Universidad de Sta.

Isabel City of Naga, Philippines College of Nursing

TABLE OF CONTENTS Content

Page no.
1 17 29 36 49 62 74

Prepared By: Garcia, Prescilla E. BSN-4C

What is the cervix? The cervix is part of a woman's reproductive system. It's in the pelvis. The cervix is the lower, narrow part of the uterus (womb). The cervix is a passageway:

The cervix connects the uterus to the vagina. During a menstrual period, blood flows from the uterus through the cervix into the vagina. The vagina leads to the outside of the body. The cervix makes mucus. During sex, mucus helps sperm move from the vagina through the cervix into the uterus. During pregnancy, the cervix is tightly closed to help keep the baby inside the uterus. During childbirth, the cervix opens to allow the baby to pass through the vagina.

What is cancer? Cancer begins in cells, the building blocks that make up tissues. Tissues make up the organs of the body. Normal cells grow and divide to form new cells as the body needs them. When normal cells grow old or get damaged, they die, and new cells take their place. Sometimes, this process goes wrong. New cells form when the body does not need them, and old or damaged cells do not die as they should. The buildup of extra cells often forms a mass of tissue called a growth or tumor.

Growths on the cervix can be benign or malignant. Benign growths are not cancer. They are not as harmful as malignant growths (cancer).

HPV infection and other risk factors may act together to increase the risk even more:

Benign growths (polyps, cysts, or genital warts):

are rarely a threat to life don't invade the tissues around them

Malignant growths (cervical cancer):

may sometimes be a threat to life can invade nearby tissues and organs can spread to other parts of the body

Cervical cancer begins in cells on the surface of the cervix. Over time, the cervical cancer can invade more deeply into the cervix and nearby tissues. The cancer cells can spread by breaking away from the original (primary) tumor. They enter blood vessels or lymph vessels, which branch into all the tissues of the body. The cancer cells may attach to other tissues and grow to form new tumors that may damage those tissues. The spread of cancer is called metastasis. See the Staging section for information about cervical cancer that has spread. Risk factors and causes of cervical cancer When you get a diagnosis of cancer, it's natural to wonder what may have caused the disease. Doctors cannot always explain why one woman develops cervical cancer and another does not. However, we do know that a woman with certain risk factors may be more likely than others to develop cervical cancer. A risk factor is something that may increase the chance of developing a disease.

HPV infection: HPV (Human Papillo Virus) is a group of viruses that can infect the cervix. An HPV infection that doesn't go away can cause cervical cancer in some women. HPV is the cause of nearly all cervical cancers. HPV infections are very common. These viruses are passed from person to person through sexual contact. Most adults have been infected with HPV at some time in their lives, but most infections clear up on their own. Some types of HPV can cause changes to cells in the cervix. If these changes are found early, cervical cancer can be prevented by removing or killing the changed cells before they can become cancer cells. Lack of regular Pap tests: Cervical cancer is more common among women who don't have regular Pap tests. The Pap test helps doctors find abnormal cells. Removing or killing the abnormal cells usually prevents cervical cancer. Smoking: Among women who are infected with HPV, smoking cigarettes slightly increases the risk of cervical cancer. Weakened immune system (the body's natural defense system): Infection with HIV (the virus that causes AIDS) or taking drugs that suppress the immune system increases the risk of cervical cancer. Sexual history: Women who have had many sexual partners have a higher risk of developing cervical cancer. Also, a woman who has had sex with a man who has had many sexual partners may be at higher risk of developing cervical cancer. In

both cases, the risk of developing cervical cancer is higher because these women have a higher risk of HPV infection.

Using birth control pills for a long time: Using birth control pills for a long time (5 or more years) may slightly increase the risk of cervical cancer among women with HPV infection. However, the risk decreases quickly when women stop using birth control pills. Having many children: Studies suggest that giving birth to many children (5 or more) may slightly increase the risk of cervical cancer among women with HPV infection.

Bleeding that occurs between regular menstrual periods Bleeding after sexual intercourse,douching, or a pelvic exam Menstrual periods that last longer and are heavier than before Bleeding after going through menopause

Increased vaginal discharge

Pelvic pain Pain during sex

Infections or other health problems may also cause these symptoms. Only a doctor can tell for sure. A woman with any of these symptoms should tell her doctor so that problems can be diagnosed and treated as early as possible. Detection and Diagnosis Doctors recommend that women help reduce their risk of cervical cancer by having regular Pap tests. A Pap test (sometimes called Pap smear or cervical smear) is a simple test used to look at cervical cells. Pap tests can find cervical cancer or abnormal cells that can lead to cervical cancer. Finding and treating abnormal cells can prevent most cervical cancer. Also, the Pap test can help find cancer early, when treatment is more likely to be effective. For most women, the Pap test is not painful. It's done in a doctor's office or clinic during a pelvic exam. The doctor or nurse scrapes a sample of cells from the cervix. A lab checks the cells under a microscope for cell changes. Most often, abnormal cells found by a Pap test are not cancerous. The same sample of cells may be tested for HPV infection.

Symptoms Early cervical cancers usually don't cause symptoms. When the cancer grows larger, women may notice one or more of these symptoms:

Abnormal vaginal bleeding

If you have abnormal Pap or HPV test results, your doctor will suggest other tests to make a diagnosis:

Staging If the biopsy shows that you have cancer, your doctor needs to learn the extent (stage) of the disease to help you choose the best treatment. Staging is a careful attempt to find out whether the tumor has invaded nearby tissues, whether the cancer has spread and, if so, to what parts of the body. Cervical cancer spreads most often to nearby tissues in the pelvis, lymph nodes, or the lungs. It may also spread to the liver or bones. When cancer spreads from its original place to another part of the body, the new tumor has the same kind of cancer cells and the same name as the original tumor. For example, if cervical cancer spreads to the lungs, the cancer cells in the lungs are actually cervical cancer cells. The disease is metastatic cervical cancer, not lung cancer. For that reason, it's treated as cervical cancer, not lung cancer. Doctors call the new tumor "distant" or metastatic disease. Your doctor will do a pelvic exam, feel for swollen lymph nodes, and may remove additional tissue. To learn the extent of disease, the doctor may order some of the following tests:

Colposcopy: The doctor uses a colposcope to look at the cervix. The colposcope combines a bright light with a magnifying lens to make tissue easier to see. It is not inserted into the vagina. A colposcopy is usually done in the doctor's office or clinic. Biopsy: Most women have tissue removed in the doctor's office with local anesthesia. A pathologist checks the tissue under a microscope for abnormal cells.
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Punch biopsy: The doctor uses a sharp tool to pinch off small samples of cervical tissue. LEEP: The doctor uses an electric wire loop to slice off a thin, round piece of cervical tissue. Endocervical curettage: The doctor uses a curette (a small, spoon-shaped instrument) to scrape a small sample of tissue from the cervix. Some doctors may use a thin, soft brush instead of a curette. Conization: The doctor removes a cone-shaped sample of tissue. A conization, or cone biopsy, lets the pathologist see if abnormal cells are in the tissue beneath the surface of the cervix. The doctor may do this test in the hospital under general anesthesia.

Chest x-rays: X-rays often can show whether cancer has spread to the lungs. CT scan: An x-ray machine linked to a computer takes a series of detailed pictures of your organs. A tumor in the liver, lungs, or elsewhere in the body can show up on the CT scan. You may receive contrast material by injection in your arm or hand, by mouth, or by enema. The contrast material makes abnormal areas easier to see. MRI: A powerful magnet linked to a computer is used to make detailed pictures of your pelvis and abdomen. The doctor can

Removing tissue from the cervix may cause some bleeding or other discharge. The area usually heals quickly. Some women also feel some pain similar to menstrual cramps. Your doctor can suggest medicine that will help relieve your pain.

view these pictures on a monitor and can print them on film. An MRI can show whether cancer has spread. Sometimes contrast material makes abnormal areas show up more clearly on the picture.

Treatment Women with cervical cancer have many treatment options. The options are surgery, radiation therapy, chemotherapy, or a combination of methods. The choice of treatment depends mainly on the size of the tumor and whether the cancer has spread. The treatment choice may also depend on whether you would like to become pregnant someday. Your doctor can describe your treatment choices, the expected results of each, and the possible side effects. You and your doctor can work together to develop a treatment plan that meets your medical and personal needs. Your doctor may refer you to a specialist, or you may ask for a referral. You may want to see a gynecologic oncologist, a surgeon who specializes in treating female cancers. Other specialists who treat cervical cancer include gynecologists, medical oncologists, and radiation oncologists. Your health care team may also include an oncology nurse and a registered dietitian. Before treatment starts, ask your health care team about possible side effects and how treatment may change your normal activities. Because cancer treatments often damage healthy cells and tissues, side effects are common. Side effects may not be the same for each person, and they may change from one treatment session to the next. At any stage of the disease, supportive care is available to relieve the side effects of treatment, to control pain and other symptoms, and to help you cope with the feelings that a diagnosis of cancer can bring. Surgery Surgery is an option for women with Stage I or II cervical cancer. The surgeon removes tissue that may contain cancer cells:

PET scan: You receive an injection of a small amount of radioactive sugar. A machine makes computerized pictures of the sugar being used by cells in your body. Cancer cells use sugar faster than normal cells and areas with cancer look brighter on the pictures.

The stage is based on where cancer is found. These are the stages of invasive cervical cancer:

Stage I: The tumor has invaded the cervix beneath the top layer of cells. Cancer cells are found only in the cervix. Stage II: The tumor extends to the upper part of the vagina. It may extend beyond the cervix into nearby tissues toward the pelvic wall (the lining of the part of the body between the hips). The tumor does not invade the lower third of the vagina or the pelvic wall. Stage III: The tumor extends to the lower part of the vagina. It may also have invaded the pelvic wall. If the tumor blocks the flow of urine, one or both kidneys may not be working well. Stage IV: The tumor invades the bladder or rectum. Or the cancer has spread to other parts of the body. Recurrent cancer: The cancer was treated, but has returned after a period of time during which it could not be detected. The cancer may show up again in the cervix or in other parts of the body.

Radical trachelectomy: The surgeon removes the cervix, part of the vagina, and the lymph nodes in the pelvis. This option is for a small number of women with small tumors who want to try to get pregnant later on. Total hysterectomy: The surgeon removes the cervix and uterus. Radical hysterectomy: The surgeon removes the cervix, some tissue around the cervix, the uterus, and part of the vagina.

