MEDICAL AND HEALTHY

Arthritis Advice

2012-01-02T00:39:00.000-08:00

Half of all people age 65 and older have arthritis. There are over 100 different forms of arthritis and many different symptoms and treatments. We do not know what causes most forms of arthritis. Some forms are better understood than others.

Arthritis causes pain and loss of movement. It can affect joints in any part of the body. Arthritis is usually chronic, meaning it can occur over a long period of time. The more serious forms can cause swelling, warmth, redness, and pain. The three most common kinds of arthritis in older people are osteoarthritis, rheumatoid arthritis, and gout.

Common Forms of Arthritis

Osteoarthritis (OA), at one time called degenerative joint disease, is the most common type of arthritis in older people. Symptoms can range from stiffness and mild pain that comes and goes to severe joint pain and even disability.

OA usually affects the hands and the large weight-bearing joints of the body: the knees and hips. Early in the disease, pain occurs after activity and rest brings relief; later on, pain occurs with very little movement, even during rest.

Scientists think that several factors may cause OA in different joints. OA in the hands or hips may run in families. OA in the knees is linked with being overweight. Injuries or overuse may cause OA in joints such as knees, hips, or hands.

Rheumatoid arthritis (RA) can be one of the more disabling forms of arthritis. Signs of RA often include morning stiffness, swelling in three or more joints, swelling of the same joints on both sides of the body (both hands, for example), and bumps (or nodules) under the skin most commonly found near the elbow. RA can occur at any age and affects women about three times more often than men.

Scientists don't know what causes RA but think it has something to do with a breakdown in the immune system, the body's defense against disease. It is also likely that people who get RA have certain inherited traits (genes) that cause a disturbance in the immune system.

Gout occurs most often in older men. It affects the toes, ankles, elbows, wrists, and hands. An acute attack of gout is very painful. Swelling may cause the skin to pull tightly around the joint and make the area red or purple and very tender. Medicines can stop gout attacks, as well as prevent further attacks and damage to the joints.

Treatments

Treatments for arthritis work to reduce pain and swelling, keep joints moving safely, and avoid further damage to joints. Treatments include medicines, special exercise, use of heat or cold, weight control, and surgery.

Medicines help relieve pain and reduce swelling. Acetaminophen or ACT should be the first drug used to control pain in patients with osteoarthritis (OA). Patients with OA who don't respond to ACT and patients with RA and gout are most commonly treated with nonsteroidal anti-inflammatory drugs such as ibuprofen. People taking medicine for any form of arthritis should limit the amount of alcohol they drink. (For more information, see the Age Page "Arthritis Medicines.")

Exercise, such as a daily walk or swim, helps keep joints moving, reduces pain, and strengthens muscles around the joints. Rest is also important for the joints affected by arthritis. Physical therapists can develop personal programs that balance exercise and rest.

Many people find that soaking in a warm bath, swimming in a heated pool, or applying heat or cold to the area around the joint helps reduce pain. Controlling or losing weight can reduce the stress on joints and can help avoid further damage.

When damage to the joints becomes disabling or when other treatments fail to reduce pain, your doctor may suggest surgery. Surgeons can repair or replace damaged joints with artificial ones. The most common operations are hip and knee replacements.

Unproven Remedies

Arthritis symptoms may go away by themselves but then come back weeks, months, or years later. This may be why many people with arthritis try quack cures or remedies that have not been proven instead of getting medical help. Some of these remedies, such as snake venom, are harmful. Others, such as copper bracelets, are harmless but also useless. The safety of many quack cures is unknown.

Here are some tipoffs that a remedy may be unproven: claims that a treatment like a lotion or cream works for all types of arthritis and other diseases too; scientific support comes from only one research study; or the label has no directions for use or warnings about side effects.

Common Warning Signs of Arthritis

Swelling in one or more joint(s)
Morning stiffness lasting 30 minutes or longer
Joint pain or tenderness that is constant or that comes and goes
Not being able to move a joint in the normal way
Redness or warmth in a joint
Weight loss, fever, or weakness and joint pain that can't be explained

If any one of these symptoms lasts longer than 2 weeks, see your regular doctor or a doctor who specializes in arthritis (a rheumatologist). The doctor will ask questions about the history of your symptoms and do a physical exam. The doctor may take x-rays or do lab tests before developing a treatment plan.

Resources

For more information on arthritis contact:

National Institute of Arthritis and Musculoskeletal and Skin Diseases
Building 31, Room 4C05
Bethesda, MD 20892
(301) 496-8188

The Arthritis Foundation
P.O. Box 19000
Atlanta, GA 30325
(800) 283-7800

For a list of free publications from the National Institute on Aging (NIA), contact the NIA Information Center, P.O. Box 8057, Gaithersburg, MD 20898-8057; 1-800-222-2225;

Arthritis Drugs for Rheumatoid Arthritis and Osteoarthritis

2011-12-28T09:57:00.000-08:00

Arthritis treatments aim to relieve pain, reduce inflammation, and slow or stop joint damage to maintain or restore the patient's functional ability and quality of life. Arthritis therapies generally used today address the medical needs of many patients. However, these therapies are occasionally associated with harmful side effects ranging from mild to severe. Medical research continues to search for effective, fast-acting treatments with fewer side effects.

New arthritis drugs designed to meet these treatment needs are presently available or awaiting approval by the U.S. Food and Drug Administration (FDA). The foundation for these new drugs was laid in basic biomedical research supported by the National Institutes of Health.

Drug Category: Biological Response Modifiers for Rheumatoid Arthritis

Description: One class of drugs in this category reduces inflammation in the joints by blocking the action of a substance called tumor necrosis factor (TNF). TNF is a protein of the body's immune system that triggers inflammation during normal immune responses; however, when overproduced, TNF can lead to excessive inflammation such as that experienced by patients with rheumatoid arthritis.

Medication (drug name): Kineret® (anakinra)

Description: Kineret® is the first direct and selective blocker of interleukin-1 (IL-1), a protein seen in excess in patients with rheumatoid arthritis. By blocking IL-1, Kineret® inhibits the inflammatory response in rheumatoid arthritis.

How taken: Daily subcutaneous (under the skin) injections by the patient or health care provider

Most common side effects: mild injection-site reactions (redness, pain, swelling)

Drug status: approved by the FDA; can be used alone or in combination with disease-modifying antirheumatic drugs that are not tumor necrosis factor (TNF) blocking agents

For more information:
Amgen Inc.
One Amgen Center Drive
Thousand Oaks, CA 91320-1799
1-866-Kineret
World Wide Web Address: http://www.kineretrx.com

Medication (drug name): Enbrel® (etanercept)

How taken: twice-weekly subcutaneous (under the skin) injections by the patient or health care provider

Most common side effects: mild to moderate injection-site reactions (itching, pain, swelling)

Drug status: approved by the FDA; not recommended for patients with active infections; caution should be used in patients with a history of infections or those who develop new infections while taking Enbrel®; not recommended for pregnant women.

For more information:
Immunex Corporation
51 University Street
Seattle, WA 98101
(800) 436-2735
World Wide Web Address: http://www.enbrelinfo.com/

Medication (drug name): Remicade® (infliximab)

How taken: intravenous (in the vein) injections by the health care provider once every 8 weeks

Most common side effects: mild infusion reactions

Drug status: approved by the FDA for use in combination with methotrexate; not recommended for pregnant women

For more information:
Centocor
200 Great Valley Parkway
Malvern, PA 19355
(800) 457-6399
World Wide Web Address: http://www.centocor.com/

Drug Category: Disease-Modifying Antirheumatic Drugs (DMARDs) for Rheumatoid Arthritis

Description: These are the mainstay arthritis drugs that are known to relieve painful, swollen joints and to slow joint damage.

Medication (drug name): Arava® (leflunomide)

How taken: orally, once daily

Most common side effects: diarrhea, hair loss, rash

Drug status: approved by the FDA; not recommended for pregnant women

For more information:
Aventis
P.O. Box 9627
Kansas City, MO 64134-0627
(816) 966-4000
World Wide Web Address: http://www.aventis.com/

Drug Category: Nonsteroidal Anti-Inflammatory Drugs (NSAIDs), Specifically Cyclo-Oxygenase-2 (COX-2) Inhibitors, for Rheumatoid Arthritis and Osteoarthritis

Description: COX-2 inhibitors, like traditional NSAIDs, block COX-2, an enzyme in the body known to stimulate an inflammatory response. Unlike traditional NSAIDs, however, they do not block the action of COX-1, an enzyme known to protect the stomach lining. Therefore, drugs in this category reduce joint pain and inflammation with reduced risk of gastrointestinal ulceration and bleeding.

Medication (drug name): Celebrex® (celecoxib) for rheumatoid arthritis and osteoarthritis

How taken: orally once or twice daily, dosage determined by the physician

Most common side effects: abdominal pain, nausea, indigestion, diarrhea

Drug status: approved by the FDA

For more information:
G.D. Searle & Company
5200 Old Orchard Road
Skokie, IL 60077
World Wide Web Address: http://www.searle.com/

Medication (drug name): Vioxx® (rofecoxib) for rheumatoid arthritis and osteoarthritis, as well as acute pain associated with primary dysmenorrhea (painful menstruation) and postsurgical pain

How taken: orally, once daily

Most common side effects: abdominal pain, diarrhea, indigestion, insomnia, edema

Drug status: approved by the FDA

For more information:
Merck & Co., Inc.
One Merck Drive
Whitehouse Station, NJ 08889-0100
World Wide Web Address: http://www.merck.com/product/usa/

Drug Category: Other Products

Description: Hyaluronic acid viscosupplementation products for osteoarthritis. These products mimic a naturally occurring substance in the body called hyaluronic acid by providing lubrication to the knee joint, thus permitting flexible joint movement without pain.

Medication (drug name): Hyalgan® (hyaluronan)

How taken: a series of five injections per knee by a health care provider over 4 weeks

Most common side effects: some pain and swelling at the injection site

Drug status: approved by the FDA

For more information:
Sanofi~Synthelabo, Inc.
90 Park Avenue
New York, NY 10016
(800) 446-6267
World Wide Web Address: http://www.hyalgan.com/

Medication (drug name): Synvisc® (hylan G-F20)

How taken: a series of three injections per knee by a health care provider over a 15-day period

Most common side effects: some pain and swelling at the injection site

Drug status: approved by the FDA

For more information:
Genzyme Biosurgery
One Kendall Square
Cambridge, MA 02139
(800) 666-7248
World Wide Web Address: http://www.synvisc.com or http://www.genzymebiosurgery.com

Description: Blood filtering device for severe rheumatoid arthritis. This device is designed to remove harmful antibodies from the patient's immune system, thus lowering disease activity associated with severe rheumatoid arthritis.

Device (device name): Prosorba Column® (apheresis)

How used: The device consists of a catheter, tubing, and a column. The catheter and tubing are used to filter the patient's blood through the column (which is coated with protein A, a substance that attracts harmful antibodies), then reinfuse it into the patient's body. The procedure takes 2 hours and is performed weekly at a health care facility for 12 weeks.

Most common side effects: flu-like symptoms (chills, fever, nausea, and joint/muscle pain)

Drug status: approved by the FDA

For more information:
Frenesius HemoCare, Inc.
6675 185th Avenue NE, Suite 100
Redmond, WA 98052
(800) 909-3872 or 425-497-1197
World Wide Web Address: http://www.freseniushc.com/

Additional Resources

To find out more about these drugs and devices, including dosage, full range of side effects, and study results, check the following resources:
National Library of Medicine's (NLM's) Internet Grateful Med is a computer system that allows users to search through 15 of the NLM's databases for bibliographic references and abstracts on medical and scientific information pertaining to rheumatic diseases, including treatments.
World Wide Web Address: http://www.nlm.nih.gov/

U.S. Food and Drug Administration (FDA), Center for Evaluation and Research, provides information on drugs that have been approved, as well as those undergoing the approval process.
World Wide Web Address: http://www.fda.gov/cder/

The Arthritis Foundation offers The Drug Guide, a reprint from Arthritis Today. World Wide Web Address: http://www.arthritis.org/

Local public university libraries have journals on rheumatic diseases and pharmaceutical (drug) therapies, as well as reference books such as the Physician's Desk Reference, an annually updated guide that describes the use, effects, dosages, and administration of FDA-approved drugs, as well as warnings, side effects, and precautions. Many libraries also provide computers with public access to the Internet.

Breast Cancer and Pregnancy

2011-12-14T09:17:00.000-08:00

General Information about Breast Cancer and Pregnancy

Breast cancer is a disease in which malignant (cancer) cells form in the tissues of the breast.

The breast is made up of lobes and ducts. Each breast has 15 to 20 sections called lobes, which have many smaller sections called lobules. The lobes and lobules are connected by thin tubes called ducts.

Each breast also contains blood vessels and lymph vessels. The lymph vessels carry an almost colorless fluid called lymph. The lymph vessels lead to small, bean-shaped organs called lymph nodes that help the body fight infection and disease. Lymph nodes are found throughout the body. Clusters of lymph nodes are found near the breast in the axilla (under the arm), above the collarbone, and in the chest.

Breast cancer is sometimes detected (found) in women who are pregnant or have just given birth.

In women who are pregnant or who have just given birth, breast cancer occurs most often between the ages of 32 and 38. Breast cancer occurs about once in every 3,000 pregnancies.

It may be difficult to detect (find) breast cancer early in pregnant or nursing women, whose breasts are often tender and swollen.

Women who are pregnant, nursing, or have just given birth usually have tender, swollen breasts. This can make small lumps difficult to detect and may lead to delays in diagnosing breast cancer. Because of these delays, cancers are often found at a later stage in these women.

Breast examination should be part of prenatal and postnatal care.

To detect breast cancer, pregnant and nursing women should examine their breasts themselves. Women should also receive clinical breast examinations during their routine prenatal and postnatal examinations.

Tests that examine the breasts are used to detect (find) and diagnose breast cancer.

If an abnormality is found, one or all of the following tests may be used:

Ultrasound: A test that uses sound waves to create images of areas inside the body. High-energy sound waves are bounced off internal tissues and organs. The echoes are changed into pictures called sonograms. The doctor can identify tumors by looking at the sonogram. Mammogram: A special x-ray of the breast that may find tumors that are too small to feel. A mammogram can be performed with little risk to the fetus. Mammograms in pregnant women may appear negative even though cancer is present. Biopsy: The removal of cells, tissues, or fluid to view under a microscope and check for signs of disease.

Certain factors affect treatment options and prognosis (chance of recovery).

The treatment options and prognosis (chance of recovery) depend on the stage of the cancer (whether it is in the breast only or has spread to other places in the body), the tumor size, the type of breast cancer, the age of the fetus, whether there are symptoms, and the patient's general health.

Survival rates of pregnant women with breast cancer may be lower than for women who are not pregnant.

Pregnant women with breast cancer may be less likely to survive because the diagnosis of their cancer is often delayed and the cancers are more advanced when they are found. Cancers found at later stages are more difficult to treat successfully.

Stages of Breast Cancer

After breast cancer has been diagnosed, tests are done to find out if cancer cells have spread within the breast or to other parts of the body.

The process used to find out if the cancer has spread within the breast or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan the best treatment. (Refer to the PDQ summary on Breast Cancer Treatment for more information on the stages used for breast cancer.)

Methods used to stage breast cancer can be changed to make them safer for the fetus.

Standard methods for giving imaging scans can be adjusted so that the fetus is exposed to less radiation. Tests to measure the level of hormones in the blood may also be used in the staging process.

Treatment Option Overview

There are different types of treatment for patients with breast cancer.

Different types of treatment are available for patients with breast cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. Before starting treatment, patients may want to think about taking part in a clinical trial. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the "standard" treatment, the new treatment may become the standard treatment.

Clinical trials are taking place in many parts of the country. Information about ongoing clinical trials is available from the NCI Cancer.gov Web site. Choosing the most appropriate cancer treatment is a decision that ideally involves the patient, family, and health care team.

Treatment options for pregnant women depend on the stage of the disease and the age of the fetus.

Three types of standard treatment are used:

Surgery

Most patients with breast cancer have surgery to remove the cancer from the breast. Some of the lymph nodes under the arm are usually taken out and looked at under a microscope to see if they contain cancer cells.

Breast-conserving surgery, an operation to remove the cancer but not the breast itself, includes the following:

Lumpectomy: Removal of the tumor and a small amount of normal tissue around it. Lumpectomy is usually followed by radiation therapy to the breast. Most doctors also take out some of the lymph nodes under the arm. Partial or segmental mastectomy: Removal of the cancer, some of the breast tissue around the tumor, and the lining over the chest muscles below the tumor. Some of the lymph nodes under the arm are usually taken out. In most cases, partial mastectomy is followed by radiation therapy.

Other types of surgery include the following:
Total or simple mastectomy: Removal of the whole breast. Sometimes lymph nodes under the arm are also taken out.
Modified radical mastectomy: Removal of the breast, many of the lymph nodes under the arm, the lining over the chest muscles, and sometimes, part of the chest wall muscles.

Even if the doctor removes all of the cancer that can be seen at the time of surgery, the patient may be given radiation therapy, chemotherapy, or hormone therapy after surgery to try to kill any cancer cells that may be left. Treatment given after surgery to increase the chances of a cure is called adjuvant therapy.

Radiation therapy

Radiation therapy is the use of x-rays or other types of radiation to kill cancer cells and shrink tumors. Radiation therapy may use external radiation (using a machine outside the body) or internal radiation. Internal radiation involves putting radioisotopes (materials that produce radiation) through thin plastic tubes into the area where cancer cells are found. Radiation may be used after surgery in addition to chemotherapy, and hormone therapy. Breast cancer is treated with external radiation.

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells. Chemotherapy may be taken by mouth, or it may be put into the body by inserting a needle into a vein or muscle. Either type of chemotherapy is called systemic treatment because the drugs enter the bloodstream, travel through the body, and can kill cancer cells throughout the body.

Chemotherapy should not be given during the first 3 months of pregnancy. Chemotherapy given after this time does not usually harm the fetus but may cause early labor and low birth weight.

Other types of treatment are being tested in clinical trials. These include the following:

Hormone therapy

Hormones are chemicals produced by glands in the body and are circulated in the bloodstream. Estrogen and progesterone are hormones that affect the way some cancers grow. If tests show that the cancer cells have estrogen and progesterone receptors (molecules found in some cancer cells to which estrogen and progesterone will attach), hormone therapy is used to block the way these hormones help the cancer grow. This may be done by using drugs that block the way hormones work or by surgically removing organs that make hormones, such as the ovaries.

The effectiveness of hormone therapy, alone or combined with chemotherapy, in treating breast cancer in pregnant women is not yet known.

This summary section refers to specific treatments under study in clinical trials, but it may not mention every new treatment being studied. Information about ongoing clinical trials is available from the NCI Cancer.gov Web site.

Ending the pregnancy does not seem to improve the mother's chance of survival and is not usually a treatment option.

If the cancer must be treated with chemotherapy and radiation therapy, which may harm the fetus, ending the pregnancy is sometimes considered. This decision may depend on the stage of cancer, the age of the fetus, and the mother's chance of survival.

Treatment Options by Stage

Early Stage Breast Cancer (Stage I and Stage II)

Treatment of early stage breast cancer (stage I and stage II) may be surgery followed by adjuvant therapy as follows:

Modified radical mastectomy. Breast-conserving surgery: Lumpectomy, partial mastectomy or segmental mastectomy. Surgery during pregnancy followed by radiation therapy after the baby is born. Surgery during pregnancy followed by chemotherapy after the first 3 months of pregnancy. Clinical trials of surgery followed by hormone therapy with or without chemotherapy.

This summary section refers to specific treatments under study in clinical trials, but it may not mention every new treatment being studied. Information about ongoing clinical trials is available from the NCI Cancer.gov Web site.

Late Stage Breast Cancer (Stage III and Stage IV)

Treatment of late stage breast cancer (stage III and stage IV) may include the following:
Radiation therapy.
Chemotherapy.

Other Considerations for Pregnancy and Breast Cancer

Lactation (breast milk production) and breast-feeding should be stopped if surgery or chemotherapy is planned.

If surgery is planned, breast-feeding should be stopped to reduce blood flow in the breasts and make them smaller. Breast-feeding should also be stopped if chemotherapy is planned. Many anticancer drugs, especially cyclophosphamide and methotrexate, may occur in high levels in breast milk and may harm the nursing baby. Women receiving chemotherapy should not breast-feed. Stopping lactation does not improve survival of the mother.

Breast cancer does not appear to harm the fetus.
Breast cancer cells do not seem to pass from the mother to the fetus.
Pregnancy does not seem to affect the survival of women who have had breast cancer in the past.

Some doctors recommend that a woman wait 2 years after treatment for breast cancer before trying to have a baby, so that any early return of the cancer would be detected. This may affect a woman's decision to become pregnant. The fetus does not seem to be affected if the mother has previously had breast cancer.

Effects of certain cancer treatments on later pregnancies are not known.

The effects of treatment with high-dose chemotherapy and a bone marrow transplant, with or without radiation therapy, on later pregnancies are not known.

To Learn More

Call

For more information, U.S. residents may call the National Cancer Institute's (NCI's) Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) Monday through Friday from 9:00 a.m. to 4:30 p.m. Deaf and hard-of-hearing callers with TTY equipment may call 1-800-332-8615. The call is free and a trained Cancer Information Specialist is available to answer your questions.

Web sites and Organizations

The NCI's Cancer.gov Web site provides online access to information on cancer, clinical trials, and other Web sites and organizations that offer support and resources for cancer patients and their families. There are also many other places where people can get materials and information about cancer treatment and services. Local hospitals may have information on local and regional agencies that offer information about finances, getting to and from treatment, receiving care at home, and dealing with problems associated with cancer treatment.

Publications

The NCI has booklets and other materials for patients, health professionals, and the public. These publications discuss types of cancer, methods of cancer treatment, coping with cancer, and clinical trials. Some publications provide information on tests for cancer, cancer causes and prevention, cancer statistics, and NCI research activities. NCI materials on these and other topics may be ordered online or printed directly from the NCI Publications Locator. These materials can also be ordered by telephone from the Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237), TTY at 1-800-332-8615.

Splenomegaly – Symptoms And Causes

2011-12-06T08:15:00.000-08:00

Splenomegaly is defined as enlargement of the spleen, exceeding the limits of physiological variations. The spleen has an average weight of 180-250 g lower in women and older men than men with the physiological property to relax for blood storage and to contract, throwing blood rich in red blood cells into circulation in case of effort or major bleeding. Splenomegaly must be distinguished from organ changes that occur in the same external region of the body in which the spleen is situated (enlarged left lobe of the liver, kidney tumors , splenic left angle tumors of the colon, pancreas tail tumors, spine tumors, uterine fibroids or cysts ovary.

Splenomegaly sometimes causes a feeling of heaviness in the left upper quadrant (upper left abdomen) and pain. Also, these changes should be considered when the cause of an illenes is not detected, the cause of splenomegaly must be found eliminating infectious diseases, parasitic diseases, taking into account the physiology and functional links with other organs of the spleen, hematopoietic system diseases, liver diseases.

Splenomegaly symptoms

Splenomegaly symptoms include mild pain, sensation of weight in the spleen area, the spleen may be palpable, under ribs (normal spleen is not palpable, and increases its volume only in pathological conditions). Palpation along with imaging test are indispensable to diagnose splenomegaly.

