Sites suitable for egg-laying and satisfactory for all aquatic stages of development.
Cancers are classi?ed according to the type of cell from which they are derived as well as the organ of origin. Hence cancers arising within the bronchi, often collectively referred to as ‘lung cancer’, include both adenocarcinomas, derived from epithelium (surface tissue), and carcinomas from glandular tissue. Sarcomas are cancers of connective tissue, including bone and cartilage. The behaviour of cancers and their response to therapy vary widely depending on this classi?cation as well as on numerous other factors such as how large the cancer is, how fast the cells grow and how well de?ned they are. It is entirely wrong to see cancer as a single disease entity with a universally poor prognosis. For example, fewer than one-half of women in whom breast cancer (see BREASTS, DISEASES OF) is discovered will die from the disease, and 75 per cent of children with lymphoblastic LEUKAEMIA can be cured.
Incidence In most western countries, cancer is the second most important cause of death after heart disease and accounts for 20–25 per cent of all deaths. In the United Kingdom in 2003, more than 154,000 people died of malignant disease. There is wide international variation in the most frequently encountered types of cancer, re?ecting the importance of environmental factors in the development of cancer. In the UK as well as the US, carcinoma of the BRONCHUS is the most common. Since it is usually inoperable at the time of diagnosis, it is even more strikingly the leading cause of cancer deaths. In women, breast cancer was for a long time the most common malignant disease, accounting for a quarter of all cancers, but ?gures for the late 1990s show that lung cancer now heads the incidence list – presumably the consequence of a rising incidence of smoking among young women. Other common sites are as follows: males – colon and rectum, prostate and bladder; females – colon and rectum, uterus, ovary and pancreas.
In 2003, of the more than 154,000 people in the UK who died of cancer, over 33,000 had the disease in their respiratory system, nearly 13,000 in the breast, over 5,800 in the stomach and more than 2,000 in the uterus or cervix, while over 4,000 people had leukaemia. The incidence of cancer varies with age; the older a person is, the more likely it is that he or she will develop the disease. The over-85s have an incidence about nine times greater than those in the 25–44 age group. There are also di?erences in incidence between sexes: for example, more men than women develop lung cancer, though the incidence in women is rising as the effects of smoking work through. The death rate from cancer is falling in people under 75 in the UK, a trend largely determined by the cancers which cause the most deaths: lung, breast, colorectal, stomach and prostate.
Causes In most cases the causes of cancer remain unknown, though a family history of cancer may be relevant. Rapid advances have, however, been made in the past two decades in understanding the di?erences between cancer cells and normal cells at the genetic level. It is now widely accepted that cancer results from acquired changes in the genetic make-up of a particular cell or group of cells which ultimately lead to a failure of the normal mechanisms regulating their growth. It appears that in most cases a cascade of changes is required for cells to behave in a truly malignant fashion; the critical changes affect speci?c key GENES, known as oncogenes, which are involved in growth regulation. (See APOPTOSIS.)
Since small genetic errors occur within cells at all times – most but not all of which are repaired – it follows that some cancers may develop as a result of an accumulation of random changes which cannot be attributed to environmental or other causes. The environmental factors known to cause cancer, such as radiation and chemicals (including tar from tobacco, asbestos, etc.), do so by increasing the overall rate of acquired genetic damage. Certain viral infections can induce speci?c cancers (e.g. HEPATITIS B VIRUS and HEPATOMA, EPSTEIN BARR VIRUS and LYMPHOMA) probably by inducing alterations in speci?c genes. HORMONES may also be a factor in the development of certain cancers such as those of the prostate and breast. Where there is a particular family tendency to certain types of cancer, it now appears that one or more of the critical genetic abnormalities required for development of that cancer may have been inherited. Where environmental factors such as tobacco smoking or asbestos are known to cause cancer, then health education and preventive measures can reduce the incidence of the relevant cancer. Cancer can also affect the white cells in the blood and is called LEUKAEMIA.
Treatment Many cancers can be cured by surgical removal if they are detected early, before there has been spread of signi?cant numbers of tumour cells to distant sites. Important within this group are breast, colon and skin cancer (melanoma). The probability of early detection of certain cancers can be increased by screening programmes in which (ideally) all people at particular risk of development of such cancers are examined at regular intervals. Routine screening for CERVICAL CANCER and breast cancer (see BREASTS, DISEASES OF) is currently practised in the UK. The e?ectiveness of screening people for cancer is, however, controversial. Apart from questions surrounding the reliability of screening tests, they undoubtedly create anxieties among the subjects being screened.
If complete surgical removal of the tumour is not possible because of its location or because spread from the primary site has occurred, an operation may nevertheless be helpful to relieve symptoms (e.g. pain) and to reduce the bulk of the tumour remaining to be dealt with by alternative means such as RADIOTHERAPY or CHEMOTHERAPY. In some cases radiotherapy is preferable to surgery and may be curative, for example, in the management of tumours of the larynx or of the uterine cervix. Certain tumours are highly sensitive to chemotherapy and may be cured by the use of chemotherapeutic drugs alone. These include testicular tumours, LEUKAEMIA, LYMPHOMA and a variety of tumours occurring in childhood. These tend to be rapidly growing tumours composed of primitive cells which are much more vulnerable to the toxic effects of the chemotherapeutic agents than the normal cells within the body.
Unfortunately neither radiotherapy nor currently available chemotherapy provides a curative option for the majority of common cancers if surgical excision is not feasible. New e?ective treatments in these conditions are urgently needed. Nevertheless the rapidly increasing knowledge of cancer biology will almost certainly lead to novel therapeutic approaches – including probably genetic techniques utilising the recent discoveries of oncogenes (genes that can cause cancer). Where cure is not possible, there often remains much that can be done for the cancer-sufferer in terms of control of unpleasant symptoms such as pain. Many of the most important recent advances in cancer care relate to such ‘palliative’ treatment, and include the establishment in the UK of palliative care hospices.
Families and patients can obtain valuable help and advice from Marie Curie Cancer Care, Cancer Relief Macmillan Fund, or the British Association of Cancer United Patients.
www.cancerbacup.org.uk
www.mariecurie.org.uk... cancer
Keloids can develop anywhere on the body, but the breastbone and shoulder are common sites.
Black people are affected more than whites.
After several months, most keloids flatten and cease to itch.
Injection of corticosteroid drugs into the keloid may reduce itchiness more quickly and cause some shrinkage.... keloid
Some authorities believe cause is vitamin and mineral deficiency – those which promote bone health being calcium and magnesium (dolomite). Supplementation helps cases but evidence confirms that some pet-owners are at risk – a virus from cats and dogs possibly responsible. The prime candidate is one exposed to canine distemper. Dogs are involved twice as much as cats. The virus is closely related to the measles virus in humans.
Symptoms. Limbs deformed, hot during inflammatory stage. Headaches. Dull aching pain in bones. Deafness from temporal bone involvement. Loss of bone rigidity. Bowing of legs.
Surgical procedures may be necessary. Appears to be a case for immunisation of dogs against distemper.
Alternatives. Black Cohosh, Boneset, Cramp bark, Bladderwrack, German Chamomile, Devil’s Claw, Helonias, Oat husks, Prickly Ash, Sage, Wild Yam.
Tea. Oats (mineral nutrient for wasting diseases) 2; Boneset (anti-inflammatory) 1; Valerian (mild analgesic) 1; Liquorice quarter. Mix. 1 heaped teaspoon to each cup boiling water; infuse 15 minutes. 1 cup thrice daily.
Decoction. Cramp bark 1; White Willow 2. Mix. 4 heaped teaspoons to 1 pint (500ml) water gently simmered 20 minutes. Dose: half-1 cup thrice daily.
Tablets/capsules. Cramp bark, Devil’s Claw, Echinacea, Helonias, Prickly Ash, Wild Yam.
Formula. Devil’s Claw 1; Black Cohosh 1; Valerian 1; Liquorice quarter. Dose: Powders: 500mg (two 00 capsules or one-third teaspoon). Liquid extracts: 1 teaspoon. Tinctures: 2 teaspoons. Action enhanced when taken in cup of Fenugreek tea. Thrice daily. Every 2 hours acute cases.
Practitioner’s analgesic. Tincture Gelsemium: 10 drops in 100ml water. Dose: 1 teaspoon every 2 hours (inflammatory stage).
Topical. Comfrey root poultice.
Diet. High protein, low salt, low fat. Oily fish.
Supplements. Daily. Vitamin C (500mg); Vitamin D (1000mg); Calcium citrate (1 gram); Dolomite (1 gram); Beta-Carotene (7500iu). Kelp. ... paget’s disease
For long it had been realised that in certain cases of ASTHMA, adrenaline had not the usual bene?cial e?ect of dilating the bronchi during an attack; rather it made the asthma worse. This was due to its acting on both the alpha and beta adrenergic receptors. A derivative, isoprenaline, was therefore produced which acted only on the beta receptors. This had an excellent e?ect in dilating the bronchi, but unfortunately also affected the heart, speeding it up and increasing its output – an undesirable e?ect which meant that isoprenaline had to be used with great care. In due course drugs were produced, such as salbutamol, which act predominantly on the beta2 adrenergic receptors in the bronchi and have relatively little e?ect on the heart.
The converse of this story was the search for what became known as BETA-ADRENOCEPTORBLOCKING DRUGS, or beta-adrenergic-blocking drugs. The theoretical argument was that if such drugs could be synthesised, they could be of value in taking the strain o? the heart – for example: stress ? stimulation of the output of adrenaline ? stimulation of the heart ? increased work for the heart. A drug that could prevent this train of events would be of value, for example in the treatment of ANGINA PECTORIS. Now there is a series of beta-adrenoceptor-blocking drugs of use not only in angina pectoris, but also in various other heart conditions such as disorders of rhythm, as well as high blood pressure. They are also proving valuable in the treatment of anxiety states by preventing disturbing features such as palpitations. Some are useful in the treatment of migraine.... adrenergic receptors
When virilisation is noted at birth, great care must be taken to determine genetic sex by karyotyping: parents should be reassured as to the baby’s sex (never ‘in between’). Blood levels of adrenal hormones are measured to obtain a precise diagnosis. Traditionally, doctors have advised parents to ‘choose’ their child’s gender on the basis of discussing the likely condition of the genitalia after puberty. Thus, where the phallus is likely to be inadequate as a male organ, it may be preferred to rear the child as female. Surgery is usually advised in the ?rst two years to deal with clitoromegaly but parent/ patient pressure groups, especially in the US, have declared it wrong to consider surgery until the children are competent to make their own decision.
Other treatment requires replacement of the missing hormones which, if started early, may lead to normal sexual development. There is still controversy surrounding the ethics of gender reassignment.
See www.baps.org.uk... adrenogenital syndrome
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
Aneurysms generally arise in the elderly, with men affected more commonly than women. The most common cause is degenerative atheromatous disease, but other rarer causes include trauma, inherited conditions such as MARFAN’S SYNDROME, or acquired conditions such as SYPHILIS or POLYARTERITIS NODOSA. Once formed, the pressure of the circulating blood within the aneurysm causes it to increase in size. At ?rst, there may be no symptoms or signs, but as the aneurysm enlarges it becomes detectable as a swelling which pulsates with each heartbeat. It may also cause pain due to pressure on local nerves or bones. Rupture of the aneurysm may occur at any time, but is much more likely when the aneurysm is large. Rupture is usually a surgical emergency, because the bleeding is arterial and therefore considerable amounts of blood may be lost very rapidly, leading to collapse, shock and even death. Rupture of an aneurysm in the circle of Willis causes subarachnoid haemorrhage, a life-threatening event. Rupture of an aneurysm in the abdominal aorta is also life-threatening.
Treatment Treatment is usually surgical. Once an aneurysm has formed, the tendency is for it to enlarge progressively regardless of any medical therapy. The surgery is often demanding and is therefore usually undertaken only when the aneurysm is large and the risk of rupture is therefore increased. The patient’s general ?tness for surgery is also an important consideration. The surgery usually involves either bypassing or replacing the affected part of the artery using a conduit made either of vein or of a man-made ?bre which has been woven or knitted into a tube. Routine X-ray scanning of the abdominal aorta is a valuable preventive procedure, enabling ‘cold’ surgery to be performed on identi?ed aneurysms.... aneurysm
Habitat: Dry woods, throughout Central and Southern States of North America. Features ? A tree-like shrub, ten to twenty feet high. Fruit shiny black, sweet and
edible. Young bark glossy purplish-brown, with scattered warts. Old bark greyish-brown, inner surface white. Fracture short. Root bark cinnamon colour. Taste bitter,astringent.Part used ? Root bark (preferred); also bark of stem and branches.Action: Uterine tonic, nervine, anti-spasmodic.
