all patients with cirrhosis, particularly cirrhosis caused by chronic hepatitis B or C, hemochromatosis, and alcohol, as well as some rarer diseases, are usually screened at six- to 12-month intervals with a blood alpha-fetoprotein and an imaging study. I favor alternating between an ultrasound and MRI. Patients with chronically (long duration) elevated alpha-fetoprotein levels warrant more frequent imaging since these patients are at even higher risk of developing liver cancer.

What is fibrolamellar carcinoma?

Fibrolamellar carcinoma is a liver cancer variant that is found in non-cirrhotic livers, usually in younger patients between 20 and 40 years of age. In fact, these patients have no associated liver disease and no risk factors have been identified. The alpha-fetoprotein in these patients is usually normal. The appearance of fibrolamellar carcinoma under the microscope is quite characteristic. That is, broad bands of scar tissue are seen running through the cancerous liver cells. The important thing about fibrolamellar carcinoma is that it has a much better prognosis than the common type of liver cancer. Thus, even with a fairly extensive fibrolamellar carcinoma, a patient can have a successful surgical removal.

What's in the future for the prevention and treatment of liver cancer?

Prevention

Worldwide, the majority of liver cancer is associated with chronic hepatitis B virus infection. Today, however, all newborns are vaccinated against hepatitis B in China and other Asian countries. Therefore, the frequency of chronic hepatitis B virus in future generations will decrease. Eventually, perhaps in three or four generations, hepatitis B virus will be totally eradicated, thereby eliminating the most common risk factor for liver cancer. Studies have already shown a decrease of up to 75% in the incidence of liver cancer in children and teenagers in Hong Kong and even in the United States since routine vaccination was introduced.

Some retrospective (looking back in time) studies suggest that patients with chronic hepatitis C who were treated with interferon were less likely to develop liver cancer than patients who were not treated. Interestingly, in these studies, interferon treatment seemed to provide this benefit, even to patients who had less than an optimal antiviral response to interferon. Still, it remains to be seen whether the risk of developing cirrhosis and liver cancer is significantly decreased in prospectively (looking ahead) followed patients who responded to interferon.

Theoretically, we know that liver cancer should be an almost totally preventable disease. Most of it is caused by infection with hepatitis; this can be reduced (if not eliminated) by treating infected mothers before they give birth, vaccinating all children regardless of where they live, screening the blood supply to avoid infected transfusion, and always using clean needles for any injections. (Many cases of hepatitis C infection are thought to have been from doctors or schools using the same needles for many patients or classroom vaccinations!) Aflatoxin contamination can be eradicated by proper storing of foodstuffs and, in fact, is not a measurable problem in developed countries. Alcohol abuse is difficult to eliminate, but at an individual level, this is a totally avoidable risk factor for liver cancer. Even more difficult is obesity and diabetes, but as with alcohol, personal lifestyle choices will directly lead to the development of this cancer. Therefore, a combination of societal, financial, and political changes around the world could lead to a very substantial decrease in the incidence of this cancer over the next two to three decades.

Treatment

Treatment options for liver cancer have grown exponentially over the past two decades. Using the way the cancer grows -- generally just within the liver, killing the person as it destroys the liver around it -- has led to many effective methods of attacking the cancer directly, through surgery, transplantation, ablation, and chemoembolization. In fact, the chances of someone with liver cancer being alive after just a year are now three times higher than they were 20 years ago, probably just because of the growth in popularity and effectiveness of these local treatment methods. The approval of sorafenib, the first drug shown to prolong lives in liver cancer, heralds a new understanding of the molecular nature of this cancer and has tremendously increased the interest of researchers and pharmaceutical companies in finding a more effective treatment for liver cancer. There is more research going on than ever before for these patients, and everyone should be encouraged to join a clinical trial if possible, to try to get the most advanced treatment available.

Liver Cancer At a Glance
  • Liver cancer is the third most common cancer in the world, and the majority of patients with liver cancer will die within one year as a result of the cancer.
  • In the U.S., patients with associated cirrhosis caused by chronic hepatitis B or C infections, alcohol, obesity or diabetes, and hemochromatosis are at the greatest risk of developing liver cancer.
  • Patients with chronic liver disease (for example, hepatitis C virus, hepatitis B virus, or hemochromatosis) should avoid drinking alcohol, which can further increase their risk of developing cirrhosis and liver cancer.
  • Many patients with liver cancer do not develop symptoms until the advanced stages of the tumor. When the patient does develop symptoms, the prognosis is usually poor.
  • The combination of an imaging study (ultrasound, CT, or MRI scans) and an elevated blood level of alpha-fetoprotein most effectively diagnoses liver cancer.
  • A liver biopsy can make a definitive diagnosis of liver cancer, but the procedure requires an expert liver pathologist and is not necessary for all patients.
  • The natural history of liver cancer is quite variable and depends on the stage of the tumor and the severity of the associated cirrhosis.
  • Medical treatments for liver cancer such as chemotherapy are slowly becoming more effective, although still disappointing. The new drug sorafenib has shown that survival can be prolonged.
  • Ablative and local techniques such as chemoembolization, radioembolization, radiofrequency or cryoablation, and stereotactic radiosurgery can by very useful in controlling individual cancers for an extended time.
  • Surgical resection (removal) of the tumor may be curative for a select group of individuals with liver cancer, specifically for those with small tumors and healthy liver function.
  • For patients with small liver cancer and significant associated liver disease, liver transplantation offers the only chance for cure.
  • This is a disease that should be almost entirely preventable by societal and lifestyle changes.

Additional resources from WebMD Boots UK on Liver Cancer

Previous contributing author and editor:

Medical Author: Tse-Ling Fong, MD
Medical Editor: Paul Oneill, MD, Board Certified Oncology

Liver Disease
(Hepatic Disease)


  • What is liver disease?
  • What are the causes of liver disease?
  • What are the risk factors for liver disease?
  • What are the symptoms of liver disease?
  • When to seek medical care for liver disease
  • How is liver disease diagnosed?
  • What is the treatment for liver disease?
  • What are the complications of liver disease?
  • Can liver disease be prevented?
  • What is the outlook (prognosis) for a person with liver disease?
  • Liver Disease At A Glance
  • Patient Discussions: Liver Disease
  • Find a local Gastroenterologist in your town

What is liver disease?

Liver disease is any disturbance of liver function that causes illness. The liver is responsible for many critical functions within the body and should it become diseased or injured, the loss of those functions can cause significant damage to the body. Liver disease is also referred to as hepatic disease.

Liver disease is a broad term that covers all the potential problems that may occur to cause the liver to fail to perform its designated functions. Usually, more than 75% or three quarters of liver tissue needs to be affected before decrease in function occurs.

The liver the largest solid organ in the body; and is also considered a gland because among its many functions, it makes and secretes bile. The liver is located in the upper right portion of the abdomen protected by the rib cage. It has two main lobes that are made up of tiny lobules. The liver cells have two different sources of blood supply. The hepatic artery supplies oxygen rich blood that is pumped from the heart, while the portal vein supplies nutrients from the intestine and the spleen.

Normally, veins return blood from the body to the heart, but the portal vein allows chemicals from the digestive tract to enter the liver for "detoxification" and filtering prior to entering the general circulation. The portal vein also efficiently delivers the chemicals and proteins that liver cells need to produce the proteins, cholesterol, and glycogen required for normal body activities.

As part of its function, the liver makes bile, a fluid that contains among other substances, water, chemicals, and bile acids (made from stored cholesterol in the liver). Bile is stored in the gallbladder and when food enters the duodenum (the first part of the small intestine), bile is secreted into the duodenum, to aid in digestion of food.

Picture of the Liver

The liver is the only organ in the body that can easily replace damaged cells, but if enough cells are lost, the liver may not be able to meet the needs of the body.

The liver can be considered a factory; and among its many functions include the:

  • production of bile that is required in the digestion of food, in particular fats;
  • conversion of the extra glucose in the body into stored glycogen in liver cells; and  then converting it back into glucose when the need arises;
  • production of blood clotting factors;
  • production of amino acids (the building blocks for making proteins), including those used to help fight infection;
  • the processing and storage iron necessary for red blood cell production;
  • manufacture of cholesterol and other chemicals required for fat transport;
  • conversion of waste products of body metabolism into urea that is excreted in the urine; and
  • metabolization medications into their active ingredient in the body.

Cirrhosis is a term that describes permanent scarring of the liver. Normal liver cells are replaced by scar tissue that cannot perform any liver function.

Acute liver failure may or may not be reversible, meaning that is there is a treatable cause and the liver is able to recover and resume its normal functions.

What are the causes of liver disease?

The liver can be damaged in a variety of ways.

  • Cells can become inflamed (such as in hepatitis: hepar=liver + itis=inflammation).
  • Bile flow can be obstructed (such as in cholestasis: chole=bile + stasis=standing).
  • Cholesterol or triglycerides can accumulate (such as in steatosis; steat=fat + osis=accumulation).
  • Blood flow to the liver may be compromised.
  • Liver tissue can be damaged by chemicals and minerals, or infiltrated by abnormal cells.

Alcohol abuse

Alcohol abuse is the most common cause of liver disease in North America. Alcohol is directly toxic to liver cells and can cause liver inflammation, referred to as alcoholic hepatitis. In chronic alcohol abuse, fatty accumulation (steatosis) occurs in liver cells causing the cells to malfunction.

Cirrhosis

Cirrhosis is a late-stage liver disease. Scarring of the liver and loss of functioning liver cells cause the liver to fail.

Drug-induced liver disease

Liver cells may become temporarily inflamed or permanently damaged by exposure to medications or drugs. Some medications or drugs require an overdose to cause liver injury while others may cause the damage even when taken in the appropriately prescribed dosage.

Taking excess amounts of acetaminophen (Tylenol, Panadol) can cause liver failure that is permanent. This is the reason that warning labels exist on many over-the-counter medications that contain acetaminophen and why prescription narcotic-acetaminophen combination medications (for example, Vicodin, Lortab, Norco, Tylenol #3) limit the numbers of tablets to be taken in a day.

 

Statin medications are commonly prescribed to control elevated blood levels of cholesterol. Even when taken in the appropriately prescribed dose, liver inflammation may occur and can be detected by blood tests that measure liver enzymes. Stopping the medication usually results in return of the liver function to normal.

Niacin is another medication used to control elevated blood levels of cholesterol, but liver inflammation for this medication is related to the dose taken. Similarly, patients with underlying liver disease may be at higher risk of developing liver disease due medications such as niacin.

There are numerous other medications that may cause liver inflammation, most of which will resolve when the medication is stopped. These include antibiotics such as nitrofurantoin (Macrodantin, Furadantin, Macrobid), amoxicillin and clavulanic acid (Augmentin, Augmentin XR), tetracycline (Sumycin), and isoniazid (INH, Nydrazid, Laniazid). Methotrexate (Rheumatrex, Trexall), a drug used to treat autoimmune disorders and cancers, has a variety of side effects including liver inflammation that can lead to cirrhosis. Disulfiram (Antabuse) used to treat alcoholics and can cause liver inflammation.

 

Some herbal remedies and excessive amounts of vitamins can cause hepatitis, cirrhosis and liver failure. Examples include vitamin A, kava kava, ma-huang, and comfrey.

Many mushrooms are poisonous to the liver and eating unidentified mushrooms gathered in the woods can be lethal.

Infectious hepatitis

The term "hepatitis" means inflammation, and liver cells can become inflamed because of infection.

Hepatitis A is a viral infection that is caused primarily through the fecal-oral route when small amounts of infected fecal matter are inadvertently ingested. Hepatitis A causes an acute inflammation of the liver which generally resolves spontaneously. The hepatitis A vaccine can prevent this infection.

Hepatitis B is spread by exposure to body fluids (needles from drug abusers, contaminated blood, and sexual contact) and can cause an acute infection, but can also progress to cause chronic inflammation (chronic hepatitis) that can lead to cirrhosis and liver cancer. The hepatitis B vaccine prevents this infection.

Hepatitis C causes chronic hepatitis. An infected individual may not recall any acute illness. Hepatitis C is spread by exposure to body fluids (needles from drug abusers, contaminated blood, and sexual contact). Chronic hepatitis C may lead to cirrhosis and liver cancer. At present, there is no vaccine against this virus.

Hepatitis D is a virus that requires concomitant infection with hepatitis B to survive, and is spread via body fluid exposure (needles from drug abusers, contaminated blood, and sexual contact).

Hepatitis E is a virus that is spread via contaminated food and water exposure.

Other viruses

Other viruses can also cause liver inflammation or hepatitis as part of the cluster of symptoms. Viral infections with infectious mononucleosis (Epstein Barr virus), adenovirus, and cytomegalovirus can inflame the liver. Non-viral infections such as toxoplasmosis and Rocky Mountain spotted fever are less common causes.

Non-Alcoholic fatty liver disease

Accumulation of fat within the liver can cause gradual decrease in liver function. Also known as nonalcoholic steatohepatitis, fatty liver disease, or NASH.

Hemochromatosis

Hemachromatosis (iron overload) is a metabolic disorder that leads to abnormally elevated iron stores in the body. The excess iron may be found in the tissues of the liver, pancreas, and heart and can lead to inflammation, cirrhosis, liver cancer, and liver failure. Hemachromatosis is an inherited disease.

Wilson's Disease

Wilson's disease is another inherited disease that affects the body's ability to metabolize copper. Wilson's disease may lead to cirrhosis and liver failure.

Gilbert's Disease

In Gilbert's disease, there is an abnormality in bilirubin metabolism in the liver. It is a common disease that affects up to 7% of the North American population. There are no symptoms and it is usually diagnosed incidentally when an elevated bilirubin level is found on routine blood tests. Gilbert's disease is a benign condition and no treatment is necessary.

Cancers

Primary cancers of the liver arise from liver structures and cells. Two examples include hepatocellular carcinoma and cholangiocarcinoma.

Metastatic cancer (secondary cancer of the liver) begins in another organ and spreads to the liver, usually through the blood stream. Common cancers that spread to the liver begin in the lung, breast, large intestine, stomach, and pancreas. Leukemia and Hodgkin's lymphoma may also involve the liver.

Blood flow abnormalities

Budd Chiari syndrome is a disease in which blood clots form in the hepatic vein and prevent blood from leaving the liver. This can increase portal vein pressure and lead to cirrhosis and liver failure. Causes of Budd Chiari syndrome include polycythemia (elevated red blood cell count), inflammatory bowel diseases, sickle cell disease, and pregnancy.

Congestive heart failure, where fluid and blood backs up in the large veins of the body can cause liver swelling and inflammation.

Bile flow abnormalities

Normally, bile flows from the liver into the gallbladder and ultimately into the intestine to help with the digestion of food. If bile flow is obstructed, it can cause inflammation within the liver. Most commonly, gallstones can cause an obstruction of the ducts that drains bile from the liver.

Abnormalities of the opening of the bile duct into the intestine (sphincter of Oddi) can lead to abnormalities of bile flow. The sphincter of Oddi acts as a "valve" that allows bile to flow from the common bile duct into the intestine.

Primary biliary cirrhosis and primary sclerosing cholangitis can lead to progressive scarring of the bile ducts, causing them to become narrow, which results in reduced bile flow through the liver. Eventually, damage and scarring of the liver architecture causes liver failure to develop.

Other diseases and conditions

Conditions such as portal hypertension (increased blood pressure within the portal vein), abnormal blood clotting, and hepatic encephalopathy (abnormal brain function due to elevated levels of ammonia in the blood stream).

What are the risk factors for liver disease?

  • Some liver diseases are potentially preventable and are associated with lifestyle choices. Hepatitis B and C are viral infections that are most often spread through the exchange of bodily fluids (for example, unprotected sexual intercourse, sharing unsterilized drug injecting equipment, using non-sterilized equipment for tattoos or body piercing). Alcohol related liver disease is due to excessive consumption of alcohol.
  • Hereditary liver disease can be passed genetically from generation to generation. Examples include Wilson's disease and hemochromatosis.
  • Chemical exposure may be toxic to the liver by irritating the liver cells causing inflammation (hepatitis), decreasing bile flow through the liver (cholestasis) and accumulation of triglycerides (steatosis). Chemicals such as anabolic steroids and vinyl chloride can cause liver cancers.
  • Acetaminophen (Tylenol) overdose is a common cause of liver failure. It is important to review the dosing guidelines for all over-the-counter medications and to ask for guidance from your health care professional or pharmacist as to how much may be taken safely.
  • Medications may irritate the blood vessels causing narrowing or formation blood clots (thrombosis). Birth control pills may cause hepatic vein thrombosis, especially in smokers.

What are the symptoms of liver disease?

Classic symptoms of liver disease include:

  • nausea,
  • vomiting,
  • right upper quadrant abdominal pain, and
  • jaundice (a yellow discoloration of the skin due to elevated bilirubin concentrations in the bloodstream).

Fatigue, weakness and weight loss may also be occur.

However, since there are a variety of liver diseases, the symptoms tend to be specific for that illness until late-stage liver disease and liver failure occurs.

Examples of liver disease symptoms due to certain conditions or diseases include:

  • A person with gallstones may experience right upper abdominal pain and vomiting after eating a greasy (fatty) meal. If the gallbladder becomes infected, fever may occur.
  • Gilbert's disease have no symptoms.
  • Individuals with cirrhosis will develop progressive symptoms as the liver fails. Some symptoms are directly related to the inability of the liver to metabolize the body's waste products. Others reflect the failure of the liver to manufacture proteins required for body function and may affect blood clotting function, secondary sex characteristics and brain function. Symptoms of cirrhosis of the liver include:

     

    • easy bruising may occur due to decreased production of clotting factors;
    • bile salts can deposit in the skin causing itching;
    • gynecomastia or enlarged breasts in men may occur because of an imbalance in sex hormones; specifically an increase in estradiol;
    • impotence (erectile dysfunction, ED), poor sex drive and shrinking testicles are due to decrease in function of sex hormones;
    • confusion and lethargy may occur if ammonia levels rise in the blood stream (ammonia is a waste product formed from protein metabolism and requires normal liver cells to remove it);
    • ascites (fluid accumulation within the abdominal cavity) occurs because of decreased protein production; and
    • muscle wasting may occur because of reduced protein production.

Additionally, there is increased pressure within the cirrhotic liver affecting blood flow through the liver. Increased pressure in the portal vein causes blood flow to the liver to slow and blood vessels to swell. Swollen veins (varices) form around the stomach and esophagus and are at risk for bleeding.

When to seek medical care for liver disease

Often, the onset of a liver disease is gradual and there is no specific symptom that brings the affected individual to seek medical care. Fatigue, weakness and weight loss that cannot be explained should prompt a visit for medical evaluation.

Jaundice or yellow skin is never normal and should prompt an evaluation by a medical professional.

Persisting fever, vomiting, and abdominal pain should also prompt medical evaluation as soon as possible.

How is liver disease diagnosed?

The precise diagnosis of liver disease involves a history and physical examination performed by the health care professional. Understanding the symptoms and the patient's risk factors for liver disease will help guide any diagnostic tests that may be considered.

Liver disease can have physical findings in almost all body systems including the heart, lungs, abdomen, skin, cognitive function, and other parts of the nervous system. The physical examination can require evaluation of the entire body.

Blood tests are helpful in assessing liver inflammation and function.

Specific liver function blood tests include:

  • AST and ALT ( transaminase chemicals released with liver cell inflammation);
  • GGT and alkaline phosphatase (chemicals released by cells lining bile ducts);
  • bilirubin; and
  • protein and albumin levels.

Other blood tests may be considered, including the following:

  • complete blood count (CBC), patients with end stage liver disease may have bone marrow suppression and low red blood cells, white blood cells and platelets;
  • INR blood clotting function may be impaired due to poor protein production,
  • lipase to check for pancreas inflammation;
  • electrolytes, BUN and creatinine to assess kidney function; and
  • ammonia blood level assessment is helpful in patients with mental confusion.

Imaging studies may be used to visualize, not only the liver, but other organs nearby that may be diseased. Examples of imaging studies include:

  • CT scan (computerized axial tomography),
  • MRI (magnetic resonance imaging), and
  • ultrasound (sound wave imaging, which is especially helpful in assessing the gallbladder and bile ducts.

Liver biopsy may be considered to confirm a specific diagnosis for liver disease. Under local anesthetic, a long thin needle is inserted through the chest wall into the liver, where a small sample of liver tissue is obtained for examination under a microscope.

When to seek medical care for liver disease

Often, the onset of a liver disease is gradual and there is no specific symptom that brings the affected individual to seek medical care. Fatigue, weakness and weight loss that cannot be explained should prompt a visit for medical evaluation.

Jaundice or yellow skin is never normal and should prompt an evaluation by a medical professional.

Persisting fever, vomiting, and abdominal pain should also prompt medical evaluation as soon as possible.

How is liver disease diagnosed?

The precise diagnosis of liver disease involves a history and physical examination performed by the health care professional. Understanding the symptoms and the patient's risk factors for liver disease will help guide any diagnostic tests that may be considered.

Liver disease can have physical findings in almost all body systems including the heart, lungs, abdomen, skin, cognitive function, and other parts of the nervous system. The physical examination can require evaluation of the entire body.

Blood tests are helpful in assessing liver inflammation and function.

Specific liver function blood tests include:

  • AST and ALT ( transaminase chemicals released with liver cell inflammation);
  • GGT and alkaline phosphatase (chemicals released by cells lining bile ducts);
  • bilirubin; and
  • protein and albumin levels.

Other blood tests may be considered, including the following:

  • complete blood count (CBC), patients with end stage liver disease may have bone marrow suppression and low red blood cells, white blood cells and platelets;
  • INR blood clotting function may be impaired due to poor protein production,
  • lipase to check for pancreas inflammation;
  • electrolytes, BUN and creatinine to assess kidney function; and
  • ammonia blood level assessment is helpful in patients with mental confusion.

Imaging studies may be used to visualize, not only the liver, but other organs nearby that may be diseased. Examples of imaging studies include:

  • CT scan (computerized axial tomography),
  • MRI (magnetic resonance imaging), and
  • ultrasound (sound wave imaging, which is especially helpful in assessing the gallbladder and bile ducts.

Liver biopsy may be considered to confirm a specific diagnosis for liver disease. Under local anesthetic, a long thin needle is inserted through the chest wall into the liver, where a small sample of liver tissue is obtained for examination under a microscope.

What is the treatment for liver disease?

Each liver disease will have its own specific treatment regimen. For example, hepatitis A requires supportive care to maintain hydration while the body's immune system fights and resolves the infection. Patients with gallstones may require surgery to remove the gallbladder. Other diseases may need long-term medical care to control and minimize the consequences of their disease

In patients with cirrhosis and end-stage liver disease, medications may be required to control the amount of protein absorbed in the diet. The liver affected by cirrhosis may not be able to metabolize the waste products, resulting in elevated blood ammonia levels and hepatic encephalopathy. Low sodium diet and water pills (diuretics) may be required to minimize water retention.

In those with large amounts of ascites fluid, the excess fluid may have to be occasionally removed with a needle and syringe (paracentesis). Using local anesthetic, a needle is inserted through the abdominal wall and the fluid withdrawn.

Operations may be required to treat portal hypertension and minimize the risk of bleeding.

Liver transplantation is the final option for patients whose liver has failed.

What are the complications of liver disease?

Except for gallstone disease and some viral infections such as Hepatitis A and infectious mononucleosis, most liver diseases are managed and not cured.

Liver disease can progress to cirrhosis and liver failure. Associated complications may include increased risk of bleeding and infection, malnutrition and weight loss, and decreased cognitive function.

Some liver diseases are associated with an increased risk for developing liver cancer.

Can liver disease be prevented?

  • Alcohol abuse is the most common cause of liver disease in North America. Consuming alcohol in moderation may help minimize the risk of alcohol-related liver disease.
  • The risk of contracting Hepatitis B and C can be decreased by minimizing the risk of exposure to other person's bodily fluids.
  • Vaccination is available for Hepatitis A and B.
  • Fatty liver disease is a preventable illness with the promotion of a healthy lifestyle including a well balanced diet, weight control, avoiding excess alcohol consumption and routine exercise program. These lifestyle modifications do not guarantee success in disease prevention in that some people will develop fatty liver disease anyway.

What is the outlook for a patient with liver disease?

The outlook and outcome for a patient depends upon the underlying diagnosis.

Interestingly, in patients with cirrhosis, there may be little correlation between the amount of damage found on liver biopsy and the ultimate outcome. A patient may never develop symptoms and have a normal life-span or may develop significant symptoms.

Liver Disease At A Glance

  • The liver has an important role in many bodily functions from protein production and blood clotting to cholesterol, glucose and iron metabolism.
  • A variety of illnesses can affect the liver.
  • Cirrhosis occurs when normal liver cells are replaced by scar tissue as a result of chronic liver disease.
  • Symptoms of liver diseases include weakness and fatigue, weight loss, nausea, vomiting, and yellow discoloration of the skin (jaundice).
  • The treatment of a particular liver disease depends on its specific cause.

Liver Resection


  • What is liver resection and why is it done?
  • Which patients with liver cancer undergo liver resection?
  • What is the goal of liver resection?
  • Can a portion of the remaining normal liver grow back?
  • What are the results (survival and recurrence) of liver resection?
  • Find a local Surgeon in your town

What is liver resection and why is it done?

 

Liver resection is the surgical removal of a portion of the liver. This operation is usually done to remove various types of liver tumors that are located in the resected portion of the liver. The goal of liver resection is to completely remove the tumor and the appropriate surrounding liver tissue without leaving any tumor behind.

Which patients with liver cancer undergo liver resection?

In patients with liver cancer (Hepatocellular Cancer, HCC), this treatment option, liver resection, is limited to patients with one or two small (5 cm or less) and confined to the liver with no invasion of the blood vessels. As a result of these strict guidelines, in practice, very few patients with HCC can undergo liver resection. The biggest concern about resection is that following the operation, the patient can develop liver failure. The liver failure can occur if the remaining portion of the liver is inadequate (for example, because of associated cirrhosis) to provide the necessary support for life. Even in carefully selected patients, about 10% of them are expected to die shortly after surgery, usually as a result of liver failure.

What is the goal of liver resection?

The goal of liver resection is to completely remove the tumor and the appropriate surrounding liver tissue without leaving any tumor behind. This option is limited to patients with one or two small (3 cm or less) tumors and excellent liver function, ideally without associated cirrhosis. As a result of these strict guidelines, in practice, very few patients with liver cancer can undergo liver resection. The biggest concern about resection is that following the operation, the patient can develop liver failure. The liver failure can occur if the remaining portion of the liver is inadequate to provide the necessary support for life. Even in carefully selected patients, about 10% of them are expected to die shortly after surgery, usually as a result of liver failure.

Can a portion of the remaining normal liver grow back?

When a portion of a normal liver is removed, the remaining liver can grow back (regenerate) to the original size within one to two weeks. A cirrhotic liver, however, cannot grow back. Therefore, before resection is performed for HCC, the non-tumor portion of the liver should be biopsied to determine whether there is associated cirrhosis.