Doctors use two types of radiation therapy to treat cervical cancer. Some women receive both types:

External radiation therapy: A large machine directs radiation at your pelvis or other tissues where the cancer has spread. The treatment usually is given in a hospital or clinic. You may receive external radiation 5 days a week for several weeks. Each treatment takes only a few minutes. Internal radiation therapy: A thin tube is placed inside the vagina. A radioactive substance is loaded into the tube. You may need to stay in the hospital while the radioactive source is in place (up to 3 days). Or the treatment session may last a few minutes, and you can go home afterward. Once the radioactive substance is removed, no radioactivity is left in your body. Internal radiation may be repeated two or more times over several weeks.

With either total or radical hysterectomy, the surgeon may remove other tissues:

Fallopian tubes and ovaries: The surgeon may remove both fallopian tubes and ovaries. This surgery is called a salpingooophorectomy. Lymph nodes: The surgeon may remove the lymph nodes near the tumor to see if they contain cancer. If cancer cells have reached the lymph nodes, it means the disease may have spread to other parts of the body.

Radiation therapy Radiation therapy (also called radiotherapy) is an option for women with any stage of cervical cancer. Women with early stage cervical cancer may choose radiation therapy instead of surgery. It also may be used after surgery to destroy any cancer cells that remain in the area. Women with cancer that extends beyond the cervix may have radiation therapy and chemotherapy Radiation therapy uses high-energy rays to kill cancer cells. It affects cells only in the treated area.

Side effects depend mainly on how much radiation is given and which part of your body is treated. Radiation to the abdomen and pelvis may cause nausea, vomiting, diarrhea, or urinary problems. You may lose hair in your genital area. Also, your skin in the treated area may become red, dry, and tender. You may have dryness, itching, or burning in your vagina. Your doctor may advise you to wait to have sex until a few weeks after radiation treatment ends. You are likely to become tired during radiation therapy, especially in the later weeks of treatment. Resting is important, but doctors usually advise patients to try to stay as active as they can.

Although the side effects of radiation therapy can be upsetting, they can usually be treated or controlled. Talk with your doctor or nurse about ways to relieve discomfort. It may also help to know that most side effects go away when treatment ends. However, you may wish to discuss with your doctor the possible long-term effects of radiation therapy. For example, the radiation may make the vagina narrower. A narrow vagina can make sex or follow-up exams difficult. There are ways to prevent this problem. If it does occur, however, your health care team can tell you about ways to expand the vagina. Another long-term effect is that radiation aimed at the pelvic area can harm the ovaries. Menstrual periods usually stop, and women may have hot flashes and vaginal dryness. Menstrual periods are more likely to return for younger women. Women who may want to get pregnant after radiation therapy should ask their health care team about ways to preserve their eggs before treatment starts. Chemotherapy For the treatment of cervical cancer, chemotherapy is usually combined with radiation therapy. For cancer that has spread to distant organs, chemotherapy alone may be used. Chemotherapy uses drugs to kill cancer cells. The drugs for cervical cancer are usually given through a vein (intravenous). You may receive chemotherapy in a clinic, at the doctor's office, or at home. Some women need to stay in the hospital during treatment.

The side effects depend mainly on which drugs are given and how much. Chemotherapy kills fast-growing cancer cells, but the drugs can also harm normal cells that divide rapidly:

Blood cells: When chemotherapy lowers the levels of healthy blood cells, you're more likely to get infections, bruise or bleed easily, and feel very weak and tired. Your health care team will check for low levels of blood cells. If your levels are low, your health care team may stop the chemotherapy for a while or reduce the dose of drug. There are also medicines that can help your body make new blood cells. Cells in hair roots: Chemotherapy may cause hair loss. If you lose your hair, it will grow back, but it may change in color and texture. Cells that line the digestive tract: Chemotherapy can cause a poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores. Your health care team can give you medicines and suggest other ways to help with these problems.

Other side effects include skin rash, tingling or numbness in your hands and feet, hearing problems, loss of balance, joint pain, or swollen legs and feet. Your health care team can suggest ways to control many of these problems. Most go away when treatment ends. Second opinion Before starting treatment, you might want a second opinion about your diagnosis and treatment plan. Some people worry that the doctor will be offended if they ask for a second opinion. Usually the opposite is true. Most doctors welcome a

second opinion. And many health insurance companies will pay for a second opinion if you or your doctor requests it. If you get a second opinion, the doctor may agree with your first doctor's diagnosis and treatment plan. Or the second doctor may suggest another approach. Either way, you have more information and perhaps a greater sense of control. You can feel more confident about the decisions you make, knowing that you've looked at your options. It may take some time and effort to gather your medical records and see another doctor. In most cases, it's not a problem to take several weeks to get a second opinion. The delay in starting treatment usually will not make treatment less effective. To make sure, you should discuss this delay with your doctor.

doctor, a registered dietitian, or another health care provider can suggest ways to cope with these problems. Research shows that people with cancer feel better when they stay active.Walking, yoga, swimming, and other activities can keep you strong and increase your energy. Exercise may reduce nausea and pain and make treatment easier to handle. It also can help relieve stress. Whatever physical activity you choose, be sure to talk to your doctor before you start. Also, if your activity causes you pain or other problems be sure to let your doctor or nurse knows about it. Follow up Care Your doctor will check for the return of cancer. Even when the cancer seems to have been completely removed or destroyed, the disease sometimes returns because undetected cancer cells remained somewhere in the body after treatment. Checkups may include a physical exam, Pap tests, and chest x-rays.

Nutrition and physical activity It's important for you to take care of yourself by eating well and staying as active as you can. You need the right amount of calories to maintain a good weight. You also need enough protein to keep up your strength. Eating well may help you feel better and have more energy. However, you may not feel like eating during or soon after treatment. You may be uncomfortable or tired. You may find that foods don't taste as good as they used to. In addition, the side effects of treatment (such as poor appetite, nausea, vomiting, or mouth sores) can make it hard to eat well. Your

What is rheumatoid arthritis (RA)? Rheumatoid arthritis (RA) is an autoimmune disease that causes chronic inflammation of the joints. Rheumatoid arthritis can also cause inflammation of the tissue around the joints, as well as in other organs in the body. Autoimmune diseases are illnesses that occur when the body's tissues are mistakenly attacked by their own immune system. The immune system contains a complex organization of cells and antibodies designed normally to "seek and destroy" invaders of the body, particulaarly infections. Patients with autoimmune diseases have antibodies in their blood that target their own body tissues, where they can be associated with inflammation. Because it can affect multiple other organs of the body, rheumatoid arthritis is referred to as a systemic illness and is sometimes called rheumatoid disease. While rheumatoid arthritis is a chronic illness, meaning it can last for years, patients may experience long periods without symptoms. However, rheumatoid arthritis is typically a progressive illness that has the potential to cause joint destruction and functional disability. A joint is where two bones meet to allow movement of body parts. Arthritis means joint inflammation. The joint inflammation of rheumatoid arthritis causes swelling, pain, stiffness, and redness in the joints. The inflammation of rheumatoid disease can also occur in tissues around the joints, such as the tendons, ligaments, and muscles. In some people with rheumatoid arthritis, chronic inflammation leads to the destruction of the cartilage, bone, and ligaments, causing deformity of the joints. Damage to the joints can occur early in the disease and be progressive. Moreover,

studies have shown that the progressive damage to the joints does not necessarily correlate with the degree of pain, stiffness, or swelling present in the joints.

Picture of a joint with rheumatoid arthritis

suspected that certain infections or factors in the environment might trigger the activation of the immune system in susceptible individuals. This misdirected immune system then attacks the body's own tissues. This leads to inflammation in the joints and sometimes in various organs of the body, such as the lungs or eyes. It is not known what triggers the onset of rheumatoid arthritis. Regardless of the exact trigger, the result is an immune system that is geared up to promote inflammation in the joints and occasionally other tissues of the body. Immune cells, called lymphocytes, are activated and chemical messengers (cytokines, such as tumor necrosis factor/TNF, interleukin-1/IL-1, and interleukin-6/IL-6) are expressed in the inflamed areas. Environmental factors also seem to play some role in causing rheumatoid arthritis. For example, scientists have reported thatsmoking tobacco increases the risk of developing rheumatoid arthritis. What are the symptoms and signs of rheumatoid arthritis? The symptoms of rheumatoid arthritis come and go, depending on the degree of tissue inflammation. When body tissues are inflamed, the disease is active. When tissue inflammation subsides, the disease is inactive (in remission). Remissions can occur spontaneously or with treatment and can last weeks, months, or years. During remissions, symptoms of the disease disappear, and people generally feel well. When the disease becomes active again (relapse), symptoms return. The return of disease activity and symptoms is called a flare. The course of rheumatoid arthritis varies among affected individuals, and periods of flares and remissions are typical.

What causes rheumatoid arthritis? The cause of rheumatoid arthritis is unknown. Even though infectious agents such as viruses, bacteria, and fungi have long been suspected, none has been proven as the cause. The cause of rheumatoid arthritis is a very active area of worldwide research. It is believed that the tendency to develop rheumatoid arthritis may be genetically inherited (hereditary). It is also

When the disease is active, symptoms can include fatigue, loss of energy, lack of appetite, low-grade fever, muscle and joint aches, and stiffness. Muscle and joint stiffness are usually most notable in the morning and after periods of inactivity. Arthritis is common during disease flares. Also during flares, joints frequently become red, swollen, painful, and tender. This occurs because the lining tissue of the joint (synovium) becomes inflamed, resulting in the production of excessive joint fluid (synovial fluid). The synovium also thickens with inflammation (synovitis). Rheumatoid arthritis usually inflames multiple joints in a symmetrical pattern (both sides of the body affected). Early symptoms may be subtle. The small joints of both the hands and wrists are often involved. Symptoms in the hands with rheumatoid arthritis include difficulty with simple tasks of daily living, such as turning door knobs and opening jars. The small joints of the feet are also commonly involved, which can lead to painful walking, especially in the morning after arising from bed. Occasionally, only one joint is inflamed. When only one joint is involved, the arthritis can mimic the joint inflammation caused by other forms of arthritis, such as gout or joint infection. Chronic inflammation can cause damage to body tissues, including cartilage and bone. This leads to a loss of cartilage and erosion andweakness of the bones as well as the muscles, resulting in joint deformity, destruction, and loss of function. Rarely, rheumatoid arthritis can even affect the joint that is responsible for the tightening of our vocal cords to change the tone of our voice, the cricoarytenoid joint. When this joint is inflamed, it can cause hoarseness of the voice. Joint symptoms in children with

rheumatoid arthritis include limping, irritability, crying, and poor appetite. Since rheumatoid arthritis is a systemic disease, its inflammation can affect organs and areas of the body other than the joints. Inflammation of the glands of the eyes and mouth can cause dryness of these areas and is referred to as Sjogren's syndrome. Dryness of the eyes can lead to corneal abrasion. Inflammation of the white parts of the eyes (the sclerae) is referred to as scleritis and can be very dangerous to the eye. Rheumatoid inflammation of the lung lining (pleuritis) causes chest pain with deep breathing, shortness of breath, or coughing. The lung tissue itself can also become inflamed, scarred, and sometimes nodules of inflammation (rheumatoid nodules) develop within the lungs. Inflammation of the tissue (pericardium) surrounding the heart, called pericarditis, can cause a chest pain that typically changes in intensity when lying down or leaning forward. The rheumatoid disease can reduce the number of red blood cells (anemia) and white blood cells. Decreased white cells can be associated with an enlarged spleen (Felty's syndrome) and can increase the risk of infections. Firm lumps under the skin (rheumatoid nodules) can occur around the elbows and fingers where there is frequent pressure. Even though these nodules usually do not cause symptoms, occasionally they can become infected. Nerves can become pinched in the wrists to cause carpal tunnel syndrome. A rare, serious complication, usually with long-standing rheumatoid disease, is blood vessel inflammation (vasculitis). Vasculitis can impair blood supply to tissues and lead to tissue death (necrosis). This is most often initially visible as tiny black areas around the nail beds or as leg ulcers.

