(American) One who takes risks Chanci, Chancie, Chancee, Chancea, Chanceah, Chancy, Chancey
The disorder is characterised by failure to gain weight in spite of a good appetite, by repeated attacks of bronchitis (with BRONCHIECTASIS developing at a young age), and by the passage of loose, foul-smelling and slimy stools (faeces). AMNIOCENTESIS, which yields amniotic ?uid along with cells shed from the fetus’s skin, can be used to diagnose cystic ?brosis prenatally. The levels of various enzymes can be measured in the ?uid and are abnormal when the fetus is affected by cystic ?brosis. Neonatal screening is possible using a test on blood spots – immunoreactive trypsin (IRT).
In children with symptoms or a positive family history, the disease can be tested for by measuring sweat chloride and sodium. This detects the abnormal amount of salt that is excreted via the sweat glands when cystic ?brosis is present. Con?rmation is by genetic testing.
Treatment This consists basically of regular physiotherapy and postural drainage, antibiotics and the taking of pancreatic enzyme tablets and vitamins. Some children need STEROID treatment and all require nutritional support. The earlier treatment is started, the better the results. Whereas two decades ago, only 12 per cent of affected children survived beyond adolescence, today 75 per cent survive into adult life, and an increasing number are surviving into their 40s. Patients with end-stage disease can be treated by heart-lung transplantation (with their own heart going to another recipient). Research is underway on the possible use of GENE THERAPY to control the disorder. Parents of children with cystic ?brosis, seeking help and advice, can obtain this from the Cystic Fibrosis Trust.... cystic fibrosis
Adverse effects can be divided into types. First, those which are closely related to the concentration of the drug and accord with what is known of its PHARMACOLOGY. These so-called type A (augmented pharmacological) effects are distinguished from type B (bizarre) effects which are unpredictable, usually rare, and often severe. ANAPHYLAXIS is the most obvious of these; other examples include bone-marrow suppression with CO-TRIMOXAZOLE; hepatic failure (see HEPATITIS) with SODIUM VALPROATE; and PULMONARY FIBROSIS with AMIODARONE. A more comprehensive classi?cation includes reactions type C (chronic effects), D (delayed effects – such as teratogenesis or carcinogenesis) and E (end-of-dose effects – withdrawal effects). Examples of adverse reactions include nausea, skin eruptions, jaundice, sleepiness and headaches.
While most reported adverse reactions are minor and require no treatment, patients should remind their doctors of any drug allergy or adverse e?ect they have suffered in the past. Medical warning bracelets are easily obtained. Doctors should report adverse effects to the authorities – in the case of Britain, to the Committee on Safety of Medicines (CSM), using the yellow-card reporting machinery.... adverse reactions to drugs
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
This technique is used when normal methods of attempted CONCEPTION or ARTIFICIAL INSEMINATION with healthy SEMEN have failed. In the UK, assisted-conception procedures are governed by the Human Fertilisation & Embryology Act 1990, which set up the Human Fertilisation & Embryology Authority (HFEA).
Human Fertilisation & Embryology Act 1990 UK legislation was prompted by the report on in vitro fertilisation produced by a government-appointed committee chaired by Baroness Warnock. This followed the birth, in 1978, of the ?rst ‘test-tube’ baby.
This Act allows regulation monitoring of all treatment centres to ensure that they carry out treatment and research responsibly. It covers any fertilisation that uses donated eggs or sperm (called gametes) – for example, donor insemination or embryos (see EMBRYO) grown outside the human body (known as licensed treatment). The Act also covers research on human embryos with especial emphasis on foolproof labelling and immaculate data collection.
Human Fertilisation & EmbryologyAuthority (HFEA) Set up by the UK government following the Warnock report, the Authority’s 221 members inspect and license centres carrying out fertilisation treatments using donated eggs and sperm. It publishes a code of practice advising centres on how to conduct their activities and maintains a register of information on donors, patients and all treatments. It also reviews routinely progress and research in fertility treatment and the attempted development of human CLONING. Cloning to produce viable embryos (reproductive cloning) is forbidden, but limited licensing of the technique is allowed in specialist centres to enable them to produce cells for medical treatment (therapeutic cloning).
In vitro fertilisation (IVF) In this technique, the female partner receives drugs to enhance OVULATION. Just before the eggs are released from the ovary (see OVARIES), several ripe eggs are collected under ULTRASOUND guidance or through a LAPAROSCOPE. The eggs are incubated with the prepared sperm. About 40 hours later, once the eggs are fertilised, two eggs (three in special circumstances) are transferred into the mother’s UTERUS via the cervix (neck of the womb). Pregnancy should then proceed normally. About one in ?ve IVF pregnancies results in the birth of a child. The success rate is lower in women over 40.
Indications In women with severely damaged FALLOPIAN TUBES, IVF o?ers the only chance of pregnancy. The method is also used in couples with unexplained infertility or with male-factor infertility (where sperms are abnormal or their count low). Women who have had an early or surgically induced MENOPAUSE can become pregnant using donor eggs. A quarter of these pregnancies are multiple – that is, produce twins or more. Twins and triplets are more likely to be premature. The main danger of ovarian stimulation for IVF is hyperstimulation which can cause ovarian cysts. (See OVARIES, DISEASES OF.)... assisted conception
Nutritional Profile Energy value (calories per serving): Moderate Protein: Low Fat: Low Saturated fat: Low Cholesterol: None Carbohydrates: High Fiber: Moderate Sodium: Low Major vitamin contribution: B vitamins, vitamin C Major mineral contribution: Potassium, magnesium
About the Nutrients in This Food A banana begins life with more starch than sugar, but as the fruit ripens its starches turn to sugar, which is why ripe bananas taste so much better than unripe ones.* The color of a banana’s skin is a fair guide to its starch/ sugar ratio. When the skin is yellow-green, 40 percent of its carbohydrates are starch; when the skin is fully yellow and the banana is ripe, only 8 per- cent of the carbohydrates are still starch. The rest (91 percent) have broken down into sugars—glucose, fructose, sucrose, the most plentiful sugar in the fruit. Its high sugar content makes the banana, in its self-contained packet, a handy energy source. Bananas are a high-fiber food with insoluble cellulose and lignin in the tiny seeds and soluble pectins in the flesh. They are also a good source of vitamin C and potassium. One small (six-inch) banana or a half-cup of sliced banana has 2.6 g dietary fiber and 8.8 mg vitamin C (12 percent of the R DA for a woman, 10 percent of the R DA for a man), plus 363 mg potassium.
The Most Nutritious Way to Serve This Food Fresh and ripe. Green bananas contain antinutrients, proteins that inhibit the actions of amylase, an enzyme that makes it possible for us to digest * They are also more healt hful. Green bananas contain proteins t hat inhibit amy- lase, an enzyme t hat makes it possible for us to digest complex carbohydrates. starch and other complex carbohydrates. Raw bananas are richer in potassium than cooked bananas; heating depletes potassium.
Buying This Food Look for: Bananas that will be good when you plan to eat them. Bananas with brown specks on the skin are ripe enough to eat immediately. Bananas with creamy yellow skin will be ready in a day or two. Bananas with mostly yellow skin and a touch of green at either end can be ripened at home and used in two or three days. Avoid: Overripe bananas whose skin has turned brown or split open. A grayish yellow skin means that the fruit has been damaged by cold storage. Bananas with soft spots under the skin may be rotten.
Storing This Food Store bananas that aren’t fully ripe at room temperature for a day or two. Like avocados, bananas are picked green, shipped hard to protect them from damage en route and then sprayed with ethylene gas to ripen them quickly. Untreated bananas release ethylene natu- rally to ripen the fruit and turn its starches to sugar, but natural ripening takes time. Artificial ripening happens so quickly that there is no time for the starches to turn into sugar. The bananas look ripe but they may taste bland and starchy. A few days at room temperature will give the starches a chance to change into sugars. Store ripe bananas in the refrigerator. The cold air will slow (but not stop) the natural enzyme action that ripens and eventually rots the fruit if you leave it at room temperature. Cold storage will darken the banana’s skin, since the chill damages cells in the peel and releases polyphenoloxidase, an enzyme that converts phenols in the banana peel to dark brown compounds, but the fruit inside will remain pale and tasty for several days.
Preparing This Food Do not slice or peel bananas until you are ready to use them. When you cut into the fruit, you tear its cell walls, releasing polyphenoloxidase, an enzyme that hastens the oxidation of phenols in the banana, producing brown pigments that darken the fruit. (Chilling a banana produces the same reaction because the cold damages cells in the banana peel.) You can slow the browning (but not stop it completely) by dipping raw sliced or peeled bananas into a solution of lemon juice or vinegar and water or by mixing the slices with citrus fruits in a fruit salad. Overripe, discolored bananas can be used in baking, where the color doesn’t matter and their intense sweetness is an asset.
What Happens When You Cook This Food When bananas are broiled or fried, they are cooked so quickly that there is very little change in color or texture. Even so, they will probably taste sweeter and have a more intense aroma than uncooked bananas. Heat liberates the volatile molecules that make the fruit taste and smell good.
How Other Kinds of Processing Affect This Food Drying. Drying removes water and concentrates the nutrients and calories in bananas. Bananas may be treated with compounds such as sulfur dioxide to inhibit polyphenoloxi- dase and keep the bananas from browning as they dry. People who are sensitive to sulfites may suffer severe allergic reactions, including anaphylactic shock, if they eat these treated bananas. Freezing. Fresh bananas freeze well but will brown if you try to thaw them at room tem- perature. To protect the creamy color, thaw frozen bananas in the refrigerator and use as quickly as possible.
Medical Uses and/or Benefits Lower risk of stroke. Various nutrition studies have attested to the power of adequate potassium to keep blood pressure within safe levels. For example, in the 1990s, data from the long-running Harvard School of Public Health/Health Professionals Follow-Up Study of male doctors showed that a diet rich in high-potassium foods such as bananas, oranges, and plantain may reduce the risk of stroke. In the study, the men who ate the higher number of potassium-rich foods (an average of nine servings a day) had a risk of stroke 38 percent lower than that of men who consumed fewer than four servings a day. In 2008, a similar survey at the Queen’s Medical Center (Honolulu) showed a similar protective effect among men and women using diuretic drugs (medicines that increase urination and thus the loss of potassium). Improved mood. Bananas and plantains are both rich in serotonin, dopamine, and other natural mood-elevating neurotransmitters—natural chemicals that facilitate the transmis- sion of impulses along nerve cells. Potassium benefits. Because potassium is excreted in urine, potassium-rich foods are often recommended for people taking diuretics. In addition, a diet rich in potassium (from food) is associated with a lower risk of stroke. A 1998 Harvard School of Public Health analysis of data from the long-running Health Professionals Study shows 38 percent fewer strokes among men who ate nine servings of high potassium foods a day vs. those who ate less than four servings. Among men with high blood pressure, taking a daily 1,000 mg potas- sium supplement—about the amount of potassium in one banana—reduced the incidence of stroke by 60 percent.
Adverse Effects Associated with This Food Digestive Problems. Unripe bananas contain proteins that inhibit the actions of amylase, an enzyme required to digest starch and other complex carbohydrates. Sulfite allergies. See How other kinds of processing affect this food. Latex-fruit syndrome. Latex is a milky fluid obtained from the rubber tree and used to make medical and surgical products such as condoms and protective latex gloves, as well as rub- ber bands, balloons, and toys; elastic used in clothing; pacifiers and baby bottle-nipples; chewing gum; and various adhesives. Some of the proteins in latex are allergenic, known to cause reactions ranging from mild to potentially life-threatening. Some of the proteins found naturally in latex also occur naturally in foods from plants such as avocados, bananas, chestnuts, kiwi fruit, tomatoes, and food and diet sodas sweetened with aspartame. Persons sensitive to these foods are likely to be sensitive to latex as well. NOTE : The National Insti- tute of Health Sciences, in Japan, also lists the following foods as suspect: Almonds, apples, apricots, bamboo shoots, bell peppers, buckwheat, cantaloupe, carrots, celery, cherries, chestnuts, coconut, figs, grapefruit, lettuce, loquat, mangoes, mushrooms, mustard, nectar- ines, oranges, passion fruit, papaya, peaches, peanuts, peppermint, pineapples, potatoes, soybeans, strawberries, walnuts, and watermelon.
Food/Drug Interactions Monoamine oxidase (MAO) inhibitors. Monoamine oxidase inhibitors are drugs used to treat depression. They inactivate naturally occurring enzymes in your body that metabolize tyra- mine, a substance found in many fermented or aged foods. Tyramine constricts blood vessels and increases blood pressure. If you eat a food containing tyramine while you are taking an M AO inhibitor, you cannot effectively eliminate the tyramine from your body. The result may be a hypertensive crisis. There have been some reports in the past of such reactions in people who have eaten rotten bananas or bananas stewed with the peel. False-positive test for tumors. Carcinoid tumors—which may arise from tissues of the endo- crine system, the intestines, or the lungs—secrete serotonin, a natural chemical that makes blood vessels expand or contract. Because serotonin is excreted in urine, these tumors are diagnosed by measuring the levels of serotonin by-products in the urine. Bananas contain large amounts of serotonin; eating them in the three days before a test for an endocrine tumor might produce a false-positive result, suggesting that you have the tumor when in fact you don’t. (Other foods high in serotonin are avocados, eggplant, pineapple, plums, tomatoes, and walnuts.)... bananas
Nutritional Profile Energy value (calories per serving): Moderate Protein: High Fat: Low Saturated fat: Low Cholesterol: None Carbohydrates: High Fiber: Very high Sodium: Low Major vitamin contribution: Vitamin B6, folate Major mineral contribution: Iron, magnesium, zinc
About the Nutrients in This Food Beans are seeds, high in complex carbohydrates including starch and dietary fiber. They have indigestible sugars (stachyose and raffinose), plus insoluble cellulose and lignin in the seed covering and soluble gums and pectins in the bean. The proteins in beans are limited in the essential amino acids methionine and cystine.* All beans are a good source of the B vitamin folate, and iron. One-half cup canned kidney beans has 7.5 g dietary fiber, 65 mcg folate (15 percent of the R DA), and 1.6 mg iron (11 percent of the R DA for a woman, 20 percent of the R DA for a man). Raw beans contain antinutrient chemicals that inactivate enzymes required to digest proteins and carbohydrates. They also contain factors that inactivate vitamin A and also hemagglutinins, substances that make red blood cells clump together. Cooking beans disarms the enzyme inhibi- tors and the anti-vitamin A factors, but not the hemagglutinins. However, the amount of hemagglutinins in the beans is so small that it has no mea- surable effect in your body. * Soybeans are t he only beans t hat contain proteins considered “complete” because t hey contain sufficient amounts of all t he essent ial amino acids. The Folate Content of ½ Cup Cooked Dried Beans
| Bean | Folate (mcg) |
| Black beans | 129 |
| Chickpeas | 191 |
| Kidney beans canned | 65 |
| Navy beans | 128 |
| Pinto beans | 147 |
The Most Nutritious Way to Serve This Food Cooked, to destroy antinutrients. With grains. The proteins in grains are deficient in the essential amino acids lysine and isoleucine but contain sufficient tryptophan, methionine, and cystine; the proteins in beans are exactly the opposite. Together, these foods provide “complete” proteins. With an iron-rich food (meat) or with a vitamin C-rich food (tomatoes). Both enhance your body’s ability to use the iron in the beans. The meat makes your stomach more acid (acid favors iron absorption); the vitamin C may convert the ferric iron in beans into ferrous iron, which is more easily absorbed by the body.
Diets That May Restrict or Exclude This Food Low-calcium diet Low-fiber diet Low-purine (antigout) diet
Buying This Food Look for: Smooth-skinned, uniformly sized, evenly colored beans that are free of stones and debris. The good news about beans sold in plastic bags is that the transparent material gives you a chance to see the beans inside; the bad news is that pyridoxine and pyridoxal, the natural forms of vitamin B6, are very sensitive to light. Avoid: Beans sold in bulk. Some B vitamins, such as vitamin B6 (pyridoxine and pyridoxal), are very sensitive to light. In addition, open bins allow insects into the beans, indicated by tiny holes showing where the bug has burrowed into or through the bean. If you choose to buy in bulk, be sure to check for smooth skinned, uniformly sized, evenly colored beans free of holes, stones, and other debris.
Storing This Food Store beans in air- and moistureproof containers in a cool, dark cabinet where they are pro- tected from heat, light, and insects.
Preparing This Food Wash dried beans and pick them over carefully, discarding damaged or withered beans and any that float. (Only withered beans are light enough to float in water.) Cover the beans with water, bring them to a boil, and then set them aside to soak. When you are ready to use the beans, discard the water in which beans have been soaked. Some of the indigestible sugars in the beans that cause intestinal gas when you eat the beans will leach out into the water, making the beans less “gassy.”
What Happens When You Cook This Food When beans are cooked in liquid, their cells absorb water, swell, and eventually rupture, releasing the pectins and gums and nutrients inside. In addition, cooking destroys antinutri- ents in beans, making them more nutritious and safe to eat.
