A medical term meaning without symptoms. For example, hypertension is often asymptomatic and is usually discovered during a routine blood pressure test.
Both HIV-1 and HIV-2 are predominantly sexually transmitted and both are associated with secondary opportunistic infections. However, HIV-2 seems to result in slower damage to the immune system. HIV-1 is known to mutate rapidly and has given rise to other subtypes.
HIV is thought to have occurred in humans in the 1950s, but whether or not it infected humans from another primate species is uncertain. It became widespread in the 1970s but its latency in causing symptoms meant that the epidemic was not noticed until the following decade. Although it is a sexually transmitted disease, it can also be transmitted by intravenous drug use (through sharing an infected needle), blood transfusions with infected blood (hence the importance of e?ective national blood-screening programmes), organ donation, and occupationally (see health-care workers, below). Babies born of HIV-positive mothers can be infected before or during birth, or through breast feeding.
Although HIV is most likely to occur in blood, semen or vaginal ?uid, it has been found in saliva and tears (but not sweat); however, there is no evidence that the virus can be transmitted from these two body ?uids. There is also no evidence that HIV can be transmitted by biting insects (such as mosquitoes). HIV does not survive well in the environment and is rapidly destroyed through drying.
Prevalence At the end of 2003 an estimated 42 million people globally were infected with HIV – up from 40 million two years earlier. About one-third of those with HIV/AIDS are aged 15–24 and most are unaware that they are carrying the virus. During 2003 it is estimated that 5 million adults and children worldwide were newly infected with HIV, and that 3 million adults and children died. In Africa in 2003,
3.4 million people were newly infected and 2.3 million died, with more than 28 million carrying the virus. HIV/AIDS was the leading cause of death in sub-Saharan Africa where over half of the infections were in women and 90 per cent of cases resulted from heterosexual sex. In some southern African countries, one in three pregnant women had HIV.
In Asia and the Paci?c there were 1.2 million new infections and 435,000 deaths. The area with the fastest-growing epidemic is Eastern Europe, especially the Russian Federation where in 2002 around a million people had HIV and there were an estimated 250,000 new infections, with intravenous drug use a key contributor to this ?gure. Seventy-?ve per cent of cases occurred in men, with male-to-male sexual transmission an important cause of infection, though heterosexual activity is a rising cause of infection.
At the end of 2002 the UK had an estimated 55,900 HIV-infected adults aged between 15 and 59. More than 3,600 individuals were newly diagnosed with the infection in 2000, the highest annual ?gure since the epidemic started
– in 1998 the ?gure was 2,817 and in 1999 just over 3,000 (Department of Health and Communicable Disease Surveillance Centre). The incidence of AIDS in the UK has declined sharply since the introduction of highly active antiretroviral therapy (HAART) and HIV-related deaths have also fallen: in 2002 there were 777 reported new AIDS cases and 395 deaths, compared with 1,769 and 1,719 respectively in 1995. (Sources: UNAIDS and WHO, AIDS Epidemic Update, December 2001; Public Health Laboratory Services AIDS and STD Centre Communicable Disease Surveillance and Scottish Centre for Infection and Environmental Health, Quarterly Surveillance Tables.)
Poverty is strongly linked to the spread of AIDS, for various reasons including lack of health education; lack of e?ective public-health awareness; women having little control over sexual behaviour and contraception; and, by comparison with the developed world, little or no access to antiretroviral drugs.
Pathogenesis The cellular target of HIV infection is a subset of white blood cells called T-lymphocytes (see LYMPHOCYTE) which carry the CD4 surface receptor. These so-called ‘helper T-cells’ are vital to the function of cell-mediated immunity. Infection of these cells leads to their destruction (HIV replicates at an enormous rate – 109) and over the course of several years the body is unable to generate suf?cient new cells to keep pace. This leads to progressive destruction of the body’s immune capabilities, evidenced clinically by the development of opportunistic infection and unusual tumours.
Monitoring of clinical progression It is possible to measure the number of viral particles present in the plasma. This gives an accurate guide to the likely progression rate, which will be slow in those individuals with fewer than 10,000 particles per ml of plasma but progressively more rapid above this ?gure. The main clinical monitoring of the immune system is through the numbers of CD4 lymphocytes in the blood. The normal count is around 850 cells per ml and, without treatment, eventual progression to AIDS is likely in those individuals whose CD4 count falls below 500 per ml. Opportunistic infections occur most frequently when the count falls below 200 per ml: most such infections are treatable, and death is only likely when the CD4 count falls below 50 cells per ml when infection is developed with organisms that are di?cult to treat because of their low intrinsic virulence.
Simple, cheap and highly accurate tests are available to detect HIV antibodies in the serum. These normally occur within three months of infection and remain the cornerstone of the diagnosis.
Clinical features Most infected individuals have a viral illness some three weeks after contact with HIV. The clinical features are often non-speci?c and remain undiagnosed but include a ?ne red rash, large lymph nodes, an in?uenza-like illness, cerebral involvement and sometimes the development of opportunistic infections. The antibody test may be negative at this stage but there are usually high levels of virus particles in the blood. The antibody test is virtually always positive within three months of infection. HIV infection is often subsequently asymptomatic for a period of ten years or more, although in most patients progressive immune destruction is occurring during this time and a variety of minor opportunistic infections such as HERPES ZOSTER or oral thrush (see CANDIDA) do occur. In addition, generalised LYMPHADENOPATHY is present in a third of patients and some suffer from severe malaise, weight loss, night sweats, mild fever, ANAEMIA or easy bruising due to THROMBOCYTOPENIA.
The presentation of opportunistic infection is highly variable but usually involves either the CENTRAL NERVOUS SYSTEM, the gastrointestinal tract or the LUNGS. Patients may present with a sudden onset of a neurological de?cit or EPILEPSY due to a sudden onset of a STROKE-like syndrome, or epilepsy due to a space-occupying lesion in the brain – most commonly TOXOPLASMOSIS. In late disease, HIV infection of the central nervous system itself may produce progressive memory loss, impaired concentration and mental slowness called AIDS DEMENTIA. A wide variety of opportunistic PROTOZOA or viruses produces DYSPHAGIA, DIARRHOEA and wasting. In the respiratory system the commonest opportunistic infection associated with AIDS, pneumonia, produces severe shortness of breath and sometimes CYANOSIS, usually with a striking lack of clinical signs in the chest.