Splenomegaly causes

Different diseases or infections can cause splenomegaly: liver disease as cirrhosis, bacterial infections: septicemia, typhoid and paratyphoid, brucellosis, tuberculosis, systemic diseases: lupus erythematosus, sarcoidosis or amyloidosis, haematological diseases: leukemia or myeloid splenomegaly, parasitic diseases like malaria, viral diseases: infectious mononucleosis. Splenomegaly may be caused by certain diseases such as blood diseases, viral diseases, liver diseases, parasites, bacteria, cysts and tumors.

Splenomegaly may be confused sometimes with a large left kidney, a tumor of the colon or left liver lobe hypertrophy. It can also be caused by infectious diseases such as typhoid fever, endocarditis, infectious mononucleosis, streptococcal septicemia and parasitic splenomegaly (malaria, spleen hydatid cyst), splenic tumors, hypersplenism (exaggerated destruction of red blood cells and platelets), cirrhosis, haemolytic anemia , septicemia, brucellosis, tuberculosis, lupus erythematosus, leukemia or myeloid splenomegaly, infectious mononucleosis. The diagnosis of splenomegaly is achieved by X-rays, echography, chest puncture, blood examination, splenic puncture, liver tests, etc..

Treatment depends on the disease that lead to splenomegaly. Chemotherapy in splenomegaly is used in the case of hematological malignancies, antibiotics in infections, and surgery in the case of splenic abscess. Voluminous spleen predisposes to a ruptured spleen by abdominal wounds or chest trauma. Morbidity and mortality in case of splenomegaly results from associated diseases and surgical procedures.

Coffee linked to heart attack for persons with certain gene variation

2011-11-28T23:04:00.000-08:00

Related

L-arginine supplement following a heart attack may be harmful

Individuals who have a genetic variation associated with slower caffeine metabolism appear to have an increased risk of non-fatal heart attack associated with higher amounts of coffee intake, according to a study in the March 8 issue of JAMA.

Studies examining the association between coffee consumption and risk of myocardial infarction (MI � heart attack) have been inconclusive. Coffee is a major source of caffeine, which is the most widely consumed stimulant in the world and has been implicated in the development of cardiovascular diseases such as heart attack, according to background information in the article. However, coffee contains a number of other chemicals that have variable effects on the cardiovascular system. It is not clear whether caffeine alone affects the risk of heart attack or whether other chemicals found in coffee may be responsible. Caffeine is metabolized primarily by the enzyme cytochrome P450 1A2 (CYP1A2) in the liver. Variations of the gene for this enzyme can slow or quicken caffeine metabolism. Carriers of the gene variant CYP1A2*1F allele are "slow" caffeine metabolizers, while individuals with the gene variant CYP1A2*1A allele are "rapid" caffeine metabolizers.

Ahmed El-Sohemy, Ph.D., of the University of Toronto, and colleagues conducted a study to determine whether gene variations of CYP1A2 modifies the association between consumption of caffeinated coffee and risk of nonfatal heart attack. The study included 2,014 case patients with a first acute nonfatal heart attack and 2,014 controls, living in Costa Rica between 1994 and 2004. The genotypes of the participants were determined. A food frequency questionnaire was used to assess the intake of caffeinated coffee.
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Fifty-five percent of cases (n = 1,114) and 54 percent of controls (n = 1,082) were carriers of the slow *1F allele. For carriers of the slow *1F allele, those who drank 2 to 3 cups of coffee a day had a 36 percent increased odds of heart attack; those who drank 4 or more cups per day had a 64 percent increased odds of heart attack. Corresponding consumption for individuals with the rapid *1A/*1A genotype resulted in the reduced odds of heart attack by 22 percent and 1 percent, respectively.

Among the slow metabolizers, younger individuals showed an increased risk. The risk associated with drinking 4 cups/d or more compared with less than 1 cup/d increased from 2-fold for individuals younger than 59 years to more than 4-fold for those younger than 50 years. Among the fast metabolizers who were younger than 59 years of age, those who drank 1 cup/d or 2 to 3 cups per day had a reduced odds of a heart attack by 52 percent and 43 percent, respectively.

"In summary, consistent with most case-control studies, we found that increased coffee intake is associated with an increased risk of nonfatal MI. The association between coffee and MI was found only among individuals with the slow CYP1A2*1F allele, which impairs caffeine metabolism, suggesting that caffeine plays a role in the association," the authors conclude.

Neurological Manifestations Of Aids

2011-11-15T07:43:00.000-08:00

What are the neurological manifestations of AIDS?

DESCRIPTION: Acquired immune deficiency syndrome (AIDS) is the result of an infection with the human immunodeficiency virus (HIV). This virus attacks selected cells of the immune, nervous, and other systems impairing their proper function. HIV infection may cause damage to the brain and spinal cord, causing encephalitis (inflammation of the brain), meningitis (inflammation of the membranes surrounding the brain), nerve damage, difficulties in thinking (i.e., AIDS dementia complex), behavioral changes, poor circulation, headache, and stroke. AIDS-related cancers such as lymphoma and opportunistic infections (OI) may also affect the nervous system. Neurological symptoms may be mild in the early stages of AIDS, but may become severe in the final stages. Complications vary widely from one patient to another. Cerebral toxoplasmosis, a common OI in AIDS patients, causes such symptoms as headache, confusion, lethargy, and low-grade fever. Other symptoms may include weakness, speech disturbance, ataxia, apraxia, seizures, and sensory loss. Progressive multifocal leukoencephalopathy (PML), a disorder that can also occur in AIDS patients, causes weakness, hemiparesis or facial weakness, dysphasia, vision loss, and ataxia. Some patients with PML may also develop compromised memory and cognition.

Is there any treatment?

TREATMENT: There is no cure for AIDS but recently developed, experimental treatments appear very promising. Some symptoms and complications may improve with treatment. For example, antidementia drugs may relieve confusion and slow mental decline. Infections may be treated with antibiotics. Radiation therapy may be needed to treat AIDS-related cancers present in the brain or spinal cord.

What is the prognosis?

PROGNOSIS: The prognosis for individuals with AIDS in recent years has improved significantly because of new drugs and treatments, and educational and preventive efforts.

What research is being done?

RESEARCH: The NINDS supports a broad spectrum of basic and clinical research studies on the neurological complications of AIDS. Much of this research is conducted at leading biomedical research institutions across the country.

Where can I find more information?

These articles, available from a medical library, are sources of in-depth information on the neurological manifestations of AIDS:

McArthur, J. "Neurologic Manifestations of Human Immunodeficiency Virus Infection." In Diseases of the Nervous System: Clinical Neurobiology, W.B. Saunders Co., Philadelphia, pp. 1312-1330 (1992).

Mintz, M, and Epstein, L. "Neurologic Manifestations of Pediatric Acquired Immunodeficiency Syndrome: Clinical Features and Therapeutic Approaches." Seminars in Neurology, 12:1; 51-56 (March 1992).

Newton, H. "Common Neurologic Complications of HIV-1 Infection and AIDS." American Family Physician, 51:2; 387-398 (February 1, 1995).

Pajeau, A, and Roman, G. "HIV Encephalopathy and Dementia." Psychiatric Clinics of North America, 15:2; 455-466 (June 1992).

Simpson, D, and Tagliati, M. "Neurologic Manifestations of HIV Infection." Annals of Internal Medicine, 121:10; 769-785 (November 1994).

Additional information or services are available from the following organizations
(last updated April 7, 1998):

American Foundation for AIDS Research
733 Third Ave., 12th Flr.
New York, NY 10017
(212) 682-7440

Pediatric AIDS Foundation.
1311 Colorado Avenue
Santa Monica, CA 90404
(310) 395-9051

Lack of sleep linked to increased risk of high blood pressure

2011-11-03T08:14:00.000-07:00

Middle aged people who sleep 5 hours or less, may be increasing their risk of developing high blood pressure.

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If you're middle age and sleep five hours or less a night, you may be increasing your risk of developing high blood pressure, according to research reported in Hypertension: Journal of the American Heart Association.

"Sleep allows the heart to slow down and blood pressure to drop for a significant part of the day," said James E. Gangwisch, Ph.D., lead author of the study and post-doctoral fellow at Columbia University's Mailman School of Public Health.

"However, people who sleep for only short durations raise their average 24-hour blood pressure and heart rate. This may set up the cardiovascular system to operate at an elevated pressure."

Gangwisch said that 24 percent of people ages 32 to 59 who slept for five or fewer hours a night developed hypertension versus 12 percent of those who got seven or eight hours of sleep. Subjects who slept five or fewer hours per night continued to be significantly more likely to be diagnosed with hypertension after controlling for factors such as obesity, diabetes, physical activity, salt and alcohol consumption, smoking, depression, age, education, gender, and ethnicity.

The researchers conducted a longitudinal analysis of data from the Epidemiologic Follow-up Studies of the first National Health and Nutrition Examination Study (NHANES I). The analysis is based on NHANES I data from 4,810 people ages 32 to 86 who did not have high blood pressure at baseline. The 1982-84 follow-up survey asked participants how many hours they slept at night. During eight to 10 years of follow-up, 647 of the 4,810 participants were diagnosed with hypertension.

Compared to people who slept seven or eight hours a night, people who slept five or fewer hours a night also exercised less and were more likely to have a higher body mass index. (BMI is a measurement used to assess body fatness). They were also more likely to have diabetes and depression, and to report daytime sleepiness.

"We had hypothesized that both BMI and a history of diabetes would mediate the relationship between sleep and blood pressure, and the results were consistent with this," Gangwisch said.

Sleep deprivation has been shown previously to increase appetite and compromise insulin sensitivity.
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Short sleep duration was linked to a new diagnosis of high blood pressure among middle-aged participants, but the association was not observed among people age 60 or older, he said. Gangwisch said the differences between the younger and older subjects might be explained by the fact that advanced age is associated with difficulties falling and staying asleep. Another factor could be that subjects suffering from hypertension, diabetes, and obesity would be less likely to survive into their later years.

Among study limitations, researchers found that high blood pressure often goes undetected. An analysis of NHANES III data showed that over 30 percent of people who had high blood pressure didn't know they had it.

Since the study is based on observational data, Gangwisch said more research is needed to confirm the association between short sleep duration and high blood pressure. "We need to investigate the biological mechanisms and, if confirmed, design interventions that will help people modify sleep behavior," he said.

Gangwisch said the study's main message is clear: "A good night's sleep is very important for good health."

Polycythemia Vera Symptoms, Causes, Risk Factors Treatment And Complications

2011-10-24T04:19:00.000-07:00

Polycythemia vera is a blood disorder in which the bone marrow produces excess blood cells (erythrocytes, platelets and leukocytes). Excess blood cells causes a thickening of the blood leading to increased coagulation risk, which in turn can lead to stroke, myocardial infaction and other complications. The exact cause of polycythemia is unknown, but it is assumed that development of the disease is influenced by certain genetic changes. Polycythemia or polycythemia vera gene evolves slowly and is especially common in older people, and quite rare in young children. Although polycythemia vera is a result of a genetic mutation, these genetic abnormalities are usually acquired during the life of an individual and are not transmitted generally from parents to children. The condition is more common in adults over 60 years
Polycythemia Symptoms

In the first phase of polycythemia vera, symptoms are mild and include flushing, dizziness and impaired senses. In more severe cases thrombosis can occur (blood clotting), which leads to more serious manifestations. In later stages of polycythemia vera, long-term presence of oxygen deprivation signs are present (as in the case of chronic smokers or people who spend long periods at high altitudes) due to increased production of red blood cells and blood thickening. This form of polycythemia disappears when the oxygen deprivation cause is treated.

However, in all cases of polycythemia, improvements can be achieved by removing a quantity of blood periodically until the number of erythrocytes in blood is reduced (phlebotomy) or administering drugs that reduce the number of blood cells. Unfortunately a permanent cure for the disease does not exist.

Although polycythemia is quite rare and can be controlled, sometimes serious complications can occur such as a heart attack or stroke, in case of lack of treatment. Emergency medical intervention will be required for any symptoms that occur suddenly like weakness, confusion, vision problems or chest pain that persists.In early stages, polycythemia vera produces no symptoms. However as the disease progresses one or more polycythemia vera symptoms may be present
Headaches
Dizziness
Itching especially after bathing with hot water
Skin redness
Shortness of breath
Shortness of breath while lying down
Numbness, tingling, burning or weakness in hands, feet, arms
Feeling of fullness or bloating in the left upper abdomen due to splenomegaly
Fatigue.
Polycythemia Vera Causes

Polycythemia vera develops when a mutation in a cell in the bone marrow causes blood cell production problems. Normally, the body carefully regulates the number of existing blood three cell types but in polycythemia vera, the mechanism used by the body to control blood cell production is impaired and the bone marrow produces too many blood cells. Mutation that causes polycythemia vera role affects a protein that signals cells to grow (JAK2 V617F mutation). Most people with polycythemia vera have this mutation.

Physicians and researchers could not fully determine the role of this mutation and its implications during studies that searched for a treatment. Scientists believe that the mutation occurs after conception therefore is acquired rather than inherited.
Polycythemia Vera Risk Factors

Factors that may increase the risk of developing polycythemia vera are:
Advanced age – chances of developing polycythemia vera increases with age, being more common in adults over the age of 60 years and quite rare in people who are under 20 years
Males – polycythemia vera effects with predilection men
Medical history – family history of polycythemia vera (especially relatives) increases the risk for developing the disease.

Any person should consult a physician if any specific signs or symptoms of polycythemia vera are present. Because polycythemia vera causes a thickening of the blood it increases the risk of developing blood clots. If a clot reaches the blood vessels of the head, it can cause a stroke. Immediately seek emergency care if any of the signs or symptoms of a stroke are present such as:
Sudden numbness, weakness, paralysis of the face, limbs – usually on one side
Difficulty in understanding speech
Sudden dizziness, loss of balance or coordination
Sudden pain, headache that might be accompanied by stiff neck, facial pain, vomiting or altered consciousness
Confusion or impaired memory, poor spatial orientation or perception.
Polycythemia Vera Treatment

Polycythemia vera is treated using blood thinners to prevent clots formation. This can be done by periodic blood collection to reduce red blood cell count. In some cases, drugs that suppress the action of the bone marrow like hydroxyurea and interferon can be administered. To prevent blood clots formation aspirin can be also used, but less frequently as it may be a triggering factor for a bleeding stomach.
Polycythemia Vera Complications

Progression of polycythemia vera is usually slow and most patients do not suffer complications if the disease is well treated. In some rare complication can occur unfortunately and are serious enough to cause strokes and heart attacks.

In addition to bone marrow dysfunction, polycythemia vera can lead to myelofibrosis (scarring of the bone marrow) or in very rare cases, to leukemia. These consequences can be life threatening and the patient should be treated immediately. The risk of serious complications can be minimized by following a correct treatment plan.

Complications of polycythemia vera include:
Blood clots (thrombosis)
Enlarged spleen (splenomegaly)
Gastrointestinal bleeding
Gout
Heart failure
Leukemia
Myelofibrosis
Peptic ulcer.

Learning About Hereditary Colon Cancer

2011-10-18T10:46:00.000-07:00

What do we know about heredity and colon cancer?

Colon cancer, a malignant tumor of the large intestine, affects both men and women. In the year 2000, there were an estimated 130,200 cases diagnosed. The vast majority of colon cancer cases are not hereditary. However, approximately 5 percent of individuals with colon cancer have a hereditary form. In those families, the chances of developing colon cancer is significantly higher than in the average person.

Scientists have discovered several genes contributing to a susceptibility to two types of colon cancer: FAP (familial adenomatous polyposis) and HNPCC (hereditary nonpolyposis colorectal cancer). The risk of inheriting these mutated genes from an affected parent is 50 percent for both males and females. These hereditary cancers typically occur at an earlier age than sporadic (non-inherited) cases of colon cancer.

FAP (familial adenomatous polyposis)
So far, only one FAP gene has been discovered - the APC gene on chromosome 5. But over 300 different mutations of that gene have been identified. Individuals with this syndrome develop many polyps in their colon. People who inherit mutations in this gene have a nearly 100 percent chance of developing colon cancer by age 40.

HNPCC (hereditary non-polyposis colorectal cancer)
Individuals with an HNPCC gene mutation have an estimated 80 percent lifetime risk of developing colon or rectal cancer. However, these cancers account for only three to five percent of all colorectal cancers.

So far, four HNPCC genes have been discovered:

1.hMSH2 on chromosome 2, which accounts for 60 percent of HNPCC colon cancer cases.
2.hMLH1 on chromosome 3, which accounts for 30 percent of HNPCC colon cancer cases.
3.hPMSI on chromosome 2, which accounts for 5 percent of HNPCC colon cancer cases.
4.hPMS2 on chromosome 7, which accounts for 5 percent of HNPCC colon cancer cases.

Together, FAP and HNPCC gene mutations account for approximately 5 percent of all colorectal cancers. The genes that cause these two syndromes were relatively easy to discover because they exert strong effects. Other genes that cause susceptibility to colon cancer are harder to discover because the cancers are caused by interplay among a number of genes, which individually exert a weak effect.

Is there a test for hereditary colon cancer?

Gene testing can identify some individuals who carry genes for FAP and some HPNCC cases of colon cancer. However, the tests are not perfect at this point in time. So, some families may have alterations in the FAP or HNPCC gene that can not be detected.

The test for FAP syndrome involves examining DNA in blood cells called lymphocytes (white blood cells), looking for mutations in the APC gene. No treatment to reduce cancer risk is currently available for people with FAP. But for those who test positive, frequent surveillance can detect the cancer at an early, more treatable stage. Because of the early age at which this syndrome appears, the test may be offered to people under 18 who have a parent known to carry the mutated gene.

Researchers hope that an easier test, now experimental, will become available in three to five years. This new test examines a stool sample and looks for cancer cells sloughed off by the APC gene.

Genetic tests for HNPCC are of limited value since the current test can identify only a few mutations on two genes that cause HNPCC (hMSH2 and hMLH1). There are no clinical tests for the other two HNPCC genes.

Because of the limitations of available tests for hereditary colon cancer, testing is not recommended for the general population. However, individuals in families at high risk may consider testing. Genetic counselors can help individuals make decisions regarding testing.

The Evidence That HIV Causes AIDS, NIAID Fact Sheet

2011-10-12T09:25:00.000-07:00

The acquired immunodeficiency syndrome (AIDS) was first recognized in 1981 and has since become a major worldwide pandemic. AIDS is caused by the human immunodeficiency virus (HIV). By leading to the destruction and/or functional impairment of cells of the immune system, notably CD4+ T cells, HIV progressively destroys the body's ability to fight infections and certain cancers.

An HIV-infected person is diagnosed with AIDS when his or her immune system is seriously compromised and manifestations of HIV infection are severe. The U.S. Centers for Disease Control and Prevention (CDC) currently defines AIDS in an adult or adolescent age 13 years or older as the presence of one of 26 conditions indicative of severe immunosuppression associated with HIV infection, such as Pneumocystis carinii pneumonia (PCP), a condition extraordinarily rare in people without HIV infection. Most other AIDS-defining conditions are also "opportunistic infections" which rarely cause harm in healthy individuals. A diagnosis of AIDS also is given to HIV-infected individuals when their CD4+ T-cell count falls below 200 cells/cubic millimeter (mm3) of blood. Healthy adults usually have CD4+ T-cell counts of 600-1,500/mm3 of blood. In HIV-infected children younger than 13 years, the CDC definition of AIDS is similar to that in adolescents and adults, except for the addition of certain infections commonly seen in pediatric patients with HIV.

In many developing countries, where diagnostic facilities may be minimal, healthcare workers use a World Health Organization (WHO) AIDS case definiton based on the presence of clinical signs associated with immune deficiency and the exclusion of other known causes of immunosuppression, such as cancer or malnutrition. An expanded WHO AIDS case definition, with a broader spectrum of clinical manifestations of HIV infection, is employed in settings where HIV antibody tests are available (http://www.niaid.nih.gov/cgi-shl/disclaimers/disclaimer.asp?location=http://www.who.int/emc/diseases/hiv/Documents/wer1994.pdf).

As of the end of 2000, an estimated 36.1 million people worldwide – 34.7 million adults and 1.4 million children younger than 15 years – were living with HIV/AIDS. Through 2000, cumulative HIV/AIDS-associated deaths worldwide numbered approximately 21.8 million – 17.5 million adults and 4.3 million children younger than 15 years. In the United States, an estimated 800,000 to 900,000 people are living with HIV infection. As of December 31, 1999, 733,374 cases of AIDS and 430,441 AIDS-related deaths had been reported to the CDC. AIDS is the fifth leading cause of death among all adults aged 25 to 44 in the United States. Among African-Americans in the 25 to 44 age group, AIDS is the leading cause of death for men and the second leading cause of death for women.

This document summarizes the abundant evidence that HIV causes AIDS. Questions and answers at the end of this document address the specific claims of those who assert that HIV is not the cause of AIDS. Evidence That HIV Causes AIDS HIV fulfills Koch's postulates as the cause of AIDS.

Among many criteria used over the years to prove the link between putative pathogenic (disease-causing) agents and disease, perhaps the most-cited are Koch's postulates, developed in the late 19th century. Koch's postulates have been variously interpreted by many scientists, and modifications have been suggested to accommodate new technologies, particularly with regard to viruses. However, the basic tenets remain the same, and for more than a century Koch's postulates, as listed below, have served as the litmus test for determining the cause of any epidemic disease:
Epidemiological association: the suspected cause must be strongly associated with the disease.
Isolation: the suspected pathogen can be isolated - and propagated - outside the host.
Transmission pathogenesis: transfer of the suspected pathogen to an uninfected host, man or animal, produces the disease in that host.
With regard to postulate #1, numerous studies from around the world show that virtually all AIDS patients are HIV-seropositive; that is they carry antibodies that indicate HIV infection. With regard to postulate #2, modern culture techniques have allowed the isolation of HIV in virtually all AIDS patients, as well as in almost all HIV-seropositive individuals with both early- and late-stage disease. In addition, the polymerase chain (PCR) and other sophisticated molecular techniques have enabled researchers to document the presence of HIV genes in virtually all patients with AIDS, as well as in individuals in earlier stages of HIV disease.

Postulate #3 has been fulfilled in tragic incidents involving three laboratory workers with no other risk factors who have developed AIDS or severe immunosuppression after accidental exposure to concentrated, cloned HIV in the laboratory. In all three cases, HIV was isolated from the infected individual, sequenced and shown to be the infecting strain of virus. In another tragic incident, transmission of HIV from a Florida dentist to six patients has been documented by genetic analyses of virus isolated from both the dentist and the patients. The dentist and three of the patients developed AIDS and died, and at least one of the other patients has developed AIDS. Five of the patients had no HIV risk factors other than multiple visits to the dentist for invasive procedures.

In addition, through December 1999, the CDC had received reports of 56 health care workers in the United States with documented, occupationally acquired HIV infection, of whom 25 have developed AIDS in the absence of other risk factors. The development of AIDS following known HIV seroconversion also has been repeatedly observed in pediatric and adult blood transfusion cases, in mother-to-child transmission, and in studies of hemophilia, injection-drug use and sexual transmission in which seroconversion can be documented using serial blood samples. For example, in a 10-year study in the Netherlands, researchers followed 11 children who had become infected with HIV as neonates by small aliquots of plasma from a single HIV-infected donor. During the 10-year period, eight of the children died of AIDS. Of the remaining three children, all showed a progressive decline in cellular immunity, and two of the three had symptoms probably related to HIV infection).