Uterine weaknesses, leucorrhaea, dysmenorrhea. Prevention of miscarriage—given four or five weeks before. Infusion of 1 ounce to 1 pint of boiling water—table-spoonful doses.... black hawComposition The cellular components are red cells or corpuscles (ERYTHROCYTES), white cells (LEUCOCYTES and lymphocytes – see LYMPHOCYTE), and platelets.
The red cells are biconcave discs with a diameter of 7.5µm. They contain haemoglobin
– an iron-containing porphyrin compound, which takes up oxygen in the lungs and releases it to the tissue.
The white cells are of various types, named according to their appearance. They can leave the circulation to wander through the tissues. They are involved in combating infection, wound healing, and rejection of foreign bodies. Pus consists of the bodies of dead white cells.
Platelets are the smallest cellular components and play an important role in blood clotting (see COAGULATION).
Erythrocytes are produced by the bone marrow in adults and have a life span of about 120 days. White cells are produced by the bone
marrow and lymphoid tissue. Plasma consists of water, ELECTROLYTES and plasma proteins; it comprises 48–58 per cent of blood volume. Plasma proteins are produced mainly by the liver and by certain types of white cells. Blood volume and electrolyte composition are closely regulated by complex mechanisms involving the KIDNEYS, ADRENAL GLANDS and HYPOTHALAMUS.... blood
Nutritional Profile Energy value (calories per serving): Low Protein: Trace Fat: Trace Saturated fat: None Cholesterol: None Carbohydrates: Trace Fiber: Trace Sodium: Low Major vitamin contribution: None Major mineral contribution: None
About the Nutrients in This Food Coffee beans are roasted seeds from the fruit of the evergreen coffee tree. Like other nuts and seeds, they are high in proteins (11 percent), sucrose and other sugars (8 percent), oils (10 to 15 percent), assorted organic acids (6 percent), B vitamins, iron, and the central nervous system stimulant caffeine (1 to 2 percent). With the exceptions of caffeine, none of these nutrients is found in coffee. Like spinach, rhubarb, and tea, coffee contains oxalic acid (which binds calcium ions into insoluble compounds your body cannot absorb), but this is of no nutritional consequence as long as your diet contains adequate amounts of calcium-rich foods. Coffee’s best known constituent is the methylxanthine central ner- vous system stimulant caffeine. How much caffeine you get in a cup of coffee depends on how the coffee was processed and brewed. Caffeine is Caffeine Content/Coffee Servings Brewed coffee 60 mg/five-ounce cup Brewed/decaffeinated 5 mg/five-ounce cup Espresso 64 mg/one-ounce serving Instant 47 mg/rounded teaspoon
The Most Nutritious Way to Serve This Food In moderation, with high-calcium foods. Like spinach, rhubarb, and tea, coffee has oxalic acid, which binds calcium into insoluble compounds. This will have no important effect as long as you keep your consumption moderate (two to four cups of coffee a day) and your calcium consumption high.
Diets That May Restrict or Exclude This Food Bland diet Gout diet Diet for people with heart disease (regular coffee)
Buying This Food Look for: Ground coffee and coffee beans in tightly sealed, air- and moisture-proof containers. Avoid: Bulk coffees or coffee beans stored in open bins. When coffee is exposed to air, the volatile molecules that give it its distinctive flavor and richness escape, leaving the coffee flavorless and/or bitter.
Storing This Food Store unopened vacuum-packed cans of ground coffee or coffee beans in a cool, dark cabinet—where they will stay fresh for six months to a year. They will lose some flavor in storage, though, because it is impossible to can coffee without trapping some flavor- destroying air inside the can. Once the can or paper sack has been opened, the coffee or beans should be sealed as tight as possible and stored in the refrigerator. Tightly wrapped, refrigerated ground coffee will hold its freshness and flavor for about a week, whole beans for about three weeks. For longer storage, freeze the coffee or beans in an air- and moistureproof container. ( You can brew coffee directly from frozen ground coffee and you can grind frozen beans without thawing them.)
Preparing This Food If you make your coffee with tap water, let the water run for a while to add oxygen. Soft water makes “cleaner”-tasting coffee than mineral-rich hard water. Coffee made with chlorinated water will taste better if you refrigerate the water overnight in a glass (not plastic) bottle so that the chlorine evaporates. Never make coffee with hot tap water or water that has been boiled. Both lack oxygen, which means that your coffee will taste flat. Always brew coffee in a scrupulously clean pot. Each time you make coffee, oils are left on the inside of the pot. If you don’t scrub them off, they will turn rancid and the next pot of coffee you brew will taste bitter. To clean a coffee pot, wash it with detergent, rinse it with water in which you have dissolved a few teaspoons of baking soda, then rinse one more time with boiling water.
What Happens When You Cook This Food In making coffee, your aim is to extract flavorful solids (including coffee oils and sucrose and other sugars) from the ground beans without pulling bitter, astringent tannins along with them. How long you brew the coffee determines how much solid material you extract and how the coffee tastes. The longer the brewing time, the greater the amount of solids extracted. If you brew the coffee long enough to extract more than 30 percent of its solids, you will get bitter compounds along with the flavorful ones. (These will also develop by let- ting coffee sit for a long time after brewing it.) Ordinarily, drip coffee tastes less bitter than percolator coffee because the water in a drip coffeemaker goes through the coffee only once, while the water in the percolator pot is circulated through the coffee several times. To make strong but not bitter coffee, increase the amount of coffee—not the brewing time.
How Other Kinds of Processing Affect This Food Drying. Soluble coffees (freeze-dried, instant) are made by dehydrating concentrated brewed coffee. These coffees are often lower in caffeine than regular ground coffees because caffeine, which dissolves in water, is lost when the coffee is dehydrated. Decaffeinating. Decaffeinated coffee is made with beans from which the caffeine has been extracted, either with an organic solvent (methylene chloride) or with water. How the coffee is decaffeinated has no effect on its taste, but many people prefer water-processed decaf- feinated coffee because it is not a chemically treated food. (Methylene chloride is an animal carcinogen, but the amounts that remain in coffees decaffeinated with methylene chloride are so small that the FDA does not consider them hazardous. The carcinogenic organic sol- vent trichloroethylene [TCE], a chemical that causes liver cancer in laboratory animals, is no longer used to decaffeinate coffee.)
Medical Uses and/or Benefits As a stimulant and mood elevator. Caffeine is a stimulant. It increases alertness and concentra- tion, intensifies muscle responses, quickens heartbeat, and elevates mood. Its effects derive from the fact that its molecular structure is similar to that of adenosine, a natural chemical by-product of normal cell activity. Adenosine is a regular chemical that keeps nerve cell activ- ity within safe limits. When caffeine molecules hook up to sites in the brain when adenosine molecules normally dock, nerve cells continue to fire indiscriminately, producing the jangly feeling sometimes associated with drinking coffee, tea, and other caffeine products. As a rule, it takes five to six hours to metabolize and excrete caffeine from the body. During that time, its effects may vary widely from person to person. Some find its stimu- lation pleasant, even relaxing; others experience restlessness, nervousness, hyperactivity, insomnia, flushing, and upset stomach after as little as one cup a day. It is possible to develop a tolerance for caffeine, so people who drink coffee every day are likely to find it less imme- diately stimulating than those who drink it only once in a while. Changes in blood vessels. Caffeine’s effects on blood vessels depend on site: It dilates coronary and gastrointestinal vessels but constricts blood vessels in your head and may relieve headache, such as migraine, which symptoms include swollen cranial blood vessels. It may also increase pain-free exercise time in patients with angina. However, because it speeds up heartbeat, doc- tors often advise patients with heart disease to avoid caffeinated beverages entirely. As a diuretic. Caffeine is a mild diuretic sometimes included in over-the-counter remedies for premenstrual tension or menstrual discomfort.
Adverse Effects Associated with This Food Stimulation of acid secretion in the stomach. Both regular and decaffeinated coffees increase the secretion of stomach acid, which suggests that the culprit is the oil in coffee, not its caffeine. Elevated blood levels of cholesterol and homocysteine. In the mid-1990s, several studies in the Netherlands and Norway suggested that drinking even moderate amounts of coffee (five cups a day or less) might raise blood levels of cholesterol and homocysteine (by-product of protein metabolism considered an independent risk factor for heart disease), thus increas- ing the risk of cardiovascular disease. Follow-up studies, however, showed the risk limited to drinking unfiltered coffees such as coffee made in a coffee press, or boiled coffees such as Greek, Turkish, or espresso coffee. The unfiltered coffees contain problematic amounts of cafestol and kahweol, two members of a chemical family called diterpenes, which are believed to affect cholesterol and homocysteine levels. Diterpenes are removed by filtering coffee, as in a drip-brew pot. Possible increased risk of miscarriage. Two studies released in 2008 arrived at different conclusions regarding a link between coffee consumption and an increased risk of miscar- riage. The first, at Kaiser Permanente (California), found a higher risk of miscarriage among women consuming even two eight-ounce cups of coffee a day. The second, at Mt. Sinai School of Medicine (New York), found no such link. However, although the authors of the Kaiser Permanente study described it as a “prospective study” (a study in which the research- ers report results that occur after the study begins), in fact nearly two-thirds of the women who suffered a miscarriage miscarried before the study began, thus confusing the results. Increased risk of heartburn /acid reflux. The natural oils in both regular and decaffeinated coffees loosen the lower esophageal sphincter (LES), a muscular valve between the esopha- gus and the stomach. When food is swallowed, the valve opens to let food into the stomach, then closes tightly to keep acidic stomach contents from refluxing (flowing backwards) into the esophagus. If the LES does not close efficiently, the stomach contents reflux and cause heartburn, a burning sensation. Repeated reflux is a risk factor for esophageal cancer. Masking of sleep disorders. Sleep deprivation is a serious problem associated not only with automobile accidents but also with health conditions such as depression and high blood pres- sure. People who rely on the caffeine in a morning cup of coffee to compensate for lack of sleep may put themselves at risk for these disorders. Withdrawal symptoms. Caffeine is a drug for which you develop a tolerance; the more often you use it, the more likely you are to require a larger dose to produce the same effects and the more likely you are to experience withdrawal symptoms (headache, irritation) if you stop using it. The symptoms of coffee-withdrawal can be relieved immediately by drinking a cup of coffee.