In very late HIV infection, when the CD4 count has fallen below 50 cells per ml, infection with CYTOMEGALOVIRUS may produce progressive retinal necrosis (see EYE, DISORDERS OF) which will lead to blindness if untreated, as well as a variety of gastrointestinal symptoms. At this stage, infection with atypical mycobacteria is also common, producing severe anaemia, wasting and fevers. The commonest tumour associated with HIV is Kaposi’s sarcoma which produces purplish skin lesions. This and nonHodgkin’s lymphoma (see LYMPHOMA), which is a hundred times more frequent among HIV-positive individuals than in the general population, are likely to be associated with or caused by opportunistic viral infections.
Prevention There is, as yet, no vaccine to prevent HIV infection. Vaccine development has been hampered
by the large number of new HIV strains generated through frequent mutation and recombination.
because HIV can be transmitted as free virus and in infected cells.
because HIV infects helper T-cells – the very cells involved in the immune response. There are, however, numerous research pro
grammes underway to develop vaccines that are either prophylactic or therapeutic. Vaccine-development strategies have included: recombinant-vector vaccines, in which a live bacterium or virus is genetically modi?ed to carry one or more of the HIV genes; subunit vaccines, consisting of small regions of the HIV genome designed to induce an immune response without infection; modi?ed live HIV, which has had its disease-promoting genes removed; and DNA vaccines – small loops of DNA (plasmids) containing viral genes – that make the host cells produce non-infectious viral proteins which, in turn, trigger an immune response and prime the immune system against future infection with real virus.
In the absence of an e?ective vaccine, preventing exposure remains the chief strategy in reducing the spread of HIV. Used properly, condoms are an extremely e?ective method of preventing exposure to HIV during sexual intercourse and remain the most important public-health approach to countering the further acceleration of the AIDS epidemic. The spermicide nonoxynol-9, which is often included with condoms, is known to kill HIV in vitro; however, its e?ectiveness in preventing HIV infection during intercourse is not known.
Public-health strategies must be focused on avoiding high-risk behaviour and, particularly in developing countries, empowering women to have more control over their lives, both economically and socially. In many of the poorer regions of the world, women are economically dependent on men and refusing sex, or insisting on condom use, even when they know their partners are HIV positive, is not a straightforward option. Poverty also forces many women into the sex industry where they are at greater risk of infection.
Cultural problems in gaining acceptance for universal condom-use by men in some developing countries suggests that other preventive strategies should also be considered. Microbicides used as vaginal sprays or ‘chemical condoms’ have the potential to give women more direct control over their exposure risk, and research is underway to develop suitable products.
Epidemiological studies suggest that male circumcision may o?er some protection against HIV infection, although more research is needed before this can be an established public-health strategy. Globally, about 70 per cent of infected men have acquired the virus through unprotected vaginal sex; in these men, infection is likely to have occurred through the penis with the mucosal epithelia of the inner surface of the foreskin and the frenulum considered the most likely sites for infection. It is suggested that in circumcised men, the glans may become keratinised and thus less likely to facilitate infection. Circumcision may also reduce the risk of lesions caused by other sexually transmitted disease.
Treatment AIDS/HIV treatment can be categorised as speci?c therapies for the individual opportunistic infections – which ultimately cause death – and highly active antiretroviral therapy (HAART) designed to reduce viral load and replication. HAART is also the most e?ective way of preventing opportunistic infections, and has had a signi?cant impact in delaying the onset of AIDS in HIV-positive individuals in developed countries.
Four classes of drugs are currently in use. Nucleoside analogues, including ZIDOVUDINE and DIDANOSINE, interfere with the activity of the unique enzyme of the retrovirus reverse transcriptase which is essential for replication. Nucleotide analogues, such as tenofovir, act in the same way but require no intracellular activation. Non-nucleoside reverse transcriptase inhibitors, such as nevirapine and EFAVIRENZ, act by a di?erent mechanism on the same enzyme. The most potent single agents against HIV are the protease inhibitors, such as lopinavir, which render a unique viral enzyme ineffective. These drugs are used in a variety of combinations in an attempt to reduce the plasma HIV viral load to below detectable limits, which is achieved in approximately 90 per cent of patients who have not previously received therapy. This usually also produces a profound rise in CD4 count. It is likely, however, that such treatments need to be lifelong – and since they are associated with toxicities, long-term adherence is di?cult. Thus the optimum time for treatment intervention remains controversial, with some clinicians believing that this should be governed by the viral load rising above 10,000 copies, and others that it should primarily be designed to prevent the development of opportunistic infections – thus, that initiation of therapy should be guided more by the CD4 count.
It should be noted that the drug regimens have been devised for infection with HIV-1; it is not known how e?ective they are at treating infection with HIV-2.
HIV and pregnancy An HIV-positive woman can transmit the virus to her fetus, with the risk of infection being particularly high during parturition; however, the risk of perinatal HIV transmission can be reduced by antiviral drug therapy. In the UK, HIV testing is available to all women as part of antenatal care. The bene?ts of antenatal HIV testing in countries where antiviral drugs are not available are questionable. An HIV-positive woman might be advised not to breast feed because of the risks of transmitting HIV via breastmilk, but there may be a greater risk associated with not breast feeding at all. Babies in many poor communities are thought to be at high risk of infectious diseases and malnutrition if they are not breast fed and may thus be at greater overall risk of death during infancy.
Counselling Con?dential counselling is an essential part of AIDS management, both in terms of supporting the psychological wellbeing of the individual and in dealing with issues such as family relations, sexual partners and implications for employment (e.g. for health-care workers). Counsellors must be particularly sensitive to culture and lifestyle issues. Counselling is essential both before an HIV test is taken and when the results are revealed.
Health-care workers Health-care workers may be at risk of occupational exposure to HIV, either through undertaking invasive procedures or through accidental exposure to infected blood from a contaminated needle (needlestick injury). Needlestick injuries are frequent in health care – as many as 600,000 to 800,000 are thought to occur annually in the United States. Transmission is much more likely where the worker has been exposed to HIV through a needlestick injury or deep cut with a contaminated instrument than through exposure of mucous membranes to contaminated blood or body ?uids. However, even where exposure occurs through a needlestick injury, the risk of seroconversion is much lower than with a similar exposure to hepatitis C or hepatitis B. A percutaneous exposure to HIV-infected blood in a health-care setting is thought to carry a risk of about one infection per 300 injuries (one in 1,000 for mucous-membrane exposure), compared with one in 30 for hepatitis C, and one in three for hepatitis B (when the source patient is e-antigen positive).