What are the results (survival and recurrence) of liver resection?

For HCC patients whose tumors are successfully resected, the five-year survival is about 30% to 40%. This means that 30% to 40 % of patients who actually undergo liver resection for liver cancer are expected to live five years. Many of these patients, however, will have a recurrence of liver cancer elsewhere in the liver. Moreover, it should be noted that the survival rate of untreated patients with similar sized tumors and similar liver function is probably comparable. Some studies from Europe and Japan have shown that survival rates with alcohol injection or radiofrequency ablation procedures are comparable to the survival rates of those patients who underwent resection. But again, the reader should be cautioned that there are no head-to-head comparisons of these procedures versus resection.

Digestive Diseases: Liver Transplantation

  • When is a liver transplant needed?
  • How are candidates for liver transplant determined?
  • Which tests are required before getting a liver transplant?
  • How does the waiting list work?
  • Where does a liver for a transplant come from?
  • What happens when they find a match?
  • What happens during the transplant operation?
  • What complications are associated with liver transplantation?
  • What are antirejection medications?
  • When will I be able to go home?
  • What follow-up is necessary after a liver transplant?
  • Find a local Surgeon in your town

The liver is the body's largest internal organ, weighing about 3 pounds in adults. It is located below the diaphragm on the right side of the abdomen.

The liver performs many complex functions in the body, including:

  • Produces most proteins needed by the body.
  • Metabolizes, or breaks down, nutrients from food to produce energy, when needed.
  • Prevents shortages of nutrients by storing certain vitamins, minerals and sugar.
  • Produces bile, a compound needed to digest fat and to absorb vitamins A, D, E and K.
  • Produces most of the substances that regulate blood clotting.
  • Helps your body fight infection by removing bacteria from the blood.
  • Removes potentially toxic byproducts of certain medications.

When Is a Liver Transplant Needed?

Liver transplantation is considered when the liver no longer functions adequately (liver failure). Liver failure can occur suddenly (acute liver failure) as a result of infection or complications from certain medications or it can be the end result of a long-term problem. The following conditions may result in liver failure:

  • Chronic hepatitis with cirrhosis.
  • Primary biliary cirrhosis (a rare condition where the immune system inappropriately attacks and destroys the bile ducts causing liver failure).
  • Sclerosing cholangitis (scarring and narrowing of the bile ducts inside and outside of the liver causing the backup of bile in the liver which can lead to liver failure).
  • Biliary atresia (malformation of the bile ducts).
  • Alcoholism
  • Wilson's disease (a rare inherited disease with abnormal deposition of copper throughout the body, including the liver, causing it to fail).
  • Hemochromatosis (a common inherited disease where the body is overwhelmed with iron).
  • Alpha-1 antitrypsin deficiency (an abnormal accumulation of alpha-1 antitrypsin protein in the liver, resulting in cirrhosis).
  • Liver cancer

How Are Candidates for Liver Transplant Determined?

Evaluations by specialists from a variety of fields are needed to determine if a liver transplant is appropriate. The evaluation includes a review of your medical history and a variety of tests. Many healthcare facilities offer an interdisciplinary approach to evaluate and to select candidates for liver transplantation. This interdisciplinary healthcare team may include the following professionals:

  • Liver specialist (hepatologist).
  • Transplant surgeons
  • Transplant coordinator, usually a registered nurse who specializes in the care of liver-transplant patients (this person will be your primary contact with the transplant team).
  • Social worker to discuss your support network of family and friends, employment history, and financial needs.
  • Psychiatrist to help you deal with issues, such as anxiety and depression, which may accompany the liver transplantation.
  • Anesthesiologist to discuss potential anesthesia risks.
  • Chemical dependency specialist to aid those with history of alcohol or drug abuse.
  • Financial counselor to act as a liaison between a patient and his or her insurance companies.

Which Tests Are Required Before Getting a Liver Transplant?

You will need to bring all of your previous doctor records, X-rays, liver biopsy slides and a record of medications to your pre-evaluation for a liver transplant. To complement and to update previous tests, some or all of the following diagnostic studies are generally performed during your evaluation.

  • Computed tomography, which uses X-rays and a computer to generate pictures of the liver, showing its size and shape.
  • Doppler ultrasound to determine if the blood vessels to and from your liver are open.
  • Echocardiogram to help evaluate your heart.
  • Pulmonary function studies to determine your lungs' ability to exchange oxygen and carbon dioxide.
  • Blood tests to determine blood type, clotting ability, and biochemical status of blood and to gauge liver function. AIDS testing and hepatitis screening are also included.

If specific problems are identified, additional tests may be ordered.

How Does the Waiting List Work?

If you become an active liver transplant candidate, your name will be placed on a waiting list. Patients are listed according to blood type, body size, and medical condition (how ill they are). Each patient is given a priority score based on three simple blood tests (creatinine, bilirubin, and INR). The score is known as the MELD (model of end stage liver disease) score in adults and PELD (pediatric end stage liver disease) in children.

Patients with the highest scores are transplanted first. As they become more ill, their scores will increase and therefore their priority for transplant increases, allowing for the sickest patients to be transplanted first. A small group of patients who are critically ill from acute liver disease have the highest priority on the waiting list.

It is impossible to predict how long a patient will wait for a liver to become available. Your transplant coordinator is always available to discuss where you are on the waiting list.

Where Does a Liver for a Transplant Come From?

There are two types of liver transplant options: living donor transplant and deceased donor transplant.

  • Living donor.

Living donor liver transplants are an option for some patients with end-stage liver disease. This involves removing a segment of liver from a healthy living donor and implanting it into a recipient. Both the donor and recipient liver segments will grow to normal size in a few weeks.

The donor, who may be a blood relative, spouse, or friend, will have extensive medical and psychological evaluations to ensure the lowest possible risk. Blood type and body size are critical factors in determining who is an appropriate donor.

Recipients for the living donor transplant must be active on the transplant waiting list. Their health must also be stable enough to undergo transplantation with excellent chances of success.

  • Deceased Donor.

In deceased donor liver transplant, the donor may be a victim of an accident or head injury. The donor's heart is still beating, but the brain has stopped functioning. Such a person is considered legally dead, because his or her brain has permanently and irreversibly stopped working. At this point, the donor is usually in an intensive-care unit.

The identity of a deceased donor and circumstances surrounding the person's death are kept confidential.

Screening for Liver Transplant Donors

Hospitals will evaluate all potential liver transplant donors for evidence of liver disease, alcohol or drug abuse, cancer, or infection. Donors will also be tested for hepatitis, AIDS, and other infections. If this screening does not reveal problems with the liver, donors and recipients are matched according to blood type and body size. Age, race, and sex are not considered.

The transplant team will discuss your transplantation options with you at the time of your pre-transplant evaluation, or you can contact the transplant team for more information.

What Happens When They Find Liver Transplant Match?

When a liver has been identified for you, a transplant coordinator will contact you by telephone or by pager. Make sure that you do not eat or drink anything once you have been called to the hospital. The transplant coordinator will notify you of any additional instructions. When you arrive at the hospital, additional blood tests, an electrocardiogram, and a chest X-ray will generally be taken before the operation. You also may meet with the anesthesiologist and a surgical resident. If the donor liver is found to be acceptable you will proceed with the transplant. If not, you will be sent home to continue waiting.

What Happens During the Liver Transplant Operation?

Liver transplants usually take from six hours to 12 hours. During the operation, surgeons will remove your liver and will replace it with the donor liver. Because a transplant operation is a major procedure, surgeons will need to place several tubes in your body. These tubes are necessary to help your body carry out certain functions during the operation and for a few days afterward.

Tube placement

  • A tube will be placed through your mouth into your windpipe (trachea) to help you breathe during the liver transplant operation and for the first day or two following the operation. The tube is attached to a ventilator that will expand your lungs mechanically.
  • A nasogastric (N/G) tube will be inserted through your nose into your stomach. The N/G tube will drain secretions from your stomach and it will remain in place for a few days until your bowel function returns to normal.
  • A tube called a catheter will be placed in your bladder to drain urine. This will be removed a few days after the operation.
  • Three tubes will be placed in your abdomen to drain blood and fluid from around the liver. These will remain in place for about one week.
  • In most cases, the surgeon will place a special tube, called a T-tube, in your bile duct. The T-tube will drain bile into a small pouch outside of your body so it can be measured several times daily. Only certain transplant patients receive a T-tube, which remains in place for five months. The tube causes no discomfort and does not interfere with daily activities.

What Complications Are Associated With Liver Transplantation?

Two of the most common complications following liver transplant are rejection and infection.

Rejection

Your immune system works to destroy foreign substances that invade your body. The immune system, however, cannot distinguish between your transplanted liver and unwanted invaders, such as viruses and bacteria. Therefore, your immune system may attempt to attack and destroy your new liver. This is called a rejection episode. About 70% of all liver-transplant patients have some degree of organ rejection prior to discharge. Anti-rejection medications are given to ward off the immune attack.

Infection

Because anti-rejection drugs that suppress your immune system are needed to prevent the liver from being rejected, you are at increased risk for infections. This problem diminishes as time passes. Not all patients have problems with infections, and most infections can be treated successfully as they occur.

What Are Anti-rejection Medications?

After the liver transplant, you will receive medications called immunosuppressants. These medications slow or suppress your immune system to prevent it from rejecting your new liver. They may include azathioprine (Imuran), Cellcept (mycophenolate mofetil), prednisone (Deltasone, Kedral, Medrol, Orasone, Prelone, Sterapred DS), cyclosporine (Neoral), Prograf (a brand of tacrolimus, also known as FK506), and Rapamune (sirolimus). You must take these drugs exactly as prescribed for the rest of your life.

When Will I Be Able to Go Home After a Liver Transplant?

The average hospital stay after liver transplant is two weeks to three weeks. Some patients may be discharged in less time, while others may be in the hospital much longer, depending on complications that may arise. You need to be prepared for both possibilities.

To provide a smooth transition from hospital to home, the nursing staff and your transplant coordinator will begin to prepare you for discharge shortly after you are transferred from the intensive-care unit to the regular nursing floor. You will be given a discharge manual, which reviews much of what you will need to know before you go home.

You will learn how to take your new medications and how to monitor your own blood pressure and pulse. As you perform these functions regularly, you will become an important participant in your own healthcare. Before your discharge, you will also learn the signs of rejection and infection and will know when it is important to call your doctor.

Readmission after discharge is common, especially within the first year after transplantation. The admission is usually for treatment of a rejection episode or infection.

What Follow-Up Is Necessary After a Liver Transplant?

Your first return appointment after a liver transplant will generally be scheduled about one week to two weeks after discharge. During this visit, you will see the transplant surgeon and transplant coordinator. If needed, a social worker or a member of the psychiatric team may also be available.

All patients return to their transplant hospital approximately five months after the transplant. If a T-tube was inserted during the operation, it will be removed by the transplant surgeon at this time.

All patients are scheduled to return to the hospital at their one-year transplant anniversary date and annually thereafter.

Your primary care doctor should be notified when you receive your transplant and when you are discharged. Though most problems related to the transplant will need to be taken care of at the transplant hospital, your primary care doctor will remain an important part of your medical care.

Loeys-Dietz Syndrome


  • What is Loeys-Dietz syndrome?
  • What are the signs and symptoms of Loeys-Dietz syndrome?
  • Is Loeys-Dietz syndrome inherited?
  • What causes Loeys-Dietz syndrome?
  • How is Loeys-Dietz syndrome diagnosed?
  • How is Loeys-Dietz syndrome treated?
  • Loeys-Dietz At A Glance

What is Loeys-Dietz syndrome?

Loeys-Dietz syndrome is a recently-described connective tissue disorder with features similar to those of Marfan syndrome, and the vascular type of Ehlers-Danlos syndrome. Loeys-Dietz syndrome is primarily characterized by aortic aneurysms (weakened outpouchings of the aorta, the main artery in the body) in children. In Loeys-Dietz syndrome, the aortic aneurysms are prone to rupture at a smaller size than other aneurysms, putting children with Loeys-Dietz at great risk for dying if the aneurysm is not identified and treated early.

The syndrome is named for pediatric geneticist Harry Dietz, director of the William S. Smilow Center for Marfan Syndrome Research at Johns Hopkins University and his colleague, Bart Loeys, who characterized the genetic and physical markers of the syndrome together with Dr. Dietz.

What are the signs and symptoms of Loeys-Dietz syndrome?

Aortic aneurysms and abnormal organization of blood vessels (widespread tortuosity of the arteries in locations other than the aorta) are the hallmarks of Loeys-Dietz syndrome, but many affected children have characteristic physical and facial features that may be the first abnormality to be recognized. Recently, LDS has been subdivided into two types, LDS type I (LDSI) and type II (LDSII), signaling the presence or the absence of cranio-facial involvement, respectively.

The craniofacial characteristics of Loeys-Dietz syndrome include early fusion of the skull bones (known as craniosynostosis), widely spaced eyes (hypertelorism), and cleft palate or split uvula. In some individuals with Loeys-Dietz syndrome, other physical abnormalities have been noted, including defects at birth in the heart and brain, osteoporosis (weak bones), skin changes (such as translucent skin and/or easy bruising), and defects of the spine or chest. It is important to note that the severity of the visible physical characteristics varies widely among affected individuals, but the danger of rupture of aneurysms remains the same no matter how severe or mild the physical characteristics are.

In many cases pediatricians may be able to recognize the characteristic facial features of Loeys-Dietz syndrome, and on this basis suggest further evaluation for the presence of aortic aneurysms and vascular irregularities. Other people with the syndrome are recognized when they seek medical assistance for other reasons, such as heart murmurs or a family history of Marfan syndrome or another condition that may cause aortic aneurysms.

Is Loeys-Dietz syndrome inherited?

Loeys-Dietz syndrome is inherited, meaning that it is a genetic syndrome that tends to run in families. The mutated abnormal gene that causes Loeys-Dietz syndrome is dominant, and only one parent needs pass the gene to a child in order for the syndrome to develop. (This is in contrast to recessive syndromes in which each parent must pass the gene to a child in order for the syndrome to develop.) A report published in the New England Journal of Medicine in August, 2006, reported that 52 affected families (with a total of 90 affected individuals) had been identified.

What causes Loeys-Dietz syndrome?

The cause of Loeys-Dietz syndrome has been determined recently. TGF-beta is a signaling molecule produced in the body that influences the growth, movement, and activity of cells as well as the death of cells by changing the way many genes within the cells are expressed. TGF-beta brings about the changes within cells by binding to receptors on the surfaces of the cells. . Loeys-Dietz syndrome is known to be a result of mutations in the TGF-beta-receptor I (TGFBR1) or II (TGFBR2) genes. The genetic mutations in Loeys-Dietz causes a change in the receptor that prevents TGF-beta from working on the cells. A test is available that can detect the genetic mutation associated with the syndrome; however, the test is not available in most laboratories.

How is Loeys-Dietz syndrome diagnosed?

The diagnosis of aortic aneurysms, including those seen in the Loeys-Dietz syndrome, usually is made by injecting a dye that is visible by X-ray, computerized tomography (CT), or magnetic resonance imaging (MRI) into the blood vessels. X-rays or scans by CT or MRI then are done that show the arteries and aneurysms (because the aneurysms are filled with dye-containing blood). Although aortic aneurysms are the hallmark of Loeys-Dietz Syndrome and the characteristic facial features may suggest the diagnosis, the definitive diagnosis of Loeys-Dietz Syndrome can only be established by the genetic test (described above).

How is Loeys-Dietz syndrome treated?

The only treatment for Loeys-Dietz syndrome to prolong life expectancy is surgical repair of the aortic aneurysm. Surgical repair of the aneurysms is generally successful. Since the aneurysms tend to rupture early, early and accurate diagnosis is critical to ensure that affected individuals receive prompt surgical treatment. The genetic test can be of value in identifying which individuals with aortic aneurysms have Loeys-Dietz syndrome, and therefore, should have immediate surgery. In contrast to Loeys-Dietz syndrome, in other inherited syndromes associated with aortic aneurysms, surgery carries a poorer prognosis, and the aneurysms can be managed with medications for a longer period of time before surgery becomes necessary. Studies are ongoing to determine whether drug treatment of the Loeys-Dietz syndrome also may be of value.

At the time of diagnosis, imaging studies of the aorta are recommended and should be repeated after 6 months to determine if aortic enlargement is occurring. If the diameter of the aorta is not enlarging, yearly magnetic resonance imaging (MRI) scans from the of the circulation from the barin to the pelvis are recommended, since affected persons commonly develop aneurysms that are treatable surgically.

 

Loeys-Dietz Syndrome At A Glance
  • Loeys-Dietz syndrome is a recently-described connective tissue disorder that predisposes to the development of aortic aneurysms and other connective tissue defects.
  • Loeys-Dietz syndrome is known to be a result of mutations in the TGF-beta-receptor I (TGFBR1) or II (TGFBR2) genes and is inherited in an autosomal dominant manner.
  • Genetic testing is performed to identify the mutation and establish the diagnosis, while imaging studies are required for evaluation of potential aneurysms.
  • Surgery to repair aortic aneurysms is essential for treatment because the aneurysms of Loeys-Dietz syndrome tend to rupture early.

References:

Hiratzka, LF, Bakris, GL, Beckman, JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010; 121:e266.

Amyotrophic Lateral Sclerosis
(ALS or "Lou Gehrig's Disease")

  • What is amyotrophic lateral sclerosis?
  • Who gets ALS?
  • What are the symptoms of ALS?
  • How is ALS diagnosed?
  • What causes ALS?
  • How is ALS treated?
  • What research is being done on ALS?
  • How Can I Help Research on ALS?
  • Where can I get more information about ALS?
  • Find a local Neurologist in your town

What is amyotrophic lateral sclerosis?

Amyotrophic lateral sclerosis (ALS), sometimes called Lou Gehrig's disease, is a rapidly progressive, invariably fatal neurological disease that attacks the nerve cells (neurons) responsible for controlling voluntary muscles. The disease belongs to a group of disorders known as motor neuron diseases, which are characterized by the gradual degeneration and death of motor neurons.

Motor neurons are nerve cells located in the brain, brainstem, and spinal cord that serve as controlling units and vital communication links between the nervous system and the voluntary muscles of the body. Messages from motor neurons in the brain (called upper motor neurons) are transmitted to motor neurons in the spinal cord (called lower motor neurons) and from them to particular muscles. In ALS, both the upper motor neurons and the lower motor neurons degenerate or die, ceasing to send messages to muscles. Unable to function, the muscles gradually weaken, waste away (atrophy), and twitch (fasciculations). Eventually, the ability of the brain to start and control voluntary movement is lost.

ALS causes weakness with a wide range of disabilities (see section titled "What are the symptoms?"). Eventually, all muscles under voluntary control are affected, and patients lose their strength and the ability to move their arms, legs, and body. When muscles in the diaphragm and chest wall fail, patients lose the ability to breathe without ventilatory support. Most people with ALS die from respiratory failure, usually within 3 to 5 years from the onset of symptoms. However, about 10 percent of ALS patients survive for 10 or more years.

Although the disease usually does not impair a person's mind or intelligence, several recent studies suggest that some ALS patients may have alterations in cognitive functions such as depression and problems with decision-making and memory.

ALS does not affect a person's ability to see, smell, taste, hear, or recognize touch. Patients usually maintain control of eye muscles and bladder and bowel functions, although in the late stages of the disease most patients will need help getting to and from the bathroom.

Who gets ALS?

As many as 20,000 Americans have ALS, and an estimated 5,000 people in the United States are diagnosed with the disease each year. ALS is one of the most common neuromuscular diseases worldwide, and people of all races and ethnic backgrounds are affected. ALS most commonly strikes people between 40 and 60 years of age, but younger and older people also can develop the disease. Men are affected more often than women.

In 90 to 95 percent of all ALS cases, the disease occurs apparently at random with no clearly associated risk factors. Patients do not have a family history of the disease, and their family members are not considered to be at increased risk for developing ALS.

About 5 to 10 percent of all ALS cases are inherited. The familial form of ALS usually results from a pattern of inheritance that requires only one parent to carry the gene responsible for the disease. About 20 percent of all familial cases result from a specific genetic defect that leads to mutation of the enzyme known as superoxide dismutase 1 (SOD1). Research on this mutation is providing clues about the possible causes of motor neuron death in ALS. Not all familial ALS cases are due to the SOD1 mutation, therefore other unidentified genetic causes clearly exist.

What are the symptoms of ALS?

The onset of ALS may be so subtle that the symptoms are frequently overlooked. The earliest symptoms may include:

  • twitching, cramping, or stiffness of muscles;
  • muscle weakness affecting an arm or a leg;
  • slurred and nasal speech; or
  • difficulty chewing or swallowing.

These general complaints then develop into more obvious weakness or atrophy that may cause a physician to suspect ALS.

The parts of the body affected by early symptoms of ALS depend on which muscles in the body are damaged first. In some cases, symptoms initially affect one of the legs, and patients experience awkwardness when walking or running or they notice that they are tripping or stumbling more often. Some patients first see the effects of the disease on a hand or arm as they experience difficulty with simple tasks requiring manual dexterity such as buttoning a shirt, writing, or turning a key in a lock. Other patients notice speech problems.

Regardless of the part of the body first affected by the disease, muscle weakness and atrophy spread to other parts of the body as the disease progresses. Patients have increasing problems with moving, swallowing (dysphagia), and speaking or forming words (dysarthria). Symptoms of upper motor neuron involvement include tight and stiff muscles (spasticity) and exaggerated reflexes (hyperreflexia) including an overactive gag reflex. An abnormal reflex commonly called Babinski's sign (the large toe extends upward as the sole of the foot is stimulated in a certain way) also indicates upper motor neuron damage. Symptoms of lower motor neuron degeneration include muscle weakness and atrophy, muscle cramps, and fleeting twitches of muscles that can be seen under the skin (fasciculations).

To be diagnosed with ALS, patients must have signs and symptoms of both upper and lower motor neuron damage that cannot be attributed to other causes.

Although the sequence of emerging symptoms and the rate of disease progression vary from person to person, eventually patients will not be able to stand or walk, get in or out of bed on their own, or use their hands and arms. Difficulty swallowing and chewing impair the patient's ability to eat normally and increase the risk of choking. Maintaining weight will then become a problem. Because the disease usually does not affect cognitive abilities, patients are aware of their progressive loss of function and may become anxious and depressed. A small percentage of patients may experience problems with memory or decision-making, and there is growing evidence that some may even develop a form of dementia.

Health care professionals need to explain the course of the disease and describe available treatment options so that patients can make informed decisions in advance. In later stages of the disease, patients have difficulty breathing as the muscles of the respiratory system weaken. Patients eventually lose the ability to breathe on their own and must depend on ventilatory support for survival. Patients also face an increased risk of pneumonia during later stages of ALS.

How is ALS diagnosed?

No one test can provide a definitive diagnosis of ALS, although the presence of upper and lower motor neuron signs in a single limb is strongly suggestive. Instead, the diagnosis of ALS is primarily based on the symptoms and signs the physician observes in the patient and a series of tests to rule out other diseases. Physicians obtain the patient's full medical history and usually conduct a neurologic examination at regular intervals to assess whether symptoms such as muscle weakness, atrophy of muscles, hyperreflexia, and spasticity are getting progressively worse.

Because symptoms of ALS can be similar to those of a wide variety of other, more treatable diseases or disorders, appropriate tests must be conducted to exclude the possibility of other conditions. One of these tests is electromyography (EMG), a special recording technique that detects electrical activity in muscles. Certain EMG findings can support the diagnosis of ALS. Another common test measures nerve conduction velocity (NCV). Specific abnormalities in the NCV results may suggest, for example, that the patient has a form of peripheral neuropathy (damage to peripheral nerves) or myopathy (muscle disease) rather than ALS. The physician may order magnetic resonance imaging (MRI), a noninvasive procedure that uses a magnetic field and radio waves to take detailed images of the brain and spinal cord. Although these MRI scans are often normal in patients with ALS, they can reveal evidence of other problems that may be causing the symptoms, such as a spinal cord tumor, a herniated disc in the neck, syringomyelia, or cervical spondylosis.

Based on the patient's symptoms and findings from the examination and from these tests, the physician may order tests on blood and urine samples to eliminate the possibility of other diseases as well as routine laboratory tests. In some cases, for example, if a physician suspects that the patient may have a myopathy rather than ALS, a muscle biopsy may be performed.

Infectious diseases such as human immunodeficiency virus (HIV), human T-cell leukemia virus (HTLV), and Lyme disease can in some cases cause ALS-like symptoms. Neurological disorders such as multiple sclerosis, post-polio syndrome, multifocal motor neuropathy, and spinal muscular atrophy also can mimic certain facets of the disease and should be considered by physicians attempting to make a diagnosis.

Because of the prognosis carried by this diagnosis and the variety of diseases or disorders that can resemble ALS in the early stages of the disease, patients may wish to obtain a second neurological opinion.

What causes ALS?

The cause of ALS is not known, and scientists do not yet know why ALS strikes some people and not others. An important step toward answering that question came in 1993 when scientists supported by the National Institute of Neurological Disorders and Stroke (NINDS) discovered that mutations in the gene that produces the SOD1 enzyme were associated with some cases of familial ALS. This enzyme is a powerful antioxidant that protects the body from damage caused by free radicals. Free radicals are highly reactive molecules produced by cells during normal metabolism. If not neutralized, free radicals can accumulate and cause random damage to the DNA and proteins within cells. Although it is not yet clear how the SOD1 gene mutation leads to motor neuron degeneration, researchers have theorized that an accumulation of free radicals may result from the faulty functioning of this gene. In support of this, animal studies have shown that motor neuron degeneration and deficits in motor function accompany the presence of the SOD1 mutation.

Studies also have focused on the role of glutamate in motor neuron degeneration. Glutamate is one of the chemical messengers or neurotransmitters in the brain. Scientists have found that, compared to healthy people, ALS patients have higher levels of glutamate in the serum and spinal fluid. Laboratory studies have demonstrated that neurons begin to die off when they are exposed over long periods to excessive amounts of glutamate. Now, scientists are trying to understand what mechanisms lead to a buildup of unneeded glutamate in the spinal fluid and how this imbalance could contribute to the development of ALS.

Autoimmune responses—which occur when the body's immune system attacks normal cells - have been suggested as one possible cause for motor neuron degeneration in ALS. Some scientists theorize that antibodies may directly or indirectly impair the function of motor neurons, interfering with the transmission of signals between the brain and muscles.

In searching for the cause of ALS, researchers have also studied environmental factors such as exposure to toxic or infectious agents. Other research has examined the possible role of dietary deficiency or trauma. However, as of yet, there is insufficient evidence to implicate these factors as causes of ALS.

Future research may show that many factors, including a genetic predisposition, are involved in the development of ALS.

How is ALS treated?