Food/Drug Interactions Drugs that make it harder to metabolize caffeine. Some medical drugs slow the body’s metabolism of caffeine, thus increasing its stimulating effect. The list of such drugs includes cimetidine (Tagamet), disulfiram (Antabuse), estrogens, fluoroquinolone antibiotics (e.g., ciprofloxacin, enoxacin, norfloxacin), fluconazole (Diflucan), fluvoxamine (Luvox), mexi- letine (Mexitil), riluzole (R ilutek), terbinafine (Lamisil), and verapamil (Calan). If you are taking one of these medicines, check with your doctor regarding your consumption of caf- feinated beverages. Drugs whose adverse effects increase due to consumption of large amounts of caffeine. This list includes such drugs as metaproterenol (Alupent), clozapine (Clozaril), ephedrine, epinephrine, monoamine oxidase inhibitors, phenylpropanolamine, and theophylline. In addition, suddenly decreasing your caffeine intake may increase blood levels of lithium, a drug used to control mood swings. If you are taking one of these medicines, check with your doctor regarding your consumption of caffeinated beverages. Allopurinol. Coffee and other beverages containing methylxanthine stimulants (caffeine, theophylline, and theobromine) reduce the effectiveness of the antigout drug allopurinol, which is designed to inhibit xanthines. Analgesics. Caffeine strengthens over-the-counter painkillers (acetaminophen, aspirin, and other nonsteroidal anti-inflammatories [NSAIDS] such as ibuprofen and naproxen). But it also makes it more likely that NSAIDS will irritate your stomach lining. Antibiotics. Coffee increases stomach acidity, which reduces the rate at which ampicillin, erythromycin, griseofulvin, penicillin, and tetracyclines are absorbed when they are taken by mouth. (There is no effect when the drugs are administered by injection.) Antiulcer medication. Coffee increases stomach acidity and reduces the effectiveness of nor- mal doses of cimetidine and other antiulcer medication. False-positive test for pheochromocytoma. Pheochromocytoma, a tumor of the adrenal glands, secretes adrenalin, which is converted to VM A (vanillylmandelic acid) by the body and excreted in the urine. Until recently, the test for this tumor measured the levels of VM A in the patient’s urine and coffee, which contains VM A, was eliminated from patients’ diets lest it elevate the level of VM A in the urine, producing a false-positive test result. Today, more finely drawn tests make this unnecessary. Iron supplements. Caffeine binds with iron to form insoluble compounds your body cannot absorb. Ideally, iron supplements and coffee should be taken at least two hours apart. Birth control pills. Using oral contraceptives appears to double the time it takes to eliminate caffeine from the body. Instead of five to six hours, the stimulation of one cup of coffee may last as long as 12 hours. 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. Caffeine is a substance similar to tyramine. If you consume excessive amounts of a caffeinated beverage such as coffee while you are taking an M AO inhibitor, the result may be a hypertensive crisis. Nonprescription drugs containing caffeine. The caffeine in coffee may add to the stimulant effects of the caffeine in over-the-counter cold remedies, diuretics, pain relievers, stimulants, and weight-control products containing caffeine. Some cold pills contain 30 mg caffeine, some pain relievers 130 mg, and some weight-control products as much as 280 mg caffeine. There are 110 –150 mg caffeine in a five-ounce cup of drip-brewed coffee. Sedatives. The caffeine in coffee may counteract the drowsiness caused by sedative drugs; this may be a boon to people who get sleepy when they take antihistamines. Coffee will not, however, “sober up” people who are experiencing the inebriating effects of alcoholic beverages. Theophylline. Caffeine relaxes the smooth muscle of the bronchi and may intensif y the effects (and/or increase the risk of side effects) of this antiasthmatic drug.... coffee
Bacteria are classi?ed according to their shape: BACILLUS (rod-like), coccus (spherical – see COCCI), SPIROCHAETE (corkscrew and spiral-shaped), VIBRIO (comma-shaped), and pleomorphic (variable shapes). Some are mobile, possessing slender hairs (?agellae) on the surfaces. As well as having characteristic shapes, the arrangement of the organisms is signi?cant: some occur in chains (streptococci) and some in pairs (see DIPLOCOCCUS), while a few have a ?lamentous grouping. The size of bacteria ranges from around 0.2 to 5 µm and the smallest (MYCOPLASMA) are roughly the same size as the largest viruses (poxviruses – see VIRUS). They are the smallest organisms capable of existing outside their hosts. The longest, rod-shaped bacilli are slightly smaller than the human erythrocyte blood cell (7 µm).
Bacterial cells are surrounded by an outer capsule within which lie the cell wall and plasma membrane; cytoplasm ?lls much of the interior and this contains genetic nucleoid structures containing DNA, mesosomes (invaginations of the cell wall) and ribosomes, containing RNA and proteins. (See illustration.)
Reproduction is usually asexual, each cell dividing into two, these two into four, and so on. In favourable conditions reproduction can be very rapid, with one bacterium multiplying to 250,000 within six hours. This means that bacteria can change their characteristics by evolution relatively quickly, and many bacteria, including Mycobacterium tuberculosis and Staphylococcus aureus, have developed resistance to successive generations of antibiotics produced by man. (METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA)) is a serious hazard in some hospitals.
Bacteria may live as single organisms or congregate in colonies. In arduous conditions some bacteria can convert to an inert, cystic state, remaining in their resting form until the environment becomes more favourable. Bacteria have recently been discovered in an inert state in ice estimated to have been formed 250 million years ago.
Bacteria were ?rst discovered by Antonj van Leewenhoek in the 17th century, but it was not until the middle of the 19th century that Louis Pasteur, the famous French scientist, identi?ed bacteria as the cause of many diseases. Some act as harmful PATHOGENS as soon as they enter a host; others may have a neutral or benign e?ect on the host unless the host’s natural immune defence system is damaged (see IMMUNOLOGY) so that it becomes vulnerable to any previously well-behaved parasites. Various benign bacteria that permanently reside in the human body are called normal ?ora and are found at certain sites, especially the SKIN, OROPHARYNX, COLON and VAGINA. The body’s internal organs are usually sterile, as are the blood and cerebrospinal ?uid.
Bacteria are responsible for many human diseases ranging from the relatively minor – for example, a boil or infected ?nger – to the potentially lethal such as CHOLERA, PLAGUE or TUBERCULOSIS. Infectious bacteria enter the body through broken skin or by its ori?ces: by nose and mouth into the lungs or intestinal tract; by the URETHRA into the URINARY TRACT and KIDNEYS; by the vagina into the UTERUS and FALLOPIAN TUBES. Harmful bacteria then cause disease by producing poisonous endotoxins or exotoxins, and by provoking INFLAMMATION in the tissues – for example, abscess or cellulitis. Many, but not all, bacterial infections are communicable – namely, spread from host to host. For example, tuberculosis is spread by airborne droplets, produced by coughing.
Infections caused by bacteria are commonly treated with antibiotics, which were widely introduced in the 1950s. However, the con?ict between science and harmful bacteria remains unresolved, with the overuse and misuse of antibiotics in medicine, veterinary medicine and the animal food industry contributing to the evolution of bacteria that are resistant to antibiotics. (See also MICROBIOLOGY.)... bacteria
Habitat: South Africa, from where the leaves are imported.
Features ? Three varieties of Buchu leaves are used therapeutic-ally ? (1) Barosma betulina or Round Buchu are rhomboid-obovate in form with blunt, recurved apex, and are preferred to either (2) Barosma crenulata or oval Buchu. the apex of which leaf is not recurved; or (3) Barosma serratifolia or long Buchu, named from its distinctive, serrate-edged leaf and truncate apex.Part used ? Leaves.Action: Diuretic, diaphoretic, stimulant:
Complaints of the urinary system, especially gravel and inflammation or catarrh of the bladder. Infusion of 1 ounce leaves to 1 pint water three or four times daily in wineglass doses.... buchuExamination 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
They work by blocking the stimulation of beta adrenergic receptors by the neurotransmitters adrenaline and noradrenaline, which are produced at the nerve endings of that part of the SYMPATHETIC NERVOUS SYSTEM – the autonomous (involuntary) network
– which facilitates the body’s reaction to anxiety, stress and exercise – the ‘fear and ?ight’ response.
Beta1 blockers reduce the frequency and force of the heartbeat; beta2 blockers prevent vasodilation (increase in the diameter of blood vessels), thus in?uencing the patient’s blood pressure. Beta1 blockers also affect blood pressure, but the mechanism of their action is unclear. They can reduce to normal an abnormally fast heart rate so the power of the heart can be concomitantly controlled: this reduces the oxygen requirements of the heart with an advantageous knock-on e?ect on the respiratory system. These are valuable therapeutic effects in patients with ANGINA or who have had a myocardial infarction (heart attack – see HEART, DISEASES OF), or who suffer from HYPERTENSION. Beta2 blockers reduce tremors in muscles elsewhere in the body which are a feature of anxiety or the result of thyrotoxicosis (an overactive thyroid gland – see under THYROID GLAND, DISEASES OF). Noncardioselective blockers also reduce the abnormal pressure caused by the increase in the ?uid in the eyeball that characterises GLAUCOMA.
Many beta-blocking drugs are now available; minor therapeutic di?erences between them may in?uence the choice of a drug for a particular patient. Among the common drugs are:
| Primarily cardioselective | Non-cardioselective |
| Acebutolol | Labetalol |
| Atenolol | Nadolol |
| Betaxolol | Oxprenolol |
| Celiprolol | Propanolol |
| Metoprolol | Timolol |
These powerful drugs have various side-effects and should be prescribed and monitored with care. In particular, people who suffer from asthma, bronchitis or other respiratory problems may develop breathing diffculties. Long-term treatment with beta blockers should not be suddenly stopped, as this may precipitate a severe recurrence of the patient’s symptoms – including, possibly, a sharp rise in blood pressure. Gradual withdrawal of medication should mitigate untoward effects.... beta-adrenoceptor-blocking drugs
Verapamil, the longest-available, is used to treat angina and hypertension. It is the only calcium-channel blocker e?ective against cardiac ARRHYTHMIA and it is the drug of choice in terminating supraventricular tachycardia. It may precipitate heart failure, and cause HYPOTENSION at high doses. Nifedipine and diltiazem act more on the vessels and less on the myocardium than verapamil; they have no antiarrhythmic activity. They are used in the prophylaxis and treatment of angina, and in hypertension. Nicardipine and similar drugs act mainly on the vessels, but are valuable in the treatment of hypertension and angina. Important di?erences exist between di?erent calcium-channel blockers so their use must be carefully assessed. They should not be stopped suddenty, as this may precipitate angina. (See also HEART, DISEASES OF.)... calcium-channel blockers
Frequent intake of sugar as well as poor oral hygiene is a major cause. The disease is more common in young people and has a predilection for specific sites. Dental caries can be most effectively prevented by restricting the frequency of sugar intake and avoiding sweet food and drinks at bedtime. The resistance of enamel to dental caries can be increased by the application of *fluoride salts to the tooth surface from toothpastes or mouth rinses. *Fluoridation of water also makes teeth resistant to caries during the period of tooth development. Once caries has spread into the dentine, treatment usually consists of removing the decayed part of the tooth using a *drill and replacing it with a *filling.... dental caries
Certain drugs (dopamine receptor agonists) have an effect on the body similar to that of dopamine. They include *apomorphine, *pergolide, *ropinirole, *cabergoline, and pramipexole and are used to treat *parkinsonism. Drugs that compete with dopamine to occupy and block the dopamine receptor sites in the body are known as dopamine receptor antagonists. They include some *antipsychotic drugs (e.g. the phenothiazines and *butyrophenones) and certain drugs (e.g. *domperidone and *metoclopramide) used to treat nausea and vomiting.... dopamine
Each year around 50 people in the United Kingdom are reported as dying from carbon monoxide poisoning, and experts have suggested that as many as 25,000 people a year are exposed to its effects within the home, but most cases are unrecognised, unreported and untreated, even though victims may suffer from long-term effects. This is regrettable, given that Napoleon’s surgeon, Larrey, recognised in the 18th century that soldiers were being poisoned by carbon monoxide when billeted in huts heated by woodburning stoves. In the USA it is estimated that 40,000 people a year attend emergency departments suffering from carbon monoxide poisoning. So prevention is clearly an important element in dealing with what is sometimes termed the ‘silent killer’. Safer designs of houses and heating systems, as well as wider public education on the dangers of carbon monoxide and its sources, are important.
Clinical effects of acute exposure resemble those of atmospheric HYPOXIA. Tissues and organs with high oxygen consumption are affected to a great extent. Common effects include headaches, weakness, fatigue, ?ushing, nausea, vomiting, irritability, dizziness, drowsiness, disorientation, incoordination, visual disturbances, TACHYCARDIA and HYPERVENTILATION. In severe cases drowsiness may progress rapidly to COMA. There may also be metabolic ACIDOSIS, HYPOKALAEMIA, CONVULSIONS, HYPOTENSION, respiratory depression, ECG changes and cardiovascular collapse. Cerebral OEDEMA is common and will lead to severe brain damage and focal neurological signs. Signi?cant abnormalities on physical examination include impaired short-term memory, abnormal Rhomberg’s test (standing unsupported with eyes closed) and unsteadiness of gait including heel-toe walking. Any one of these signs would classify the episode as severe. Victims’ skin may be coloured pink, though this is very rarely seen even in severe incidents. The venous blood may look ‘arterial’. Patients recovering from acute CO poisoning may suffer neurological sequelae including TREMOR, personality changes, memory impairment, visual loss, inability to concentrate and PARKINSONISM. Chronic low-level exposures may result in nausea, fatigue, headache, confusion, VOMITING, DIARRHOEA, abdominal pain and general malaise. They are often misdiagnosed as in?uenza or food poisoning.