How is rheumatoid arthritis diagnosed? There is no singular test for diagnosing rheumatoid arthritis. Instead, rheumatoid arthritis is diagnosed based on a combination of the presentation of the joints involved, characteristic joint stiffness in the morning, the presence of blood rheumatoid factor andcitrulline antibody, as well as findings of rheumatoid nodules and radiographic changes (X-ray testing). The first step in the diagnosis of rheumatoid arthritis is a meeting between the doctor and the patient. The doctor reviews the history of symptoms, examines the joints for inflammation, tenderness, swelling, and deformity, the skin for rheumatoid nodules (firm bumps under the skin, most commonly over the elbows or fingers), and other parts of the body for inflammation. Certain blood and X-ray tests are often obtained. The diagnosis will be based on the pattern of symptoms, the distribution of the inflamed joints, and the blood and X-ray findings. Several visits may be necessary before the doctor can be certain of the diagnosis. A doctor with special training in arthritis and related diseases is called a rheumatologist. The distribution of joint inflammation is important to the doctor in making a diagnosis. In rheumatoid arthritis, the small joints of the hands, wrists, feet, and knees are typically inflamed in a symmetrical distribution (affecting both sides of the body). When only one or two joints are inflamed, the diagnosis of rheumatoid arthritis becomes more difficult. The doctor may then perform other tests to exclude arthritis due to infection or gout. The detection of rheumatoid nodules (described above), most often around the elbows and fingers, can suggest the diagnosis.

Abnormal antibodies can be found in the blood of people with rheumatoid arthritis. An antibody called "rheumatoid factor" can be found in 80% of patients with rheumatoid arthritis. Patients who are felt to have rheumatoid arthritis and do not have positive rheumatoid factor testing is referred as having "seronegative rheumatoid arthritis." Citrulline antibody (also referred to as anticitrulline antibody, anticyclic citrullinated peptide antibody, and anti-CCP) is present in most people with rheumatoid arthritis. It is useful in the diagnosis of rheumatoid arthritis when evaluating cases of unexplained joint inflammation. A test for citrulline antibodies is most helpful in looking for the cause of previously undiagnosed inflammatory arthritis when the traditional blood test for rheumatoid arthritis, rheumatoid factor, is not present. Citrulline antibodies have been felt to represent the earlier stages of rheumatoid arthritis in this setting. Another antibody called the "antinuclear antibody" (ANA) is also frequently found in people with rheumatoid arthritis. A blood test called the sedimentation rate (sed rate) is a measure of how fast red blood cells fall to the bottom of a test tube. The sed rate is used as a crude measure of the inflammation of the joints. The sed rate is usually faster during disease flares and slower during remissions. Another blood test that is used to measure the degree of inflammation present in the body is the C-reactive protein. Blood testing may also reveal anemia, since anemia is common in rheumatoid arthritis, particularly because of the chronic inflammation. The rheumatoid factor, ANA, sed rate, and C-reactive protein tests can also be abnormal in other systemic autoimmune and inflammatory conditions. Therefore, abnormalities in these

blood tests alone are not sufficient for a firm diagnosis of rheumatoid arthritis. Joint X-rays may be normal or only show swelling of soft tissues early in the disease. As the disease progresses, X-rays can show bony erosions typical of rheumatoid arthritis in the joints. Joint X-rays can also be helpful in monitoring the progression of disease and joint damage over time. Bone scanning, a procedure using a small amount of a radioactive substance, can also be used to demonstrate the inflamed joints. MRI scanning can also be used to demonstrate joint damage. Stage I

joint deformity without permanent stiffening or fixation of the joint extensive muscle atrophy abnormalities of soft tissue around joint possible

Stage IV

on X-ray, evidence of cartilage and bone damage and osteoporosis around joint joint deformity with permanent fixation of the joint (referred to as ankylosis) extensive muscle atrophy abnormalities of soft tissue around joint possible

no damage seen on X-rays, although there may be signs of bone thinning

Stage II

on X-ray, evidence of bone thinning around a joint with or without slight bone damage slight cartilage damage possible joint mobility may be limited; no joint deformities observed atrophy of adjacent muscle abnormalities of soft tissue around joint possible

Rheumatologists also classify the functional status of people with rheumatoid arthritis as follows:

Class I: completely able to perform usual activities of daily living Class II: able to perform usual self-care and work activities but limited in activities outside of work (such as playing sports, household chores) Class III: able to perform usual self-care activities but limited in work and other activities. Class IV: limited in ability to perform usual self-care, work, and other activities

Stage III

on X-ray, evidence of cartilage and bone damage and bone thinning around the joint

How is rheumatoid arthritis treated? There is no known cure for rheumatoid arthritis. To date, the goal of treatment in rheumatoid arthritis is to reduce joint inflammation and pain, maximize joint function, and prevent joint destruction and deformity. Early medical intervention has been shown to be important in improving outcomes. Aggressive management can improve function, stop damage to joints as monitored on X-rays, and prevent work disability. Optimal treatment for the disease involves a combination of medications, rest, joint-strengthening exercises, joint protection, and patient (and family) education. Treatment is customized according to many factors such as disease activity, types of joints involved, general health, age, and patient occupation. Treatment is most successful when there is close cooperation between the doctor, patient, and family members. Two classes of medications are used in treating rheumatoid arthritis: fast-acting "first-line drugs" and slow-acting "second-line drugs". The first-line drugs, such as aspirin and cortisone (corticosteroids), are used to reduce pain and inflammation. The slow-acting second-line drugs, such as gold, methotrexate(Rheumatrex,Trexall),andhydroxychloroquine ( Plaquenil), promote disease remission and prevent progressive joint destruction, but they are not anti-inflammatory agents. The degree of destructiveness of rheumatoid arthritis varies among affected individuals. Those with uncommon, less destructive forms of the disease or disease that has quieted after years of activity ("burned out" rheumatoid arthritis) can be

managed with rest plus pain control and anti-inflammatory medications alone. In general, however, function is improved and disability and joint destruction are minimized when the condition is treated earlier with second-line drugs (disease-modifying antirheumatic drugs), even within months of the diagnosis. Most people require more aggressive second-line drugs, such as methotrexate, in addition to anti-inflammatory agents. Sometimes these second-line drugs are used in combination. In some cases with severe joint deformity, surgery may be necessary.

What is dengue fever? Dengue fever is a disease caused by a family of viruses that are transmitted by mosquitoes. It is an acute illness of sudden onset that usually follows a benign course with symptoms such as headache, fever, exhaustion, severe muscle and joint pain, swollen glands (lymphadenopathy), and rash. The presence (the "dengue triad") of fever, rash, and headache (and other pains) is particularly characteristic of dengue. Other signs of dengue fever include bleeding gums, severe pain behind the eyes, and red palms and soles. Dengue affect anyone but tends to be more severe in people with compromised immune systems. Because it is caused by one of four serotypes of virus, it is possible to get dengue fever multiple times. However, an attack of dengue produces immunity for a lifetime to that particular serotype to which the patient was exposed. Dengue goes by other names, including "breakbone" or "dandy fever." Victims of dengue often have contortions due to the intense joint and muscle pain, hence the name breakbone fever. Slaves in the West Indies who contracted dengue were said to have dandy fever because of their postures and gait. Dengue hemorrhagic fever is a more severe form of the viral illness. Symptoms include headache, fever, rash, and evidence of hemorrhage in the body. Petechiae (small red or purple splotches or blisters under the skin), bleeding in the nose or gums, black stools, or easy bruising are all possible signs of hemorrhage. This form of dengue fever can be life-threatening and can progress to the most severe form of the illness, dengue shock syndrome.

How is dengue fever contracted? The virus is contracted from the bite of a striped Aedes aegypti mosquito that has previously bitten an infected person. The mosquito flourishes during rainy seasons but can breed in water-filled flower pots, plastic bags, and cans year-round. One mosquito bite can cause the disease. The virus is not contagious and cannot be spread directly from person to person. There must be a person-to-mosquito-toanother-person pathway. What are dengue fever symptoms and signs? After being bitten by a mosquito carrying the virus, the incubation period ranges from three to 15 (usually five to eight) days before the signs and symptoms of dengue appear in stages. Dengue starts with chills, headache, pain upon moving the eyes, and low backache. Painful aching in the legs and joints occurs during the first hours of illness. The temperature rises quickly as high as 104 F (40 C), with relatively low heart rate (bradycardia) and low blood pressure(hypotension). The eyes become reddened. A flushing or pale pink rash comes over the face and then disappears. The glands (lymph nodes) in the neck and groin are often swollen. Fever and other signs of dengue last for two to four days, followed by a rapid drop in body temperature (defervescence) with profuse sweating. This precedes a period with normal temperature and a sense of well-being that lasts about a day. A second rapid rise in temperature follows. A characteristic rash appears along with the fever and spreads from the extremities to

cover the entire body except the face. The palms and soles may be bright red and swollen.

How is dengue fever diagnosed? The diagnosis of dengue fever is usually made when a patient exhibits the typical clinical symptoms of headache, fever, eye pain, severe muscle aches and petechial rash and has a history of being in an area where dengue fever is endemic. Dengue fever can be difficult to diagnose because its symptoms overlap with those of many other viral illnesses, such as West Nile virus and chikungunya fever.

