Most Important Health Informations For All

How Can I Stop Drinking So Much Soda?

2008-01-09T18:00:00.001+02:00

Do you have a soda habit? Here's some advice on how to cut back.

By Elaine Magee, MPH, RD
WebMD Weight Loss Clinic - Expert Column

Soda -- it's everywhere! Even if you wanted to drink something else, you'd be hard-pressed to find it as prominently displayed in vending machines, at fast-food chains, and supermarket checkouts. You might not realize how ubiquitous Coke, Pepsi, and the like are in our society until you try to stop drinking soda.

For some people, drinking several sodas a day is a fierce habit. You know drinking soda is a habit when you find yourself going to the grocery store at 10 p.m. because your refrigerator is tapped out, or you feel like having a tantrum when the drive-through attendant tells you the soda machine is broken. If the idea of drinking one token soda a day is unfathomable, you just might have a serious soda habit.

Why Stop Drinking So Much Soda?

So why would you want to make the effort to kick the soda habit? As the beverage industry out, soft drinks, in and of themselves, aren't necessarily a dietary "don't."

"All of our industry's beverages -- including regular or diet soft drinks -- can be part of a healthy way of life when consumed in moderation and as part of a balanced lifestyle," says Tracey Halliday, a spokesperson for the American Beverage Association.

The problem, say many health experts, is that Americans don't always drink their sodas in moderation. Many believe we should cut back on our intake of the two sweeteners used in sweetened soda: fructose (like the high-fructose corn syrup often used in sodas) and sugar. Calories from beverages make up 21% of the total daily calories consumed by Americans over 2 years old, according to a 2004 article in the American Journal of Preventive Medicine. And the proportion of calories Americans consume from sweetened soft drinks and fruit "drinks" has tripled between 1977 and 2001.

"Many people either forget or don't realize how many extra calories they consume in what they drink, yet beverages are a major contributor to the alarming increase in obesity," Barry Popkin, PhD, director of the University of North Carolina Interdisciplinary Obesity Program, says in an email interview.

In 2006, a panel of experts assembled by Popkin developed the first Healthy Beverage Guidelines, which recommended people should drink more water and limit or eliminate high-calorie beverages with little or no nutritional value.

So is simply switching to diet soda the answer? Not necessarily, some experts believe.

Popkin has said there's no proof that artificial sweeteners are bad for you, but because the data are slim, the Beverage Guidance Panel was uneasy about recommending them.

Michael Jacobson, executive director of the advocacy group Center for Science in the Public Interest (CSPI), suggests that people who drink diet sodas should choose those sweetened with Splenda when possible.

Of the alternative sweeteners used in soda, CSPI gives the "avoid" label to Acesulfame-K, aspartame, and saccharin, but the "appears to be safe" label to sucralose (Splenda). All these sweeteners have received FDA approval. And, in a 100-page report published in Critical Reviews in Toxicology in September, an expert panel said it was confident aspartame poses no health risks. But CSPI believes those on its "avoid" list need more or better testing.

Still, while Jacobson believes "less is better" when it comes to alternative sweeteners, he concedes that drinking diet soda is better than gulping down the equivalent of 10 teaspoons of sugar -- which is what you'll get in a can of regular soda.

And just how do you go about kicking a soda habit? If you want to stop drinking so much soda, it basically comes down to four steps, according to the experts:

1. Make Up Your Mind. You have to make up your mind to give it up, notes Jacobson. Even if you're just trying to cut back on your soda consumption, it can take a firm commitment to make it happen.

2.Switch to Diet Sodas. Gradually make the switch to diet sodas, suggests Paul Rozin, PhD, a psychology professor at the University of Pennsylvania. "Just make a small decrease at a time, like one sugared soda a day," he says in an email interview. If you're drinking much more than one soda a day, work toward decreasing the amount of diet sodas you drink as well -- eventually.

3. Go Caffeine-Free. Popkin and Jacobson believe that caffeine, and the fact that it is mildly addictive, is part of the reason soda is such a hard habit to break. Look for caffeine-free soft drinks, and gradually decrease the number of caffeinated drinks you have each day as you work toward kicking the soda habit completely. If you're addicted to the caffeine in soda, you're really kicking two habits -- the soda habit and the caffeine habit. "It takes a few weeks to truly forget the craving," Popkin says.

4. Stock Up on Alternatives. Keep plenty of tasty non-soda drinks on hand to make giving up soda as convenient as possible.

What Are Some Soda Alternatives?