First-aid treatment is to remove the victim from the source of exposure, ensure an e?ective airway and give 100-per-cent oxygen by tight-?tting mask. In hospital, management is largely suppportive, with oxygen administration. A blood sample for COHb level determination should be taken as soon as practicable and, if possible, before oxygen is given. Ideally, oxygen therapy should continue until the COHb level falls below 5 per cent. Patients with any history of unconsciousness, a COHb level greater than 20 per cent on arrival, any neurological signs, any cardiac arrhythmias or anyone who is pregnant should be referred for an expert opinion about possible treatment with hyperbaric oxygen, though this remains a controversial therapy. Hyperbaric oxygen therapy shortens the half-life of COHb, increases plasma oxygen transport and reverses the clinical effects resulting from acute exposures. Carbon monoxide is also an environmental poison and a component of cigarette smoke. Normal body COHb levels due to ENDOGENOUS CO production are 0.4 to
0.7 per cent. Non-smokers in urban areas may have level of 1–2 per cent as a result of environmental exposure. Smokers may have a COHb level of 5 to 6 per cent.... carbon monoxide (co)
Habitat: California and British Columbia. Features ? Bark in quills about three-quarter inch wide by one-sixteenth inch thick,
furrowed-longitudinally, purplish-brown in colour. Inner surface longitudinallystriated, transversely wrinkled. Fracture pale brown, or dark brown when older.Persistently bitter taste, leather-like odour.Older bark is preferred, younger sometimes griping. Part used ? Bark.Action: Tonic laxative.
In habitual constipation due to sluggishness and atony of the lower bowel, and for digestive disorders generally. Doses for chronic constipation, firstly 1/2 to 1 teaspoonful at bedtime, afterwards 5-10 drops before each meal, of the fluid extract.... cascara sagradaPregnancy lasts about 280 days and is calculated from the ?rst day of the last menstrual period – see MENSTRUATION. Pregnancy-testing kits rely on the presence of the hormone beta HUMAN CHORIONIC GONADOTROPHIN (b HCG) which is excreted in the woman’s urine as early as 30 days from the last menstrual period. The estimated date of delivery can be accurately estimated from the size of the developing fetus measured by ULTRASOUND (see also below) between seven and 24 weeks. ‘Term’ refers to the time that the baby is due; this can range from 38 weeks to 41 completed weeks.
Physical changes occur in early pregnancy – periods stop and the abdomen enlarges. The breasts swell, with the veins becoming prominent and the nipples darkening. About two in three women will have nausea with a few experiencing such severe vomiting as to require hospital admission for rehydration.
Antenatal care The aim of antenatal care is to ensure a safe outcome for both mother and child; it is provided by midwives (see MIDWIFE) and doctors. Formal antenatal care began in Edinburgh in the 1930s with the recognition that all aspects of pregnancy – normal and abnormal – warranted surveillance. Cooperation between general practitioners, midwives and obstetricians is now established, with pregnancies that are likely to progress normally being cared for in the community and only those needing special intervention being cared for in a hospital setting.
The initial visit (or booking) in the ?rst half of pregnancy will record the history of past events and the results of tests, with the aim of categorising the patients into normal or not. Screening tests including blood checks and ultrasound scans are a routine part of antenatal care. The ?rst ultrasound scan is done at about 11 weeks to date the pregnancy, with a further one done at 20 weeks – the anomaly scan – to assess the baby’s structure. Some obstetric units will check the growth of the baby with one further scan later in the pregnancy or, in the case of twin pregnancies (see below), many scans throughout. The routine blood tests include checks for ANAEMIA, DIABETES MELLITUS, sickle-cell disease and THALASSAEMIA, as well as for the blood group. Evidence of past infections is also looked for; tests for RUBELLA (German measles) and SYPHILIS are routine, whereas tests for human immunode?ciency virus (see AIDS/ HIV below) and HEPATITIS are being o?ered as optional, although there is compelling evidence that knowledge of the mother’s infection status is bene?cial to the baby.
Traditional antenatal care consists of regular appointments, initially every four weeks until 34 weeks, then fortnightly or weekly. At each visit the mother’s weight, urine and blood pressure are checked, and assessment of fetal growth and position is done by palpating the uterus. Around two-thirds of pregnancies and labours are normal: in the remainder, doctors and midwives need to increase the frequency of surveillance so as to prevent or deal with maternal and fetal problems.
Common complications of pregnancy
Some of the more common complications of pregnancy are listed below.
As well as early detection of medical complications, antenatal visits aim to be supportive and include emotional and educational care. Women with uncomplicated pregnancies are increasingly being managed by midwives and general practitioners in the community and only coming to the hospital doctors should they develop a problem. A small number will opt for a home delivery, but facilities for providing such a service are not always available in the UK.
Women requiring more intensive surveillance have their management targeted to the speci?c problems encountered. Cardiologists will see mothers-to-be with heart conditions, and those at risk of diabetes are cared for in designated clinics with specialist sta?. Those women needing more frequent surveillance than standard antenatal care can be looked after in maternity day centres. These typically include women with mildly raised blood pressure or those with small babies. Fetal medicine units have specialists who are highly skilled in ultrasound scanning and specialise in the diagnosis and management of abnormal babies still in the uterus. ECTOPIC PREGNANCY Chronic abdominal discomfort early in pregnancy may be caused by unruptured ectopic pregnancy, when, rarely, the fertilised OVUM starts developing in the Fallopian tube (see FALLOPIAN TUBES) instead of the uterus. The patient needs hospital treatment and LAPAROSCOPY. A ruptured ectopic pregnancy causes acute abdominal symptoms and collapse, and the woman will require urgent abdominal surgery. URINARY TRACT INFECTIONS These affect around 2 per cent of pregnant women and are detected by a laboratory test of a mid-stream specimen of urine. In pregnancy, symptoms of these infections do not necessarily resemble those experienced by non-pregnant women. As they can cause uterine irritability and possible premature labour (see below), it is important to ?nd and treat them appropriately. ANAEMIA is more prevalent in patients who are vegetarian or on a poor diet. Iron supplements are usually given to women who have low concentrations of HAEMOGLOBIN in their blood (less than 10.5 g/dl) or who are at risk of becoming low in iron, from bleeding, twin pregnancies and those with placenta previa (see below). ANTEPARTUM HAEMORRHAGE Early in pregnancy, vaginal bleedings may be due to a spontaneous or an incomplete therapeutic ABORTION. Bleeding from the genital tract between 24 completed weeks of pregnancy and the start of labour is called antepartum haemorrhage. The most common site is where the PLACENTA is attached to the wall of the uterus. If the placenta separates before delivery, bleeding occurs in the exposed ‘bed’. When the placenta is positioned in the upper part of the uterus it is called an abruption. PLACENTA PRAEVIA is sited in the lower part and blocks or partly blocks the cervix (neck of the womb); it can be identi?ed at about the 34th week. Ten per cent of episodes of antepartum bleeding are caused by placenta previa, and it may be associated with bleeding at delivery. This potentially serious complication is diagnosed by ultrasound scanning and may require a caesarean section (see below) at delivery. INCREASED BLOOD PRESSURE, associated with protein in the urine and swelling of the limbs, is part of a condition known as PRE-ECLAMPSIA. This occurs in the second half of pregnancy in about 1 in 10 women expecting their ?rst baby, and is mostly very mild and of no consequence to the pregnancy. However, some women can develop extremely high blood pressures which can adversely affect the fetus and cause epileptic-type seizures and bleeding disorders in the mother. This serious condition is called ECLAMPSIA. For this reason a pregnant woman with raised blood pressure or PROTEIN in her urine is carefully evaluated with blood tests, often in the maternity day assessment unit. The condition can be stopped by delivery of the baby, and this will be done if the mother’s or the fetus’s life is in danger. If the condition is milder, and the baby not mature enough for a safe delivery, then drugs can be used to control the blood pressure. MISCARRIAGE Also called spontaneous abortion, miscarriage is the loss of the fetus. There are several types:
threatened miscarriage is one in which some vaginal bleeding occurs, the uterus is enlarged, but the cervix remains closed and pregnancy usually proceeds.
inevitable miscarriage usually occurs before the 16th week and is typi?ed by extensive blood loss through an opened cervix and cramp-like abdominal pain; some products of conception are lost but the developing placental area (decidua) is retained and an operation may be necessary to clear the womb.
missed miscarriages, in which the embryo dies and is absorbed, but the decidua (placental area of uterine wall) remains and may cause abdominal discomfort and discharge of old blood.
THERAPEUTIC ABORTION is performed on more than 170,000 women annually in England and Wales. Sometimes the woman may not have arranged the procedure through the usual health-care channels, so that a doctor may see a patient with vaginal bleeding, abdominal discomfort or pain, and open cervix – symptoms which suggest that the decidua and a blood clot have been retained; these retained products will need to be removed by curettage.
Septic abortions are now much less common in Britain than before the Abortion Act (1967) permitted abortion in speci?ed circumstances. The cause is the passage of infective organisms from the vagina into the uterus, with Escherichia coli and Streptococcus faecalis the most common pathogenic agents. The woman has abdominal pain, heavy bleeding, usually fever and sometimes she is in shock. The cause is usually an incomplete abortion or one induced in unsterile circumstances. Antibiotics and curettage are the treatment. INTRAUTERINE GROWTH RETARDATION describes a slowing of the baby’s growth. This can be diagnosed by ultrasound scanning, although there is a considerable margin of error in estimates of fetal weight. Trends in growth are favoured over one-o? scan results alone. GESTATIONAL DIABETES is a condition that is more common in women who are overweight or have a family member with diabetes. If high concentrations of blood sugar are found, e?orts are made to correct it as the babies can become very fat (macrosomia), making delivery more di?cult. A low-sugar diet is usually enough to control the blood concentration of sugars; however some women need small doses of INSULIN to achieve control. FETAL ABNORMALITIES can be detected before birth using ultrasound. Some of these defects are obvious, such as the absence of kidneys, a condition incompatible with life outside the womb. These women can be o?ered a termination of their pregnancy. However, more commonly, the pattern of problems can only hint at an abnormality and closer examination is needed, particularly in the diagnosis of chromosomal deformities such as DOWN’S (DOWN) SYNDROME (trisomy 21 or presence of three 21 chromosomes instead of two).
Chromosomal abnormalities can be de?nitively diagnosed only by cell sampling such as amniocentesis (obtaining amniotic ?uid – see AMNION – from around the baby) done at 15 weeks onwards, and chorionic villus sampling (sampling a small part of the placenta) – another technique which can be done from 12 weeks onwards. Both have a small risk of miscarriage associated with them; consequently, they are con?ned to women at higher risk of having an abnormal fetus.
Biochemical markers present in the pregnant woman’s blood at di?erent stages of pregnancy may have undergone changes in those carrying an abnormal fetus. The ?rst such marker to be routinely used was a high concentration of alpha-fetol protein in babies with SPINA BIFIDA (defects in the covering of the spinal cord). Fuller research has identi?ed a range of diagnostic markers which are useful, and, in conjunction with other factors such as age, ethnic group and ultrasound ?ndings, can provide a predictive guide to the obstetrician – in consultation with the woman – as to whether or not to proceed to an invasive test. These tests include pregnancy-associated plasma protein assessed from a blood sample taken at 12 weeks and four blood tests at 15–22 weeks – alphafetol protein, beta human chorionic gonadotrophin, unconjugated oestriol and inhibin A. Ultrasound itself can reveal physical ?ndings in the fetus, which can be more common in certain abnormalities. Swelling in the neck region of an embryo in early pregnancy (increased nuchal thickness) has good predictive value on its own, although its accuracy is improved in combination with the biochemical markers. The e?ectiveness of prenatal diagnosis is rapidly evolving, the aim being to make the diagnosis as early in the pregnancy as possible to help the parents make more informed choices. MULTIPLE PREGNANCIES In the UK, one in 95 deliveries is of twins, while the prevalence of triplets is one in 10,000 and quadruplets around one in 500,000. Racial variations occur, with African women having a prevalence rate of one in 30 deliveries for twins and Japanese women a much lower rate than the UK ?gure. Multiple pregnancies occur more often in older women, and in the UK the prevalence of fertility treatments, many of these being given to older women, has raised the incidence. There is now an o?cial limit of three eggs being transferred to a woman undergoing ASSISTED CONCEPTION (gamete intrafallopian transfer, or GIFT).