Koch's postulates also have been fulfilled in animal models of human AIDS. Chimpanzees experimentally infected with HIV have developed severe immunosuppression and AIDS. In severe combined immunodeficiency (SCID) mice given a human immune system, HIV produces similar patterns of cell killing and pathogenesis as seen in people. HIV-2, a less virulent variant of HIV which causes AIDS in people, also causes an AIDS-like syndrome in baboons. More than a dozen strains of simian immunodeficiency virus (SIV), a close cousin of HIV, cause AIDS in Asian macaques. In addition, chimeric viruses known as SHIVs, which contain an SIV backbone with various HIV genes in place of the corresponding SIV genes, cause AIDS in macaques. Further strengthening the association of these viruses with AIDS, researchers have shown that SIV/SHIVs isolated from animals with AIDS cause AIDS when transmitted to uninfected animals.

AIDS and HIV infection are invariably linked in time, place and population group.

Historically, the occurence of AIDS in human populations around the world has closely followed the appearance of HIV. In the United States, the first cases of AIDS were reported in 1981 among homosexual men in New York and California, and retrospective examination of frozen blood samples from a U.S. cohort of gay men showed the presence of HIV antibodies as early as 1978, but not before then. Subsequently, in every region, country and city where AIDS has appeared, evidence of HIV infection has preceded AIDS by just a few years.

Many studies agree that only a single factor, HIV, predicts whether a person will develop AIDS.

Other viral infections, bacterial infections, sexual behavior patterns and drug abuse patterns do not predict who develops AIDS. Individuals from diverse backgrounds, including heterosexual men and women, homosexual men and women, hemophiliacs, sexual partners of hemophiliacs and transfusion recipients, injection-drug users and infants have all developed AIDS, with the only common denominator being their infection with HIV.

In cohort studies, severe immunosuppression and AIDS-defining illnesses occur almost exclusively in individuals who are HIV-infected.

For example, analysis of data from more than 8,000 participants in the Multicenter AIDS Cohort Study (MACS) and the Women's Interagency HIV Study (WIHS) demonstrated that participants who were HIV-seropositive were 1,100 times more likely to develop an AIDS-associated illness than those who were HIV-seronegative. These overwhelming odds provide a clarity of association that is unusual in medical research.

In a Canadian cohort, investigators followed 715 homosexual men for a median of 8.6 years. Every case of AIDS in this cohort occurred in individuals who were HIV-seropositive. No AIDS-defining illnesses occurred in men who remained negative for HIV antibodies, despite the fact that these individuals had appreciable patterns of illicit drug use and receptive anal intercourse.

Before the appearance of HIV, AIDS-related diseases such as PCP, KS and MAC were rare in developed countries; today, they are common in HIV-infected individuals.

Prior to the appearance of HIV, AIDS-related conditions such as Pneumocystis carinii pneumonia (PCP), Kaposi's sarcoma (KS) and disseminated infection with the Mycobacterium avium complex (MAC) were extraordinarily rare in the United States. In a 1967 survey, only 107 cases of PCP in the United States had been described in the medical literature, virtually all among individuals with underlying immunosuppressive conditions. Before the AIDS epidemic, the annual incidence of Kaposi's sarcoma in the United States was only 0.2 to 0.6 cases per million population, and only 32 individuals with disseminated MAC disease had been described in the medical literature.

By the end of 1999, CDC had received reports of 166,368 HIV-infected patients in the United States with definitive diagnoses of PCP, 46,684 with definitive diagnoses of KS, and 41,873 with definitive diagnoses of disseminated MAC (personal communication).

In developing countries, patterns of both rare and endemic diseases have changed dramatically as HIV has spread, with a far greater toll now being exacted among the young and middle-aged, including well-educated members of the middle class.

In developing countries, the emergence of the HIV epidemic has dramatically changed patterns of disease in affected communities. As in developed countries, previously rare, "opportunistic" diseases such as PCP and certain forms of meningitis have become more commonplace. In addition, as HIV seroprevalence rates have risen, there have been significant increases in the burden of endemic conditions such as tuberculosis (TB), particularly among young people. For example, as HIV seroprevalence increased sharply in Blantyre, Malawi from 1986 to 1995, tuberculosis admissions at the city's main hospital rose more than 400 percent, with the largest increase in cases among children and young adults. In the rural Hlabisa District of South Africa, admissions to tuberculosis wards increased 360 percent from 1992 to 1998, concomitant with a steep rise in HIV seroprevalence. High rates of mortality due to endemic conditions such as TB, diarrheal diseases and wasting syndromes, formerly confined to the elderly and malnourished, are now common among HIV-infected young and middle-aged people in many developing countries.

In studies conducted in both developing and developed countries, death rates are markedly higher among HIV-seropositive individuals than among HIV-seronegative individuals.

For example, Nunn and colleagues (BMJ 1997;315:767) assessed the impact of HIV infection over five years in a rural population in the Masaka District of Uganda. Among 8,833 individuals of all ages who had an unambiguous result on testing for HIV-antibodies (either 2 or 3 different test kits were used for blood samples from each individual), HIV-seropositive people were 16 times more likely to die over five years than HIV-seronegative people. Among individuals ages 25 to 34, HIV-seropositive people were 27 times more likely to die than HIV-seronegative people.

In another study in Uganda, 19,983 adults in the rural Rakai District were followed for 10 to 30 months. AIDS 2000;14:2391). In this cohort, HIV-seropositive people were 20 times more likely to die than HIV-seronegative people during 31,432 person-years of observation.

Similar findings have emerged from other studies for example,
in Tanzania, HIV-seropositive people were 12.9 time more likely to die over two years than HIV-seronegative people (Borgdorff et al. Genitourin Med 1995;71:212)
in Malawi, mortality over three years among children who survived the first year of life was 9.5 times higher among HIV-seropositive children than among HIV-seronegative children (Taha et al. Pediatr Infect Dis J 1999;18:689)
in Rwanda, mortality was 21 times higher for HIV-seropositive children than for HIV-seronegative children after five years (Spira et al. Pediatrics 1999;14:e56). Among the mothers of these children, mortality was 9 times higher among HIV-seropositive women than among HIV-seronegative women in four years of follow-up (Leroy et al. J Acquir Immune Defic Syndr Hum Retrovirol 1995;9:415).
in Cote d'Ivoire, HIV-seropositive individuals with pulmonary tuberculosis (TB) were 17 times more likely to die within six months than HIV-seronegative individuals with pulmonary TB (Ackah et al. Lancet 1995; 345:607).
in the former Zaire (now the Democratic Republic of Congo), HIV-infected infants were 11 times more likely to die from diarrhea than uninfected infants (Thea et al. NEJM 1993;329:1696).
in South Africa, the death rate for children hospitalized with severe lower respiratory tract infections was 6.5 times higher for HIV-infected infants than for uninfected children (Madhi et al. Clin Infect Dis 2000;31:170).

Kilmarx and colleagues (Lancet 2000; 356:770) recently reported data on HIV infection and mortality in a cohort of female commercial sex workers in Chiang Rai, Thailand. Among 500 women enrolled in the study between 1991 and 1994, the mortality rate through October 1998 among women who were HIV-infected at enrollment (59 deaths among 160 HIV-infected women) was 52.7 times higher than among women who remained uninfected with HIV (2 deaths among 306 uninfected women). The mortality rate among women who became infected during the study (7 deaths among 34 seroconverting women) was 22.5 higher than among persistently uninfected women. Among the HIV-infected women, only 3 of whom received antiretroviral medications, all reported causes of death were associated with immunosuppression, whereas the reported causes of death of the two uninfected women were postpartum amniotic embolism and gunshot wound.

Excess mortality among HIV-seropositive people also has been repeatedly observed in studies in developed countries, perhaps most dramatically among hemophiliacs. For example, Darby et al. (Nature 1995;377:79) studied 6,278 hemophiliacs living in the United Kingdom during the period 1977-91. Among 2,448 individuals with severe hemophilia, the annual death rate was stable at 8 per 1,000 during 1977-84. While death rates remained stable at 8 per 1,000 from 1985-1992 among HIV-seronegative persons with severe hemophilia, deaths rose steeply among those who had become HIV-seropositive following HIV-tainted transfusions during 1979-1986, reaching 81 per 1,000 in 1991-92. Among 3,830 individuals with mild or moderate hemophilia, the pattern was similar, with an initial death rate of 4 per 1,000 in 1977-84 that remained stable among HIV-seronegative individuals but rose to 85 per 1,000 in 1991-92 among seropositive individuals.

Similar data have emerged from the Multicenter Hemophilia Cohort Study. Among 1,028 hemophiliacs followed for a median of 10.3 years, HIV-infected individuals (n=321) were 11 times more likely to die than HIV-negative subjects (n=707), with the dose of Factor VIII having no effect on survival in either group (Goedert. Lancet 1995;346:1425).

In the Multicenter AIDS Cohort Study (MACS), a 16-year study of 5,622 homosexual and bisexual men, 1,668 of 2,761 HIV-seropositive men have died (60 percent), 1,547 after a diagnosis of AIDS. In contrast, among 2,861 HIV-seronegative participants, only 66 men (2.3 percent) have died (A. Munoz, MACS, personal communication).

HIV can be detected in virtually everyone with AIDS.

Recently developed sensitive testing methods, including the polymerase chain reaction (PCR) and improved culture techniques, have enabled researchers to find HIV in patients with AIDS with few exceptions. HIV has been repeatedly isolated from the blood, semen and vaginal secretions of patients with AIDS, findings consistent with the epidemiologic data demonstrating AIDS transmission via sexual activity and contact with infected blood.

Numerous studies of HIV-infected people have shown that high levels of infectious HIV, viral antigens, and HIV nucleic acids (DNA and RNA) in the body predict immune system deterioration and an increased risk for developing AIDS. Conversely, patients with low levels of virus have a much lower risk of developing AIDS.

For example, in an anlysis of 1,604 HIV-infected men in the Multicenter AIDS Cohort Study (MACS), the risk of a patient developing AIDS with six years was strongly associated with levels of HIV RNA in the plasma as measured by a sensitive test known as the branched-DNA signal-amplification assay (bDNA):
Plasma RNA concentration
(copies/mL of blood) Proportion of patients
developing AIDS within six years
<500
501 - 3,000
3,001 - 10,000
10,001 - 30,000
>30,000 5.4%
16.6%
31.7%
55.2%
80.0%

Similar associations between increasing HIV RNA levels and a greater risk of disease progression have been observed in HIV-infected children in both developed and developing countries.

In the very small proportion of untreated HIV-infected individuals whose disease progresses very slowly, the amount of HIV in the blood and lymph nodes is significantly lower than in HIV-infected people whose disease progression is more typical.

The availability of potent combinations of drugs that specifically block HIV replication has dramatically improved the prognosis for HIV-infected individuals. Such an effect would not be seen if HIV did not have a central role in causing AIDS.

Clinical trials have shown that potent three-drug combinations of anti-HIV drugs, known as highly active antiretroviral therapy (HAART), can significantly reduce the incidence of AIDS and death among HIV-infected individuals as compared to previously available HIV treatment regimens.

Use of these potent anti-HIV combination therapies has contributed to dramatic reductions in the incidence of AIDS and AIDS-related deaths in populations where these drugs are widely available, among both adults and children.

For example, in a prospective study of more than 7,300 HIV-infected patients in 52 European outpatient clinics, the incidence of new AIDS-defining illnesses declined from 30.7 per 100 patient-years of observation in 1994 (before the availability of HAART) to 2.5 per 100 patient years in 1998, when the majority of patients received HAART Mocroft et al. Lancet 2000;356:291).

Among HIV-infected patients who receive anti-HIV therapy, those whose viral loads are driven to low levels are much less likely to develop AIDS or die than patients who do not respond to therapy. Such an effect would not be seen if HIV did not have a central role in causing AIDS.

Clinical trials in both HIV-infected children and adults have demonstrated a link between a good virologic response to therapy (i.e. much less virus in the body) and a reduced risk of developing AIDS or dying.

This effect has also been seen in routine clinical practice. For example, in an analysis of 2,674 HIV-infected patients who started highly active antiretroviral therapy (HAART) in 1995-1998, 6.6 percent of patients who achieved and maintained undetectable viral loads (<400 copies/mL of blood) developed AIDS or died within 30 months, compared with 20.1 percent of patients who never achieved undetectable concentrations.

Nearly everyone with AIDS has antibodies to HIV.

A survey of 230,179 AIDS patients in the United States revealed only 299 HIV-seronegative individuals. An evaluation of 172 of these 299 patients found 131 actually to be seropositive; an additional 34 died before their serostatus could be confirmed.

Numerous serosurveys show that AIDS is common in populations where many individuals have HIV antibodies. Conversely, in populations with low seroprevalence of HIV antibodies, AIDS is extremely rare.

For example, in the southern African country of Zimbabwe (population 11.4 million), more than 25 percent of adults ages 15 to 49 are estimated to be HIV antibody-positive, based on numerous studies. As of November 1999, more than 74,000 cases of AIDS in Zimbabwe had been reported to the World Health Organization (WHO). In contrast, Madagascar, an island country off the southeast coast of Africa (population 15.1 million) with a very low HIV seroprevalence rate, reported only 37 cases of AIDS to WHO through November 1999. Yet, other sexually transmitted diseases, notably syphilis, are common in Madagascar, suggesting that conditions are ripe for the spread of HIV and AIDS if the virus becomes entrenched in that country.

The specific immunologic profile that typifies AIDS – a persistently low CD4+ T-cell count – is extraordinarily rare in the absence of HIV infection or other known cause of immunosuppression.

For example, in the NIAID-supported Multicenter AIDS Cohort Study (MACS), 22,643 CD4+ T-cell determinations in 2,713 HIV-seronegative homosexual and bisexual men revealed only one individual with a CD4+ T-cell count persistently lower than 300 cells/mm3 of blood, and this individual was receiving immunosuppressive therapy. Similar results have been reported from other studies.

Newborn infants have no behavioral risk factors for AIDS, yet many children born to HIV-infected mothers have developed AIDS and died.

Only newborns who become HIV-infected before or during birth, during breastfeeding, or (rarely) following exposure to HIV-tainted blood or blood products after birth, go on to develop the profound immunosuppression that leads to AIDS. Babies who are not HIV-infected do not develop AIDS. In the United States, 8,718 cases of AIDS among children younger than age 13 had been reported to the CDC as of December 31, 1999. Cumulative U.S. AIDS deaths among individuals younger than age 15 numbered 5,044 through December 31, 1999. Globally, UNAIDS estimates that 480,000 child deaths due to AIDS occurred in 1999 alone. HIV/AIDS Surveillance Report 1999;11[2]:1; UNAIDS. AIDS epidemic update: June 2000).

Because many HIV-infected mothers abuse recreational drugs, some have argued that maternal drug use itself causes pediatric AIDS. However, studies have consistently shown that babies who are not HIV-infected do not develop AIDS, regardless of their mothers' drug use.

For example, a majority of the HIV-infected, pregnant women enrolled in the European Collaborative Study are current or former injection drug users. In this ongoing study, mothers and their babies are followed from birth in 10 centers in Europe. In a paper in Lancet, study investigators reported that none of 343 HIV-seronegative children born to HIV-seropositive mothers had developed AIDS or persistent immune deficiency. In contrast, among 64 seropositive children, 30 percent presented with AIDS within 6 months of age or with oral candidiasis followed rapidly by the onset of AIDS. By their first birthday, 17 percent died of HIV-related diseases.

In a study in New York, investigators followed 84 HIV-infected and 248 HIV-uninfected infants, all born to HIV-seropositive mothers. The mothers of the two groups of infants were equally likely to be injection drug users (47 percent vs. 50 percent), and had similar rates of alcohol, tobacco, cocaine, heroin and methadone use. Of the 84 HIV-infected children, 22 died during a median follow-up period of 27.6 months, including 20 infants who died before their second birthday. Twenty-one of these deaths were classified as AIDS-related. Among the 248 uninfected children, only one death (due to child abuse) was reported during a median follow-up period of 26.1 months.

The HIV-infected twin develops AIDS while the uninfected twin does not.

Because twins share an in utero environment and genetic relationships, similarities and differences between them can provide important insight into infectious diseases, including AIDS. Acta Paediatr Supp 1997;421:56). Researchers have documented cases of HIV-infected mothers who have given birth to twins, one of whom is HIV-infected and the other not. The HIV-infected children developed AIDS, while the other children remained clinically and immunologically normal.

Studies of transfusion-acquired AIDS cases have repeatedly led to the discovery of HIV in the patient as well as in the blood donor.

Numerous studies have shown an almost perfect correlation between the occurrence of AIDS in a blood recipient and donor, and evidence of homologous HIV strains in both the recipient and the donor (NIAID, 1995).

HIV is similar in genetic structure and morphology to other lentiviruses that often cause immunodeficiency in their animal hosts in addition to slow, progressive wasting disorders, neurodegeneration and death.

Like HIV in humans, animal viruses such as feline immunodeficiency virus (FIV) in cats, visna virus in sheep and simian immunodeficiency virus (SIV) in monkeys primarily infect cells of the immune system such as T cells and macrophages. For example, visna virus infects macrophages and causes a slowly progressive neurologic disease (Haase Nature 1986;322:130).

HIV causes the death and dysfunction of CD4+ T lymphocytes in vitro and in vivo.

CD4+ T cell dysfunction and depletion are hallmarks of HIV disease. The recognition that HIV infects and destroys CD4+ T cells in vitro strongly suggests a direct link between HIV infection, CD4+ T cell depletion, and development of AIDS. A variety of mechanisms, both directly and indirectly related to HIV infection of CD4+ T cells, are likely responsible for the defects in CD4+ T cell function observed in HIV-infected people. Not only can HIV enter and kill CD4+ T cells directly, but several HIV gene products may interfere with the function of uninfected cells (NIAID, 1995; Pantaleo et al. NEJM 1993;328:327).

Answering The Skeptics:
Responses To Arguments That HIV Does Not Cause AIDS
MYTH: HIV antibody testing is unreliable.

FACT: Diagnosis of infection using antibody testing is one of the best-established concepts in medicine. HIV antibody tests exceed the performance of most other infectious disease tests in both sensitivity (the ability of the screening test to give a positive finding when the person tested truly has the disease ) and specificity (the ability of the test to give a negative finding when the subjects tested are free of the disease under study). Current HIV antibody tests have sensitivity and specificity in excess of 98% and are therefore extremely reliable (WHO, 1998; Sloand et al. JAMA 1991;266:2861).

Progress in testing methodology has also enabled detection of viral genetic material, antigens and the virus itself in body fluids and cells. While not widely used for routine testing due to high cost and requirements in laboratory equipment, these direct testing techniques have confirmed the validity of the antibody tests.

MYTH: There is no AIDS in Africa. AIDS is nothing more than a new name for old diseases.

FACT: The diseases that have come to be associated with AIDS in Africa – such as wasting syndrome, diarrheal diseases and TB – have long been severe burdens there. However, high rates of mortality from these diseases, formerly confined to the elderly and malnourished, are now common among HIV-infected young and middle-aged people, including well-educated members of the middle class (UNAIDS, 2000).

For example, in a study in Cote d'Ivoire, HIV-seropositive individuals with pulmonary tuberculosis (TB) were 17 times more likely to die within six months than HIV-seronegative individuals with pulmonary TB (Ackah et al. Lancet 1995; 345:607). In Malawi, mortality over three years among children who had received recommended childhood immunizations and who survived the first year of life was 9.5 times higher among HIV-seropositive children than among HIV-seronegative children. The leading causes of death were wasting and respiratory conditions (Taha et al. Pediatr Infect Dis J 1999;18:689). Elsewhere in Africa, findings are similar.

MYTH: HIV cannot be the cause of AIDS because researchers are unable to explain precisely how HIV destroys the immune system.

FACT: A great deal is known about the pathogenesis of HIV disease, even though important details remain to be elucidated. However, a complete understanding of the pathogenesis of a disease is not a prerequisite to knowing its cause. Most infectious agents have been associated with the disease they cause long before their pathogenic mechanisms have been discovered. Because research in pathogenesis is difficult when precise animal models are unavailable, the disease-causing mechanisms in many diseases, including tuberculosis and hepatitis B, are poorly understood. The critics' reasoning would lead to the conclusion that M. tuberculosis is not the cause of tuberculosis or that hepatitis B virus is not a cause of liver disease (Evans. Yale J Biol Med 1982;55:193).

MYTH: AZT and other antiretroviral drugs, not HIV, cause AIDS.

FACT: The vast majority of people with AIDS never received antiretroviral drugs, including those in developed countries prior to the licensure of AZT in 1987, and people in developing countries today where very few individuals have access to these medications (UNAIDS, 2000).

As with medications for any serious diseases, antiretroviral drugs can have toxic side effects. However, there is no evidence that antiretroviral drugs cause the severe immunosuppression that typifies AIDS, and abundant evidence that antiretroviral therapy, when used according to established guidelines, can improve the length and quality of life of HIV-infected individuals (Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents, 2000).

In the 1980s, clinical trials enrolling patients with AIDS found that AZT given as single-drug therapy conferred a modest (and short-lived) survival advantage compared to placebo. Among HIV-infected patients who had not yet developed AIDS, placebo-controlled trials found that AZT given as single-drug therapy delayed, for a year or two, the onset of AIDS-related illnesses. Significantly, long-term follow-up of these trials did not show a prolonged benefit of AZT, but also never indicated that the drug increased disease progression or mortality. The lack of excess AIDS cases and death in the AZT arms of these placebo-controlled trials effectively counters the argument that AZT causes AIDS (NIAID, 1995).

Subsequent clinical trials found that patients receiving two-drug combinations had up to 50 percent increases in time to progression to AIDS and in survival when compared to people receiving single-drug therapy. In more recent years, three-drug combination therapies have produced another 50 percent to 80 percent improvements in progression to AIDS and in survival when compared to two-drug regimens in clinical trials (Deeks, Volberding, 1999). Use of potent anti-HIV combination therapies has contributed to dramatic reductions in the incidence of AIDS and AIDS-related deaths in populations where these drugs are widely available, an effect which clearly would not be seen if antiretroviral drugs caused AIDS.

MYTH: Behavioral factors such as recreational drug use and multiple sexual partners account for AIDS.

FACT: The proposed behavioral causes of AIDS, such as multiple sexual partners and long-term recreational drug use, have existed for many years. The epidemic of AIDS, characterized by the occurrence of formerly rare opportunistic infections such as Pneumocystis carinii pneumonia (PCP) did not occur in the United States until a previously unknown human retrovirus – HIV – spread through certain communities (NIAID, 1995a; NIAID, 1995b).

Compelling evidence against the hypothesis that behavioral factors cause AIDS comes from recent studies that have followed cohorts of homosexual men for long periods of time and found that only HIV-seropositive men develop AIDS.

For example, in a prospectively studied cohort in Vancouver, 715 homosexual men were followed for a median of 8.6 years. Among 365 HIV-positive individuals, 136 developed AIDS. No AIDS-defining illnesses occurred among 350 seronegative men despite the fact that these men reported appreciable use of inhalable nitrites ("poppers") and other recreational drugs, and frequent receptive anal intercourse (Schechter et al. Lancet 1993;341:658).

Other studies show that among homosexual men and injection-drug users, the specific immune deficit that leads to AIDS – a progressive and sustained loss of CD4+ T cells – is extremely rare in the absence of other immunosuppressive conditions. For example, in the Multicenter AIDS Cohort Study, more than 22,000 T-cell determinations in 2,713 HIV-seronegative homosexual men revealed only one individual with a CD4+ T-cell count persistently lower than 300 cells/mm3 of blood, and this individual was receiving immunosuppressive therapy (Vermund et al. NEJM 1993;328:442).