In the event of an injury, health-care workers are advised to report the incident immediately where, depending on a risk assessment, they may be o?ered post-exposure prophylaxis (PEP). They should also wash the contaminated area with soap and water (but without scrubbing) and, if appropriate, encourage bleeding at the site of injury. PEP, using a combination of antiretroviral drugs (in a similar regimen to HAART – see above), is thought to greatly reduce the chances of seroconversion; it should be commenced as soon as possible, preferably within one or two hours of the injury. Although PEP is available, safe systems of work are considered to o?er the greatest protection. Double-gloving (latex gloves remove much of the blood from the surface of the needle during a needlestick), correct use of sharps containers (for used needles and instruments), avoiding the resheathing of used needles, reduction in the number of blood samples taken from a patient, safer-needle devices (such as needles that self-blunt after use) and needleless drug administration are all thought to reduce the risk of exposure to HIV and other blood-borne viruses. Although there have been numerous cases of health-care workers developing HIV through occupational exposure, there is little evidence of health-care workers passing HIV to their patients through normal medical procedures.... aids/hiv
Many snakes are non-venomous (e.g. pythons, garter snakes, king snakes, boa constrictors) but may still in?ict painful bites and cause local swelling. Most venomous snakes belong to the viper and cobra families and are common in Asia, Africa, Australia and South America. Victims of bites may experience various effects including swelling, PARALYSIS of the bitten area, blood-clotting defects, PALPITATION, respiratory di?culty, CONVULSIONS and other neurotoxic and cardiac effects. Victims should be treated as for SHOCK – that is, kept at rest, kept warm, and given oxygen if required but nothing by mouth. The bite site should be immobilised but a TOURNIQUET must not be used. All victims require prompt transfer to a medical facility. When appropriate and available, antivenoms should be administered as soon as possible.
Similar management is appropriate for bites and stings by spiders, scorpions, sea-snakes, venomous ?sh and other marine animals and insects.
Bites and stings in the UK The adder (Vipera berus) is the only venomous snake native to Britain; it is a timid animal that bites only when provoked. Fatal cases are rare, with only 14 deaths recorded in the UK since 1876, the last of these in 1975. Adder bites may result in marked swelling, weakness, collapse, shock, and in severe cases HYPOTENSION, non-speci?c changes in the electrocardiogram and peripheral leucocytosis. Victims of adder bites should be transferred to hospital even if asymptomatic, with the affected limb being immobilised and the bite site left alone. Local incisions, suction, tourniquets, ice packs or permanganate must not be used. Hospital management may include use of a speci?c antivenom, Zagreb®.
The weever ?sh is found in the coastal waters of the British Isles, Europe, the eastern Atlantic, and the Mediterranean Sea. It possesses venomous spines in its dorsal ?n. Stings and envenomation commonly occur when an individual treads on the ?sh. The victim may experience a localised but increasing pain over two hours. As the venom is heat-labile, immersion of the affected area in water at approximately 40 °C or as hot as can be tolerated for 30 minutes should ease the pain. Cold applications will worsen the discomfort. Simple ANALGESICS and ANTIHISTAMINE DRUGS may be given.
Bees, wasps and hornets are insects of the order Hymenoptera and the females possess stinging apparatus at the end of the abdomen. Stings may cause local pain and swelling but rarely cause severe toxicity. Anaphylactic (see ANAPHYLAXIS) reactions can occur in sensitive individuals; these may be fatal. Deaths caused by upper-airway blockage as a result of stings in the mouth or neck regions are reported. In victims of stings, the stinger should be removed as quickly as possible by ?icking, scraping or pulling. The site should be cleaned. Antihistamines and cold applications may bring relief. For anaphylactic reactions ADRENALINE, by intramuscular injection, may be required.... bites and stings
K
Diagram of glomerulus (Malpighian corpuscle).
Fortunately the body has two kidneys and, as most people can survive on one, there is a good ‘functional reserve’ of kidney tissue.
Symptoms Many patients with kidney disorders do not have any symptoms, even when the condition is quite advanced. However,
others experience loin pain associated with obstruction (renal colic) or due to infection; fevers; swelling (oedema), usually of the legs but occasionally including the face and arms; blood in the urine (haematuria); and excess quantities of urine (polyuria), including at night (nocturia), due to failure of normal mechanisms in the kidney for concentrating urine. Patients with chronic renal failure often have very di?use symptoms including nausea and vomiting, tiredness due to ANAEMIA, shortness of breath, skin irritation, pins and needles (paraesthesia) due to damage of the peripheral nerves (peripheral neuropathy), and eventually (rarely seen nowadays) clouding of consciousness and death.
Signs of kidney disease include loin tenderness, enlarged kidneys, signs of ?uid retention, high blood pressure and, in patients with end-stage renal failure, pallor, pigmentation and a variety of neurological signs including absent re?exes, reduced sensation, and a coarse ?apping tremor (asterixis) due to severe disturbance of the body’s normal metabolism.
Renal failure Serious kidney disease may lead to impairment or failure of the kidney’s ability to ?lter waste products from the blood and excrete them in the urine – a process that controls the body’s water and salt balance and helps to maintain a stable blood pressure. Failure of this process causes URAEMIA – an increase in urea and other metabolic waste products – as well as other metabolic upsets in the blood and tissues, all of which produce varying symptoms. Failure can be sudden or develop more slowly (chronic). In the former, function usually returns to normal once the underlying cause has been treated. Chronic failure, however, usually irreparably reduces or stops normal function.
Acute failure commonly results from physiological shock following a bad injury or major illness. Serious bleeding or burns can reduce blood volume and pressure to the point where blood-supply to the kidney is greatly reduced. Acute myocardial infarction (see HEART, DISEASES OF) or pancreatitis (see PANCREAS, DISORDERS OF) may produce a similar result. A mismatched blood transfusion can produce acute failure. Obstruction to the urine-?ow by a stone (calculus) in the urinary tract, a bladder tumour or an enlarged prostate can also cause acute renal failure, as can glomerulonephritis (see below) and the haemolytic-uraemia syndrome.
HYPERTENSION, DIABETES MELLITUS, polycystic kidney disease (see below) or AMYLOIDOSIS are among conditions that cause chronic renal failure. Others include stone, tumour, prostatic enlargement and overuse of analgesic drugs. Chronic failure may eventually lead to end-stage renal failure, a life-threatening situation that will need DIALYSIS or a renal transplant (see TRANSPLANTATION).