Multiple pregnancies are now usually diagnosed as a result of routine ultrasound scans between 16 and 20 weeks of pregnancy. The increased size of the uterus results in the mother having more or worse pregnancy-related conditions such as nausea, abdominal discomfort, backache and varicose veins. Some congenital abnormalities in the fetus occur more frequently in twins: NEURAL TUBE defects, abnormalities of the heart and the incidence of TURNER’S SYNDROME and KLINEFELTER’S SYNDROME are examples. Such abnormalities may be detected by ultrasound scans or amniocentesis. High maternal blood pressure and anaemia are commoner in women with multiple pregnancies (see above).
The growth rates of multiple fetuses vary, but the di?erence between them and single fetuses are not that great until the later stages of pregnancy. Preterm labour is commoner in multiple pregnancies: the median length of pregnancy is 40 weeks for singletons, 37 for twins and 33 for triplets. Low birth-weights are usually the result of early delivery rather than abnormalities in growth rates. Women with multiple pregnancies require more frequent and vigilant antenatal assessments, with their carers being alert to the signs of preterm labour occurring. CEPHALOPELVIC DISPROPORTION Disparity between the size of the fetus and the mother’s pelvis is not common in the UK but is a signi?cant problem in the developing world. Disparity is classi?ed as absolute, when there is no possibility of delivery, and relative, when the baby is large but delivery (usually after a dif?cult labour) is possible. Causes of absolute disparity include: a large baby – heavier than 5 kg at birth; fetal HYDROCEPHALUS; and an abnormal maternal pelvis. The latter may be congenital, the result of trauma or a contraction in pelvic size because of OSTEOMALACIA early in life. Disproportion should be suspected if in late pregnancy the fetal head has not ‘engaged’ in the pelvis. Sometimes a closely supervised ‘trial of labour’ may result in a successful, if prolonged, delivery. Otherwise a caesarean section (see below) is necessary. UNUSUAL POSITIONS AND PRESENTATIONS OF THE BABY In most pregnant women the baby ?ts into the maternal pelvis head-?rst in what is called the occipito-anterior position, with the baby’s face pointing towards the back of the pelvis. Sometimes, however, the head may face the other way, or enter the pelvis transversely – or, rarely, the baby’s neck is ?exed backwards with the brow or face presenting to the neck of the womb. Some malpositions will correct naturally; others can be manipulated abdominally during pregnancy to a better position. If, however, the mother starts labour with the baby’s head badly positioned or with the buttocks instead of the head presenting (breech position), the labour will usually be longer and more di?cult and may require intervention using special obstetric forceps to assist in extracting the baby. If progress is poor and the fetus distressed, caesarean section may be necessary. HIV INFECTION Pregnant women who are HIV positive (see HIV; AIDS/HIV) should be taking antiviral drugs in the ?nal four to ?ve months of pregnancy, so as to reduce the risk of infecting the baby in utero and during birth by around 50 per cent. Additional antiviral treatment is given before delivery; the infection risk to the baby can be further reduced – by about 40 per cent – if delivery is by caesarean section. The mother may prefer to have the baby normally, in which case great care should be taken not to damage the baby’s skin during delivery. The infection risk to the baby is even further reduced if it is not breast fed. If all preventive precautions are taken, the overall risk of the infant becoming infected is cut to under 5 per cent.
Premature birth This is a birth that takes place before the end of the normal period of gestation, usually before 37 weeks. In practice, however, it is de?ned as a birth that takes place when the baby weighs less than 2·5 kilograms (5••• pounds). Between 5 and 10 per cent of babies are born prematurely, and in around 40 per cent of premature births the cause is unknown. Pre-eclampsia is the most common known cause; others include hypertension, chronic kidney disease, heart disease and diabetes mellitus. Multiple pregnancy is another cause. In the vast majority of cases the aim of management is to prolong the pregnancy and so improve the outlook for the unborn child. This consists essentially of rest in bed and sedation, but there are now several drugs, such as RITODRINE, that may be used to suppress the activity of the uterus and so help to delay premature labour. Prematurity was once a prime cause of infant mortality but modern medical care has greatly improved survival rates in developing countries.
Labour Also known by the traditional terms parturition, childbirth or delivery, this is the process by which the baby and subsequently the placenta are expelled from the mother’s body. The onset of labour is often preceded by a ‘show’ – the loss of the mucus and blood plug from the cervix, or neck of the womb; this passes down the vagina to the exterior. The time before the beginning of labour is called the ‘latent phase’ and characteristically lasts 24 hours or more in a ?rst pregnancy. Labour itself is de?ned by regular, painful contractions which cause dilation of the neck of the womb and descent of the fetal head. ‘Breaking of the waters’ is the loss of amniotic ?uid vaginally and can occur any time in the delivery process.
Labour itself is divided into three stages: the ?rst is from the onset of labour to full (10 cm) dilation of the neck of the womb. This stage varies in length, ideally taking no more than one hour per centimetre of dilation. Progress is monitored by regular vaginal examinations, usually every four hours. Fetal well-being is observed by intermittent or continuous monitoring of the fetal heart rate in relation to the timing and frequency of the contractions. The print-out is called a cardiotocograph. Abnormalities of the fetal heart rate may suggest fetal distress and may warrant intervention. In women having their ?rst baby (primigravidae), the common cause of a slow labour is uncoordinated contractions which can be overcome by giving either of the drugs PROSTAGLANDIN or OXYTOCIN, which provoke contractions of the uterine muscle, by an intravenous drip. Labours which progress slowly or not at all may be due to abnormal positioning of the fetus or too large a fetus, when prostaglandin or oxytocin is used much more cautiously.
The second stage of labour is from full cervical dilation to the delivery of the baby. At this stage the mother often experiences an irresistible urge to push the baby out, and a combination of strong coordinated uterine contractions and maternal e?ort gradually moves the baby down the birth canal. This stage usually lasts under an hour but can take longer. Delay, exhaustion of the mother or distress of the fetus may necessitate intervention by the midwife or doctor. This may mean enlarging the vaginal opening with an EPISIOTOMY (cutting of the perineal outlet – see below) or assisting the delivery with specially designed obstetric forceps or a vacuum extractor (ventouse). If the cervix is not completely dilated or open and the head not descended, then an emergency caesarean section may need to be done to deliver the baby. This procedure involves delivering the baby and placenta through an incision in the mother’s abdomen. It is sometimes necessary to deliver by planned or elective caesarean section: for example, if the placenta is low in the uterus – called placenta praevia – making a vaginal delivery dangerous.
The third stage occurs when the placenta (or afterbirth) is delivered, which is usually about 10–20 minutes after the baby. An injection of ergometrine and oxytocin is often given to women to prevent bleeding.
Pain relief in labour varies according to the mother’s needs. For uncomplicated labours, massage, reassurance by a birth attendant, and a warm bath and mobilisation may be enough for some women. However, some labours are painful, particularly if the woman is tired or anxious or is having her ?rst baby. In these cases other forms of analgesia are available, ranging from inhalation of NITROUS OXIDE GAS, injection of PETHIDINE HYDROCHLORIDE or similar narcotic, and regional local anaesthetic (see ANAESTHESIA).
Once a woman has delivered, care continues to ensure her and the baby’s safety. The midwives are involved in checking that the uterus returns to its normal size and that there is no infection or heavy bleeding, as well as caring for stitches if needed. The normal blood loss after birth is called lochia and generally is light, lasting up to six weeks. Midwives o?er support with breast feeding and care of the infant and will visit the parents at home routinely for up to two weeks.
Some complications of labour All operative deliveries in the UK are now done in hospitals, and are performed if a spontaneous birth is expected to pose a bigger risk to the mother or her child than a specialist-assisted one. Operative deliveries include caesarean section, forceps-assisted deliveries and those in which vacuum extraction (ventouse) is used. CAESAREAN SECTION Absolute indications for this procedure, which is used to deliver over 15 per cent of babies in Britain, are cephalopelvic disproportion and extensive placenta praevia, both discussed above. Otherwise the decision to undertake caesarean section depends on the clinical judgement of the specialist and the views of the mother. The rise in the proportion of this type of intervention (from 5 per cent in the 1930s to its present level of over 23 per cent
P
of the 600,000 or so annual deliveries in England) has been put down to defensive medicine
– namely, the doctor’s fear of litigation (initiated often because the parents believe that the baby’s health has suffered because the mother had an avoidably di?cult ‘natural’ labour). In Britain, over 60 per cent of women who have had a caesarean section try a vaginal delivery in a succeeding pregnancy, with about two-thirds of these being successful. Indications for the operation include:
absolute and relative cephalopelvic disproportion.
placenta previa.
fetal distress.
prolapsed umbilical cord – this endangers the viability of the fetus because the vital supply of oxygen and nutrients is interrupted.
malpresentation of the fetus such as breech or transverse lie in the womb.
unsatisfactory previous pregnancies or deliveries.
a request from the mother.
Caesarean sections are usually performed using regional block anaesthesia induced by a spinal or epidural injection. This results in loss of feeling in the lower part of the body; the mother is conscious and the baby not exposed to potential risks from volatile anaesthetic gases inhaled by the mother during general anaesthesia. Post-operative complications are higher with general anaesthesia, but maternal anxiety and the likelihood that the operation might be complicated and di?cult are indications for using it. A general anaesthetic may also be required for an acute obstetric emergency. At operation the mother’s lower abdomen is opened and then her uterus opened slowly with a transverse incision and the baby carefully extracted. A transverse incision is used in preference to the traditional vertical one as it enables the woman to have a vaginal delivery in any future pregnancy with a much smaller risk of uterine rupture. Women are usually allowed to get up within 24 hours and are discharged after four or ?ve days. FORCEPS AND VENTOUSE DELIVERIES Obstetric forceps are made in several forms, but all are basically a pair of curved blades shaped so that they can obtain a purchase on the baby’s head, thus enabling the operator to apply traction and (usually) speed up delivery. (Sometimes they are used to slow down progress of the head.) A ventouse or vacuum extractor comprises an egg-cup-shaped metal or plastic head, ranging from 40 to 60 mm in diameter with a hollow tube attached through which air is extracted by a foot-operated vacuum pump. The instrument is placed on the descending head, creating a negative pressure on the skin of the scalp and enabling the operator to pull the head down. In mainland Europe, vacuum extraction is generally preferred to forceps for assisting natural deliveries, being used in around 5 per cent of all deliveries. Forceps have a greater risk of causing damage to the baby’s scalp and brain than vacuum extraction, although properly used, both types should not cause any serious damage to the baby.
Episiotomy Normal and assisted deliveries put the tissues of the genital tract under strain. The PERINEUM is less elastic than the vagina and, if it seems to be splitting as the baby’s head
moves down the birth canal, it may be necessary to cut the perineal tissue – a procedure called an episiotomy – to limit damage. This is a simple operation done under local anaesthetic. It should be done only if there is a speci?c indication; these include:
to hasten the second stage of labour if the fetus is distressed.
to facilitate the use of forceps or vacuum extractor.
to enlarge a perineum that is restricted because of unyielding tissue, perhaps because of a scar from a previous labour. Midwives as well as obstetricians are trained
to undertake and repair (with sutures) episiotomies.
(For organisations which o?er advice and information on various aspects of childbirth, including eclampsia, breast feeding and multiple births, see APPENDIX 2: ADDRESSES: SOURCES OF INFORMATION, ADVICE, SUPPORT AND SELF-HELP.)... pregnancy and labour
common pain pathways in the CENTRAL NERVOUS SYSTEM. (See also PAIN.)... referred pain
– see CELLS). Consisting of approximately 65 per cent RNA and 35 per cent PROTEIN, they are the sites where protein is made.... ribosome
Rarely, the UTERUS may be completely absent as a result of abnormal development. In such patients secondary sexual development is normal but MENSTRUATION is absent (primary amennorhoea). The chromosomal make-up of the patient must be checked (see CHROMOSOMES; GENES): in a few cases the genotype is male (testicular feminisation syndrome). No treatment is available, although the woman should be counselled.
The uterus develops as two halves which fuse together. If the fusion is incomplete, a uterine SEPTUM results. Such patients with a double uterus (uterus didelphys) may have fertility problems which can be corrected by surgical removal of the uterine septum. Very rarely there may be two uteri with a double vagina.
The uterus of most women points forwards (anteversion) and bends forwards (ante?exion). However, about 25 per cent of women have a uterus which is pointed backwards (retroversion) and bent backwards (retro?exion). This is a normal variant and very rarely gives rise to any problems. If it does, the attitude of the uterus can be corrected by an operation called a ventrosuspension.