No cure has yet been found for ALS. However, the Food and Drug Administration (FDA) has approved the first drug treatment for the disease - riluzole (Rilutek). Riluzole is believed to reduce damage to motor neurons by decreasing the release of glutamate. Clinical trials with ALS patients showed that riluzole prolongs survival by several months, mainly in those with difficulty swallowing. The drug also extends the time before a patient needs ventilation support. Riluzole does not reverse the damage already done to motor neurons, and patients taking the drug must be monitored for liver damage and other possible side effects. However, this first disease-specific therapy offers hope that the progression of ALS may one day be slowed by new medications or combinations of drugs.

 

Other treatments for ALS are designed to relieve symptoms and improve the quality of life for patients. This supportive care is best provided by multidisciplinary teams of health care professionals such as physicians; pharmacists; physical, occupational, and speech therapists; nutritionists; social workers; and home care and hospice nurses. Working with patients and caregivers, these teams can design an individualized plan of medical and physical therapy and provide special equipment aimed at keeping patients as mobile and comfortable as possible.

Physicians can prescribe medications to help reduce fatigue, ease muscle cramps, control spasticity, and reduce excess saliva and phlegm. Drugs also are available to help patients with pain, depression, sleep disturbances, and constipation. Pharmacists can give advice on the proper use of medications and monitor a patient's prescriptions to avoid risks of drug interactions.

Physical therapy and special equipment can enhance patients' independence and safety throughout the course of ALS. Gentle, low-impact aerobic exercise such as walking, swimming, and stationary bicycling can strengthen unaffected muscles, improve cardiovascular health, and help patients fight fatigue and depression. Range of motion and stretching exercises can help prevent painful spasticity and shortening (contracture) of muscles. Physical therapists can recommend exercises that provide these benefits without overworking muscles. Occupational therapists can suggest devices such as ramps, braces, walkers, and wheelchairs that help patients conserve energy and remain mobile.

ALS patients who have difficulty speaking may benefit from working with a speech therapist. These health professionals can teach patients adaptive strategies such as techniques to help them speak louder and more clearly. As ALS progresses, speech therapists can help patients develop ways for responding to yes-or-no questions with their eyes or by other nonverbal means and can recommend aids such as speech synthesizers and computer-based communication systems. These methods and devices help patients communicate when they can no longer speak or produce vocal sounds.

Patients and caregivers can learn from speech therapists and nutritionists how to plan and prepare numerous small meals throughout the day that provide enough calories, fiber, and fluid and how to avoid foods that are difficult to swallow. Patients may begin using suction devices to remove excess fluids or saliva and prevent choking. When patients can no longer get enough nourishment from eating, doctors may advise inserting a feeding tube into the stomach. The use of a feeding tube also reduces the risk of choking and pneumonia that can result from inhaling liquids into the lungs. The tube is not painful and does not prevent patients from eating food orally if they wish.

When the muscles that assist in breathing weaken, use of nocturnal ventilatory assistance (intermittent positive pressure ventilation [IPPV] or bilevel positive airway pressure [BIPAP]) may be used to aid breathing during sleep. Such devices artificially inflate the patient's lungs from various external sources that are applied directly to the face or body. When muscles are no longer able to maintain oxygen and carbon dioxide levels, these devices may be used full-time.

Patients may eventually consider forms of mechanical ventilation (respirators) in which a machine inflates and deflates the lungs. To be effective, this may require a tube that passes from the nose or mouth to the windpipe (trachea) and for long-term use, an operation such as a tracheostomy, in which a plastic breathing tube is inserted directly in the patient's windpipe through an opening in the neck. Patients and their families should consider several factors when deciding whether and when to use one of these options. Ventilation devices differ in their effect on the patient's quality of life and in cost. Although ventilation support can ease problems with breathing and prolong survival, it does not affect the progression of ALS. Patients need to be fully informed about these considerations and the long-term effects of life without movement before they make decisions about ventilation support.

Social workers and home care and hospice nurses help patients, families, and caregivers with the medical, emotional, and financial challenges of coping with ALS, particularly during the final stages of the disease. Social workers provide support such as assistance in obtaining financial aid, arranging durable power of attorney, preparing a living will, and finding support groups for patients and caregivers. Respiratory therapists can help caregivers with tasks such as operating and maintaining respirators, and home care nurses are available not only to provide medical care but also to teach caregivers about giving tube feedings and moving patients to avoid painful skin problems and contractures. Home hospice nurses work in consultation with physicians to ensure proper medication, pain control, and other care affecting the quality of life of patients who wish to remain at home. The home hospice team can also counsel patients and caregivers about end-of-life issues.

What research is being done?

The National Institute of Neurological Disorders and Stroke, part of the National Institutes of Health, is the Federal Government's leading supporter of biomedical research on ALS. The goals of this research are to find the cause or causes of ALS, understand the mechanisms involved in the progression of the disease, and develop effective treatment.

Scientists are seeking to understand the mechanisms that trigger selective motor neurons to degenerate in ALS and to find effective approaches to halt the processes leading to cell death. This work includes studies in animals to identify the means by which SOD1 mutations lead to the destruction of neurons. The excessive accumulation of free radicals, which has been implicated in a number of neurodegenerative diseases including ALS, is also being closely studied. In addition, researchers are examining how the loss of neurotrophic factors may be involved in ALS. Neurotrophic factors are chemicals found in the brain and spinal cord that play a vital role in the development, specification, maintenance, and protection of neurons. Studying how these factors may be lost and how such a loss may contribute to motor neuron degeneration may lead to a greater understanding of ALS and the development of neuroprotective strategies. By exploring these and other possible factors, researchers hope to find the cause or causes of motor neuron degeneration in ALS and develop therapies to slow the progression of the disease.

Researchers are also conducting investigations to increase their understanding of the role of programmed cell death or apoptosis in ALS. In normal physiological processes, apoptosis acts as a means to rid the body of cells that are no longer needed by prompting the cells to commit "cell suicide." The critical balance between necessary cell death and the maintenance of essential cells is thought to be controlled by trophic factors. In addition to ALS, apoptosis is pervasive in other chronic neurodegenerative conditions such as Parkinson's disease and Alzheimer's disease and is thought to be a major cause of the secondary brain damage seen after stroke and trauma. Discovering what triggers apoptosis may eventually lead to therapeutic interventions for ALS and other neurological diseases.

Scientists have not yet identified a reliable biological marker for ALS—a biochemical abnormality shared by all patients with the disease. Once such a biomarker is discovered and tests are developed to detect the marker in patients, allowing early detection and diagnosis of ALS, physicians will have a valuable tool to help them follow the effects of new therapies and monitor disease progression.

NINDS-supported researchers are studying families with ALS who lack the SOD1 mutation to locate additional genes that cause the disease. Identification of additional ALS genes will allow genetic testing useful for diagnostic confirmation of ALS and prenatal screening for the disease. This work with familial ALS could lead to a greater understanding of sporadic ALS as well. Because familial ALS is virtually indistinguishable from sporadic ALS clinically, some researchers believe that familial ALS genes may also be involved in the manifestations of the more common sporadic form of ALS. Scientists also hope to identify genetic risk factors that predispose people to sporadic ALS.

Potential therapies for ALS are being investigated in animal models. Some of this work involves experimental treatments with normal SOD1 and other antioxidants. In addition, neurotrophic factors are being studied for their potential to protect motor neurons from pathological degeneration. Investigators are optimistic that these and other basic research studies will eventually lead to treatments for ALS.

Results of an NINDS-sponsored phase III randomized, placebo-controlled trial of the drug minocycline to treat ALS were reported in 2007. This study showed that people with ALS who received minocycline had a 25 percent greater rate of decline than those who received the placebo, according to the ALS functional rating scale (ALSFRS-R).

How Can I Help Research?

The NINDS contributes to the support of the Human Brain and Spinal Fluid Resource Center in Los Angeles. This bank supplies investigators around the world with tissue from patients with neurological and other disorders. Tissue from individuals with ALS is needed to enable scientists to study this disorder more intensely. Prospective donors may contact:

http://www.loni.ucla.edu/~nnrsb/NNRSB

Where can I get more information?

For more information on neurological disorders or research programs funded by the National Institute of Neurological Disorders and Stroke, contact the Institute's Brain Resources and Information Network (BRAIN) at:

Lymphedema


  • What is lymphedema?
  • What causes lymphedema?
  • What are the symptoms of lymphedema?
  • How is lymphedema diagnosed?
  • What are possible treatments for lymphedema?
  • What are complications of lymphedema?
  • Can lymphedema be prevented?
  • What is the outlook (prognosis) for lymphedema?
  • Where can I get help and support for lymphedema?
  • Lymphedema At A Glance
  • Related lymphedema article:
    Lymphedema - on eMedicineHealth
  • Find a local Internist in your town

 

What is lymphedema?

Lymphedema is a condition characterized by swelling in one or more extremities that results from impaired flow of the lymphatic system.

The lymphatic system is a network of specialized vessels (lymph vessels) throughout the body whose purpose is to collect excess lymph fluid with proteins, lipids, and waste products from the tissues. This fluid is then carried to the lymph nodes, which filter waste products and contain infection-fighting cells called lymphocytes. The excess fluid in the lymph vessels is eventually returned to the bloodstream. When the lymph vessels are blocked or unable to carry lymph fluid away from the tissues, localized swelling (lymphedema) is the result.

Lymphedema most often affects a single arm or leg, but in uncommon situations both limbs are affected.

  • Primary lymphedema is the result of a design flaw of the lymph vessels and is a rare, inherited condition.
  • Secondary lymphedema results from an identifiable damage to or obstruction of normally-functioning lymph vessels and nodes.
  • Worldwide, lymphedema is most commonly caused by filariasis (a parasitic infection), but in the U.S., lymphedema most commonly occurs in women who have had breast cancer surgery, particularly when followed by radiation treatment.

It has been estimated that worldwide, there are 140-250 million people affected by lymphedema.

What causes lymphedema?

Primary lymphedema causes

Primary lymphedema is an abnormality of an individual's lymphatic system and is likely present at birth, although symptoms may not become apparent until later in life. Depending upon the age at which symptoms develop, three forms of primary lymphedema have been described. Most primary lymphedema occurs without any known family history of the condition.

  • Congenital lymphedema is evident at birth, is more common in females, and accounts for 10%-25% of all cases of primary lymphedema. A subgroup of people with congenital lymphedema has a genetic inheritance (in medical genetics termed "familial sex-linked pattern"), which is termed Milroy disease.
  • Lymphedema praecox is the most common form of primary lymphedema, making up 65%-80% of cases. It is defined as lymphedema that becomes apparent after birth and before age 35 years and symptoms most often develop during puberty. Lymphedema praecox is four times more common in females as in males.
  • Primary lymphedema that becomes evident after 35 years of age is known as Meige disease. It is less common than congenital lymphedema and lymphedema praecox and accounts for 10% of cases of primary lymphedema.

Secondary lymphedema causes

Secondary lymphedema develops when a normally-functioning lymphatic system is blocked or damaged. In the U.S., breast cancer surgery, particularly when combined with radiation treatment, is the most common cause. This results in one-sided (unilateral) lymphedema of the arm. Any type of surgical procedure that requires removal of regional lymph nodes or lymph vessels can potentially cause lymphedema. Surgical procedures that have been associated with lymphedema include vein stripping, lipectomy, burn scar excision, and peripheral vascular surgery.

Damage to lymph node and lymph vessels, leading to lymphedema, can also occur due to trauma, burns, radiation, infections, or compression or invasion of lymph nodes by tumors.

Worldwide, however, filariasis is the most common cause of lymphedema. Filariasis is the direct infestation of lymph nodes by the parasite Wuchereria bancrofti. The disease is spread among persons by mosquitoes, and affects millions of people in the tropics and sub-tropics of Asia, Africa, Western Pacific, and parts of Central and South America. Infestation by the parasite damages the lymph system, leading to swelling in the arms, breasts, legs, and, for men, the genital area. The entire leg, arm, or genital area may swell to several times its normal size. Also, the swelling and the decreased function of the lymph system make it difficult for the body to fight infections. Lymphatic filariasis is a leading cause of permanent disability in the world.

What are the symptoms of lymphedema?

The swelling of lymphedema usually occurs in one or both arms or legs, depending upon the extent and localization of damage. Primary lymphedema can occur on one or both sides of the body as well. Lymphedema may be only mildly apparent or debilitating and severe, as in the case of lymphatic filariasis (see above), in which an extremity may swell to several times its normal size. It may first be noticed by the affected individual as an asymmetry between both arms or legs or difficulty fitting into clothing. If the swelling becomes pronounced, fatigue due to added weight may occur, along with embarrassment and restriction of daily activities.

The long-term accumulation of fluid and proteins in the tissues leads to inflammation and eventual scarring of tissues, leading to a firm, taut swelling that does not retain its displacement when indented with a fingertip (nonpitting edema). The skin in the affected area thickens and may take on a lumpy appearance described as an orange-peel (peau d'orange) effect. The overlying skin can also become scaly and cracked, and secondary bacterial or fungal infections of the skin may develop. Affected areas may feel tender and sore, and loss of mobility or flexibility can occur.

The immune system function is also suppressed in the scarred and swollen areas affected by lymphedema, leading to frequent infections and even a malignant tumor of lymph vessels known as lymphangiosarcoma.

How is lymphedema diagnosed?

A thorough medical history and physical examination are preformed to rule out other causes of limb swelling, such as edema due to congestive heart failure, kidney failure, blood clots, or other conditions. Often, the medical history of surgery or other conditions involving the lymph nodes will point to the cause and establish the diagnosis of lymphedema.

If the cause of swelling is not clear, other tests may be carried out to help determine the cause of limb swelling.

  • CT or MRI scans may be useful to help define lymph node architecture or to identify tumors or other abnormalities.
  • Lymphoscintigraphy is a test that involves injecting a tracer dye into lymph vessels and then observing the flow of fluid using imaging technologies. It can illustrate blockages in lymph flow.
  • Doppler ultrasound scans are sound wave tests used to evaluate blood flow, and can help identify blood clot in the veins (deep venous thrombosis) that may be a cause of limb swelling.

What are possible treatments for lymphedema?

There is no cure for lymphedema. Treatments are designed to reduce the swelling and control discomfort and other symptoms.

Compression treatments can help reduce swelling and prevent scarring and other complications. Examples of compression treatments are:

  • Elastic sleeves or stockings: These must fit properly and provide gradual compression from the end of the extremity toward the trunk.
  • Bandages: Bandages that are wrapped more tightly around the end of the extremity and wrapped more loosely toward the trunk, to encourage lymph flow out of the extremity toward the center of the body
  • Pneumatic compression devices: These are sleeves or stockings connected to a pump that provides sequential compression from the end of the extremity toward the body. These may be used in the clinic or in the home and are useful in preventing long-term scarring, but they cannot be used in all individuals, such as those with congestive heart failure, deep venous thrombosis, or certain infections.
  • Manual compression: Massage techniques, known as manual lymph drainage, can be useful for some people with lymphedema.
  • Exercises: Exercises that lightly contract and stimulate arm or leg muscles may be prescribed by your doctor or physical therapist to help stimulate lymph flow.

Surgical treatments for lymphedema are used to remove excess fluid and tissue in severe cases, but no surgical treatment is able to cure lymphedema.

Infections of skin and tissues associated with lymphedema must be promptly and effectively treated with appropriate antibiotics to avoid spread to the bloodstream (sepsis). Patients affected by lymphedema must constantly monitor for infection of the affected area. In affected areas of the world, the drug diethylcarbamazine is used to treat filariasis.

What are complications of lymphedema?

As noted before, secondary infections of the skin and underlying tissues can complicate lymphedema. Inflammation of the skin and connective tissues, known as cellulitis, and inflammation of the lymphatic vessels (lymphangitis) are common complications of lymphedema. Deep venous thrombosis (formation of blood clots in the deeper veins) is also a known complication of lymphedema.

Those who have had chronic, long-term lymphedema for more than 10 years have a 10% chance of developing a cancer of the lymphatic vessels known as lymphangiosarcoma. The cancer begins as a reddish or purplish lump visible on the skin and spreads rapidly. This is an aggressive cancer that is treated by amputation of the affected limb. Even with treatment, the prognosis is poor, with less than 10% of patients surviving after 5 years.

Can lymphedema be prevented?

Primary lymphedema cannot be prevented, but measures can be taken to reduce your risk of developing lymphedema if you are at risk for secondary lymphedema, such as after cancer surgery or radiation treatment.

The following steps may help reduce the risk of developing lymphedema in those at risk for secondary lymphedema:

  • Keep the affected arm or leg elevated above the level of the heart, when possible.
  • Avoid tight or constricting garments or jewelry (also avoid the use of blood pressure cuffs on an affected arm).
  • Do not apply a heating pad to the affected area or use hot tubs, steam baths, etc..
  • Keep the body adequately hydrated.
  • Avoid heavy lifting and forceful activity with the affected limb; but normal, light activity is encouraged.
  • Do not carry a heavy purse on an affected arm.
  • Practice thorough and careful skin hygiene.
  • Avoid insect bites and sunburns.

In this Article

  • What is lymphedema?
  • What causes lymphedema?
  • What are the symptoms of lymphedema?
  • How is lymphedema diagnosed?
  • What are possible treatments for lymphedema?
  • What are complications of lymphedema?
  • Can lymphedema be prevented?
  • What is the outlook (prognosis) for lymphedema?
  • Where can I get help and support for lymphedema?
  • Lymphedema At A Glance
  • Find a local Internist in your town

What is the outlook (prognosis) for lymphedema?

Lymphedema cannot be cured, but compression treatments and preventive measures for those at risk for secondary lymphedema can help minimize swelling and associated symptoms. As mentioned above, chronic, long-term edema that persists for many years is associated with an increased risk of developing a rare cancer, lymphangiosarcoma.

Where can I get help and support for lymphedema?

Many hospitals and treatment centers have support groups for people dealing with specific chronic conditions. Your health care practitioner may be able to direct you to a local support group for those with lymphedema.

The National Lymphedema Network (NLN) (http://www.lymphnet.org/) is a non-profit organization founded in 1988 to provide education and guidance to lymphedema patients, health care professionals, and the general public by disseminating information on the prevention and management of primary and secondary lymphedema.

 

Lymphedema At A Glance
  • Lymphedema is a condition that results from impaired flow of the lymphatic system.
  • Symptoms of lymphedema include swelling in one or more extremities. The swelling may range from mild to severe and disfiguring.
  • Primary lymphedema is present at birth; secondary lymphedema develops as a result of damage to or dysfunction of the lymphatic system.
  • Breast cancer treatment is the most common cause of lymphedema in the U.S.
  • While there is no cure for lymphedema, compression treatments and physical therapy may help reduce the swelling and discomfort.
Last Updated on Sunday, 18 December 2011 15:24
 
Larynx Cancer (Throat Cancer) PDF Print E-mail
Written by Ruai Pharmaceuticals   
Wednesday, 14 September 2011 16:58

Larynx Cancer (Throat Cancer)


  • What is the larynx?
  • What is cancer?
  • Who is at risk for larynx cancer?
  • What are symptoms of larynx cancer?
  • How is larynx cancer diagnosed?
  • What are treatment options for larynx cancer?
    • Methods of treatment
    • Patient Discussions: Larynx Cancer - Describe Your Experience
    • Find a local Oncologist in your town
  • What are the side effects of treatment for larynx cancer?
  • What is involved in rehabilitation after surgery for larynx cancer?
  • What happens after treatment for larynx cancer?
  • What support is available for patients with larynx cancer?
  • What resources are available to patients with larynx cancer and their families?
  • Larynx Cancer At A Glance

What is the larynx?

The larynx is an organ at the front of your neck. It is also called the voice box. It is about 2 inches long and 2 inches wide. It is above the windpipe (trachea). Below and behind the larynx is the esophagus.

The larynx has two bands of muscle that form the vocal cords. The cartilage at the front of the larynx is sometimes called the Adam's apple.

The larynx has three main parts:

  • The top part of the larynx is the supraglottis.
  • The glottis is in the middle. Your vocal cords are in the glottis.
  • The subglottis is at the bottom. The subglottis connects to the windpipe.

The larynx plays a role in breathing, swallowing, and talking. The larynx acts like a valve over the windpipe. The valve opens and closes to allow breathing, swallowing, and speaking:

  • Breathing: When you breathe, the vocal cords relax and open. When you hold your breath, the vocal cords shut tightly.
  • Swallowing: The larynx protects the windpipe. When you swallow, a flap called the epiglottis covers the opening of your larynx to keep food out of your lungs. The food passes through the esophagus on its way from your mouth to your stomach.
  • Talking: The larynx produces the sound of your voice. When you talk, your vocal cords tighten and move closer together. Air from your lungs is forced between them and makes them vibrate. This makes the sound of your voice. Your tongue, lips, and teeth form this sound into words.
Thyroid Gland illustration - Larynx Cancer

What is cancer?

Cancer begins in cells, the building blocks that make up tissues. Tissues make up the organs of your body. Normally, cells grow and divide to form new cells as your 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. Growths on the larynx also may be called nodules or polyps. Not all growths are cancer. Growths can be benign or malignant:

Benign growths are not cancer:

  • They are rarely life-threatening.
  • Usually, benign tumors can be removed, and they seldom grow back.
  • Cells from benign tumors do not spread to tissues around them or to other parts of the body.

Malignant growths are cancer:

  • They are generally more serious and may be life-threatening.
  • Malignant tumors usually can be removed, but they can grow back.
  • Cells from malignant tumors invade and damage nearby tissues and organs. Also, cancer cells can break away from a malignant tumor and enter the bloodstream or lymphatic system. That is how cancer cells spread from the original cancer (the primary tumor) to form new tumors in other organs. The spread of cancer is called metastasis. Different types of cancer tend to spread to different parts of the body.

Cancer of the larynx also may be called laryngeal cancer. It can develop in any part of the larynx. Most cancers of the larynx begin in the glottis. The inner walls of the larynx are lined with cells called squamous cells. Almost all laryngeal cancers begin in these cells. These cancers are called squamous cell carcinomas.

If cancer of the larynx spreads (metastasizes), the cancer cells often spread to nearby lymph nodes in the neck. The cancer cells can also spread to the back of the tongue, other parts of the throat and 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 in the larynx. For example, if cancer of the larynx spreads to the lungs, the cancer cells in the lungs are actually laryngeal cancer cells. The disease is called metastatic cancer of the larynx, not lung cancer. It is treated as cancer of the larynx, not lung cancer. Doctors sometimes call the new tumor "distant" disease.

Who's at risk for larynx cancer?

No one knows the exact causes of cancer of the larynx. Doctors cannot explain why one person gets this disease and another does not. We do know that cancer is not contagious. You cannot "catch" cancer from another person.

People with certain risk factors are more likely to get cancer of the larynx. A risk factor is anything that increases your chance of developing this disease.

Studies have found the following risk factors:

  • Age. Cancer of the larynx occurs most often in people over the age of 55.
  • Gender. Men are four times more likely than women to get cancer of the larynx.
  • Race. African Americans are more likely than whites to be diagnosed with cancer of the larynx.
  • Smoking. Smokers are far more likely than nonsmokers to get cancer of the larynx. The risk is even higher for smokers who drink alcohol heavily. People who stop smoking can greatly decrease their risk of cancer of the larynx, as well as cancer of the lung, mouth, pancreas, bladder, and esophagus. Also, quitting smoking reduces the chance that someone with cancer of the larynx will get a second cancer in the head and neck region. (Cancer of the larynx is part of a group of cancers called head and neck cancers.)
  • Alcohol. People who drink alcohol are more likely to develop laryngeal cancer than people who don't drink. The risk increases with the amount of alcohol that is consumed. The risk also increases if the person drinks alcohol and also smokes tobacco.
  • A personal history of head and neck cancer. Almost one in four people who have had head and neck cancer will develop a second primary head and neck cancer.
  • Occupation. Workers exposed to sulfuric acid mist or nickel have an increased risk of laryngeal cancer. Also, working with asbestos can increase the risk of this disease. Asbestos workers should follow work and safety rules to avoid inhaling asbestos fibers.

Other studies suggest that having certain viruses or a diet low in vitamin A may increase the chance of getting cancer of the larynx. Another risk factor is having gastroesophageal reflux disease (GERD), which causes stomach acid to flow up into the esophagus.

Most people who have these risk factors do not get cancer of the larynx. If you are concerned about your chance of getting cancer of the larynx, you should discuss this concern with your health care provider. Your health care provider may suggest ways to reduce your risk and can plan an appropriate schedule for checkups.

Symptoms

The symptoms of cancer of the larynx depend mainly on the size of the tumor and where it is in the larynx. Symptoms may include the following:

  • Hoarseness or other voice changes
  • A lump in the neck
  • A sore throat or feeling that something is stuck in your throat
  • A cough that does not go away
  • Problems breathing
  • Bad breath
  • An earache
  • Weight loss

These symptoms may be caused by cancer or by other, less serious problems. Only a doctor can tell for sure.

Diagnosis

If you have symptoms of cancer of the larynx, the doctor may do some or all of the following exams:

  • Physical exam. The doctor will feel your neck and check your thyroid, larynx, and lymph nodes for abnormal lumps or swelling. To see your throat, the doctor may press down on your tongue.
  • Indirect laryngoscopy. The doctor looks down your throat using a small, long-handled mirror to check for abnormal areas and to see if your vocal cords move as they should. This test does not hurt. The doctor may spray a local anesthesia in your throat to keep you from gagging. This exam is done in the doctor's office.
  • Direct laryngoscopy. The doctor inserts a thin, lighted tube called a laryngoscope through your nose or mouth. As the tube goes down your throat, the doctor can look at areas that cannot be seen with a mirror. A local anesthetic eases discomfort and prevents gagging. You may also receive a mild sedative to help you relax. 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.
  • CT scan. An x-ray machine linked to a computer takes a series of detailed pictures of the neck area. You may receive an injection of a special dye so your larynx shows up clearly in the pictures. From the CT scan, the doctor may see tumors in your larynx or elsewhere in your neck.
  • Biopsy. If an exam shows an abnormal area, the doctor may remove a small sample of tissue. Removing tissue to look for cancer cells is called a biopsy. For a biopsy, you receive local or general anesthesia, and the doctor removes tissue samples through a laryngoscope. 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 a tumor is cancerous.
If you need a biopsy, you may want to ask the doctor the following questions:
  • What kind of biopsy will I have? Why?
  • 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?
  • If I do have cancer, who will talk with me about treatment? When?

Treatment for larynx cancer

Staging

To plan the best treatment, your doctor needs to know the stage, or extent, of your disease. Staging is a careful attempt to learn whether the cancer has spread and, if so, to what parts of the body. The doctor may use x-rays, CT scans, or magnetic resonance imaging to find out whether the cancer has spread to lymph nodes, other areas in your neck, or distant sites.