How Other Kinds of Processing Affect This Food Canning. The heat of canning destroys some of the B vitamins in the beans. Vitamin B is water-soluble. You can recover all the lost B vitamins simply by using the liquid in the can, but the liquid also contains the indigestible sugars that cause intestinal gas when you eat beans. Preprocessing. Preprocessed dried beans have already been soaked. They take less time to cook but are lower in B vitamins.
Medical Uses and/or Benefits Lower risk of some birth defects. As many as two of every 1,000 babies born in the United States each year may have cleft palate or a neural tube (spinal cord) defect due to their moth- ers’ not having gotten adequate amounts of folate during pregnancy. The current R DA for folate is 180 mcg for a woman and 200 mcg for a man, but the FDA now recommends 400 mcg for a woman who is or may become pregnant. Taking a folate supplement before becoming pregnant and continuing through the first two months of pregnancy reduces the risk of cleft palate; taking folate through the entire pregnancy reduces the risk of neural tube defects. Lower risk of heart attack. In the spring of 1998, an analysis of data from the records for more than 80,000 women enrolled in the long-run ning Nurses Health Study at Har vard School of Public Health/ Brigham and Woman’s Hospital in Boston demonstrated that a diet providing more than 400 mcg folate and 3 mg vitamin B6 a day from either food or supple- ments, more than t wice the current R DA for each, may reduce a woman’s risk of heart attack by almost 50 percent. A lthough men were not included in the analysis, the results are assumed to apply to them as well. NOT E : Beans are high in B6 as well as folate. Fruit, green leaf y vegetables, whole grains, meat, fish, poultr y, and shellfish are good sources of vitamin B6. To reduce the levels of serum cholesterol. The gums and pectins in dried beans and peas appear to lower blood levels of cholesterol. Currently there are two theories to explain how this may happen. The first theory is that the pectins in the beans form a gel in your stomach that sops up fats and keeps them from being absorbed by your body. The second is that bacteria in the gut feed on the bean fiber, producing short-chain fatty acids that inhibit the production of cholesterol in your liver. As a source of carbohydrates for people with diabetes. Beans are digested very slowly, produc- ing only a gradual rise in blood-sugar levels. As a result, the body needs less insulin to control blood sugar after eating beans than after eating some other high-carbohydrate foods (such as bread or potato). In studies at the University of Kentucky, a bean, whole-grain, vegetable, and fruit-rich diet developed at the University of Toronto enabled patients with type 1 dia- betes (who do not produce any insulin themselves) to cut their daily insulin intake by 38 percent. Patients with type 2 diabetes (who can produce some insulin) were able to reduce their insulin injections by 98 percent. This diet is in line with the nutritional guidelines of the American Diabetes Association, but people with diabetes should always consult with their doctors and/or dietitians before altering their diet. As a diet aid. Although beans are high in calories, they are also high in bulk (fiber); even a small serving can make you feel full. And, because they are insulin-sparing, they delay the rise in insulin levels that makes us feel hungry again soon after eating. Research at the University of Toronto suggests the insulin-sparing effect may last for several hours after you eat the beans, perhaps until after the next meal.
Adverse Effects Associated with This Food Intestinal gas. All legumes (beans and peas) contain raffinose and stachyose, complex sug- ars that human beings cannot digest. The sugars sit in the gut and are fermented by intestinal bacteria which then produce gas that distends the intestines and makes us uncomfortable. You can lessen this effect by covering the beans with water, bringing them to a boil for three to five minutes, and then setting them aside to soak for four to six hours so that the indigestible sugars leach out in the soaking water, which can be discarded. Alternatively, you may soak the beans for four hours in nine cups of water for every cup of beans, discard the soaking water, and add new water as your recipe directs. Then cook the beans; drain them before serving. Production of uric acid. Purines are the natural metabolic by-products of protein metabo- lism in the body. They eventually break down into uric acid, sharp cr ystals that may concentrate in joints, a condition known as gout. If uric acid cr ystals collect in the urine, the result may be kidney stones. Eating dried beans, which are rich in proteins, may raise the concentration of purines in your body. Although controlling the amount of purines in the diet does not significantly affect the course of gout (which is treated with allopurinol, a drug that prevents the formation of uric acid cr ystals), limiting these foods is still part of many gout regimens.
Food/Drug Interactions Monoamine oxidase (MAO) inhibitors. Monoamine oxidase inhibitors are drugs used to treat depression. They inactivate naturally occurring enzymes in your body that metabolize tyramine, a substance found in many fermented or aged foods. Tyramine constricts blood vessels and increases blood pressure. If you eat a food containing tyramine while you are taking an M AO inhibitor, you cannot effectively eliminate the tyramine from your body. The result may be a hypertensive crisis. Some nutrition guides list dried beans as a food to avoid while using M AO inhibitors.... beans
Nutritional Profile Energy value (calories per serving): Moderate to high Protein: Moderate to high Fat: Low to high Saturated fat: High Cholesterol: Low to high Carbohydrates: Low Fiber: None Sodium: High Major vitamin contribution: Vitamin A, vitamin D, B vitamins Major mineral contribution: Calcium
About the Nutrients in This Food Cheese making begins when Lactobacilli and/or Streptococci bacteria are added to milk. The bacteria digest lactose (milk sugar) and release lactic acid, which coagulates casein (milk protein) into curds. Rennet (gastric enzymes extracted from the stomach of calves) is added, and the mixture is put aside to set. The longer the curds are left to set, the firmer the cheese will be. When the curds are properly firm, they are pressed to squeeze out the whey (liquid) and cooked. Cooking evaporates even more liquid and makes the cheese even firmer.* At this point, the product is “fresh” or “green” cheese: cottage cheese, cream cheese, farmer cheese. Making “ripe” cheese requires the addition of salt to pull out more moisture and specific organisms, such as Penicil- lium roquefort for Roquefort cheese, blue cheese, and Stilton, or Penicillium cambembert for Camembert and Brie. The nutritional value of cheese is similar to the milk from which it is made. All cheese is a good source of high quality proteins with sufficient amounts of all the essential amino acids. Cheese is low to high in fat, mod- erate to high in cholesterol. * Natural cheese is cheese made direct ly from milk. Processed cheese is natural cheese melted and combined wit h emulsifiers. Pasteurized process cheese foods contain ingredients t hat allow t hem to spread smoot hly; t hey are lower in fat and higher in moisture t han processed cheese. Cholesterol and Saturated Fat Content of Selected Cheeses Mozzarella Source: USDA, Nutritive Value of Foods, Home and Garden Bullet in No. 72 (USDA, 1989). All cheeses, except cottage cheese, are good sources of vitamin A. Orange and yellow cheeses are colored with carotenoid pigments, including bixin (the carotenoid pigment in annatto) and synthetic beta-carotene. Hard cheeses are an excellent source of calcium; softer cheeses are a good source; cream cheese and cottage cheese are poor sources. The R DA for calcium is 1,000 mg for a woman, 1,200 mg for a man, and 1,500 mg for an older woman who is not on hormone- replacement therapy. All cheese, unless otherwise labeled, is high in sodium.
| Calcium Content of Cheese | ||
| Cheese | Serving | Calcium (mg) |
| Blue | oz. | 150 |
| Camembert | wedge | 147 |
| Cheddar | oz. | 204 |
| Cottage cheese | ||
| creamed | cup | 135 |
| uncreamed | cup | 46 |
| Muenster | oz. | 203 |
| Pasteurized processed American | oz. | 174 |
| Parmesan grated | tbsp. | 69 |
| Provolone | oz. | 214 |
| Swiss | oz. | 272 |
The Most Nutritious Way to Serve This Food With grains, bread, noodles, beans, nuts, or vegetables to add the essential amino acids miss- ing from these foods, “complete” their proteins, and make them more nutritionally valuable.
Diets That May Restrict or Exclude This Food Antiflatulence diet Controlled-fat, low-cholesterol diet Lactose- and galactose-free diet (lactose, a disaccharide [double sugar] is composed of one unit of galactose and one unit of glucose) Low-calcium diet (for patients with kidney disease) Sucrose-free diet (processed cheese)
Buying This Food Look for: Cheese stored in a refrigerated case. Check the date on the package. Avoid: Any cheese with mold that is not an integral part of the food.
Storing This Food Refrigerate all cheese except unopened canned cheeses (such as Camembert in tins) or grated cheeses treated with preservatives and labeled to show that they can be kept outside the refrigerator. Some sealed packages of processed cheeses can be stored at room temperature but must be refrigerated once the package is opened. Wrap cheeses tightly to protect them from contamination by other microorganisms in the air and to keep them from drying out. Well-wrapped, refrigerated hard cheeses that have not been cut or sliced will keep for up to six months; sliced hard cheeses will keep for about two weeks. Soft cheeses (cottage cheese, ricotta, cream cheese, and Neufchatel) should be used within five to seven days. Use all packaged or processed cheeses by the date stamped on the package. Throw out moldy cheese (unless the mold is an integral part of the cheese, as with blue cheese or Stilton).
Preparing This Food To grate cheese, chill the cheese so it won’t stick to the grater. The molecules that give cheese its taste and aroma are largely immobilized when the cheese is cold. When serving cheese with fruit or crackers, bring it to room temperature to activate these molecules.
What Happens When You Cook This Food Heat changes the structure of proteins. The molecules are denatured, which means that they may be broken into smaller fragments or change shape or clump together. All of these changes may force moisture out of the protein tissue, which is why overcooked cheese is often stringy. Whey proteins, which do not clump or string at low temperatures, contain the sulfur atoms that give hot or burned cheese an unpleasant “cooked” odor. To avoid both strings and an unpleasant odor, add cheese to sauces at the last minute and cook just long enough to melt the cheese.
How Other Kinds of Processing Affect This Food Freezing. All cheese loses moisture when frozen, so semisoft cheeses will freeze and thaw better than hard cheeses, which may be crumbly when defrosted. Drying. The less moisture cheese contains, the less able it is to support the growth of organ- isms like mold. Dried cheeses keep significantly longer than ordinary cheeses.
Medical Uses and/or Benefits To strengthen bones and reduce age-related loss of bone density. High-calcium foods protect bone density. The current recommended dietary allowance (R DA) for calcium is still 800 mg for adults 25 and older, but a 1984 National Institutes of Health (NIH) Conference advisory stated that lifelong protection for bones requires an R DA of 1,000 mg for healthy men and women age 25 to 50 ; 1,000 mg for older women using hormone replacement therapy; and 1,500 mg for older women who are not using hormones, and these recommendations have been confirmed in a 1994 NIH Consensus Statement on optimal calcium intake. A diet with adequate amounts of calcium-rich foods helps protect bone density. Low-fat and no-fat cheeses provide calcium without excess fat and cholesterol. Protection against tooth decay. Studies at the University of Iowa (Iowa City) Dental School confirm that a wide variety of cheeses, including aged cheddar, Edam, Gouda, Monterey Jack, Muenster, mozzarella, Port Salut, Roquefort, Romano, Stilton, Swiss, and Tilsit—limit the tooth decay ordinarily expected when sugar becomes trapped in plaque, the sticky film on tooth surfaces where cavity-causing bacteria flourish. In a related experiment using only cheddar cheese, people who ate cheddar four times a day over a two-week period showed a 20 percent buildup of strengthening minerals on the surface of synthetic toothlike material attached to the root surfaces of natural teeth. Protection against periodontal disease. A report in the January 2008 issue of the Journal of Periodontology suggests that consuming adequate amounts of dairy products may reduce the risk of developing periodontal disease. Examining the dental health of 942 subjects ages 40 to 79, researchers at Kyushu University, in Japan, discovered that those whose diets regularly included two ounces (55 g) of foods containing lactic acid (milk, cheese, and yogurt) were significantly less likely to have deep “pockets” (loss of attachment of tooth to gum) than those who consumed fewer dairy products.
Adverse Effects Associated with This Food Increased risk of heart disease. Like other foods from animals, cheese is a source of choles- terol and saturated fats, which increase the amount of cholesterol circulating in your blood and raise your risk of heart disease. To reduce the risk of heart disease, the USDA /Health and Human Services Dietary Guidelines for Americans recommends limiting the amount of cholesterol in your diet to no more than 300 mg a day. The guidelines also recommend limit- ing the amount of fat you consume to no more than 30 percent of your total calories, while holding your consumption of saturated fats to more than 10 percent of your total calories (the calories from saturated fats are counted as part of the total calories from fat). Food poisoning. Cheese made from raw (unpasteurized) milk may contain hazardous microorganisms, including Salmonella and Listeria. Salmonella causes serious gastric upset; Lis- teria, a flulike infection, encephalitis, or blood infection. Both may be life-threatening to the very young, the very old, pregnant women, and those whose immune systems are weakened either by illness (such as AIDS) or drugs (such as cancer chemotherapy). In 1998, the Federal Centers for Disease Control (CDC) released data identif ying Listeria as the cause of nearly half the reported deaths from food poisoning. Allergy to milk proteins. Milk is one of the foods most frequently implicated as a cause of allergic reactions, particularly upset stomach. However, in many cases the reaction is not a true allergy but the result of lactose intolerance (see below). Lactose intolerance. Lactose intolerance—the inability to digest the sugar in milk—is an inherited metabolic deficiency that affects two thirds of all adults, including 90 to 95 percent of all Orientals, 70 to 75 percent of all blacks, and 6 to 8 percent of Caucasians. These people do not have sufficient amounts of lactase, the enzyme that breaks the disaccharide lactose into its easily digested components, galactose and glucose. When they drink milk, the undi- gested sugar is fermented by bacteria in the gut, causing bloating, diarrhea, flatulence, and intestinal discomfort. Some milk is now sold with added lactase to digest the lactose and make the milk usable for lactase-deficient people. In making cheese, most of the lactose in milk is broken down into glucose and galactose. There is very little lactose in cheeses other than the fresh ones—cottage cheese, cream cheese, and farmer cheese. Galactosemia. Galactosemia is an inherited metabolic disorder in which the body lacks the enzymes needed to metabolize galactose, a component of lactose. Galactosemia is a reces- sive trait; you must receive the gene from both parents to develop the condition. Babies born with galactosemia will fail to thrive and may develop brain damage or cataracts if they are given milk. To prevent this, children with galactosemia are usually kept on a protective milk- free diet for several years, until their bodies have developed alternative pathways by which to metabolize galactose. Pregnant women who are known carriers of galactosemia may be advised to give up milk and milk products while pregnant lest the unmetabolized galactose in their bodies cause brain damage to the fetus (damage not detectable by amniocentesis). Genetic counseling is available to identif y galactosemia carriers and assess their chances of producing a baby with the disorder. Penicillin sensitivity. People who experience a sensitivity reaction the first time they take penicillin may have been sensitized by exposure to the Penicillium molds in the environment, including the Penicillium molds used to make brie, blue, camembert, roquefort, Stilton, and other “blue” cheeses.
Food/Drug Interactions Tetracycline. The calcium ions in milk products, including cheese, bind tetracyclines into insoluble compounds. If you take tetracyclines with cheese, your body may not be able to absorb and use the drug efficiently. Monoamine oxidase (MAO) inhibitors. Monoamine oxidase inhibitors are drugs used to treat depression. They inactivate naturally occurring enzymes in your body that metabolize tyra- mine, a substance found in many fermented or aged foods. Tyramine constricts blood ves- sels and increases blood pressure. If you eat a food such as aged or fermented cheese which is high in tyramine while you are taking an M AO inhibitor, your body may not be able to eliminate the tyramine. The result may be a hypertensive crisis.
Tyramine Content of Cheeses High Boursault, Camembert, Cheddar, Emmenthaler, Stilton Medium to high Blue, brick, Brie, Gruyère, mozzarella, Parmesan, Romano, Roquefort Low Processed American cheese Very little or none Cottage and cream cheese Sources: The Medical Letter Handbook of Adverse Drug Interactions (1985); Handbook of Clinical Dietetics ( The A merican Dietet ic Associat ion, 1981). False-positive test for pheochromocytoma. Pheochromocytomas (tumors of the adrenal glands) secrete adrenalin that is converted by the body to vanillyl-mandelic acid ( VM A) and excreted in the urine. Tests for this tumor measure the level of VM A in the urine. Since cheese contains VM A, taking the test after eating cheese may result in a false-positive result. Ordinarily, cheese is prohibited for at least 72 hours before this diagnostic test.... cheese
Nutritional Profile Energy value (calories per serving): Low Protein: Low Fat: Low Saturated fat: Low Cholesterol: None Carbohydrates: High Fiber: High Sodium: Low (fresh or dried fruit) High (dried fruit treated with sodium sulfur compounds) Major vitamin contribution: Vitamin C Major mineral contribution: Potassium
About the Nutrients in This Food Apples are a high-fiber fruit with insoluble cellulose and lignin in the peel and soluble pectins in the flesh. Their most important vitamin is vitamin C. One fresh apple, 2.5 inches in diameter, has 2.4 g dietary fiber and 4.6 mg vitamin C (6 percent of the R DA for a woman, 5 percent of the R DA for a man). The sour taste of all immature apples (and some varieties, even when ripe) comes from malic acid. As an apple ripens, the amount of malic acid declines and the apple becomes sweeter. Apple seeds contain amygdalin, a naturally occurring cyanide/sugar compound that degrades into hydrogen cyanide. While accidentally swal- lowing an apple seed once in a while is not a serious hazard for an adult, cases of human poisoning after eating apple seeds have been reported, and swallowing only a few seeds may be lethal for a child.