What is the treatment for dengue fever? Because dengue fever is caused by a virus, there is no specific medicine or antibiotic to treat it. For typical dengue, the treatment is purely concerned with relief of the symptoms. Rest and fluid intake for adequate hydration is important. Aspirin and nonsteroidal anti-inflammatory drugs should only be taken under a doctor's supervision because of the possibility of worsening bleeding complications. Acetaminophen (Tylenol) andcodeine may be given for severe headache and for joint and muscle pain (myalgia). What is the prognosis for typical dengue fever? Typical dengue is fatal in less than 1% of cases. The acute phase of the illness with fever and myalgias lasts about one to two weeks. Convalescence is accompanied by a feeling of weakness (asthenia), and full recovery often takes several weeks. What is dengue hemorrhagic fever? Dengue hemorrhagic fever (DHF) is a specific syndrome that tends to affect children under 10 years of age. It causes abdominal pain, hemorrhage(bleeding), and circulatory collapse (shock). DHF is also called Philippine, Thai, or Southeast Asian hemorrhagic fever and dengue shock syndrome. DHF starts abruptly with high continuous fever and headache. There are respiratory and intestinal symptoms with sore throat, cough, nausea,vomiting, and abdominal pain. Shock occurs two to six days after the start of symptoms with sudden collapse, cool, clammy extremities (the trunk is often

warm), weak pulse, and blueness around the mouth (circumoral cyanosis). In DHF, there is bleeding with easy bruising, blood spots in the skin (petechiae), spitting up blood (hematemesis), blood in the stool (melena), bleeding gums, and nosebleeds (epistaxis). Pneumonia is common, and inflammation of the heart (myocarditis) may be present. Patients with DHF must be monitored closely for the first few days since shock may occur or recur precipitously (dengue shock syndrome). Cyanotic(bluish) patients are given oxygen. Vascular collapse (shock) requires immediate fluid replacement. Blood transfusions may be needed to control bleeding. How can dengue fever be prevented? The transmission of the virus to mosquitoes must be interrupted to prevent the illness. To this end, patients are kept under mosquito netting until the second bout of fever is over and they are no longer contagious. The prevention of dengue requires control or eradication of the mosquitoes carrying the virus that causes dengue. In nations plagued by dengue fever, people are urged to empty stagnant water from old tires, trash cans, and flower pots. Governmental initiatives to decrease mosquitoes also help to keep the disease in check but have been poorly effective. To prevent mosquito bites, wear long pants and long sleeves. For personal protection, use mosquito repellant sprays that contain DEET when visiting places where dengue is endemic. There are no specific risk factors for contracting dengue fever, except living in or traveling to an area where the mosquitoes and

virus are endemic. Limiting exposure to mosquitoes by avoiding standing water and staying indoors two hours after sunrise and before sunset will help. The Aedes aegypti mosquito is a daytime biter with peak periods of biting around sunrise and sunset. It may bite at any time of the day and is often hidden inside homes or other dwellings, especially in urban areas. There is currently no vaccination available for dengue fever.

Gastroenteritis Causes Gastroenteritis has many causes. Viruses and bacteria are the most common. Viruses and bacteria are very contagious and can spread through contaminated food or water. In up to 50% of diarrheal outbreaks, no specific agent is found. The infection can spread from person to person because of improper hand washing following a bowel movement or handling a soiled diaper. Gastroenteritis caused by viruses may last one to two days. However, some bacterial cases can continue for a longer period of time. Viruses Norovirus - Fifty to seventy percent of cases of gastroenteritis in adults are caused by thenoroviruses (genus Norovirus, familyCaliciviridae. This virus is highly contagious and spreads rapidly. Norovirus is the most common cause of gastroenteritis in the United States.

Other viruses that cause gastrointestinal symptoms include: Adenoviruses - This virus most commonly causes respiratory illness; however, other illnesses may be caused by adenoviruses such as gastroenteritis, bladder infections, and rash illnesses. Parvoviruses - The human bocavirus (HBoV), which can cause gastroenteritis belongs to the family Parvoviridae. Astroviruses - Astrovirus infection is the third most frequent cause of gastroenteritis in infants. Bacteria Bacteria may cause gastroenteritis directly by infecting the lining of the stomach and intestine. Some bacteria such as Staphylococcus aureus produce a toxin that is the cause of the symptoms. Staph is a common type of food poisoning. Escherichia coli infection can cause significant complications. E. coli O157:H7(one type of the bacteria) can cause complications in approximately 10% of affected individuals (for example, kidney failure in children [hemolytic-uremic syndrome or HUS), bloody diarrhea, and thrombotic thrombocytopenic purpura (TTP) in the elderly. Salmonella, Shigella and Campylobacter Salmonella, Shigella and Campylobacter are also common causes of illness.

Noroviruses can be transmitted and infect individuals by:

contaminated food and liquids, touching objects contaminated with norovirus and then placing the hands or fingers in the mouth, direct contact with an infected individual (for example, exposure to norovirus when caring or sharing foods, drinks, eating utensils with an affected individual, andexposure to infected individuals and objects in daycare centers and nursing homes.

Salmonella is contracted by ingesting the bacteria in contaminated food or water, and by handling poultry or reptiles such as turtles that carry the germs.

Campylobacter occurs by the consumption of raw or undercooked poultry meat and cross-contamination of other foods. Infants may contract the infection by contact with poultry packages in shopping carts. Campylobacter is also associated with unpasteurized milk or contaminated water. The infection can be spread to humans by contact with infected stool of an ill pet (for example, cats or dogs). It is generally not passed from human to human. Shigella bacteria generally spreads from an infected person to another person.Shigella are in diarrheal stools of infected individuals while they are ill, and for up to one to two weeks after contracting the infection. Shigella infection also may be contracted from eating contaminated food, drinking contaminated water, or swimming or playing in contaminated water (for example, wading pools, shallow play fountains). Shigella can also be spread among men who have sex with men. Clostridium difficile Clostridium difficile (C difficile) bacteria may overgrow in the large intestine after a person has been on antibiotics for an infection. The most common antibiotics that pose a potential risk factor for C difficile include

Other risk factors for C difficile infection are hospitalization, individuals 65 years of age or greater, and existing chronic medical conditions. Parasites and Protozoans These tiny organisms are less frequently responsible for intestinal irritation. A person may become infected by one of these by drinking contaminated water. Swimming pools are common places to come in contact with these parasites. Common parasites include

Giardia is the most frequent cause of waterborne diarrhea, causing giardiasis. Often, people become infected after swallowing water that has been contaminated by animal feces (poop). This may occur by drinking infected water from river or lakes but giardia may also be found in swimming pools, wells and cisterns. Cryptosporidium (Crypto) is a parasite that lives in the intestine of affected individuals or animals. The infected individual or animal sheds theCryptosporidium parasite in the stool. Crypto may also be found in food, water, soil, or contaminated surfaces (swallowing contaminated recreational water, beverages, uncooked food, unwashed fruits and vegetables, touching contaminated surfaces such as bathroom fixtures, toys, diaper pails, changing tables, changing diapers, caring for an infected individual or handling an infected cow or calf). Those at risk for serious disease are individuals with weakened immune systems.

clindamycin (for example, Cleocin), fluoroquinolones example, levofloxacin [Levaquin'], ciprofloxacin [Cipro, XR, Proquin XR]), penicillins, and cephalosporins. (for Cirpo

Other Common Causes of Gastroenteritis Gastroenteritis that is not contagious to others can be caused by chemical toxins, most often found in seafood, food allergies, heavy metals, antibiotics, and other medications. Gastroenteritis Symptoms Gastroenteritis affects both the stomach and the intestines, resulting in both vomiting and diarrhea. Common gastroenteritis symptoms

Dehydration weakness, lightheadedness, decreased urination, dry skin, dry mouth and lack of sweat and tears are characteristic signs and symptoms.

Gastroenteritis Diagnosis Gastroenteritis is often self-limiting, and the care is supportive to control symptoms and prevent dehydration. Tests may not be needed. If the symptoms persist for a prolonged period of time, the health care practitioner may consider blood and stool tests to determine the cause of the vomiting and diarrhea. Patient History and Physical Examination Taking a thorough patient history and physical examination is very helpful in accessing the diagnosis. Questions asked by the health care practitioner may ask include 1. Have any other family members or friends had had similar exposure or symptoms? 2. What is the duration, frequency, and description of the patient's bowel movements, and is vomiting present? 3. Can the patient is tolerate any fluids by mouth? These questions help determine the potential risk of dehydration and may also include asking questions about the amount and frequency of urination, weight loss, lightheadedness, andfainting (syncope).

Low grade fever to 100 F (37.7 C) Nausea with or without vomiting Mild-to-moderate diarrhea Crampy painful abdominal bloating (The cramps may come in cycles, increasing in severity until a loose bowel movement occurs and the pain resolves somewhat.) More serious symptoms of gastroenteritis

Blood in vomit or stool (Blood in vomit or stool is never normal and the affected individual should call or a visit a health care practitioner.) Vomiting more than 48 hours Fever higher than 101 F (40 C) Swollen abdomen or abdominal pain

Other information in the medical history that may be helpful in the diagnosis of gastroenteritis include:

giving too much fluid at one time may cause increased nausea due to a distended stomach, which causes additional irritation. Clear fluids do not include carbonated beverages but colas or ginger ale with the fizz gone is often well tolerated. Coke syrup may also be helpful in settling the stomach. Jello and popsicles may be "solid food" alternatives to clear fluids in children who aren't interested in clear fluids. Dehydration in children Oral rehydration therapy using balanced electrolyte solutions such as Pedialyte or Gatorade/Powerade may be all that is needed to replenish the fluid supply in an infant or child. Plain water is not recommended because it can dilute the electrolytes in the body and cause complications such as seizures due to low sodium. The key to oral rehydration is small frequent feedings. If offered free access to a bottle, infants especially may drink quickly to quench their thirst and then vomit. Instead it may be best to limit the amount of fluid given at one time. There are a variety of regimens that are used and they follow a basic format:

Travel history: Travel may suggest E. coli bacterial infection or a parasite infection from something the patient ate or drank. Norovirus infections tend to occur when many people are confined to a close space (for example, cruise ship). Exposure to poisons or other irritants: Swimming in contaminated water or drinking from suspicious fresh water such as mountain streams or wells may indicate infection with Giardia - an organism found in water that causes diarrhea. Gastroenteritis Treatment Gastroenteritis Self-Care and Home Remedies The treatment of gastroenteritis is aimed at hydration and home remedies that address keeping fluid in the body are key to recovery. Since most causes of gastroenteritis are due to viruses, replacing the fluid lost because of vomiting and diarrhea allows the body to recuperate and fight the infection. Dehydration can also intensify the symptoms of nausea and vomiting. The critical step is replacing fluids when the affected individual is nauseous and doesn't want to drink (hydrate). This is especially difficult with infants and children. Small frequent offerings of clear fluids, sometimes only a mouthful at a time, may be enough to replenish the body's fluid stores and prevent an admission to the hospital for intravenous (IV) fluid administration. In general, clear fluids (anything you can see through), may be tolerated in small amounts. Think of it as adding just an ounce or less to the saliva that the patient is already swallowing. However,

Offer 1/3 of an ounce (5 to 10 cc) of fluid at one time. Wait 5 to 10 minutes then repeat. If this amount is tolerated without vomiting, increase the amount of fluid to 2/3 of an ounce (10 to 20 cc). Wait and repeat. If tolerated, increase the fluid offered to 1 ounce (30 cc) at a time.