Familial renal disorders include autosomal dominant inherited polycystic kidney disease and sex-linked familial nephropathy. Polycystic kidney disease is an important cause of renal failure in the UK. Patients, usually aged 30–50, present with HAEMATURIA, loin or abdominal discomfort or, rarely, urinary-tract infection, hypertension and enlarged kidneys. Diagnosis is based on ultrasound examination of the abdomen. Complications include renal failure, hepatic cysts and, rarely, SUBARACHNOID HAEMORRHAGE. No speci?c treatment is available. Familial nephropathy occurs more often in boys than in girls and commonly presents as Alport’s syndrome (familial nephritis with nerve DEAFNESS) with PROTEINURIA, haematuria, progressing to renal failure and deafness. The cause of the disease lies in an absence of a speci?c ANTIGEN in a part of the glomerulus. The treatment is conservative, with most patients eventually requiring dialysis or transplantation.
Acute glomerulonephritis is an immune-complex disorder due to entrapment within glomerular capillaries of ANTIGEN (usually derived from B haemolytic streptococci – see STREPTOCOCCUS) antibody complexes initiating an acute in?ammatory response (see IMMUNITY). The disease affects children and young adults, and classically presents with a sore throat followed two weeks later by a fall in urine output (oliguria), haematuria, hypertension and mildly abnormal renal function. The disease is self-limiting with 90 per cent of patients spontaneously recovering. Treatment consists of control of blood pressure, reduced ?uid and salt intake, and occasional DIURETICS and ANTIBIOTICS.
Chronic glomerulonephritis is also due to immunological renal problems and is also classi?ed by taking a renal biopsy. It may be subdivided into various histological varieties as determined by renal biospy. Proteinuria of various degrees is present in all these conditions but the clinical presentations vary, as do their treatments. Some resolve spontaneously; others are treated with steroids or even the cytotoxic drug CYCLOPHOSPHAMIDE or the immunosuppressant cyclosporin. Prognoses are generally satisfactory but some patients may require renal dialysis or kidney transplantation – an operation with a good success rate.
Hydronephrosis A chronic disease in which the kidney becomes greatly distended with ?uid. It is caused by obstruction to the ?ow of urine at the pelvi-ureteric junction (see KIDNEYS – Structure). If the ureter is obstructed, the ureter proximal to the obstruction will dilate and pressure will be transmitted back to the kidney to cause hydronephrosis. Obstruction may occur at the bladder neck or in the urethra itself. Enlargement of the prostate is a common cause of bladder-neck obstruction; this would give rise to hypertrophy of the bladder muscle and both dilatation of the ureter and hydronephrosis. If the obstruction is not relieved, progressive destruction of renal tissue will occur. As a result of the stagnation of the urine, infection is probable and CYSTITIS and PYELONEPHRITIS may occur.
Impaired blood supply may be the outcome of diabetes mellitus and physiological shock, which lowers the blood pressure, also affecting the blood supply. The result can be acute tubular necrosis. POLYARTERITIS NODOSA and SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) may damage the large blood vessels in the kidney. Treatment is of the underlying condition.
Infection of the kidney is called pyelonephritis, a key predisposing factor being obstruction of urine ?ow through the urinary tract. This causes stagnation and provides a fertile ground for bacterial growth. Acute pyelonephritis is more common in women, especially during pregnancy when bladder infection (CYSTITIS) spreads up the ureters to the kidney. Symptoms are fever, malaise and backache. Antibiotics and high ?uid intake are the most e?ective treatment. Chronic pyelonephritis may start in childhood as a result of congenital deformities that permit urine to ?ow up from the bladder to the kidney (re?ux). Persistent re?ux leads to recurrent infections causing permanent damage to the kidney. Specialist investigations are usually required as possible complications include hypertension and kidney failure.
Tumours of the kidney are fortunately rare. Non-malignant ones commonly do not cause symptoms, and even malignant tumours (renal cell carcinoma) may be asymptomatic for many years. As soon as symptoms appear – haematuria, back pain, nausea, malaise, sometimes secondary growths in the lungs, bones or liver, and weight loss – urgent treatment including surgery, radiotherapy and chemotherapy is necessary. This cancer occurs mostly in adults over 40 and has a hereditary element. The prognosis is not good unless diagnosed early. In young children a rare cancer called nephroblastoma (Wilm’s tumour) can occur; treatment is with surgery, radiotherapy and chemotherapy. It may grow to a substantial size before being diagnosed.
Cystinuria is an inherited metabolic defect in the renal tubular reabsorption of cystine, ornithine, lysine and arginine. Cystine precipitates in an alkaline urine to form cystine stones. Triple phosphate stones are associated with infection and may develop into a very large branching calculi (staghorn calculi). Stones present as renal or ureteric pain, or as an infection. Treatment has undergone considerable change with the introduction of MINIMALLY INVASIVE SURGERY (MIS) and the destruction of stone by sound waves (LITHOTRIPSY).... kidneys, diseases of
Rarely, the UTERUS may be completely absent as a result of abnormal development. In such patients secondary sexual development is normal but MENSTRUATION is absent (primary amennorhoea). The chromosomal make-up of the patient must be checked (see CHROMOSOMES; GENES): in a few cases the genotype is male (testicular feminisation syndrome). No treatment is available, although the woman should be counselled.
The uterus develops as two halves which fuse together. If the fusion is incomplete, a uterine SEPTUM results. Such patients with a double uterus (uterus didelphys) may have fertility problems which can be corrected by surgical removal of the uterine septum. Very rarely there may be two uteri with a double vagina.
The uterus of most women points forwards (anteversion) and bends forwards (ante?exion). However, about 25 per cent of women have a uterus which is pointed backwards (retroversion) and bent backwards (retro?exion). This is a normal variant and very rarely gives rise to any problems. If it does, the attitude of the uterus can be corrected by an operation called a ventrosuspension.
Endometritis The lining of the uterine cavity is called the ENDOMETRIUM. It is this layer that is partially shed cyclically in women of reproductive age giving rise to menstruation. Infection of the endometrium is called endometritis and usually occurs after a pregnancy or in association with the use of an intrauterine contraceptive device (IUCD – see CONTRACEPTION). The symptoms are usually of pain, bleeding and a fever. Treatment is with antibiotics. Unless the FALLOPIAN TUBES are involved and damaged, subsequent fertility is unaffected. Very rarely, the infection is caused by TUBERCULOSIS. Tuberculous endometritis may destroy the endometrium causing permanent amenorrhoea and sterility.