The Most Nutritious Way to Serve This Food Fresh and unpared, to take advantage of the fiber in the peel and preserve the vitamin C, which is destroyed by the heat of cooking.
Diets That May Restrict or Exclude This Food Antiflatulence diet (raw apples) Low-fiber diet
Buying This Food Look for: Apples that are firm and brightly colored: shiny red Macintosh, Rome, and red Delicious; clear green Granny Smith; golden yellow Delicious. Avoid: Bruised apples. When an apple is damaged the injured cells release polyphenoloxi- dase, an enzyme that hastens the oxidation of phenols in the apple, producing brownish pigments that darken the fruit. It’s easy to check loose apples; if you buy them packed in a plastic bag, turn the bag upside down and examine the fruit.
Storing This Food Store apples in the refrigerator. Cool storage keeps them from losing the natural moisture that makes them crisp. It also keeps them from turning brown inside, near the core, a phe- nomenon that occurs when apples are stored at warm temperatures. Apples can be stored in a cool, dark cabinet with plenty of circulating air. Check the apples from time to time. They store well, but the longer the storage, the greater the natural loss of moisture and the more likely the chance that even the crispest apple will begin to taste mealy.
Preparing This Food Don’t peel or slice an apple until you are ready to use it. When you cut into the apple, you tear its cells, releasing polyphenoloxidase, an enzyme that darkens the fruit. Acid inactivates polyphenoloxidase, so you can slow the browning (but not stop it completely) by dipping raw sliced and/or peeled apples into a solution of lemon juice and water or vinegar and water or by mixing them with citrus fruits in a fruit salad. Polyphenoloxidase also works more slowly in the cold, but storing peeled apples in the refrigerator is much less effective than immersing them in an acid bath.
What Happens When You Cook This Food When you cook an unpeeled apple, insoluble cellulose and lignin will hold the peel intact through all normal cooking. The flesh of the apple, though, will fall apart as the pectin in its cell walls dissolves and the water inside its cells swells, rupturing the cell walls and turning the apples into applesauce. Commercial bakers keep the apples in their apple pies firm by treating them with calcium; home bakers have to rely on careful timing. To prevent baked apples from melting into mush, core the apple and fill the center with sugar or raisins to absorb the moisture released as the apple cooks. Cutting away a circle of peel at the top will allow the fruit to swell without splitting the skin. Red apple skins are colored with red anthocyanin pigments. When an apple is cooked, the anthocyanins combine with sugars to form irreversible brownish compounds.
How Other Kinds of Processing Affect This Food Juice. Apple juice comes in two versions: “cloudy” (unfiltered) and “clear” (filtered). Cloudy apple juice is made simply by chopping or shredding apples and then pressing out and straining the juice. Clear apple juice is cloudy juice filtered to remove solid particles and then treated with enzymes to eliminate starches and the soluble fiber pectin. Since 2000, follow- ing several deaths attributed to unpasteurized apple juice contaminated with E. coli O157: H7, the FDA has required that all juices sold in the United States be pasteurized to inactivate harmful organisms such as bacteria and mold. Note: “Hard cider” is a mildly alcoholic bever- age created when natural enzyme action converts the sugars in apple juice to alcohol; “non- alcohol cider” is another name for plain apple juice. Drying. To keep apple slices from turning brown as they dry, apples may be treated with sulfur compounds that may cause serious allergic reactions in people allergic to sulfites.
Medical Uses and/or Benefits As an antidiarrheal. The pectin in apple is a natural antidiarrheal that helps solidif y stool. Shaved raw apple is sometimes used as a folk remedy for diarrhea, and purified pectin is an ingredient in many over-the-counter antidiarrheals. Lower cholesterol levels. Soluble fiber (pectin) may interfere with the absorption of dietary fats, including cholesterol. The exact mechanism by which this occurs is still unknown, but one theory is that the pectins in the apple may form a gel in your stomach that sops up fats and cholesterol, carrying them out of your body as waste. Potential anticarcinogenic effects. A report in the April 2008 issue of the journal Nutrition from a team of researchers at the Universit y of Kaiserslautern, in Germany, suggests that several natural chemicals in apples, including but yrate (produced naturally when the pectin in apples and apple juice is metabolized) reduce the risk of cancer of the colon by nourishing and protecting the mucosa (lining) of the colon.
Adverse Effects Associated with This Food Intestinal gas. For some children, drinking excess amounts of apple juice produces intestinal discomfort (gas or diarrhea) when bacteria living naturally in the stomach ferment the sugars in the juice. To reduce this problem, the American Academy of Pediatrics recommends that children ages one to six consume no more than four to six ounces of fruit juice a day; for children ages seven to 18, the recommended serving is eight to 12 ounces a day. Cyanide poisoning. See About the nutrients in this food. Sulfite allergies (dried apples). See How other kinds of processing affect this food.
Food/Drug Interactions Digoxin (Lanoxicaps, Lanoxin). Pectins may bind to the heart medication digoxin, so eating apples at the same time you take the drug may reduce the drug’s effectiveness.... apples
Examination of the ear includes inspection of the external ear. An auriscope is used to examine the external ear canal and the ear drum. If a more detailed inspection is required, a microscope may be used to improve illumination and magni?cation.
Tuning-fork or Rinne tests are performed to identify the presence of DEAFNESS. The examiner tests whether the vibrating fork is audible at the meatus, and then the foot of the fork is placed on the mastoid bone of the ear to discover at which of the two sites the patient can hear the vibrations for the longest time. This can help to di?erentiate between conductive and nerve deafness.
Hearing tests are carried out to determine the level of hearing. An audiometer is used to deliver a series of short tones of varying frequency to the ear, either through a pair of headphones or via a sound transducer applied directly to the skull. The intensity of the sound is gradually reduced until it is no longer heard and this represents the threshold of hearing, at that frequency, through air and bone respectively. It may be necessary to play a masking noise into the opposite ear to prevent that ear from hearing the tones, enabling each ear to be tested independently.
General symptoms The following are some of the chief symptoms of ear disease: DEAFNESS (see DEAFNESS). EARACHE is most commonly due to acute in?ammation of the middle ear. Perceived pain in this region may be referred from other areas, such as the earache commonly experienced after tonsillectomy (removal of the TONSILS) or that caused by carious teeth (see TEETH, DISORDERS OF). The treatment will depend on the underlying cause. TINNITUS or ringing in the ear often accompanies deafness, but is sometimes the only symptom of ear disease. Even normal people sometimes experience tinnitus, particularly if put in soundproofed surroundings. It may be described as hissing, buzzing, the sound of the sea, or of bells. The intensity of the tinnitis usually ?uctuates, sometimes disappearing altogether. It may occur in almost any form of ear disease, but is particularly troublesome in nerve deafness due to ageing and in noise-induced deafness. The symptom seems to originate in the brain’s subcortical regions, high in the central nervous system. It may be a symptom of general diseases such as ANAEMIA, high blood pressure and arterial disease, in which cases it is often synchronous with the pulse, and may also be caused by drugs such as QUININE, salicylates (SALICYLIC ACID and its salts, for example, ASPIRIN) and certain ANTIBIOTICS. Treatment of any underlying ear disorder or systemic disease, including DEPRESSION, may reduce or even cure the tinnitis, but unfortunately in many cases the noises persist. Management involves psychological techniques and initially an explanation of the mechanism and reassurance that tinnitus does not signify brain disease, or an impending STROKE, may help the person. Tinnitus maskers – which look like hearing aids – have long been used with a suitably pitched sound helping to ‘mask’ the condition.
Diseases of the external ear
WAX (cerumen) is produced by specialised glands in the outer part of the ear canal only. Impacted wax within the ear canal can cause deafness, tinnitis and sometimes disturbance of balance. Wax can sometimes be softened with olive oil, 5-per-cent bicarbonate of soda or commercially prepared drops, and it will gradually liquefy and ‘remove itself’. If this is ineffective, syringing by a doctor or nurse will usually remove the wax but sometimes it is necessary for a specialist (otologist) to remove it manually with instruments. Syringing should not be done if perforation of the tympanic membrane (eardrum) is suspected. FOREIGN BODIES such as peas, beads or buttons may be found in the external ear canal, especially in children who have usually introduced them themselves. Live insects may also be trapped in the external canal causing intense irritation and noise, and in such cases spirit drops are ?rst instilled into the ear to kill the insect. Except in foreign bodies of vegetable origin, where swelling and pain may occur, syringing may be used to remove some foreign bodies, but often removal by a specialist using suitable instrumentation and an operating microscope is required. In children, a general anaesthetic may be needed. ACUTE OTITIS EXTERNA may be a di?use in?ammation or a boil (furuncle) occurring in the outer ear canal. The pinna is usually tender on movement (unlike acute otitis media – see below) and a discharge may be present. Initially treatment should be local, using magnesium sulphate paste or glycerine and 10-per-cent ichthaminol. Topical antibiotic drops can be used and sometimes antibiotics by mouth are necessary, especially if infection is acute. Clotrimazole drops are a useful antifungal treatment. Analgesics and locally applied warmth should relieve the pain.
CHRONIC OTITIS EXTERNA producing pain and discharge, can be caused by eczema, seborrhoeic DERMATITIS or PSORIASIS. Hair lotions and cosmetic preparations may trigger local allergic reactions in the external ear, and the chronic disorder may be the result of swimming or use of dirty towels. Careful cleaning of the ear by an ENT (Ear, Nose & Throat) surgeon and topical antibiotic or antifungal agents – along with removal of any precipitating cause – are the usual treatments. TUMOURS of the ear can arise in the skin of the auricle, often as a result of exposure to sunlight, and can be benign or malignant. Within the ear canal itself, the commonest tumours are benign outgrowths from the surrounding bone, said to occur in swimmers as a result of repeated exposure to cold water. Polyps may result from chronic infection of the ear canal and drum, particularly in the presence of a perforation. These polyps are soft and may be large enough to ?ll the ear canal, but may shrink considerably after treatment of the associated infection.
Diseases of the middle ear
OTITIS MEDIA or infection of the middle ear, usually occurs as a result of infection spreading up the Eustachian tubes from the nose, throat or sinuses. It may follow a cold, tonsillitis or sinusitis, and may also be caused by swimming and diving where water and infected secretions are forced up the Eustachian tube into the middle ear. Primarily it is a disease of children, with as many as 1.5 million cases occurring in Britain every year. Pain may be intense and throbbing or sharp in character. The condition is accompanied by deafness, fever and often TINNITUS.
In infants, crying may be the only sign that something is wrong – though this is usually accompanied by some localising manifestation such as rubbing or pulling at the ear. Examination of the ear usually reveals redness, and sometimes bulging, of the ear drum. In the early stages there is no discharge, but in the later stages there may be a discharge from perforation of the ear drum as a result of the pressure created in the middle ear by the accumulated pus. This is usually accompanied by an immediate reduction in pain.
Treatment consists of the immediate administration of an antibiotic, usually one of the penicillins (e.g. amoxicillin). In the majority of cases no further treatment is required, but if this does not quickly bring relief then it may be necessary to perform a myringotomy, or incision of the ear drum, to drain pus from the middle ear. When otitis media is treated immediately with su?cient dosage of the appropriate antibiotic, the chances of any permanent damage to the ear or to hearing are reduced to a negligible degree, as is the risk of any complications such as mastoiditis (discussed later in this section). CHRONIC OTITIS MEDIA WITH EFFUSION or glue ear, is the most common in?ammatory condition of the middle ear in children, to the extent that one in four children in the UK entering school has had an episode of ‘glue ear’. It is characterised by a persistent sticky ?uid in the middle ear (hence the name); this causes a conductive-type deafness. It may be associated with enlarged adenoids (see NOSE, DISORDERS OF) which impair the function of the Eustachian tube. If the hearing impairment is persistent and causes problems, drainage of the ?uid, along with antibiotic treatment, may be needed – possibly in conjunction with removal of the adenoids. The insertion of grommets (ventilation tubes) was for a time standard treatment, but while hearing is often restored, there may be no long-term gain and even a risk of damage to the tympanic membrane, so the operation is less popular than it was a decade or so ago. MASTOIDITIS is a serious complication of in?ammation of the middle ear, the incidence of which has been dramatically reduced by the introduction of antibiotics. In?ammation in this cavity usually arises by direct spread of acute or chronic in?ammation from the middle ear. The signs of this condition include swelling and tenderness of the skin behind the ear, redness and swelling inside the ear, pain in the side of the head, high fever, and a discharge from the ear. The management of this condition in the ?rst instance is with antibiotics, usually given intravenously; however, if the condition fails to improve, surgical treatment is necessary. This involves draining any pus from the middle ear and mastoid, and removing diseased lining and bone from the mastoid.
Diseases of the inner ear
MENIÈRE’S DISEASE is a common idiopathic disorder of ENDOLYMPH control in the semicircular canals (see EAR), characterised by the triad of episodic VERTIGO with deafness and tinnitus. The cause is unknown and usually one ear only is affected at ?rst, but eventually the opposite ear is affected in approximately 50 per cent of cases. The onset of dizziness is often sudden and lasts for up to 24 hours. The hearing loss is temporary in the early stages, but with each attack there may be a progressive nerve deafness. Nausea and vomiting often occur. Treatment during the attacks includes rest and drugs to control sickness. Vasodilator drugs such as betahistine hydrochloride may be helpful. Surgical treatment is sometimes required if crippling attacks of dizziness persist despite these measures. OTOSCLEROSIS A disorder of the middle ear that results in progressive deafness. Often running in families, otosclerosis affects about one person in 200; it customarily occurs early in adult life. An overgrowth of bone ?xes the stapes (the innermost bone of the middle ear) and stops sound vibrations from being transmitted to the inner ear. The result is conductive deafness. The disorder usually affects both ears. Those affected tend to talk quietly and deafness increases over a 10–15 year period. Tinnitus often occurs, and occasionally vertigo.
Abnormal hearing tests point to the diagnosis; the deafness may be partially overcome with a hearing aid but surgery is eventually needed. This involves replacing the stapes bone with a synthetic substitute (stapedectomy). (See also OTIC BAROTRAUMA.)... ear, diseases of
Fortunah, Fortuin, Fortuyn, Fortunata, Fortunatus... fortuna
Children with Down’s syndrome are usually friendly and ?t in well with the family. Despite their learning disabilities, some learn to read and, if they have appropriate educational and environmental stimulation, can make the most of their abilities.
A heart defect is present in around 25 per cent of the children at birth, and deafness and acute LEUKAEMIA occur more frequently than in unaffected youngsters. Those with the syndrome are particularly prone to developing ear infections. ATHEROSCLEROSIS often develops early in adults and ALZHEIMER’S DISEASE tends to occur as early as 40 years of age. A friendly home environment helps them to enjoy life, but a few individuals with the syndrome may eventually require institutional care. Improved social and medical care means that many now live until their 60s.
Routine screening tests early in pregnancy, starting with blood analysis but going on if necessary to AMNIOCENTESIS and chorionic villus sampling (see PRENATAL SCREENING OR DIAGNOSIS), can identify fetuses likely to develop the disorder. If a sample of fetal cells con?rms the chromosome defect (triple marker test – see PREGNANCY AND LABOUR), the parents may consider termination of the pregnancy. In the UK, screening is normally o?ered to women over 35 because of their increased risk. When younger parents have a child with Down’s syndrome, the chances of a subsequent child with the disorder are relatively high as it is probable that both parents carry a chromosome abnormality insu?cient to cause ill-health until combined. So they may wish to discuss with their medical advisers the question of further pregnancies.
Parents who have a child with Down’s syndrome will understandably feel a combination of strong emotions, including anger and guilt, and constructive counselling can be valuable. Among societies o?ering advice and support is the Down’s Syndrome Association.... down’s (down) syndrome
Nutritional Profile Energy value (calories per serving): Low Protein: Low Fat: Low Saturated fat: Low Cholesterol: None Carbohydrates: High Fiber: Moderate Sodium: Low Major vitamin contribution: Vitamin C Major mineral contribution: Calcium
About the Nutrients in This Food Blueberries have some protein and a little fat. They have no starch but do contain sugars and dietary fiber—primarily pectin, which dissolves as the fruit matures—and lignin in the seeds. (The difference between blueber- ries and huckleberries is the size of their seeds; blueberries have smaller ones than huckleberries.) One-half cup fresh blueberries has 1.5 g dietary fiber and 9.5 mg. vitamin C (13 percent of the R DA for a woman, 11 percent of the R DA for a man).
The Most Nutritious Way to Serve This Food Fresh, raw, or lightly cooked.