If vomiting occurs, go back to the 1/3 of an ounce (5 to 10 cc) and restart. Once the child is tolerating significant fluids by mouth, a more solid diet can be offered. The important thing to remember is that the goal is to provide fluid to the child and not necessarily calories. In the short term, hydration is more important than nutrition. For infants and children, fluid status can be monitored by

Clear fluids are appropriate for the first 24 hours to maintain adequate hydration. After 24 hours of fluid diet without vomiting, begin a softbland solid diet such as the BRAT diet (bananas, rice, apples, toast) and then progress the diet to other foods as tolerated. Diet change, food preparation habits, and storage: When the disease occurs following exposure to undercooked or improperly stored or prepared food (for example foods at picnics and BBQs that should be refrigerated to avoid contamination), food poisoning must be considered. In general, symptoms caused by bacteria or their toxins will become apparent after the following amount of time:
o

whether they are urinating, if they have saliva in their mouths, tears in their eyes, and
o

Staphylococcus aureus in 2 to 6 hours Clostridium 8 to 10 hours Salmonella in 12 to 72 hours Medications: If the patient has used antibiotics recently, they may have antibiotic-associated irritation of the gastrointestinal tract, caused byclostridium difficile infection.

sweat in their armpits or groin.

If the child's baseline weight is known, dehydration can be measured by comparing weight. Medical care should be accessed immediately, if the child is listless, floppy or does not seem to be acting like they normally do. Dehydration in adults Although adults and adolescents have a larger electrolyte reserve than children, electrolyte imbalance and dehydration may still occur as fluid is lost through vomiting and diarrhea. Severe symptoms and dehydration usually develop as complications of medication use or chronic diseases such as diabetes or kidney failure; however, symptoms may occur in healthy people.

Physical examination will explore the reasons for symptoms that may not be related to infection. If there are specific tender areas in the abdomen, the health care practitioner may want to determine if the patient has appendicitis, gallbladder disease, pancreatitis, diverticulitis, or other conditions that may be the cause of the patient's symptoms. Other noninfectious gastrointestinal diseases such as Crohn's disease, ulcerative colitis, or microscopic colitis also must be considered. The health care practitioner will feel the abdomen for

masses. A rectal examination may be considered, in which the physician inspects the anus for any abnormalities and then inserts a finger in the rectum to feel for any masses. Stool obtained during this test may be tested for the presence of blood. The health care practitioner may perform other laboratory tests, including complete blood count (CBC), electrolytes, and kidney function tests. Stool samples may collected and tested for blood or different types of infection.

Vaccinations for Vibrio cholerae, androtavirus have been developed. Rotavirus vaccination is recommended for infants in the U.S.. Vaccines for V. cholerae may be administered to individuals traveling in at-risk areas.

Gastroenteritis Medical Treatment Upon seeking medical attention, if the patient cannot take fluids by mouth because of vomiting, the health care practitioner may insert an IV replace fluid back into the body (rehydration). In infants, depending upon the level of dehydration, intravenous fluids may be delayed to consider trying oral rehydration therapy. Frequent feedings, as small as a 1/6 ounce (5 cc) at a time, may be used to restore hydration. Gastroenteritis Prevention With most infections, the key is to block the spread of the organism.

Always wash your hands. Eat properly prepared and stored food. Bleach soiled laundry.

What is a urinary tract infection (UTI)? The urinary tract is comprised of the kidneys, ureters, bladder, and urethra (see Figure 1). A urinary tract infection (UTI) is an infection caused by pathogenic organisms (for example, bacteria, fungi, or parasites) in any of the structures that comprise the urinary tract. However, this is the broad definition of urinary tract infections; many authors prefer to use more specific terms that localize the urinary tract infection to the major structural segment involved such as urethritis (urethral infection), cystitis (bladder infection), ureter infection, and pyelonephritis (kidney infection). Other structures that eventually connect to or share close anatomic proximity to the urinary tract (for example, prostate, epididymis, and vagina) are sometimes included in the discussion of UTIs because they may either cause or be caused by UTIs. Technically, they are not UTIs and will be only be briefly mentioned in this article. UTIs are common, leading to between seven and 10 million doctor visits per year. Although some infections go unnoticed, UTIs can cause problems that range from dysuria (pain and/or burning when urinating) to organ damage and even death. The kidneys are the active organs that produce about 1.5 quarts of urine per day. They help keep electrolytes and fluids (for example, potassium, sodium and water) in balance, assist in the removal of waste products (urea), and produce a hormone that aids in the formation of red blood cells. If kidneys are injured or destroyed by infection, these vital functions can be damaged or lost. While most investigators state that UTIs are not transmitted from person to person, other investigators dispute

this and say UTIs may be contagious and recommend that sex partners avoid relations until the UTI has cleared. There is general agreement that sexual intercourse can cause a UTI. This is mostly thought to be a mechanical process whereby bacteria are introduced into the urinary tracts during the sexual act. There is no dispute about the transmission of UTIs caused by sexually transmitted disease (STD) organisms; these infections (for example, gonorrhea and chlamydia) are easily transmitted between sex partners and are very contagious. Some of the symptoms of UTIs and sexually transmitted diseas What causes a urinary tract infection (UTI)? The most common causes of UTI infections (about 80%) are E. coli bacterial strains that usually inhabit the colon. However, many other bacteria can occasionally cause an infection (for example, Klebsiella, Pseudomonas, Enterobacter, Proteus, Staphylococcus, Mycoplasma, Chlamydia, Serratiaand Neisseria spp.), but are far less frequent causes than E. coli. In addition, fungi (Candida and Cryptococcus spp.) and some parasites (Trichomonas and Schistosoma) also may cause UTIs; Schistosoma causes other problems, with bladder infections as only a part of its complicated infectious process What are urinary tract infection (UTI) risk factors? There are many risk factors for UTIs. In general, any interruption or impedance of the usual flow of urine (about 50 cc per hour in normal adults) is a risk factor for a UTI. For example, kidney stones, urethral strictures, an enlarged prostate, or any anatomical abnormalities in the urinary tract increases infection risk. This is due in part to the flushing or washout effect of flowing urine; in effect, the pathogens have to "go against flow" because the majority of pathogens enter through the urethra and have to go retrograde (against a barrier of urine flow in the urinary tract) to reach the bladder, ureters, and eventually the kidneys. Many investigators suggest that women are far more susceptible than men to UTIs because their urethra is short and its exit (or entry for pathogens) is close to the anus and vagina, which can be sources of pathogens.

People who require catheters have an increased risk (about 30% of patients with indwelling catheters get UTIs) as the catheter has none of the protective immune systems to eliminate bacteria and offers a direct connection to the bladder. Catheters that are designed to reduce the incidence of catheter-related infections are available (they incorporate antibacterial substances into the catheter that suppress bacterial growth), but are not used by many clinicians because of short-termed effectiveness, cost, and concern about resistance development in bacteria. There are reports that suggest that women who use a diaphragm or who have partners that use condoms with spermicidal foam are at increased risk for UTIs. In addition, females who become sexually active seem to have a higher risk of UTI. The term, honeymoon cystitis, is sometimes applied to a UTI acquired either during the first sexual encounter or a UTI after a short interval of frequent sexual activity. Men over the age of 60 have a higher risk for UTIs because many men at or above that age develop enlarged prostatesthat may cause slow and incomplete bladder emptying. In addition, oldermales and female populations have seen recent rises in STDs; this increase is thought to be due to this group not using condoms as frequently as younger age groups. Occasionally, people with bacteremia (bacteria in the bloodstream) have the infecting bacteria lodge in the kidney; this is termed hematogenous spread. Similarly, people with infected areas that are connected to the urinary tract (for example, prostate, epididymis, or fistulas) are more likely to get a UTI. Additionally, patients who undergo urologic surgery also have an increased risk of UTIs. Pregnancy does not apparently increase

the risk of UTIs according to some clinicians; others think there is an increased risk between weeks six through 26 of the pregnancy. However, most agree that if UTIs occur in pregnancy, the risk of the UTI progressing in seriousness to pyelonephritis is increased, according to several investigators. In addition, their baby may be premature and have a low birth weight. Patients with chronic diseases such as diabetics or those who are immunosuppressed (HIV or cancer patients) also are at higher risk for UTIs. What are urinary tract infection (UTI) symptoms and signs in women, men, and children? The UTI symptoms and signs may vary according to age, sex, and location of the infection in the tract. Some individuals will have no symptoms or mild symptoms and may clear the infection in about two to five days. Many people will not spontaneously clear the infection; one of the most frequent symptoms and signs experienced by most patients is a frequent urge to urinate, accompanied by pain or burning on urination. The urine often appears cloudy and occasionally dark, if blood is present. The urine may develop an unpleasant odor. Women often have lower abdominal discomfort or feel bloated and experience sensations like their bladder is full. Women may also complain of a vaginal discharge, especially if their urethra is infected, or if they have an STD. Although men may complain of dysuria, frequency, and urgency, other symptoms may include rectal, testicular, penile, or abdominal pain. Men with a urethral infection, especially if it is caused by an STD, may have a pus-like drip or discharge from their penis. Toddlers and children with UTIs often show blood in the urine, abdominal pain, fever, and vomitingalong with pain and urgency with urination.