In a survey of 229 HIV-seronegative injection-drug users in New York City, mean CD4+ T-cell counts of the group were consistently more than 1000 cells/mm3 of blood. Only two individuals had two CD4+ T-cell measurements of less than 300/mm3 of blood, one of whom died with cardiac disease and non-Hodgkin's lymphoma listed as the cause of death (Des Jarlais et al. J Acquir Immune Defic Syndr 1993;6:820).

MYTH: AIDS among transfusion recipients is due to underlying diseases that necessitated the transfusion, rather than to HIV.

FACT: This notion is contradicted by a report by the Transfusion Safety Study Group (TSSG), which compared HIV-negative and HIV-positive blood recipients who had been given transfusions for similar diseases. Approximately 3 years after the transfusion, the mean CD4+ T-cell count in 64 HIV-negative recipients was 850/mm3 of blood, while 111 HIV-seropositive individuals had average CD4+ T-cell counts of 375/mm3 of blood. By 1993, there were 37 cases of AIDS in the HIV-infected group, but not a single AIDS-defining illness in the HIV-seronegative transfusion recipients (et al. Ann Intern Med 1990;113:733; Cohen. Science 1994;266:1645).

MYTH: High usage of clotting factor concentrate, not HIV, leads to CD4+ T-cell depletion and AIDS in hemophiliacs.

FACT: This view is contradicted by many studies. For example, among HIV-seronegative patients with hemophilia A enrolled in the Transfusion Safety Study, no significant differences in CD4+ T-cell counts were noted between 79 patients with no or minimal factor treatment and 52 with the largest amount of lifetime treatments. Patients in both groups had CD4+ T cell-counts within the normal range (Hasset et al. Blood 1993;82:1351). In another report from the Transfusion Safety Study, no instances of AIDS-defining illnesses were seen among 402 HIV-seronegative hemophiliacs who had received factor therapy (Aledort et al. NEJM 1993;328:1128).

In a cohort in the United Kingdom, researchers matched 17 HIV-seropositive hemophiliacs with 17 HIV-seronegative hemophiliacs with regard to clotting factor concentrate usage over a ten-year period. During this time, 16 AIDS-defining clinical events occurred in 9 patients, all of whom were HIV-seropositive. No AIDS-defining illnesses occurred among the HIV-negative patients. In each pair, the mean CD4+ T cell count during follow-up was, on average, 500 cells/mm3 lower in the HIV-seropositive patient (abin< et al. BMJ 1996;312:207).

Among HIV-infected hemophiliacs, Transfusion Safety Study investigators found that neither the purity nor the amount of Factor VIII therapy had a deleterious effect on CD4+ T cell counts (Gjerset et al., Blood 1994;84:1666). Similarly, th Multicenter Hemophilia Cohort Study found no association between the cumulative dose of plasma concentrate and incidence of AIDS among HIV-infected hemophiliacs. MYTH: The distribution of AIDS cases casts doubt on HIV as the cause. Viruses are not gender-specific, yet only a small proportion of AIDS cases are among women.

FACT: The distribution of AIDS cases, whether in the United States or elsewhere in the world, invariably mirrors the prevalence of HIV in a population. In the United States, HIV first appeared in populations of homosexual men and injection-drug users, a majority of whom are male. Because HIV is spread primarily through sex or by the exchange of HIV-contaminated needles during injection-drug use, it is not surprising that a majority of U.S. AIDS cases have occurred in men (U.S. Census Bureau, 1999; UNAIDS, 2000).

Increasingly, however, women in the United States are becoming HIV-infected, usually through the exchange of HIV-contaminated needles or sex with an HIV-infected male. The CDC estimates that 30 percent of new HIV infections in the United States in 1998 were in women. As the number of HIV-infected women has risen, so too has the number of female AIDS patients in the United States. Approximately 23 percent of U.S. adult/adolescent AIDS cases reported to the CDC in 1998 were among women. In 1998, AIDS was the fifth leading cause of death among women aged 25 to 44 in the United States, and the third leading cause of death among African-American women in that age group (NIAID Fact Sheet: HIV/AIDS Statistics).

In Africa, HIV was first recognized in sexually active heterosexuals, and AIDS cases in Africa have occurred at least as frequently in women as in men. Overall, the worldwide distribution of HIV infection and AIDS between men and women is approximately 1 to 1 (U.S. Census Bureau, 1999; UNAIDS, 2000).

MYTH: HIV cannot be the cause of AIDS because the body develops a vigorous antibody response to the virus.

FACT: This reasoning ignores numerous examples of viruses other than HIV that can be pathogenic after evidence of immunity appears. Measles virus may persist for years in brain cells, eventually causing a chronic neurologic disease despite the presence of antibodies. Viruses such as cytomegalovirus, herpes simplex and varicella zoster may be activated after years of latency even in the presence of abundant antibodies. In animals, viral relatives of HIV with long and variable latency periods, such as visna virus in sheep, cause central nervous system damage even after the production of antibodies (NIAID, 1995).

Also, HIV is well recognized as being able to mutate to avoid the ongoing immune response of the host (Levy. Microbiol Rev 1993;57:183).

MYTH: Only a small number of CD4+ T cells are infected by HIV, not enough to damage the immune system.

FACT: New techniques such as the polymerase chain reaction (PCR) have enabled scientists to demonstrate that a much larger proportion of CD4+ T cells are infected than previously realized, particularly in lymphoid tissues. Macrophages and other cell types are also infected with HIV and serve as reservoirs for the virus. Although the fraction of CD4+ T cells that is infected with HIV at any given time is never extremely high (only a small subset of activated cells serve as ideal targets of infection), several groups have shown that rapid cycles of death of infected cells and infection of new target cells occur throughout the course of disease (Richman J Clin Invest 2000;105:565).

MYTH: HIV is not the cause of AIDS because many individuals with HIV have not developed AIDS.

FACT: HIV disease has a prolonged and variable course. The median period of time between infection with HIV and the onset of clinically apparent disease is approximately 10 years in industrialized countries, according to prospective studies of homosexual men in which dates of seroconversion are known. Similar estimates of asymptomatic periods have been made for HIV-infected blood-transfusion recipients, injection-drug users and adult hemophiliacs (Alcabes et al. Epidemiol Rev 1993;15:303).

As with many diseases, a number of factors can influence the course of HIV disease. Factors such as age or genetic differences between individuals, the level of virulence of the individual strain of virus, as well as exogenous influences such as co-infection with other microbes may determine the rate and severity of HIV disease expression. Similarly, some people infected with hepatitis B, for example, show no symptoms or only jaundice and clear their infection, while others suffer disease ranging from chronic liver inflammation to cirrhosis and hepatocellular carcinoma. Co-factors probably also determine why some smokers develop lung cancer while others do not.

MYTH: Some people have many symptoms associated with AIDS but do not have HIV infection.

FACT: Most AIDS symptoms result from the development of opportunistic infections and cancers associated with severe immunosuppression secondary to HIV.

However, immunosuppression has many other potential causes. Individuals who take glucocorticoids and/or immunosuppressive drugs to prevent transplant rejection or for autoimmune diseases can have increased susceptibility to unusual infections, as do individuals with certain genetic conditions, severe malnutrition and certain kinds of cancers. There is no evidence suggesting that the numbers of such cases have risen, while abundant epidemiologic evidence shows a staggering rise in cases of immunosuppression among individuals who share one characteristic: HIV infection.

MYTH: The spectrum of AIDS-related infections seen in different populations proves that AIDS is actually many diseases not caused by HIV.

FACT: The diseases associated with AIDS, such as PCP and Mycobacterium avium complex (MAC), are not caused by HIV but rather result from the immunosuppression caused by HIV disease. As the immune system of an HIV-infected individual weakens, he or she becomes susceptible to the particular viral, fungal and bacterial infections common in the community. For example, HIV-infected people in certain midwestern and mid-Atlantic regions are much more likely than people in New York City to develop histoplasmosis, which is caused by a fungus. A person in Africa is exposed to different pathogens than is an individual in an American city. Children may be exposed to different infectious agents than adults.

NIAID is a component of the National Institutes of Health (NIH). NIAID supports basic and applied research to prevent, diagnose, and treat infectious and immune-mediated illnesses, including HIV/AIDS and other sexually transmitted diseases, illness from potential agents of bioterrorism, tuberculosis, malaria, autoimmune disorders, asthma and allergies.

Rheumatoid Arthritis

2011-09-20T16:36:00.000-07:00

This booklet is for people who have rheumatoid arthritis, as well as for their family members, friends, and others who want to find out more about this disease. The booklet describes how rheumatoid arthritis develops, how it is diagnosed, and how it is treated, including what patients can do to help manage their disease. It also highlights current research efforts supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and other components of the National Institutes of Health (NIH). If you have further questions after reading this booklet, you may wish to discuss them with your doctor.

Features of Rheumatoid Arthritis

Rheumatoid arthritis is an inflammatory disease that causes pain, swelling, stiffness, and loss of function in the joints. It has several special features that make it different from other kinds of arthritis (see information box below). For example, rheumatoid arthritis generally occurs in a symmetrical pattern. This means that if one knee or hand is involved, the other one is also. The disease often affects the wrist joints and the finger joints closest to the hand. It can also affect other parts of the body besides the joints (see illustrations below). In addition, people with the disease may have fatigue, occasional fever, and a general sense of not feeling well (malaise).

Another feature of rheumatoid arthritis is that it varies a lot from person to person. For some people, it lasts only a few months or a year or two and goes away without causing any noticeable damage. Other people have mild or moderate disease, with periods of worsening symptoms, called flares, and periods in which they feel better, called remissions. Still others have severe disease that is active most of the time, lasts for many years, and leads to serious joint damage and disability.

Although rheumatoid arthritis can have serious effects on a person's life and well-being, current treatment strategies--including pain relief and other medications, a balance between rest and exercise, and patient education and support programs--allow most people with the disease to lead active and productive lives. In recent years, research has led to a new understanding of rheumatoid arthritis and has increased the likelihood that, in time, researchers can find ways to greatly reduce the impact of this disease. Features of Rheumatoid Arthritis

Tender, warm, swollen joints.
Symmetrical pattern. For example, if one knee is affected, the other one is also.
Joint inflammation often affecting the wrist and finger joints closest to the hand; other affected joints can include those of the neck, shoulders, elbows, hips, knees, ankles, and feet.
Fatigue, occasional fever, a general sense of not feeling well (malaise).
Pain and stiffness lasting for more than 30 minutes in the morning or after a long rest.
Symptoms that can last for many years.
Symptoms in other parts of the body besides the joints.
Variability of symptoms among people with the disease.

How Rheumatoid Arthritis Develops and Progresses

The Joints

A normal joint (the place where two bones meet) is surrounded by a joint capsule that protects and supports it (see illustration). Cartilage covers and cushions the ends of the two bones. The joint capsule is lined with a type of tissue called synovium, which produces synovial fluid. This clear fluid lubricates and nourishes the cartilage and bones inside the joint capsule.

In rheumatoid arthritis, the immune system, for unknown reasons, attacks a person's own cells inside the joint capsule. White blood cells that are part of the normal immune system travel to the synovium and cause a reaction. This reaction, or inflammation, is called synovitis, and it results in the warmth, redness, swelling, and pain that are typical symptoms of rheumatoid arthritis. During the inflammation process, the cells of the synovium grow and divide abnormally, making the normally thin synovium thick and resulting in a joint that is swollen and puffy to the touch (see illustration).

As rheumatoid arthritis progresses, these abnormal synovial cells begin to invade and destroy the cartilage and bone within the joint. The surrounding muscles, ligaments, and tendons that support and stabilize the joint become weak and unable to work normally. All of these effects lead to the pain and deformities often seen in rheumatoid arthritis. Doctors studying rheumatoid arthritis now believe that damage to bones begins during the first year or two that a person has the disease. This is one reason early diagnosis and treatment are so important in the management of rheumatoid arthritis.

A joint (the place where two bones meet) is surronded by a capsule that protects and supports it. The joint capsule is lined with a type of tissue called synovium, which produces synovial fluid that lubricates and nourishes joint tissues. In rheumatoid arthritis, the synovium becomes inflmaed, causing warmth, redness, swelling, and pain. As the disease progresses, abnormal synovial cells invade and erode, or destroy, cartilage and bone within the joint. Surronding muscels, ligaments, and tendons become weakened. Rheumatoid arthritis can also cause more generalized bone loss that may lead to osteoporosis (fragile bones that are prone to fracture).

Other Parts of the Body

Some people also experience the effects of rheumatoid arthritis in places other than the joints. About one-quarter develop rheumatoid nodules. These are bumps under the skin that often form close to the joints. Many people with rheumatoid arthritis develop anemia, or a decrease in the normal number of red blood cells. Other effects, which occur less often, include neck pain and dry eyes and mouth. Very rarely, people may have inflammation of the blood vessels, the lining of the lungs, or the sac enclosing the heart.

Occurrence and Impact of Rheumatoid Arthritis

Scientists estimate that about 2.1 million people, or 1 percent of the U.S. adult population, have rheumatoid arthritis. Interestingly, some recent studies have suggested that the overall number of new cases of rheumatoid arthritis may actually be going down. Scientists are now investigating why this may be happening.

Rheumatoid arthritis occurs in all races and ethnic groups. Although the disease often begins in middle age and occurs with increased frequency in older people, children and young adults also develop it. Like some other forms of arthritis, rheumatoid arthritis occurs much more frequently in women than in men. About two to three times as many women as men have the disease.

By all measures, the financial and social impact of all types of arthritis, including rheumatoid arthritis, is substantial, both for the Nation and for individuals. From an economic standpoint, the medical and surgical treatment for rheumatoid arthritis and the wages lost because of disability caused by the disease add up to millions of dollars. Daily joint pain is an inevitable consequence of the disease, and most patients also experience some degree of depression, anxiety, and feelings of helplessness. In some cases, rheumatoid arthritis can interfere with a person's ability to carry out normal daily activities, limit job opportunities, or disrupt the joys and responsibilities of family life. However, there are arthritis self-management programs that help people cope with the pain and other effects of the disease and help them lead independent and productive lives. These programs are described later in the section Diagnosing and Treating Rheumatoid Arthritis.

Searching for the Cause of Rheumatoid Arthritis

Rheumatoid arthritis is one of several "autoimmune" diseases ("auto" means self), so-called because a person's immune system attacks his or her own body tissues. Scientists still do not know exactly what causes this to happen, but research over the last few years has begun to unravel the factors involved.

Genetic (inherited) factors:Scientists have found that certain genes that play a role in the immune system are associated with a tendency to develop rheumatoid arthritis. At the same time, some people with rheumatoid arthritis do not have these particular genes, and other people have these genes but never develop the disease. This suggests that a person's genetic makeup is an important part of the story but not the whole answer. It is clear, however, that more than one gene is involved in determining whether a person develops rheumatoid arthritis and, if so, how severe the disease will become.

Environmental factors: Many scientists think that something must occur to trigger the disease process in people whose genetic makeup makes them susceptible to rheumatoid arthritis. An infectious agent such as a virus or bacterium appears likely, but the exact agent is not yet known. Note, however, that rheumatoid arthritis is not contagious: A person cannot "catch" it from someone else.

Other factors: Some scientists also think that a variety of hormonal factors may be involved. These hormones, or possibly deficiencies or changes in certain hormones, may promote the development of rheumatoid arthritis in a genetically susceptible person who has been exposed to a triggering agent from the environment.

Even though all the answers aren't known, one thing is certain: Rheumatoid arthritis develops as a result of an interaction of many factors. Much research is going on now to understand these factors and how they work together (see the Current Research section).

Diagnosing and Treating Rheumatoid Arthritis

Diagnosing and treating rheumatoid arthritis is a team effort between the patient and several types of health care professionals. A person can go to his or her family doctor or internist or to a rheumatologist. A rheumatologist is a doctor who specializes in arthritis and other diseases of the joints, bones, and muscles. As treatment progresses, other professionals often help. These may include nurses, physical or occupational therapists, orthopedic surgeons, psychologists, and social workers.

Studies have shown that people who are well informed and participate actively in their own care experience less pain and make fewer visits to the doctor than do other people with rheumatoid arthritis.

Patient education and arthritis self-management programs, as well as support groups, help people to become better informed and to participate in their own care. An example of a self-management program is the arthritis self-help course offered by the Arthritis Foundation and developed at one of the NIAMS-supported Multipurpose Arthritis and Musculoskeletal Diseases Centers. Self-management programs teach about rheumatoid arthritis and its treatments, exercise and relaxation approaches, patient/health care provider communication, and problem solving. Research on these programs has shown that they have the following clear and long-lasting benefits:
They help people understand the disease.
They help people reduce their pain while remaining active.
They help people cope physically, emotionally, and mentally.
They help people feel greater control over their disease and help build a sense of confidence in the ability to function and lead a full, active, and independent life.

Diagnosis

Rheumatoid arthritis can be difficult to diagnose in its early stages for several reasons. First, there is no single test for the disease. In addition, symptoms differ from person to person and can be more severe in some people than in others. Also, symptoms can be similar to those of other types of arthritis and joint conditions, and it may take some time for other conditions to be ruled out as possible diagnoses. Finally, the full range of symptoms develops over time, and only a few symptoms may be present in the early stages. As a result, doctors use a variety of tools to diagnose the disease and to rule out other conditions.

Medical history: This is the patient's description of symptoms and when and how they began. Good communication between patient and doctor is especially important here. For example, the patient's description of pain, stiffness, and joint function and how these change over time is critical to the doctor's initial assessment of the disease and his or her assessment of how the disease changes.

Physical examination: This includes the doctor's examination of the joints, skin, reflexes, and muscle strength.

Laboratory tests: One common test is for rheumatoid factor, an antibody that is eventually present in the blood of most rheumatoid arthritis patients. (An antibody is a special protein made by the immune system that normally helps fight foreign substances in the body.) Not all people with rheumatoid arthritis test positive for rheumatoid factor, however, especially early in the disease. And, some others who do test positive never develop the disease. Other common tests include one that indicates the presence of inflammation in the body (the erythrocyte sedimentation rate), a white blood cell count, and a blood test for anemia.

X rays: X rays are used to determine the degree of joint destruction. They are not useful in the early stages of rheumatoid arthritis before bone damage is evident, but they can be used later to monitor the progression of the disease.

Treatment

Doctors use a variety of approaches to treat rheumatoid arthritis. These are used in different combinations and at different times during the course of the disease and are chosen according to the patient's individual situation. No matter what treatment the doctor and patient choose, however, the goals are the same: relieve pain, reduce inflammation, slow down or stop joint damage, and improve the person's sense of well-being and ability to function.

Treatment is another key area for communication between patient and doctor. Talking to the doctor can help ensure that exercise and pain management programs are provided as needed and that drugs are prescribed appropriately. Talking can also help in making decisions about surgery.

Goals of Treatment
Relieve pain
Reduce inflammation
Slow down or stop joint damage
Improve a person's sense of well-being and ability to function

Current Treatment Approaches
Lifestyle
Medications
Surgery
Routine monitoring and ongoing care

Lifestyle

This approach includes several activities that help improve a person's ability to function independently and maintain a positive outlook.

Rest and exercise: Both rest and exercise help in important ways. People with rheumatoid arthritis need a good balance between the two, with more rest when the disease is active and more exercise when it is not. Rest helps to reduce active joint inflammation and pain and to fight fatigue. The length of time needed for rest will vary from person to person, but in general, shorter rest breaks every now and then are more helpful than long times spent in bed.

Exercise is important for maintaining healthy and strong muscles, preserving joint mobility, and maintaining flexibility. Exercise can also help people sleep well, reduce pain, maintain a positive attitude, and lose weight. Exercise programs should be planned and carried out to take into account the person's physical abilities, limitations, and changing needs.

Care of joints: Some people find that using a splint for a short time around a painful joint reduces pain and swelling by supporting the joint and letting it rest. Splints are used mostly on wrists and hands, but also on ankles and feet. A doctor or a physical or occupational therapist can help a patient get a splint and ensure that it fits properly. Other ways to reduce stress on joints include self-help devices (for example, zipper pullers, long-handled shoe horns); devices to help with getting on and off chairs, toilet seats, and beds; and changes in the ways that a person carries out daily activities.

Stress reduction: People with rheumatoid arthritis face emotional challenges as well as physical ones. The emotions they feel because of the disease--fear, anger, frustration--combined with any pain and physical limitations can increase their stress level. Although there is no evidence that stress plays a role in causing rheumatoid arthritis, it can make living with the disease difficult at times. Stress may also affect the amount of pain a person feels. There are a number of successful techniques for coping with stress. Regular rest periods can help, as can relaxation, distraction, or visualization exercises. Exercise programs, participation in support groups, and good communication with the health care team are other ways to reduce stress.

Healthful diet: With the exception of several specific types of oils (mentioned in the Current Research section), there is no scientific evidence that any specific food or nutrient helps or harms most people with rheumatoid arthritis. However, an overall nutritious diet with enough--but not an excess of--calories, protein, and calcium is important. Some people may need to be careful about drinking alcoholic beverages because of the medications they take for rheumatoid arthritis. Those taking methotrexate may need to avoid alcohol altogether. Patients should ask their doctors for guidance on this issue.

Climate: Some people notice that their arthritis gets worse when there is a sudden change in the weather. However, there is no evidence that a specific climate can prevent or reduce the effects of rheumatoid arthritis. Moving to a new place with a different climate usually does not make a long-term difference in a person's rheumatoid arthritis.

Medications

Most people who have rheumatoid arthritis take medications. Some medications are used only for pain relief; others are used to reduce inflammation. Still others--often called disease-modifying antirheumatic drugs, or DMARDs--are used to try to slow the course of the disease. The person's general condition, the current and predicted severity of the illness, the length of time he or she will take the drug, and the drug's effectiveness and potential side effects are important considerations in prescribing drugs for rheumatoid arthritis. The table below about "Medications Commonly Used To Treat Rheumatoid Arthritis" shows currently used rheumatoid arthritis medications, along with their effects, side effects, and monitoring requirements.

Traditionally, rheumatoid arthritis therapy has involved an approach in which doctors prescribed aspirin or similar drugs, rest, and physical therapy first, and prescribed more powerful drugs later only if the disease became much worse. Recently, many doctors have changed their approach, especially for patients with severe, rapidly progressing rheumatoid arthritis. This change is based on the belief that early treatment with more powerful drugs, and the use of drug combinations in place of single drugs, may be more effective ways to halt the progression of the disease and reduce or prevent joint damage.

Medications Commonly Used To Treat Rheumatoid Arthritis

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

Surgery

Several types of surgery are available to patients with severe joint damage. The primary purpose of these procedures is to reduce pain, improve the affected joint's function, and improve the patient's ability to perform daily activities. Surgery is not for everyone, however, and the decision should be made only after careful consideration by patient and doctor. Together they should discuss the patient's overall health, the condition of the joint or tendon that will be operated on, and the reason for and the risks and benefits of, the surgical procedure. Cost may be another factor. Commonly performed surgical procedures include joint replacement, tendon reconstruction, and synovectomy.

Joint replacement: This is the most frequently performed surgery for rheumatoid arthritis, and it is done primarily to relieve pain and improve or preserve joint function. Artificial joints are not always permanent and may eventually have to be replaced. This may be an issue for younger people.

Tendon reconstruction: Rheumatoid arthritis can damage and even rupture tendons, the tissues that attach muscle to bone. This surgery, which is used most frequently on the hands, reconstructs the damaged tendon by attaching an intact tendon to it. This procedure can help to restore hand function, especially if the tendon is completely ruptured.