Buying This Food Look for: Plump, firm dark-blue berries. The whitish color on the ber- ries is a natural protective coating. Avoid: Baskets of berries with juice stains or liquid leaking out of the berries. The stains and leaks are signs that there are crushed (and possibly moldy) berries inside.
Storing This Food Cover berries and refrigerate them. Then use them in a day or two. Do not wash berries before storing. The moisture increases the chance that they will mold in the refrigerator. Also, handling the berries can damage them, tearing cells and releas- ing enzymes that will destroy vitamins. Do not store blueberries in metal containers. The anthocyanin pigments in the berries can combine with metal ions to form dark, unattractive pigment/metal compounds that stain the containers and the berries.
Preparing This Food R inse the berries under cool running water, then drain them and pick them over carefully to remove all stems, leaves, and hard (immature) or soft (over-ripe) berries.
What Happens When You Cook This Food Cooking destroys some of the vitamin C in fresh blueberries and lets water-soluble B vitamins leach out. Cooked berries are likely to be mushy because heat dissolves the pectin inside. Blueberries may also change color when cooked. The berries are colored with blue anthocyanin pigments. Ordinarily, anthocyanin-pigmented fruits and vegetables turn red- dish in acids (lemon juice, vinegar) and deeper blue in bases (baking soda). But blueberries also contain yellow pigments (anthoxanthins). In a basic (alkaline) environments, as in a batter with too much baking soda, the yellow and blue pigments will combine, turning the blueberries greenish blue. Adding lemon juice to a blueberry pie stabilizes these pigments; it is a practical way to keep the berries a deep, dark reddish blue.
How Other Kinds of Processing Affect This Food Canning and freezing. The intense heat used in canning the fruit or in blanching it before freezing reduces the vitamin C content of blueberries by half.
Medical Uses and/or Benefits Anticancer activity. According to the U.S. Department of Agriculture, wild blueberries rank first among all fruits in antioxidant content; cultivated blueberries (the ones sold in most food markets) rank second. Antioxidants are natural chemicals that inactivate free radicals, molecule fragments that can link together to form cancer-causing compounds. Several ani- mal studies attest to the ability of blueberries to inhibit the growth of specific cancers. For example, in 2005, scientists at the University of Georgia reported in the journal Food Research International that blueberry extracts inhibited the growth of liver cancer cells in laboratory settings. The following year, researchers at Rutgers University (in New Jersey) delivered data to the national meeting of the American Chemical Society from a study in which laboratory rats fed a diet supplemented with pterostilbene, another compound extracted from blueber- ries, had 57 percent fewer precancerous lesions in the colon than rats whose diet did not contain the supplement. The findings, however, have not been confirmed in humans. Enhanced memory function. In 2008, British researchers at the schools of Food Biosciences and Psychology at the University of Reading and the Institute of Biomedical and Clinical Sciences at the Peninsula Medical School (England) reported that adding blueberries to one’s normal diet appears to improve both long-term and short-term memory, perhaps because anthocyanins and flavonoids (water-soluble pigments in the berries) activate signals in the hippocampus, a part of the brain that controls learning and memory. If confirmed, the data would support the role played by diet in maintaining memory and brain function. Urinary antiseptic. A 1991 study at the Weizmann Institute of Science (Israel) suggests that blueberries, like cr anber r ies, contain a compound that inhibits the ability of Escherichia coli, a bacteria commonly linked to urinary infections, to stick to the wall of the bladder. If it cannot cling to cell walls, the bacteria will not cause an infection. This discovery lends some support to folk medicine, but how the berries work, how well they work, or in what “dos- ages” remains to be proven.
Adverse Effects Associated with This Food Allergic reaction. Hives and angiodemea (swelling of the face, lips, and eyes) are common allergic responses to berries, virtually all of which have been reported to trigger these reac- tions. According to the Merck Manual, berries are one of the 12 foods most likely to trigger classic food allergy symptoms. The others are chocolate, corn, eggs, fish, legumes (peas, lima beans, peanuts, soybeans), milk, nuts, peaches, pork, shellfish, and wheat (see wheat cer ea ls).... blueberries
Bone cysts typically develop at one end of a long bone and maybe discovered only by chance after a bone fracture at the site of the cyst.
Minor surgery to scrape out the cyst and fill the the cavity with bone chips usually cures the condition, although many small cysts do not need treatment.... bone cyst
Severe and extensive burns are most frequently produced by the clothes – for example, of a child – catching ?re. This applies especially to cotton garments, which blaze up quickly. It should be remembered that such a ?ame can immediately be extinguished by making the individual lie on the ?oor so that the ?ames are uppermost, and wrapping him or her in a rug, mat or blanket. As prevention is always better than cure, particular care should always be exercised with electric ?res and kettles or pots of boiling water in houses where there are young children or old people. Children’s clothes, and especially night-clothes, should be made of non-in?ammable material: pyjamas are also much safer than nightdresses.
Severe scalds are usually produced by escape of steam in boiler explosions. Cigarettes are a common cause of ?res and therefore of burns; people who have fallen asleep in bed or in a chair while smoking may set ?re to the bed or chair. Discarded, unextinguished cigarettes are another cause.
Degrees of burns Burns are referred to as either super?cial (or partial-thickness) burns, when there is su?cient skin tissue left to ensure regrowth of skin over the burned site; and deep (or full-thickness) burns, when the skin is totally destroyed and grafting will be necessary.
Symptoms Whilst many domestic burns are minor and insigni?cant, more severe burns and scalds can prove to be very dangerous to life. The main danger is due to SHOCK, which arises as a result of loss of ?uid from the circulating blood at the site of a serious burn. This loss of ?uid leads to a fall in the volume of the circulating blood. As the maintenance of an adequate blood volume is essential to life, the body attempts to compensate for this loss by withdrawing ?uid from the uninjured areas of the body into the circulation. If carried too far, however, this in turn begins to affect the viability of the body cells. As a sequel, essential body cells, such as those of the liver and kidneys, begin to suffer, and the liver and kidneys cease to function properly. This will show itself by the development of JAUNDICE and the appearance of albumin in the urine (see PROTEINURIA). In addition, the circulation begins to fail with a resultant lack of oxygen (see ANOXIA) in the tissues, and the victim becomes cyanosed (see CYANOSIS), restless and collapsed: in some cases, death ensues. In addition, there is a strong risk of infection occurring. This is the case with severe burns in particular, which leave a large raw surface exposed and very vulnerable to any micro-organisms. The combination of shock and infection can all too often be life-threatening unless expert treatment is immediately available.
The immediate outcome of a burn is largely determined by its extent. This is of more signi?cance than the depth of the burn. To assess the extent of a burn in relation to the surface of the body, what is known as the Rule of Nine has been evolved. The head and each arm cover 9 per cent of the body surface, whilst the front of the body, the back of the body, and each leg each cover 18 per cent, with the perineum (or crutch) accounting for the remaining 1 per cent. The greater the extent of the burn, the more seriously ill will the victim become from loss of ?uid from his or her circulation, and therefore the more prompt should be his or her removal to hospital for expert treatment. The depth of the burn, unless this is very great, is mainly of import when the question arises as to how much surgical treatment, including skin grafting, will be required.
Treatment This depends upon the severity of the burn. In the case of quite minor burns or scalds, all that may be necessary if they are seen immediately is to hold the part under cold running water until the pain is relieved. Cooling is one of the most e?ective ways of relieving the pain of a burn. If the burn involves the distal part of a limb – for example, the hand and forearm – one of the most e?ective ways of relieving pain is to immerse the burned part in lukewarm water and add cold water until the pain disappears. As the water warms and pain returns, more cold water is added. After some three to four hours, pain will not reappear on warming, and the burn may be dressed in the usual way. Thereafter a simple dressing (e.g. a piece of sterile gauze covered by cotton-wool, and on top of this a bandage or adhesive dressing) should be applied. The part should be kept at rest and the dressing kept quite dry until healing takes place. Blisters should be pierced with a sterile needle, but the skin should not be cut away. No ointment or oil should be applied, and an antiseptic is not usually necessary.
In slightly more severe burns or scalds, it is probably advisable to use some antiseptic dressing. These are the cases which should be taken to a doctor – whether a general practitioner, a factory doctor, or to a hospital Accident & Emergency department. There is still no general consensus of expert opinion as to the best ‘antiseptic’ to use. Among those recommended are CHLORHEXIDINE, and antibiotics such as BACITRACIN, NEOMYCIN and polymixin. An alternative is to use a Tulle Gras dressing which has been impregnated with a suitable antibiotic.
In the case of severe burns and scalds, the only sound rule is immediate removal to hospital. Unless there is any need for immediate resuscitation, such as arti?cial respiration, or attention to other injuries there may be, such as fractures or haemorrhage, nothing should be done on the spot to the patient except to make sure that s/he is as comfortable as possible and to keep them warm, and to cover the burn with a sterile (or clean) cloth such as a sheet, pillowcases, or towels wrung out in cold water. If pain is severe, morphine should be given – usually intravenously. Once the victim is in hospital, the primary decision is as to the extent of the burn, and whether or not a transfusion is necessary. If the burn is more than 9 per cent of the body surface in extent, a transfusion is called for. The precise treatment of the burn varies, but the essential is to prevent infection if this has not already occurred, or, if it has, to bring it under control as quickly as possible. The treatment of severe burns has made great advances, with quick transport to specialised burns units, modern resuscitative measures, the use of skin grafting and other arti?cial covering techniques and active rehabilitation programmes, o?ering victims a good chance of returning to normal life.
CHEMICAL BURNS Phenol or lysol can be washed o? promptly before they do much damage. Acid or alkali burns should be neutralised by washing them repeatedly with sodium bicarbonate or 1 per cent acetic acid, respectively. Alternatively, the following bu?er solution may be used for either acid or alkali burns: monobasic potassium phosphate (70 grams), dibasic sodium phosphate (70 grams) in 850 millilitres of water. (See also PHOSPHORUS BURNS.)... burns and scalds
These drugs suppress ovulation and make cervical mucus thick and impenetrable to sperm.
They also cause thinning of the endometrium (lining of the uterus), which reduces the chance of a fertilized egg implanting successfully.
The best-known form of hormonal contraception is the contraceptive pill (see oral contraceptives).
The hormones can also be given as contraceptive implants under the skin, by injection (see contraceptives, injectable), or be released by IUDs.... contraception, hormonal methods of
An appreciation of the need to account for chance and bias has led to development of methods where new treatments are compared to either a PLACEBO or to the standard treatment (or both) in a controlled, randomised clinical trial. ‘Controlled’ means that there is a comparison group of patients not receiving the test intervention, and ‘randomised’ implies that patients have been assigned to one or other treatment group entirely by chance and not because of their doctor’s preference. If possible, trials are ‘double-blind’ – that is, neither the patient nor the investigator knows who is receiving which intervention until after the trial is over. All such trials must follow proper ethical standards with the procedure fully explained to patients and their consent obtained.
The conduct, e?ectiveness and duplication of clinical trials have long been subjects of debate. Apart from occasional discoveries of deliberately fraudulent research (see RESEARCH FRAUD AND MISCONDUCT), the structure of some trials are unsatisfactory, statistical analyses are sometimes disputed and major problems have been the – usually unwitting – duplication of trials and non-publication of some trials, restricting access to their ?ndings. Duplication occurs because no formal international mechanism exists to enable research workers to discover whether a clinical trial they are planning is already underway elsewhere or has been completed but never published, perhaps because the results were negative, or no journal was willing to publish it, or the authors or funding authorities decided not to submit it for publication.
In the mid 1980s a proposal was made for an international register of clinical trials. In 1991 the NHS launched a research and development initiative and, liaising with the COCHRANE COLLABORATION, set out to collect systematically data from published randomised clinical trials. In 1994 the NHS set up a Centre for Reviews and Dissemination which, among other responsibilities, maintains a database of research reviews to provide NHS sta? with relevant information.
These e?orts are hampered by availability of information about trials in progress and unpublished completed trials. With a view to improving accessibility of relevant information, the publishers of Current Science, in 1998, launched an online metaregister of ongoing randomised controlled trials.
Subsequently, in October 1999, the editors of the British Medical Journal and the Lancet argued that the case for an international register of all clinical trials prior to their launch was unanswerable. ‘The public’, they said, ‘has the right to know what research is being funded. Researchers and research funders don’t want to waste resources repeating trials already underway.’ Given the widening recognition of the importance to patients and doctors of the practice of EVIDENCE-BASED MEDICINE, the easy availability of information on planned, ongoing and completed clinical trials is vital. The register was ?nally set up in 2005.... clinical trials
Heart transplant Replacement of a person’s unhealthy heart with a normal heart from a healthy donor. The donor’s heart needs to be removed immediately after death and kept chilled in saline before rapid transport to the recipient. Heart transplants are technically demanding operations used to treat patients with progressive untreatable heart disease but whose other body systems are in good shape. They usually have advanced coronary artery disease and damaged heart muscle (CARDIOMYOPATHY). Apart from the technical diffculties of the operation, preventing rejection of the transplanted heart by the recipient’s immune system requires complex drug treatment. But once the patient has passed the immediate postoperative phase, the chances of ?ve-year survival is as high as 80 per cent in some cardiac centres. A key di?culty in doing heart transplants is a serious shortage of donor organs.... heart surgery
Crohn’s disease is rare in the developing world, but in the western world the incidence is increasing and is now 6–7 per 100,000 population. Around 80,000 people in the UK have the disorder with more than 4,000 new cases occurring annually. Commonly Crohn’s disease starts in young adults, but a second incidence surge occurs in people over 70 years of age. Both genetic and environmental factors are implicated in the disease – for example, if one identical twin develops the disease, the second twin stands a high chance of being affected; and 10 per cent of sufferers have a close relative with in?ammatory bowel disease. Among environmental factors are low-residue, high-re?ned-sugar diets, and smoking.
Symptoms and signs of Crohn’s disease depend on the site affected but include abdominal pain, diarrhoea (sometimes bloody), ANOREXIA, weight loss, lethargy, malaise, ANAEMIA, and sore tongue and lips. An abdominal mass may be present. Complications can be severe, including life-threatening in?ammation of the colon (which may cause TOXAEMIA), perforation of the colon and the development of ?stulae between the bowel and other organs in the abdomen or pelvis. If Crohn’s disease persists for a decade or more there is an increased risk of the victim developing colon cancer. Extensive investigations are usually necessary to diagnose the disease; these include blood tests, bacteriological studies, ENDOSCOPY and biopsy, and barium X-ray examinations.
Treatment As with ulcerative colitis, treatment is aimed primarily at controlling symptoms. Physicians, surgeons, radiologists and dietitians usually adopt a team approach, while counsellors and patient support groups are valuable adjuncts in a disease that is typically lifelong. Drug treatment is aimed at settling the acute phase and preventing relapses. CORTICOSTEROIDS, given locally to the affected gut or orally, are used initially and the effects must be carefully monitored. If steroids do not work, the immunosuppressant agent AZATHIOPRINE should be considered. Antidiarrhoeal drugs may occasionally be helpful but should not be taken during an acute phase. The anti-in?ammatory drug SULFASALAZINE can be bene?cial in mild colitis. A new generation of genetically engineered anti-in?ammatory drugs is now available, and these selective immunosuppressants may prove of value in the treatment of Crohn’s disease.
Diet is important and professional guidance is advisable. Some patients respond to milk- or wheat-free diets, but the best course for most patients is to eat a well-balanced diet, avoiding items that the sufferer knows from experience are poorly tolerated. Of those patients with extensive disease, as many as 80 per cent may require surgery to alleviate symptoms: a section of affected gut may be removed or, as a lifesaving measure, a bowel perforation dealt with.
(See APPENDIX 2: ADDRESSES: SOURCES OF INFORMATION, ADVICE, SUPPORT AND SELFHELP – Colitis; Crohn’s disease.)... crohn’s disease
HLA incompatibility causes the immune response, or rejection reaction, that occurs with unmatched tissue grafts. Strong associations between HLA and susceptibility to certain diseases – notably the AUTOIMMUNE DISORDERS such as rheumatoid arthritis, insulin-dependent diabetes, and thyrotoxicosis – have been described. Certain HLA antigens occur together more frequently than would be expected by chance (linkage disequilibrium), and may have a protective e?ect, conferring resistance to a disease. (See IMMUNITY.)... hla system
An oral drug for treating erectile function is sildena?l citrate (Viagra®), the ?rst in a new class of drugs called phosphodiesterase type 5 inhibitors, also including tadala?l (Cialis®) and vardena?l (Levitra®). They work by improving blood ?ow to the penis. They can be taken an hour before intercourse (up to 12 hours before, in the case of tadala?l). These drugs are not aphrodisiacs, and side-effects include headache, facial ?ushing and indigestion. There are some suggestions that they may affect retinal function.