Symptoms and signs of a UTI in the very young and the elderly are not as diagnostically helpful as they are for other patients. Newborns and infants may develop fever or hypothermia, poor feeding, jaundice, vomiting, and diarrhea. Unfortunately, the elderly often have mild symptoms or no symptoms of a UTI until they become weak, lethargic, or confused. Location of the infection in the urinary tract usually results in certain symptoms. Urethral infections usually have dysuria (pain or discomfort when urinating). STD infections may cause a pus-like fluid to drain or drip from the urethra. Cystitis (bladder infection) symptoms include suprapubic pain, usually without fever and flank pain. Ureter and kidney infections often have flank pain and fever as symptoms. These symptoms and signs are not highly specific, but they do help the physician determine where the UTI may be located. What is the treatment for a urinary tract infection (UTI)? Treatment for a UTI should be designed for each patient individually and is usually based on the patient's underlying medical conditions, what pathogen(s) are causing the infection, and the susceptibility of the pathogen(s) to treatments. Patients who are very ill usually require intravenous (IV) antibiotics and admission to a hospital; they usually have a kidney infection (pyelonephritis) that may be spreading to the bloodstream. Other people may have a milder infection (cystitis) and may get well quickly with oral antibiotics. Still others may have a UTI caused by pathogens that cause STDs and may require more than a single oral antibiotic. The caregivers often begin treatment before the pathogenic agent and its antibiotic susceptibilities are known, so

in some individuals, the antibiotic treatment may need to be changed. In addition, pediatric patients and pregnant patients should not use certain antibiotics that are commonly used in adults. For example, ciprofloxacin(Cipro) and other related quinolones should not be used in children or pregnant patients due to side effects. However, penicillins and cephalosporins are usually considered safe for both groups if the individuals are not allergic to the antibiotics. Patients with STD-related UTIs usually require two antibiotics to eliminate STD pathogens. The less frequent or rare fungal and parasitic pathogens require specific antifungal or antiparasitic medications; these more complicated UTIs should often be treated in consultation with an infectious disease expert. All antibiotics prescribed should be taken even if the person's symptoms disappear early. Reoccurrence of the UTI and evenantibiotic resistance of the pathogen may happen in individuals who are not adequately treated. Over-the-counter (OTC) medicines offer relief from the pain and discomfort of UTIs but they don't cure UTIs. OTC products like AZO or Uristat contain the medicine, phenazopyridine (Pyridium and Urogesic), which works in the bladder to relieve pain. This medication turns urine an orange-red color, so patients should not be worried when this occurs. This medication can also turn other body fluids orange, including tears, and can stain contact lenses.

What are common antibiotics used to treat a urinary tract infection (UTI)? The following antibiotics are used to treat UTIs:

infecting agent to the drug, the seriousness of the infection, if the infected person is an adult, child or is pregnant, and on the treating doctor's experience and knowledge of local antibiotic resistance patterns of commonly infecting bacteria. Are there any home remedies for a urinary tract infection (UTI)? The best "home remedy" for a UTI is prevention. However, although there are many "home remedies" available from web sites, holistic medicine publications, and from friends and family members; there is controversy about them in the medical literature as few have been adequately studied. However, a few remedies will be mentioned because there may be some positive effect from these home remedies. The reader should be aware that while reading about these remedies (the term means to correct, relieve, or cure), they should not to overlook the frequent admonition that UTIs can be dangerous. If the person does not experience relief or if his or her symptoms worsen over one to two days, the person should seek medical care. In fact, many of the articles about UTI remedies actually describe ways to reduce or prevent UTIs. Examples of home treatments that may help to prevent UTIs, that may have some impact on an ongoing infection, and that are unlikely to harm people are as follows:

Beta-lactams, including penicillins and cephalosporins (for example, Amoxicillin, Augmentin, Keflex, Duricef, Ceftin, Lorabid, Rocephin, Cephalexin, Suprax, and others); many organisms have resistance to some of these drugs. Trimethoprim-sulfamethoxazolecombination antibiotic (for example, Bactrim DS and Septra); many organisms may show resistance. Fluoroquinolones (for example, Cipro, Levaquin, and Floxacin) resistance is developing; also these should not be used in pregnancy or in the pediatric population. Tetracyclines (for example, tetracycline,doxycycline, or minocycline) used most often for Mycoplasma or Chlamydia infections; like fluoroquinolones, they should not be used in pregnancy or by the pediatric population. Aminoglycosides (for example, gentamycin, amikacin, and tobramycin) used usually in combination with other antibiotics to combat severe UTIs. Macrolides (for example, clarithromycin,azithromycin, and erythromycin), used more often with some STD-caused urinary problems.

Increasing fluid intake: This may work by washing out organisms in the tract, making it more difficult for pathogens to adhere or stay in close proximity to human cells. Not delaying in emptying the bladder (urination): This has the same effects of increasing fluid intake and helps the bladder reduce the number of pathogens that may reach the bladder.

There are other antibiotics that are used occasionally, such as Nitrofurantoin, but its use is limited to cystitis and should not be used to treat more serious (kidney) UTIs. Choice of antibiotics for treatment depends mainly on the susceptibility of the

Eating cranberries or blueberries or drinking their unsweetened juice:These berries contain antioxidants that may help the immune system, and some investigators suggest they contain compounds that reach the urine and reduce the adherence of pathogens to human cells. Eating pineapple: Pineapple contains bromelain that has antiinflammatory properties that may reduce UTI symptoms. Taking vitamin C: Vitamin C may function to increase urine acidity to reduce bacterial growth. Using other methods: Yogurt, Echinacea, baking soda, Oregon grape root, and aromatherapy have had people claim effectiveness in treating UTIs, but the mechanisms are not clear.

Can a urinary tract infection (UTI) be prevented? Many methods have been suggested to reduce or prevent UTIs. Some of these are considered home remedies and have been discussed. There are other suggestions that may help prevent UTIs. Good hygiene for males and females is useful; for females, wiping from front to back helps keep pathogens that may reside or pass through the anal opening away from the urethra; for males, retracting the foreskin before urinating reduces the chance of urine lingering at the urethral opening and acting as a culture media for pathogens. Incomplete bladder emptying and resisting the normal urge to urinate can allow pathogens to survive and replicate easier in a non-flowing system. Some clinicians recommend washing before and urinating soon after sex to reduce the chance of urethritis/cystitis. Many clinicians suggest that anything that causes a person irritation in the genital area (for example, tight clothing, deodorant sprays, or other feminine products like bubble bath) may encourage UTI development. Wearing underwear that is somewhat adsorptive (for example, cotton) may help wick away urine drops that otherwise may be areas for pathogen growth. Is it possible to prevent urinary tract infections (UTIs) with diet and supplements? It is possible to reduce the chance that a UTI will develop with dietary methods and some supplements but prevention of all UTIs is unlikely with these methods. Dietary changes such as increasing fluid intake will usually increase urine formation and even diluted urine with increased flow rates will tend to reduce or eliminate retrograde bacterial advancement and reduce the chance for infection. Supplements such as eating cranberries,

What are possible complications of a urinary tract infection (UTI)? Most UTIs cause no complications if they spontaneously resolve quickly (a few days) or if treated early in the infection with appropriate medications. However, there are a number of complications that can occur if the UTI becomes chronic or rapidly advances. Chronic infections may result in urinary strictures, abscesses, fistulas, and kidney damage. Rapid advancement of UTIs can lead to dehydration, kidney failure,sepsis, and death. Pregnant females with untreated UTIs may develop premature delivery and a low birth weight for the infant and run the risks of rapid advancement of the infection.

taking vitamin C tablets, and eating yogurt and other substances also may reduce the chance that a UTI will. However, as stated in the prevention section, changes in a person's lifestyle may reduce the chance getting a UTI as good as, if not better than, any diet or supplement.

What is asthma? Asthma is a chronic inflammation of the bronchial tubes (airways) that causes swelling and narrowing (constriction) of the airways. The result is difficulty breathing. The bronchial narrowing is usually either totally or at least partially reversible with treatments. Bronchial tubes that are chronically inflamed may become overly sensitive to allergens (specific triggers) or irritants (nonspecific triggers). The airways may become "twitchy" and remain in a state of heightened sensitivity. This is called "bronchial hyperreactivity" (BHR). It is likely that there is a spectrum of bronchial hyperreactivity in all individuals. However, it is clear that asthmatics and allergic individuals (without apparent asthma) have a greater degree of bronchial hyperreactivity than nonasthmatic and nonallergic people. In sensitive individuals, the bronchial tubes are more likely to swell and constrict when exposed to triggers such as allergens, tobacco smoke, or exercise. Amongst asthmatics, some may have mild BHR and no symptoms while others may have severe BHR and chronic symptoms. Asthma affects people differently. Each individual is unique in their degree of reactivity to environmental triggers. This naturally influences the type and dose of medication prescribed, which may vary from one individual to another.

Normal bronchial tubes Before we can appreciate how asthma affects the bronchial airways, we should first take a quick look at the structure and function of normal bronchial tubes.

The air we breathe in through our nose is processed to prepare it for presentation to our lower respiratory tract. This air is moistened, heated, and cleansed prior to passage through the vocal cords (larynx) and into the windpipe (trachea). Dry or cold air presented to our trachea can cause coughing and wheezing as a normal response to this type of irritation. The air then enters the lungs by way of two large air passages (bronchi), one for each

lung. The bronchi divide within each lung into smaller and smaller air tubes (bronchioles), just like branches of an inverted tree. Inhaled air is brought through these airways to the millions of tiny air sacs (alveoli) that are contained in the lungs. Oxygen (O2) passes from the air sacs into the bloodstream through numerous tiny blood vessels called capillaries. Similarly, the body's waste product, carbon dioxide (CO2), is returned to the air sacs and then eliminated upon each exhalation. Normal bronchial tubes allow rapid passage of air in and out of the lungs to ensure that the levels of O2 and CO2 remain constant in the bloodstream. The outer walls of the bronchial tubes are surrounded by smooth muscles that contract and relax automatically with each breath. This allows the required amount of air to enter and exit the lungs to achieve this normal exchange of O2 and CO2. The contraction and relaxation of the bronchial smooth muscles are controlled by two different nervous systems that work in harmony to keep the airways open. The inner lining of the bronchial tubes, called the bronchial mucosa, contains: 1) Mucus glands that produce just enough mucus to properly lubricate the airways 2) A variety of so-called inflammatory as eosinophil, lymphocytes, and mast cells. cells, such

the bronchial tubes causes them to be a prime target for allergic inflammation. How does asthma affect breathing? Asthma causes a narrowing of the breathing airways, which interferes with the normal movement of air in and out of the lungs. Asthma involves only the bronchial tubes and does not affect the air sacs or the lung tissue. The narrowing that occurs in asthma is caused by three major factors: inflammation, bronchospasm, and hyperreactivity. Inflammation The first and most important factor causing narrowing of the bronchial tubes is inflammation. The bronchial tubes become red, irritated, and swollen. This inflammation increases the thickness of the wall of the bronchial tubes and thus results in a smaller passageway for air to flow through. The inflammation occurs in response to an allergen or irritant and results from the action of chemical mediators (histamine,leukotrienes, and others). The inflamed tissues produce an excess amount of "sticky" mucus into the tubes. The mucus can clump together and form "plugs" that can clog the smaller airways. Specialized allergy and inflammation cells (eosinophils and white blood cells), which accumulate at the site, cause tissue damage. These damaged cells are shed into the airways, thereby contributing to the narrowing. Bronchospasm The muscles around the bronchial tubes tighten during an attack of asthma. This muscle constriction of the airways is called bronchospasm. Bronchospasm causes the airway to narrow