Treatment

People with cancer of the larynx often 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 treatment choices. However, shock and stress after a diagnosis of cancer can make it hard to remember what you want to ask the doctor. Here are some ideas that might help:

  • Make a list of questions.
  • Take notes at the appointment.
  • Ask the doctor if you may use a tape recorder during the appointment.
  • Ask a family member or friend to come to the appointment with you.

Your doctor may refer you to a specialist who treats cancer of the larynx, such as a surgeon, otolaryngologist (an ear, nose, and throat doctor), radiation oncologist, or medical oncologist. You can also ask your doctor for a referral. Treatment usually begins within a few weeks of the diagnosis. Usually, there is time to talk to your doctor about treatment choices, get a second opinion, and learn more about the disease before making a treatment decision.

Getting a second opinion

Before starting treatment, you might want a second opinion about your diagnosis and 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 or you may ask for a referral to one or more specialists. At cancer centers, several specialists often work together as a team. The team may include a surgeon, radiation oncologist, medical oncologist, speech pathologist, and nutritionist. At some cancer centers, you may be able to see them all on the same day.
  • The Cancer Information Service, at 1-800-4-CANCER, can tell you about treatment centers near you.
  • A local medical society, a nearby hospital, or a medical school can often provide the names of specialists in your area.
  • The American Board of Medical Specialties (ABMS) has a list of doctors who have met certain education and training requirements and have passed specialty examinations. The Official ABMS Directory of Board Certified Medical Specialists lists doctors' names along with their specialty and their educational background. The directory is available in most public libraries. Also, ABMS offers this information on the Internet at http://www.abms.org. (Click on "Who's Certified.")

Preparing for treatment

The doctor can describe your treatment choices and the results you can expect for each treatment option. You will want to consider how treatment may change the way you look, breathe, and talk. You and your doctor can work together to develop a treatment plan that meets your needs and personal values.

The choice of treatment depends on a number of factors, including your general health, where in the larynx the cancer began, the size of the tumor, and whether the cancer has spread.

If you smoke, a good way to prepare for treatment is to stop smoking. Studies show that treatment is more likely to be successful for people who don't smoke. Your doctor or the Cancer Information Service (1-800-4-CANCER) may be able to suggest ways to help you stop smoking.

You may want to talk with the doctor about taking part in a clinical trial, a research study of new treatment methods. Clinical trials are an important option. Patients who join trials have the first chance to benefit from new treatments that have shown promise in earlier research. The section on "The Promise of Cancer Research" has more information about research in progress.

These are questions you may want to ask your doctor before treatment begins:

  • Where is my cancer and has it spread?
  • What are my treatment choices? Which do you recommend for me? Why?
  • What are the benefits of each treatment?
  • What are the risks and possible side effects of each treatment?
  • How will I look after treatment?
  • How will I speak after treatment? Will I need to work with a speech therapist?
  • Will I have problems eating?
  • Will I need to change my daily activities?
  • When can I return to work?
  • What is the treatment likely to cost? Is this treatment covered by my insurance plan?
  • Would a clinical trial (research study) be right for me? Can you help me find one?
  • How often will I need checkups?

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

Methods of treatment

Cancer of the larynx may be treated with radiation therapy, surgery, or chemotherapy. Some patients have a combination of therapies.

Radiation therapy (also called radiotherapy) uses high-energy x-rays to kill cancer cells. The rays are aimed at the tumor and the tissue around it. Radiation therapy is local therapy. It affects cells only in the treated area. Treatments are usually given 5 days a week for 5 to 8 weeks.

Laryngeal cancer may be treated with radiation therapy alone or in combination with surgery or chemotherapy:

  • Radiation therapy alone: Radiation therapy is used alone for small tumors or for patients who cannot have surgery.
  • Radiation therapy combined with surgery: Radiation therapy may be used to shrink a large tumor before surgery or to destroy cancer cells that may remain in the area after surgery. If a tumor grows back after surgery, it is often treated with radiation.
  • Radiation therapy combined with chemotherapy: Radiation therapy may be used before, during, or after chemotherapy.

After radiation therapy, some people need feeding tubes placed into the abdomen. The feeding tube is usually temporary.

These are questions you may want to ask your doctor before having radiation therapy:

  • Why do I need this treatment?
  • What are the risks and side effects of this treatment?
  • Are there any long-term effects?
  • Should I see my dentist before I start treatment?
  • When will the treatments begin? When will they end?
  • How will I feel during therapy?
  • What can I do to take care of myself during therapy?
  • Can I continue my normal activities?
  • How will my neck look afterward?
  • What is the chance that the tumor will come back?
  • How often will I need checkups?

Surgery is an operation in which a doctor removes the cancer using a scalpel or laser while the patient is asleep. When patients need surgery, the type of operation depends mainly on the size and exact location of the tumor.

There are several types of laryngectomy (surgery to remove part or all of the larynx):

  • Total laryngectomy: The surgeon removes the entire larynx.
  • Partial laryngectomy (hemilaryngectomy): The surgeon removes part of the larynx.
    • Supraglottic laryngectomy: The surgeon takes out the supraglottis, the top part of the larynx.
    • Cordectomy: The surgeon removes one or both vocal cords.

Sometimes the surgeon also removes the lymph nodes in the neck. This is called lymph node dissection. The surgeon also may remove the thyroid.

During surgery for cancer of the larynx, the surgeon may need to make a stoma. (This surgery is called a tracheostomy.) The stoma is a new airway through an opening in the front of the neck. Air enters and leaves the windpipe (trachea) and lungs through this opening. A tracheostomy tube, also called a trach ("trake") tube, keeps the new airway open. For many patients, the stoma is temporary. It is needed only until the patient recovers from surgery. More information about stomas can be found in the "Living with a Stoma" section.

After surgery, some people may need a temporary feeding tube.

This picture shows the pathways for air and food after a total laryngectomy.

The stoma is the new opening into the trachea.

Here are some questions to ask the doctor before having surgery:
  • How will I feel after the operation?
  • Will I need a tracheostomy?
  • Will I need to learn how to take care of myself or my incision when I get home?
  • Where will the scars be? What will they look like?
  • Will surgery affect my ability to speak? If so, who will teach me how to speak in a new way?
  • When can I get back to my normal activities?

Chemotherapy is the use of drugs to kill cancer cells. Your doctor may suggest one drug or a combination of drugs. The drugs for cancer of the larynx are usually given by injection into the bloodstream. The drugs enter the bloodstream and travel throughout the body.

Chemotherapy is used to treat laryngeal cancer in several ways:

  • Before surgery or radiation therapy: In some cases, drugs are given to try to shrink a large tumor before surgery or radiation therapy.
  • After surgery or radiation therapy: Chemotherapy may be used after surgery or radiation therapy to kill any cancer cells that may be left. It also may be used for cancers that have spread.
  • Instead of surgery: Chemotherapy may be used with radiation therapy instead of surgery. The larynx is not removed and the voice is spared.

Chemotherapy 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.

These are questions you may want to ask your doctor before having chemotherapy:
  • Why do I need this treatment?
  • What will it do?
  • Will I have side effects? What can I do about them?
  • How long will I be on this treatment?
  • How often will I need checkups?

Side effects of treatment for larynx cancer

Cancer treatments are very powerful. Treatments that remove or destroy cancer cells are likely to damage healthy cells, too. That's why treatments often cause side effects. This section describes some of the side effects of each kind of 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 how they can be managed. It may help to know that although some side effects may not go away completely, most of them become less troubling.

It may also help to talk with other patients. A social worker, nurse, or other member of the medical team can set up a visit with someone who has had the same treatment.

The NCI provides helpful booklets about cancer treatments and coping with side effects, such as Radiation Therapy and You and Eating Hints for Cancer Patients. See the "National Cancer Institute Information Resources" and "National Cancer Institute Booklets" sections for other sources of information about side effects.

Radiation therapy

 

People treated with radiation therapy may have some or all of these side effects:

  • Dry mouth. Drinking lots of fluids can help. Some patients find artificial saliva helpful. It comes in a spray or squeeze bottle.
  • Sore throat or mouth. Your health care provider may suggest special rinses to numb your throat and mouth and help relieve the soreness.
  • Delayed healing after dental care. Many doctors recommend having a dental exam and any needed dental work before radiation therapy.
  • Tooth decay. Good mouth care can help keep your teeth and gums healthy and can help you feel better. If it's hard to floss or brush your teeth in the usual way, you can try using gauze, a soft toothbrush, or a toothbrush that has a spongy tip instead of bristles. A mouthwash made with diluted peroxide, salt water, baking soda, or a combination can keep your mouth fresh and help protect your teeth from decay. It may also be helpful to use fluoride toothpaste or rinse.
  • Changes in sense of taste and smell. During radiation therapy, food may taste or smell different.
  • Fatigue. During radiation therapy, you may become very tired, especially in the later weeks of treatment. Resting is important, but doctors usually advise their patients to stay as active as they can.
  • 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. Voice changes and the feeling of a lump in your throat may come from swelling in the larynx caused by the radiation. The doctor may suggest medicine to reduce this swelling.
  • Skin changes in treated area. The skin in the treated area may become red or dry. Good skin care is important at this time. Try to expose this area to the air but protect it from the sun. Avoid wearing clothes that rub, and do not shave the treated area. You should not put anything on your skin before radiation treatments. Also, you should never use lotion or cream without your doctor's advice.

Surgery

People who have surgery may have any of these side effects:

  • Pain. You may be uncomfortable for the first few days after surgery. However, medicine can usually control the pain. You should feel free to discuss pain relief with the doctor or nurse.
  • Low energy. It is common to feel tired or weak after surgery. The length of time it takes to recover from an operation is different for each patient.
  • Swelling in the throat. For a few days after surgery, you won't be able to eat, drink, or swallow. At first, you will receive fluid through an intravenous (IV) tube placed into your arm. Within a day or two, you will get fluids and nutrition through a feeding tube (put in place during surgery) that goes through your nose and throat into your stomach. When the swelling goes away and the area begins to heal, the feeding tube will be removed. Swallowing may be difficult at first, and you may need the help of a nurse or speech pathologist. Soon you will be eating your regular diet. If you need a feeding tube for longer than one week, you may get a tube that goes directly into the abdomen. Most patients slowly return to eating solid foods by mouth, but for a very few patients, the feeding tube may be permanent.
  • Increased mucus production. After the operation, the lungs and windpipe produce a lot of mucus, also called sputum. To remove it, the nurse applies gentle suction by placing a small plastic tube in the stoma. You will learn to cough and suction mucus through the stoma without the nurse's help.
  • Numbness, stiffness, or weakness. After a laryngectomy, parts of the neck and throat may be numb because nerves have been cut. Also, the shoulder, neck, and arm may be weak and stiff. You may need physical therapy to improve your strength and flexibility after surgery.
  • Changes in physical appearance. Your neck will be somewhat smaller, and it will have scars. Some patients find it helpful to wear clothing that covers the neck area.
  • Tracheostomy. Patients who have surgery will have a stoma. With most supraglottic and partial laryngectomies, the stoma is temporary. After a short recovery period, the tube can be removed, and the stoma closes up. You should then be able to breathe and talk in the usual way. In some people, however, the voice may be hoarse or weak.

After a total laryngectomy, the stoma is permanent. If you have a total laryngectomy, you will need to learn to speak in a new way. The section called "Learning to Speak Again" has more information.

More information about stomas may be found in the "Living with a Stoma" section.

Chemotherapy

The side effects of chemotherapy depend mainly on the specific drugs and the dose. In general, anticancer drugs affect cells that divide rapidly:

  • Blood cells: These cells fight infection, help your blood to clot, and carry oxygen to all parts of your body. If your blood cells are affected, you are more likely to get infections, may bruise or bleed easily, and may feel very weak and tired.
  • Cells in hair roots: Chemotherapy can lead to hair loss, but hair will grow back. However, the new hair may be 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 new or improved drugs.

Nutrition

Some people who have had treatment for cancer of the larynx may lose their interest in food. Soreness and changes in smell and taste may make eating difficult. Yet good nutrition is important. Eating well means getting enough calories and protein to prevent weight loss, regain strength, and rebuild healthy tissues.

If eating is difficult because your mouth is dry from radiation therapy, you may want to try soft, bland foods moistened with sauces or gravies. Thick soups, puddings, and milkshakes often are easier to swallow. The nurse and the dietitian will help you choose the right foods.

After surgery or radiation therapy, some people need feeding tubes placed into the abdomen. Most people slowly return to a regular diet. Learning to swallow again may take some practice with the help of a nurse or speech pathologist. Some people find liquids easier to swallow; others do better with solid foods. You will find what works best for you.

Rehabilitation after surgery for larynx cancer

Living with a stoma

Learning to live with the changes brought about by cancer of the larynx is a special challenge. The medical team will make every effort to help you return to your normal routine as soon as possible.

If you have a stoma, you will need to learn how to care for it:

  • Before leaving the hospital, you will learn to remove and clean the trach tube, suction the trach, and care for the skin around the stoma.
  • If the air is too dry, as it may be in heated buildings in the winter, the tissues of the windpipe and lungs may produce extra mucus. Also, the skin around the stoma may get sore. Keeping the skin around the stoma clean and using a humidifier at home or at the office can lessen these problems.
  • It is very dangerous for water to get into the windpipe and lungs through the stoma. Wearing a special plastic stoma shield or holding a washcloth over the stoma keeps water out when showering or shaving. Other types of stoma covers-such as scarves, neckties, and specially made covers-help keep moisture in and around the stoma. They help filter smoke and dust from the air before it enters the stoma. They also catch any fluids that come out of the windpipe when you cough or sneeze. Many people choose to wear something over their stoma even after the area heals. Stoma covers can be attractive as well as useful.
  • When shaving, men should keep in mind that the neck may be numb for several months after surgery. To avoid nicks and cuts, it may be best to use an electric shaver until the numbness goes away.

People with stomas work in almost every type of business and can do nearly all of the things they did before. However, they cannot hold their breath, so straining and heavy lifting may be difficult. Also, swimming and water skiing are not possible without special instruction and equipment to keep water from entering the stoma.

Some people may feel self-conscious about the way they look and speak. They may be concerned about how other people feel about them. They may be concerned about how their sexual relationships may be affected. Many people find that talking about these concerns helps them. Counseling or support groups may also be helpful.

Learning to speak again

Talking is part of nearly everything we do, so it's natural to be scared if your voice box must be removed. Losing the ability to talk-even for a short time-is hard. Patients and their families and friends need understanding and support during this time.

Within a week or so after a partial laryngectomy, you will be able to talk in the usual way. After a total laryngectomy, however, you must learn to speak in a new way. A speech pathologist usually meets with you before surgery to explain the methods that can be used. In many cases, speech lessons start before you leave the hospital.

Until you begin to talk again, it is important to have other ways to communicate. Here are some ideas that you may find helpful:

  • Keep pads of paper and pens or pencils in your pocket or purse.
  • Use a typewriter, computer, or other electronic device. Your words can be printed on paper, displayed on a screen, or produced in a male or female voice.
  • Carry a small dictionary or a picture book and point to the words you need.
  • Write notes on a "magic slate" (a toy with a plastic sheet that covers black wax; lifting the plastic erases the sheet).

The health care team can help patients learn new ways to speak. It takes practice and patience to learn techniques such as esophageal speech or tracheoesophageal puncture speech, and not everyone is successful. How quickly a person learns, how understandable the speech is, and how natural the new voice sounds depend on the extent of the surgery on the larynx.

Esophageal speech

A speech pathologist can teach you how to force air into the top of your esophagus and then push it out again. The puff of air is like a burp. It vibrates the walls of the throat, making sound for the new voice. The tongue, lips, and teeth form words as the sound passes through the mouth.

This type of speech sounds low pitched and gruff, but it usually sounds more like a natural voice than speech made by a mechanical larynx. There is also no device to carry around, so your hands are free.

Tracheoesophageal puncture

For tracheoesophageal puncture (TEP), the surgeon makes an opening between the trachea and the esophagus. The opening is made at the time of initial surgery or later. A small plastic or silicone valve fits into this opening. The valve keeps food out of the trachea. After TEP, patients can cover their stoma with a finger and force air into the esophagus through the valve. The air produces sound by making the walls of the throat vibrate. The sound is a lot like natural speech.

Mechanical speech

You may choose to use a mechanical larynx while you learn esophageal or TEP speech or if you are unable to use these methods. The device may be powered by batteries (electrolarynx) or by air (pneumatic larynx).

Many different mechanical devices are available. The speech pathologist will help you choose the best device for your needs and abilities and will train you to use it.

One kind of electrolarynx looks like a small flashlight. It makes a humming sound. You hold the device against your neck, and the sound travels through your neck to your mouth. Another type of electrolarynx has a flexible plastic tube that carries sound into your mouth from a hand-held device. There are also devices that are built into a denture or retainer and can be worn inside your mouth and operated by a hand-held remote control.

A pneumatic larynx is held over the stoma and uses air from the lungs instead of batteries to make it vibrate. The sound it makes travels to the mouth through a plastic tube.

Followup care

Followup care is important after treatment for cancer of the larynx. Regular checkups ensure that any changes in health are noted. Problems can be found and treated as soon as possible. The doctor will check closely to be sure that the cancer has not returned. Checkups include exams of the stoma, neck, and throat. From time to time, the doctor may do a complete physical exam and take x-rays. If you had radiation therapy or a partial laryngectomy, the doctor will also examine you with a laryngoscope.

Treatments for laryngeal cancer can affect the thyroid. A blood test can tell if the thyroid is making enough thyroid hormone. If the level is low, you may need to take thyroid hormone pills.

People who have laryngeal 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 are smokers or drink alcohol heavily. Most doctors strongly urge their patients to stop smoking 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 followup care and other concerns. Facing Forward Series: Life After Cancer Treatment provides tips for getting the most out of medical visits. It describes the kinds of help people may need.

Support for people with larynx cancer

Living with a serious disease such as cancer is not easy. Some people find they need help coping with the emotional and practical aspects of their disease. Support groups can help. In these groups, people living with cancer get together to share what they have learned about coping with the disease and the effects of treatment. People interested in finding a support group may want to talk with their health care provider for suggestions.

People living with cancer may worry about caring for their families, keeping their jobs, or continuing daily activities. Concerns about tests, treatments, hospital stays, and medical bills are also common. Doctors, nurses, and other members of the health care team can answer questions about treatment, working, or other activities. Meeting with a social worker, counselor, or member of the clergy can be helpful for those who want to talk about their feelings or discuss their concerns. Often, a social worker can suggest resources for help with rehabilitation, emotional support, financial aid, transportation, or home care.

The Cancer Information Service (1-800-4-CANCER) can provide printed materials on coping, as well as information to help patients and their families locate programs and services.

The promise of cancer research

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

People who join these studies have the first chance to benefit from treatments that have shown promise in earlier research. They also make an important contribution to medical science by helping doctors learn more about the disease. Although clinical trials may pose some risks, researchers take very careful steps to protect their patients.

People with laryngeal cancer are participating in several types of treatment studies:

  • Radiation therapy. Researchers are studying a new approach to radiation therapy. Patients receive radiation three times a day, 5 days a week, for just over 2 weeks, instead of once a day for 5 to 7 weeks.
  • Drugs that reduce side effects. Researchers are testing therapies that reduce the side effects of radiation therapy. They are testing drugs that may help patients maintain their weight or help lessen damage to the skin during radiation therapy.
  • Chemotherapy. Scientists are studying drugs that kill cancer cells. These drugs are used alone or in combination with radiation therapy to spare the larynx from surgery.
  • Biological therapy. Scientists are studying monoclonal antibodies that slow or stop the growth of cancer.

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. NCI also offers an easy-to-read brochure called If You Have Cancer: What You Should Know About Clinical Trials. These NCI booklets describe how research studies are carried out and explain their possible benefits and risks. NCI's Web site includes a section on clinical trials at http://cancer.gov/clinical_trials. This section of the Web site provides general information about clinical trials. It also offers detailed information about specific ongoing studies of cancer of the larynx. The Cancer Information Service at 1-800-4-CANCER can answer questions and provide information from the NCI's database of clinical trials.

National Cancer Institute information resources

You may want more information for yourself, your family, and your doctor. The following National Cancer Institute (NCI) services are available to help you.

Telephone

Cancer Information Service (CIS) Provides accurate, up-to-date information on cancer to patients and their families, health professionals, and the general public. Information specialists explain the latest scientific information in understandable language and respond in English, Spanish, or on TTY equipment.

Toll-free: 1-800-4-CANCER (1-800-422-6237) TTY (for deaf and hard of hearing callers): 1-800-332-8615

Internet

The NCI's Cancer.gov™ Web site provides information from numerous NCI sources. It offers current information on cancer prevention, screening, diagnosis, treatment, genetics, supportive care, and ongoing clinical trials. It also provides information about NCI's research programs and funding opportunities, cancer statistics, and the Institute itself. Cancer.gov can be accessed at http://cancer.gov on the Internet.

Cancer.gov also provides live, online assistance through LiveHelp. Information specialists are available Monday through Friday from 9:00 AM to 10:00 PM Eastern Time. LiveHelp is at http://cancer.gov on the Internet.

Larynx Cancer At A Glance
  • The larynx is the voice box located at the top of the windpipe (trachea).
  • Cancer of the larynx occurs most often in people over the age of 55 years.
  • People who stop smoking can greatly reduce their risk of cancer of the larynx.
  • Painless hoarseness can be a symptom of cancer of the larynx.
  • The larynx can be examined with a viewing tube called a laryngoscope.
  • Treatment of cancer of the larynx depends on the location and size of the tumor as well as the age and health of the patient.
  • Cancer of the larynx is usually treated with radiation therapy or surgery. Chemotherapy can also be used for cancers that have spread.

Laryngitis


  • Laryngitis facts
  • What is laryngitis?
  • What causes laryngitis?
  • What are the symptoms of laryngitis?
  • Symptoms of laryngitis in adults
  • Symptoms of laryngitis in infants and children
  • Is laryngitis contagious?
  • How is laryngitis diagnosed?
  • What is the treatment for laryngitis?
  • Are there any home remedies for laryngitis?
  • What are the complications of laryngitis?
  • Patient Discussions: Laryngitis
  • Find a local Ear, Nose, & Throat Doctor in your town

Laryngitis facts

  • Laryngitis is an inflammation of the voice box.
  • Causes of laryngitis include upper respiratory infection or cold; excess talking, singing, or shouting; reflux laryngitis; chronic irritation of the vocal cords; or stroke.
  • Laryngitis is contagious if it is caused by an infection.
  • The most common symptoms of laryngitis are hoarseness, loss of voice, and throat pain.
  • Symptoms of laryngitis in adults include dry cough, sore throat, fever, swollen lymph nodes, pain with swallowing, and a feeling of fullness in the throat or neck.
  • Symptoms of laryngitis in infants in children include croup, hoarse barky cough, and fever.
  • Chronic laryngitis, in which the symptoms last for weeks, may be caused by by gastroesophageal reflux disease, smoking, or alcohol use.
  • Chronic inflammation due to laryngitis may cause nodules or polyps to form on the vocal cords.
  • Treatment of laryngitis is usually symptomatic, home remedies, and resting the voice.
  • If symptoms of laryngitis persist for more than a couple of weeks, further testing may be recommended.
  • Complications of laryngitis include pneumonia, GERD, chronic bronchitis, or vocal chord paralysis.

What is laryngitis?

The larynx is the voice box that allows us to speak, shout, whisper, and sing. The larynx consists of a cartilage skeleton that houses the vocal cords that are covered by a mucus lining. Muscles inside the larynx adjust the position, shape, and tension of the vocal cords, allowing us to make different sounds from whispering to to singing. Any change in the air flow (which is generated by the lungs exhaling air) across the vocal cords will affect the voice and the quality of the sound.

The larynx is located at the junction of the mouth and trachea and has a flap-like covering called the epiglottis, whose job it is to prevent food and saliva from entering the larynx during swallowing.

Laryngitis (larynx + itis = inflammation) is an inflammation of the voice box, causing a person to lose their voice. The quality of the voice becomes hoarse or gravelly-sounding or even too quiet or soft to hear.

Picture of the larynx and trachea
Picture of the larynx and trachea

 

What causes laryngitis?

  • Laryngitis is an inflammation of the vocal cords. Most commonly, acute laryngitis is caused by an infection that inflames the vocal cords.
  • Laryngitis may also be caused by voice overuse with excess talking, singing, or shouting.
  • Chronic laryngitis, often described as lasting for more than three weeks, may be caused by prolonged alcohol use, smoking, and excess coughing.
  • Gastroesophageal reflux disease (GERD) may cause laryngeal inflammation and chronic cough, if acid and digestive juices from the stomach reflux up into the esophagus and back of the throat. Sometimes people are aware of the presence of the acid and experience waterbrash, a sour taste in their mouth. Repeat spills of acid onto the vocal cords will cause a chemical irritation and result in inflammation of the vocal cords that hinders appropriate vibration and generation of sound.
  • Chronic irritation of the vocal cords may also cause polyps or nodules to form on the vocal cords, which may affect the ability of the vocal cords to vibrate causing hoarseness.
  • Stroke may also cause vocal cord muscle paralysis and lead to a weak, hoarse voice and swallowing problems.
  • Damage to the muscles or to the nerves that control them may lead to hoarseness. These nerves may be damaged if there has been trauma to the neck or if surgery has been performed and the nerves inadvertently irritated or severed.
  • Tumors in the neck and chest may compress the nerves and cause them to function poorly.
  • Thyroid inflammation and enlargement can also cause irritation of nerves that supply the vocal cord muscles.
  • Not all individuals who have lost their voice have an infection.
  • Diphtheria is rarely a cause of laryngitis-like symptoms because most people are immunized and protected against this infection.

What are the symptoms of laryngitis?

Hoarseness, loss of voice, and throat pain are the primary symptoms of laryngitis.

Symptoms of laryngitis in adults

If the cause of laryngitis is infectious, affected individuals will have symptoms of:

  • Upper respiratory tract infection or cold
  • Dry cough
  • Sore throat

  • Fever

     

  • Swollen lymph nodes (lymph glands) in the neck
  • Pain with swallowing
  • A feeling of fullness in the throat or neck
  • Runny nose

  • Loss of voice

Symptoms of laryngitis in infants and young children

Air is brought into our lungs like a bellows, sucking air in through the mouth. In children with croup, there also may be difficulty breathing. As the child tries to breathe through a swollen and narrow larynx, the cartilage may collapse, just like when attempting to breathe through a straw. As we age, the cartilage becomes stiffer and is able to withstand deeply indrawn breaths, but in children the cartilage is weaker and with each inspiration, the child may need to work hard to inhale.

In infants and young children, the classic signs and symptoms of an inflamed larynx caused by infection include:

  • croup,
  • a hoarse barky cough, and
  • fever.

Other symptoms of laryngitis

When the cause of laryngitis is not infectious, cough may be a significant symptom along with the hoarseness.

Is laryngitis contagious?

Laryngitis is contagious if it is caused by an infection. If a respiratory infection or cold is caused by an infection, they are contagious. Laryngitis, upper respiratory infections, and colds are commonly a viral infection spread by aerosol droplets.