Intracavernosal injection or urethral application of alprostadil, a drug which increases local blood supply to the penis, has been used for some years under medical supervision, but success has been variable and oral sildena?l seems to be a more convenient and e?ective treatment for a man with this disorder.... impotence
It is a recurrent and paroxysmal disorder starting suddenly and ceasing spontaneously due to occasional sudden excessive rapid and local discharge of the nerve cells in the grey matter (cortex) of the BRAIN. Epilepsy always arises in this way from the brain, but its origin is often of microscopic size. It is diagnosed by the clinical symptoms based on the observations of witnesses. Its cause can sometimes be established by laboratory tests, and brain scanning. Fits can be the ?rst sign of a tumour, or follow a stroke, brain injury or infection, but in the large majority no underlying cause is found – so-called idiopathic epilepsy.
A single epileptic ?t is not epilepsy. Of those people who have a single seizure, a signi?cant minority (20 per cent) have no further attacks.
Major (generalised) seizures have a sudden, often unprovoked onset; the patient emits a cry, then falls to the ground, rigid, blue, and then twitching or jerking both sides of the body: the tonic-clonic convulsion. Drowsiness and confusion may last for some hours after recovering consciousness. Some experience a momentary warning (AURA): a smell, or sensation in the head or abdomen, vision, or déjà vu.
Partial seizures: focal motor (Jacksonian) begin with twitching of the angle of the mouth, the thumb, or the big toe. If the seizure discharge then spreads, the twitching or jerking spreads gradually through the limbs. Consciousness is preserved unless the seizure spreads to produce a secondary generalised ?t. In some attacks the eyes and head may turn, the arm may rise, and the body may turn, while some patients feel tingling in the limbs.
Complex partial seizures (temporal lobe epilepsy) The patient usually appears blank, vacant and may be unable to talk, or may mumble or chatter – though later they often have no memory of this period. They may be able to carry out complex tasks, taking o? gloves or clothes, and may smack their lips or rub repeatedly on one limb (automatisms). A sense of strangeness supervenes: unreality, or a feeling of having experienced it all before (déja vu). There may be a sense of panic. Strange unpleasant smells and tastes are olfactory and gustatory hallucinations. The visual hallucinations evoke complex scenes. An initial rising sense of warmth or discomfort in the stomach, or ‘speeding-up’ of thoughts are common psychomotor symptoms. All these strange symptoms are brief, disappearing within a few seconds or up to 3–4 minutes.
Minor seizures (petit mal) Attacks start in childhood. They last a few seconds. The child ceases what he or she is doing, stares, looks a little pale, and may ?utter the eyelids. The head may drop forwards. Attacks are commonly provoked by overbreathing. The child and parents may be unaware of the attacks
– ‘just daydreaming’. Major ?ts develop in one-third of subjects. By contrast with other types of epilepsy, the ELECTROENCEPHALOGRAM (EEG) is diagnostic.
Precautions Children with epilepsy should take normal school exercises and games, and can swim under supervision. Adults must avoid working at heights, with exposed dangerous machinery, and driving vehicles on public roads. Current legislation allows driving after two years of complete freedom from attacks during waking hours; those who for more than three years have had a history of attacks only while asleep may also drive.
Treatment identi?es, and avoids where possible, any factors (such as shortage of sleep or excessive ?uids) which aggravate or trigger attacks. If ?ts are very infrequent, treatment may not be recommended. However, frequent ?ts may be embarassing, may cause injury or may cause long-term brain damage so treatment is advisable. Anti-epileptic drugs are usually necessary for several years under medical supervision. Carbamazepine and sodium valproate are the most frequently prescribed. The dose is governed by the degree of control of ?ts and sometimes drug levels can be monitored by blood tests to check on dosage. Strict adherence to the drug schedule gives a reasonable chance of total suppression of ?ts, especially in younger patients whose ?ts have started recently. The table summarises anticonvulsant drugs in use. Interactions can occur between anti-epileptics and, if drug treatment is changed, the patient needs careful monitoring. In particular, abrupt withdrawal of a drug should be avoided as this may precipitate severe rebound seizures.
Indications First-choice drugs: Ethosuximide PM, JME Phenobarbitone M, P Phenytoin M, P, CP Carbamazepine M, P, CP Valproate M, PM, JME Second-line drugs: Primidone M, P, CP Clobazam M, CP Vigabatrin M, P, CP Lamotrigine M, P, CP Gabapentin M, P, CP Topirimate P
M = major generalised tonic-clonic; P = partial or focal; CP = complex partial (temporal lobe); PM = petit mal; JME = juvenile myoclonic epilepsy.
Anticonvulsant drugs
As all anticonvulsant drugs have an e?ect on the brain, it is not surprising that there may be side-effects, especially inolving alertness or behaviour. In each case careful assessment is necessary for doctor and patient to agree on the best compromise between stopping ?ts and avoiding ill-effects of medication.
Patients who have an epileptic seizure should not be restrained or have a gag or anything else placed in their mouths; nor should they be moved unless in danger of further injury. Any tight clothing around the neck should be loosened and, when the seizure has passed, the person should be placed in the recovery position to facilitate a return to consciousness (see APPENDIX 1: BASIC FIRST AID).
Patients with epilepsy and their relatives can obtain further advice and information from the British Epilepsy Association or Epilepsy Action Scotland.... epilepsy
Dominant genes A dominant characteristic is an e?ect which is produced whenever a gene or gene defect is present. If a disease is due to a dominant gene, those affected are heterozygous – that is, they only carry a fault in the gene on one of the pair of chromosomes concerned. A?ected people married to normal individuals transmit the gene directly to one-half of the children, although this is a random event just like tossing a coin. HUNTINGTON’S CHOREA is due to the inheritance of a dominant gene, as is neuro?bromatosis (see VON RECKLINGHAUSEN’S DISEASE) and familial adenomatous POLYPOSIS of the COLON. ACHONDROPLASIA is an example of a disorder in which there is a high frequency of a new dominant mutation, for the majority of affected people have normal parents and siblings. However, the chances of the children of a parent with the condition being affected are one in two, as with any other dominant characteristic. Other diseases inherited as dominant characteristics include spherocytosis, haemorrhagic telangiectasia and adult polycystic kidney disease.
Recessive genes If a disease is due to a recessive gene, those affected must have the faulty gene on both copies of the chromosome pair (i.e. be homozygous). The possession of a single recessive gene does not result in overt disease, and the bearer usually carries this potentially unfavourable gene without knowing it. If that person marries another carrier of the same recessive gene, there is a one-in-four chance that their children will receive the gene in a double dose, and so have the disease. If an individual sufferer from a recessive disease marries an apparently normal person who is a heterozygous carrier of the same gene, one-half of the children will be affected and the other half will be carriers of the disease. The commonest of such recessive conditions in Britain is CYSTIC FIBROSIS, which affects about one child in 2,000. Approximately 5 per cent of the population carry a faulty copy of the gene. Most of the inborn errors of metabolism, such as PHENYLKETONURIA, GALACTOSAEMIA and congenital adrenal hyperplasia (see ADRENOGENITAL SYNDROME), are due to recessive genes.
There are characteristics which may be incompletely recessive – that is, neither completely dominant nor completely recessive – and the heterozygotus person, who bears the gene in a single dose, may have a slight defect whilst the homozygotus, with a double dose of the gene, has a severe illness. The sickle-cell trait is a result of the sickle-cell gene in single dose, and sickle-cell ANAEMIA is the consequence of a double dose.
Sex-linked genes If a condition is sex-linked, affected males are homozygous for the mutated gene as they carry it on their single X chromosome. The X chromosome carries many genes, while the Y chromosome bears few genes, if any, other than those determining masculinity. The genes on the X chromosome of the male are thus not matched by corresponding genes on the Y chromosome, so that there is no chance of the Y chromosome neutralising any recessive trait on the X chromosome. A recessive gene can therefore produce disease, since it will not be suppressed by the normal gene of the homologous chromosome. The same recessive gene on the X chromosome of the female will be suppressed by the normal gene on the other X chromosome. Such sex-linked conditions include HAEMOPHILIA, CHRISTMAS DISEASE, DUCHENNE MUSCULAR
DYSTROPHY (see also MUSCLES, DISORDERS OF – Myopathy) and nephrogenic DIABETES INSIPIDUS.
If the mother of an affected child has another male relative affected, she is a heterozygote carrier; half her sons will have the disease and half her daughters will be carriers. The sister of a haemophiliac thus has a 50 per cent chance of being a carrier. An affected male cannot transmit the gene to his son because the X chromosome of the son must come from the mother; all his daughters, however, will be carriers as the X chromosome for the father must be transmitted to all his daughters. Hence sex-linked recessive characteristics cannot be passed from father to son. Sporadic cases may be the result of a new mutation, in which case the mother is not the carrier and is not likely to have further affected children. It is probable that one-third of haemophiliacs arise as a result of fresh mutations, and these patients will be the ?rst in the families to be affected. Sometimes the carrier of a sex-linked recessive gene can be identi?ed. The sex-linked variety of retinitis pigmentosa (see EYE, DISORDERS OF) can often be detected by ophthalmoscopic examination.
A few rare disorders are due to dominant genes carried on the X chromosome. An example of such a condition is familial hypophosphataemia with vitamin-D-resistant RICKETS.
Polygenic inheritance In many inherited conditions, the disease is due to the combined action of several genes; the genetic element is then called multi-factorial or polygenic. In this situation there would be an increased incidence of the disease in the families concerned, but it will not follow the Mendelian (see MENDELISM; GENETIC CODE) ratio. The greater the number of independent genes involved in determining a certain disease, the more complicated will be the pattern of inheritance. Furthermore, many inherited disorders are the result of a combination of genetic and environmental in?uences. DIABETES MELLITUS is the most familiar of such multi-factorial inheritance. The predisposition to develop diabetes is an inherited characteristic, although the gene is not always able to express itself: this is called incomplete penetrance. Whether or not the individual with a genetic predisposition towards the disease actually develops diabetes will also depend on environmental factors. Diabetes is more common in the relatives of diabetic patients, and even more so amongst identical twins. Non-genetic factors which are important in precipitating overt disease are obesity, excessive intake of carbohydrate foods, and pregnancy.
SCHIZOPHRENIA is another example of the combined effects of genetic and environmental in?uences in precipitating disease. The risk of schizophrenia in a child, one of whose parents has the disease, is one in ten, but this ?gure is modi?ed by the early environment of the child.... genetic disorders
Causes The disease is directly contagious from another person already suffering from it – usually by sexual intercourse, but occasionally conveyed by the discharge on sponges, towels or clothing as well as by actual contact. The gonococcus is found in the discharge expressed from the urethra, which may be spread as a ?lm on a glass slide, suitably stained, and examined under the microscope; or a culture from the discharge may be made on certain bacteriological media and ?lms from this, similarly examined under the microscope. Since discharges resembling that of gonorrhoea accompany other forms of in?ammation, the identi?cation of the organism is of great importance. A gram-stained smear of urethral discharge enables rapid identi?cation of the gonococcus in around 90 per cent of men.
Symptoms These di?er considerably, according to whether the disease is in an acute or a chronic stage.
MEN After an incubation period of 2–10 days, irritation in the urethra, scalding pain on passing water, and a viscid yellowish-white discharge appear; the glands in the groin often enlarge and may suppurate. The urine when passed is hazy and is often found to contain yellowish threads of pus visible to the eye. After some weeks, if the condition has become chronic, the discharge is clear and viscid, there may be irritation in passing urine, and various forms of in?ammation in neighbouring organs may appear – the TESTICLE, PROSTATE GLAND and URINARY BLADDER becoming affected. At a still later stage the in?ammation of the urethra is apt to lead to gradual formation of ?brous tissue around this channel. This contracts and produces narrowing, so that urination becomes di?cult or may be stopped for a time altogether (the condition known as stricture). In?ammation of some of the joints is a common complication in the early stage – the knee, ankle, wrist, and elbow being the joints most frequently affected – and this form of ‘rheumatism’ is very intractable and liable to lead to permanent sti?ness. The ?brous tissues elsewhere may also develop in?ammatory changes, causing pain in the back, foot, etc. In occasional cases, during the acute stage, SEPTICAEMIA may develop, with in?ammation of the heart-valves (ENDOCARDITIS) and abscesses in various parts of the body. The infective matter occasionally is inoculated accidentally into the eye, producing a very severe form of conjunctivitis: in the newly born child this is known as ophthalmia neonatorum and, although now rare in the UK. has in the past been a major cause of blindness (see EYE, DISORDERS OF). WOMEN The course and complications of the disease are somewhat di?erent in women. It begins with a yellow vaginal discharge, pain on urination, and very often in?ammation or abscess of the Bartholin’s glands, situated close to the vulva or opening of the vagina. The chief seriousness, however, of the disease is due to the spread of in?ammation to neighbouring organs, the UTERUS, FALLOPIAN TUBES, and OVARIES, causing permanent destructive changes in these, and leading occasionally to PERITONITIS through the Fallopian tube with a fatal result. Many cases of prolonged ill-health and sterility or recurring miscarriages are due to these changes.
Treatment The chances of cure are better the earlier treatment is instituted. PENICILLIN is the antibiotic of choice but unfortunately the gonococcus is liable to become resistant to this. In patients who are infected with penicillin-resistant organisms, one of the other antibiotics (e.g. cefotaxime, cipro?oxacin or spectinomycin) is used. In all cases it is essential that bacteriological investigation should be carried out at weekly intervals for three or four weeks, to make sure that the patient is cured. Patients attending with gonorrhoea are asked if they will agree to tests for other sexually transmitted infections, such as HIV (see AIDS/HIV) and for assistance in contact tracing.... gonorrhoea
Various gases, liquids and solids will emit light when they are suitably stimulated. A gassed laser is pumped by the ionising e?ect of a high-voltage current. This is the same process as that used in a ?uorescent tube. Each type of laser has a di?erent e?ect on biological tissues and this is related to the wavelength of the light produced. The wavelength determines the degree of energy absorption by di?erent tissues, and because of this, di?erent lasers are needed for di?erent tasks. The argon laser produces light in the visible green wavelength which is selectively absorbed by HAEMOGLOBIN. It heats and coagulates (see COAGULATION) tissues so can be used to seal bleeding blood vessels and to selectively destroy pigmented lesions. The carbon-dioxide laser is the standard laser for cutting tissue: the infra-red beam it produces is strongly absorbed by water and so vaporises cells. Thus, by moving a ?nely focused beam across the tissue, it is possible to make an incision.
The two main uses of laser in surgery are the endoscopic (see ENDOSCOPE) photocoagulation of bleeding vessels, and the incision of tissue. Lasers have important applications in OPHTHALMOLOGY in the treatment of such disorders as detachment of the retina and the diabetic complications of proliferative retinopathy and of the cornea (see EYE, DISORDERS OF). The destruction of abnormal cells – a sign of pre-malignancy – in the CERVIX UTERI is done using lasers. The beams may also be used to remove scar tissue from the FALLOPIAN TUBES resulting from infection, thus unblocking the tubes and improving the chances of CONCEPTION. Lasers also have several important applications in DERMATOLOGY. They are used in the treatment of pigmented lesions such as LENTIGO, in the obliteration of port-wine stains, in the removal of small, benign tumours such as verrucas, and ?nally in the removal of tattoos.
Low-intensity laser beams promote tissue healing and reduce in?ammation, pain and swelling. Their e?ect is achieved by stimulating blood and lymph ?ow and by cutting the production of PROSTAGLANDINS, which provoke in?ammation and pain. The beams are used to treat ligament sprains, muscle tears and in?amed joints and tendons.
The three great advantages of lasers are their potency, their speed of action, and the ability to focus on an extremely small area. For these reasons they are widely used, and have allowed great advances to be made in microsurgery, and particularly in FIBREOPTIC ENDOSCOPY.... laser
In recent years, however, the position has been altered by the introduction of the so-called fertility drugs, such as CLOMIPHENE, and human menopausal gonadotrophin which, through the medium of the PITUITARY GLAND, stimulate the production of ova (see OVUM). Their wide use in the treatment of INFERTILITY has resulted in an increase in the number of multiple births, a recognised hazard of giving too large a dose.
Twins may be binovular or uniovular. Binovular, or fraternal, twins are the result of the mother’s releasing two ova within a few days of each other and both being fertilised by separate spermatozoa (see SPERMATOZOON). They both develop separately in the mother’s womb and are no more alike than is usual with members of the same family. They are three times as common as uniovular, or identical, twins, who are developed from a single ovum fertilised by a single spermatozoon, but which has split early in development. This is why they are usually so remarkably alike in looks and mental characteristics. Unlike binovular twins, who may be of the same or di?erent sex, they are always of the same sex.
So far as fraternal, or binovular, twins are concerned, multiple pregnancy may be an inherited tendency; it certainly occurs more often in certain families, but this may be partly due to chance. A woman who has already given birth to twins is ten times more likely to have another multiple pregnancy than one who has not previously had twins. The statistical chance of a third pair of twins is 1:512,000. Identical twins do not run in families.
The relative proportion of twins of each type varies in di?erent races. Identical twins have much the same frequency all over the world: around 3 per 1,000 maternities. Fraternal twins are rare in Mongolian races: less than 3 per 1,000 maternities. In Caucasians they occur two or three times as often as identical twins: between 7 (Spain and Portugal) and 10 (Czech and Slovak Republics and Greece) per 1,000 maternities. They are more common in Afro-Caribbeans, reaching 30 per 1,000 maternities in certain West African populations.