Synovectomy: In this surgery, the doctor actually removes the inflamed synovial tissue. Synovectomy by itself is seldom performed now because not all of the tissue can be removed, and it eventually grows back. Synovectomy is done as part of reconstructive surgery, especially tendon reconstruction.

Routine Monitoring and Ongoing Care

Regular medical care is important to monitor the course of the disease, determine the effectiveness and any negative effects of medications, and change therapies as needed. Monitoring typically includes regular visits to the doctor. It may also include blood, urine, and other laboratory tests and x rays.

Osteoporosis prevention is one issue that patients may want to discuss with their doctors as part of their long-term, ongoing care. Osteoporosis is a condition in which bones lose calcium and become weakened and fragile. Many older women are at increased risk for osteoporosis, and their rheumatoid arthritis increases the risk further, particularly if they are taking corticosteroids such as prednisone. These patients may want to discuss with their doctors the potential benefits of calcium and vitamin D supplements, hormone replacement therapy, or other treatments for osteoporosis.

Alternative and Complementary Therapies

Special diets, vitamin supplements, and other alternative approaches have been suggested for the treatment of rheumatoid arthritis. Although many of these approaches may not be harmful in and of themselves, controlled scientific studies either have not been conducted or have found no definite benefit to these therapies. Some alternative or complementary approaches may help the patient cope or reduce some of the stress associated with living with a chronic illness. As with any therapy, patients should discuss the benefits and drawbacks with their doctors before beginning an alternative or new type of therapy. If the doctor feels the approach has value and will not be harmful, it can be incorporated into a patient's treatment plan. However, it is important not to neglect regular health care. The Arthritis Foundation publishes material on alternative therapies as well as established therapies, and patients may want to contact this organization for information. (See the For More Information section.)

Current Research

Over the last several decades, research has greatly increased our understanding of immunology, genetics, and cellular and molecular biology. This foundation in basic science is now showing results in several areas important to rheumatoid arthritis. Scientists are thinking about rheumatoid arthritis in exciting ways that were not possible even 10 years ago.

The National Institutes of Health funds a wide variety of medical research at its headquarters in Bethesda, Maryland, and at universities and medical centers across the United States. One of the NIH institutes, the National Institute of Arthritis and Musculoskeletal and Skin Diseases, is a major supporter of research and research training in rheumatoid arthritis through grants to individual scientists, Specialized Centers of Research, and Multipurpose Arthritis and Musculoskeletal Diseases Centers.

Following are examples of current research directions in rheumatoid arthritis supported by the Federal Government through the NIAMS and other parts of the NIH.

Scientists are looking at basic abnormalities in the immune systems of people with rheumatoid arthritis and in some animal models of the disease to understand why and how the disease develops. Findings from these studies may lead to precise, targeted therapies that could stop the inflammatory process in its earliest stages. They may even lead to a vaccine that could prevent rheumatoid arthritis.

Researchers are studying genetic factors that predispose some people to developing rheumatoid arthritis, as well as factors connected with disease severity. Findings from these studies should increase our understanding of the disease and will help develop new therapies as well as guide treatment decisions. In a major effort aimed at identifying genes involved in rheumatoid arthritis, the NIH and the Arthritis Foundation have joined together to support the North American Rheumatoid Arthritis Consortium. This group of 12 research centers around the United States is collecting medical information and genetic material from 1,000 families in which two or more siblings have rheumatoid arthritis. It will serve as a national resource for genetic studies of this disease.

Scientists are also gaining insights into the genetic basis of rheumatoid arthritis by studying rats with autoimmune inflammatory arthritis that resembles human disease. NIAMS researchers have identified several genetic regions that affect arthritis susceptibility and severity in these animal models of the disease, and found some striking similarities between rats and humans. Identifying disease genes in rats should provide important new information that may yield clues to the causes of rheumatoid arthritis in humans.

Scientists are studying the complex relationships among the hormonal, nervous, and immune systems in rheumatoid arthritis. For example, they are exploring whether and how the normal changes in the levels of steroid hormones (such as estrogen and testosterone) during a person's lifetime may be related to the development, improvement, or flares of the disease. Scientists are also looking at how these systems interact with environmental and genetic factors. Results from these studies may suggest new treatment strategies.

Researchers are exploring why so many more women than men develop rheumatoid arthritis. In hopes of finding clues, they are studying female and male hormones and other elements that differ between women and men, such as possible differences in their immune responses.

To find clues to new treatments, researchers are examining why rheumatoid arthritis often improves during pregnancy. Results of one study suggest that the explanation may be related to differences in certain special proteins between a mother and her unborn child. These proteins help the immune system distinguish between the body's own cells and foreign cells. Such differences, the scientists speculate, may change the activity of the mother's immune system during pregnancy.

A growing body of evidence indicates that infectious agents, such as viruses and bacteria, may trigger rheumatoid arthritis in people who have an inherited predisposition to the disease. Investigators are trying to discover which infectious agents may be responsible. More broadly, they are also working to understand the basic mechanisms by which these agents might trigger the development of rheumatoid arthritis. Identifying the agents and understanding how they work could lead to new therapies.

Scientists are searching for new drugs or combinations of drugs that can reduce inflammation, can slow or stop the progression of rheumatoid arthritis, and also have few side effects. Studies in humans have shown that a number of compounds have such potential. For example, some studies are breaking new ground in the area of "biopharmaceuticals", or "biologics". These new drugs are based on compounds occurring naturally in the body, and are designed to target specific aspects of the inflammatory process.

Investigators have also shown that treatment of rheumatoid arthritis with minocycline, a drug in the tetracycline family, has a modest benefit. The effects of a related tetracycline called doxycycline are under investigation. Other studies have shown that the omega-3 fatty acids in certain fish or plant seed oils also may reduce rheumatoid arthritis inflammation. However, many people are not able to tolerate the large amounts of oil necessary for any benefit.

Investigators are examining many issues related to quality of life for rheumatoid arthritis patients and quality, cost, and effectiveness of health care services for these patients. Scientists have found that even a small improvement in a patient's sense of physical and mental well-being can have an impact on his or her quality of life and use of health care services. Results from studies like these will help health care providers design integrated treatment strategies that cover all of a patient's needs--emotional as well as physical.

Hope for the Future

Scientists are making rapid progress in understanding the complexities of rheumatoid arthritis--how and why it develops, why some people get it and others do not, why some people get it more severely than others. Results from research are having an impact today, enabling people with rheumatoid arthritis to remain active in life, family, and work far longer than was possible 20 years ago. There is also hope for tomorrow, as researchers continue to explore ways of stopping the disease process early, before it becomes destructive, or even preventing rheumatoid arthritis altogether.

For More Information

National Institute of Arthritis and Musculoskeletal and Skin Diseases
Information Clearinghouse
NIAMS/National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
TTY: (301) 565-2966
Fax: (301) 718-6366
World Wide Web address: http://www.niams.nih.gov/

The National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse is a public service sponsored by the NIAMS that provides health information and information sources. The clearinghouse provides information on rheumatoid arthritis, including a fact sheet on arthritis and exercise. Fact sheets, additional information, and research updates can also be found on the NIAMS Web site at http://www.niams.nih.gov/.

American College of Rheumatology
1800 Century Place, Suite 250
Atlanta, GA 30345
(404) 633-3777
Fax:(404) 633-1870
World Wide Web address: http://www.rheumatology.org

The association provides referrals to rheumatologists and physical and occupational therapists who have experience working with people who have rheumatoid arthritis. The organization also provides educational materials and guidelines.

American Academy of Orthopaedic Surgeons
P.O. Box 2058
Des Plaines, IL 60017
Phone: 800-824-BONE (2663) (free of charge)
World Wide Web address: http://www.aaos.org

The academy provides education and practice management services for orthopaedic surgeons and allied health professionals. It also serves as an advocate for improved patient care and informs the public about the science of orthopaedics. The orthopaedist's scope of practice includes disorders of the body's bones, joints, ligaments, muscles, and tendons. For a single copy of an AAOS brochure, send a self-addressed stamped envelope to the address above or visit the AAOS Web site.

Acknowledgments

The NIAMS gratefully acknowledges the assistance of the following people in the preparation and review of this publication: John H. Klippel, M.D., NIAMS, NIH; Reva Lawrence, M.P.H., NIAMS, NIH; Amye L. Leong, San Pedro Peninsula, California; Michael D. Lockshin, M.D., Barbara Volcker Center for Women and Rheumatic Disease, Hospital for Special Surgery, New York, New York; Kate Lorig, R.N., Dr.P.H., Stanford University, Stanford, California; J. Lee Nelson, M.D., Fred Hutchinson Cancer Research Center, Seattle, Washington; Stanley R. Pillemer, M.D., NIH; Paul H. Plotz, M.D., NIAMS, NIH; Paul G. Rochmis, M.D., Fairfax, Virginia; and Ronald L. Wilder, M.D., Ph.D., NIAMS, NIH. Special thanks also go to Cheryl Yarboro, R.N., B.S.P.A., NIAMS, NIH, and to the patients who reviewed this publication and provided valuable input. This booklet was written by Anne Brown Rodgers of Cygnus Corporation.

About NIAMS and NAMSIC

The NIAMS, a part of the National Institutes of Health (NIH), leads the Federal medical research effort in arthritis and musculoskeletal and skin diseases. The NIAMS supports research and research training throughout the United States as well as on the NIH campus in Bethesda, Maryland, and disseminates health and research information. The National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse is a public service sponsored by the NIAMS that provides health information and information sources. Additional information and research updates can be found on the NIAMS Web site at http://www.niams.nih.gov/.

Information provided by:
Arthritis Foundation
1330 West Peachtree Street
Atlanta, GA 30309
(800) 283-7800
(404) 872-7100
or your local chapter, listed in the telephone directory
World Wide Web address: http://www.arthritis.org

The Arthritis Foundation is the major voluntary organization devoted to supporting arthritis research and providing educational and other services to individuals with arthritis. The foundation publishes a free pamphlet on rheumatoid arthritis and a magazine for members on all types of arthritis. It also provides up-to-date information on research and treatment, nutrition, alternative therapies, and self-management strategies. Chapters nationwide offer exercise programs, classes, support groups, physician referral services, and free literature.

The Facts About Breast Cancer and Mammograms

2011-09-12T19:50:00.000-07:00

Getting the facts about breast cancer and mammograms is an important step in taking care of your health. This pamphlet will help you to get the information that you need. It provides information on a woman's risk for breast cancer, the National Cancer Institute's recommendations about mammograms, and the benefits and limitations of the procedure.

After skin cancer, breast cancer is the most frequently diagnosed cancer in women in the United States. It is second only to lung cancer in cancer-related deaths. Approximately 180,000 new cases of breast cancer are estimated for 1997, and about 44,000 women are expected to die from the disease.

Who Is at Risk for Breast Cancer?

Simply being a woman and getting older puts you at some risk for breast cancer. Your risk for breast cancer continues to increase over your lifetime. Several known factors can further increase your risk for breast cancer. Most women who get breast cancer have no known risk factors such as a family history of the disease. Talk to your doctor about the known risk factors for breast cancer.

What factors can increase your risk for breast cancer?

One or more of the following conditions place a woman at higher than average risk for breast cancer:
personal history of a prior breast cancer
evidence of a specific genetic change that increases susceptibility to breast cancer (BRCA1/BRCA2 mutations)
mother, sister, daughter, or two or more close relatives, such as cousins, with a history of breast cancer (especially if diagnosed at a young age)
a diagnosis of a breast condition (i.e., atypical hyperplasia) that may predispose a woman to breast cancer, or a history of two or more breast biopsies for benign breast disease

Additional Factors Can Play A Role In A Woman's Risk For Breast Cancer

Women age 45 or older who have at least 75 percent dense tissue on a mammogram are at some increased risk. A slight increase in risk for breast cancer is associated with having a first birth at age 30 or older.

In addition, women who receive chest irradiation for conditions such as Hodgkin's disease at age 30 or younger, remain at higher risk for breast cancer throughout their lives.

Not having any of the above risk factors does NOT mean that you are "safe." The majority of women who develop breast cancer do not have a family history of the disease, nor do they fall into any other special high-risk category.

What Can You Do?

If you are in your 40s or older, get a mammogram on a regular basis, every 1 to 2 years. Talk with your doctor or nurse about planning your personal schedule for screening mammograms and breast exams. Gather as much information as you can about your family history of cancer, breast cancer, and screening mammograms. Call the National Cancer Institute's Cancer Information Service for more information about breast cancer and mammograms at 1-800-4-CANCER (1-800-422-6237). People with TTY equipment, dial 1-800-332-8615. For the latest information on cancer, visit the National Cancer Institute's website for patients and the public at http://rex.nci.nih.gov or CancerNet at http://cancernet.nci.nih.gov.

What Are the Benefits of Getting Mammograms?

A mammogram can find breast cancer before a lump can be felt. A mammogram is the best method available today to detect breast cancer early. Early detection of the disease may allow more treatment options.

What Are the Limitations*of Getting Mammograms?

Mammograms may miss cancer that is present. Mammograms may find something that turns out NOT to be cancer.

*These limitations occur more often in women under age 50.

To learn more about mammograms, call the National Cancer Institute's
Cancer Information Service at 1-800-4-CANCER (1-800-422-6237).
People with TTY equipment, dial 1-800-332-8615.

Information provided by NIH.

HIV Infection in Infants and Children

2011-09-02T12:48:00.000-07:00

The National Institute of Allergy and Infectious Diseases (NIAID) has a lead role in research devoted to children infected with the human immunodeficiency virus (HIV), the virus that causes the acquired immunodeficiency syndrome (AIDS).

NIAID-supported researchers are developing and refining treatments to prolong the survival and improve the quality of life of HIV-infected infants and children. Many promising therapies are being tested in the Pediatric AIDS Clinical Trials Group (ACTG), a nationwide clinical trials network jointly sponsored by NIAID and the National Institute of Child Health and Human Development (NICHD). Scientists also are improving tests for diagnosing HIV infection in infants soon after birth so that therapy can begin as soon as possible.

Epidemiologic studies are examining risk factors for transmission as well as the course of HIV disease in pregnant women and their babies in an era of antiretroviral therapy. Researchers have helped illuminate the mechanisms of HIV transmission as well as the distinct features of pediatric HIV infection and how the course of disease and the usefulness of therapies can differ in children and adults.

Researchers also are studying ways to prevent transmission of HIV from mother to infant. Notably, Pediatric ACTG investigators have demonstrated that a specific regimen of zidovudine (AZT) treatment, given to an HIV-infected woman during pregnancy and to her baby after birth, can reduce maternal transmission of HIV by two-thirds.1 Many consider this finding to be one of the most significant research advances to date in the fight against HIV and AIDS.

A Global Problem

According to UNAIDS (The Joint United Nations Programme on HIV/AIDS) and the World Health Organization (WHO),2,3 at the end of 1998, an estimated 1.2 million children worldwide under age 15 were living with HIV/AIDS. Approximately 3.2 million children under 15 had died from the virus or associated causes. The number of children who had lived with HIV from the start of the epidemic through 1997 was estimated to be 3.8 million. As HIV infection rates rise in the general population, new infections are increasingly concentrating in younger age groups.

Statistics for the year 1998 alone show that

590,000 children under age 15 were newly infected with HIV.
One-tenth of all new HIV infections were in children under age 15.
Approximately 7,000 young people aged 10 to 24 became infected with HIV every day-that is, five each minute.
Nine out of 10 new infections in children under 15 were in sub-Saharan Africa.
An estimated 510,000 children under 15 died of AIDS-related causes, up from 460,000 in 1997.

More than 95 percent of all HIV-infected people now live in developing countries, which have also suffered 95 percent of all deaths from AIDS. In countries with the longest-lived AIDS epidemics, some doctors report that children ill from HIV occupy three-quarters of pediatric hospital beds, and childrens' life expectancy has been shortened dramatically. In Botswana, for example, because of AIDS, the life expectancy of children born early in the next decade is just over age 40; without AIDS, it would have been 70. In Namibia, the infant mortality rate is expected to reach 72 deaths per 1000, up from a non-AIDS rate of 45 per 1000.

The United States has a relatively small percentage of the world's children living with HIV/AIDS. From the beginning of the epidemic through the end of 1998, 5,237 American children under age 13 had been reported to the Centers for Disease Control and Prevention (CDC) as living with HIV/AIDS.4 Three hundred eighty-two cases of pediatric AIDS were reported in 1998.5 There are many more children who are infected with HIV but have not yet developed AIDS. Half of all new HIV infections reported to the CDC have been in people younger than 25.6 One encouraging fact is that the number of pediatric AIDS cases estimated by the CDC fell by two-thirds from 1992 to 1997 (947 to 310 cases).7

The U.S. cities that had the five highest rates of pediatric AIDS during 1998 were New York City; Miami, Florida; Newark, New Jersey; Washington, D.C.; and San Juan, Puerto Rico.8 The disease disproportionately affects children in minority groups, especially African Americans.9 Out of 8,461 cases in children under 13 reported to the CDC through December 1998, 58 percent were in blacks/not-Hispanic, 23 percent were in Hispanics, 17.5 percent were in whites/not-Hispanic, and 5.33 percent were in other minority groups.10

According to 1996 data, the latest available, HIV infection was the seventh leading cause of death for U.S. children through 14 years of age.11 However, the CDC reported a drop of 56 percent from 1994 to 1997 in the estimated number of children who died from AIDS.12 New anti-HIV drug therapies and promotion of voluntary testing are having a major impact.

Transmission

Almost all HIV-infected children acquire the virus from their mothers before or during birth or through breast-feeding. In the United States, approximately 25 percent of pregnant HIV-infected women not receiving AZT therapy have passed on the virus to their babies. The rate is higher in developing countries.

Most mother-to-child transmission, estimated to cause over 90 percent of infections worldwide in infants and children,13,14 probably occurs late in pregnancy or during birth. Although the precise mechanisms are unknown, scientists think HIV may be transmitted when maternal blood enters the fetal circulation, or by mucosal exposure to virus during labor and delivery. The role of the placenta in maternal-fetal transmission is unclear and the focus of ongoing research.

The risk of maternal-infant transmision (MIT) is significantly increased if the mother has advanced HIV disease, increased levels of HIV in her bloodstream, or fewer numbers of the immune system cells -- CD4+ T cells -- that are the main targets of HIV.

Other factors that may increase the risk are maternal drug use, severe inflammation of fetal membranes, or a prolonged period between membrane rupture and delivery. A study sponsored by NIAID and others found that HIV-infected women who gave birth more than four hours after the rupture of the fetal membranes were nearly twice as likely to transmit HIV to their infants, as compared to women who delivered within four hours of membrane rupture.15

HIV also may be transmitted from a nursing mother to her infant. Studies have suggested that breast-feeding introduces an additional risk of HIV transmission of approximately 10 to 14 percent among women with chronic HIV infection.16 In developing countries, an estimated one-third to one-half of all HIV infections are transmitted through breast-feeding.17 The WHO recommends that all HIV-infected women be advised as to both the risks and benefits of breast-feeding of their infants so that they can make informed decisions. In countries where safe alternatives to breast-feeding are readily available and economically feasible, this alternative should be encouraged. In general, in developing countries where safe alternatives to breast-feeding are not readily available, the benefits of breast-feeding in terms of decreased illness and death due to other infectious diseases greatly outweigh the potential risk of HIV transmission.

Prior to 1985 when screening of the nation's blood supply for HIV began, some children were infected through transfusions with blood or blood products contaminated with HIV. A small number of children also have been infected through sexual or physical abuse by HIV-infected adults.

Preventing Maternal-Infant Transmission (MIT)
In 1994, a landmark study conducted by the Pediatric ACTG demonstrated that AZT, given to HIV-infected women who had very little or no prior antiretroviral therapy and CD4+ T cell counts above 200/mm3, reduced the risk of MIT by two-thirds, from 25 percent to 8 percent.18 In the study, known as ACTG 076, AZT therapy was initiated in the second or third trimester and continued during labor, and infants were treated for six weeks following birth. AZT produced no serious side effects in mothers or infants. Long-term follow-up of the infants and mothers is ongoing. Pediatric ACTG protocol 185 tested an AZT regimen and was reported in 1999 to have lowered MIT to about 5 percent.19 Combination therapies have been shown to be beneficial in the treatment of HIV-infected adults, and current guidelines have been designed accordingly.20 In HIV-infected pregnant women, the safety and pharmacology of these potent drug combinations need to be better understood, and NIAID is conducting studies in this area.

Researchers have shown that this AZT regimen has reduced MIT in other populations in which it has been used. Observational studies in the past few years in the United States and Europe indicate that similar reductions can be achieved by using this regimen in regular clinical care settings. In the U.S., the number of MIT-acquired AIDS cases reported to the CDC fell 43 percent from 1992 to 1996, probably because of providing AZT to HIV-infected mothers, better guidelines for prenatal HIV counseling and testing, and changes in obstetrical management.21,22

Recent studies have shown that short regimens, too, of AZT can be beneficial in cutting back on MIT. In March 1999, researchers reported on a randomized study in Thailand on the short-term use of AZT during late pregnancy and labor in a group of non-breast-feeding women (the drug was not given to infants). They concluded that the treatment was safe and effective and can reduce the rate of MIT by 50 percent.23 Another recent study using a short-term AZT regimen (including post-partum) in groups of women in Ivory Coast and Burkina Faso, Africa, while limited, supported this finding.24

Following up on the success of ACTG 076, the Pediatric ACTG has begun new HIV prevention trials that build on the AZT regimen. These trials include other antiviral agents and multidrug combinations in an attempt to reduce MIT even more than that achieved by AZT alone. Also, in early 1999, a study sponsored by UNAIDS of a combination regimen of AZT plus lamivudine (3TC) in three African countries showed promising results.25

The AZT regimen used in ACTG 076 is not available in much of the world because of its high cost (approximately $1000 per pregnancy, not counting counseling or testing) and logistical demands. The cost of a short-course AZT regimen is substantially lower, but is still prohibitive in many countries. International agencies are studying whether there may be innovative ways to provide AZT at lower cost, e.g., through reductions in drug prices to developing countries, partnerships with industry, etc. NIAID is pursuing a global strategy that assesses whether simpler and less costly regimens to prevent mother-to-infant HIV transmission can be effective in various settings.

In September 1999, an NIAID-funded study (HIVNET 012) demonstrated that short-course therapy with nevirapine lowered the risk of HIV-1 transmission during the first 14-16 weeks of life by nearly 50 percent compared to AZT in a breastfeeding population.26 This simple, inexpensive regimen offers a potential cost-effective alternative for decreasing mother-to-child transmission in developing countries.27.

The International Perinatal HIV Group reported in April 1999 that elective caesarean section delivery can help reduce vertical transmission of HIV, though it is not without risk to certain women.28 When AZT treatment is combined with elective caesarean delivery, a transmission rate of 2 percent has been reported.29

Because a significant amount of MIT occurs around the time of birth, and the risk of maternal-fetal transmission depends, in part, on the amount of HIV in the mother's blood, it may be possible to reduce transmission using drug therapy only around the time of birth. NIAID has planned other studies that will assess the effectiveness of this approach as well as the role of new antiretrovirals, microbicides and other innovative strategies in reducing the risk of MIT of HIV.