Covering the nose and mouth when coughing and sneezing, and proper hygiene habits (for example, washing the hands often) help prevent transmission of viruses.

How is laryngitis diagnosed?

The health care practitioner can often diagnose laryngitis quickly at the doctor's office. The history of upper respiratory tract infection associated with loss of voice is reinforced by the patient answering questions in a hoarse voice. The examination is often brief and limited to the ears, nose, and throat, looking for other potential causes of the cold-like symptoms. If the throat is red and there is a concern about a strep throat in addition to the laryngitis, a throat swab for a strep screen may be done.

If the hoarse voice becomes chronic, the health care practitioner may want to take a more detailed history, accessing reasons why the larynx and vocal cords have become inflamed for a prolonged period of time.

Questions may be asked about:

  • Diet, use of alcohol, aspirin, ibuprofen, and smoking, all of which may cause gastroesophageal reflux disease. Alcohol and tobacco smoking can irritate the vocal cords.
  • Work and hobbies may reveal evidence of repeated chemical inhalation and exposure.
  • Exploration in regard to whether there may be thyroid disease, symptoms of stroke, or cancers of the head and neck.

Most cases of laryngitis need no testing to confirm the diagnosis. In those patients with chronic laryngitis, the necessity for blood tests, X-rays and other diagnostic tests will depend upon the patient presentation and the potential concerns that the health care practitioner has regarding the cause of the hoarseness.

Laryngoscopy is the most common test performed to look directly at the vocal cords and evaluate their function. Using a thin tube containing a lighted fiberoptic camera inserted through the nose into the back of the throat, an otolaryngologist (ear, nose, and throat specialist) can see whether the vocal cords are inflamed, if there are any polyps or nodules growing on them, and if they move appropriately with breathing and speaking.

What is the treatment for laryngitis?

As with any other structure in the body that becomes inflamed, rest is the key to recovery. For laryngitis, this means limiting the amount of talking. If talking is required, the affected individual should avoid whispering and instead talk in a regular voice, regardless of how it sounds. Whispering requires the vocal cords to be stretched tightly and requires more work by the surrounding muscles and delays recovery time.

  • The treatment for viral laryngitis is supportive: plenty of fluids, humidified air, acetaminophen or ibuprofen for pain, and time for recovery.
  • For patients with significant laryngitis, a short course of steroids (prednisone, prednisolone, or dexamethasone) may be used to decrease the inflammation and shorten the course of symptoms. This treatment option is often considered for actors, singers, or other affected individuals who have to make a time sensitive presentation using their voice.
  • Dexamethasone as a single dose given orally (Decadron, DexPak) or by intramuscular injection (Adrenocot, CPC-Cort-D, Decadron Phosphate, Decaject-10, Solurex) may be used to treat croup.
  • The treatment of chronic laryngitis will be determined by the cause of the inflammation or loss of function. Discontinuation of smoking and alcohol use will have a positive effect.

Are there any home remedies for laryngitis?

It is reasonable not to seek medical care for most cases of laryngitis. Home treatment begins with resting the voice and keeping well hydrated. Symptoms may be controlled by exposure to humidified air. Often, the bathroom is the best place to create a highly humidified area.

  • Turn on the hot water in the shower until there is plenty of steam.
  • Make certain that all the hot water is drained from the tub or shower to prevent the risk of burns.
  • Spend 15- 20 minutes breathing the warm moist air to help with symptoms.

A cold water vaporizer may also be used to help with humidity. Avoid hot water vaporizers because of the risk of burns.

Stay well hydrated, especially if the pain makes it difficult to swallow fluid.

Warm water gargles may be soothing. Alternatively, popsicles may offer comfort.

Tylenol and/or ibuprofen may be helpful in decreasing the amount of pain.

 

What are the complications of laryngitis?

If the cause of laryngitis is vocal cord paralysis, the swallowing mechanism may also be affected, and food particles may enter the larynx and lungs, leading to coughing. This process can also lead to pneumonia and its accompanying symptoms (fever, cough, shortness of breath) when the food is aspirated deep into the lungs and causes irritation and inflammation of lung tissue.

Repeated episodes of gastroesophageal reflux may cause small amounts of acid to get past the inflamed larynx and enter the lung, causing recurrent pneumonia or bronchitis.

Prior to the advent of Haemophilus influenzae immunization, epiglottitis due to this infection was always considered as a possible alternative diagnosis for children with croup. This was a life-threatening medical emergency because the epiglottis could massively swell, blocking air from entering the larynx and lungs. X-rays of the neck may be taken to visualize the epiglottis and look for swelling. The diagnosis was often confirmed in the operating room where the otolaryngologist and anesthesiologist would use laryngoscopy to look at the epiglottis and vocal cords and decide whether to insert a breathing tube in the child's airway to prevent the airway from swelling shut. Fortunately, because of immunization, this disease is rarely seen.

 

LASEK laser eye surgery

  • Introduction to LASEK laser eye surgery
  • What are the advantages of LASEK laser eye surgery?
  • What are the disadvantages of LASIK laser eye surgery?
  • What are the side effects of LASIK laser eye surgery?
  • How do I know if LASIK laser eye surgery is for me?
  • How do I prepare for LASIK laser eye surgery?
  • What happens duing LASIK laser eye surgery?
  • What happends after LASIK laser eye surgery?
  • When to call the doctor
  • Find a local Eye Doctor in your town

Introduction

LASEK laser eye surgery is a newer surgery that combines many of the benefits of older vision correction surgeries, explain doctors at The Cleveland Clinic.

Laser epithelial keratomileusis, or LASEK, combines benefits of the two most commonly performed procedures -- LASIK and PRK. LASEK laser eye surgery is used to treat astigmatism, nearsightedness or farsightedness.

In LASEK laser eye surgery, the epithelium, or outer layer of the cornea, is cut not with the microkeratome cutting tool used in LASIK, but with a finer blade called a trephine and a 20% alcohol solution.

What Are the Advantages of LASEK Laser Eye Surgery?

  • Complications associated with cutting and reattaching the flap in the cornea are avoided.
  • LASEK laser eye surgery causes dry eye less frequently than LASIK laser eye surgery.

What Are the Disadvantages of LASEK Laser Eye Surgery?

  • Longer visual recovery time compared to LASIK laser eye surgery. Many LASEK patients will not fully recover functional vision for 1 to 2 weeks while their eye heals, which is similar to the healing time experienced in PRK laser eye surgery. LASIK laser eye surgery patients often have good vision by the day after surgery.
  • LASEK laser eye surgery may cause more pain and discomfort than LASIK , but less pain than PRK laser eye surgery. Most LASEK laser eye surgery patients say the discomfort lasts about 2 days or less.
  • Patients need to wear a "bandage contact lens" for about 3 or 4 days after LASEK laser eye surgery to serve as a protective layer between your blinking eyelids and the treated eye surface, which is not necessary after LASIK.
  • Patients must use topical steroid drops for several weeks longer than that used after LASIK laser eye surgery.

What Are the Side Effects of LASEK Laser Eye Surgery?

LASEK laser eye surgery shows side effects less frequently than is seen with PRK, however side effects may occur. These may include:

  • Sensation of having a foreign object in your eye (can last anywhere from 1 to 4 days)
  • Temporary reduced vision under poorly lit conditions (up to 12 months)
  • Dry eyes, requiring the use of moisturizing drops (up to 6 months)
  • Hazy or cloudy vision (should disappear within 6 to 9 months)

How Do I Know if LASEK Laser Eye Surgery Is for Me?

LASEK laser eye surgery may be better for patients who have steep or very thin corneas, which make it difficult for the surgeon to make a proper LASIK flap. Since traumatic injury to the eye is more serious after LASIK than LASEK laser eye surgery, patients who engage in professional or leisure activities that put their eyes at increased risk for injury (such as boxing) may be better suited for LASEK. LASEK laser eye surgery is better for people with dry eye syndrome because in avoiding a deeper flap, the corneal nerves responsible for the tearing reflex are not cut.

How Do I Prepare for LASEK Laser Eye Surgery?

Before your LASEK laser eye surgery you will have met with a coordinator who will discuss what you should expect during and after the laser eye surgery. During this session your medical history will be evaluated and your eyes will be tested. Likely tests include measuring corneal thickness, refraction, and pupil dilation. Once you have gone through your evaluation, you will meet the surgeon, who will answer any further questions you may have. Afterwards, you can schedule an appointment for the procedure.

If you wear rigid gas permeable contact lenses, you should not wear them for three weeks before your surgery. Other types of contact lenses shouldn't be worn for at least three days prior to surgery. Be sure to bring your eyeglasses to the surgeon so your prescription can be reviewed.

On the day of your LASEK laser eye surgery, eat a light meal before going to the doctor, and take all of your prescribed medications. Do not wear eye makeup or have any bulky accessories in your hair that will interfere with positioning your head under the laser. If you do not feel well that morning, call the doctor's office to determine whether the procedure needs to be postponed.

What Happens During LASEK Laser Eye Surgery?

LASEK laser eye surgery is done under local anesthesia. During the procedure, the top layer of cells, or epithelium, is treated with alcohol for about 30 seconds to detach it from the underlying tissue. It is then lifted or rolled back so that the eye doctor can access the cornea tissue. The newly exposed tissue is treated with the same laser used in LASIK laser eye surgery and PRK. Then the top layer of cells is replaced.

This is in contrast to LASIK laser eye surgery, in which a cutting device makes a flap in the cornea. LASEK laser eye surgery differs from PRK by preserving the top layer of cells, rather than scraping them away and waiting for them to grow back. This is believed to facilitate healing of the cornea with less discomfort than PRK.

What Happens After LASEK Laser Eye Surgery?

After LASEK laser eye surgery, expectations are similar to what can expected after LASIK. However, even though the flap created by LASEK laser eye surgery heals in about a day, patient usually wear a special contact lens that acts as a bandage for up to four days after surgery. Patients also may experience irritation in their eye during the first day or two after LASEK laser eye surgery For patients who undergo the LASIK procedure, good vision is usually attained in a few days. For LASEK laser eye surgery this may take as long as a week.

You will revisit the doctor for an evaluation the day after LASEK laser eye surgery, as well as one week and three months after surgery.

When to Call the Doctor

If you have any questions after your LASEK laser eye surgery or if you experience pain, a sudden decrease in vision, red eye(s), or discharge from your eye(s), contact your eye doctor immediately.

 

Laser Resurfacing


  • Who Is a Good Candidate For Laser Resurfacing
  • How Does Laser Skin Resurfacing Work?
  • CO2 Laser Resurfacing
  • Erbium Laser Resurfacing
  • What Can Be Expected During Laser Resurfacing?
  • What Happens After Laser Resurfacing
  • What Are The Possible Complications of Laser Resurfacing?
  • How Should I Take Care Of My Skin After Laser Resurfacing?
  • Will My Insurance Cover Laser Resurfacing
  • Find a local Dermatologist in your town

Introduction

Laser resurfacing is a relatively new treatment for reducing facial wrinkles and skin irregularities, such as blemishes or acne scars.

The technique directs short, concentrated pulsating beams of light at irregular skin. Laser skin resurfacing removes skin very precisely, layer by layer, resulting in fewer problems with hypopigmentation (lightening of skin). This popular procedure is known by several other names, including lasabrasion, laser peel or laser vaporization.

Who Is a Good Candidate For Laser Resurfacing?

If you have fine lines or wrinkles around or under the eyes, the forehead, the mouth, or scars from acne, non-responsive skin after a facelift, then you may be an ideal candidate for laser skin resurfacing.

If you have active acne or if you have very dark skin, you are not a candidate. This technique is also not recommended for stretch marks.

How Does Laser Skin Resurfacing Work?

The two types of lasers most commonly used in laser resurfacing are carbon dioxide (CO2) and erbium. Each laser vaporizes superficial, damaged skin cells and both reduce the risk for the patient because they limit the amount of heat absorbed by the skin.

CO2 Laser Resurfacing

This method has been used for years to treat different skin conditions including wrinkles, scars, warts, birthmarks, enlarged oil glands on the nose (rhinophyma), skin cancer and other conditions.

The newest version of the CO2 laser resurfacing uses very short pulsed light energy (ultrapulsed) or continuous light beams that are delivered in a scanning pattern to very precisely remove thin layers of skin with minimal heat damage to the surrounding structures. Recovery time from the procedure is up to two weeks.

Patients should seek out surgeons with documented training and experience in laser skin resurfacing.

Erbium Laser Resurfacing

Erbium laser resurfacing is designed to remove superficial and moderately deep lines and wrinkles on the face hands, neck, or chest. One of the benefits of erbium laser resurfacing is minimal burning of surrounding tissue. This laser causes minimal side effects, such as swelling, bruising and redness, so your recovery time should be more rapid than with CO2 laser resurfacing - one week in most cases.

If you have a darker skin tone, erbium laser resurfacing may work better for you. Your doctor will determine which laser is best for you after he or she fully evaluates your medical history, current physical condition, and desired results.

What Can Be Expected During Laser Resurfacing?

Both erbium and CO2 laser resurfacing are performed on an outpatient basis, using local anesthesia (pain relief at the site of the procedure) in combination with orally- or intravenously-administered sedative medications.

Wrinkles around the eyes, mouth or forehead may be treated individually, or a full-face laserabrasion may be performed.

The areas to be treated are numbed with a local anesthetic. General anesthesia may be used when the entire face is treated. A partial-face laserabrasion takes 30-45 minutes and the full-face treatment takes 1-1/2 to 2 hours.

What Happens After Laser Resurfacing?

Following laser resurfacing, a sterile dressing is applied to the treatment sites for 24 hours. The patient then cleans the treated areas two to five times a day with saline or a dilute vinegar solution. An ointment such as Vaseline, Eucerin or Aquaphor is then applied. This wound care is intended to prevent any scab formation. In general, the areas heal in 10-21 days, depending on the nature of the condition that was treated.

Once the areas have healed, makeup may be worn to camouflage the pink to red color that is generally seen after laser skin resurfacing. Green-based make-ups are particularly suitable for this camouflage since they neutralize the red color. Oil-free make-ups are recommended after laser resurfacing. The redness in the laser-treated sites generally fades in two to three months but may take as long as six months to completely disappear. The redness generally persists longer in blondes and redheads.

Patients with darker skin tones have a greater risk of healing with darker pigmentation. This may be minimized by use of a bleaching agent before laser skin resurfacing as well as continued use of this agent after healing.

What Are the Possible Complications of Laser Resurfacing?

  • Milia, which are small white bumps, may appear in the laser-treated areas during healing. These may be removed by gentle cleansing with a washcloth.
  • Hyperpigmentation (increased pigmentation), and more rarely hypopigmentation (decreased skin pigmentation), may result in the laser-treated areas. In general, the hyperpigmented areas may be treated with bleaching cream to speed fading of the pigment.
  • Reappearance of a cold sore may occur, especially after laser skin resurfacing around the mouth. You can prevent this by asking your doctor for an antiviral medication, which you can begin taking before your surgery and continue taking seven to 10 days after laser resurfacing.
  • You can also prevent bacterial infections by taking an antibiotic prior to the surgery and continuing for seven to 10 days afterwards.
  • You should expect swelling after laser skin resurfacing. Ask your doctor about steroids injected into the muscles, which can lessen this effect.
  • Patients are encouraged to sleep on an extra pillow at night to help reduce the swelling after laser resurfacing. Ice pack application is also helpful in the first 24-48 hours.
  • Scarring after laser skin resurfacing, although very rare, may occur in laser-treated areas.
  • Cessation of smoking is highly recommended because smoking is known to have harmful effects on the healing process.

How Should I Take Care of My Skin After Laser Resurfacing?

It's important to remember that skin treated with laser resurfacing may react in different ways.

Most commonly, you may feel like you have mild sunburn. There will be slight swelling and redness of the skin. You may experience itching or stinging for 12 to 72 hours after the procedure. Five to seven days after laser resurfacing, your skin will become dry and peel.

New skin will form after the treated area has been peeled. This skin will at first appear pink. It should begin to gradually lighten for up to a year after treatment. Your doctor will not consider retreating the area until the area is completely healed.

Daily sunscreen application is necessary after healing to protect the newly laser-resurfaced skin. A "broad-spectrum" sunscreen, which screens both ultraviolet B and ultraviolet A rays, is recommended. A sunscreen specifically formulated for use on the face should be chosen, with at least a sun protection factor (SPF) of 15.

Liberal moisturizer application is also recommended after healing. Patients may resume application of Retin-A and/or glycolic acid products around six weeks after laser resurfacing or as directed by their physician.

Will My Insurance Cover Laser Skin Resurfacing?

Insurance does not cover laser resurfacing because it is an elective cosmetic surgery.

LTK Laser Eye Surgery

  • Introduction to LTK laser eye surgery
  • What are the advantages of LTK laser eye surgery?
  • What are the disadvantages of LTK laser eye surgery?
  • What are the potential side effects of LTK laser eye surgery?
  • Who's a candidate for LTK laser eye surgery?
  • How should I prepare for LTK laser eye surgery?
  • What happens during the LTK laser eye surgery?
  • What should I expect after the LTK laser eye surgery?
  • Find a local Eye Doctor in your town

Introduction

 

Laser thermokeratoplasty, or LTK laser eye surgery, is a new procedure used to treat farsightedness and astigmatism.

During LTK laser eye surgery, a laser beam uses heat to shrink and reshape the cornea. Vision problems from farsightedness or astigmatism are corrected in a matter of seconds, without any cutting or removal of tissue.

Although highly effective in the short-term, the results of LTK laser eye surgery are not permanent. Your vision gradually regresses, mostly during the first three months following LTK laser eye surgery. To compensate, the doctor will intentionally overcorrect, so you end up with your desired vision.

What Are the Advantages of LTK Laser Eye Surgery?

The advantages of LTK laser eye surgery include:

  • Little risk of infection or vision loss since the laser is the only thing that touches the eye during LTK laser eye surgery.
  • LTK laser eye surgery s very fast.
  • Little discomfort results from LTK laser eye surgery and patients are often able to resume normal activities the following day.

What Are the Disadvantages of LTK Laser Eye Surgery?

The disadvantages of LTK laser eye surgery include:

  • LTK laser eye surgery is not permanent.
  • Patients experience temporary nearsightedness following the procedure since over-correction of vision is required to account for regression. Some patients may even need to wear glasses for a few weeks following LTK laser eye surgery.
  • It is common for people who have had the LTK laser eye surgery to lose about half of the corrective effects within two years of the surgery.

What Are the Potential Side Effects of LTK Laser Eye Surgery?

Other than nearsightedness, you may also feel as if you have a foreign object in your eye. But this sensation should go away after the first day with the help of eye drops given to you by your doctor. You may also experience sensitivity to light the first day or so following LTK laser eye surgery, but pain or other discomfort is rarely associated with this procedure.

Who's a Candidate for LTK Laser Eye Surgery?

Due to its non-permanent effects, LTK laser eye surgery is only performed in people over the age of 40 who are mildly farsighted. Other than age, the qualifications for this surgery are the same as the qualifications for any refractive surgery.


In this Article

  • What are the disadvantages of
  • What are the potential side effects of LTK laser eye surgery
  • Who's a candidate for LTK laser eye surgery?
  • How should I prepare for LTK laser eye surgery?
  • What happens during the LTK laser eye surgery?
  • What should I expect after the LTK laser eye surgery?
  • Find a local Eye Doctor in your town

How Should I Prepare for LTK Laser Eye Surgery?

Before your LTK laser eye surgery you will meet with a coordinator who will discuss what you should expect during and after the surgery. During this session your medical history will be evaluated and your eyes will be tested. Likely tests include measuring corneal thickness, refraction, and pupil dilation. Once you have gone through your evaluation, you will meet the surgeon, who will answer any further questions you may have. Afterwards, you can schedule an appointment for the procedure.

If you wear rigid gas permeable contact lenses, you should not wear them for three weeks before your surgery. Other types of contact lenses shouldn't be worn for at least three days prior to surgery. Be sure to bring your eyeglasses to the surgeon so your prescription can be reviewed.

On the day of your surgery, eat a light meal before going to the doctor and take all of your prescribed medications. Do not wear eye makeup or have any bulky accessories in your hair that will interfere with positioning your head under the laser. If you do not feel well that morning, call the doctor's office to determine whether the procedure needs to be postponed.

What Happens During the LTK Laser Eye Surgery?

LTK laser eye surgery is done under a local anesthesia. During LTK laser eye surgery, a laser beam uses heat to shrink and reshape the cornea. Vision is corrected in a matter of seconds, without any cutting or removal of tissue.

What Should I Expect After LTK Laser Eye Surgery?

After LTK laser eye surgery, most doctors will schedule follow-up appointments for the next day as well as for one week, one month, and 3-6 months after LTK laser eye surgery. To prevent infection or any irritation that may occur, you will be given antibiotic drops as well as anti-inflammatory drops to take for one week after LTK laser eye surgery.

As previously mentioned, for the first week after LTK laser eye surgery it is common to experience nearsightedness, however as the regression slows your distance vision will improve considerably. From the end of the first week to 3 months following LTK laser eye surgery, you should expect some fluctuations of vision.

 

Reviewed by the doctors at The Cleveland Clinic Cole Eye Institute.

Laser Use in Dentistry


  • Introduction to laser use in dentistry
  • How do lasers work?
  • What are the pros and cons of using a laser in dentistry?
  • Find a local Doctor in your town

Introduction

Lasers have been used in dentistry since 1994 to treat a number of dental problems. But, despite FDA approval, no laser system has received the American Dental Association's Seal of Acceptance. That seal assures dentists that the product or device meets ADA standards of safety and efficacy, among other things. The ADA, however, states that it is cautiously optimistic about the role of laser technology in the field of dentistry. These lasers are different from the cold lasers used in phototherapy for the relief of headaches, pain, and inflammation.

Still, some dentists are using lasers to treat:

  • Tooth decay. Lasers are used to remove decay within a tooth and prepare the surrounding enamel for receipt of the filling. Lasers are also used to "cure" or harden a filling.
  • Gum disease. Lasers are used to reshape gums and remove bacteria during root canal procedures.
  • Biopsy or lesion removal. Lasers can be used to remove a small piece of tissue (called a biopsy) so that it can be examined for cancer. Laser are also used to remove lesions in the mouth; and relieve the pain of canker sores.
  • Teeth whitening. Lasers are used to speed up the in-office teeth whitening procedures. A peroxide bleaching solution, applied to the tooth surface, is "activated" by laser energy, which speeds up of the whitening process.

How Do Lasers Work?

All lasers work by delivering energy in the form of light. When used for surgical procedures, the laser acts as a cutting instrument or a vaporizer of tissue that it comes in contact with. When used for "curing" a filling, the laser helps to strengthen the bond between the filling and the tooth. When used in teeth whitening procedures, the laser acts as a heat source and enhances the effect of tooth beaching agents.

What Are the Pros and Cons of Using a Laser?

Pros
Compared to the traditional dental drill, lasers:

  • May cause less pain in some instances, therefore, reducing the need for anesthesia
  • May reduce anxiety in patients uncomfortable with the use of the dental drill
  • Minimize bleeding and swelling during soft tissue treatments
  • May preserve more healthy tooth during cavity removal

Cons
The disadvantages of lasers are that:

  • Lasers can't be used on teeth with fillings already in place.
  • Lasers can't be used in many commonly performed dental procedures. For example, lasers can't be used to fill cavities located between teeth, around old fillings, and large cavities that need to be prepared for a crown. In addition, lasers cannot be used to remove defective crowns or silver fillings, or prepare teeth for bridges.
  • Traditional drills may still be needed to shape the filling, adjust the bite, and polish the filling even when a laser is used.
  • Lasers do not eliminate the need for anesthesia.
  • Laser treatment tends to be more expensive since the cost of the laser is much higher than a dental drill. Lasers can cost between $39,000 and $45,000 compared to about $600 for a standard drill.

LASIK Eye Surgery


  • What is LASIK?
  • How does LASIK work?
  • What is refractive error?
  • What are the primary types of refractive error?
  • How do glasses or contacts improve vision in people with refractive errors?
  • What happens to vision when we age?
  • Are there different types of LASIK?
  • What is conventional LASIK?
  • What is wavefront-optimized LASIK?
  • What is wavefront-guided LASIK?
  • What other types of refractive surgery are available?
  • Am I a good candidate for LASIK?
  • What is my doctor looking for during my evaluation?
  • What are the risks of LASIK?
  • How do I find the right doctor?
  • What should I expect before, during and after surgery?
  • What are the advantages of LASIK surgery?
  • What are the disadvantages of LASIK surgery?
  • LASIK checklist
  • Find a local Eye Doctor in your town

What is LASIK?

LASIK stands for laser in situ keratomileusis, which means using a laser underneath a corneal flap (in situ) to reshape the cornea (keratomileusis). This procedure utilizes a highly specialized laser (excimer laser) designed to treat refractive errors, improve vision, and reduce or eliminate the need for glasses or contact lenses. This laser procedure alters the shape of the cornea, which is the transparent front covering of the eye. Though the excimer laser had been used for many years before, the development of LASIK is generally credited to Ioannis Pallikaris from Greece around 1991.

How does LASIK work?

During the LASIK procedure, a specially trained eye surgeon first creates a precise, thin hinged corneal flap using a microkeratome. The surgeon then pulls back the flap to expose the underlying corneal tissue, and then the excimer laser ablates (reshapes) the cornea in a unique pre-specified pattern for each patient. The flap is then gently repositioned onto the underlying cornea without sutures.

What is refractive error?

In the human eye, the front surface (cornea) and lens inside the eye form the eye's "focusing system" and are primarily responsible for focusing incoming light rays onto the surface of the retina, much like the lenses of a camera focus light onto the film. In a perfect optical system, the power of the cornea and lens are perfectly matched with the length of the eye and images are in focus; any mismatch in this system is called a refractive error, and the result is a blurred image at some location.

What are the primary types of refractive error?

Myopia (nearsightedness): In people with myopia, the mismatch in focusing power and eye length causes distant objects to be blurry and near objects to be clearer.

Hyperopia (farsightedness): In people with hyperopia, the mismatch in focusing power and eye length causes near objects to be blurry and distant objects to be relatively clearer.

Astigmatism: In people with astigmatism, either the corneal or lens shape is distorted, causing multiple images on the retina. This causes objects at all distances to appear blurry. Many people have a combination of either myopia or hyperopia with astigmatism.

How do glasses or contacts improve vision in people with refractive errors?

Glasses or contact lenses are used to compensate for the eye's refractive error by bending light rays in a way that complements the eye's specific refractive error. In contrast, LASIK and other forms of refractive surgery are intended to correct the eye's refractive error to reduce the need for other visual aids.

What happens to vision when we age?