Rarely, uniovular twins may not develop as separate individuals, being physically joined in some way. They are called conjoined or (traditionally) Siamese twins. Depending on the extent of common structures shared by the infants – this ranges from a common umbilical cord to twins with conjoined heads or a common liver – the infants may be successfully separated by surgery. (See CONJOINED TWINS.)
Parents of twins, triplets, etc. can obtain advice and help from the Twins and Multiple Births Association (TAMBA).... multiple births
Symptoms When a sensory nerve is injured or diseased, sensation is immediately more or less impaired in the part supplied by the nerve. Ulceration or death of the tissue supplied by the defective nerve may occur. When the nerve in question is a motor one, the muscles governed through it are instantly paralysed. In the latter case, the portion of nerve beyond the injury degenerates and the muscles gradually waste, losing their power of contraction in response to electrical applications. Finally, deformities result and the joints become ?xed. This is particularly noticeable when the ulnar nerve is injured, the hand and ?ngers taking up a claw-like position. The skin may also be affected.
Treatment Damaged or severed (peripheral) nerve ?bres should be sewn together, using microsurgery. Careful realignment of the nerve endings gives the ?bres an excellent chance of regenerating along the right channels. Full recovery is rare but, with regular physiotherapy to keep paralysed muscles in good shape and to prevent their shortening, the patient can expect to obtain a reasonable return of function after a few weeks, with improvement continuing over several months.... nerves, injuries to
For a diagnosis of PVS to be made, the state should have continued for more than a prede?ned period, usually one month. Half of patients die within 2–6 months, but some can survive for longer with arti?cial feeding. To assess a person’s level of consciousness, a numerical marking system rated according to various functions – eye opening, motor and verbal responses – has been established called the GLASGOW COMA SCALE.
The ETHICS of keeping patients alive with arti?cial support are controversial. In the UK, a legal ruling is usually needed for arti?cial support to be withdrawn after a diagnosis of PVS has been made. The chances of regaining consciousness after one year are slim and, even if patients do recover, they are usually left with severe neurological disability.
PVS must be distinguished from conditions which appear similar. These include the ‘LOCKED-IN SYNDROME’ which is the result of damage to the brain stem (see BRAIN). Patients with this syndrome are conscious but unable to speak or move except for certain eye movements and blinking. The psychiatric state of CATATONIA is another condition in which the patient retains consciousness and will usually recover.... persistent vegetative state (pvs)
The disease is ENDEMIC in dogs and wolves in some countries; an EPIDEMIC may occasionally occur. It also occurs in foxes, coyotes and skunks, as well as in vampire bats. Thanks to QUARANTINE measures, since 1897 rabies has been rare in Great Britain, which still retains strict measures (the Rabies Act) to prevent the entry of infected animals into the country, including a six-month quarantine period and vaccination (see IMMUNISATION). This policy was relaxed somewhat in 2001 with the launch of the Pet Travel Scheme; this allows cats and dogs to enter the UK from speci?ed countries without the need for quarantine, as long as stringent conditions as to microchipping and vaccinations are met. Full details can be obtained from the Department for the Environment, Food and Rural A?airs (DEFRA) or from a veterinary surgeon engaged in operating the scheme. Six months has to elapse between vaccination against rabies and a positive blood test before the ‘pet passport’ can be issued.
Rabies is highly infectious from the bite of an animal already affected, but the chance of infection from di?erent animals varies. Thus only about one person in every four bitten by rabid dogs contracts rabies, whilst the bites of rabid wolves and cats almost invariably produce the disease.
Symptoms In animals there are two types of the disease: mad rabies and dumb rabies. In the former, the dog (or other animal) runs about, snapping at objects and other animals, unable to rest; in the latter, which is also the ?nal stage of the mad type, the limbs become paralysed and the dog crawls about or lies still.
In humans the incubation period is usually 6–8 weeks, but may be as short as ten days or as long as two years. The disease begins with mental symptoms, the person becoming irritable, restless and depressed. Fever and DYSPHAGIA follow. The irritability passes into a form of MANIA and the victim has great di?culty in swallowing either food or drink.
Treatment The best treatment is, of course, preventive. Local treatment consists of immediate, thorough and careful cleansing of the wound-surfaces and surrounding skin. This is followed by a course of rabies vaccine therapy.
Only people bitten (or in certain circumstances, licked) by a rabid animal or by one thought to be infected with rabies need treatment; this is with rabies vaccine and antiserum and one of the IMMUNOGLOBULINS. A person previously vaccinated against rabies who is subsequently bitten by a rabid animal should be given three or four doses of the vaccine. The vaccine is also used to give protection to those liable to infection, such as kennel-workers and veterinary surgeons. Those who develop the disease require intensive care with ventilatory support, despite which the death rate is very high.... rabies
In Britain, for instance, preventive medicine is usually taken to encompass a range of activities whose purpose is:
to reduce the chance of a person contracting a disease or becoming disabled.
to identify either an increased susceptibility to develop a disease, or an early manifestation of a disease at a stage which will still allow treatment to be e?ective. The American College of Preventive Medi
cine (1983) de?ned it as ‘a specialised ?eld of medical practice composed of distinct disciplines which utilise skills focusing on the health of de?ned populations in order to promote and maintain health and well-being and to prevent disease, disability and premature death’.
However de?ned, the spectrum of activities encompassed by preventive medicine is wide and includes actions, such as counselling about lifestyle, where there may not be a clear cut-o? between a preventive and a curative act. For example, advice about smoking and exercise to a recent victim of a myocardial infarction (see under HEART, DISEASES OF) is both essential to treatment and preventive against a future attack. Action aimed at a whole population – such as the addition of ?uoride to drinking-water to protect against dental caries (see under TEETH, DISORDERS OF) – is part of a population-based public-health strategy but would also be widely regarded as preventive medicine.
A common and widely accepted classi?cation of preventive medicine is as follows:
Primary prevention which aims at the complete avoidance of a disease (for example, by immunising a child against an infectious disease – see IMMUNISATION).
Secondary prevention which aims at detecting and curing a disease at an early stage before it has caused any symptoms. This requires ‘screening’ procedures to detect either the early pre-symptomatic condition, or a risk factor which may lead to it. (An example of the former is cervical cytology, where a sample of cells is scraped from the cervix of the UTERUS and examined microscopically for abnormality.
An example of the latter is CHOLESTEROL measurement as part of assessing an individual’s risk of developing ischaemic heart disease (see under HEART, DISEASES OF). If it is signi?cantly raised, dietary or drug treatment can be advised.)
Tertiary prevention aims at minimising the consequences for a patient who already has the disease (e.g. advising people to take more exercise and stop smoking after a heart attack).
Many prefer to limit the term ‘preventive medicine’ to primary and secondary prevention, emphasising the focus on risk-reducing interventions targeted at ‘well’ individuals. Others prefer the wider emphasis because of the importance of a preventive approach in reducing further disability by recognising and treating symptoms early. This can be particularly important in older people, where, for example, vigorous treatment of an orthopaedic problem can enable the patient to maintain physical mobility with all the bene?ts to health that brings. Whether primary, secondary or tertiary prevention, some form of screening question or test is normally necessary to identify a problem.
The range and extent of opportunities for prevention are expanding as research identi?es the causes of diseases and more e?ective treatment becomes feasible. Inevitably there is economic and political debate about the cost-e?ectiveness of prevention versus cure, as well as about the ETHICS. The situation varies in relation to the natural history of the speci?c disease. Some conditions can easily be prevented but once contracted cannot be cured
(e.g. RABIES); others are easily cured but are not yet preventable.
Screening Screening involves carrying out tests either to identify a treatable disease at a very early stage, before it has caused symptoms or damage; or to identify a risk factor which can lead to a disease. The tests might be by simple questioning (e.g. ‘Do you smoke cigarettes?’ – this predicts a considerable increase in the risk of chronic bronchitis, heart disease, bronchial cancer and many other diseases, and enables targeted advice and help to stop smoking to be given). Other screening tests involve carrying out complex special investigations such as blood tests or the microscopic investigations of cells – for example, for precancerous changes.
Many conditions can be identi?ed at an early stage before they cause symptoms or signs of disease and in time for e?ective treatment to be carried out. Inevitably, some of the screening tests proposed can be expensive (particularly if used in large populations), painful or inaccurate and may not improve the results of treatment. Screening can also provoke considerable anxiety in those waiting for tests or results. Therefore, over the years considerable research has been carried out into the appropriateness and ethics of screening, and the World Health Organisation in 1968 identi?ed a set of rules for evaluating screening tests:
The condition sought should be an important health problem, for which there should be an accepted treatment for patients with recognised disease.
Facilities for diagnosis and treatment should be available if a case is found.
The screening test or examination must be suitable and valid. A false positive test will cause massive anxiety and also considerable expense in proving that there is no disease. Similarly, false negatives can lead people to be reassured and to ignore serious symptoms until too late. If large numbers of positive tests or false positives occur during a screening programme, health services can be swamped.
The test, and any treatment as a possible result, should be acceptable. For example, there is little point in screening for a fetal abnormality which, if found, would lead to a recommendation for termination if the mother will refuse it on religious or moral grounds.
Screening tests also need to be considered from an economic perspective and the cost of case-?nding (including diagnosis and treatment of patients diagnosed) balanced in relation to possible expenditure on medical care as a whole.
Finally the programme should re?ect the natural history of the disease, and case-?nding should normally be a continuing process and not a ‘once for all’ project. If these rules are followed, considerable
bene?ts can result from well-planned and well-managed screening programmes, and they form an important part of any health-care system. The extent to which manipulation of genetic material will be added to more traditional approaches such as counselling, immunisation and drug treatment cannot yet be predicted but, as time goes by, it is often likely to be ethical and social controls which limit developments rather than technical and scienti?c limits.... preventive medicine
0.1 and 1 per cent. A ?gure of 1 per cent means that, in the United Kingdom at any one time, maybe 30 studies are being conducted, or their results published, which could contain false information. Examples include forged ethics-committee approval, patient signatures and diary cards; fabricated ?gures and results; invention of non-existent patient subjects; or sharing one electrocardiogram or blood sample amongst many subjects.
Research fraud should be ?rst suspected by a clinical-trial monitor who recognises that data are not genuine, or by a quality-assurance auditor who cannot reconcile data in clinical-trial report forms with original patient records. Unfortunately, it often comes to light by chance. There may be suspicious similarities between data ostensibly coming from more than one source, or visits may have been recorded when it was known that the clinic was shut. Statistical analysis of a likely irregularity will frequently con?rm such suspicion. The motivation for fraud is usually greed, but a desire to publish at all costs, to be the original author of a medical breakthrough, to bolster applications for research grants, or to strengthen a bid for more departmental resources are other recognised reasons for committing fraud.
In the USA, those proved to have committed fraud are debarred from receiving federal funds for research purposes or from undertaking government-funded therapeutic research. The four Nordic countries (Denmark, Finland, Norway and Sweden) have committees on research dishonesty that investigate all cases of suspected research misconduct. In the United Kingdom, an informal system operated by the pharmaceutical industry, using the disciplinary mechanism of the General Medical Council (GMC), has led to more than 16 doctors in the past ten years being disciplined for having committed research fraud. Editors of many of the world’s leading medical journals have united to form the Committee on Publishing Ethics, which advises doctors on proper practice and assists them in retracting or refusing to publish articles found or known to be false. (See ETHICS; ETHICS COMMITTEES.) Where an author does not o?er a satisfactory explanation, the matter is passed to his or her institution to investigate; where an editor or the committee is not satis?ed with the result they may pass the complaint to the appropriate regulatory body, such as the GMC in Britain.... research fraud and misconduct
Symptoms. Unhealthy pallor, listlessness, sore tongue, dizziness, vague aches and pains, rapid pulse and breathing, tinnitus, palpitation. The skull may be disproportionately large, resistance to infection feeble, chances of survival poor. This form of anaemia is linked with defective colour vision. Impaired liver function. Stunted growth, great pain. Sufferers have a higher risk of infection.
Malaria. Sufferers are less likely to die of malaria because their red cells do not support the growth of malaria parasites very well.
Carriers: Carriers of the sickle-cell gene can now be identified by a simple blood test.
Treatment. No specifics exist but supportive herbal treatment has been known to increase output of red cells and raise haemoglobin levels:– Red Clover flowers, Yellow Dock, Echinacea, Burdock, Wild Indigo, Gentian, Nettles, Birch leaves, Sage, Walnut leaves, Centaury, Gota Kola (Indian Pennywort). Alternatives:– Tea. Mix equal parts: Iceland Moss, Nettles, Red Clover flowers. 2 teaspoons to each cup boiling water; infuse 15 minutes; 1 cup morning and evening.
Decoction. Mix equal parts; Echinacea, Walnut leaves, Balm of Gilead buds; 1 teaspoon to each cup water gently simmered for 20 minutes. Half-1 cup, cold, 3 times daily, before meals.
Tablets/capsules. Sarsaparilla. Ginseng. Iceland Moss. Red Clover. Echinacea. Gentian.
Powders. Formula: Echinacea 1; Fringe Tree half; Ginseng half; White Poplar bark 1. Dose: 500mg (two 00 capsules or one-third teaspoon) thrice daily before meals.
Liquid extracts. Formula. Echinacea 2; Dandelion 1; Oat Husk (avena sativa) 1. Mix. Dose, 1-2 teaspoons before meals, in water or one of the above teas or decoctions.
Tinctures. Same combination. Dose: 2-3 teaspoons.
Dong quai. See entry.
Pollen. Claimed to be of value.
Diet. Dandelion coffee. Molasses. Desiccated liver. Calf liver, fresh. Green leafy vegetables contain chlorophyll, iron and folic acid. Cider vinegar. Dried beans, apricots and shellfish. Dandelion leaves in salads. Milk, eggs, meats, Soya. Carrot juice to increase red cells.
Supplements. Daily. Vitamin B12. Vitamin C, 1g; Folic acid 400mcg, Floradix. Of particular value: Vitamin E 400iu. Zinc.
Note: Those at risk should submit themselves for screening. The disease cannot be cured but can be controlled largely by orthodox measures and sometimes by natural medicine. ... anaemia: sickle cell
Causes There is a major immunogenetic predisposition to rheumatoid arthritis in people carrying the HLA-DR4 antigen (see HLA SYSTEM). Other minor immunogenetic factors have also been implicated. In addition, there is a degree of familial clustering which suggests other unidenti?ed genetic factors. Genetic factors cannot alone explain aetiology, and environmental and chance factors must be important, but these have yet to be identi?ed.
Epidemiology Rheumatoid arthritis more commonly occurs in women from the age of 30 onwards, the sex ratio being approximately 4:1. Typical rheumatoid arthritis may occur in adolescence, but in childhood chronic SYNOVITIS usually takes one of a number of di?erent patterns, classi?ed under juvenile chronic arthritis.
Pathology The primary lesion is an in?ammation of the synovial membrane of joints. The synovial ?uid becomes diluted with in?ammatory exudate: if this persists for months it leads to progressive destruction of articular CARTILAGE and BONE. Cartilage is replaced by in?ammatory tissue known as pannus; a similar tissue invades bone to form erosions. Synovitis also affects tendon sheaths, and may lead to adhesion ?brosis or attrition and rupture of tendons. Subcutaneous and other bursae may be involved. Necrobiotic nodules also occur at sites outside synovium, including the subcutaneous tissues, the lungs, the pericardium and the pleura.
Clinical features Rheumatoid arthritis varies from the very mild to the severely disabling. Many mild cases probably go undiagnosed. At least 50 per cent of patients continue to lead a reasonably normal life; around 25 per cent are signi?cantly disabled in terms of work and leisure activities; and a minority become markedly disabled and are limited in their independence. There is often an early acute phase, followed by substantial remission, but in other patients gradual step-wise deterioration may occur, with progressive involvement of an increasing number of joints.
The diagnosis of rheumatoid arthritis is largely based on clinical symptoms and signs. Approximately 70 per cent of patients have rheumatoid factor ANTIBODIES in the SERUM but, because of the large number of false positives and false negatives, this test has very little value in clinical practice. It may be a useful pointer to a worse prognosis in early cases if the level is high. X-RAYS may help in diagnosing early cases and are particularly helpful when considering surgery or possible complications such as pathological fracture. Patients commonly develop ANAEMIA, which may be partly due to gastrointestinal blood loss from antiin?ammatory drug treatment (see below).
Treatment involves physical, pharmacological, and surgical measures, together with psychological and social support tailored to the individual patient’s needs. Regular activity should be maintained. Resting of certain joints such as the wrist with splints may be helpful at night or to assist prolonged manual activities. Sound footwear is important. Early use of antirheumatic drugs reduces long-term disability. Drug treatment includes simple ANALGESICS, NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS), and slow-acting drugs including GOLD SALTS (in the form of SODIUM AUROTHIOMALATE), PENICILLAMINE, SULFASALAZINE, METHOTREXATE and AZATHIOPRINE.