Menstrual disorders are common. Heavy periods (menorrhagia) are often caused by ?broids (see below) or adenomyosis (see below) or by anovulatory cycles. Anovulatory cycles result in the endometrium being subjected to unopposed oestrogen stimulation and occasionally undergoing hyperplasia. Treatment is with cyclical progestogens (see PROGESTOGEN) initially. If this form of treatment fails, endoscopic surgery to remove the endometrium may be successful. The endometrium may be removed using LASER (endometrial laser ablation) or electrocautery (transcervical resection of endometrium). Hysterectomy (see below) will cure the problem if endoscopic surgery fails. Adenomyosis is a condition in which endometrial tissue is found in the muscle layer (myometrium) of the uterus. It usually presents as heavy and painful periods, and occasionally pain during intercourse. Hysterectomy is usually required.
Oligomenorhoea (scanty or infrequent periods) may be caused by a variety of conditions including thyroid disease (see THYROID GLAND, DISEASES OF). It is most commonly associated with usage of the combined oral contraceptive pill. Once serious causes have been eliminated, the patient should be reassured. No treatment is necessary unless conception is desired, in which case the patient may require induction of ovulation.
Primary amenorrhoea means that the patient has never had a period. She should be investigated, although usually it is only due to an inexplicable delay in the onset of periods (delayed menarche) and not to any serious condition. Secondary amenorrhoea is the cessation of periods after menstruation has started. The most common cause is pregnancy. It may be also caused by endocrinological or hormonal problems, tuberculous endometritis, emotional problems and severe weight loss. The treatment of amenorrhoea depends on the cause.
Dysmenorrhoea, or painful periods, is the most common disorder; in most cases the cause is unknown, although the disorder may be due to excessive production of PROSTAGLANDINS.
Irregular menstruation (variations from the woman’s normal menstrual pattern or changes in the duration of bleeding or the amount) can be the result of a disturbance in the balance of OESTROGENS and PROGESTERONE hormone which between them regulate the cycle. For some time after the MENARCHE or before the MENOPAUSE, menstruation may be irregular. If irregularity occurs in a woman whose periods are normally regular, it may be due to unsuspected pregnancy, early miscarriage or to disorders in the uterus, OVARIES or pelvic cavity. The woman should seek medical advice.
Fibroids (leiomyomata) are benign tumours arising from the smooth muscle layer (myometrium) of the uterus. They are found in 80 per cent of women but only a small percentage give rise to any problems and may then require treatment. They may cause heavy periods and occasionally pain. Sometimes they present as a mass arising from the pelvis with pressure symptoms from the bladder or rectum. Although they can be shrunk medically using gonadorelin analogues, which raise the plasma concentrations of LUTEINISING HORMONE and FOLLICLE-STIMULATING HORMONE, this is not a long-term solution. In any case, ?broids only require treatment if they are large or enlarging, or if they cause symptoms. Treatment is either myomectomy (surgical removal) if fertility is to be retained, or a hysterectomy.
Uterine cancers tend to present after the age of 40 with abnormal bleeding (intermenstrual or postmenopausal bleeding). They are usually endometrial carcinomas. Eighty per cent present with early (Stage I) disease. Patients with operable cancers should be treated with total abdominal hysterectomy and bilateral excision of the ovaries and Fallopian tubes. Post-operative RADIOTHERAPY is usually given to those patients with adverse prognostic factors. Pre-operative radiotherapy is still given by some centres, although this practice is now regarded as outdated. PROGESTOGEN treatment may be extremely e?ective in cases of recurrence, but its value remains unproven when used as adjuvant treatment. In 2003 in England and Wales, more than 2,353 women died of uterine cancer.
Disorders of the cervix The cervix (neck of the womb) may produce an excessive discharge due to the presence of a cervical ectopy or ectropion. In both instances columnar epithelium – the layer of secreting cells – which usually lines the cervical canal is exposed on its surface. Asymptomatic patients do not require treatment. If treatment is required, cryocautery – local freezing of tissue – is usually e?ective.
Cervical smears are taken and examined in the laboratory to detect abnormal cells shed from the cervix. Its main purpose is to detect cervical intraepithelial neoplasia (CIN) – the presence of malignant cells in the surface tissue lining the cervix – since up to 40 per cent of women with this condition will develop cervical cancer if the CIN is left untreated. Women with abnormal smears should undergo colposcopy, a painless investigation using a low-powered microscope to inspect the cervix. If CIN is found, treatment consists of simply removing the area of abnormal skin, either using a diathermy loop or laser instrument.
Unfortunately, cervical cancer remains the most common of gynaecological cancers. The most common type is squamous cell carcinoma and around 4,000 new cases (all types) are diagnosed in England and Wales every year. As many as 50 per cent of the women affected may die from the disease within ?ve years. Cervical cancer is staged clinically in four bands according to how far it has extended, and treatment is determined by this staging. Stage I involves only the mucosal lining of the cervix and cone BIOPSY may be the best treatment in young women wanting children. In Stage IV the disease has spread beyond the cervix, uterus and pelvis to the URINARY BLADDER or RECTUM. For most women, radiotherapy or radical Wertheim’s hysterectomy – the latter being preferable for younger women – is the treatment of choice if the cancer is diagnosed early, both resulting in survival rates of ?ve years in 80 per cent of patients. Wertheim’s hysterectomy is a major operation in which the uterus, cervix, upper third of vagina and the tissue surrounding the cervix are removed together with the LYMPH NODES draining the area. The ovaries may be retained if desired. Patients with cervical cancer are treated by radiotherapy, either because they present too late for surgery or because the surgical skill to perform a radical hysterectomy is not available. These operations are best performed by gynaecological oncologists who are gynaecological surgeons specialising in the treatment of gynaecological tumours. The role of CHEMOTHERAPY in cervical and uterine cancer is still being evaluated.