During our youth, the natural lens has the ability to change shape and power. This allows us to focus on close objects through a process of lens power change called accommodation. As we age, the natural lens becomes stiffer and loses the ability to change shape. This is termed presbyopia, which is the loss of accommodation, and the need for reading glasses, bifocals, or other visual aids to facilitate near work. LASIK cannot directly "fix" accommodation, but there are a variety of strategies that can be successful, including blended vision or monovision, in which one eye is corrected for better distance vision and one eye is corrected for better near vision.

Are there different types of LASIK?

There are a variety of different types of lasers used in ophthalmology. All LASIK procedures are performed with a specific type of laser (excimer laser), so in one sense, all LASIK procedures are similar. However, there are a variety of different laser manufacturers, including Visx, Wavelight, Alcon, Bausch & Lomb, and Nidek, among others, that have all designed specific excimer lasers. Further, there are different types of laser ablations that can be performed (see below), including conventional laser treatments, wavefront-optimized treatments, and wavefront-guided treatments. Finally, a completely different type of laser (femtosecond laser) can be used instead of a mechanical microkeratome to create the LASIK (corneal) flap.

What is conventional LASIK?

Conventional LASIK is the ablation pattern available on most lasers that treats directly based upon the patient's glasses prescription, with fixed treatment parameters for each patient. This type of treatment is effective for most patients but can result in more visual aberrations such as glare, halos, and night vision issues than other forms of laser treatment.

What is wavefront-optimized LASIK?

Wavefront-optimized LASIK is the type of laser treatment available on the Wavelight laser. This treatment is also based on the patient's glasses prescription, but also takes into account corneal curvature and thickness, and applies laser energy in a unique fashion in the periphery of the cornea. This laser has been found to reduce the aforementioned complications such as glare, halos, and other nighttime visual aberrations that can occasionally occur with conventional treatments.

What is wavefront-guided LASIK?

Wavefront-guided LASIK, also referred to as custom LASIK or wavefront LASIK, is similar to conventional LASIK, except that in addition to treating a patient's basic refractive error, specific alterations in a patient's eye (high order aberrations) can also be treated. In wavefront-guided LASIK, special mapping is performed prior to surgery to identify any small irregularities in the patient's optical system. When these irregularities are severe, they can affect vision quality, contrast sensitivity, and night vision. When significant irregularities in a patient's wavefront mapping are found, wavefront-guided LASIK can be used, and the treatment will be based on the wavefront-map generated.

What other types of refractive surgery are available?

Other types of refractive surgery are available and may be more appropriate than LASIK for certain individuals.

Advanced surface ablation: There are a variety of other techniques that utilize the excimer laser to reshape the cornea in much the same way as LASIK, but without the creation of a corneal flap. These are generically termed advanced surface ablation (ASA) and include photorefractive keratectomy (PRK), laser subepithelial keratomileusis (LASEK), and epipolis laser in situ keratomileusis (Epi-LASIK). All of these techniques involve first removing the most superficial corneal layer (epithelium) and then performing excimer laser ablation.

Phakic intraocular lenses: For patients with extreme myopia, LASIK and advanced surface ablation are not reasonable options. In these cases, a phakic intraocular lens may be used. This lens is implanted inside the eye and can effectively treat nearsightedness up to -20 diopters.

Conductive keratoplasty: Conductive keratoplasty (CK) is a technique that can be used for the temporary correction of hyperopia or presbyopia. CK involves using radiofrequency waves in the peripheral cornea to cause peripheral corneal shrinkage and central steepening. This procedure is very safe, but its effect is often not long-lasting, and regression is common after a few years.

Intracorneal ring segments: Intacs (Addition Technology, Inc.) are approved for the correction of low myopia and for patients with keratoconus in the U.S. Intacs are micro-thin plastic segments that are implanted into the peripheral cornea in order to flatten the cornea centrally. Once implanted, the rings generally cannot be felt by the patient. These rings can be removed, and their effect is usually completely reversible. They are only able to correct up to -3 diopters of myopia, and visual recovery is generally slower and less predictable than LASIK.

Am I a good candidate for LASIK?

Refractive surgery is not for everyone. In addition to having a complete eye exam to find out if you are a candidate for surgery, there are certain questions you should ask yourself before considering LASIK or other refractive procedures.

    1. Am I willing to accept a low but real risk of surgical complications? Even though modern LASIK is extremely safe with rare complications, there are still times when unavoidable complications occur that can negatively affect your vision.

    2. Does my career allow me to have LASIK? Although there are now very few organizations that prohibit their employees or members to have refractive surgery, if there is any doubt, then it is important to ask your employer, professional society, or military service whether or not it is allowed for you to undergo refractive surgery.

    3. Has my vision been stable long enough to have LASIK? While minor changes in your prescription are not uncommon from year to year, if your prescription continues to get progressively stronger (for example, more myopic, more hyperopic, or more astigmatism) each year, then you may not yet be a good candidate for refractive surgery.

    4. Do I have any health conditions that make me a poor surgical candidate? Certain advanced autoimmune diseases, such as lupus and rheumatoid arthritis, may influence postoperative healing.

    5. Do my recreational activities make me a bad surgical candidate? There is a lifelong risk of LASIK flap dislocation if there is significant trauma to the eye, so people who participate in contact sports such as boxing, martial arts, or wrestling are not likely not be a good candidate for LASIK. In these instances, other refractive procedures, especially surface ablation, may be more appropriate choices.

    6. Am I too young or too old to have LASIK? There are no hard and fast rules about the appropriate age to have LASIK. However, patients under age 18 are rarely stable enough for LASIK, and older patients may begin to develop cataracts or other eye health issues that preclude them from undergoing LASIK. Again, the best way to determine these things is have a complete eye exam.

    7. Do I have keratoconus?Keratoconus is a corneal disease resulting from decreased corneal strength that can be detected as an abnormal curvature on testing. Patients that have evidence of keratoconus are not candidates for LASIK or surface ablation, but new technologies may become available for these individuals.

 

What is my doctor looking for during my evaluation?

Your eye doctor should look for risk factors prior to surgery that may make you a less than ideal candidate for surgery and discuss any abnormal findings with you at length. The following are considered to be risk factors for refractive surgery.

    1. High prescriptions: Patients with extreme eyeglass prescriptions (high myopia or high hyperopia) may not be good candidates for LASIK because too much corneal tissue would need to be removed to safely perform the procedure.

    2. Thin corneas: Because all excimer laser surgery (LASIK and surface ablation) requires the removal of small amounts of corneal tissue to correct your refractive error, the thickness of your corneas must be measured before surgery. Patients who have very thin corneas are at risk for excessive corneal weakening after surgery and may not be good candidates for LASIK. In these cases, surface ablation or other procedures may be more appropriate.

    3. Abnormal corneal curvature: There are many devices used today to measure the overall shape and curvature of your cornea. These devices are called topographers and are an essential part of your initial evaluation. Abnormalities in the shape and curvature of your cornea may indicate that your cornea is weaker than that of the average person, and this will exclude you from having LASIK safely.

    4. Dry eyes: Patients with dry eye symptoms, such as burning, redness, and tearing may have worse symptoms after LASIK surgery. This occurs because corneal nerves are cut during this procedure, and these nerves are partly responsible for stimulating tear secretion. Most patients have a full return back to their baseline state after surgery; however, patients with significant dry eye before surgery may not be appropriate surgical candidates

    5. Large pupils: Although less common today, some patients still notice glare, halos, or other night vision issues after LASIK. Patients with larger pupils may be more prone to noticing these things, so your screening evaluation should include measurement of your pupil size in a dark room.

    6. Previous refractive surgery: Prior corneal surgery or other types of refractive surgery, especially radial keratotomy (RK), may complicate additional procedures. You should talk to your eye doctor about this situation in order to make the best decision possible about your ability to be corrected with further surgery.

What are the risks of LASIK?

LASIK has been shown to be a very effective procedure, and most patients are very happy with their vision following the procedure. However, like any surgical procedure, LASIK does come with some risks. In order for you to decide whether LASIK surgery is right for you, you need to be aware of potential risks and complications and weigh these carefully before proceeding with surgery.

    1. You may be over-corrected or under-corrected. Most patients are satisfied with their vision after a single treatment, but in some cases, you may not achieve quality vision initially and need a second surgery, called an enhancement, to sharpen your vision. Patients with more extreme prescriptions are at higher risk for needing an enhancement. This enhancement cannot be performed for many months after your initial surgery to allow for your eyes to heal appropriately from the first surgery and for your eyeglass prescription to stabilize. In some rare cases, you may not be able to have an enhancement if your corneas are too thin or abnormally shaped after surgery.

    2. You may still need glasses or contact lenses after surgery to achieve your best vision. This is extremely rare for the average person; however, it is something you should discuss with your surgeon. In addition, if both of your eyes are corrected for good distance vision, you will still need glasses for close work when presbyopia develops as a part of normal aging process.

    3. Your results may not be permanent. Although uncommon, some patients do experience a regression of their desired treatment effect many years after the surgery. This is more common in patients with hyperopia, or farsightedness. Those who need reading glasses are especially prone to having changes in their vision after LASIK surgery. If regression does occur, it may be possible for you to have an additional surgery many years after your initial LASIK.

    4. You may experience visual aberrations, especially in low light. Visual effects that can occur with LASIK and decrease visual quality include: anisometropia (difference in refractive power between the two eyes), aniseikonia (difference in image size between the two eyes), double vision, hazy vision, fluctuating vision during the day and from day to day, increased sensitivity to light, glare, shadows, and seeing halos around lights. These visual aberrations are extremely unusual; however, they may be incapacitating for some time and may not ever go away completely.

    5. Dry eye symptoms may persist or get worse. Most people experience some dry-eye symptoms immediately after surgery. In some cases, people may develop worsening of dry-eye symptoms, such as burning and redness, or even decreased vision, after surgery. This condition is occasionally permanent and may require medication to improve tear production or punctal plugs, which temporarily close off the drainage system for tears.

    6. You may lose vision. Rarely, LASIK may result in worse vision that cannot be corrected with glasses or contact lenses. This could result from flap-related complications, equipment malfunction, infection, scarring, or extreme changes in corneal shape postoperatively.

How do I find the right doctor?

If you are considering refractive surgery, it is imperative that you compare all the different variables that go into your surgery. The overall success of your procedure will depend on the type of surgery you are considering, the type of instruments or lasers that are used for that particular surgery, and the level of experience of your surgeon. You should not base your decision solely on how much the procedure costs, and you should compare different eye centers and eye doctors before coming to a decision. Refractive surgery is permanent and will affect your vision for the rest of your life, so you need to carefully consider all of your options. The following are some specific things for you to consider:

    1. Beware of "guarantees." Be cautious of eye centers that advertise guarantees on refractive surgeries, including "lifetime" guarantees, "20/20 or free," or "perfect vision." Remember that there are never any guarantees with surgery.

    2. Know your surgeon. Make sure that the surgeon you choose has appropriate training and a good reputation in the community. You should ask your eye doctor to discuss his or her outcomes and compare them to the results of the studies that are printed in the device manufacturer's handbook. It is also important to know that your surgeon will be available to you after surgery should you develop a complication that requires management.

    3. Know your surgical center. It is equally important to make sure that the center where you have your surgery is equipped with the latest technology, knowledgeable staff, and has a good reputation in the community.

    4. Become an educated consumer. Because this is an important decision, you should read as much information as possible. Ask your eye doctor to provide you with the patient education booklet from the device manufacturer. It is also important to have an in-depth discussion about the most appropriate procedure for your eyes, as this may vary from individual to individual.

What should I expect before, during and after surgery?

What you should expect before, during, and after surgery may vary slightly from patient to patient and from surgeon to surgeon; however, the information listed below is a general guideline for the LASIK process. Each patient may also have slightly different expectations, and it is important to talk to your eye doctor about these expectations before surgery.

Before surgery

Prior to any procedure, you will need a full eye examination by your eye doctor. This process will help determine if you are a good candidate for surgery and whether you have certain risk factors listed above. If you wear contact lenses, you should take them out for many days before your initial examination and use your glasses full-time. This is important because contact lenses will change the shape of your cornea, and if your cornea has not had enough time without the contact lenses, then the measurements taken before surgery may be inaccurate. You should discuss the amount of time you are required to be out of your contact lenses with the surgical center performing your evaluation.

During your initial examination, you should talk to your eye doctor about your past and present medical and eye conditions, including any previous eye surgery or trauma. It is also important to discuss all medicines you are taking, including over the counter medicines, as these can sometimes affect your vision or surgery. Also be sure to mention any medication allergies you have.

During this eye exam, your doctor should discuss certain topics with you, including whether you are a good candidate for refractive surgery. He or she should discuss the risks, benefits, and alternatives of the surgery, and what you should expect before, during, and after the procedure. Your doctor should also explain what will be expected from you before, during, and following the surgery.

It is quite important that you ask questions during this examination, and ideally you should already have the questions you want answered in mind before your examination. You will need to think about all of the risks and benefits and take time to review handouts that are provided to you by your doctor. After you have had plenty of time to think about these issues and had all of your questions answered, you will need to sign an informed consent form. It is not recommended to have your initial evaluation and surgery performed on the same day, as this does not give you enough time to fully contemplate your decision. It is also not ideal to first meet your surgeon on the day of surgery, because this again does not give you ample time and opportunity to ask the questions only your surgeon can answer before your procedure.

On the day of the surgery, you will need to avoid using all lotions, creams, makeup, and perfumes. Some of these items build up on the eyelashes and may increase your risk of infection, while others (lotions and perfumes) can affect the function of the laser. In an effort to clean your eyelid margin, your doctor may ask that you scrub your eyelids and lashes with a gentle soap that is safe for the eyes prior to surgery.

You will also need to arrange for transportation to and from the surgery center both on the day of surgery and for your first follow-up visit the following day. You will not be allowed to drive yourself home after surgery under any circumstances.

During surgery

LASIK eye surgery normally takes less than 30 minutes to perform surgery on both eyes. You will be taken to the surgical suite and placed into a reclining chair or bed where you will lie on your back. The laser system consists of a microscope that is attached to a large machine and a computer screen.

After you are lying down and have been positioned underneath the laser, numbing eye drops will be placed in your eyes, and the area around your eyes will be cleaned thoroughly. After your surgical team, including your surgeons and assistants, have reviewed and confirmed all of your treatment information, a lid speculum will be placed to keep your eyelids open during the surgery. When it is time to create the LASIK flap, a suction device will be placed on your eye that will fixate it. During this period, you may feel pressure that may be somewhat uncomfortable, and your vision will go dark for a brief period of time. Your doctor will then use the microkeratome to create the corneal flap. After the flap has been created, the microkeratome will be removed, the suction will be off, and your vision will return, although it will likely remain blurry for the remainder of the procedure.

Your doctor will then carefully move the flap in order to expose the underlying corneal tissue. Any excess moisture on the tissue will be dried, and your underlying corneal thickness will be measured. The laser apparatus will then be positioned over your eye. Your doctor will ask you to stare directly at the light. It should be noted that the light you are staring at is not the laser that is being used for the surgery and may have different colors based on the specific laser being used for your treatment. This light is simply used so that your eye will remain in a fixed position.

The laser will be started by your doctor once your eye is in a satisfactory position. Do not be alarmed if you notice ticking sounds and new smells during this part of the procedure. The ticking sound is the sound of the laser pulses and the smell, which has been described by some as that of burning hair, is the evaporation of fluid from your cornea during laser ablation. The amount of laser treatment time varies among patients but is usually less than 60 seconds. After the appropriate amount of corneal tissue has been ablated by the laser, the corneal flap is gently placed back down into its original position.

To protect your eye, a shield will be placed around your eye. This is to prevent you from accidentally rubbing your eye or putting any pressure onto your eye. Your cornea is especially vulnerable in this early postoperative period, which is why it is very important to keep your eye protected. If you are having both eyes treated during the same surgery, the surgeon will reposition the laser over your other eye and the same process will be repeated for the second eye.

After surgery

As soon as the procedure is finished, you may notice that your eyes feel irritated, burn, itch, or feel like there is something in them. Your eyes will frequently water or tear excessively, and your vision will be somewhat blurry. The most important thing to avoid during this time is rubbing your eyes. Do not rub your eyes under any circumstances, as rubbing can dislocate or shift the corneal flap, which could require you to have an additional procedure to reposition it. Using copious artificial tears and resting with your eyes closed will most effectively ease these sensations. In some instances, there may be increased discomfort or even a mild degree of pain, for which your doctor may advise you to take a pain reliever. In most cases, nonsteroidal anti-inflammatory drugs, such as ibuprofen, are enough to relieve the pain. In addition to artificial tears, you will have antibiotic drops and anti-inflammatory drops (steroids) to use beginning on the day of surgery that you will continue to use for days to weeks after surgery.

Other symptoms you may notice immediately after surgery include light sensitivity, hazy vision, glare, seeing starbursts or halos around lights, and reddened or bloodshot eyes. All of these symptoms should improve over the first few days following surgery. It is very important that you contact your doctor immediately on the first night after surgery if you are having severe pain or if your vision is getting worse and not better. You do not need to wait until your first follow-up visit if you are experiencing either of these things.

Your first postoperative visit should be scheduled within the first 24 hours following surgery. At that visit, your doctor will check your vision and examine your eyes. You will continue to use your antibiotics and steroid drops as well as artificial tears. Your vision should be clearer but may still be blurry the first few days after surgery, and you may need to adjust your work or travel schedule or even take some time off after surgery to fully recuperate.

You should ask your doctor how long you need to wait to start participating in sports again, such as walking or jogging. In general, you should wait anywhere from one to three days following surgery to restart low impact sports, and avoid any possible eye trauma, such as more competitive sports, for a minimum of two or more weeks. In addition, it is unwise to expose yourself to eye infection risks such as pools, lakes, or hot tubs during the early healing process. Your surgeon will tell you when you can resume these activities.

As mentioned earlier, lotions, creams, makeup, and perfumes can often cause buildup on the eyelids and may increase the risk for infection. Ask your doctor when it is advisable to resume use of these products.

Typically, your vision will stabilize within the first week or two, but it may continue to change over the first couple of months following surgery. It may take anywhere from three to six months for your vision to stabilize completely. Other visual symptoms, such as glare, seeing halos, and difficulty driving at night, may continue during this stabilization period. Additional treatments, or enhancements, may be needed after surgery, but the stability of your cornea will need to be established before any repeat treatments are performed. Before enhancements are considered, you should have had consistent eye measurements at two consecutive visits. When considering additional treatments, you should know that while it is likely that your vision can be improved by enhancements, just as with the initial surgery, there are no guarantees, and there are still risks associated with having surgery.

You should not hesitate to call your eye doctor immediately if you develop worsening or unusual symptoms at any time after surgery. These symptoms could be a sign of a serious problem that could result in loss of vision if not treated properly in a timely fashion.

What are the advantages of LASIK surgery?

In summary, despite the risks outlined above, LASIK has been proven to be safe and effective for most people. With careful patient screening and selection, reasonable expectations, and in the care of an experienced surgeon, most patients will be very pleased with their results. These are some of the other advantages of LASIK:

  • LASIK is able to accurately correct most levels of myopia (nearsightedness), hyperopia (farsightedness), and astigmatism.
  • The procedure is fast, usually lasting only five to 10 minutes, and is generally painless.
  • Because the laser is guided by a computer, it is very precise and results are very accurate.
  • In most cases, a single treatment will achieve the desired outcome; however, enhancements are possible if needed, even many years after the initial surgery.

What are the disadvantages of LASIK surgery?

  • Because each patient will heal slightly differently, results may vary from patient to patient.
  • LASIK could make some aspects of your vision worse, including night vision with glare and halos.
  • LASIK may make dry-eye symptoms worse in certain individuals.
  • In rare circumstances, LASIK can make your vision worse and not correctable with regular glasses or contact lenses.

LASIK checklist

    • Career issues
    • Vision stability
    • Medical or eye diseases
    • Age
    • Corneal thickness
    • Corneal Shape and curvature
    • Pupil size
    • Dry Eyes
    • Previous refractive surgery
    • Over-correction or under-correction
    • May still need glasses or contacts after surgery
    • Results may not be permanent
    • Visual aberrations
    • Dry eye may worsen
    • May lose vision
    • Experienced
    • Good reputation in community
    • Access to latest technology
    • Available after surgery to manage any complications that may occur
    • Beware of "guarantees"
  • 1. Know your refractive error.

    2. Know your treatment options.

    3. Know the type of laser that has been recommended for your treatment and why this specific laser was chosen.

    4. Know what to look for to determine if you are a good candidate for surgery.

    5. Know the risks possible with surgery. 6. Know how to find the right surgeon. 7. Know what to expect before, during, and after surgery.

Latex Allergy

  • Why latex?
  • What is latex and where is it found?
  • Who is at risk?
  • How is latex allergy detected?
  • How is latex allergy treated?
  • Latex-Containing Products
  • Latex Allergy At A Glance
  • Find a local Asthma & Allergy Specialist in your town

Why latex?

In 1987, there was a movement throughout the world to take precautions that would prevent the spread of infectious diseases, especially the AIDS virus. This effort resulted in the application of universal precautions for protecting a person from infectious material using protective barriers. One such barrier was the latex glove. It is estimated that since 1987, the annual United States usage of latex gloves has been 10 billion. This increase in the use of latex has resulted in a dramatic rise in allergy to latex. Health care workers are at particular risk for latex allergy and it is estimated that this allergy affects 2% of all hospital employees. Latex is used in over 40,000 products.

What is latex and where is it found?

Latex is a natural product which comes from the light milky fluid that is extracted from the rubber tree. This milky fluid is often modified during the manufacturing process to form a latex mixture. A person can be allergic to the latex or the mixture or both. Latex-containing products are many and varied (see the list below). One of two procedures is employed during the manufacturing of the latex-containing product. One procedure is "dipping," wherein a form is dipped into a vat of latex and after drying, the latex product is washed and then peeled from the form. If the latex product is not washed well, as is the case with rushed production, more "free" latex is present on the surface. This "free" latex is responsible for a great deal of latex allergy. Dipped latex products include gloves, balloons and condoms. A much less allergic latex product is made by molding the latex. Products such as rubber stoppers and erasers are manufactured using this process. The powder of surgical gloves is a significant problem. Latex will easily stick to powder that is commonly used in surgical gloves.

When the glove is placed on or taken off the hand the glove is frequently "snapped." This snapping places the powder, with latex sticking to it, into the air. Inhaled latex can be a serious allergic problem.

Who is at risk?

Some people are born with a genetic predisposition to be allergic to latex. However, repeated exposure to latex is necessary for an allergy to develop. If a person is repeatedly exposed to latex, especially products that are "dipped," the risk of latex allergy substantially increases. Therefore, persons at risk are health care workers exposed to latex products (such as gloves and catheters), people who require frequent surgery or catheter use, and workers in the manufacturing or distribution of latex products. For unknown reasons, people who have surgeries of the spine or urinary tract have a much higher risk of latex allergy for reasons unknown.

There is also an interesting association of unique food allergy among persons allergic to latex. People allergic to latex are frequently allergic to bananas and sometimes other foods like kiwi, papaya, avocados and apricots. This association with food allergy is real, but the cause of the relationship is uncertain.

How is latex allergy detected?

Allergy to latex comes in two different forms. One form is called a "delayed hypersensitivity" which is usually seen as a skin rash at the site where the latex product contacts the skin. This rash can be quite severe. A more dangerous form of latex allergy is an "immediate reaction" to latex. This is also referred to as anaphylaxis. Anaphylaxis can result in seriously low blood pressure, breathing difficulty, and even death. Some patients can experience irritation of the nasal passages similar to hay fever (allergic rhinitis).

To detect the delayed hypersensitivity reaction, latex, its preservatives and accelerators are placed on the skin using a standard patch test. Caution is used because an immediate reaction is possible with patch testing. To detect an immediate reaction, a blood test and skin test is available. With latex allergy, the blood test is performed first because of the potential severe reaction.

How is latex allergy treated?

Avoidance of the provoking agent (allergen), such as latex, is the most effective way to manage any allergy. Latex free synthetic rubber, such as neoprene, nitrile, SBR, Butyl, and Vitron are polymers that are available as alternatives to natural rubber. There are no naturally occurring proteins in them and they are NOT responsible for latex allergy. Labeling is extremely important, but mandatory labeling is currently not required.

 

Patients who are known to be allergic should avoid any product that might contain latex until the latex content is determined by contacting the manufacturer. Even products labeled "safe latex" (which indicates lower proportions of natural latex) can cause latex allergy. There is no safe latex for latex allergic sufferers. Federal legislation is pending on truth and labeling for latex products. Powderless gloves are a great help in preventing airborne latex and have been very helpful in reducing surgical exposure of latex for the health care worker and the patient. No current treatment is available to desensitize the person allergic to latex. Treatment of reactions includes antihistamines, adrenaline, and steroids.

Latex-Containing Products (partial list):

Band-Aids, rubber bands, erasers, some shoes and articles of clothing, balloons, surgical gloves, catheters, condoms, some items of sporting equipment , blood pressure cuffs, some watch bands, helmets, tooth brush massagers, bowling balls and ventilator tubing.

Latex Allergy At A Glance
  • Latex allergy is dramatically on the rise throughout the world.
  • Latex allergy rises with exposure and is suspected to continue to rise until a latex substitute is found.
  • Latex allergy can be serious.
  • Latex is found in more than 40,000 products and is a common component of surgical gloves.

Laxatives for Constipation


  • What is constipation?
  • What causes constipation?
  • When should a doctor be consulted for constipation?
  • What non-drug measures can you take for constipation?
  • What over-the-counter preparations can be used for constipation?
  • Bulk-Forming Laxatives
  • Stool Softeners (emollient laxatives)
  • Lubricant Laxatives
  • Stimulant Laxatives
  • Saline Laxatives
  • Enemas and Suppositories
  • Laxatives for Constipation At A Glance
  • Find a local Gastroenterologist in your town

What is constipation?

Constipation is a condition that is characterized by infrequent bowel movements that are painful or difficult, or stools that are hard in consistency. Infrequent bowel movements alone are not a reliable indicator of constipation because bowel frequency can vary between three times a day to once a week among normal individuals. Therefore, hard stools that are difficult to pass or infrequent stools accompanied by abdominal pain, back pain, and abdominal bloating define important constipation.

What are the causes of constipation?

There are many causes of constipation including:

  • Diets low in fiber. Fiber is vegetable material that is resistant to digestion. It promotes soft stools by adding bulk to the stool and causing water to be retained in stool.
  • Side effects of medications such as narcotic pain killers, antidepressants, iron supplements, calcium channel blockers (a class of medications for high blood pressure), and certain types of antacids.
  • Narrowing or blockage of the large intestine (colon) due to colon cancer or advanced diverticulosis.
  • Ineffective contraction or spasm of the colon's muscles due to irritable bowel syndrome or other diseases of the colon's muscles.
  • Hormonal (endocrine) disturbances such as an under- active thyroid gland and diabetes mellitus with nerve damage.
  • Parkinson's disease, multiple sclerosis, and other neurologic conditions.