The non-steroidal agents are largely e?ective in reducing pain and early-morning sti?ness, and have no e?ect on the chronic in?ammatory process. It is important, especially in the elderly, to explain to patients the adverse effects of NSAIDs, the dosage of which can be cut by prescribing paracetamol at the same time. Combinations of anti-rheumatic drugs seem better than single agents. The slow-acting drugs take approximately three months to act but have a more global e?ect on chronic in?ammation, with a greater reduction in swelling and an associated fall in erythrocyte sedimentation rate (ESR) and rise in the level of HAEMOGLOBIN. Local CORTICOSTEROIDS are useful, given into individual joints. Systemic corticosteroids carry serious problems if continued long term, but may be useful under special circumstances. Much research is currently going on into the use of tumour necrosis factor antagonists such as INFLIXIMAB and etanercept, but their precise role remains uncertain.... rheumatoid arthritis
Causes There is an inherited element: parents, children or siblings of schizophrenic sufferers have a one in ten chance of developing the disorder; a twin has a 50 per cent chance if the other twin has schizophrenia. Some BRAIN disorders such as temporal lobe EPILEPSY, tumours and ENCEPHALITIS seem to be linked with schizophrenia. Certain drugs – for example, AMPHETAMINES – can precipitate schizophrenia and DOPAMINE-blocking drugs often relieve schizophrenic symptoms. Stress may worsen schizophrenia and recreational drugs may trigger an attack.
Symptoms These usually develop gradually until the individual’s behaviour becomes so distrubing or debilitating that work, relationships and basic activities such as eating and sleeping are interrupted. The patient may have disturbed perception with auditory HALLUCINATIONS, illogical thought-processes and DELUSIONS; low-key emotions (‘?at affect’); a sense of being invaded or controlled by outside forces; a lack of INSIGHT and inability to acknowledge reality; lethargy and/or agitation; a disrespect for personal appearance and hygiene; and a tendency to act strangely. Violence is rare although some sufferers commit violent acts which they believe their ‘inner voices’ have commanded.
Relatives and friends may try to cope with the affected person at home, but as severe episodes may last several months and require regular administration of powerful drugs – patients are not always good at taking their medication
– hospital admission may be necessary.
Treatment So far there is no cure for schizophrenia. Since the 1950s, however, a group of drugs called antipsychotics – also described as NEUROLEPTICS or major tranquillisers – have relieved ?orid symptoms such as thought disorder, hallucinations and delusions as well as preventing relapses, thus allowing many people to leave psychiatric hospitals and live more independently outside. Only some of these drugs have a tranquillising e?ect, but their sedative properties can calm patients with an acute attack. CHLORPROMAZINE is one such drug and is commonly used when treatment starts or to deal with an emergency. Halperidol, tri?uoperazine and pimozide are other drugs in the group; these have less sedative effects so are useful in treating those whose prominent symptoms are apathy and lethargy.
The antipsychotics’ mode of action is by blocking the activity of DOPAMINE, the chemical messenger in the brain that is faulty in schizophrenia. The drugs quicken the onset and prolong the remission of the disorder, and it is very important that patients take them inde?nitely. This is easier to ensure when a patient is in hospital or in a stable domestic environment.
CLOZAPINE – a newer, atypical antipsychotic drug – is used for treating schizophrenic patients unresponsive to, or intolerant of, conventional antipsychotics. It may cause AGRANULOCYTOSIS and use is con?ned to patients registered with the Clorazil (the drug’s registered name) Patient Monitoring Service. Amisulpride, olanzapine, quetiapine, risperidone, sertindole and zotepine are other antipsychotic drugs described as ‘atypical’ by the British National Formulary; they may be better tolerated than other antipsychotics, and their varying properties mean that they can be targeted at patients with a particular grouping of symptoms. They should, however, be used with caution.
The welcome long-term shift of mentally ill patients from large hospitals to community care (often in small units) has, because of a lack of resources, led to some schizophrenic patients not being properly supervised with the result that they fail to take their medication regularly. This leads to a recurrence of symptoms and there have been occasional episodes of such patients in community care becoming a danger to themselves and to the public.
The antipsychotic drugs are powerful agents and have a range of potentially troubling side-effects. These include blurred vision, constipation, dizziness, dry mouth, limb restlessness, shaking, sti?ness, weight gain, and in the long term, TARDIVE DYSKINESIA (abnormal movements and walking) which affects about 20 per cent of those under treatment. Some drugs can be given by long-term depot injection: these include compounds of ?upenthixol, zuclopenthixol and haloperidol.
Prognosis About 25 per cent of sufferers recover fully from their ?rst attack. Another 25 per cent are disabled by chronic schizophrenia, never recover and are unable to live independently. The remainder are between these extremes. There is a high risk of suicide.... schizophrenia
Symptoms. Bladder irritability; increased frequency during the night. Feeble forked stream of urine. Sometimes blood. Three quarters of such tumours are located in the posterior lobe of the prostate gland – readily accessible to the examining finger through the front wall of the rectum. Rectal examination reveals a hard rugged prostate. Cystoscopy confirms. Bone pains in the low back or pelvis reflect a stage where the tumour has already spread. Anaemia, weight loss, urgency.
All symptoms are worse by alcohol and spicy foods.
Harvard University scientists report: heavy consumption of animal fat, especially the fat in red meat appears to increase the chance that a man will develop advanced prostate cancer.
Of therapeutic value. Comfrey, Echinacea, Horsetail, Poke root, Thuja, Cornsilk, Goldenseal.
Tea. Combination. Comfrey leaves, Horsetail, Cornsilk. Equal parts. 2-3 teaspoons to each cup boiling water. Drink freely.
Formula No. 1. Echinacea 2; Comfrey 1; Poke root half; Thuja half. Mix. Dose: Powders: 500mg (two 00 capsules or one-third teaspoon). Liquid extracts: 1 teaspoon. Tinctures: 2 teaspoons. Thrice daily in water or cup of Cornsilk tea.
Formula No. 2. (Alternative) Echinacea 2; Goldenseal 1; Gotu Kola 1; Poke root half. Mix. Dose: Powders: 500mg (two 00 capsules or one-third teaspoon). Liquid extracts: 1 teaspoon. Tinctures: 2 teaspoons in water or cup of Cornsilk tea.
Bee pollen. Of value.
Garlic. Of value.
Diet. See: DIET – CANCER.
There is a very low incidence of prostate cancer in countries where Soya products are widely consumed – Soya contains a female hormone which is a protector factor.
Supplements. Morning and evening.
Vitamin A 7500iu or more. Large doses may be required. Vitamin C 1-2g. Vitamin E 200iu. Calcium 500mg. Selenium 100mcg. Zinc.
Study. Men with prostate cancer may not need to undergo radical prostatectomy (removal of the prostate gland). A 10-year follow-up study of men with early prostate cancer left untreated showed that 10 years later only 8.5 per cent of the 223 patients had died from prostate cancer. The survival rate of 86.8 per cent in the untreated group was nearly identical to a subgroup who met all the conditions for radical prostatectomy. (Journal of American Medical Association, 22/29 April 1992)
Commonly treated with female sex hormone or by orchidectomy.
It would appear that surgical removal of the gland offers little benefit, and possibly a disadvantage to patients wishing to leave well alone, particularly the elderly. Treatment by a general medical practitioner or oncologist. ... cancer – prostate gland
The human backbone is about 70 cm (28
inches) in length, and varies little in full-grown people; di?erences in height depend mainly upon the length of the lower limbs. The number of vertebrae is 33 in children, although in adult life ?ve of these fuse together to form the sacrum, and the lowest four unite in the coccyx, so that the number of separate bones is reduced to 26. Of these there are seven in the neck, known as cervical vertebrae; 12 with ribs attached, in the region of the thorax known as thoracic or dorsal vertebrae; ?ve in the loins, called lumbar vertebrae; ?ve fused to form the sacrum; and four joined in the coccyx. These numbers are expressed in a formula thus: C7, D12, L5, S5, Coc4=33.
Although the vertebrae in each of these regions have distinguishing features, all the vertebrae are constructed on the same general plan. Each has a thick, rounded, bony part in front, known as the body, and these bodies form the main thickness of the column. Behind the body of each is a ring of bone, the neural ring, these rings placed one above another forming the bony canal which lodges the spinal cord. From each side of the ring a short process of bone known as the transverse process stands out, and from the back of the ring a larger process, the spinous process, projects. These processes give attachment to the strong ligaments and muscles which unite, support, and bend the column. The spines can be seen or felt beneath the skin of the back lying in the centre of a groove between the muscular masses of the two sides, and they give to the column its name of the spinal column. One of these spines, that of the seventh cervical vertebra, is especially large and forms a distinct bony prominence, where the neck joins the back. Between the bodies of the vertebrae lies a series of thick discs of ?brocartilage known as intervertebral discs. Each disc consists of an outer portion, known as the annulus ?brosus, and an inner core, known as the nucleus pulposus. These 23 discs provide the upper part of the spine with pliability and resilience.
The ?rst and second cervical vertebrae are specially modi?ed. The ?rst vertebra, known as the atlas, is devoid of a body, but has a specially large and strong ring with two hollows upon which the skull rests, thus allowing forward and backward movements (nodding). The second vertebra, known as the axis, has a pivot on its body which ?ts into the ?rst vertebra and thus allows free rotation of the head from side to side. The spinal column has four natural curves (see diagram) which help to cushion the shocks of walking and running.
The neural rings of the vertebrae form a canal, which is wide in the neck, smaller and almost round in the dorsal region, and wide again in the lumbar vertebrae. Down the canal runs the spinal cord, and the nerves leaving the cord do so through openings between the vertebrae which are produced by notches on the upper and lower margins of each ring. The intervertebral foramina formed by these notches are so large in comparison with the nerves passing through them that there is no chance of pressure upon the latter, except in very serious injuries which dislocate and fracture the spine.... spinal column
Cases of Down’s have followed use of nonoxynol-9 (vaginal contraceptive device) such as the polyurethane sponge. The sponge. when left in situ for a long time, may cause Down’s to follow.
Certain physical characteristics are present. The most important feature is impaired mental development. Almost all are coeliacs.
Symptoms. Low IQ, short fingers, small flat head, flattened nose, low-set ears. May be subject to umbilical hernia, and heart disease. No treatment can cure, but certain herb teas rich in minerals (Alfalfa, Red Clover) together with Kelp (either in tablet or powder form) may help children, with possible improvements in IQ. Vitamin supplements – A, D, Thiamine, Riboflavin, B6, B12, C and E improve a child’s physical and mental health – as do also the minerals: Magnesium, Calcium, Zinc, Manganese, Copper, Iron and Iodine.
Children with Down’s syndrome run an increased risk of coeliac disease, due to disturbed immunity. A substantial evidence is held in America that links a low level of Selenium in the mother. Unnecessary X- rays should be avoided. Ensure fitness before conception by gentle exercise and nutrients: Folic Acid, Selenium and Zinc.
Children with the condition are noted for their happy disposition and warmth of feeling towards others. ... down’s syndrome
Insomnia, malaise, agitation, and tearfulness are also common. Gradually, but usually within 2 years, the bereaved person adjusts to the loss.
Family and friends can often provide support. Outside help may be required and may be given by a social worker, health visitor, member of the clergy, or self-help group. For some people, when depression, apathy, and lethargy impede any chance of recovery, specialized counselling or psychotherapy is necessary. (See also stillbirth.)... bereavement
A genetic basis has been found for some types of colon cancer.
However, in most cases, the precise cause is unknown.
Contributory factors include diet: eating a lot of meat and fatty foods and not enough fibre may increase the risk.
The disease often occurs in association with other diseases of the colon, such as ulcerative colitis and familial polyposis.
The chances of cure depend critically on early diagnosis.
Screening for this cancer includes an occult blood test; if the test is positive, sigmoidoscopy and colonoscopy may be carried out.
In most cases of colon cancer, a partial colectomy is performed.... colon, cancer of
Initially, automatic contraction of a muscle at the entrance to the windpipe, a mechanism called the laryngeal reflex, prevents water from entering the lungs; instead it enters the oesophagus and stomach.
However, the laryngeal reflex impairs breathing and can quickly lead to hypoxia and to loss of consciousness.
If the person is buoyant at this point and floats face-up, his or her chances of survival are reasonable because the laryngeal reflex begins to relax and normal breathing may resume.
An ambulance should be called and the person’s medical condition assessed.
If breathing and/or the pulse is absent, resuscitative measures should be started (see artificial respiration; cardiopulmonary resuscitation) and continued until an ambulance or doctor arrives.
Victims can sometimes be resuscitated, despite a long period immersed in very cold water (which reduces the body’s oxygen needs) and the initial appearance of being dead.
In all cases of successful resuscitation, the person should be sent to a hospital.... drowning
Fitness depends on strength, flexibility, and endurance.
Because cardiovascular fitness is the precondition for all other forms of fitness, regular aerobic exercise (see aerobics), which makes the body’s use of oxygen more efficient, is the basis of any fitness programme.
Specific activities, such as weight training or yoga, can help develop strength and flexibility when included in a programme (see exercise).
When the body is fit, the maximum work capacity and endurance are increased.
A fit person has a better chance of avoiding coronary artery disease and preventing the effects of age and chronic disease.... fitness
infant A term usually applied to a baby up to the age of 12 months.... induction of labour
Basal Cell Cancer. Strong sunlight on fair skins. Common on face and hands and other exposed areas. Commences as a tiny hard nodule. See – RODENT ULCER.
Squamous Cell Cancer. The role of sunlight in this type of cancer is even more positive. Other causes: photosensitisers such as pitch and PUVA photochemotherapy. Commences as a raised scaly rapidly- growing nodule.
Malignant Melanoma. Rare, but incidence rising. Four different kinds. Incidence is increased in individuals with fair or red hair who tend to burn rather than tan in the sun.
Causes may be numerous: genetic, occupational hazards or exposure to low-level radiation. Heavy freckling in youth doubles the risk. (Western Canada Melanoma study)
A study carried out by the New York’s Memorial-Sloan Kettering Cancer Centre refers to damage to the ultra violet-blocking ozone layer by supersonic jet exhaust and aerosol propellants that can also raise the malignant melanoma rate. A University of Sydney study links fluorescent lighting with the disease. Symptoms. Itching lesion increases in size and with growing discoloration. Colours may present as brown, black, red, blue, white, with a red inflammatory border. May progress to a dry crust, with bleeding.
Study. A study conducted by a team from Melbourne University, Anti-Cancer Council and St Vincent’s Hospital, Australia, describes a summer-long experiment that showed that people who used a sun-screen lotion (in this case SPF-17) cut their chances of developing the first signs of skin cancer.
Study. Patients who receive blood transfusions are more likely to develop malignant lymphomas and non- melanomatous skin cancers. (European Journal of Cancer (Nov 1993))
Eclectic physicians of the 19th century reported success from the use of American Mandrake (podophylum peltatum). Recent experience includes a 76 per cent cure rate achieved in 68 patients with carcinoma of the skin by treatment twice daily for 14 days with an ointment consisting of Podophyllum resin 20 per cent, and Linseed oil 20 per cent, in lanolin, followed by an antibiotic ointment. (Martindale 27; 1977, p. 1341) Podophyllum is an anti-mitotic and inhibits cell-division and should not be applied to normal cells.
Aloe Vera. Fresh cut leaf, or gel, to wipe over exposed surfaces.
Vitamin E oil. Applying the oil to the skin can reduce chances of acquiring skin cancer from the sun. (University of Arizona College of Medicine)
Red Clover. “I have seen a case of skin cancer healed by applying Red Clover blossoms. After straining a strong tea, the liquid was simmered until it was the consistency of tar. After several applications the skin cancer was gone, and has not returned.” (May Bethel, in “Herald of Health”, Dec. 1963)
Clivers. Equal parts juice of Clivers (from juice extractor) and glycerine. Internally and externally.
Thuja. Internal: 3-5 drops Liquid Extract, morning and evening.
Topical. “Take a small quantity powdered Slippery Elm and add Liquid Extract Thuja to make a stiff paste. Apply paste to the lesion. Cover with gauze and protective covering. When dry remove pack and follow with compresses saturated with Thuja.” (Ellingwood’s Therapeutist, Vol 10, No 6, p. 212) Echinacea and Thuja. Equal parts liquid extracts assist healthy granulation and neutralise odour.
Rue Ointment. Simmer whole fresh leaves in Vaseline.
Poke Root. An old physician laid great stress on the use of concentrated juice of green leaves. Leaves are bruised, juice extracted, and concentrated by slow evaporation until the consistency of a paste, for persistent skin cancer. Care should be taken to confine to the distressed area. (Ellingwood’s Therapeutist, Vol 8, No 7, p. 275)
Maria Treben. Horsetail poultice.
Laetrile. Some improvement claimed. 1 gram daily.
Cider vinegar. Anecdotal evidence: external use: small melanoma.
Diet. See: DIET – CANCER. Beta-carotene foods.