Diagnosis

HIV infection is often difficult to diagnose in very young children. Infected babies, especially in the first few months of life, often appear normal and may exhibit no telltale signs that would allow a definitive diagnosis of HIV infection. Moreover, all children born to infected mothers have antibodies to HIV, made by the mother's immune system, that cross the placenta to the baby's bloodstream before birth and persist for up to 18 months. Because these maternal antibodies reflect the mother's but not the infant's infection status, the test is not useful in newborns or young infants.
In recent years, investigators have demonstrated the utility of highly accurate blood tests in diagnosing HIV infection in children 6 months of age and younger. One laboratory technique called polymerase chain reaction (PCR) can detect minute quantities of the virus in an infant's blood. Another procedure allows physicians to culture a sample of an infant's blood and test it for the presence of HIV.

Currently, PCR assays or HIV culture techniques can identify at birth about one-third of infants who are truly HIV-infected. With these techniques, approximately 90 percent of HIV-infected infants are identifiable by 2 months of age, and 95 percent by 3 months of age. One innovative new approach to both RNA and DNA PCR testing uses dried blood spot specimens, which should make it much simpler to gather and store specimens in field settings.

Progression of HIV Disease in Children

Researchers have observed two general patterns of illness in HIV-infected children. About 20 percent of children develop serious disease in the first year of life; most of these children die by age 4 years.

The remaining 80 percent of infected children have a slower rate of disease progression, many not developing the most serious symptoms of AIDS until school entry or even adolescence. A recent report from a large European registry of HIV-infected children indicated that half of the children with perinatally acquired HIV disease were alive at age 9. Another study, of 42 perinatally HIV-infected children who survived beyond 9 years of age, found about one-quarter of the children to be asymptomatic with relatively intact immune systems.

The factors responsible for the wide variation observed in the rate of disease progression in HIV-infected children are a major focus of the NIAID pediatric AIDS research effort. The Women and Infants Transmission Study, a multisite perinatal HIV study funded by NIH, has found that maternal factors including Vitamin A level and CD4 counts during pregnancy, as well as infant viral load and CD4 counts in the first several months of life, can help identify those infants at risk for rapid disease progression who may benefit from early aggressive therapy.

Signs and Symptoms of Pediatric HIV Disease
Many children with HIV infection do not gain weight or grow normally. HIV-infected children frequently are slow to reach important milestones in motor skills and mental development such as crawling, walking and speaking. As the disease progresses, many children develop neurologic problems such as difficulty walking, poor school performance, seizures, and other symptoms of HIV encephalopathy.

Like adults with HIV infection, children with HIV develop life-threatening opportunistic infections (OIs), although the incidence of various OIs differs in adults and children. For example, toxoplasmosis is seen less frequently in HIV-infected children than in HIV-infected adults, while serious bacterial infections occur more commonly in children than in adults. Also, as children with HIV become sicker, they may suffer from chronic diarrhea due to opportunistic pathogens.

Pneumocystis carinii pneumonia (PCP) is the leading cause of death in HIV-infected children with AIDS. PCP, as well as cytomegalovirus (CMV) disease, usually are primary infections in children, whereas in adults these diseases result from the reactivation of latent infections.

A lung disease called lymphocytic interstitial pneumonitis (LIP), rarely seen in adults, also occurs frequently in HIV-infected children. This condition, like PCP, can make breathing progressively more difficult and often results in hospitalization.

Children with HIV suffer the usual childhood bacterial infections -- only more frequently and more severely than uninfected children. These bacterial infections can cause seizures, fever, pneumonia, recurrent colds, diarrhea, dehydration and other problems that often result in extended hospital stays and nutritional problems.

HIV-infected children frequently have severe candidiasis, a yeast infection that can cause unrelenting diaper rash and infections in the mouth and throat that make eating difficult.

Treatment of HIV-Infected Children
NIAID investigators are defining the best treatments for pediatric patients. Currently there are 16 drug products approved by the FDA for the treatment of adult HIV infection. Through major contributions by the Pediatric ACTG, 10 antiretroviral agents have pediatric label information, including 3 protease inhibitors.28 While the basic principles that guide treatment of pediatric HIV infection are the same as for any HIV-infected person, there are a number of unique scientific and medical concerns that are important to consider in the treatment of children with HIV infection. These range from differences from adults in age-related issues such as CD4 lymphocyte counts and drug metabolism to requirements for special formulations and treatment regimens that are appropriate for infants through adolescents. As in adults, treatment of HIV-infected children today is a complex task of using potent combinations of antiretroviral agents to maximally suppress viral replication.

Researchers supported by NIAID are focusing not only on the development of new antiretroviral products but also on the critical question of how to best use the treatments that are currently available. Treatment strategy questions designed to identify what the best initial therapy is, when failing regimens should be switched and strategies for how to address the antiretroviral needs of children with advanced disease are examples. Long-term assessment of these children is also a high priority to assess sustained antiretroviral benefits as well as to monitor for potential adverse consequences of treatment.

Problems of Families
A mother and child with HIV usually are not the only family members with the disease. Often, the mother's sexual partner is infected, and other children in the family may be infected as well. Frequently, a parent with AIDS does not survive to care for his or her HIV-infected child.

In the countries hardest hit by the AIDS epidemic, some 8.2 million children under 15 around the world have been orphaned by AIDS - 90 percent of them in sub-Saharan Africa alone.31 The rate is expected to increase. One in three of these orphans is under age five.32 Communities and extended families are struggling with and often overwhelmed by the vast number of AIDS orphans. Many orphans and other children from families devastated by AIDS face multiple risks, such as forced relocation, violence, living on the streets, drug use, and even commercial sex. Other children suffer because sex education and services are not available to them or do not communicate effectively to them. Living in a country undergoing political turmoil or where fathers migrate for work can also raise the risk of a child becoming HIV-infected.

In the U.S., most children living with HIV/AIDS live in inner cities, where poverty, illicit drug use, poor housing and limited access to and use of medical care and social services add to the challenges of HIV disease.

One encouraging note is that, according to UNAIDS, where information, training, and services to help prevent HIV infection are made available and affordable to young people, they are more likely to make use of them than their elders are.33

Management of the complex medical and social problems of families affected by HIV requires a multidisciplinary case management team, integrating medical, social, mental health and educational services. NIAID provides special funding to many of its clinical research sites to provide for services, such as transportation, day care, and the expertise of social workers, crucial to families devastated by HIV.

Resources
Note: The UNAIDS and CDC publications referenced in this article may be viewed on the World Wide Web at http://www.unaids.org and http://www.cdc.gov.

AIDS Clinical Trials Information Service. For information about pediatric and adult AIDS clinical trials open to enrollment, call (800) TRIALS-A, 9 a.m. to 7 p.m. Eastern Time, Monday through Friday. Web: http://www.actis.org E-mail: actis@actis.org.

National AIDS Hotline. Staffed 24 hours a day, seven days a week. English Service: 1-800-342-AIDS. Spanish service: 1-800-344-7432. Deaf service (TDD): 1-800-243-7889.

The National Pediatric HIV Resource Center. A non-profit organization that serves professionals who care for children, adolescents and families with HIV infection and AIDS. Phone: 973-972-0410 or toll free: 1-800-362-0071. Web: http://pedhivaids.org/. E-mail: ortegaes@umdnj.edu.

The Pediatric AIDS Foundation. A national non-profit organization dedicated exclusively to supporting reseach for AIDS in children. Phone: 310-314-1459. Web: http://www.pedaids.org E-mail: info@pedaids.org.

The Pediatric Branch of the National Cancer Institute (NCI) conducts clinical trials for HIV-infected children on the NIH campus in Bethesda, Md. Phone: (301) 402-0696. NCI webpage: http://www.nci.nih.gov

References
Connor, E. et al. 1994. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. N Engl J Med 311:1173-80.
UNAIDS. AIDS Epidemic Update (Dec., 1998):1, 2, 3, 7, 8., 9, 17.
UNAIDS. Report on the Global HIV/AIDS Epidemic (June, 1998):6, 8.
Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report (Dec. 1998) 10(2):7.
Ibid., p. 26
Rosenberg, P., et al. 1994. Declining age at HIV infection in the United States. N Engl J Med 330:789-90.
Centers for Disease Control and Prevention, op cit., p. 36.
Ibid., pp. 10-11.
UNAIDS, Update, p. 6.
Centers for Disease Control and Prevention, op. cit., p. 24.
Centers for Disease Control and Prevention. National Center for Health Statistics. 1998. National Vital Statistics Report 47 (9):26.
Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report, p. 39.
NAIDS, Report.
Quinn, T. 1996. Global burden of the HIV pandemic. Lancet:348:99-106.
Landesman, S., et al. 1996. Obstetrical factors and the transmission of human immunodeficiency virus type 1 from mother to child. N Engl J Med 334: 1617-23.
Monitoring the AIDS Pandemic (MAP) Network. 1998. The status and trends of the HIV/AIDS epidemics in the world:17.
UNAIDS, Report, p. 48.
Connor, E., et al., op. cit.
Stiehm, E., et al. 1999. Efficacy of zidovudine and human immunodeficiency virus (HIV) hyperimmune immunoglobulin for reducing perinatal HIV transmission from HIV-infected women with advanced disease: results of Pedatric ACTG protocol 185. J Infect Dis 179(3):567-75.
Centers for Disease Control and Prevention. 1998. Public Health Service Task Force recommendations for the use of antiretroviral drugs in pregnant women infected with HIV-1 for maternal health and for reducing perinatal HIV-1 transmission in the United States. MMWR Recommendations and Reports 47 (RR-2). May be viewed on the Web at http://www.hivatis.org.
Wilfert, C., et al. 1999. Consensus statement: Science, ethics, and the future of research into maternal infant transmission of HIV-1. Lancet 353 (9155):832-35.
Centers for Disease Control and Prevention. 1997. Update: Perinatally acquired HIV/AIDS-United States, 1997. MMWR 46: 1086-92.
Shaffer, N., et al. 1999. Short-course zidovudine for perinatal HIV-1 transmission in Bangkok, Thailand: A randomised controlled trial. Lancet 353 (9155):773-79.
Dabis, F. et al. 1999. 6-month efficacy, tolerance, and acceptability of a short regimen of oral zidovudine to reduce vertical transmission of HIV in breastfed children in Cote d'Ivoire and Burkina Faso. Lancet 353 (9155):786-92.
Saba, J., The PETRA Trial Study Team. 1999. Interim analysis of early efficacy of three short course ZDV/3TC combination regimens to prevent mother-to-child transmission of HIV-1. Presented at the Sixth Conference on Retroviruses and Opportunistic Infections. Chicago: February 1, 1999.
Guay, L, et al. 1999. Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial. Lancet 354:795-802.
Marseille, E., et al. 1999. Cost effectiveness of single-dose nevirapine regimen for mothers and babies to decrease vertical HIV-1 transmission in sub-Saharan Africa. Lancet 654:803-09.
Riley, L.E. and Green, M.F. Elective caesarean delivery to reduce the transmission of HIV. 1999. N Engl J Med 340:13, 1032.
Mofenson, L.M., Fowler, M.G. In press. Interruption of materno-fetal transmission. Reported in Shaffer, N., op. cit.
HIV/AIDS Treatment Information Service. 1999. Guidelines for the use of antiretroviral agents in pediatric HIV infection. May be viewed on the Web at http://www.hivatis.org/.
UNAIDS, Report, p. 9.
Centers for Disease Control and Prevention. National Center for HIV, STD, and TB Prevention. Divisions of HIV/AIDS. International Projections/Statistics. Web: http://www.cdc.gov/hiv/stats.htm#international
UNAIDS, Update, p. 9.

NIAID is a component of the National Institutes of Health (NIH). NIAID conducts and supports research to prevent, diagnose and treat illnesses such as HIV disease and other sexually transmitted diseases, tuberculosis, malaria, and other infectious diseases as well as asthma and allergies.

Coxsackie and Echovirus

2011-08-30T14:26:00.000-07:00

Coxsackie and echoviruses belong to a class known as enteroviruses. Enteroviruses are transmitted orally (by ingestion of contaminated food) through what is known as the faeco-oral route. Enteroviruses are the most common cause of aseptic meningitis and nonspecific febrile illnesses of neonates. Certain clinical syndromes are more likely to be caused by certain serotypes, but there is much overlap.

Nonspecific Febrile Illness (Summer Grippe) The most common clinical manifestation of enterovirus infection is a nonspecific febrile illness.

Generalized Disease of the Newborn Neonates often present with an illness resembling bacterial sepsis, with fever, irritability, and lethargy.
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Aseptic Meningitis and Encephalitis Enteroviruses are the cause of up to 90% of cases of aseptic meningitis in children and young adults in which an etiologic agent can be identified. Patients with aseptic meningitis typically present with an acute onset of fever, chills, headache, photophobia, and pain on eye movement. Nausea and vomiting are also common.

Pleurodynia (Bornholm Disease) Patients with pleurodynia present with an acute onset of fever and spasms of pleuritic chest or upper abdominal pain. Chest pain is more frequent in adults, and abdominal pain is more common in children.

Myocarditis and Pericarditis Enteroviruses are estimated to cause up to one-third of cases of acute myocarditis. Coxsackievirus B and its RNA have been detected in pericardial fluid and myocardial tissue in some cases of acute myocarditis and pericarditis. Most cases of enteroviral myocarditis or pericarditis occur in newborns, adolescents, or young adults.

Exanthems Enterovirus infection is the leading cause of exanthems in children in the summer and fall. While exanthems are associated with many enteroviruses, certain types have been linked to specific syndromes.

Hand-Foot-and-Mouth Disease Patients with hand-foot-and-mouth disease present with fever, anorexia, and malaise; these manifestations are followed by the development of sore throat and vesicles on the buccal mucosa and often on the tongue and then by the appearance of tender vesicular lesions on the dorsum of the hands, sometimes with involvement of the palms. The vesicles may form bullae (ballooning of the skin) and quickly ulcerate. About one-third of patients also have lesions on the palate, uvula, or tonsillar pillars, and one-third have a rash on the feet (including the soles) or on the buttocks. The disease is highly infectious.

Herpangina Herpangina is usually caused by coxsackievirus A and presents as acute-onset fever, sore throat, dysphagia, and grayish-white papulovesicular lesions on an erythematous base that ulcerate.

Acute Hemorrhagic Conjunctivitis Patients with acute hemorrhagic conjunctivitis present with an acute onset of severe eye pain, blurred vision, photophobia, and watery discharge from the eye.

Handout on Health: Osteoarthritis

2011-08-23T09:38:00.000-07:00

This booklet is for people who have osteoarthritis, their families, and others interested in learning more about the disorder. The booklet describes osteoarthritis and its symptoms and contains information about diagnosis and treatment as well as current research efforts supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and other components of the National Institutes of Health (NIH). It also discusses pain relief, exercise, and quality of life for people with osteoarthritis. If you have further questions after reading this booklet, you may wish to discuss them with your doctor.

What Is Osteoarthritis?

Osteoarthritis (AH-stee-oh-ar-THREYE-tis) is the most common type of arthritis, especially among older people. Sometimes it is called degenerative joint disease or osteoarthrosis.

Osteoarthritis is a joint disease that mostly affects the cartilage (KAR-til-uj). Cartilage is the slippery tissue that covers the ends of bones in a joint. Healthy cartilage allows bones to glide over one another. It also absorbs energy from the shock of physical movement. In osteoarthritis, the surface layer of cartilage breaks down and wears away. This allows bones under the cartilage to rub together, causing pain, swelling, and loss of motion of the joint. Over time, the joint may lose its normal shape. Also, bone spurs--small growths called osteophytes--may grow on the edges of the joint. Bits of bone or cartilage can break off and float inside the joint space. This causes more pain and damage.

People with osteoarthritis usually have joint pain and limited movement. Unlike some other forms of arthritis, osteoarthritis only affects joints, and not internal organs. For example, rheumatoid arthritis--the second most common form of arthritis--affects other parts of the body besides the joints. It begins earlier than osteoarthritis, causes inflammation, and may make people feel sick, tired, and sometimes feverish.

Who Has Osteoarthritis?

Osteoarthritis is one of the most frequent causes of physical disability among adults. More than 20 million people in the United States probably have the disease. Some younger people get osteoarthritis from a joint injury, but osteoarthritis most often occurs in older people. In fact, by age 65, more than half of the population has x-ray evidence of osteoarthritis in at least one joint. Since the number of older Americans is increasing, so is the number of people with osteoarthritis. Both men and women have the disease. Before age 45, more men have it, while after age 45 osteoarthritis is more common in women.

How Does Osteoarthritis Affect People?

Osteoarthritis affects each person differently. In some people, it progresses more quickly; in others, the symptoms are more serious. Scientists do not yet know what causes the disease, but they suspect a combination of factors in the body and in the environment. Also, diet, weight, and stresses on the joints from certain jobs affect the disease and how a person reacts to it.

Osteoarthritis hurts people in more than their joints: their finances and lifestyles are also affected.

Financial effects include:
The cost of treatment
Wages lost because of disability.

Lifestyle effects include
Depression
Anxiety
Feelings of helplessness
Limits on daily activities
Job limitations
Loss of everyday family joys and responsibilities.

Despite these challenges, most people with osteoarthritis can lead active and productive lives. They succeed by using osteoarthritis treatment strategies such as:
Pain relief medications
Rest and exercise
Patient education and support programs
Learning self-care and having a "good-health attitude."

Osteoarthritis Basics: The Joint and Its Parts

Most joints--the place where two moving bones come together--are designed to protect bone ends from wearing away and to absorb shock from movements like walking or repetitive movements. The joint includes
Cartilage. A hard but slippery coating on the end of each bone. Cartilage, which breaks down and wears away in osteoarthritis, is described in more detail in the box below.
Joint capsule. A tough membrane sac that holds all the bones and other joint parts together.
Synovium (sin-O-vee-um). A thin membrane inside the joint capsule.
Synovial fluid. A fluid that lubricates the joint and keeps the cartilage smooth and healthy.
Muscles, ligaments, and tendons. Together, muscles and connective tissues keep the bones stable and allow the joint to bend and move. Ligaments are tough, cord-like tissues that connect one bone to another. Tendons are tough, fibrous cords that connect muscles to bones.

How Do You Know If You Have Osteoarthritis?

Usually, osteoarthritis comes on slowly. Early in the disease, joints may ache after physical work or exercise. Osteoarthritis can occur in any joint. Most often it occurs at the hands, hips, knees, or spine.

Hands: Osteoarthritis of the fingers is the one type of the disease that seems to be hereditary; that is, it runs in families. More women than men have it, especially after menopause. Small, bony knobs appear on the end joints of the fingers. They are called Heberden's nodes. Similar knobs (called Bouchard's [boo-SHARDZ] nodes) can appear on the middle joints of the fingers. Fingers can become enlarged and gnarled, and may ache or be stiff and numb. The base of the thumb joint is also commonly affected by osteoarthritis. This kind of osteoarthritis can be helped by medications, splints, or heat treatment.

Cartilage: the Key to Healthy Joints

Cartilage is 65 to 80 percent water. Three other substances make up the rest of cartilage tissue: collagen, proteoglycans, and chondrocytes.
Collagen (KAHL-uh-jen). A fibrous protein. Collagen is also the building block of skin, tendon, bone, and other connective tissues.
Proteoglycans (PRO-tee-uh-GLY-kanz). A combination of proteins and sugars. Strands of proteoglycans and collagen weave together and form a mesh-like tissue. This allows cartilage to flex and absorb physical shock.
Chondrocytes (KAHN-druh-sytz). Cells that grow all through the cartilage. They mainly help cartilage stay healthy and grow. Sometimes, however, they release substances called enzymes that destroy collagen and other proteins. Researchers are trying to learn more about chondrocytes.

Knees: The knees are the body's primary weight-bearing joints. For this reason, they are among the joints most commonly affected by osteoarthritis. They may be stiff, swollen, and painful, making it hard to walk, climb, get in and out of chairs, and use bathtubs. If not treated, osteoarthritis in the knees can lead to disability. Medications, losing weight, exercise, and walking aids can reduce pain and disability. In severe cases, knee replacement surgery may be helpful.

The Warning Signs of Osteoarthritis
Steady or intermittent pain in a joint
Stiffness after getting out of bed
Joint swelling or tenderness in one or more joints
A crunching feeling or sound of bone rubbing on bone
Hot, red, or tender? Probably not osteoarthritis. Check with your doctor about other causes, such as rheumatoid arthritis.
Not always pain. Not everyone with osteoarthritis feels pain. In fact, only a third of people with osteoarthritis in their x rays report pain or other symptoms.

Hips: Osteoarthritis in the hip can cause pain, stiffness, and severe disability. People may feel the pain in their hips, or in their groin, inner thigh, or knees. Walking aids such as canes or walkers can reduce stress on the hip. Osteoarthritis in the hip may limit moving and bending. This can make daily activities such as dressing and foot care a challenge. Walking aids, medication, and exercise can help relieve pain and improve motion. The doctor may recommend hip replacement if the pain is severe and not helped by other methods.

Spine: Stiffness and pain in the neck or in the lower back can result from osteoarthritis of the spine. Weakness or numbness of the arms or legs can also result. Some people feel better when they sleep on a firm mattress or sit using back support pillows. Others find help from heat treatment or an exercise program to strengthen the back and abdominal muscles. In severe cases, the doctor may suggest surgery to reduce pain and help restore function.

How Do Doctors Diagnose Osteoarthritis?

No single test can diagnose osteoarthritis. Most doctors use a combination of the following methods to diagnose the disease and rule out other conditions:

Clinical History: The doctor begins by asking the patient to describe the symptoms, and when and how the condition started. Good doctor-patient communication is important. The doctor can give a better assessment if the patient gives a good description of pain, stiffness, and joint function, and how they changed over time. It is also important for the doctor to know how the condition is affecting the patient's work and daily life. Finally, the doctor also needs to know about other medical conditions and whether the patient is taking any medicines.

Physical Examination: The doctor will check the patient's general health. Joints bothering the patient will be examined, including checking reflexes and muscle strength. The doctor will also observe the patient's ability to walk, bend, and carry out activities of daily living.

X Rays: Doctors take x rays to see how much joint damage has been done. X rays of the affected joint can show such things as cartilage loss, bone damage, and bone spurs. But there is often a big difference between the severity of osteoarthritis that the x ray shows and the degree of pain and disability the patient has. And x rays may not show early osteoarthritis damage (before much cartilage loss has taken place).

Other Tests: The doctor may order blood tests to determine the cause of symptoms. Another common test includes "joint aspiration," where fluid is drawn from the joint for examination.

It is usually not difficult to tell if a patient has osteoarthritis. It is more difficult to tell if the disease is causing the patient's symptoms. Osteoarthritis is so common, especially in older people, that other conditions may play a role in the symptoms. The doctor will try to find out what is causing the symptoms, ruling out other disorders and identifying conditions that may make the symptoms worse. The severity of symptoms in osteoarthritis is greatly influenced by the patient's attitudes, anxiety, depression, or daily activity level.

How Is Osteoarthritis Treated?

Most successful treatment programs involve a combination of treatments tailored to the patient's needs, lifestyle, and health. Osteoarthritis treatment has four general goals:
Control pain through drugs and other measures.
Improve joint care through rest and exercise.
Maintain an acceptable body weight.
Achieve a healthy lifestyle.

Osteoarthritis treatment plans often include ways to manage pain and improve function. Such plans can involve exercise, rest and joint care, pain relief, weight control, medications, surgery, and nontraditional treatment approaches.

Exercise: Research shows that one of the best treatments for osteoarthritis is exercise. This activity can improve mood and outlook, decrease pain, increase flexibility, improve the heart and blood flow, maintain weight, and promote general physical fitness. It is also inexpensive and, if done correctly, has few negative side effects. The amount and form of exercise will depend on which joints are involved, how stable the joints are, and whether a joint replacement has already been done. (See Be a Winner! Practice Self-Care and Keep a Good-Health Attitude.)