 

Examples of common medications that can cause constipation:

  • Narcotic pain medications: codeine (Tylenol #3), oxycodone (Percocet), and guaifenesin/hydromorphone (Dilaudid) and others
  • Antidepressants: amitriptyline (Elavil), fluoxetine (Prozac), and imipramine (Tofranil)
  • Anticonvulsants: phenytoin (Dilantin) and carbamazepine (Tegretol)
  • Iron supplements
  • Calcium channel blockers [for example, diltiazem (Cardizem) and nifedipine (Procardia)]
  • Antacids [for example, aluminum hydroxide (Amphojel) and aluminum carbonate (Basaljel)]

When should a doctor be consulted for constipation?

Many people have a life-long tendency toward constipation while others tend to have occasional constipation alternating with a normal bowel pattern or even diarrhea. While mild and intermittent constipation in these individuals is usually not a cause for concern, a doctor should be consulted under the following circumstances:

  • A new onset of constipation or recent change in bowel habits;
  • Moderate to severe constipation, or constipation that does not respond to self-treatment with simple bulking agents that provide fiber;
  • Constipation that is accompanied by rectal bleeding, abdominal pain and cramps, nausea and vomiting, and involuntary weight loss; and
  • Constipation during pregnancy or while breastfeeding.

 

What non-drug measures can you take for constipation?

Mild constipation that does not have an underlying cause (such as medications, an under-active thyroid, or colon obstruction) can often improve with life-style modifications that include:

  1. Increasing fiber in the diet. Fiber improves bowel function by adding bulk and softening the stool. Examples of foods that are high in fiber content include:
  • vegetables,
  • fruits (include the skin),
  • whole grain breads,
  • whole grain cereals,
  • prunes,
  • corn,
  • whole beans (such as kidney beans and pinto beans),
  • oat bran,
  • corn, and

     

  • barley.
  • over-the-counter fiber supplements can also be taken.
  1. Increasing fluid intake.
  1. Regular exercise such as walking, swimming, or running.

What over-the-counter preparations can be used for constipation?

Laxatives are medicines that increase the frequency and ease of passing bowel movements. Many types of laxatives are available over-the-counter (OTC) for the relief of mild, occasional constipation. If the constipation becomes moderate to severe or does not respond to OTC products, a doctor should be consulted.

Most OTC laxatives are safe, effective, and well tolerated. There are distinct classes of laxatives, which function differently and have varying degrees of effectiveness and potential side effects.

Bulk-Forming Laxatives

Bulk-forming laxatives are the most commonly recommended initial treatments for constipation. Bulk-forming laxatives may work as quickly as 12 hours or take as long as three days to be effective. Some bulk-forming laxatives are derived from natural sources such as agar, psyllium, kelp (alginates), and plant gum. Others are synthetic cellulose compounds such as methylcellulose and carboxymethylcellulose. Natural and synthetic bulk-forming laxatives act similarly. They dissolve or swell in the intestines, lubricate and soften the stool, and make the passage of bowel movements easier and more frequent.

Examples of bulk-forming laxatives are methylcellulose (Citrucel) psyllium hydrophilic mucilloid (Metamucil), polycarbophil (FiberCon), guar gum (Benefiber) and malt soup extract (Maltsupex). Many of these agents are available as powders and are mixed with fluids. Fruit drinks, fruit juice, and soft drinks mask the gritty taste of these laxatives better than water. Some are available as wafers, which are designed to be eaten with a separate beverage.

The benefits of bulk-forming laxatives are:

  • Bulk-forming laxatives are not absorbed from the intestines into the body and are safe for long-term use. They are also safe for elderly patients with constipation.
  • They are helpful in patients with irritable bowel syndrome, diverticulosis, and colostomies.
  • Some bulk-forming laxatives (such as guar gum) are used as fiber supplements in patients whose diets contain insufficient fiber. High fiber consumption can help control weight gain and sometimes modestly lower the level of cholesterol in the blood.

Precautions for using bulk-forming laxatives.

  • Each dose of a bulk-forming laxative should be taken with at least a full glass (8 ounces) of fluid to be safe and effective. Therefore, bulk-forming laxatives may not be appropriate for patients who must restrict oral fluid intake (such as patients with kidney failure).
  • Patients with narrowing of the digestive tract (including esophageal stricture, intestinal stricture, or severe adhesions) should not use bulk-forming agents without their doctors' approval due to the risk of blockage of the intestine or the esophagus.
  • Some patients may be allergic to the laxative or other substances contained in the product, such as coloring or artificial sweeteners.
  • Abdominal bloating, discomfort, and flatulence (gas) can be bothersome to some patients using bulk-forming laxatives.
  • Some of these products contain sugar. Diabetes mellitus patients may need to select sugar-free bulk-forming laxatives. By trying different types of bulk-forming laxatives, it usually is possible to find one that does not cause discomfort.
  • They can decrease the absorption of certain medications (aspirin, warfarin (Coumadin), and carbamazepine (Tegretol) and can also reduce blood sugar levels.

Stool Softeners (emollient laxatives)

Stool softeners, called emollient laxatives, prevent hardening of the feces by adding moisture to the stool. The active ingredient in most stool softeners is a medicine called docusate. Agents containing docusate do not by themselves stimulate or increase the number of bowel movements. They are used more to prevent constipation than to treat it.

Stool softeners are commonly recommended for patients who should avoid straining while defecating, including:

  • Patients recovering from abdominal, pelvic, or rectal surgery, childbirth, or a heart attack; persons with severe high blood pressure or abdominal hernias; and
  • patients with painful hemorrhoids and/or anal fissures. Softening the stool in these patients can help reduce pain during defecation.

Stool softeners available OTC include Colace, Surfak, and pharmacy or store-branded products containing docusate. Some preparations (for example, Peri-Colace) combine a stool softener with a stimulant laxative to activate bowel movements.

Precautions for using stool softeners

Stool softeners are generally safe and well tolerated. They should not be combined with mineral oil, a lubricant laxative, because stool softeners may increase the absorption and toxicity of mineral oil. Mineral oil droplets absorbed into the body can deposit and cause inflammation in the lymph glands, liver, and spleen.

Lubricant Laxatives

Mineral oil (liquid petrolatum) coats and softens stool. Like stool softeners, mineral oil is used by patients who need to avoid straining (for example, after hernia repair, hemorrhoid surgery, heart attacks, and childbirth).

Precautions for using lubricant laxatives

  • Mineral oil should be avoided in patients taking blood thinners, such as warfarin (Coumadin). Mineral oil decreases the absorption of vitamin K (important in forming clotting factors in the blood) from the intestines. The decreased assimilation of vitamin K in patients taking Coumadin can potentially lead to "over-thinning" of the blood and increasing the risk of excessive bleeding.
  • Mineral oil should not be taken during pregnancy since it may inhibit vitamin absorption and decrease the availability of vitamin K to the fetus.
  • Mineral oil can cause pneumonia if it leaks into the lungs. Leakage of secretions and other contents from the mouth and the esophagus into the lungs is called aspiration. Certain individuals (for example, the very young, the elderly, stroke victims, and those with swallowing difficulties) are prone to aspirate, especially while lying down. Therefore, mineral oil should not be given at bedtime or to individuals who are prone to aspirate.
  • Mineral oil should only be used for short periods of time. A significant absorption of mineral oil into the body can occur if used repeatedly over prolonged periods.

Stimulant Laxatives

Stimulant laxatives induce bowel movements by increasing the contraction of muscles in the intestines, and are effective when used on a short term basis. Examples of stimulant laxatives include aloe, cascara, senna compounds, bisacodyl, and castor oil. Bisacodyl (Dulcolax, Correctol) is available OTC in oral pill form and as a suppository or enema. The oral form takes 6 to 10 hours to work. Bisacodyl is commonly used in cleansing the colon for colonoscopies, barium enemas, and intestinal surgeries. While effective for occasional constipation, bisacodyl should not be taken for more than a week, and a doctor should supervise repeated use.

Other stimulant laxatives include senna (Ex-Lax, Senokot), cascara sagrada (Nature's Remedy), and casanthranol. These laxatives are converted by the bacteria in the colon into active compounds which then stimulate the contraction of colon muscles. After taking these products orally, bowel movements occur after 8 to 24 hours. Prolonged, chronic use of these laxatives can cause the lining of the colon to become darker than normal (melanosis coli) due to the accumulation of a pigment (melanin).

Castor oil (an ingredient of Purge Concentrate) is a liquid stimulant laxative that works in the small intestine. It causes the accumulation of fluid in the small intestine and promotes evacuation of the bowels. Castor oil should not be taken with food, although juice or other flavored liquids can help hide its unpleasant taste. This laxative works rather quickly, usually within 2 to 6 hours. Castor oil is usually used to cleanse the colon for surgery, barium enema, or colonoscopy. The absorption of nutrients and minerals by the small intestine can be impaired by the frequent use of castor oil. Therefore, this medicine is not recommended for the repeated treatment for constipation.

Precautions

  • The intensity of the action of stimulant laxatives is dose related. A large dose of any stimulant laxative can produce serious adverse effects.
  • Side effects include severe cramps, excess fluid loss and dehydration, blood electrolyte disturbances such as low levels of blood potassium, and malnutrition with chronic use.
  • Chronic, long-term use of stimulant laxatives can lead to loss of colon function (cathartic colon). After years to decades of frequent use of stimulant laxatives, the nerves of the colon slowly disappear, the colon muscles wither, and the colon becomes dilated. Consequently, constipation becomes increasingly worse and unresponsive to laxatives.

Saline Laxatives

The active ingredients in saline laxatives are mostly magnesium, sulfate, citrate, and phosphate ions. These ions draw water into the intestines. The additional water softens the stool, increases pressure within the intestines, and increases intestinal contractions resulting in the discharge of softer stool. Fleet Phospho-Soda, milk of magnesia, and magnesium citrate are examples of saline laxatives.

Oral doses of saline laxatives should be taken with one to two glasses of water. The onset of bowel response is usually 1/2 to 3 hours after consuming the laxative. Small doses are sometimes recommended for the treatment of occasional constipation, while larger doses can produce complete evacuation of the intestine. Complete cleansing of the bowel is useful in preparing for colonoscopy, sigmoidoscopy, and barium enema.

Precautions

Since there may be some absorption of the active ingredients from the intestines into the blood circulation, saline laxatives should not be used in certain patients. Patients with impaired kidney function should not use laxatives containing magnesium or phosphate salts. Excess accumulation of magnesium and phosphate in the blood of these patients can lead to toxicity. Patients who need to limit their sodium intake, such as those with congestive heart failure, kidney disease, and high blood pressure, should not use laxatives that contain sodium.

Enemas and Suppositories

Rectally administered enemas and suppositories are commonly used to cleanse the rectum and the sigmoid colon (the part of the colon closest to the rectum) prior to surgery, child delivery, and flexible sigmoidoscopy. Enemas and suppositories are also used to relieve constipation and rectal fecal impaction (blockage of the rectum by hard, compacted stool). They can also be used in conjunction with oral laxatives in cleansing the colon in preparation for barium enema studies.

Enemas and suppositories include  docusate (Microenema), bisacodyl (Dulcolax Suppository), and sodium phosphate (Fleet Enema). These products are intended for occasional use and are not recommended as a chronic laxative regimen unless directed by a physician.

Patients should carefully follow instructions in using enemas. The patient should lie on the left side with the knees bent. The enema solution should be inserted slowly into the rectum. The person should retain the solution in the rectum until definite rectal pressure and the urge to have a bowel movement are felt. Evacuation usually occurs within minutes to an hour.

Precautions

  • Soapsuds enemas can cause rectal irritation and sometimes rectal gangrene. Therefore, soapsuds enemas are not recommended.
  • Enema solutions can cause fluid and electrolyte disturbances in the blood if used on a chronic basis.
Laxatives for Constipation At A Glance
  • Constipation is infrequent bowel movements that are painful, difficult or hard in consistency.
  • Common causes of constipation include diets low in fiber, medications, and certain medical conditions.
  • Consult a doctor for constipation if it is severe, it does not respond to home treatment, is accompanied by bleeding, abdominal pain, nausea and vomiting and weight loss, or if you are pregnant.
  • Non-drug measures for constipation include adding fiber to the diet, increasing fluids, and regular exercise.
  • Over-the-counter preparations for constipation include bulk-forming laxatives, stool softeners, lubricant laxatives, stimulant laxatives, saline laxatives enemas and suppositories.
  • Over-use of laxatives, especially the stimulant laxatives, can have a deleterious effect on your colon and actually make the constipation worse.

Lead Poisoning

  • Lead poisioning tips
  • How are children exposed to lead?
  • Who is at risk for lead poisoning?
  • Can lead poisoning be prevented?

Lead Poisoning Tips

Lead poisoning is entirely preventable. The key is stopping children from coming into contact with lead and treating children who have been poisoned by lead.

The goal is to prevent lead exposure to children before they are harmed. There are many ways parents can reduce a child's exposure to lead. The key is stopping children from coming into contact with lead. Lead hazards in a child's environment must be identified and controlled or removed safely.

How Are Children Exposed to Lead?

Lead-based paint and lead contaminated dust are the main sources of exposure for lead in U.S. children. Lead-based paints were banned for use in housing in 1978. All houses built before 1978 are likely to contain some lead-based paint. However, it is the deterioration of this paint that causes a problem. Approximately 24 million housing units have deteriorated leaded paint and elevated levels of lead-contaminated house dust. More than 4 million of these dwellings are homes to one or more young children.

Who Is At Risk For Lead Poisoning?

All children under the age of 6 years old are at risk because they are growing so rapidly and because they tend to put their hands or other objects, which may be contaminated with lead dust, into their mouths.

However, children living at or below the poverty line who live in older housing are at greatest risk. Additionally, children of some racial and ethnic groups and those living in older housing are disproportionately affected by lead.

Can Lead Poisoning Be Prevented?

It is important to determine the construction year of the house or the dwelling where your child may spend a large amount of time (e.g., grandparents or daycare). In housing built before 1978, assume that the paint has lead unless tests show otherwise.

Talk to your state or local health department about testing paint and dust from your home for lead.

Make sure your child does not have access to peeling paint or chewable surfaces painted with lead-based paint.

Pregnant women and children should not be present in housing built before 1978 that is undergoing renovation. They should not participate in activities that disturb old paint or in cleaning up paint debris after work is completed.

Create barriers between living/play areas and lead sources. Until environmental clean-up is completed, parents should clean and isolate all sources of lead. They should close and lock doors to keep children away from chipping or peeling paint on walls. You can also apply temporary barriers such as contact paper or duct tape, to cover holes in walls or to block children's access to other sources of lead.

Regularly wash children's hands and toys. Hands and toys can become contaminated from household dust or exterior soil. Both are known lead sources.

Regularly wet-mop floors and wet-wipe window components. Because household dust is a major source of lead, parents should wet-mop floors and wet-wipe horizontal surfaces every 2-3 weeks. Windowsills and wells can contain high levels of leaded dust. They should be kept clean. If feasible, windows should be shut to prevent abrasion of painted surfaces or opened from the top sash.

Prevent children from playing in bare soil; if possible, provide them with sandboxes. Parents should plant grass on areas of bare soil or cover the soil with grass seed, mulch, or wood chips, if possible. Until the bare soil is covered, parents should move play areas away from bare soil and away from the sides of the house. If using a sandbox, parents should also cover the box when not in use to prevent cats from using it as a litter box. That will help protect children from exposure to animal waste.

To further reduce a child's exposure from non-residential paint sources:

  • avoid using traditional home remedies and cosmetics that may contain lead;
  • avoid eating candies imported from Mexico;
  • avoid using containers, cookware, or tableware to store or cook foods or liquids that are not shown to be lead free;
  • remove recalled toys and toy jewelry immediately from children. Check Lead Recalls lists.
  • use only cold water from the tap for drinking, cooking, and for making baby formula (Hot water is more likely to contain higher levels of lead. Most of the lead in household water usually comes from the plumbing in your house, not from the local water supply.);
  • shower and change clothes after finishing a task that involves working with lead-based products such as stain glass work, bullet making, or using a firing range.

Learning Disabilities

  • What are learning disabilities?
  • How common are learning disabilities?
  • What are the signs of a learning disability?
  • What about school and learning disabilities?
  • Tips for parents of children with learning disabilities
  • Tips for teachers of children with learning disabilities
  • Is there any treatment for learning disabilities?
  • What is the prognosis for learning disabilities?
  • What research is being done for learning disabilities?
  • For more information
  • Patient Discussions: Learning Disability
  • Find a local Developmental-Behavioral Pediatrician in your town

What are learning disabilities?

Learning disability is a general term that describes specific kinds of learning problems. A learning disability can cause a person to have trouble learning and using certain skills. The skills most often affected are:

  • reading,
  • writing,
  • listening,
  • speaking,
  • reasoning, and
  • doing math.

Learning disabilities (LD) vary from person to person. One person with learning disabilities may not have the same kind of learning problems as another person with learning disabilities. One person may have trouble with reading and writing. Another person with learning disabilities may have problems with understanding math. Still another person may have trouble in each of these areas, as well as with understanding what people are saying.

Researchers think that learning disabilities are caused by differences in how a person's brain works and how it processes information. Children with learning disabilities are not "dumb" or "lazy." In fact, they usually have average or above average intelligence. Their brains just process information differently.

The definition of "learning disability" just below comes from the Individuals with Disabilities Education Act (IDEA). The IDEA is the federal law that guides how schools provide special education and related services to children with disabilities.

There is no "cure" for learning disabilities. They are life-long. However, children with learning disabilities can be high achievers and can be taught ways to get around the learning disability. With the right help, children with learning disabilities can and do learn successfully.

 

IDEA's Definition of "Learning Disability"

Our nation's special education law, the Individuals with Disabilities Education Act, defines a specific learning disability as . . .

". . . a disorder in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, that may manifest itself in an imperfect ability to listen, think, speak, read, write, spell, or do mathematical calculations, including conditions such as perceptual disabilities, brain injury, minimal brain dysfunction, dyslexia, and developmental aphasia."

However, learning disabilities do not include, "...learning problems that are primarily the result of visual, hearing, or motor disabilities, of mental retardation, of emotional disturbance, or of environmental, cultural, or economic disadvantage." 34 Code of Federal Regulations §3

How common are learning disabilities?

Very common! As many as 1 out of every 5 people in the United States has a learning disability. Almost 3 million children (ages 6 through 21) have some form of a learning disability and receive special education in school. In fact, over half of all children who receive special education have a learning disability (Twenty-fourth Annual Report to Congress, U.S. Department of Education, 2002).

What are the signs of a learning disability?

There is no one sign that shows a person has a learning disability. Experts look for a noticeable difference between how well a child does in school and how well he or she could do, given his or her intelligence or ability. There are also certain clues that may mean a child has a learning disability. We've listed a few below. Most relate to elementary school tasks, because learning disabilities tend to be identified in elementary school. A child probably won't show all of these signs, or even most of them. However, if a child shows a number of these problems, then parents and the teacher should consider the possibility that the child has a learning disability.

When a child has a learning disability, he or she:

  • may have trouble learning the alphabet, rhyming words, or connecting letters to their sounds;
  • may make many mistakes when reading aloud, and repeat and pause often;
  • may not understand what he or she reads;
  • may have real trouble with spelling;
  • may have very messy handwriting or hold a pencil awkwardly;
  • may struggle to express ideas in writing;
  • may learn language late and have a limited vocabulary;
  • may have trouble remembering the sounds that letters make or hearing slight differences between words;
  • may have trouble understanding jokes, comic strips, and sarcasm;
  • may have trouble following directions;
  • may mispronounce words or use a wrong word that sounds similar;
  • may have trouble organizing what he or she wants to say or not be able to think of the word he or she needs for writing or conversation;
  • may not follow the social rules of conversation, such as taking turns, and may stand too close to the listener;
  • may confuse math symbols and misread numbers;
  • may not be able to retell a story in order (what happened first, second, third); or
  • may not know where to begin a task or how to go on from there.

If a child has unexpected problems learning to read, write, listen, speak, or do math, then teachers and parents may want to investigate more. The same is true if the child is struggling to do any one of these skills. The child may need to be evaluated to see if he or she has a learning disability.

What about school and learning disabilities?

Learning disabilities tend to be diagnosed when children reach school age. This is because school focuses on the very things that may be difficult for the child - reading, writing, math, listening, speaking, reasoning. Teachers and parents notice that the child is not learning as expected. The school may ask to evaluate the child to see what is causing the problem. Parents can also ask for their child to be evaluated.

With hard work and the proper help, children with learning disabilities can learn more easily and successfully. For school-aged children (including preschoolers), special education and related services are important sources of help. School staff work with the child's parents to develop an Individualized Education Program, or IEP. This document describes the child's unique needs. It also describes the special education services that will be provided to meet those needs. These services are provided at no cost to the child or family.

Supports or changes in the classroom (sometimes called accommodations) help most students with learning disabilities. Some common accommodations are listed below in "Tips for Teachers". Assistive technology can also help many students work around their learning disabilities. Assistive technology can range from "low-tech" equipment such as tape recorders to "high-tech" tools such as reading machines (which read books aloud) and voice recognition systems (which allow the student to "write" by talking to the computer).

It's important to remember that a childs learning disabilities may need help at home as well as in school. The resources listed below will help families and teachers learn more about the many ways to help children with learning disabilities.

Tips for parents of children with learning disabilities

Learn about learning disabilities. The more you know, the more you can help yourself and your child. See the list of resources and organizations at the end of this article.

  • Praise your child when he or she does well. Children with learning disabilities are often very good at a variety of things. Find out what your child really enjoys doing, such as dancing, playing soccer, or working with computers. Give your child plenty of opportunities to pursue his or her strengths and talents.
  • Find out the ways your child learns best. Does he or she learn by hands-on practice, looking, or listening? Help your child learn through his or her areas of strength.
  • Let your child help with household chores. These can build self-confidence and concrete skills. Keep instructions simple, break down tasks into smaller steps, and reward your child's efforts with praise.
  • Make homework a priority. Read more about how to help your child be a success at homework. (See resource list at the end.)
  • Pay attention to your child's mental health (and your own!). Be open to counseling, which can help your child deal with frustration, feel better about himself or herself, and learn more about social skills.
  • Talk to other parents whose children have learning disabilities. Parents can share practical advice and emotional support. Call NICHCY (1.800.695.0285) and ask how to find parent groups near you. Also let us put you in touch with the parent training and information (PTI) center in your state.
  • Meet with school personnel and help develop an educational plan to address your child's needs. Plan what accommodations your child needs, and don't forget to talk about assistive technology!
  • Establish a positive working relationship with your child's teacher. Through regular communication, exchange information about your child's progress at home and at school.

Tips for teachers of children with learning disabilities

Learn as much as you can about the different types of learning disabilities. The resources and organizations at the end of this document can help you identify specific techniques and strategies to support the student educationally.

Seize the opportunity to make an enormous difference in this student's life! Find out and emphasize what the student's strengths and interests are. Give the student positive feedback and lots of opportunities for practice.

Review the student's evaluation records to identify where specifically the student has trouble. Talk to specialists in your school (e.g., special education teacher) about methods for teaching this student. Provide instruction and accommodations to address the student's special needs. Examples include:

  • breaking tasks into smaller steps, and giving directions verbally and in writing;
  • giving the student more time to finish schoolwork or take tests;
  • letting the student with reading problems use textbooks-on-tape (available through Recording for the Blind and Dyslexic, listed under "For more information");
  • letting the student with listening difficulties borrow notes from a classmate or use a tape recorder; and
  • letting the student with writing difficulties use a computer with specialized software that spell checks, grammar checks, or recognizes speech.

     

Learn about the different testing modifications that can really help a student with learning disabilities show what he or she has learned.

Teach organizational skills, study skills, and learning strategies. These help all students but are particularly helpful to those with learning disabilities.

Work with the student's parents to create an educational plan tailored to meet the student's needs.

Establish a positive working relationship with the student's parents. Through regular communication, exchange information about the student's progress at school.

Is there any treatment for learning disabilities?

The most common treatment for learning disabilities is special education. Specially trained educators may perform a diagnostic educational evaluation assessing the child's academic and intellectual potential and level of academic performance. Once the evaluation is complete, the basic approach is to teach learning skills by building on the child's abilities and strengths while correcting and compensating for disabilities and weaknesses. Other professionals such as speech and language therapists also may be involved. Some medications may be effective in helping the child learn by enhancing attention and concentration. Psychological therapies may also be used.

What is the prognosis for learning disabilities?

Learning disabilities can be lifelong conditions. In some people, several overlapping learning disabilities may be apparent. Other people may have a single, isolated learning problem that has little impact on their lives.

What research is being done for learning disabilities?

The NINDS and other institutes of the National Institutes of Health including the National Institute of Child Health and Human Development, the National Institute of Deafness and Other Communication Disorders, and the National Institute of Mental Health support research on learning disabilities. Current research avenues focus on developing techniques to diagnose and treat learning disabilities and increase understanding of the biological basis of learning disabilities.

For more information

http://www.chadd.org

This e-mail address is being protected from spambots. You need JavaScript enabled to view it

This e-mail address is being protected from spambots. You need JavaScript enabled to view it

National Center for Learning Disabilities
381 Park Avenue South Suite 1401
New York, NY 10016
http://www.ld.org

Loop Electrosurgical Excision Procedure
(LEEP)


  • What is LEEP?
  • How is a LEEP done?
  • How effective is LEEP?
  • What are complications of LEEP?
  • Related loop electrosurgical excision procedure (LEEP) article:
    Loop Electrosurgical Excision Procedure (LEEP) - on eMedicineHealth
  • Find a local Obstetrician-Gynecologist in your town

What is LEEP?

Loop electrosurgical excision procedure (LEEP), uses a low-voltage electrical current to remove abnormal tissues of the cervix. It has an advantage, therefore, over the destructive techniques (CO2 laser and cryocautery) in that an intact tissue sample for analysis can be obtained. LEEP also is popular because it is inexpensive, simple, and typically has few risks or side effects. LEEP is also known as large loop excision of the transformation zone (LLETZ).

This procedure is used most often for treating mild to moderate dysplasia (abnormal changes of the cells lining the cervix or precancers) that have been identified by colposcopy and/or cervical biopsy. In certain situations, severe dysplasia and noninvasive cancer that are localized and can be removed, may also be treated by LEEP.

How is a LEEP done?

The patient lies on an examining table with the feet elevated in stirrups (the position used to obtain a Pap smear). A speculum (as used for the Pap test) is inserted to open the vaginal walls. Sometimes a special solution, either vinegar (acetic acid) or iodine, is applied to the cervix prior to the procedure, which makes the abnormal areas of tissue more recognizable).

The area is numbed using a local anesthetic (cervical block). Oral or intravenous medications to control pain may also be given. A low-voltage electrical current is delivered via a thin wire that is passed through tissues to remove the abnormal areas of the cervix. A chemical is applied afterwards to prevent bleeding.