Endometritis The lining of the uterine cavity is called the ENDOMETRIUM. It is this layer that is partially shed cyclically in women of reproductive age giving rise to menstruation. Infection of the endometrium is called endometritis and usually occurs after a pregnancy or in association with the use of an intrauterine contraceptive device (IUCD – see CONTRACEPTION). The symptoms are usually of pain, bleeding and a fever. Treatment is with antibiotics. Unless the FALLOPIAN TUBES are involved and damaged, subsequent fertility is unaffected. Very rarely, the infection is caused by TUBERCULOSIS. Tuberculous endometritis may destroy the endometrium causing permanent amenorrhoea and sterility.
Menstrual disorders are common. Heavy periods (menorrhagia) are often caused by ?broids (see below) or adenomyosis (see below) or by anovulatory cycles. Anovulatory cycles result in the endometrium being subjected to unopposed oestrogen stimulation and occasionally undergoing hyperplasia. Treatment is with cyclical progestogens (see PROGESTOGEN) initially. If this form of treatment fails, endoscopic surgery to remove the endometrium may be successful. The endometrium may be removed using LASER (endometrial laser ablation) or electrocautery (transcervical resection of endometrium). Hysterectomy (see below) will cure the problem if endoscopic surgery fails. Adenomyosis is a condition in which endometrial tissue is found in the muscle layer (myometrium) of the uterus. It usually presents as heavy and painful periods, and occasionally pain during intercourse. Hysterectomy is usually required.
Oligomenorhoea (scanty or infrequent periods) may be caused by a variety of conditions including thyroid disease (see THYROID GLAND, DISEASES OF). It is most commonly associated with usage of the combined oral contraceptive pill. Once serious causes have been eliminated, the patient should be reassured. No treatment is necessary unless conception is desired, in which case the patient may require induction of ovulation.
Primary amenorrhoea means that the patient has never had a period. She should be investigated, although usually it is only due to an inexplicable delay in the onset of periods (delayed menarche) and not to any serious condition. Secondary amenorrhoea is the cessation of periods after menstruation has started. The most common cause is pregnancy. It may be also caused by endocrinological or hormonal problems, tuberculous endometritis, emotional problems and severe weight loss. The treatment of amenorrhoea depends on the cause.
Dysmenorrhoea, or painful periods, is the most common disorder; in most cases the cause is unknown, although the disorder may be due to excessive production of PROSTAGLANDINS.
Irregular menstruation (variations from the woman’s normal menstrual pattern or changes in the duration of bleeding or the amount) can be the result of a disturbance in the balance of OESTROGENS and PROGESTERONE hormone which between them regulate the cycle. For some time after the MENARCHE or before the MENOPAUSE, menstruation may be irregular. If irregularity occurs in a woman whose periods are normally regular, it may be due to unsuspected pregnancy, early miscarriage or to disorders in the uterus, OVARIES or pelvic cavity. The woman should seek medical advice.
Fibroids (leiomyomata) are benign tumours arising from the smooth muscle layer (myometrium) of the uterus. They are found in 80 per cent of women but only a small percentage give rise to any problems and may then require treatment. They may cause heavy periods and occasionally pain. Sometimes they present as a mass arising from the pelvis with pressure symptoms from the bladder or rectum. Although they can be shrunk medically using gonadorelin analogues, which raise the plasma concentrations of LUTEINISING HORMONE and FOLLICLE-STIMULATING HORMONE, this is not a long-term solution. In any case, ?broids only require treatment if they are large or enlarging, or if they cause symptoms. Treatment is either myomectomy (surgical removal) if fertility is to be retained, or a hysterectomy.
Uterine cancers tend to present after the age of 40 with abnormal bleeding (intermenstrual or postmenopausal bleeding). They are usually endometrial carcinomas. Eighty per cent present with early (Stage I) disease. Patients with operable cancers should be treated with total abdominal hysterectomy and bilateral excision of the ovaries and Fallopian tubes. Post-operative RADIOTHERAPY is usually given to those patients with adverse prognostic factors. Pre-operative radiotherapy is still given by some centres, although this practice is now regarded as outdated. PROGESTOGEN treatment may be extremely e?ective in cases of recurrence, but its value remains unproven when used as adjuvant treatment. In 2003 in England and Wales, more than 2,353 women died of uterine cancer.
Disorders of the cervix The cervix (neck of the womb) may produce an excessive discharge due to the presence of a cervical ectopy or ectropion. In both instances columnar epithelium – the layer of secreting cells – which usually lines the cervical canal is exposed on its surface. Asymptomatic patients do not require treatment. If treatment is required, cryocautery – local freezing of tissue – is usually e?ective.
Cervical smears are taken and examined in the laboratory to detect abnormal cells shed from the cervix. Its main purpose is to detect cervical intraepithelial neoplasia (CIN) – the presence of malignant cells in the surface tissue lining the cervix – since up to 40 per cent of women with this condition will develop cervical cancer if the CIN is left untreated. Women with abnormal smears should undergo colposcopy, a painless investigation using a low-powered microscope to inspect the cervix. If CIN is found, treatment consists of simply removing the area of abnormal skin, either using a diathermy loop or laser instrument.
Unfortunately, cervical cancer remains the most common of gynaecological cancers. The most common type is squamous cell carcinoma and around 4,000 new cases (all types) are diagnosed in England and Wales every year. As many as 50 per cent of the women affected may die from the disease within ?ve years. Cervical cancer is staged clinically in four bands according to how far it has extended, and treatment is determined by this staging. Stage I involves only the mucosal lining of the cervix and cone BIOPSY may be the best treatment in young women wanting children. In Stage IV the disease has spread beyond the cervix, uterus and pelvis to the URINARY BLADDER or RECTUM. For most women, radiotherapy or radical Wertheim’s hysterectomy – the latter being preferable for younger women – is the treatment of choice if the cancer is diagnosed early, both resulting in survival rates of ?ve years in 80 per cent of patients. Wertheim’s hysterectomy is a major operation in which the uterus, cervix, upper third of vagina and the tissue surrounding the cervix are removed together with the LYMPH NODES draining the area. The ovaries may be retained if desired. Patients with cervical cancer are treated by radiotherapy, either because they present too late for surgery or because the surgical skill to perform a radical hysterectomy is not available. These operations are best performed by gynaecological oncologists who are gynaecological surgeons specialising in the treatment of gynaecological tumours. The role of CHEMOTHERAPY in cervical and uterine cancer is still being evaluated.
Prolapse of the uterus is a disorder in which the organ drops from its normal situation down into the vagina. First-degree prolapse is a slight displacement of the uterus, second-degree a partial displacement and third-degree when the uterus can be seen outside the VULVA. It may be accompanied by a CYSTOCOELE (the bladder bulges into the front wall of the vagina), urethrocoele (the urethra bulges into the vagina) and rectocoele (the rectal wall bulges into the rear wall of the vagina). Prolapse most commonly occurs in middle-aged women who have had children, but the condition is much less common now than in the past when prenatal and obstetric care was poor, women had more pregnancies and their general health was poor. Treatment is with pelvic exercises, surgical repair of the vagina or hysterectomy. If the woman does not want or is not ?t for surgery, an internal support called a pessary can be ?tted – and changed periodically.
Vertical section of female reproductive tract (viewed from front) showing sites of common gynaecological disorders.
Hysterectomy Many serious conditions of the uterus have traditionally been treated by hysterectomy, or removal of the uterus. It remains a common surgical operation in the UK, but is being superseded in the treatment of some conditions, such as persistent MENORRHAGIA, with endometrial ablation – removal of the lining of the uterus using minimally invasive techniques, usually using an ENDOSCOPE and laser. Hysterectomy is done to treat ?broids, cancer of the uterus and cervix, menorrhagia, ENDOMETRIOSIS and sometimes for severely prolapsed uterus. Total hysterectomy is the usual type of operation: it involves the removal of the uterus and cervix and sometimes the ovaries. After hysterectomy a woman no longer menstruates and cannot become pregnant. If the ovaries have been removed as well and the woman had not reached the menopause, hormone replacement therapy (HRT – see MENOPAUSE) should be considered. Counselling helps the woman to recover from the operation which can be an emotionally challenging event for many.... uterus, diseases of
A number of co-factors are necessary for AIDS to develop: diet, environment, immoral lifestyle, drugs, etc also dispose to the disease which, when eliminated, suggest that AIDS needs not be fatal. However, there is no known cure. Smoking hastens onset. Causes include needle-sharing and sexual contacts. Also known as the ‘Gay Plague’ it can be transmitted from one member of the family to another non-sexual contact.
The virus kills off cells in the brain by inflammation, thus disposing to dementia.
Symptoms. Onset: brief fever with swollen glands. “Feeling mildly unwell”. This may pass off without incident until recurrence with persistent diarrhoea, night sweats, tender swollen lymph nodes, cough and shortness of breath. There follows weight loss, oral candida. Diagnosis is confirmed by appearance of ugly skin lesions known as Kaposi’s sarcoma – a malignant disease. First indication is the appearance of dark purple spots on the body followed by fungoid growths on mouth and throat.
While some cases of STDs have been effectively treated with phytotherapy, there is evidence to suggest it may be beneficial for a number of reasons. Whatever the treatment, frequent blood counts to monitor T-4 cells (an important part of the immune system) are necessary. While a phytotherapeutic regime may not cure, it is possible for patients to report feeling better emotionally and physically and to avoid some accompanying infections (candida etc).
Treatment. Without a blood test many HIV positives may remain ignorant of their condition for many years. STD clinics offer free testing and confidential counselling.
Modern phytotherapeutic treatment:–
1. Anti-virals. See entry.
2. Enhance immune function.
3. Nutrition: diet, food supplements.
4. Psychological counselling.
To strengthen body defences: Garlic, Echinacea, Lapacho, Sage, Chlorella, Reisha Mushroom, Shiitake Mushroom. Of primary importance is Liquorice: 2-4 grams daily.
Upper respiratory infection: Pleurisy root, Elecampane.
Liver breakdown: Blue Flag root, Milk Thistle, Goldenseal.
Diarrhoea: Bayberry, Mountain Grape, American Cranesbill, Slippery Elm, lactobacillus acidophilus.
Prostatitis: Saw Palmetto, Goldenrod, Echinacea.
Skin lesions: External:– Comfrey, Calendula or Aloe Vera cream.
To help prevent dementia: a common destructive symptom of the disease: agents rich in minerals – Alfalfa, Irish Moss, Ginkgo, St John’s Wort, Calcium supplements.
Nervous collapse: Gotu Kola, Siberian Ginseng, Oats, Damiana.
Ear Inflammation: Echinacea. External – Mullein ear drops.
With candida: Lapacho tea. Garlic inhibits candida.
Anal fissure: Comfrey cream or Aloe Vera gel (external).
Practitioner: Formula. Liquid extract Echinacea 30ml (viral infection) . . . Liquid extract Poke root 10ml (lymphatic system) . . . Liquid extract Blue Flag root 10ml (liver stimulant) . . . Tincture Goldenseal 2ml (inflamed mucous membranes) . . . Liquid extract Guaiacum 1ml (blood enricher) . . . Decoction of Sarsaparilla to 100ml. Sig: 5ml (3i) aq cal pc.
Gargle for sore throat: 5-10 drops Liquid extract or Tincture Echinacea to glass water, as freely as desired.
Abdominal Castor oil packs: claimed to enhance immune system.
Chinese medicine: Huang Qi (astragalus root).
Urethral and vaginal irrigation: 2 drops Tea Tree oil in strong decoction Marshmallow root: 2oz to 2 pints water. Inject warm.
Diet. Vitamin C-rich foods, Lecithin, Egg Yolk, Slippery Elm gruel, Red Beet root, Artichokes. Garlic is particularly indicated as an anti-infective.
Nutrition. Vitamin A is known to increase resistance by strengthening the cell membrane; preferably taken as beta carotene 300,000iu daily as massive doses of Vitamin A can be toxic. Amino acid – Glutathione: Garlic’s L-cysteine relates.
Vitamin C. “The virus is inactivated by this vitamin. Saturating cells infected with the HIV virus with the vitamin results in 99 per cent inactivation of the virus. The vitamin is an anti-viral and immune system modulator without unwanted side-effects. The ascorbate, when added to HIV cells, substantially reduced the virus’s activity without harming the cells at specific concentrations. Patients taking large doses report marked improvement in their condition. Minimum daily oral dose: 10 grams.” (Linus Pauling Institute, Science and Medicine, Palo Alto, California, USA)
Periwinkle. An anti-AIDS compound has been detected in the Madagascan Periwinkle (Catharanthus roseus), at the Chelsea Physic Garden.