Rest and Joint Care: Treatment plans include regularly scheduled rest. Patients must learn to recognize the body's signals, and know when to stop or slow down. This prevents pain caused by overexercising. Some patients find that relaxation techniques, stress reduction, and biofeedback help. Some use canes and splints to protect joints and take pressure off them. Splints or braces provide extra support for weakened joints. They also keep the joint in proper position during sleep or activity. Splints must be used for limited periods because joints and muscles need to be exercised to prevent stiffness and weakness. An occupational therapist or a doctor can help the patient get a properly fitting splint.

On the Move: Fighting Osteoarthritis With Exercise

You can use exercises to keep strong and limber, extend your range of movement, and reduce weight. Ask your doctor or physical therapist what exercises are best for you.

Strength: Exercise bands are inexpensive devices that add resistance.

Aerobics: Activities that keep your lungs and circulation systems in shape.

Range of Motion: These activities keep the joints limber.

Agility: Many of these exercises help you to maintain daily living skills.

Neck and Back Strength: Don't forget to keep your spine strong and limber.

Ask your doctor or physical therapist what exercises are best for you. Ask for guidelines on exercising when a joint is sore or if swelling is present. Also, check if you should (1) use drugs such as analgesics or anti-inflammatories (NSAIDs) to make exercising easier, or (2) use ice afterwards.

Pain Relief: People with osteoarthritis may have nonmedical ways to relieve pain. Patients can use warm towels, hot packs, or a warm bath or shower to apply moist heat to the joint. This can relieve pain and stiffness. In some cases, cold packs (a bag of ice or frozen vegetables wrapped in a towel) can relieve pain or numb the sore area. (Check with a doctor or physical therapist to find out if heat or cold is the best treatment.) Water therapy in a heated pool or whirlpool may also relieve pain and stiffness. For osteoarthritis in the knee, patients may wear insoles or cushioned shoes to redistribute weight and reduce joint stress.

Weight Control: Osteoarthritis patients who are overweight or obese need to lose weight. Weight loss can reduce stress on weight-bearing joints and limit further injury. A dietician can help patients develop healthy eating habits. A healthy diet and regular exercise help reduce weight.

Medicines: Doctors use medicines to eliminate or reduce pain and to improve functioning. Doctors consider a number of factors when choosing medicines for their patients with osteoarthritis. Two important factors are the nature of the pain and potential drug side effects. Patients must use medicines carefully and tell doctors about any changes that occur.

The following types of medicines are commonly used in treating osteoarthritis:
NSAIDs (Nonsteroidal anti-inflammatory drugs). Many NSAIDs are used to treat osteoarthritis. Patients can buy some over the counter (for example, aspirin, Advil®*, Motrin® IB, Aleve®, ketoprofen). Others need a prescription. These drugs work in a similar way: they fight inflammation or swelling and relieve pain. However, each NSAID is a different chemical, and has slightly different effects in the body.

* Note: Brand names included in this booklet are provided as examples only. Their inclusion does not mean they are endorsed by the National Institutes of Health or any other Government agency. Also, if a certain brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.
Side effects. NSAIDs can cause stomach irritation or affect kidney function. The longer a person uses NSAIDs, the more likely he or she is to have side effects, and the more serious those effects can be. Many other drugs cannot be taken with NSAIDs, because NSAIDs alter the way the body uses or gets rid of these drugs. NSAIDs are associated with serious gastrointestinal problems, including ulcers, bleeding, and perforation. They should be used with caution in people over 65 and in those with any history of ulcers or gastrointestinal bleeding. COX-2 inhibitors. Two new NSAIDs, Celebrex® and Vioxx®, from a class of drugs known as COX-2 inhibitors, are now being used against osteoarthritis. These medicines reduce inflammation like traditional NSAIDs, but cause fewer gastrointestinal side effects.
Acetaminophen. A non-anti-inflammatory pain reliever (for example, Tylenol®). This drug does not irritate the stomach and is less likely than NSAIDs to cause long-term side effects. Research has shown that in many patients with osteoarthritis, acetaminophen relieves pain as effectively as NSAIDs. Warning: Patients with liver disease, heavy alcohol drinkers, and those on blood-thinning medicines should use acetaminophen with caution.
Other Medicines. Doctors may prescribe several other medicines for osteoarthritis. They include

Topical pain-relieving creams, rubs, and sprays (for example, capsaicin cream) applied directly to the skin.

Mild narcotic painkillers, which--while very effective--are addictive and rarely used.

Corticosteroids, powerful anti-inflammatory hormones made naturally in the body or man made for use as drugs. Corticosteroids are typically injected into affected joints to relieve pain temporarily. This is a short-term measure, not recommended for more than two or three times per year.

Hyaluronic acid, a new medicine for joint injection, used to treat osteoarthritis of the knee. This substance is a normal component of the joint, involved in joint lubrication and nutrition. Many patients experience pain relief after a series of three to five injections.

Questions to Ask Your Doctor
or Pharmacist About Medicines
How often should I take this medicine?
Should I take this medicine with food or between meals?
What side effects can I expect?
Should I take this medicine with other prescription medicines I take?
Should I take this medicine with the over-the-counter medicines I take?

Most medicines used to treat osteoarthritis have side effects. So it is important for patients to learn about the drugs they are taking. Even nonprescription drugs should be checked. Several groups of patients are at high risk for side effects. Those patients are people with a history of peptic ulcers or digestive tract bleeding, those taking oral corticosteroids or anticoagulants (blood thinners), those who smoke, and those who consume alcohol. Some patients may be able to help reduce side effects by taking some drugs with food. Others should avoid stomach irritants such as alcohol, tobacco, and caffeine. Some patients take other medicines to try to protect their stomachs by coating the stomach or blocking stomach acids. These measures help, but are not always completely effective.

Treatment Approaches to Osteoarthritis Exercise Medicines
Rest and joint care Surgery
Pain relief techniques Alternative therapies
Weight control

Surgery: For some people, surgery helps relieve the pain and disability of osteoarthritis. Surgery may be performed to
Resurface (smooth out) bones.
Reposition bones.
Replace joints. Surgeons may replace affected joints with artificial joints called prostheses. These joints can be made from metal alloys, high-density plastic, and ceramic material, and can be joined to bone surfaces by special cements. Artificial joints can last from 10 to 15 years or more. About 10 percent may need revision. Surgeons choose the design and components of prostheses according to their patient's weight, sex, age, activity level, and other medical conditions.
Remove loose pieces of bone or cartilage from the joint to improve joint function.

Health Professionals Who Treat Osteoarthritis

Many types of health professionals care for people with osteoarthritis:
Rheumatologists. Doctors who specialize in treating arthritis and related conditions that affect joints, muscles, and bones.
Orthopaedists. Doctors who specialize in treatment of and surgery for bone diseases.
Physical therapists. Health professionals who work with patients to improve joint function.
Occupational therapists. Health professionals who teach ways to protect joints, minimize pain, and conserve energy.
Dietitians. Health professionals who teach ways to use a good diet to improve health and maintain a healthy weight.
Nurse educators. Nurses who specialize in helping patients understand their overall condition and implement their treatment plans.
Physiatrists (rehabilitation specialists). Doctors who help patients make the most of their physical potential.
Licensed acupuncture therapists. Health professionals who reduce pain and improve physical functioning by inserting fine needles into the skin at various points on the body.
Psychologists. Health professionals who help patients cope with difficulties in the home and workplace resulting from their conditions.
Social workers. Professionals who assist patients with social challenges caused by disability, unemployment, financial hardships, home health care, and other needs resulting from their conditions.

The decision to use surgery depends on several things. Both surgeon and patient consider the patient's level of disability, intensity of pain, interference with lifestyle, age, and occupation. Currently, more than 80 percent of osteoarthritis surgery cases involve replacing the hip or knee joint. After surgery and rehabilitation, the patient usually feels less pain and swelling, and can move more easily.

Nontraditional Approaches: Among the alternative therapies for treating osteoarthritis are:
Acupuncture. Some people have found pain relief using acupuncture (the use of fine needles inserted at specific points on the skin). Preliminary research shows that acupuncture may be a useful component in an osteoarthritis treatment plan for some patients. (See the Current Research section.)
Folk Remedies. Some patients seek alternative therapies for their pain and disability. Some of these alternative therapies have included wearing copper bracelets, drinking herbal teas, and taking mud baths. While these practices are not harmful, some can be expensive. They also cause delays in seeking medical treatment. To date, no scientific research shows these approaches to be helpful in treating osteoarthritis.

Be a Winner! Practice Self-Care and Keep a "Good-Health Attitude"

People with osteoarthritis can enjoy good health despite having the disease. How? By learning self-care skills and developing a "good-health attitude."

Self-care is central to successfully managing the pain and disability of osteoarthritis. Patients have a much better chance for a rewarding lifestyle when they educate themselves about the disease and take part in their own care. Working actively with a team of health care providers enables people with the disease to minimize pain, share in decisionmaking about treatment, and feel a sense of control over their lives. Research shows that patients who take part in their own care report less pain and make fewer doctor visits. They also enjoy a better quality of life.

Self-Management Programs Do Help

People with osteoarthritis find that self-management programs help them:
Understand the disease
Reduce pain while remaining active
Cope physically, emotionally, and mentally
Have greater control over the disease
Build confidence in their ability to live an active, independent life.

Self-Help and Education Programs: Three kinds of programs help people learn about osteoarthritis, learn self-care, and improve their good-health attitude. These programs are
Patient education programs
Arthritis self-management programs
Arthritis support groups.

These programs teach about osteoarthritis, its treatments, exercise and relaxation, patient/health care provider communication, and problem solving. Research has shown that these programs have clear and long-lasting benefits.

Enjoy a "Good-Health Attitude"
Focus on your abilities instead of disabilities.
Focus on your strengths instead of weaknesses.
Break down activities into small tasks that you can manage.
Incorporate fitness and nutrition into daily routines.
Develop methods to minimize and manage stress.
Balance rest with activity.
Develop a support system of family, friends, and health professionals.

Exercise: Regular physical activity plays a key role in self-care and wellness. Two types of exercise are important in osteoarthritis management. Therapeutic exercises keep joints working as well as possible. Aerobic conditioning exercises improve strength and fitness, and control weight. Patients should be realistic when they start exercising. They should learn how to exercise correctly, because exercising incorrectly can actually cause problems.

Most people with osteoarthritis exercise best when pain is least severe. Start with an adequate warmup and begin exercising slowly. Resting frequently ensures a good workout. It also reduces the risk of injury. A physical therapist can evaluate how a patient's muscles are working. This information helps the therapist develop a safe, personalized exercise program to increase strength and flexibility.

Many people enjoy sports or other activities in their exercise program. Good activities include swimming and aquatic exercise, walking, running, biking, cross-country skiing, and using exercise machines and exercise videotapes.

People with osteoarthritis should check with their doctor or physical therapist before embarking on an exercise program. Health care providers will suggest what exercises are best for you, how to warm up safely, and when to avoid exercising a joint affected by arthritis. Pain medications and ice applications may make exercising easier.

Body, Mind, Spirit: Making the most of good health requires careful attention to the body, mind, and spirit. People with osteoarthritis must plan and develop daily routines that maximize their quality of life and minimize disability. They also need to evaluate these routines periodically to make sure they are working well.

Good health also requires a positive attitude. People must decide to make the most of things when faced with the challenges of osteoarthritis. This attitude--a good-health mindset--doesn't just happen. It takes work, every day. And with the right attitude, you will enjoy it.

Current Research

The leading role in osteoarthritis research is played by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), within the National Institutes of Health (NIH). The NIAMS funds many researchers across the United States to study osteoarthritis. It has established a Specialized Center of Research devoted to osteoarthritis. Also, a large number of researchers study arthritis at the NIAMS Multipurpose Arthritis and Musculoskeletal Disease Centers. These centers conduct basic, laboratory, and clinical research aimed at understanding the causes, treatment options, and prevention of arthritis and musculoskeletal diseases. Center researchers also study professional, patient, and public education; epidemiology; and health services.

For years, scientists thought that osteoarthritis was simply a disease of "wear and tear" that occurred in joints as people got older. In the last decade, however, research has shown that there is more to the disorder than aging alone. The production, maintenance, and breakdown of cartilage, as well as bone changes in osteoarthritis, are now seen as a series or "cascade" of events. Many researchers are trying to discover where in that cascade of events things go wrong. By understanding what goes wrong, they hope to find new ways to prevent or treat osteoarthritis. Some key areas of research are described below.

Animal Models: Animals help researchers understand how diseases work and why they occur. In osteoarthritis, animal models help researchers learn many things about osteoarthritis. They help reveal what happens to cartilage, how treatment strategies might work, and what might prevent the disease. Animal models also help scientists study osteoarthritis in very early stages, before it causes joint damage.

Diagnostic Tools: Some scientists want to find ways to detect osteoarthritis at earlier stages so that they can treat it earlier. They seek specific abnormalities in the blood, joint fluid, or urine of people with the disease. Other scientists use new technologies to analyze differences in cartilage from different joints. For example, many people have osteoarthritis in the knees or hips, but few have it in their ankles. Can ankle cartilage be different? Does it age differently? Answering these questions will help us understand the disease better.

Genetic Studies: Researchers suspect that inheritance plays a role in 25 to 30 percent of osteoarthritis cases. Scientists have identified a mutation (a gene defect) affecting collagen, an important part of cartilage in patients with an inherited kind of osteoarthritis that starts at an early age. The mutation weakens collagen protein, which may break or tear more easily under stress. Scientists are looking for other mutations in osteoarthritis. In the future, a test to determine who carries the genetic defect (or defects) could help people reduce their risk for osteoarthritis with lifestyle adjustments.

Comprehensive Treatment Strategies: Effective treatment for osteoarthritis takes more than drugs or surgery. Getting help from a variety of care professionals can often improve patient treatment and self-care. (See Health Professionals Who Treat Osteoarthritis.) Research shows that adding patient education and social support is a low-cost, effective way to decrease pain and reduce the amount of medicine used.

Exercise plays a key part in comprehensive treatment. Researchers are studying exercise in greater detail, finding out just how to use it in treating or preventing osteoarthritis. For example, several scientists have looked at knee osteoarthritis and exercise. They have found that:
The level of muscle strength in the thigh muscle (quadriceps) is very important. Strengthening this muscle can relieve symptoms and prevent more damage.
Walking can result in better functioning and increased walking distance.
People with knee osteoarthritis who were active in an exercise program feel less pain. They also function better.

Research has shown that losing extra weight can help people with osteoarthritis. Most important, weight loss may reduce the risk of developing osteoarthritis of the knee in overweight or obese people.

Using NSAIDs: Many patients have pain that persists despite the use of simple pain relievers like acetaminophen. Some of these patients use NSAIDs instead. Health care providers are concerned about long-term NSAID use because dangerous side effects can result. Scientists are working to design and test new, safer NSAIDs. One example currently available is a class of drugs called COX-2 inhibitors. These medicines relieve symptoms and are less likely to produce serious side effects such as stomach ulcers and bleeding, which are associated with long-term NSAID use.

Drugs to Prevent Joint Damage: No treatment actually prevents osteoarthritis or reverses or blocks the disease process once it begins. Present treatments just relieve the symptoms. Researchers are looking for drugs that would prevent, slow down, or reverse joint damage. One experimental antibiotic drug, doxycycline, may stop certain enzymes from damaging cartilage. The drug has responded well in clinical studies, but more studies are needed. Researchers are also studying growth factors or other natural chemical messengers. These potential medicines may be able to stimulate cartilage growth or repair.

Acupuncture: Licensed acupuncture therapists insert very fine needles into the skin at various points on the body. Scientists think that the needles stimulate the release of natural, pain-relieving chemicals produced by the brain or the nervous system. Researchers are looking at acupuncture treatment of patients who have knee osteoarthritis. Early findings suggest that traditional Chinese acupuncture is effective in some patients as an additional therapy for osteoarthritis, reducing pain and improving function.

Nutritional Supplements: Nutritional supplements are often reported as helpful in treating osteoarthritis. Such reports should be viewed with caution, however, since very few studies have carefully evaluated the role of nutritional supplements in osteoarthritis.
Glucosamine and chondroitin sulfate. Both of these nutrients are found in small quantities in food and are components of normal cartilage. Scientific studies on these two nutritional supplements have not yet shown that they affect the disease. They may relieve symptoms in some patients, however. The National Center for Complementary and Alternative Medicine at NIH is supporting a clinical trial to test whether either glucosamine or chondroitin sulfate alone, or in combination with each other, reduces pain and improves function. Patients using this therapy should do so only under the supervision of their doctor, as part of an overall treatment program with exercise, relaxation, and pain relief.
Vitamins D and C. Progression of the disease appears to be less in patients with high levels of vitamin D or C intake. More studies are needed to confirm these reports.

Hyaluronic Acid: Injecting this substance into the knee joint provides long-term pain relief for some people with osteoarthritis. Hyaluronic acid is a natural component of cartilage and joint fluid. It lubricates and absorbs shock in the joint. The Food and Drug Administration (FDA) recently approved this therapy for patients with osteoarthritis of the knee if they do not get relief from exercise, physical therapy, or simple analgesics. Researchers are testing whether hyaluronic acid can slow down the progression of osteoarthritis.

Estrogen: In studies of older women, scientists found a lower risk of osteoarthritis in women who had used oral estrogens for hormone replacement therapy. The researchers suspect that low estrogen levels could increase risk for the disease. Further studies are needed to answer this question.

Tissue Engineering: This technology involves removing cells from the body and replacing them to improve certain body functions. NIAMS researchers are exploring three types of tissue engineering for use in treating osteoarthritis.
Enzyme engineering. Certain body chemicals called enzymes may help cartilage break down. Scientists are working to genetically engineer cells that would inhibit these enzymes and prevent the damage they cause. Cells are removed from the body, genetically changed, and then injected back into the affected joint. They live in the joint and protect it from damaging enzymes.
Cartilage cell replacement. Researchers remove cartilage cells from the patient's own joint, clone or grow new cells using tissue culture and other laboratory techniques, and inject the newly grown cells into the patient's joint. Patients with cartilage cell replacement have decreased osteoarthritis symptoms. Actual cartilage repair is limited, however.
Stem cell transplantation. Stem cells are primitive cells that can transform into other kinds of cells, such as muscle or bone cells. They are usually taken from bone marrow. In the future, researchers hope to insert stem cells into cartilage where they will make new cartilage. If successful, this process could be used to repair damaged cartilage and avoid the need for surgical joint replacements with metal or plastics.

Hope for the Future

Research is opening up new avenues of treatment for people with osteoarthritis. A balanced, comprehensive approach is still the key to staying active and healthy with the disease. People with osteoarthritis should combine exercise, relaxation education, social support, and medicines in their treatment strategies. Meanwhile, as scientists unravel the complexities of the disease, new treatments and prevention methods should appear. They will improve the quality of life for people with osteoarthritis and their families.

Additional Resources

National Institute of Arthritis and Musculoskeletal
and Skin Diseases Information Clearinghouse
National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
(301) 495-4484 or (877) 22-NIAMS (toll free)
TTY: (301) 565-2966
Fax: (301) 718-6366
World Wide Web address: http://www.niams.nih.gov/

This clearinghouse, a public service sponsored by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), provides information about various forms of arthritis and rheumatic diseases. The clearinghouse distributes patient and professional education materials and also refers people to other sources of information.

American College of Rheumatology
1800 Century Place, Suite 250
Atlanta, GA 30345
(404) 633-3777
Fax: (404) 633-1870
World Wide Web address: http://www.rheumatology.org/

This association provides referrals to rheumatologists and physical and occupational therapists who have experience working with people who have osteoarthritis. The organization also provides educational materials and guidelines.

American Academy of Orthopaedic Surgeons
P.O. Box 2058
Des Plaines, IL 60017
Phone: 800-824-BONE (2663) (free of charge)
World Wide Web address: http://www.aaos.org/

The academy provides education and practice management services for orthopaedic surgeons and allied health professionals. It also serves as an advocate for improved patient care and informs the public about the science of orthopaedics. The orthopaedist's scope of practice includes disorders of the body's bones, joints, ligaments, muscles, and tendons. For a single copy of an AAOS brochure, send a self-addressed stamped envelope to the address above or visit the AAOS Web site.

Arthritis Foundation
1330 West Peachtree Street
Atlanta, GA 30309
(404) 872-7100
(800) 283-7800, or call your local chapter (listed in the telephone directory)
World Wide Web address: http://www.arthritis.org/

This is the main voluntary organization devoted to arthritis. The foundation publishes a free pamphlet on osteoarthritis and a magazine for members on arthritis and related conditions. It also provides up-to-date information on research and treatment, nutrition, alternative therapies, and self-management strategies. Chapters nationwide offer exercise programs, classes, support groups, physician referral services, and free literature.

Acknowledgments

The NIAMS gratefully acknowledges the assistances of John Klippel, M.D., and Joan McGowan, Ph.D., NIAMS, NIH; Kenneth D. Brandt, M.D., Indiana University School of Medicine, Indianapolis; Marc C. Hochberg, M.D., M.P.H., University of Maryland, Baltimore; and Roland Moskowitz, M.D., University Hospital of Cleveland, Ohio, in preparation and review of this publication. Special thanks also go to the patients who reviewed this publication and provided valuable input. Debbie Novak of Johnson, Bassin, and Shaw, Inc. wrote this booklet.

About NIAMS and Its Clearinghouse: The mission of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) is to support research into the causes, treatment, and prevention of arthritis and musculoskeletal and skin diseases; the training of basic and clinical scientists to carry out this research; and the dissemination of information on research progress in these diseases. The NIAMS Information Clearinghouse is a public service sponsored by the NIAMS that provides health information and information sources. Additional information and research updates can be found on the NIAMS Web site at http://www.niams.nih.gov/hi/.

This is a publication of the National Institutes of Health National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS).

This booklet is not copyrighted. Readers are encouraged to duplicate and distribute as many copies as needed.

Clinical features of Angina Pectoris and Myocardial Infarction

2011-08-11T20:00:00.000-07:00

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Chest pain is one of the common complaints heard in medical OPDs as well as at the GP�s clinic. Chest pain causes a lot of anxiety in the patient as it is many a time related to �heart attack� or angina and people are quite aware of the serious consequences of the symptom. Anyone having a chest pain would first think of the heart and would like to know if he/she is having a �heart attack�.

However not all times is a chest pain necessarily originating from or caused by diseases of the heart. There are plenty of other structures in the thoracic cavity and a systematic approach is needed to arrive at the correct diagnosis or in other words to find out the �real culprit� causing the chest pain.

Of special importance is the issue of chest pain in women, as this group is less liable to get heart disease till menopause. Estrogen is said to confer a protective effect and prevents the development of atherosclerosis. Myocardial infarction or Coronary artery disease (CAD) is very rare in menstruating women. As menopause approaches and estrogen levels go down, the probability of development of CAD catches up with those in men.