These cells are designed to protect the bronchial mucosa from the microorganisms, allergens, and irritants we inhale, and which can cause the bronchial tissue to swell. Remember, however, that these inflammatory cells are also important players in the allergic reaction. Therefore, the presence of these cells in

further. Chemical mediators and nerves in the bronchial tubes cause the muscles to constrict. Bronchospasm can occur in all humans and can be brought on by inhaling cold or dry air. Hyperreactivity (hypersensitivity) In patients with asthma, the chronically inflamed and constricted airways become highly sensitive, or reactive, to triggers such as allergens, irritants, and infections. Exposure to these triggers may result in progressively more inflammation and narrowing. The combination of these three factors results in difficulty with breathing out, or exhaling. As a result, the air needs to be forcefully exhaled to overcome the narrowing, thereby causing the typical "wheezing" sound. People with asthma also frequently "cough" in an attempt to expel the thick mucus plugs. Reducing the flow of air may result in less oxygen passing into the bloodstream, and if very severe, carbon dioxide may dangerously accumulate in the blood. The importance of inflammation Inflammation, or swelling, is a normal response of the body to injury or infection. The blood flow increases to the affected site and cells rush in and ward off the offending problem. The healing process has begun. Usually, when the healing is complete, the inflammation subsides. Sometimes, the healing process causes scarring. The central issue in asthma, however, is that the inflammation does not resolve completely on its own. In the short term, this results in recurrent "attacks" of asthma. In the long term, it may lead to permanent thickening of the bronchial walls, called airway "remodeling." If this occurs, the narrowing of the bronchial tubes may become irreversible and poorly responsive

to medications. When this fixed obstruction to airflow develops, asthma is then classified in the group of lung conditions known as chronic obstructive pulmonary disease (COPD). Therefore, the goals of asthma treatment are: (1) in the short term, to control airway inflammation in order to reduce the reactivity of the airways; and (2) in the long term, to prevent airway remodeling.

Various triggers in susceptible individuals result in airway inflammation. Prolonged inflammation induces a state of airway hyperreactivity, which might progress to airway remodeling unless treated effectively. Asthma symptoms may be activated or aggravated by many agents. Not all asthmatics react to the same triggers. Additionally, the effect that each trigger has on the lungs varies from one individual to another. In general, the severity of your asthma depends on how many agents activate your symptoms and how sensitive your lungs are to them. Most of these triggers can also worsen nasal or eye symptoms.

Triggers fall into two categories:

allergens ("specific") nonallergens - mostly irritants (nonspecific).

outdoor factors, such as smog, weather changes, and diesel fumes indoor factors, such as paint, detergents, deodorants, chemicals, and perfumes nighttime GERD (gastroesophageal reflux disorder) exercise, especially under cold dry conditions work-related factors, such as chemicals, dusts, gases, and metals emotional factors, such as laughing, crying, yelling, and distress hormonal factors, such as in premenstrual syndrome

Once your bronchial tubes (nose and eyes) become inflamed from an allergic exposure, a re-exposure to the offending allergens will often activate symptoms. These "reactive" bronchial tubes might also respond to other triggers, such as exercise, infections, and other irritants. The following is a simple checklist. Common asthma triggers: Allergens

"seasonal" pollens year-round dust mites, molds, pets, and insect parts foods, such as fish, egg, peanuts, nuts, cow's milk, and soy additives, such as sulfites work-related agents, formaldehyde such as latex, epoxides, and

Types: allergic (extrinsic) and nonallergic (intrinsic) asthma Your doctor may refer to asthma as being "extrinsic" or "intrinsic." A better understanding of the nature of asthma can help explain the differences between them. Extrinsic, or allergic asthma, is more common (90% of all cases) and typically develops in childhood. Approximately 80% of children with asthma also have documented allergies. Typically, there is a family history of allergies. Additionally, other allergic conditions, such as nasal allergies or eczema, are often also present. Allergic asthma often goes into remission in early adulthood. However, in 75% of cases, the asthma reappears later. Intrinsic asthma represents about 10% of all cases. It usually develops after the age of 30 and is not typically associated with allergies. Women are more frequently involved and many

Irritants

respiratory infections, such as those caused by viral "colds," bronchitis, and sinusitis drugs, such as aspirin, other NSAIDs (nonsteroidal antiinflammatory drugs), and beta blockers (used to treat blood pressure and other heart conditions) tobacco smoke

cases seem to follow a respiratory tract infection. The condition can be difficult to treat and symptoms are often chronic and yearround. Typical asthma symptoms and signs The symptoms of asthma vary from person to person and in any individual from time to time. It is important to remember that many of these symptoms can be subtle and similar to those seen in other conditions. All of the symptoms mentioned below can be present in other respiratory, and sometimes, in heart conditions. This potential confusion makes identifying the settings in which the symptoms occur and diagnostic testing very important in recognizing this disorder. The following are the four major recognized asthma symptoms:

30% of affected patients have mild, intermittent (less than two episodes a week) symptoms of asthma with normal breathing tests 30% have mild, persistent (two or mores episodes a week) symptoms of asthma with normal or abnormal breathing tests 40% have moderate or severe, persistent (daily or continuous) symptoms of asthma with abnormal breathing tests

Acute asthma attack An acute, or sudden, asthma attack is usually caused by an exposure to allergens or an upper-respiratory-tract infection. The severity of the attack depends on how well your underlying asthma is being controlled (reflecting how well the airway inflammation is being controlled). An acute attack is potentially life-threatening because it may continue despite the use of your usual quick-relief medications (inhaled bronchodilators). Asthma that is unresponsive to treatment with an inhaler should prompt you to seek medical attention at the closest hospital emergency room or your asthma specialist office, depending on the circumstances and time of day. Asthma attacks do not stop on their own without treatment. If you ignore the early warning signs, you put yourself at risk of developing status asthmaticus. Asthma At A Glance

Shortness of breath, especially with exertion or at night Wheezing is a whistling or hissing sound when breathing out Coughing may be chronic, is usually worse at night and early morning, and may occur after exercise or when exposed to cold, dry air Chest tightness may occur with or without the above symptoms

Asthma fact Asthma is classified according to the frequency and severity of symptoms, or "attacks," and the results of pulmonary (lung) function tests.

Asthma is a chronic inflammation of the bronchial tubes (airways) that causes swelling and narrowing (constriction) of the airways. The bronchial narrowing is usually either totally or at least partially reversible with treatments. Asthma is now the most common chronic illness in children, affecting one in every 15.

Asthma involves only the bronchial tubes and usually does not affect the air sacs or the lung tissue. The narrowing that occurs in asthma is caused by three major factors: inflammation, bronchospasm, and hyperreactivity. Allergy can play a role in some, but not all, asthma patients. Many factors can precipitate asthma attacks and they are classified as either allergens or irritants. Symptoms of asthma include shortness of breath, wheezing, cough, and chest tightness. Asthma is usually diagnosed based on the presence of wheezing and confirmed with breathing tests. Chest X-rays are usually normal in asthma patients. Avoiding precipitating factors is important in the management of asthma. Medications can be used to reverse or prevent bronchospasm in patients with asthma.

Angina Pectoris Causes Angina is classified as one of the following two types:

The symptoms are worse in unstable angina - the pains are more frequent, more severe, last longer, occur at rest, and are not relieved by nitroglycerin under the tongue. Unstable angina is not the same as a heart attack, but it warrants an immediate visit to the healthcare provider or a hospital emergency department. The patient may need to be hospitalized to prevent a heart attack. If the patient has stable angina, any of the following may indicate worsening of the condition:

Stable angina Unstable angina Stable Angina Stable angina is the most common angina, and the type most people mean when they refer to angina.

An angina episode that is different from the regular pattern Being awakened at night by angina symptoms More severe symptoms than usual Having angina symptoms more often than usual Angina symptoms lasting longer than usual Coronary Heart Disease The most common cause for the heart not getting enough blood is coronary heart disease, also called coronary artery disease.

People with stable angina usually have angina symptoms on a regular basis. The episodes occur in a pattern and are predictable. For most people, angina symptoms occur after short bursts of exertion. Stable angina symptoms usually last less than five minutes. They are usually relieved by rest or medication, such as nitroglycerin under the tongue. Unstable Angina Unstable angina is less common. Angina symptoms are unpredictable and often occur at rest.

In this disease, the coronary arteries become blocked, narrowed, or otherwise damaged. They can no longer supply the heart with all of the blood it needs. Most cases of coronary heart disease are caused by atherosclerosis (hardening of the arteries).

This may indicate a worsening of stable angina, but sometimes the first time a person has angina it is already unstable.

Atherosclerosis is a condition in which a fatty substance/cholesterol builds up inside the blood vessels. These buildups are called plaques, and they can block blood flow through the vessels partially or completely. Multiple risk factors, particularly:
o o o o o

Cocaine use/abuse can cause significant spasm of the coronary arteries and lead to a heart attack. Other Causes Other causes of angina symptoms include the following:

diabetes, high blood pressure, smoking, high cholesterol, and genetic predisposition may accelerate this build up.

Blockage of a coronary artery by a blood clot or by compression from something outside the artery Inflammation or infection of the coronary arteries Injury to one or more coronary arteries Poor functioning of the tiny blood vessels of the heart (microvascular angina) When a person has underlying atherosclerosis, spasm, or damage to the coronary arteries, angina symptoms usually are set off by one of the following triggers:

Coronary Artery Spasm Another cause of unstable angina is coronary artery spasm.

Spasm of the muscles surrounding the coronary arteries causes them to narrow or close off temporarily. This blocks the flow of blood to the heart muscle for a brief time, causing angina symptoms. This is called variant angina or Prinzmetal angina.

Physical exertion or exercise Emotional stress Exposure to cold Decreased oxygen content in the air you breathe (for example flying in an airplane or at high altitudes) Using a stimulant such as caffeine or smoking cigarettes (which lowers the amount of oxygen in the blood)

This is not the same as atherosclerosis, although some people have both conditions.

The symptoms often come on at rest (or during sleep) and without apparent cause.

Risk Factors for Atherosclerosis and Angina Risk factors for atherosclerosis and angina include the following. Some of these are reversible.