Mulberry. The black Mulberry appears to inhibit the AIDS virus.
Hyssop. An AIDS patient improved to a point where ulcers were healed, blood infection eliminated, and Kaposi’s sarcoma started to clear when her mother gave her a traditional Jamaican tea made from Hyssop, Blessed Thistle and Senna. From test-tube research doctors found that Hyssopus officinalis could be effective in treatment of HIV/AIDS. (Medical Journal Antiviral Research, 1990, 14, 323-37) Circumcision. Studies have shown that uncircumcised African men were more than five to eight times more likely to contract AIDS than were circumcised men; life of the virus being short-lived in a dry environment. (Epidemiologist Thomas Quinn, in Science Magazine)
Study. A group of 13 HIV and AIDS patients received 200mg capsules daily of a combination of Chelidonium (Greater Celandine) 175mg; Sanguinaria (Blood root) 5mg; and Slippery Elm (Ulmus fulva) 20mg. More than half the patients enjoyed increased energy and improved immune function with reduction in both size and tenderness of lymph nodes. (D’Adamo P. ‘Chelidonium and Sanguinaria alkaloids as anti-HIV therapy. Journal of Naturopathic Medicine (USA) 3.31-34 1992)
Bastyr College of Naturopathy, Seattle, MA, USA. During 1991 the College carried out a study which claimed that a combination of natural therapies including nutrition, supplements, herbal medicine, hydrotherapy and counselling had successfully inhibited HIV and other viral activity in all patients in controlled trials lasting a year.
Patients chosen for the trial were HIV positive, not on anti-viral drugs and showing symptoms of a compromised immune system, but without frank AIDS (generally taken to be indicated by Karposi’s sarcoma and/or PCP-pneumocystitis carinii pneumonia).
Symptoms included: Lymphadenopathy in at least two sites, oral thrush, chronic diarrhoea, chronic sinusitis, leukoplakia, herpes, night sweats and fatigue.
Assessment was subjective and objective (including T-cell ratio tests). The patients did better than comparable groups in published trials using AZT.
Treatment was naturopathic and herbal. Patients receiving homoeopathy and acupuncture did not do as well as those receiving herbs.
Best results with herbs were: Liquorice (1g powder thrice daily); St John’s Wort (Yerba prima tablets, 3, on two days a week only). Patients reported a great increase in the sense of well-being on St John’s Wort. An equivalent dose of fresh plant tincture would be 10ml. The tincture should be of a good red colour. The College did not use Echinacea, which would stimulate the central immune system and which would therefore be contra-indicated.
Supplements given daily. Calcium ascorbate 3g+ (to bowel tolerance). Beta-carotene 300,000iu. Thymus gland extract tablets 6. Zinc 60mg (with some Copper). B-vitamins and EFAs.
To control specific symptoms: most useful herbs were: Tea Tree oil for fungal infections; Goldenseal and Gentian as bitters. Ephedra and Eyebright for sinusitis. Carob drinks for non-specific enteritis. Vitamin B12 and topical Liquorice for shingles.
Counselling and regular massage were used to maintain a positive spirit. Studies show all long term HIV positive survivors have a positive attitude and constantly work at empowering themselves.
Results showed significant improvements in symptoms suffered by HIV patients despite a slow deterioration in blood status. Methods used in the study had dramatically reduced mortality and morbidity. A conclusion was reached that AIDS may not be curable but it could be manageable. (Reported by Christopher Hedley MNIMH, London NW1 8JD, in Greenfiles Herbal Journal) ... aids
Symptoms: inflammation of the lung and high temperature with dry cough.
Tea: Equal parts; Elderflowers (to reduce temperature). Comfrey leaves (cough), Thyme (antibiotic), Peppermint (to assist breathing). 2 teaspoons to each cup boiling water; infuse 5-15 minutes. 1 cup freely. Alternative: Combine Tinctures: Pleurisy root 2; Lobelia 1; Ginger half. One or two 5ml teaspoons in water 3-4 times daily. ... damp hay disease
Habitat: Native to Sudan and Arabia. Now cultivated mainly in Tirunelveli and Ramnathpuram districts and to a lesser extent in Madurai, Salem and Tiruchirapalli districts of Tamil Nadu. Also grown on a small scale in Cuddapah district of Andhra Pradesh and certain parts of Karnataka.
English: Indian Senna, Tinnevelly Senna.Ayurvedic: Svarna-pattri, Maarkandikaa, Maarkandi.Unani: Sannaa, Sanaa-makki, Senaai, Sonaamukhi, Sanaa-Hindi.Siddha/Tamil: Nilaavaarai.Folk: Sanaai.Action: Purgative (free from astringent action of rhubark type herbs, but causes gripe), used in compounds for treating biliousness, distention of stomach, vomiting and hiccups. Also used as a febrifuge, in splenic enlargements, jaundice, amoebic dysentery. Contraindicated in inflammatory colon diseases.
Key application: Leaf and dried fruit—in occasional constipation. (German Commission E.) As a stimulant laxative. (The British Herbal Pharmacopoeia.) 1,8- dihydoxy-anthracene derivatives have a laxative effect. This effect is due to the sennosides, specifically, due to their active metabolite in the colon, rheinanthrone. The effect is primarily caused by the influence on the motility of the colon by inhibiting stationary and stimulating propulsive contractions. (German Commission E, ESCOP, WHO.) Seena has been included in I.P. as a purgative.Most of the Senna sp. contain rhein, aloe-emodin, kaempferol, isormam- netin, both free and as glucosides, together with mycricyl alcohol. The purgative principles are largely attributed to anthraquinone derivatives and their glucosides.Senna is an Arabian name. The drug was brought into use by Arabian physicians for removing capillary congestion (pods were preferred to leaves).The active purgative principle of senna was discovered in 1866.Cassia acutifolia Delile is also equated with Maarkandikaa, Svarna-pattri, Sanaai.Dosage: Leaves—500 mg to 2 g (API Vol. I.)... cassia angustifoliaHabitat: Throughout India, up to an altitude of 1,500 m.
English: Coffee Senna, Foetid Cassia, Negro Coffee.Ayurvedic: Kaasamarda, Kaasaari.Unani: Kasondi.Siddha/Tamil: Paeyaavarai, Thagarai.Folk: Kasondi (bigger var.).Action: Purgative, diuretic, febrifugal, expectorant, stomachic. Leaves—used internally and externally in scabies, ringworm and other skin diseases. A hot decoction is given as an antiperiodic. Seeds— used for cough, whooping cough and convulsions. Roasted seeds (roasting destroys the purgative property) are mixed with coffee for strength.
The pods contain sennosides and anthraquinones; seeds polysacchari- des, galactomannan; leaves dianthron- ic hetroside; pericarp apigenin; roots emodol; plant xanthone—cassiolin; seeds phytosterolin; flowers physcion and its glucosides, emodin and beta- sitosterol.The volatile oil obtained from the leaves, roots and seeds showed antibacterial and antifungal activity.The seeds, when fed to animals, resulted in weight loss and also were found to be toxic to experimental animals. Leaves are preferred to quinine as a tonic, seeds are considered as a hae- mateinic toxic and root is used as a hepatic tonic.Dosage: Seed—3-6 g powder; leaf—10-20 ml juice; root bark— 50-100 ml decoction. (CCRAS.)... cassia occidentalisThe interaction may take place:
(1) Prior to absorption or administration – for example, antacids bind tetracycline in the gut and prevent absorption.
(2) By interfering with protein binding – one drug may displace another from binding sites on plasma proteins. The action of the displaced drug will be increased because more drug is now available; for example, anticoagulants are displaced by analgesics.
(3) During metabolism or excretion of the drug – some drugs increase or decrease the activity of liver enzymes which metabolise drugs, thus affecting their rate of destruction; for example, barbiturates, nicotine, and alcohol all activate hepatic enzymes. Altering the pH of urine will affect the excretion of drugs via the kidney.
(4) At the drug receptor – one drug may displace another at the receptor, affecting its e?cacy or duration of action.... drug interactions
Iscador is based on the philosophy of anthroposophy founded by Dr Rudolph Steiner and requires a special process of manufacture based on time of gathering and aspect of the moon. ... iscador
Traditional Chinese medicine maintains that the chi (life-force) flows through the body along channels called meridians. A blockage in one or more of these meridians is thought to cause ill health. Acupuncturists aim to restore health by inserting needles at appropriate sites along the affected meridians. The needles are stimulated by rotation or by an electric current. Acupuncture has been used successfully as an anaesthetic for surgical procedures and to provide pain relief after operations and for chronic conditions.... acupuncture
STAPHYLOCOCCUS AUREUS. The back of the neck and the buttocks are common sites. Carbuncles mainly affect people with reduced immunity, particularly those with diabetes mellitus. Treatment is usually with an antibiotic and hot compresses. Incision and drainage may be necessary if a carbuncle is persistent.... carbuncle
Symptoms depend on the site of the metastases (secondary tumours).
Carcinomatosis may be confirmed by X-rays or by radionuclide scanning of the bones and lungs, by biochemical tests, or during an operation.
The condition is not improved by removing the primary tumour unless the tumour is producing a hormone that stimulates the growth of metastases.
Anticancer drugs or radiotherapy may be given to treat metastases.... carcinomatosis
Before surgery, sites of blockage in the arteries are identified using angiography. In some cases, minimally invasive surgery can be used, avoiding the need to stop the heart and use a heart–lung machine during the operation. The long term outlook after a bypass is good, but the grafted vessels may also eventually become blocked by atherosclerosis.... coronary artery bypass
Major diet-related health problems in prosperous communities tend to be the result of dietary excesses, whereas in underdeveloped, poor communities, problems associated with dietary de?ciencies predominate. Excessive intakes of dietary energy, saturated fats, sugar, salt and alcohol, together with an inadequate intake of dietary ?bre, have been linked to the high prevalence of OBESITY, cardiovascular disease, dental caries, HYPERTENSION, gall-stones (see GALL-BLADDER, DISEASES OF), non-insulindependent DIABETES MELLITUS and certain cancers (e.g. of the breast, endometrium, intestine and stomach) seen in developed nations. Health-promotion strategies in these countries generally advocate a reduction in the intake of fat, particularly saturated fat, and salt, the avoidance of excessive intakes of alcohol and simple sugars, an increased consumption of starch and ?bre and the avoidance of obesity by taking appropriate physical exercise. A maximum level of dietary cholesterol is sometimes speci?ed.
Undernutrition, including protein-energy malnutrition and speci?c vitamin and mineral de?ciencies, is an important cause of poor health in underdeveloped countries. Priorities here centre on ensuring that the diet provides enough nutrients to maintain health.
In healthy people, dietary requirements depend on age, sex and level of physical activity. Pregnancy and lactation further alter requirements. The presence of infections, fever, burns, fractures and surgery all increase dietary energy and protein requirements and can precipitate undernutrition in previously well-nourished people.
In addition to disease prevention, diet has a role in the treatment of certain clinical disorders, for example, obesity, diabetes mellitus, HYPERLIPIDAEMIA, inborn errors of metabolism, food intolerances and hepatic and renal diseases. Therapeutic diets increase or restrict the amount and/or change the type of fat, carbohydrate, protein, ?bre, vitamins, minerals and/or water in the diet according to clinical indications. Additionally, the consistency of the food eaten may need to be altered. A commercially available or ‘homemade’ liquid diet can be used to provide all or some of a patient’s nutritional needs if necessary. Although the enteral (by mouth) route is the preferred route for feeding and can be used for most patients, parenteral or intravenous feeding is occasionally required in a minority of patients whose gastrointestinal tract is unavailable or unreliable over a period of time.
A wide variety of weight-reducing diets are well publicised. People should adopt them with caution and, if in doubt, seek expert advice.... diet
Patients often have a poor sleep pattern, waking exhausted. Unexplained headache, urinary frequency and abdominal symptoms are common, but no cause has been found. Patients generally score highly on measures of anxiety and DEPRESSION. Fibromyalgia is not an ideal description; idiopathic di?use-pain syndrome and non-restorative sleep disorder are increasingly preferred terms.