Mild pain and cramping that can be relieved by oral medications may occur for the first few hours following the procedure. Vaginal discharge and spotting commonly occur after this procedure for up to a few weeks. Sexual intercourse and tampons use should be avoided for several weeks to allow better healing. Douching should also be avoided.


In this Article

  • What is LEEP?
  • How is a LEEP done?
  • How effective is LEEP?
  • What are complications of LEEP?
  • Find a local Obstetrician-Gynecologist in your town

How effective is LEEP?

 

LEEP has been shown to be comparable to cryotherapy, cold knife conization (surgical removal of the abnormal area), laser ablation (destruction of the abnormal tissue), and laser conization for the removal of abnormal or precancerous tissues of the cervix. Studies have shown that about 90% of these methods result in a cure (removal of all the affected tissue).

Further treatment is not typically necessary if all of the abnormal area has been removed, although the precancerous changes may develop again (recur) at a later time. Regular follow-up Pap tests are required following LEEP to evaluate for possible recurrence of the cellular abnormalities.

What are complications of LEEP?

Complications occur in about 1% to 2% of women undergoing LEEP and include narrowing (stenosis) of the opening of the cervix, greater than expected amounts of bleeding, or infection or the cervix or uterus.

Left Ventricular Assist Device (LVAD) for Heart Failure


  • What is a left ventricular assist device (LVAD)?
  • How does an LVAD work?
  • What are the benefits of an LVAD?
  • What are the risks of getting an LVAD?
  • Find a local Cardiologist in your town

What Is an LVAD?

The left ventricular assist device, or LVAD, is a mechanical pump that is implanted inside a person's chest to help a weakened heart ventricle pump blood throughout the body.

Unlike a total artificial heart, the LVAD doesn't replace the heart. It just helps it do its job. This can mean the difference between life and death for a person whose heart needs a rest after open-heart surgery, or for some patients waiting for a heart transplant (called "bridge to transplant").

LVADs may also be used as destination therapy, which is an alternative to transplant. Destination therapy is used for long-term support in some terminally ill patients whose condition makes them ineligible for heart transplantation.

 

Left Ventricular Assist Device

How Does an LVAD Work?

Like the heart, the LVAD is a pump. The LVAD is surgically implanted just below the heart. One end is attached to the left ventricle -- that's the chamber of the heart that pumps blood out of the lungs and into the body. The other end is attached to the aorta, the body's main artery. Blood flows from the ventricles into the pump which passively fills up. When the sensors indicate it is full, the blood is ejected out of the device to the aorta.

A tube passes from the device through the skin. This tube, called the driveline, connects the pump to the external controller and power source.

The pump and its connections are implanted during open-heart surgery. A computer controller, a power pack, and a reserve power pack remain outside the body. Some models let a person wear these external units on a belt or harness outside.

The power pack has to be recharged at night.

 

What Are the Benefits of an LVAD?

An LVAD restores blood flow to a person whose heart has been weakened by heart disease. This helps relieve some symptoms such as being constantly tired or short of breath. And sometimes it lets the heart recover normal function by giving it a chance to rest (although this is rare). It maintains or improves other organ functions, improves exercise performance, and enables participation in cardiac rehabilitation.


In this Article

  • What is a left ventricular assist device (LVAD)?
  • How does an LVAD work?
  • What are the benefits of an LVAD?
  • What are the risks of getting an LVAD?
  • Find a local Cardiologist in your town

What Are the Risks of Getting an LVAD?

As with any surgery, there are risks involved. Your surgeon will discuss the risks of the procedure with you.

After surgery, there are other risks, including:

  • Infection
  • Internal bleeding
  • Heart failure
  • Device failure
  • Blood clots
  • Stroke
  • Respiratory failure
  • Kidney failure

In studies, therapy with the permanent LVAD device doubled the one-year survival rate of patients with end-stage heart failure as compared with drug treatment alone. However, there were some risks, including infection, stroke, and bleeding.

Talk to your doctor to find out if a LVAD is right for you.

Legionellosis
(Legionnaires' Disease and Pontiac Fever)


  • What is legionellosis?
  • How common is legionellosis?
  • What are the usual symptoms of legionellosis?
  • How is the diagnosis of Legionnaires' disease made?
  • Who develops legionellosis?
  • What is the treatment for legionellosis?
  • How is legionellosis spread?
  • Where is the Legionella bacterium found?
  • How can legionellosis be prevented?
  • Legionellosis At A Glance

 

What is legionellosis?

Legionellosis is an infection that is caused by the bacterium Legionella pneumophila. The disease has two distinct forms:

  • Legionnaires' disease is the more severe form of the infection, which may involve pneumonia. The onset of this form of the disease is usually two to 10 days after infection but can occur up to 16 days later. Legionnaires' disease acquired its name in 1976 after an outbreak of pneumonia occurred among people attending a convention of the American Legion in Philadelphia. Later, the bacterium causing the illness was named Legionella pneumophila.
  • Pontiac fever is a milder illness that develops from hours to two days after initial infection and resolves spontaneously.

 

How common is legionellosis?

It is estimated that approximately 10,000 to 15,000 people contract Legionnaires' disease in the United States each year. An additional unknown number of people are infected with the Legionella bacterium but have only mild symptoms or no symptoms at all.

Outbreaks of Legionnaires' disease have received the most media attention. However, the disease most often occurs as single, isolated cases not associated with any identified outbreak. Outbreaks are usually recognized in the summer and early fall, but cases may occur year-round. About 5%-15% of known cases of Legionnaires' disease have been fatal.

Since the bacterium of Legionnaires' disease was identified in 1976, numerous hospital-acquired outbreaks of the disease have been reported. These outbreaks have enabled researchers to study epidemics of legionellosis.

 

What are the usual symptoms of legionellosis?

Patients with Legionnaires' disease usually develop a fever, chills, and a cough. The cough may either be dry or produce sputum. Some patients with Legionnaires' disease also have muscle aches, headache, tiredness, loss of appetite, and occasionally diarrhea. Legionnaires' disease at its worst can cause a severe pneumonia, seriously affect breathing, even lead to respiratory failure and adult respiratory distress syndrome (ARDS).

People with Pontiac fever experience a self-limiting influenza-like illness with fever, chills, headache, and muscle aches but, by definition, do not have pneumonia. Affected individuals generally recover in two to five days without treatment.

How is the diagnosis of Legionnaires' disease made?

Laboratory tests may include a modest increase in white blood cells, mild abnormalities in liver function studies, and even some decreased function of the kidneys, but these features can also be seen with a variety of different types of pneumonia. Chest X-rays often demonstrate abnormal densities (areas of that lungs that on the X-ray film appear whiter). However, it is difficult to distinguish Legionnaires' disease from other types of pneumonia by symptoms and chest X-ray alone. Additional specific tests are required for diagnosis.

These other tests are specialized and are not routinely performed on people with fever or pneumonia. Several types of tests are available. The most useful test uses a urine sample to detect identifiable proteins of the Legionnaires' bacterium (Legionella antigens). Additionally, detecting the bacteria in a culture of the sputum may be helpful. Lastly, tests that compare antibody levels of Legionella in two blood samples obtained three to six weeks apart showing a fourfold rise in the antibodies in the blood against the bacterium can be confirmatory after the disease is gone.

Because these tests complement each other, a positive result from each test when Legionnaires' disease is suspected increases the probability of confirming the diagnosis. However, because none of the laboratory tests is 100% sensitive, the diagnosis of legionellosis is not excluded even if one or more of the tests is negative. Of the available tests, the most specific is culture isolation of the bacterium from secretions from the respiratory tract.

Who develops legionellosis?

People of any age can develop Legionnaires' disease, but the illness most often affects middle-aged and older people, particularly those who smoke cigarettes or have chronic lung disease, as these individuals have a greater likelihood of developing any respiratory illness.

People at an increased risk for Legionnaires' disease also include people whose immune systems are suppressed by diseases such as cancer, kidney failure requiring dialysis, diabetes, or AIDS. Those who take medications that suppress the immune system are also at risk.

Pontiac fever most commonly occurs in people who are otherwise healthy.

What is the treatment for legionellosis?

There are three major classes of antibiotics that are effective in treating legionellosis. These include the fluoroquinolones such as ciprofloxacin (Cipro), levofloxacin (Levaquin), and moxifloxacin (Avelox), the macrolides such as erythromycin, azithromyocin (Zithromax), and clarithromycin (Biaxin), and the tetracyclines including doxycycline (Vibramycin). The choice of antibiotic is often dependent on the patient's clinical state, tolerance to the medication, and degree of certainty as to the diagnosis.

In severe cases of Legionnaires' disease that seem more resistant to a single antibiotic, a second drug called rifampin may be added.

Pontiac fever requires no specific treatment.

How is legionellosis spread?

Outbreaks of legionellosis have occurred after people have inhaled aerosols that come from a water source (for example, air-conditioning cooling towers, whirlpool spas, or showers) contaminated with Legionella bacteria. People may be exposed to these aerosols in homes, workplaces, hospitals, or public places. Infection cannot be acquired from another person with legionellosis, and there is no evidence of people becoming infected from auto air conditioners or household window air-conditioning units.

Where is the Legionella bacterium found?

Legionella organisms can be found in many types of water systems. However, the bacteria reproduce to high numbers in warm, stagnant water (95-115 F), such as that which is found in certain plumbing systems and hot-water tanks, cooling towers, and evaporative condensers of large air-conditioning systems, and whirlpool spas. Cases of legionellosis have been identified throughout the United States and in several other countries. The disease likely occurs worldwide.

The bacterium thrives in the mist sprayed from air-conditioning ducts. Thus, it can infest an entire building or airplane. Factors that are now known to enhance the growth of Legionella bacteria in man-made water environments include the following:

  • water temperatures of 25-42 C;
  • stagnation of the water;
  • scale and sediment in the water; and
  • certain free-living amoebae organisms in water capable of supporting intracellular growth of legionellae.

How can legionellosis be prevented?

Prevention is aimed at improving the design and maintenance of cooling towers and plumbing systems. The goal is limiting the growth and aerosolization of Legionella organisms.

During outbreaks, health investigators seek to identify the source of disease transmission and recommend appropriate prevention and control measures, such as decontamination of the water source.

Detailed guidelines for the prevention of Legionnaires' disease both in hospitals with no identified cases ("primary prevention") and in hospitals with reported cases ("secondary prevention") have been published and are available in the U.S. from the Centers for Disease Control and Prevention.

Legionellosis At A Glance
  • Legionellosis is an infection that is caused by a bacterium.
  • The bacterium thrives in the mist that is sprayed from air-conditioning ducts.
  • The bacterium can infest an entire building.
  • The illness takes two distinct forms: Legionnaires' disease and Pontiac fever.
  • Legionnaires' disease is the more severe form and can be fatal.
  • Pontiac fever is the far milder form of the illness.
  • Symptoms of Legionnaires' disease include fever, chills, and a cough.
  • At its worst, Legionnaires' disease can cause severe pneumonia and respiratory failure.
  • Although antibiotics are effective for treatment, the most useful approach is prevention.

Leigh's Disease
(Leigh's Syndrome)

  • What is Leigh's disease (Leigh's syndrome)?
  • What causes Leigh's disease?
  • What are the symptoms of Leigh's disease?
  • Is there any treatment for Leigh's disease?
  • Are there other forms of Leigh's disease?
  • What is the prognosis for Leigh's disease?
  • What research is being done with Leigh's disease?
  • Clinical trials for Leigh's disease
  • Support for Leigh's disease

What is Leigh's Disease?

Leigh's disease is a rare inherited neurometabolic disorder that affects the central nervous system. This progressive disorder begins in infants between the ages of three months and two years. Rarely, it occurs in teenagers and adults.

What causes Leigh's disease?

Leigh's disease can be caused by mutations in mitochondrial DNA or by deficiencies of an enzyme called pyruvate dehydrogenase.

What are the symptoms of Leigh's disease?

Symptoms of Leigh's disease usually progress rapidly. The earliest signs may be poor sucking ability, and the loss of head control and motor skills. These symptoms may be accompanied by loss of appetite, vomiting, irritability, continuous crying, and seizures. As the disorder progresses, symptoms may also include generalized weakness, lack of muscle tone, and episodes of lactic acidosis, which can lead to impairment of respiratory and kidney function.

In Leigh's disease, genetic mutations in mitochondrial DNA interfere with the energy sources that run cells in an area of the brain that plays a role in motor movements. The primary function of mitochondria is to convert the energy in glucose and fatty acids into a substance called adenosine triphosphate (ATP). The energy in ATP drives virtually all of a cell's metabolic functions. Genetic mutations in mitochondrial DNA, therefore, result in a chronic lack of energy in these cells, which in turn affects the central nervous system and causes progressive degeneration of motor functions.

Is there any treatment for Leigh's disease?

The most common treatment for Leigh's disease is thiamine or Vitamin B1. Oral sodium bicarbonate or sodium citrate may also be prescribed to manage lactic acidosis. Researchers are currently testing dichloroacetate to establish its effectiveness in treating lactic acidosis. In individuals who have the X-linked form of Leigh's disease, a high-fat, low-carbohydrate diet may be recommended.

Are there other forms of Leigh's disease?

There is also a form of Leigh's disease (called X-linked Leigh's disease) which is the result of mutations in a gene that produces another group of substances that are important for cell metabolism. This gene is only found on the X chromosome.

What is the prognosis for Leigh's disease?

The prognosis for individuals with Leigh's disease is poor. Individuals who lack mitochondrial complex IV activity and those with pyruvate dehydrogenase deficiency tend to have the worst prognosis and die within a few years. Those with partial deficiencies have a better prognosis, and may live to be 6 or 7 years of age. Some have survived to their mid-teenage years.

What research is being done with Leigh's disease?

The NINDS supports and encourages a broad range of basic and clinical research on neurogenetic disorders such as Leigh's disease. The goal of this research is to understand what causes these disorders and then to apply these findings to new ways to diagnose, treat, and prevent them.

Clinical trials for Leigh's disease

NIH Patient Recruitment for Leigh's Disease Clinical Trials

  • At NIH Clinical Center
  • Throughout the U.S. and Worldwide
  • NINDS Clinical Research Collaboration Trials

Support for Leigh's disease

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Leishmaniasis

  • Leishmaniasis facts
  • What is leishmaniasis?
  • What are the different types of leishmaniasis?
  • What causes leishmaniasis? How is leishmaniasis transmitted?
  • What are risk factors for leishmaniasis?
  • What are leishmaniasis symptoms and signs?
  • How is leishmaniasis diagnosed?
  • What is the treatment for leishmaniasis?
  • What is the prognosis of leishmaniasis?
  • Can leishmaniasis be prevented?
  • Where can people get more information about leishmaniasis?

Leishmaniasis facts

  • Leishmaniasis is caused by a parasite that is spread to humans through the bite of infected sand flies.
  • Leishmaniasis exists in many temperate and tropical countries of the world. The disease is most common in India, Bangladesh, Nepal, Sudan, Ethiopia, Afghanistan, Algeria, Iran, Saudi Arabia, Syria, Brazil, Colombia, Peru, and Bolivia.
  • The most common type of leishmaniasis is cutaneous leishmaniasis. This causes nodules or sores to form on the skin, including the skin of the face. Affected people may have a single lesion or many lesions. Sores heal slowly over months to years and leave scars.
  • Another type is called visceral leishmaniasis. Parasites infect the tissues of key organs, especially the liver, spleen, and bone marrow. Serious cases are usually fatal if not treated.
  • Uncommonly, people who have had cutaneous leishmaniasis may get new sores in the mucous membranes of the mouth, nose, and larynx even years after the cutaneous leishmaniasis has resolved. This is called mucocutaneous leishmaniasis and only occurs in limited areas of the New World.
  • Treatment consists of medications that are specific to the type of leishmaniasis, the species of the parasite, and to the country in which the disease was acquired.
  • Consultation with the CDC and an infectious-disease consultant is strongly recommended for assistance with diagnosis and treatment of cases imported into the United States.
  • Those who work in or travel to affected areas can reduce their risk by using insect repellents, protective clothing, and bed nets. These precautions are especially important after dusk, because that is when the sand fly is most active.

What is leishmaniasis?

Leishmaniasis is an infection caused by a parasite that is spread to people through the bite of the female phlebotomine sand fly. The parasite exists in many tropical and temperate countries. Cases in the United States are almost always imported from other countries by travelers or immigrants. It has been estimated that there are 2 million new cases of leishmaniasis every year in the world, of which 1.5 million are categorized as cutaneous leishmaniasis and 0.5 million are visceral leishmaniasis. Epidemics occur when people are displaced into affected regions through war or migration or when people in affected regions experience high rates of disease or malnutrition.

Picture of a sand fly biting a human arm.
Figure 1: Picture of a sand fly biting a human arm. SOURCE: CDC/Frank Collins

What are the different types of leishmaniasis?

Leishmaniasis is divided into clinical syndromes according to what part of the body is affected most. In visceral leishmaniasis (VL), the parasite affects the organs of the body. Infections from India, Bangladesh, Nepal, Sudan, Ethiopia, and Brazil account for 90% of cases of VL. Cutaneous leishmaniasis (CL) is the most common form of leishmaniasis and, as the name implies, the skin is the predominate site of infection. Over 90% of cases of CL are acquired in Afghanistan, Algeria, Iran, Saudi Arabia, Syria, Brazil, Colombia, Peru, or Bolivia. Less commonly, cases are reported from other countries including southern Europe. Of note, U.S. troops stationed in Iraq and Afghanistan have acquired CL. Very rarely, isolated cases have been reported from border states like Texas. In some people, CL progresses to involve the mucocutaneous membranes, a condition known as mucocutaneous leishmaniasis (ML). Mucocutaneous leishmaniasis occurs only in the New World and is most common in Bolivia, Brazil, and Peru.

What causes leishmaniasis? How is leishmaniasis transmitted?

Leishmaniasis is caused by protozoal parasites from the Leishmania species. The organisms are microscopic in size. There are about 21 species of Leishmania that affect humans, including the L. donovani complex and the L. Mexicana complex, among others. The life cycle is relatively simple. When the sand fly bites a human, it injects small numbers of parasites which are rapidly taken up by mononuclear blood cells. This stage is called the promastigote stage. Once inside the human mononuclear cells, the parasite enters the amastigote stage and begins to multiply and infect other cells and tissues. Uninfected sand flies acquire the parasite by feeding on infected people or infected animals such as dogs, foxes, or rodents.

Figure 2: Life cycle of Leishmania
Figure 2: Life cycle of Leishmania

 

 

Less commonly, parasites may be transmitted by blood transfusion or through drug users sharing contaminated needles. Leishmania may also be transmitted from a pregnant mother to her fetus.

What are risk factors for leishmaniasis?

The major risk factor for leishmaniasis is being exposed to infected sand flies. The sand flies are most active after dusk and are more common in rural areas. Casual travelers do not usually visit these areas at night, so infection is more common in adventure travelers, Peace Corps workers, missionaries, soldiers, and those with occupational activities that require them to live in rural areas. In healthy people, the degree of immune response to leishmaniasis appears to be genetically determined. In visceral leishmaniasis, a weak immune response is associated with more severe disease. Factors that weaken the immune system include malnutrition and infection with the human immunodeficiency virus (HIV). However, in mucocutaneous leishmaniasis, the symptoms appear to be caused in part by an overactive immune response. Interestingly, the Leishmania parasite itself can be infected with a virus that may cause the parasite to be more dangerous by overstimulating the inflammatory response from the human immune system.

Leishmania may live quietly for years in the body and then begin to multiply (reactivate) if the person's immune system becomes suppressed. Thus, people who were born in a country with leishmaniasis and those who have had travel-related exposure are at risk if they become immunosuppressed by conditions such as chemotherapy, use of steroids, or infection with HIV. Patients who have previously had cutaneous leishmaniasis acquired in certain parts of the New World are at risk for mucocutaneous leishmaniasis.

What are leishmaniasis symptoms and signs?

Visceral leishmaniasis (VL) may be mild or severe. Some patients are asymptomatic and do not realize that they carry the parasite. Symptoms appear in weeks to months after the bite of the sand fly. Less commonly, symptoms arise only years later when a person's immune system becomes suppressed. The five classic symptoms of more severe disease are

  1. weight loss, which may be severe,
  2. low blood counts (pancytopenia),
  3. enlargement of the liver and spleen (hepatosplenomegaly),
  4. fever, which is usually intermittent,
  5. high levels of immune globulin in the blood (hypergammaglobulinemia).

The skin may turn dark, causing VL to be called "kala-zar," which means "black sickness." Some people who recover will have a persistent rash or pigment changes in the skin. The kidney is also affected, which may lead to renal failure. Other organs, including the bowel and the lung, may be affected.

Cutaneous leishmaniasis (CL) is known by a host of other names, including Oriental sore. The site of the sand fly bite usually forms a raised papule that expands and ulcerates, with a heaped up border on the edges. The disease becomes manifest over several weeks. There may be only one lesion, or multiple lesions may appear over time. The skin lesions take on a variety of appearances and may resemble acne, warts, or psoriasis. They may look like large scaly, ulcerated plaques, or form shallow ulcerated nodules. The lesions may be dry or weeping and are not usually painful unless they are secondarily infected by bacteria. Sores occur predominately on the extremities and face. They heal over months to years, leaving scars that often resemble old burns. In severe cases, known as diffuse cutaneous leishmaniasis, nodular lesions may occur widely and last for years or even for life.

Picture of a crater lesion of leishmaniasis, skin.
Figure 3: Picture of a crater lesion of leishmaniasis, skin. SOURCE: CDC

 

Picture of a skin ulcer due to leishmaniasis, hand of Central American adult.
Figure 4: Picture of a skin ulcer due to leishmaniasis, hand of Central-American adult. SOURCE: CDC/Dr. D.S. Martin

Mucocutaneous leishmaniasis (ML) involves the nose, mouth, and larynx. It is less common than VL and CL. Initially, the patient experiences a nodule at the site of the sand fly bite with symptoms consistent with CL. Subsequently, mucocutaneous involvement leads to nodules inside the nose, perforation of the nasal septum, and enlargement of the nose or lips. If the larynx is involved, the voice changes as well. Ulcerated lesions may lead to scarring and tissue destruction that can be disfiguring. The disease occurs predominately in Bolivia, Brazil, and Peru.

How is leishmaniasis diagnosed?

In countries where the disease is common, patients with compatible clinical symptoms and findings can be presumed to have leishmaniasis. Other patients require definitive diagnosis, which is done by examining tissue under a microscope (Figure 5) to detect the parasite or through a blood test to detect antibodies (see below). There is a skin test called the Montenegro skin test, but it is imperfect and not used for diagnosis of disease.

It is important to remember that there are many diseases that can cause fever, weight loss, skin lesions, or enlargement of organs. Conditions like malaria, typhoid fever, toxoplasmosis, Chagas disease, schistosomiasis, tuberculosis, histoplasmosis, syphilis, and others may mimic some symptoms of leishmaniasis so a definitive diagnosis is useful to rule out these other diseases.

Image of parasites inside a macrophage; arrows show parasites.
Figure 5: Image of parasites inside a macrophage; arrows show parasites. SOURCE: CDC/NCID/DPDx

 

In VL, tissue for microscopic examination may be obtained from the spleen, liver, or bone marrow. Some patients with VL, especially those from Sudan, have enlarged lymph nodes that can be biopsied. In cutaneous leishmaniasis or mucocutaneous disease, biopsies or scrapings are taken from the affected area. Special stains are used on biopsies, some of which employ polymerase chain reaction (PCR) methods. The tissue can also be cultured on special media, which allows the parasite to multiply and be detected more easily under the microscope. In the United States, the Centers for Disease Control and Prevention (CDC) should be contacted to obtain advice and the appropriate media.

Antibodies in the blood can be detected using enzyme-linked immunosorbent assays (ELISA). Antibody assays are usually positive in VL but are variably positive in CL and ML because these conditions do not stimulate reliably and consistently elevated antibody titers in the blood.

What is the treatment for leishmaniasis?

Visceral leishmaniasis is treated with an intravenous medication called liposomal amphotericin B, which is the only drug approved in the U.S. for this purpose. Amphotericin is generally safe but may have side effects, including renal insufficiency. In developing countries where the drug is not available, an older agent called pentavalent antimony (SbV) may be used intravenously or intramuscularly. More recently, paromomycin (Humatin) and miltefosine (Miltex) have been used, but neither is available in the United States.

Cutaneous leishmaniasis is not always treated. Cases with few lesions that are small and appear to be healing are sometimes simply monitored. More significant disease is treated with medications, but treatment recommendations vary with where the disease was acquired and the species of Leishmania (if known). Possible treatments for cases arriving in the U.S. include oral ketoconazole (Nizoral, Extina, Xolegel, Kuric), intravenous pentamidine, or liposomal amphotericin B. An antimonite called stibogluconate (pentostam) is available under an investigational new drug protocol through the CDC. Because treatment must be individualized according to the country of acquisition and the species, consultation with public-health officials, infectious-disease consultants, and the CDC is strongly recommended. Mucocutaneous leishmaniasis is less common, and there is no clear consensus on treatment; as such, consultation with the CDC and an infectious-diseases consultant is again recommended.

What is the prognosis of leishmaniasis?

Cutaneous leishmaniasis is rarely fatal but may result in disfiguring scars. Untreated, severe cases of visceral leishmaniasis are almost always fatal. Death can result directly from the disease through organ failure or wasting syndromes. It may also occur as a result of a secondary bacterial infection such as pneumonia. In people with advanced HIV/AIDS, it is necessary to treat the underlying HIV infection along with the leishmaniasis to avoid relapse of the leishmaniasis. For this reason, patients with leishmaniasis should be tested for HIV.

Can leishmaniasis be prevented?

Leishmaniasis can be prevented by avoiding the bite of the sand fly. Simple insect precautions, including protective clothing (long sleeves, long pants, socks) and insect repellents containing N,N-diethylmetatoluamide (DEET), reduce the risk of bites. Because sand flies are most active in the evening and nighttime, efforts should be made to reduce exposure in sleeping accommodations. Sand flies are very small and are even smaller than mosquitoes. Finely meshed bed nets may be used and may be impregnated with insecticides such as permethrin (Elimite, NIX) or deltamethrin. Sand flies are weak fliers, so bed nets should be tucked under mattresses. Clothing may also be treated with permethrin to repel insects. Domestic dogs can be fitted with an insecticide-containing collar, such as the Scalibor collar, which contains deltamethrin.

From a larger perspective, treatment of infected animals and people along with judicious use of insecticide has the potential to reduce the burden of infection in endemic areas. This approach is being tried in several regions with mixed success. There is no vaccine that is currently approved for human use, but research in this area is ongoing.

Where can people get more information about leishmaniasis?

  • The CDC has an excellent web site with information regarding leishmaniasis: http://www.cdc.gov/parasites/leishmaniasis/.
  • Additional information is available from the World Health Organization: http://www.who.int/leishmaniasis/en/.
Last Updated on Sunday, 18 December 2011 14:23
 
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