The pain may spread to the shoulders, neck, or arms. It may be located in the upper abdomen, back, or jaw. The pain may be of any intensity from mild to severe. Other symptoms may occur with an angina attack, as follows:

High blood pressure (hypertension) High levels of cholesterol and other fats in the blood

Diabetes

Shortness of breath Lightheadedness Fainting Anxiety or nervousness Sweating or cold, sweaty skin Nausea Rapid or irregular heart beat Pallor (pale skin) Feeling of impending doom These symptoms are identical to the signs of an impending heart attack described by the American Heart Association. It is not always easy to tell the difference between angina and a heart attack, except angina only lasts a few minutes and heart attack pain does not go away.

Smoking

Male gender

Inactive (sedentary) lifestyle

Family history of coronary heart disease

Aging

Regular use of stimulants, especially nicotine, cocaine, or amphetamines: Other stimulants include theophyllines, inhaled beta-agonists, caffeine, diet pills, and decongestants. Angina Pectoris Symptoms Angina itself is a symptom (or set of symptoms), not a disease. Any of the following may signal angina:

An uncomfortable pressure, fullness, squeezing, or pain in the center of the chest

It may also feel like tightness, burning, or a heavy weight.

If you have never had symptoms like this before, sit down. If you are able, call your healthcare provider, call 911, or go to the closest hospital emergency department.

If you have had angina attacks before and this attack is similar to those, rest for a few minutes. Take your sublingual nitroglycerin. Your angina should be totally relieved in five minutes. If not, you may repeat the nitroglycerin dose and wait another five minutes. Exams and Tests Upon hearing about the patient's symptoms, the primary healthcare provider or the provider in the emergency department will immediately think of angina and other heart problems. Time is of the essence - treatment will probably begin as the evaluation continues. An electrocardiogram (ECG) will be done.

suggest that a person may be having a heart attack. These tests may be done if a heart attack is suspected. While these tests are going on, the healthcare provider will be asking questions to help with the diagnosis. The questions will be about the symptoms and about the patient's medical history:
o o o o

previous operations, medications, allergies, and habits and lifestyle. The physical exam will include listening to the heart and lungs and feeling the heart through the chest.

This painless test checks for abnormalities in the beating of the heart. Electrodes are attached to the chest and other points on the body. The electrodes read the electrical impulses linked to the beating of the heart. The ECG looks for signs of a heart attack or of impaired blood flow to the heart. For many patients with angina, the ECG result is normal. The patient may have a chest x-ray. This will show any fluid buildup in the lungs. It can also rule out some other causes of chest pain. There is no blood lab test that can tell with certainty that someone is having angina. There are certain blood tests that

If, after these tests, the healthcare provider suspects the patient may have coronary heart disease, additional tests will be performed to confirm the possibility.

Exercise stress test: An ECG is taken before, during, and after exercise (usually walking on a treadmill) to detect inadequate blood flow to the heart muscle indirectly by changes on the ECG. This usually is done only for stable angina. Thallium stress test: This is a more complex and expensive test that injects a radioisotope into the circulation and indirectly detects parts of the heart that may not be getting enough blood during "stress" (usually walking on a treadmill, or after administration of a drug that mimics exercise in those unable to walk on the treadmill). This information indicates

more accurately whether any of the coronary arteries may be narrowed, causing inadequate blood flow to the heart muscle or ventricle. Again, this is usually done only for stable angina.

Self-Care at Home Stop doing whatever it is that causes the symptoms and call the hospitals immediate help and intervention is the best chance for survival if someone is having a heart attack or other serious problem.

Dobutamine echocardiogram stress test: This is done for people who cannot walk on a treadmill. A drug called dobutamine stimulates and speeds up the heart, creating an increased demand or need for blood flow tot he left ventricle or muscle. If the muscle shows a slowing of function on the ultrasound image of the heart muscle, then it indirectly indicates inadequate blood flow to the muscle. Coronary angiogram (or arteriogram): This test of the coronary arteries is the most accurate but also the most invasive. It is a type of x-ray. A thin, plastic tube called a catheter is threaded through an artery in the arm or groin to one of the main coronary arteries. A contrast, or harmless dye is injected into the arteries. The dye depicts the arteries directly and shows any blockage more accurately than the above or more noninvasive procedures. The healthcare provider will make the decision about whether these tests or any treatment need to be done on an urgent basis. If so, the patient will be admitted to the hospital. If not, the tests will be scheduled for the next few days, and the patient may be allowed to go home. Angina Pectoris Treatment The treatment for angina depends on the severity of the symptoms and the results of tests that are done to find the underlying cause.

Lie down in a comfortable position with the head up. Chew a regular adult aspirin or its equivalent (as long as the patient is not allergic to aspirin). Chewing more than one will not do any good and may cause unwanted side effects. If the patient has had angina before and been evaluated by a healthcare provider, follow his or her recommendations.

This may mean rest and the immediate use of sublingual nitroglycerin. It may include a visit to the hospital emergency department. Medical Treatment If the patient has come to the hospital emergency department, they may be sent to another care area for further testing, treatment, or observation. On the basis of the provider's preliminary diagnosis, the patient may be sent to the following units:

An observation unit pending test results or further testing A cardiac care unit A cardiac catheterization unit

Regardless of where the patient is sent, several basic treatments may be started. Which ones are given depends on the severity of the symptoms and the underlying disease.

After reviewing the patient's immediate test results, the hospital healthcare provider will make a decision about where the patient should be for the next hours and days.

At least one IV line will be started. This line is used to give medication or fluids. Aspirin will probably be administered (unless the patient has already taken one) Oxygen will be administered through a face mask or a tube in the nose. This will help if the patient is having trouble breathing or feeling uncomfortably short of breath. The direct administration of oxygen raises the oxygen content of the blood. Treatment will depend on the severity of the symptoms, severity of the underlying disease, and extent of damage to the heart muscle, if any.

If the diagnosis of angina is made, and the patient is feeling better and their condition is stable they may be allowed to go home. The patient may be given medications to take. Followup with a primary healthcare provider within the next day or two will be recommended. The patient will be admitted o the hospital if the they are unstable with continuing symptoms. Further testing will be ordered, and if the arteries are critically blocked, the patient may undergo coronary angiography, coronary artery angioplasty, or even coronary artery bypass surgery. Angioplasty is a treatment used for people whose angina does not get better with medication and/or who are at high risk of having a heart attack.

Simple rest and observation, an aspirin, breathing oxygen, and sublingual nitroglycerin may be all that the patient needs, if it is only angina. Medication may be administered to reduce anxiety. Medication may be administered to lower blood pressure or heart rate. Medication may be administered to reduce the risk of having a blood clot or to prevent further clotting. If the healthcare provider believes the chest pain actually represents a heart attack, the patient may be given a fibrinolytic (apowerful clot-buster medication).

Before angioplasty can be done, the area(s) of coronary artery narrowing is located with coronary arteriography. A thin plastic tube called a catheter is inserted into an artery in the arm or groin with local sedation. The catheter has a tiny balloon attached to the end. The catheter is threaded through the arteries and into the artery where the narrowing is. The balloon on the catheter is inflated, opening up the narrowing.

Following ballon treatment, many patients require placement of a "stent," a small metal sleeve that is placed in the narrowed artery. The stent holds the artery open. Surgery Like angioplasty, surgery is an option for people whose angina does not improve with medications and others who are at high risk of having a heart attack. Surgery is usually reserved for people with very severe narrowing or blockage in several coronary arteries. In almost all cases, the operation used for severely narrowed coronary arteries is coronary artery bypass grafting. Coronary Artery Bypass Surgery

Transmyocardial Revascularization Transmyocardial revascularization is a procedure for people who cannot undergo angioplasty or surgery. A simple incision is made in the chest, and a laser is used to "drill" small holes through the outside wall of the heart into the left ventricle. About 20-40 holes are made. Bleeding from these holes is minimal and usually stops after a few minutes of pressure. It is not clear why this helps relieve angina. One theory is that it stimulates growth of new blood vessels that improve blood flow to the heart. Other investigators believe it is a placebo effect. Current research is focusing on trying to find growth factors that could be injected into coronary arteries or directly into the left ventricle to encourage growth of new blood vessels. Follow-up If a patient has stable angina, they will need to visit their healthcare provider on a regular basis to monitor angina episodes and assess if risk factors are being reduced. The patient's healthcare provider will probably test their heart function periodically and assess the underlying disease. These tests will probably include the following:

The chest and rib cage are opened up (open heart surgery) The narrowed part of the artery is bypassed by a piece of vein removed from the leg, or with a piece of artery behind the sternum (internal mammary artery), or a portion of the radial artery taken from the lower arm or forearm. Several arteries can be bypassed in one operation. This is a very safe operation, with a mortality rate of less than 1%, in people whose heart muscle is not severely damaged irreversibly and who have normal lungs, kidneys, liver, and other organs. Because the chest is opened, the recovery time can be quite long, especially if the patient is older and has multiple other health problems.

ECG

Exercise tolerance tests Thallium stress test Repeat cardiac catheterization to see if the dilated artery or stent is still open and/or a surgical bypass graft is still open or closed. This is the key downside of both angioplasty and surgery: arteries, stents, and grafts restenose (occlude) with the same disease process of atherosclerosis. None of these procedures are a permanent cure. The patient has to be very compulsive in correcting potential risk factors, or they will return with the same blockages they started with. Prevention The best action is to reduce risk factors early in life. The goal is to not have angina, a heart attack, or sudden death in the first place. Although no one can escape aging, inherited risk, or gender, certain risk factors are in your control.

"triggers" will help keep the person comfortable and free of symptoms. Quit smoking Do not use caffeine, cocaine, amphetamines, or other stimulants Drink alcohol moderately (no more than 1-2 drinks daily) Avoid large and heavy meals that leave you feeling "stuffed" Decrease stress Establish a regular exercise routine (discuss the plan with your healthcare provider) The question of exercise for a person with angina is important. Exercise is recommended.

Stop smoking and using nicotine in any form. Control high blood pressure. Lower blood fats (through diet, exercise, and medications). Maintain a healthy weight. Control diabetes and blood sugar Do not use stimulants such as cocaine or amphetamines. If a person already has atherosclerosis and angina, they can learn to take precautions to avoid having symptoms. Avoiding the

If the patient has been exercising strenuously, they may need to cut back to avoid symptoms. If the patient has not been exercising, or has been exercising moderately, talk to a healthcare provider first about physical activity that will be safe and comfortable. Sometimes a structured cardiac rehabilitation program is a beneficial way to begin an exercise program.