Treatment by skin specialist or oncologist. ... cancer – skin
Genes are organized into chromosomes in the cell nucleus. Genes controlling most characteristics come in pairs, 1 from the father, the other from the mother. Everyone has 22 pairs of chromosomes (called autosomes) bearing these paired genes, in addition to 2 sex chromosomes. Females have 2 X chromosomes; males have an X and a Y chromosome.
Most physical characteristics, many disorders, and some mental abilitiesand aspects of personality are inherited. The inheritance of normal traits and disorders can be divided into those controlled by a single pair of genes on the autosomal chromosomes (unifactorial inheritance, such as eye colour); those controlled by genes on the sex chromosomes (sex-linked inheritance, such as haemophilia); and those controlled by the combination of many genes (multifactorial inheritance, such as height).
Either of the pair of genes controlling a trait may take any of several forms, known as alleles. For example, the genes controlling eye colour exist as 2 main alleles, coding for blue and brown eye colour. The brown allele is dominant over blue in that it “masks” the blue allele, which is called recessive to the brown allele. Only 1 of the pair of genes controlling a trait is passed to a child from each parent. For example, someone with the brown/blue combination for eye colour has a 50 per cent chance of passing on the blue gene, and a 50 per cent chance of passing on the brown gene, to any child. This factor is combined with the gene coming from the other parent, according to dominant or recessive relationships, to determine the child’s eye colour. Certain genetic disorders are also inherited in a unifactorial manner (for example, cystic fibrosis and achondroplasia).
Sex-linked inheritance depends on the 2 sex chromosomes, X and Y. The most obvious example is gender. Male gender is determined by genes on the Y chromosome, which is present only in males. Any faults in a male’s genes on the X chromosome tend to be expressed outwardly because such a fault cannot be masked by the presence of a normal gene on a 2nd X chromosome (as it can in females). Faults in the genes of the X chromosome include those responsible for colour vision deficiency, haemophilia, and other sex-linked inherited disorders, which almost exclusively affect males.
Multifactorial inheritance, along with the effects of environment, may play a part in causing certain disorders, such as diabetes mellitus and neural tube defects.... inheritance
Main causes of a raised pressure include increase in blood thickness, kidney disorder or loss of elasticity in the arteries by hardening or calcification.
Well defined physical problems account for 10 per cent of high blood pressure cases. By the age of 60, a third of the peoples of the West are hypertensive. Other causes: genetic pre-disposition, endocrine disorders such as hyperactive thyroid and adrenal glands, lead and other chemical poisoning, brain tumour, heart disorder, anxiety, stress and emotional instability.
Other causes may be food allergies. By taking one’s pulse after eating a certain food one can see if the food raises the pulse. If so, that food should be avoided. Most cases of high blood pressure are related to lifestyle – how people think, act and care for themselves. When a person is under constant stress blood pressure goes up. It temporarily increases on drinking the stimulants: alcohol, strong tea, coffee, cola and caffeine drinks generally.
Symptoms. Morning headache (back of the head), possible palpitation, visual disturbances, dizziness, angina-like pains, inability to concentrate, nose-bleeds, ringing in the ears, fatigue, breathlessness (left ventricular failure).
Dr Wm Castelli, Director of the Framlingham Heart Study in Massachusetts, U.S.A., records: “The greatest risk is for coronary heart disease (CHD). Hypertensives have more than double the risk of people with normal blood pressure and seven times the risk of strokes.”
In countries where salt intake is restricted, a rise in blood pressure with age is not seen.
Simple hypotensive herbs may achieve effective control without the side-effects of sleep disturbance, adverse metabolic effects, lethargy and impaired peripheral circulation.
Essential hypertension is where high blood pressure is not associated with any disease elsewhere; it accounts for 90 per cent cases. Most of the remainder have kidney disease except for a few other abnormalities.
Alternatives. Balm, Black Haw, Black Cohosh (blood pressure of the menopause), Cactus, Cramp bark, Chamomile (German). Garlic, Buckwheat, Lily of the Valley, Balm, Mistletoe, Motherwort. Passion flower, Nettles, Lime flowers, Wood Betony, Yarrow, Rosemary, Hawthorn flowers, Olive leaves, Dandelion. Where there is nerve excitability: Valerian.
Tea No 1. Equal parts: Hawthorn leaves and flowers, Mistletoe, Lime flowers. Mix. 2 teaspoons to each cup boiling water; infuse 5-10 minutes. 1 cup 2-3 times daily. Alternative:–
Tea No 2. Equal parts: Nettles, Lime flowers, Yarrow, Passion flower. Mix. 2 teaspoons to each cup boiling water; infuse 5-10 minutes. 1 cup 2-3 times daily.
Nettles. Nettle tea is capable of removing cholesterol deposits (“fur”) from artery walls, increasing their elasticity. Like so many herbs they are rich in chlorophyll. The tea may be made as strong as desired. Mistletoe. 2-3 teaspoons cut herb (fresh or dried) to cup cold water. Allow to infuse overnight (at least 8 hours). 1 cup morning and evening.
Garlic. Juice from one Garlic corm expressed through a juicer taken morning and evening. Garlic dilates blood vessels. Alternative: 2-3 Garlic capsules at night.
Blood pressure of pregnancy: See – PREGNANCY.
Tablets/capsules: Cramp bark, Mistletoe, Motherwort, Rutin, Garlic.
Powders. Formula. Buckwheat (rutin) 1; Motherwort 1; Mistletoe half; Valerian quarter. Dose: 500mg (two 00 capsules or one-third teaspoon) thrice daily.
Liquid extracts, tinctures. Formula. Equal parts: Cactus, Mistletoe, Valerian. Dose: liquid extracts, one 5ml teaspoon; tinctures, two 5ml teaspoons; thrice daily.
Practitioner Formula. Tinctures: equal parts: Lily of the Valley, Mistletoe, Valerian. Dose: 30-60 drops thrice daily.
Where high blood pressure is due to faulty kidney function diuretics such as Dandelion or Bearberry will be added according to individual requirements. Dandelion root is one of the most widely-used potassium-conserving agents for increasing flow of urine, as well as being a mild beta-blocker to reduce myocardial infarction. Broom (Sarothamnus scoparius) (diuretic) is not used in cases of high blood pressure. It is good practice to assess kidney function in all new cases of hypertension for renal artery stenosis.
Evidence from two major studies confirms that diuretics rather than beta-blockers should be the treatment of choice for most elderly hypertensives. The addition of a diuretic (Yarrow, etc) to prescriptions for the elderly is commended.
Prevention. Chances of developing high blood pressure are said to be reduced by a daily dose of Cod
Liver oil. Results from studies at the University of Munich, Germany, show that when an ounce of Cod Liver oil was added to the typical Western diet, better pressure readings and lower cholesterol levels followed. When the flavour renders it objectionable to the palate, taste may be masked by stirring briskly into fruit juice.
General. Stop smoking. Watch weight. Moderate exercise. Avoidance of stress by relaxation, yoga, music, etc. These relieve constriction of peripheral blood vessels. Curb temper
Diet. Avoid processed and fast foods high in fat and salt, and empty calories. Cheese and meat sparingly. Eat plenty of natural foods. Positively reject coffee, strong tea and alcohol. “There is a significant drop in plasma Cortisol with a fall in blood pressure after stopping alcohol.” (Dr J.F. Potter, University of Birmingham, England) It is well-documented that a vegetarian diet is associated with a lower blood pressure.
Salt. The association of salt with blood pressure is larger than generally appreciated and increases with age and initial blood pressure. Even a small reduction in salt (3g) may reduce a systolic and diastolic pressure by 5mmHg and 2.5mmHg respectively. All processed foods containing salt should be avoided. Supplementation. Inositol, zinc, Vitamin C, Vitamin B6. (Dr C. Pfeiffer) Vitamin E to improve circulation. Check with practitioner pressure level before starting 200iu increasing to 400iu daily. Magnesium: 300mg daily. Choline.
See: BLOOD PRESSURE. ... hypertension
Affects women more than men by 10:1 especially after menopause, whether this is natural or due to destruction or removal of ovaries in early adult life.
By means of a calcium-rich diet after 35 years it is a preventable disease. Like so many degenerative diseases a common cause is widespread consumptions of refined, processed, chemicalised foods. It is possible that dental caries is in reality osteoporosis.
In men, alcohol is the chief cause. It wreaks its greatest havoc in women 10-15 years after the menopause. Increased calcium will not restore tissue already lost by wasting. Emphasis is therefore on prevention. It is estimated that a quarter of women over 50 in the West suffer bone loss after the menopause when reduced oestrogen speeds loss of calcium with possible bone damage to wrist, spine and especially hip. The chances of such fractures in women reaching seventy are one in two.
Vitamin D deficiency predisposes, as also does over-prescription of thyroxine for hypothyroid cases. Fat-free diets can break bones.
In menopausal women, increased bone loss is associated with disorders of the ovaries, which organs should receive treatment. Specially at risk are anorexic women with absence of periods. Secondary causes: hyperthyroidism, long-term use of steroids, liver disease, drugs (Tamoxifen, Antacids).
Common fractures are those of hips, spine and wrist. Wrist bone mineral content and grip strength are related. Squeezing a tennis ball hard three times each morning and evening reduces risk of fractures of the wrist.
Drinking of Lemon juice contributes to brittle bones. The habit of daily drinking of the juice causes enamel of teeth to crumble and the removal of calcium from the bones.
Cod Liver oil (chief of the iodised oils) reaches and nourishes cartilage, imparting increased elasticity which prevents degeneration.
Coffee. Two or more cups of coffee a day significantly reduces bone mineral density in women, but drinking milk each day can counter it.
Alternatives. Alfalfa, Black Cohosh, Chamomile, Clivers, Fennel, Dong quai, Fenugreek, Liquorice, Meadowsweet, Mullein, Pimpernel, Helonias, Plantain, Rest Harrow, Shepherd’s Purse, Silverweed, Toadflax, Unicorn root. Nettle tea.
Tea. Equal parts. Alfalfa, Comfrey leaves, Nettles. Mix. 2 teaspoons to each cup boiling water; infuse 5- 15 minutes; 1 cup thrice daily.
Decoction. Equal parts: Comfrey root, Irish Moss (for minerals), Horsetail. Mix. 3 heaped teaspoons to 1 pint (500ml) water gently simmered 20 minutes. Dose: 1 cup thrice daily.
Tablets/capsules. Bamboo gum, Helonias, Iceland Moss, Irish Moss for minerals, Kelp, Prickly Ash. Formula. Horsetail 2; Alfalfa 2; Helonias 1. Mix. Powders: 500mg (two 00 capsules or one-third teaspoon). Liquid extracts: 1 teaspoon. Tinctures: 2 teaspoons. Action is enhanced by taking in a cup of Fenugreek tea.
Comfrey decoction. 1 heaped teaspoon to cup water gently simmered 5 minutes. Strain when cold. Dose: 1 cup, to which is added 10 drops Tincture Helonias, morning and evening. Fenugreek seeds may be used as an alternative to Comfrey root. Comfrey and Fenugreek are osteo-protectives. For this condition the potential benefit of Comfrey outweighs possible risk.
Propolis. Regeneration of bone tissue.
Dr John Christopher. Mix powders: Horsetail 6, de-husked Oats 3; Comfrey root 4; Lobelia 4. Dose: quarter to half a teaspoon 2-3 times daily.
Diet. Fresh raw fruit and green vegetables. Consumption of raw bran (which contains calcium-binding phytic acid) and wholemeal bread should be suspended until recovery is advanced. Natural spring water. Fish and fish oils. Reject high salt intake which aggravates bone loss and places the skeleton at risk by creating increasing loss of calcium and phosphorus through the kidneys. Avoid soft drinks, alcohol. Heavy meat meals inhibit calcium metabolism. Incidence of the disease is lower in vegetarians. High protein. Supplements. Daily. Vitamin A, Vitamin B12 (50mcg); Vitamin C (500mg); Vitamin D, Vitamin E, Folic acid 200mcg; Vitamin B6 (50mg); Calcium citrate 1g; Magnesium citrate 500mg. Boron and Vitamin D. Zinc 15mg.
Calcium helps reduce risk of fracture particularly in menopausal women who may increase their daily intake to 800mg – Calcium citrate malate being more effective than the carbonate. Dried skimmed milk can supply up to 60 per cent of the recommended daily amount of Calcium.
Stop smoking.
Information. National Osteoporosis Society, PO Box 10, Radstock, Bath BA3 3YB, UK. Send SAE. ... osteoporosis
Language function in the brain lies in the dominant cerebral hemisphere (see cerebrum). Two particular areas in this hemisphere, Broca’s and Wernicke’s areas, and the pathways connecting the two, are important in language skills. Damage to these areas, which most commonly occurs as a result of stroke or head injury, can lead to aphasia.
Some recovery from aphasia is usual following a stroke or head injury, although the more severe the aphasia, the less the chances of recovery. Speech therapy is the main treatment. (See also dysphasia; speech; speech disorders.)
| SIGN | SCORE 0 | SCORE 1 | SCORE 2 |
| Heart-rate | None | Below 100 beats per minute | Over 100 beats per minute |
| Breathing | None | Weak cry; irregular breathing | Strong cry; regular breathing |
| Muscle tone | Limp | Some muscle tone | Active movement |
| Response to stimulation | None | Grimace or whimpering | Cry, sneeze or cough |
| Colour | Pale; blue | Blue extremities | Pink |
Acute liver failure requires urgent hospital care.
Although no treatment can repair damage that has already occurred in acute and chronic liver failure, certain measures, such as prescribing diuretic drugs to reduce abdominal swelling, may be taken to reduce the severity of symptoms.
Consumption of alcohol should cease in all cases.
The prognoses for sufferers of chronic liver failure vary depending on the cause, but some people survive for many years.
For acute liver failure, a liver transplant is necessary to increase the chances of survival.... liver failure
A mutation results from a fault in the replication of when a cell divides. A daughter cell inherits some faulty , and the fault is copied each time the new cell divides, creating a cell population containing the altered.
Some mutations occur by chance. Any agent that makes mutations more likely is called a mutagen.
There are several types of mutation. Point mutations affect only one gene and may lead to the production of defective enzymes or other proteins. In other mutations, chromosomes (or parts of them) are deleted, added, or rearranged. This type may produce greater disruptive effects than point mutations.
If a mutated cell is a somatic (body) cell, it can, at worst, multiply to form a group of abnormal cells. These cells often die out, are destroyed by the body’s immune system, or have only a minor effect. Sometimes, however, they may become a tumour.
A mutation in a germ cell (immature egg or sperm) may be passed on to a child, who then has the mutation in all of his or her cells.
This may cause an obvious birth defect or an abnormality in body chemistry.
The mutation may also be passed on to the child’s descendants.
Genetic disorders (such as haemophilia and achondroplasia) stem from point mutations that occurred in the germ cell of a parent, grandparent, or more distant ancestor.
Chromosomal abnormalities (such as Down’s syndrome) are generally due to mutations in the formation of parental eggs or sperm.... mutation
Since there is a 50 per cent chance that children of an affected person will inherit the disease, medical surveillance is necessary from around the age of 12.
Individual polyps may be cauterized (see cauterization).
The high risk of developing cancer often means that a colectomy and an ileostomy are performed.... polyposis, familial
A diagnosis may be made by a chest X-ray, radionuclide scanning, and pulmonary angiography.
An ECG and venography may also be performed.
Treatment depends on the size and severity of the embolus.
A small one gradually dissolves and thrombolytic drugs may be given to hasten this process.
Anticoagulant drugs are given to reduce the chance of more clots.
Surgery may be needed to remove larger clots.... pulmonary embolism
The incidence of stroke rises with age and is higher in men. Certain factors increase the risk. The most important are hypertension and atherosclerosis (and, by association, factors such as smoking that contribute to these disorders). Other risk factors are atrial fibrillation, a damaged heart valve, and a recent myocardial infarction; these can cause clots in the heart which may migrate to the brain.
Symptoms usually develop abruptly and, depending on the site, cause, and extent of brain damage, may include headache, dizziness, visual disturbance, and difficulty in swallowing. Sensation, movement, or function controlled by the damaged area of the brain is impaired. Weakness or paralysis on one side of the body, called hemiplegia, is a common effect of a serious stroke. A stroke that affects the dominant cerebral hemisphere may cause disturbance of language (see aphasia). About a third of major strokes are fatal, a third result in some disability, and a third have no lasting ill effects (see transient ischaemic attack).In some cases, urgent treatment may improve the chances of recovery.
ECG, CT scanning, chest X-rays, blood tests, angiography, and MRI may be used to investigate the cause and extent of brain damage.
If a stroke is proven by scan to be due to thrombosis, thrombolytic drugs may be given.
Anticoagulants may be given if there is an obvious source of an embolism, such as atrial fibrillation or a narrowed carotid artery.
In some cases, antiplatelet agents such as aspirin are given.
In most cases, attention to hydration and pressure areas, and good nursing care, are the most important influences on outcome.
Physiotherapy may restore lost movement or sensation; speech therapy may help language disturbances.... stroke
Health Encyclopedia