Prolapse of the uterus is a disorder in which the organ drops from its normal situation down into the vagina. First-degree prolapse is a slight displacement of the uterus, second-degree a partial displacement and third-degree when the uterus can be seen outside the VULVA. It may be accompanied by a CYSTOCOELE (the bladder bulges into the front wall of the vagina), urethrocoele (the urethra bulges into the vagina) and rectocoele (the rectal wall bulges into the rear wall of the vagina). Prolapse most commonly occurs in middle-aged women who have had children, but the condition is much less common now than in the past when prenatal and obstetric care was poor, women had more pregnancies and their general health was poor. Treatment is with pelvic exercises, surgical repair of the vagina or hysterectomy. If the woman does not want or is not ?t for surgery, an internal support called a pessary can be ?tted – and changed periodically.
Vertical section of female reproductive tract (viewed from front) showing sites of common gynaecological disorders.
Hysterectomy Many serious conditions of the uterus have traditionally been treated by hysterectomy, or removal of the uterus. It remains a common surgical operation in the UK, but is being superseded in the treatment of some conditions, such as persistent MENORRHAGIA, with endometrial ablation – removal of the lining of the uterus using minimally invasive techniques, usually using an ENDOSCOPE and laser. Hysterectomy is done to treat ?broids, cancer of the uterus and cervix, menorrhagia, ENDOMETRIOSIS and sometimes for severely prolapsed uterus. Total hysterectomy is the usual type of operation: it involves the removal of the uterus and cervix and sometimes the ovaries. After hysterectomy a woman no longer menstruates and cannot become pregnant. If the ovaries have been removed as well and the woman had not reached the menopause, hormone replacement therapy (HRT – see MENOPAUSE) should be considered. Counselling helps the woman to recover from the operation which can be an emotionally challenging event for many.... uterus, diseases of
Gall-stones affect 22 per cent of women and 11 per cent of men. The incidence increases with age, but only about 30 per cent of those with gall-stones undergo treatment as the majority of cases are asymptomatic. There are three types of stone: cholesterol, pigment and mixed, depending upon their composition; stones are usually mixed and may contain calcium deposits. The cause of most cases is not clear but sometimes gall-stones will form around a ‘foreign body’ within the bile ducts or gall-bladder, such as suture material. BILIARY COLIC Muscle ?bres in the biliary system contract around a stone in the cystic duct or common bile duct in an attempt to expel it. This causes pain in the right upper quarter of the abdomen, with nausea and occasionally vomiting. JAUNDICE Gall-stones small enough to enter the common bile duct may block the ?ow of bile and cause jaundice. ACUTE CHOLECYSTITIS Blockage of the cystic duct may lead to this. The gall-bladder wall becomes in?amed, resulting in pain in the right upper quarter of the abdomen, fever, and an increase in the white-blood-cell count. There is characteristically tenderness over the tip of the right ninth rib on deep inhalation (Murphy’s sign). Infection of the gall-bladder may accompany the acute in?ammation and occasionally an EMPYEMA of the gall-bladder may result. CHRONIC CHOLECYSTITIS A more insidious form of gall-bladder in?ammation, producing non-speci?c symptoms of abdominal pain, nausea and ?atulence which may be worse after a fatty meal.
Diagnosis Stones are usually diagnosed on the basis of the patient’s reported symptoms, although asymptomatic gall-stones are often an incidental ?nding when investigating another complaint. Con?rmatory investigations include abdominal RADIOGRAPHY – although many gall-stones are not calci?ed and thus do not show up on these images; ULTRASOUND scanning; oral CHOLECYSTOGRAPHY – which entails a patient’s swallowing a substance opaque to X-rays which is concentrated in the gall-bladder; and endoscopic retrograde cholangiopancreatography (ERCP) – a technique in which an ENDOSCOPE is passed into the duodenum and a contrast medium injected into the biliary duct.
Treatment Biliary colic is treated with bed rest and injection of morphine-like analgesics. Once the pain has subsided, the patient may then be referred for further treatment as outlined below. Acute cholecystitis is treated by surgical removal of the gall-bladder. There are two techniques available for this procedure: ?rstly, conventional cholecystectomy, in which the abdomen is opened and the gall-bladder cut out; and, secondly, laparoscopic cholecystectomy, in which ?breoptic instruments called endoscopes (see FIBREOPTIC ENDOSCOPY) are introduced into the abdominal cavity via several small incisions (see MINIMALLY INVASIVE SURGERY (MIS)). Laparoscopic surgery has the advantage of reducing the patient’s recovery time. Gall-stones may be removed during ERCP; they can sometimes be dissolved using ultrasound waves (lithotripsy) or tablet therapy (dissolution chemotherapy). Pigment stones, calci?ed stones or stones larger than 15 mm in diameter are not suitable for this treatment, which is also less likely to succeed in the overweight patient. Drug treatment is prolonged but stones can disappear completely after two years. Stones may re-form on stopping therapy. The drugs used are derivatives of bile salts, particularly chenodeoxycholic acid; side-effects include diarrhoea and liver damage.... gall-bladder, diseases of
2. It is mostly acquired as a result of sexual activity; some cases are caused by simplex type
1. After initial infection the virus lies latent in the dorsal nerve root ganglion (of the spinal cord) which enervates the affected area of the skin. Latent virus is never cured and reactivation results in either a recurrence of symptoms or in asymptomatic shedding of the virus which then infects a sexual partner. Around 30,000 cases of genital herpes are reported annually from clinics dealing with SEXUALLY TRANSMITTED DISEASES (STDS) in England, but there are also many unrecognised (by either patient or doctor) infections. Patients may have a history of painful attacks of ulceration of the genitals for many years before seeking medical advice. All patients with a ?rst episode of the infection should be given oral antiviral treatment, and those who suffer more than six attacks a year should be considered for suppressive antiviral treatment. ACICLOVIR, valaciclovir and famciclovir are all e?ective antiviral drugs. If a woman in the ?nal three months of her pregnancy contracts herpes genitalis, this can have serious consequences for the baby as he or she will be at risk of herpes encephalitis after delivery.... herpes genitalis
Viral infections by any of hepatitis A, B, C, D, or E viruses and also CYTOMEGALOVIRUS (CMV), EPSTEIN BARR VIRUS, and HERPES SIMPLEX.
Autoimmune disorders such as autoimmune chronic hepatitis, toxins, alcohol and certain drugs – ISONIAZID, RIFAMPICIN, HALOTHANE and CHLORPROMAZINE.
WILSON’S DISEASE.
Acute viral hepatitis causes damage throughout the liver and in severe infections may destroy whole lobules (see below).