Even then, there are lots of young to middle aged, menstruating women complaining of chest pain and quite distressed about it. Before I highlight the special features of this particular issue lets first review the differential diagnosis of chest pain.
Differential Diagnosis of Chest Pain

1. Angina Pectoris/Myocardial Infarction

2. Other Cardiovascular Causes

a. Possibly Ischemic Pain

1) Aortic Stenosis
2) Hypertrophic Cardiomyopathy
3) Severe Systemic Hypertension
4) Severe Right Ventricular Hypertension
5) Aortic Regurgitation
6) Severe Anemia/hypoxia

b. Non Ischemic in Origin

1) Aortic Dissection
2) Pericarditis
3) Mitral Valve Prolapse

3. Gastrointestinal

a. Esophageal Spasm
b. Esophageal Reflux
c. Esophageal Rupture
d. Peptic Ulcer Disease

4. Psychogenic

a. Anxiety
b. Depression
c. Cardiac Psychosis
d. Self Gain

5. Neuromusculoskeletal

a. Thoracic Outlet syndrome
b. Lesions of Cervical/Thoracic Spine
c. Costochondritis[Tietze�s Syndrome]
d. Herpes Zoster
e. Chest wall pain

6. Pulmonary

a. Pulmonary Embolus/Infarction
b. Pneumothorax
c. Pneumonia with pleural involvement

7. Pleurisy

As most patients are anxious of their chest pain being that of Heart origin, we shall first have a look at the features of Cardiac Pain.
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Clinical features of Angina Pectoris and Myocardial Infarction

Cardiac Pain or Angina Pectoris ( reversible loss of blood supply to the heart muscle) is retrosternal, vague, poorly localized, heavy, compressive, squeezy feeling. It rarely lasts less than 1 minute or more than 20 minutes, unless it is a heart attack. Patients get prompt relief in less than 5 minutes on cessation of all activities or use of sublingual nitrates. Angina pain can also be in the left shoulder, left arm, neck or the jaws.

Pain of a Myocardial Infarction ( total sudden blockage of an artery supplying blood to the heart muscle) would be similar to this but more severe and can last longer, will not be relieved by rest or sublingual nitrate and associated with palpitation, perspiration, nausea/vomiting, dizziness, blackout or even collapse.

Pain that is unlikely to be of cardiac origin is typically well localized, sharp, pricky, lancinating type sometimes lasting less than 15 seconds. It can be aching type too but mostly will be aggravated on deep inspiration and coughing. Patient will be able to localize it with the tip of her finger.

Pain that is localized just below left nipple is almost NEVER of cardiac origin.
Common causes of chest pain in young females
1. Valvular Heart Disease

Mitral Prolapse: This is a common and benign condition. Leaflets of the Mitral valve are long, bulky and redundant. They prolapse into the left atrium during systole. It is unknown how this causes chest pain. Suffice to say that the pain occurs at rest, is sharp, non- radiating and prolonged in duration.

Rheumatic Valve Disease: Mitral stenosis is a common rheumatic valve condition in females and can cause chest pain and dyspnea. The patient will have associated cough, expectoration, there would be a low pitched rumbling diastolic murmur which will clinch the diagnosis. A 2D echocardiography will be confirmatory.
2. Anxiety/Depression

There are a lot of personal/social causes for a young female to get into a vicious cycle of anxiety causing various physical symptoms, and those symptoms in turn causing more anxiety. Depression also causes �somatization� and produces various symptoms, chest pain being one of them. This chest pain can take any form; it can even mimic Anginal pain accurately. One needs to rule out organic causes before stamping the diagnosis of anxiety/depression.
3. Neuromusculoskeletal

The pain is very well localized, tender on touch, aggravated on deep inspiration, and not aggravated on exertion. Underlying cause can be pinpointed by suitable investigations like X ray of cervical spine, chest (thoracic outlet syndrome) etc. Pain of herpes Zoster sometimes defies diagnosis until the rash develops.
4. Gastrointestinal

Esophageal reflux is one of the most common causes of retrosternal pain. The pain is mostly burning in nature, occurs more often in reclining posture, and is relieved by assuming upright position. It is more frequent after an oily, heavy meal. Esophageal spasm is a variety of the same disease. Sometimes peptic ulcer disease can also cause pain in lower chest.
5. Pulmonary

Pulmonary cause of chest pain in young female could be a pulmonary embolism/infarct caused by deep vein thromboembolism resulting from oral contraception usage. The pain is acute, severe and patient generally is in a critical condition.

Pneumonia can also cause chest pain if there is pleural involvement with it, which usually is the case.

Pneumothorax, which is rupture of a lung alveolus into the pleural cavity will cause sudden acute filling up of air pressure in pleura and will cause severe acute chest pain if it is Tension Pneumothorax and moderate dull aching pain if it is simple Pneumothorax.
6. Pleurisy

Tubercular involvement of the pleura is called pleurisy. The pain is sharp stab like, occurring on slightest act of breathing. Associated features are low grade fever, cough, and malaise, loss of appetite and loss of weight.

Chest pain in a young female has lots of reasons as we have seen. Most of the time they are not of cardiac origin. A thorough clinical examination, appropriate investigations, and reassurance will go a long way in resolving this issue.

Dr. Apurva Madia
References

1. Hurst�s The Heart. 11th Edition, Mcgrow Hill. P 219

2. Sullivan J I: Are menstruating women protected from heart disease because of or in spite of Estrogen? Relevance to the iron hypothesis. Am Heart J 145:190, 2003

3. Mikkola B, Clarkson TB: Estrogen replacement therapy, atherosclerosis and vascular function. Cardiovasc Res 53: 605, 2002

4. Douglas PS, Ginsberg GS: The evaluation of chest pain in women. N Eng J Med 334: 1311, 1996.

5. Marroquin OC, Hloubkov R, Edmindowocz D et al: Heterogenity of microvascular dysfunction in women with chest pain not attributable to coronary artery disease: Implication for clinical practice. Am Heart J 145: 628, 2003.

6. D�Anton B, Dupis G, Fleet R et al: Sex differences in chest pain & predilection of exercise induces ischemia. Can J Cardiol 19:515, 2003
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Cholera

2011-07-24T18:18:00.000-07:00

Cholera is an acute diarrheal disease that can, in a matter of hours, result in profound, rapidly progressive dehydration and death. It is caused by infection with the bacterial organism known as V. cholerae.

Humans become infected incidentally but, once infected, can act as vehicles for spread. Ingestion of water contaminated by human feces is the most common means of acquisition of V. cholerae. Consumption of contaminated food in the home, in restaurants, or from street vendors can also contribute to spread.

Cholera is a toxin-mediated disease. Its characteristic watery diarrhea is due to the action of cholera toxin (CTX), a potent protein enterotoxin elaborated by the organism following its colonization of the small intestine.
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Clinical manifestations

It passes through 3 phases: Evacuation (profound watery diarrhea), collapse (hypovolemic shock) and recovery phases.

After a 24- to 48-h incubation period, cholera begins with the sudden onset of painless watery diarrhea that may quickly become voluminous and is often followed shortly by vomiting. In severe cases, stool volume can exceed 250 mL/kg in the first 24 h. If fluids and electrolytes are not replaced, hypovolemic shock and death ensue. Fever is usually absent. Muscle cramps due to electrolyte disturbances are common. The stool has a characteristic "rice-water" appearance because of its resemblance to the water in which rice has been washed.
Diagnosis

The clinical suspicion of cholera can be confirmed by the identification of V. cholerae in stool; however, the organism must be specifically sought. In experienced hands, it can be detected directly by dark-field microscopy on a wet mount of fresh stool, and its serotype can be discerned by immobilization with Inaba- or Ogawa-specific antiserum.
Treatment

Cholera is simple to treat; only the rapid and adequate replacement of fluids, electrolytes, and base is required. Oral rehydration solution (ORS) with the WHO formulation forms the standard of therapy.

For initial management of severely dehydrated patients, intravenous fluid replacement is preferable, if available. Because profound acidosis (pH < 7.2) is common in this group, Ringer's lactate is the best choice among commercial products. It must be used with additional potassium supplements, preferably given by mouth.

Although not necessary for cure, the use of an antibiotic to which the organism is susceptible will diminish the duration and volume of fluid loss and will hasten clearance of the organism from the stool. Single-dose tetracycline (2 g) or doxycycline (300 mg) is effective in adults.

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Cholesterol Lowering in Elderly Reduces Heart Disease and Strokes

2011-07-15T05:24:00.000-07:00

Older Americans have the Nation's highest rate of coronary heart disease (CHD) and can benefit greatly from lowering elevated cholesterol, according to a new report from the National Cholesterol Education Program (NCEP). The report notes that cholesterol lowering also has been shown to reduce the risk of strokes.

NCEP is coordinated by the National Heart, Lung, and Blood Institute (NHLBI), part of the National Institutes of Health.

The report, which appears in the August 9/23 issue of the Archives of Internal Medicine, makes clear the NCEP's stand on the controversial issue of cholesterol lowering in those age 65 and older.

"Some investigators have questioned the value of testing cholesterol and treating high levels in the elderly," said NHLBI Director Dr. Claude Lenfant. "But an overview of the research shows that cholesterol lowering can improve both the quality and length of life for many older Americans."

"Because most older Americans have cholesterol buildup in their arteries, an elevated cholesterol causes more cases of CHD in the elderly than in any other age group," said Dr. Scott Grundy, Director of the Center for Human Nutrition at The University of Texas Southwestern Medical Center at Dallas and lead author of the NCEP report. "It is clear that cholesterol counts in the elderly."

Dr. James Cleeman, NCEP Coordinator and a coauthor of the report said, "The new report reviews the evidence from epidemiological studies and clinical trials, and concludes that controlling cholesterol produces significant benefits in the elderly. For those with CHD, it can prolong life and dramatically reduce their risk of having a heart attack. For healthy seniors, it will reduce their high risk of developing CHD."

NCEP recommends that older Americans keep their cholesterol in check by following an eating pattern lower in saturated fat, total fat, and cholesterol, being physically active, and maintaining a healthy weight.

High cholesterol is a major risk factor for CHD. It leads to hardening of the arteries, or atherosclerosis, in which cholesterol deposits build up in vessel walls, including the coronary arteries that feed the heart. According to the new report, two-thirds to three-quarters of those over age 65 have either obvious CHD or "silent" atherosclerosis. In the latter form, the person has no symptoms but plaques have formed in arteries.

As noted, older Americans have more CHD than any other age group and suffer more coronary events, such as heart attacks and angina. Most first CHD events strike after age 65, according to the report.

The report notes that, in the past decade, treatment of high cholesterol has expanded and includes a wider range of cholesterol-lowering drugs, especially the statins, which produce the largest reduction in cholesterol levels. The report adds that cholesterol-lowering treatment works for both women and men.

The report's recommendations include:

Older Americans should have their total cholesterol tested once every 5 years and, if an accurate measurement is available, their high density lipoprotein (HDL, the "good" cholesterol)--the same recommendation as for all American adults. The test should be done in a medical setting, so the presence of other CHD risk factors can be checked.
Those with high cholesterol should take steps to lower it, especially if they also have other CHD risk factors. These include cigarette smoking, high blood pressure, physical inactivity, overweight, and diabetes.
For seniors without CHD who need to lower a high cholesterol, the first line of treatment should be the adoption of the healthy life habits noted above--eating a diet lower in saturated fat, total fat, and cholesterol, being physically active, and maintaining a healthy weight.
When life habit changes do not sufficiently lower cholesterol and seniors are at high risk for CHD, drug therapy may be advisable. However, physicians should evaluate a patient's overall health status in making that decision.
For most seniors with CHD, life habit changes and medication should be used together from the start of treatment.
Postmenopausal women who are judged to need drug treatment to reduce their risk for CHD should consider cholesterol-lowering drugs instead of hormone replacement therapy. A study of women with CHD found that a combination of estrogen and progesterone did not reduce the risk of CHD events. By contrast, studies have shown that postmenopausal women at high risk for CHD benefit greatly from treatment with statin drugs.
"It is important for older Americans to pay attention to their cholesterol," said NCEP's Cleeman. "Even if you're 70 and feeling fine, you can develop CHD, so you should take action".
"Whether you are old or young, cholesterol counts--you can improve your quality of life by caring about your cholesterol," he added.

To arrange an interview about the NCEP report, contact the NHLBI Communications Office at (301) 496-4236.

September is National Cholesterol Education Month and NCEP will launch an expanded Web site to help Americans control their cholesterol. Check it out at www.nhlbi.nih.gov/chd/.

Information provided by NIH.Older Americans have the Nation

Chagas' disease

2011-07-04T11:09:00.000-07:00

(American Trypansomiasis)

Chagas' disease is caused by infection with protozoan parasite Trypanosoma cruzi.

T. cruzi is transmitted among its mammalian hosts by hematophagous triatomine insects, often called reduviid bugs. The insects become infected by sucking blood from animals or humans who have circulating parasites. It can also be transmitted through blood transfusion of infected blood, from the pregnant mother mother to her fetus, and in lab lab accidents. Chagas' disease is only a problem in the Americas (South America mainly).
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Clinical manifestations

The first signs of acute Chagas' disease develop at least 1 week after invasion by the parasites. When the organisms enter through a break in the skin, an indurated area of erythema and swelling (the chagoma), accompanied by local lymphadenopathy, may appear. Romana's sign -- the classic finding in acute Chagas' disease, which consists of unilateral painless edema of the palpebrae and periocular tissues. This results when the conjunctiva is the portal of entry.

This phase is usually followed by malaise, fever, generalized edema, a rash may develop as well as generalized lymphadenopathy and hepatosplenomegaly.

Usually the symptoms resolve spontaneously and patient enters the chronic phase.

In rare cases infection could be serious and lead to heart affection progressing to heart failure, achlasia and megacolon.
Diagnosis

1. Acute Chagas' disease

Microscopic examination of fresh anticoagulated blood or of the buffy coat is the simplest way to see the motile organisms. Parasites also can be seen in Giemsa-stained thin and thick blood smears. When repeated attempts to visualize the organisms are unsuccessful, mouse inoculation, culture of blood in specialized media, or xenodiagnosis can be performed.

Serologic testing is of limited usefulness in diagnosing acute Chagas' disease.

2. Chronic Chagas' disease

The diagnosis of chronic Chagas' disease is made by the detection of antibodies that bind to T. cruzi antigens. Demonstration of the parasite is not of primary importance.
Treatment

Therapy for Chagas' disease is unsatisfactory. Nifurtimox is the only drug active against T. cruzi that is available in the United States. In acute Chagas' disease, nifurtimox markedly reduces the duration of symptoms and parasitemia and decreases the mortality rate. Nevertheless, its efficacy at eradicating parasites is low. Limited studies have shown that only 70% of acute infections are cured parasitologically by a full course of treatment. Despite its limitations, nifurtimox treatment should be initiated as early as possible in acute Chagas' disease.

Adverse effects of nifurtimox include abdominal pain, anorexia, nausea, vomiting, and weight loss. Neurologic reactions to the drug may include restlessness, disorientation, insomnia, twitching, paresthesia, polyneuritis, and seizures.
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Cancer Tests

2011-06-29T20:02:00.000-07:00

Cancer Tests You Should Know About, A Guide For People 65 And Over

NATIONAL INSTITUTES OF HEALTH
National Cancer Institutes Most people don't like to think about cancer. But think about this: The earlier cancer is found, the better the chances of beating it.

Cancer Tests You Should Know About describes simple tests that can help find cancer early, long before any symptoms appear. You may have heard of some of them, such as mammograms or rectal and prostate exams.

Despite what many people think, most people who are tested will not have cancer. But if it turns out you do, this booklet can help you find the best care.

Why Is It Important To Find Cancer Early?

Cancers that are found early may be easier to cure. Early treatment can be simpler, making it easier to go about daily life. All in all, finding cancer early could:
Save your life.
Help you live life to the fullest.

Why Should You Think About Cancer?

Anyone can get cancer. But you are more likely to get cancer as you get older--even if no one in your family has had it. It may surprise you to learn that more than one-half of all cancers occur in people age 65 and over.

If You Did Have Cancer, Wouldn't You Know It?

Most cancers in their earliest, most treatable stages do not cause any symptoms or pain. That is why it is so important to have regular cancer tests. They can find problems early--long before you would notice anything wrong.

But What If You Do Notice Something Wrong?

Certain changes could be a sign of cancer. For example, a change in bowel habits could mean cancer of the colon or rectum. A breast lump could mean breast cancer. Don't assume these or other changes are just a normal pan of growing older. See your doctor right away.

Who Should You Ask About Cancer Tests?

Perhaps you see one doctor just for your back or another doctor just for your heart. Maybe you see one doctor for checkups, but the subject of cancer has not come up. Why not bring it up yourself? Ask your family doctor, internist, or other trusted health professional about getting tested for cancer. The next section tells you about the tests to detect cancer early.

Cancer Tests

The tests in this booklet are right for most people age 65 and over.* But you and your doctor need to decide what is right for you. You may need certain tests more often if you have had cancer before, have some other medical conditions, or have a family member who has had cancer.

Most of the cancer tests described in this booklet take little time. Some tests may be uncomfortable, but they are not painful. Cancer tests are usually done right in your doctor's office.

Pring this out and bring this the next time you see your doctor. Together you can schedule your cancer tests. Then, as you get each test, write the date in the space provided.

You may be concerned about the cost of these cancer tests. Ask your doctor if Medicare will help or ask your own insurance company if they cover these tests. Medicare helps pay for some mammograms and Pap smears.

* For guidelines for people under 65, call the Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237).

BREASTS

A woman's risk of breast cancer increases with age. Fortunately, women can take three steps to find cancer early:

Mammogram

This x-ray of the breast can reveal problems up to 2 years before a lump can be felt. To find out where to get a mammogram, ask your doctor. Or, call the National Cancer Institute's Cancer Information Service at: 1-800-4-CANCER (1-800-422-6237).

Recommended: Every year.

Breast Exam

Your doctor should check your breasts for problems or changes that could be a sign of breast cancer.

Recommended: Every year, or as part of your regular health checkup.

Breast self-exam

Ask your doctor or nurse for instructions. You also can call the Cancer Information Service at 1-800-4-CANCER (1-800-422-6237) for a free booklet.

Recommended: Every month.

UTERUS AND CERVIX

As women get older they have a higher risk of cancers of the female sex organs--especially cancers of the uterus and cervix. If you stopped seeing your gynecologist after menopause (change of life), it is important to ask your doctor about the following tests:

Pelvic Exam

The doctor feels the internal sex organs, bladder, and rectum for any changes in size or shape.

Recommended: Every year.

Pap smear

A Pap smear, also called a Pap test, is usually done at the same time as the pelvic exam. During this test, the doctor removes a few cells from the cervix with a swab. The cells then are checked under a microscope. After three normal annual Pap tests, your doctor may decide not to do the test for the next 1 to 3 years.

Recommended: Every year.

COLON AND RECTUM

Cancers of the colon and rectum are more likely to occur as people get older. Three tests can help find these cancers early:

Rectal Exam

In this test, the doctor gently feels for any bumps or irregular areas on the rectum.

Recommended: Every year, or as part of your regular health checkup.

Guaiac stool test

The guaiac (pronounced "gwy-ack") stool test is sometimes called a "fecal" or "stool" occult test or "hemoccult" test. This test can find unseen blood in stool samples. Your doctor can give you a simple kit to collect stool samples at home. Or, your doctor can do the test as part of a rectal exam.

Recommended: Every year.

Sigmoidoscopy or "procto"

The doctor looks for cancer in the colon and rectum with a thin, lighted instrument called a sigmoidoscope.

Recommended: Every 3 to 5 years.

PROSTATE

Prostate cancer is the most common cancer in American men--especially older men. More than 80 percent of prostate cancer cases occur in men age 65 and over.

Rectal Exam

The doctor feels the prostate through the rectum. Hard or lumpy areas may mean cancer is present.

Recommended: Every year.

PSA

The prostate-specific antigen test (PSA) measures the level of a specific protein in a man's blood. The protein seems to increase in cases of prostate cancer and other prostate diseases.

The National Cancer Institute is studying whether screening with the PSA test along with a rectal exam may help decrease deaths from prostate cancer.

TRUS

Transrectal ultrasound (TRUS) detects cancer by using sound waves produced by an instrument inserted into the rectum. The waves bounce off the prostate, and the pattern of the echoes made by the waves is converted to a picture by computer. TRUS is not a routine test. The doctor will use this exam to help diagnose a man's problem.

COLON AND RECTUM

The three tests suggested for women also are suggested for men.

Rectal exam

Recommended: Every year, or as part of your regular health checkup.

Guaiac stool test

Recommended: Every year.

Sigmoidoscopy or "procto"

Recommended: Every 3 to 5 years.

What If You Find Out You Have Cancer?

Today, there are new and better ways to treat cancer. If you are told you have cancer, take these steps to get the best possible care:

Find a doctor who is right for you and the kind of cancer you have. Oncologists are doctors specially trained to treat cancer.

Find out what your treatment choices are and which are best for you. If you don't understand something, ask.

Get a second opinion from another doctor before treatment begins. Doctors and most insurance companies expect their patients to do this. Many doctors will help you get a second opinion.

Talk to your family and friends and ask for their support. Or ask your doctor to help you find other people or groups who can help. No one needs to handle cancer alone.

Call the Cancer Information Service at 1-800-4-CANCER (1-800-422-6237) for help with all these steps. Staff members can give you information about treatment and where to get it. They also can direct you to groups that may be able to help with transportation, finances, and dealing with your problems. Spanish-speaking staff members can be reached at this toll-free number.

Ask your doctor to check the National Cancer Institute's PDQ system. This computer system has the most up-to-date treatment information in the United States. You or your doctor can call the Cancer Information Service (1-800-4-CANCER) to learn more about PDQ.

Want To Learn More About Cancer?

Call the Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) for information and booklets about cancer.

Or, write to:

Office of Cancer Communications
National Cancer Institute
Building 31, Room 10A24
Bethesda, MD 20892

For more information on aging, write to:

National Institute on Aging
P.O. Box 8057
Gaithersburg, MD 20898-8057

Why Get Tested for Cancer?

Most cancers in their earliest stages do not cause symptoms or pain. Get checked for cancer when you're feeling well... for good health and a good life.

Information provided by NIH.

Candidiasis

2011-06-27T10:02:00.000-07:00

Candidiasis, commonly called yeast infection or thrush, is a fungal infection of any of the Candida species, of which Candida albicans is probably the most common. Yeast organisms are always present in all people, but are usually prevented from "overgrowth" (uncontrolled multiplication resulting in symptoms) by naturally occurring microorganisms.

In immunocompetent people, candidiasis can usually only be found in exposed and moist parts of the body, such as the oral cavity (oral thrush), the vagina (vaginal candidiasis or thrush), or folds of skin in the diaper area (diaper rash). Oral thrush presents as a grayish yellow membrane over the tongue and various parts of the oral cavity.

Candidiasis is the most common cause of vaginal irritation or vaginitis. At least three quarters of all women will experience candidiasis at some point in their lives. The Candida albicans organism is found in the vaginas of almost all women and normally causes no problems. However, when it gets out of balance with the other "normal flora", an overgrowth and symptoms can result. Pregnancy, the use of oral contraceptives and some antibiotics, and diabetes mellitus increase the risk of infection.

The most common symptoms are itching and irritation of the vagina and/or vulva. A whitish or whitish-gray discharge may be present, sometimes resembling cottage cheese, and may have a "yeasty" smell like beer or baking bread.

In immunocompromised patients, the candida infection can become systemic, causing much more serious disease.
Treatment

Candidiasis should be treated with antifungal medication. If indicated, an underlying reason should be looked for. As an example, oral candidiasis is often linked to the use of inhaled steroids in asthma medication. Patients on long term inhaled steroids should rinse their mouth after each dose of steroids. Babies with diaper rash should have their diaper areas kept clean, dry, and exposed to air as much as possible.

Following the health tips at vulvovaginal health can help prevent vaginal candidiasis.

Local treatment may include vaginal suppositories or medicated douches.