Clinical ?ndings are generally unremarkable; most important is the presence of multiple hyperalgesic tender sites (e.g. low cervical spine, low lumbar spine, suboccipital muscle, mid upper trapezius, tennis-elbow sites, upper outer quadrants of buttocks, medial fat pad of knees). In ?bromyalgia, hyperalgesia (excessive discomfort) is widespread and symmetrical, but absent at sites normally non-tender. Claims by patients to be tender all over are more likely to be due to fabrication or psychiatric disturbance. OSTEOARTHRITIS and periarticular syndrome are much more common and should be excluded, together with other conditions, such as hypothyroidism (see THYROID GLAND, DISEASES OF), SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) and in?ammatory myopathy (see MUSCLES, DISORDERS OF), which may present with similar symptoms.
Cause There is no investigational evidence of in?ammatory, metabolic or structural abnormality, and the problem seems functional rather than pathological. SEROTONIN de?ciency has a signi?cant role in ?bromyalgia syndrome.
Management Controlled trials have con?rmed the usefulness of low-dose AMITRIPTYLINE or DOTHIEPIN together with a graded exercise programme to increase aerobic ?tness. How this works is still unclear; its e?cacy may be due to its normalising effects on the sleep centre or ‘pain gating’ (reduction of pain sensation) at the spinal-cord level. Prognosis is often poor. Nevertheless, suitable advice and training can help most patients to learn to cope better with their condition and avoid unnecessary investigations and drug treatments.... fibromyalgia syndrome
Cryosurgery causes only minimal scarring and is used to treat cancerous tumours in sites where heavy scarring can block vital openings such as in the cervix, the liver, and the intestines.
It may be used in eye operations, for example in cataract surgery and treatment for retinal detachment.
It is also commonly used for removing warts, skin tags, some birthmarks, some skin cancers, and to treat haemorrhoids.... cryosurgery
The tumour is hard, with a well-defined edge.
The tumours occur most frequently in women who have had children.
They may also arise at the sites of old surgical incisions.
Surgical removal is the usual treatment.... desmoid tumour
Shigellosis This form is usually caused by Shigella dysenteriae-1 (Shiga’s bacillus), Shigella ?exneri, Shigella boydii, and Shigella sonnei; the latter is the most benign and occurs in temperate climates also. It is transmitted by food and water contamination, by direct contact, and by ?ies; the organisms thrive in the presence of overcrowding and insanitary conditions. The incubation is between one and seven days, and the severity of the illness depends on the strain responsible. Duration of illness varies from a few days to two weeks and can be particularly severe in young, old, and malnourished individuals. Complications include perforation and haemorrhage from the colo-rectum, the haemolytic uraemic syndrome (which includes renal failure), and REITER’S SYNDROME. Diagnosis is dependent on demonstration of Shigella in (a) faecal sample(s) – before or usually after culture.
If dehydration is present, this should be treated accordingly, usually with an oral rehydration technique. Shigella is eradicated by antibiotics such as trimethoprimsulphamethoxazole, trimethoprim, ampicillin, and amoxycillin. Recently, a widespread resistance to many antibiotics has developed, especially in Asia and southern America, where the agent of choice is now a quinolone compound, for example, cipro?oxacin; nalidixic acid is also e?ective. Prevention depends on improved hygiene and sanitation, careful protection of food from ?ies, ?y destruction, and garbage disposal. A Shigella carrier must not be allowed to handle food.
Entamoeba histolytica infection Most cases occur in the tropics and subtropics. Dysentery may be accompanied by weight loss, anaemia, and occasionally DYSPNOEA. E. histolytica contaminates food (e.g. uncooked vegetables) or drinking water. After ingestion of the cyst-stage, and following the action of digestive enzymes, the motile trophozoite emerges in the colon causing local invasive disease (amoebic colitis). On entering the portal system, these organisms may gain access to the liver, causing invasive hepatic disease (amoebic liver ‘abscess’). Other sites of ‘abscess’ formation include the lungs (usually right) and brain. In the colo-rectum an amoeboma may be di?cult to di?erentiate from a carcinoma. Clinical symptoms usually occur within a week, but can be delayed for months, or even years; onset may be acute – as for Shigella spp. infection. Perforation, colo-rectal haemorrhage, and appendicitis are unusual complications. Diagnosis is by demonstration of E. histolytica trophozoites in a fresh faecal sample; other amoebae affecting humans do not invade tissues. Research techniques can be used to di?erentiate between pathogenic (E. dysenteriae) and non-pathogenic strains (E. dispar). Alternatively, several serological tests are of value in diagnosis, but only in the presence of invasive disease.
Treatment consists of one of the 5nitroimidazole compounds – metronidazole, tinidazole, and ornidazole; alcohol avoidance is important during their administration. A ?ve- to ten-day course should be followed by diloxanide furoate for ten days. Other compounds – emetine, chloroquine, iodoquinol, and paromomycin – are now rarely used. Invasive disease involving the liver or other organ(s) usually responds favourably to a similar regimen; aspiration of a liver ‘abscess’ is now rarely indicated, as controlled trials have indicated a similar resolution rate whether this technique is used or not, provided a 5-nitroimidazole compound is administered.... dysentery
Habitat: Grows abundantly throughout France, Spain, and large areas of Central
Europe.Part used ? Large quantities of Gentiana lutea root are imported into this country as it is preferred to the English variety (Gentiana campestris—see below) for no very apparent therapeutic reason. It is certain, however, that Gentian root, of whichever kind, is the most popular of all herbal tonics and stomachics—and deservedly so.Features ? Gentiana lutea root is cylindrical in form, half to one inch thick, and ringed in the upper portion, the lower being longitudinally wrinkled. It is flexible and tough, internally spongy and nearly white when fresh, an orange-brown tint and strong distinctive odour developing during drying. The taste is extremely bitter.A decoction of 1 ounce to 1 pint (reduced from 1 1/2 pints) of water, given in wineglass doses, will be found very helpful in dyspepsia and loss of tone, or general debility of the digestive organs. One of the effects of the medicine is to stimulate the nerve-endings of taste, thus increasing the flow of gastric juice. As a simple bitter it may be given in all cases when a tonic is needed.The English Gentian (also known locally as Baldmoney and Felwort) grows to six inches high and is branched above. Leaves opposite, ovate- lanceolate above and ovate-spatulate below, entire margins. Flowers are bluish-purple. The whole herb may be used for the same purposes as the foreign root, although here also the root contains the more active principles.... gentianVarieties Haemorrhoids are classi?ed into ?rst-, second- and third-degree, depending on how far they prolapse through the anal canal. First-degree ones do not protrude; second-degree piles protrude during defaecation; third-degree ones are trapped outside the anal margin, although they can be pushed back. Most haemorrhoids can be described as internal, since they are covered with glandular mucosa, but some large, long-term ones develop a covering of skin. Piles are usually found at the three, seven and eleven o’clock sites when viewed with the patient on his or her back.
Causes The veins in the anus tend to become distended because they have no valves; because they form the lowest part of the PORTAL SYSTEM and are apt to become over?lled when there is the least interference with the circulation through the portal vein; and partly because the muscular arrangements for keeping the rectum closed interfere with the circulation through the haemorrhoidal veins. An absence of ?bre from western diets is probably the most important cause. The result is that people often strain to defaecate hard stools, thus raising intra-abdominal pressure which slows the rate of venous return and engorges the network of veins in the anal mucosa. Pregnancy is an important contributory factor in women developing haemorrhoids. In some people, haemorrhoids are a symptom of disease higher up in the portal system, causing interference with the circulation. They are common in heart disease, liver complaints such as cirrhosis or congestion, and any disease affecting the bowels.
Symptoms Piles cause itching, pain and often bleeding, which may occur whenever the patient defaecates or only sometimes. The piles may prolapse permanently or intermittently. The patient may complain of aching discomfort which, with the pain, may be worsened.
Treatment Prevention is important; a high-?bre diet will help in this, and is also necessary after piles have developed. Patients should not spend a long time straining on the lavatory. Itching can be lessened if the PERINEUM is properly washed, dried and powdered. Prolapsed piles can be replaced with the ?nger. Local anaesthetic and steroid ointments can help to relieve symptoms when they are relatively mild, but do not remedy the underlying disorder. If conservative measures fail, then surgery may be required. Piles may be injected, stretched or excised according to the patient’s particular circumstances.
Where haemorrhoids are secondary to another disorder, such as cancer of the rectum or colon, the underlying condition must be treated – hence the importance of medical advice if piles persist.... haemorrhoids
Symptoms Symptoms vary with the age of infection. In young infants, herpes simplex may cause a generalised infection which is sometimes fatal. In young children the infection is usually in the mouth, and this may be associated with enlargement of the glands in the neck, general irritability and fever. The condition usually settles in 7–10 days. In adults the vesicles may occur anywhere in the skin or mucous membranes: the more common sites are the lips, mouth and face, where they are known as cold sores. The vesicles may also appear on the genitalia (herpes genitalis) or in the conjunctiva or cornea of the EYE, and the brain may be infected, causing ENCEPHALITIS or MENINGITIS. The ?rst sign is the appearance of small painful swellings; these quickly develop into vesicles which contain clear ?uid and are surrounded by a reddened area of skin. Some people are particularly liable to recurrent attacks, and these often tend to be associated with some debilitating condition or infection, such as pneumonia.
Except in the case of herpes of the cornea, the eruption clears completely unless it becomes contaminated with some other organism. In the case of the cornea, there may be residual scarring, which may impair vision.
Treatment Aciclovir is e?ective both topically as cream or eye drops or orally. In severe systemic infections it can be given intravenously.... herpes simplex
The number of homosexual men and women in the UK is unknown. Re-analysis of the Kinsey report suggests that only 3 per cent of adult men have exclusively homosexual leanings and a further 3 per cent have extensive homosexual and heterosexual experience. Homosexuality among women (lesbianism) seems to be less common. Some homosexual men have high rates of sexual activity and multiple partners and, as with heterosexual men and women, this increases the risk of acquiring sexually transmitted diseases, unless appropriate precautionary measures are taken – for example, the use of condoms for penetrative sex, whether vaginal or anal. It was in homosexual males that the virus responsible for AIDS (see AIDS/HIV) was ?rst identi?ed, but the infection now occurs in both sexes.... homosexuality
Insulin is extracted mainly from pork pancreas and puri?ed by crystallisation; it may be made biosynthetically by recombinant DNA technology using Escherichia coli, or semisynthetically by enzymatic modi?cation of porcine insulin to produce human insulin. The latter is the form now generally used, although some patients ?nd it unsuitable and have to return to porcine insulin.
The hormone acts by enabling the muscles and other tissues requiring sugar for their activity to take up this substance from the blood. All insulin preparations are to a greater or lesser extent immunogenic in humans, but immunological resistance to insulin action is uncommon.
Previously available in three strengths, of 20, 40, and 80 units per millilitre (U/ml), these have now largely been replaced by a standard strength of 100 U/ml (U100). Numerous different insulin preparations are listed; these differ in their speed of onset and duration of action, and hence vary in their suitability for individual patients.
Insulin is inactivated by gastrointestinal enzymes and is therefore generally given by subcutaneous injection, usually into the upper arms, thighs, buttocks, or abdomen. Some insulins are also available in cartridge form, which may be administered by injection devices (‘pens’). The absorption may vary from di?erent sites and with strenuous activity. About 25 per cent of diabetics require insulin treatment: most children from the onset, and all patients presenting with ketoacidosis. Insulin is also often needed by those with a rapid onset of symptoms such as weight loss, weakness, and sometimes vomiting, often associated with ketonuria.
The aim of treatment is to maintain good control of blood glucose concentration, while avoiding severe HYPOGLYCAEMIA; this is usually achieved by a regimen of preprandial injections of short-acting insulin (often with a bedtime injection of long-acting insulin). Insulin may also be given by continuous subcutaneous infusion with an infusion pump. This technique has many disadvantages: patients must be well motivated and able to monitor their own blood glucose, with access to expert advice both day and night; it is therefore rarely used.
Hypoglycaemia is a potential hazard for many patients converting from porcine to human insulin, because human insulin may result in them being unaware of classical hypoglycaemic warning symptoms. Drivers must be particularly careful, and individuals may be forbidden to drive if they have frequent or severe hypoglycaemic attacks. For this reason, insurance companies should be warned, and diabetics should – after taking appropriate medical advice – either return to porcine insulin or consider stopping driving.... insulin
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