Chronic hepatitis is typi?ed by an invasion of the portal tract by white blood cells (mild hepatitis). If these mononuclear in?ammatory cells invade the body (parenchyma) of the liver tissue, ?brosis and then chronic disease or cirrhosis can develop. Cirrhosis may develop at any age and commonly results in prolonged ill health. It is an important cause of premature death, with excessive alcohol consumption commonly the triggering factor. Sometimes, cirrhosis may be asymptomatic, but common symptoms are weakness, tiredness, poor appetite, weight loss, nausea, vomiting, abdominal discomfort and production of abnormal amounts of wind. Initially, the liver may enlarge, but later it becomes hard and shrunken, though rarely causing pain. Skin pigmentation may occur along with jaundice, the result of failure to excrete the liver product BILIRUBIN. Routine liver-function tests on blood are used to help diagnose the disease and to monitor its progress. Spider telangiectasia (caused by damage to blood vessels – see TELANGIECTASIS) usually develop, and these are a signi?cant pointer to liver disease. ENDOCRINE changes occur, especially in men, who lose their typical hair distribution and suffer from atrophy of their testicles. Bruising and nosebleeds occur increasingly as the cirrhosis worsens, and portal hypertension (high pressure of venous blood circulation through the liver) develops due to abnormal vascular resistance. ASCITES and HEPATIC ENCEPHALOPATHY are indications of advanced cirrhosis.
Treatment of cirrhosis is to tackle the underlying cause, to maintain the patient’s nutrition (advising him or her to avoid alcohol), and to treat any complications. The disorder can also be treated by liver transplantation; indeed, 75 per cent of liver transplants are done for cirrhosis. The overall prognosis of cirrhosis, however, is not good, especially as many patients attend for medical care late in the course of the disease. Overall, only 25 per cent of patients live for ?ve years after diagnosis, though patients who have a liver transplant and survive for a year (80 per cent do) have a good prognosis.
Autoimmune hepatitis is a type that most commonly occurs in women between 20 and 40 years of age. The cause is unknown and it has been suggested that the disease has several immunological subtypes. Symptoms are similar to other viral hepatitis infections, with painful joints and AMENORRHOEA as additional symptoms. Jaundice and signs of chronic liver disease usually occur. Treatment with CORTICOSTEROIDS is life-saving in autoimmune hepatitis, and maintenance treatment may be needed for two years or more. Remissions and exacerbations are typical, and most patients eventually develop cirrhosis, with 50 per cent of victims dying of liver failure if not treated. This ?gure falls to 10 per cent in treated patients.
Viral hepatitis The ?ve hepatic viruses (A to E) all cause acute primary liver disease, though each belongs to a separate group of viruses.
•Hepatitis A virus (HAV) is an ENTEROVIRUS
which is very infectious, spreading by faecal contamination from patients suffering from (or incubating) the infection; victims excrete viruses into the faeces for around ?ve weeks during incubation and development of the disease. Overcrowding and poor sanitation help to spread hepatitis A, which fortunately usually causes only mild disease.
Hepatitis B (HBV) is caused by a hepadna virus, and humans are the only reservoir of infection, with blood the main agent for transferring it. Transfusions of infected blood or blood products, and injections using contaminated needles (common among habitual drug abusers), are common modes of transfer. Tattooing and ACUPUNCTURE may spread hepatitis B unless high standards of sterilisation are maintained. Sexual intercourse, particularly between male homosexuals, is a signi?cant infection route.
Hepatitis C (HCV) is a ?avivirus whose source of infection is usually via blood contacts. E?ective screening of blood donors and heat treatment of blood factors should prevent the spread of this infection, which becomes chronic in about 75 per cent of those infected, lasting for life. Although most carriers do not suffer an acute illness, they must practise life-long preventive measures.
Hepatitis D (HDV) cannot survive independently, needing HBV to replicate, so its sources and methods of spread are similar to the B virus. HDV can infect people at the same time as HBV, but it is capable of superinfecting those who are already chronic carriers of the B virus. Acute and chronic infection of HDV can occur, depending on individual circumstances, and parenteral drug abuse spreads the infection. The disease occurs worldwide, being endemic in Africa, South America and the Mediterranean littoral.
Hepatitis E virus (HEV) is excreted in the stools, spreading via the faeco-oral route. It causes large epidemics of water-borne hepatitis and ?ourishes wherever there is poor sanitation. It resembles acute HAV infection and the patient usually recovers. HEV does not cause chronic infection. The clinical characteristics of the ?ve hepatic
viruses are broadly similar. The initial symptoms last for up to two weeks (comprising temperature, headache and malaise), and JAUNDICE then develops, with anorexia, nausea, vomiting and diarrhoea common manifestations. Upper abdominal pain and a tender enlarged liver margin, accompanied by enlarged cervical lymph glands, are usual.
As well as blood tests to assess liver function, there are speci?c virological tests to identify the ?ve infective agents, and these are important contributions to diagnosis. However, there is no speci?c treatment of any of these infections. The more seriously ill patients may require hospital care, mainly to enable doctors to spot at an early stage those developing acute liver failure. If vomiting is a problem, intravenous ?uid and glucose can be given. Therapeutic drugs – especially sedatives and hypnotics – should be avoided, and alcohol must not be taken during the acute phase. Interferon is the only licensed drug for the treatment of chronic hepatitis B, but this is used with care.
Otherwise-?t patients under 40 with acute viral hepatitis have a mortality rate of around
0.5 per cent; for those over 60, this ?gure is around 3 per cent. Up to 95 per cent of adults with acute HBV infection recover fully but the rest may develop life-long chronic hepatitis, particularly those who are immunode?cient (see IMMUNODEFICIENCY).
Infection is best prevented by good living conditions. HVA and HVB can be prevented by active immunisation with vaccines. There is no vaccine available for viruses C, D and E, although HDV is e?ectively prevented by immunisation against HBV. At-risk groups who should be vaccinated against HBV include:
Parenteral drug abusers.
Close contacts of infected individuals such as regular sexual partners and infants of infected mothers.
Men who have sex with men.
Patients undergoing regular haemodialysis.
Selected health professionals, including laboratory sta? dealing with blood samples and products.... hepatitis
Lifestyle While this may change as people grow older – for instance, physical activity is commonly reduced – some lifestyle factors are unchanged: for example, cigarette smoking, commonly started in adolescence, may be continued as an adult, resulting in smoker’s cough and eventually chronic BRONCHITIS and EMPHYSEMA; widespread ATHEROSCLEROSIS causing heart attacks and STROKE; osteoporosis (see BONE, DISORDERS OF) producing bony fractures; and cancer affecting the lungs and bladder.
Genetic factors can cause sickle cell disease (see ANAEMIA), HUNTINGTON’S CHOREA and polycystic disease of the kidney.
Ageing process This is associated with the MENOPAUSE in women and, in both sexes, with a reduction in the body’s tissue elasticity and often a deterioration in mental and physical capabilities. When compared with illnesses described in much younger people, similar illnesses in old age present in an atypical manner
– for example, confusion and changed behaviour due to otherwise asymptomatic heart failure, causing a reduced supply of oxygen to the brain. Social adversity in old age may result from the combined effects of reduced body reserve, atypical presentation of illness, multiple disorders and POLYPHARMACY.
Age-related change in the presentation of illnesses This was ?rst recognised by the specialty of geriatric medicine (also called the medicine of ageing) which is concerned with the medical and social management of advanced age. The aim is to assess, treat and rehabilitate such patients. The number of institutional beds has been steadily cut, while availability of day-treatment centres and respite facilities has been boosted – although still inadequate to cope with the growing number of people over 65.
These developments, along with day social centres, provide relatives and carers with a break from the often demanding task of looking after the frail or ill elderly. As the proportion of elderly people in the population rises, along with the cost of hospital inpatient care, close cooperation between hospitals, COMMUNITY CARE services and primary care trusts (see under GENERAL PRACTITIONER (GP)) becomes increasingly important if senior citizens are not to suffer from the consequences of the tight operating budgets of the various medical and social agencies with responsibilities for the care of the elderly. Private or voluntary nursing and residential homes have expanded in the past 15 years and now care for many elderly people who previously would have been occupying NHS facilities. This trend has been accelerated by a tightening of the bene?t rules for funding such care. Local authorities are now responsible for assessing the needs of elderly people in the community and deciding whether they are eligible for ?nancial support (in full or in part) for nursing-home care.
With a substantial proportion of hospital inpatients in the United Kingdom being over 60, it is sometimes argued that all health professionals should be skilled in the care of the elderly; thus the need for doctors and nurses trained in the specialty of geriatrics is diminishing. Even so, as more people are reaching their 80s, there seems to be a reasonable case for training sta? in the type of care these individuals need and to facilitate research into illness at this stage of life.... medicine of ageing
Much more serious is spina bi?da cystica, in which the spinal-wall defect is accompanied by a protrusion of the spinal cord. This may take two forms: a meningocele, in which the MENINGES, containing CEREBROSPINAL FLUID, protrude through the defect; and a meningomyelocele, in which the protrusion contains spinal cord and nerves.
Meningocele is less common and has a good prognosis. HYDROCEPHALUS and neurological problems affecting the legs are rare, although the bladder may be affected. Treatment consists of surgery which may be in the ?rst few days of life or much later depending upon the precise situation; long-term follow-up is necessary to pick up any neurological problems that may develop during subsequent growth of the spine.
Meningomyelocele is much more serious and more common, accounting for 90 per cent of all cases. Usually affecting the lumbo-sacral region, the range of severity may vary considerably and, while early surgery with careful attention in a minor case may achieve good mobility, normal bladder function and intellect, a more extensive protrusion may cause complete ANAESTHESIA of the skin, with increased risk of trauma; extensive paralysis of the trunk and limbs, with severe deformities; and paralysis and insensitivity of the bladder and bowel. Involuntary movements may be present, and hydrocephalus occurs in 80 per cent of cases. The decision to operate can only be made after a full examination of the infant to determine the extent of the defect and any co-existent congenital abnormalities. The child’s potential can then be estimated, and appropriate treatment discussed with the parents. Carefully selected patients should receive long-term treatment in a special centre, where full attention can be paid to all their various problems.
There is growing evidence of the value of vitamin supplements before and during pregnancy in reducing the incidence of spina bi?da. Parents of affected infants may obtain help, advice, and encouragement from the Association for Spina Bi?da and Hydrocephalus which has branches throughout the country, or the Scottish Spina Bi?da Association.... spina bifida
Whilst an infected patient is frequently asymptomatic, heavy infection can cause jejunal mucosal abnormalities, and an absorptive defect, with weight loss. During the migratory phase an itchy linear rash (larva currens) may be present on the lower abdomen, buttocks, and groins; this gives rise to recurrent transient itching. In an immunosuppressed individual, the ‘hyperinfection syndrome’ may ensue; migratory larvae invade all organs and tissues, including the lungs and brain. Associated with this widespread infection, the patient may develop an Enterobacteriacae spp. SEPTICAEMIA; this, together with S. stercoralis larvae, produces a MENINGOENCEPHALITIS. There is no evidence that this syndrome is more common in patients with HIV infection.
Diagnosis consists of visualisation of S. stercoralis (larvae or adults) in a jejunal biopsy-section or aspirate. Larvae may also be demonstrable in a faecal sample, especially following culture. Eosinophilia may be present in peripheral blood, during the invasive stage of infection. Chemotherapy consists of albendazole. The formerly used benzimidazole compound, thiabendazole, is now rarely prescribed in an uncomplicated infection due to unpleasant side-effects; even so, in the ‘hyperinfection syndrome’ it probably remains the more e?ective of the two compounds.... strongyloidiasis
AIDS is largely a sexually transmitted disease, either homosexually or heterosexually. The two other main routes of spread are via infected blood or blood products (as by drug users sharing contaminated needles) and by the maternofetal route. The virus may be transmitted from an infected mother to the child in the uterus or it may be acquired from maternal blood during parturition; it may also be transmitted in breast milk. HIV has been isolated from semen, cervical secretions, plasma, cerebrospinal fluid, tears, saliva, urine, and breast milk but the concentration shows wide variations. Moreover HIV is a fragile virus and does not survive well outside the body. It is therefore considered that ordinary social contact with HIV-positive subjects involves no risk of infection. However, high standards of clinical practice are required by all health workers in order to avoid inadvertent infection via blood, blood products, or body fluids from HIV-positive people. Staff who become HIV-positive are expected to declare their status and will be counselled.
Until recently, AIDS was considered to be universally fatal, although the type and length of illness preceding death varies considerably. However, with the development of *antiretroviral drugs used in dual or triple combinations, AIDS is now perceived as a chronic disease rather than a fatal one.
AIH see artificial insemination.... aids
Health Encyclopedia