Here is a list of non-soda beverage possibilities to consider. You'll notice the drinks that contain calories also contribute important nutrients like calcium or vitamin C.

1. Give Soy Milk a Chance. If you'd like to work in a serving of soy a day, give soy milk a try. Lots of brands and flavors are available. If calories are an issue, try one of the lower-calorie options.

2. Don't Skimp on Skim Milk. Skim milk is a great way to boost your intake of protein, calcium, vitamin D, and other important nutrients. One cup of skim milk has only around 85 calories. The Beverage Guidance Panel recommends up to two servings a day of nonfat or 1% milk and fortified soy beverages.

3. Pimp Your Water. To an avid soda drinker, water can seem a little unexciting. One of the best ways around that is to add noncaloric flavors to your water. A sprig of mint or a slice of lemon or lemon will do wonders. If you like subtler flavors, try a slice or two of cucumber or a frozen strawberry.

4. Make Green or Black Tea Your New Drink Habit. Popkin says tea is a healthy alternative to water for people who prefer flavored beverages. Tea is calorie free and contains powerful phytochemicals like the antioxidant in green tea, epigallocatechin gallate (EGCG). Great-tasting green and black teas abound in supermarkets and specialty stores. If you're cutting back on caffeine, look for caffeine-free teas.

5. Think Outside the Juice Box. Although 100% fruit or vegetable juice contains important nutrients, the Beverage Guidance Panel recommends having no more than one serving a day because they can also contain plenty of calories (about 100 in 1 cup of fresh orange or carrot juice). One way to cut those calories is by making a homemade juice spritzer: Combine one or two parts seltzer, mineral water, or club soda with one part 100% fruit juice (try fresh orange juice). Or try the new vegetable juice flavors in your supermarket, as well as fruit and vegetable juice blends. While they're not super low in calories, each serving contains a serving of fruit and a serving of vegetable.

6. Discover the Coffee Cure. For java lovers, coffee can be a calorie-free, flavorful alternative to soda. And you can easily find lower-caffeine coffees in coffee shops and supermarkets. But to keep coffee low-calorie, be sure to keep it simple -- skip the syrups, whipped cream, and whole milk.

7. Make Good Old H2O Convenient. The Beverage Guidance Panel recommends at least 4 servings a day of water for women and at least 6 servings for men. When you need to quench thirst or hydrate your body, nothing does it better than water. If cold, refreshing water was more convenient, and if we were reminded to drink it during our day, a lot more people would reach this daily goal. So keep water bottles ready to go in your refrigerator, and every time you leave the house, take a bottle with you. If chilled water is sitting in your car or on your desk at work, you'll be more likely to get into the water-drinking habit.

Reference Link:

http://www.webmd.com/diet/features/how-can-i-stop-drinking-so-much-soda?

5 Easy Ways to Cut Back on Salt

2008-01-09T17:57:00.001+02:00

5 Easy Ways to Cut Back on Salt

Yes, you should still watch your sodium. Here are tips on how to do it.

By Elaine Magee, MPH, RD
WebMD Weight Loss Clinic - Expert Column

Too much salt in the diet is a bad thing -- or is it?

Most of us have long heard that it's best to go easy on the salt shaker. But a recent study has confused the issue somewhat.

In the study, published in the March 2006 American Journal of Medicine, people who reported eating limited salt were found to be 37% more likely to die of cardiovascular disease (conditions such as stroke and heart disease) than people who ate more salt. The researchers concluded that their findings raise questions, and that further studies are needed.

But, experts say, it's important to keep in mind that this is just one study, compared with scores of others that have found health benefits to avoiding a high-sodium diet.

According to the American Heart Association, 1,500 milligrams of sodium is the ideal daily goal for African-Americans, middle- and older-aged Americans, and people with high blood pressure. The rest should aim for less than 2,300 milligrams of sodium a day -- the equivalent of about 1 teaspoon of salt.

The Salt Connection

New research shows that a high-salt diet may have a negative effect on our bodies' levels of vitamin D -- a vitamin considered important to many aspects of health.

Older women who had high blood pressure caused by salt were found to have lower concentrations of a certain marker of vitamin D than women with normal blood pressure, Myrtle Thierry-Palmer, PhD, a biochemistry professor at Morehouse School of Medicine in Atlanta, tells WebMD.

There is also some evidence that a high-sodium intake increases calcium losses in the urine -- which is bad news for bone density. Too much sodium may also contribute to the development of kidney stones.

And what about heart disease? Research has shown a connection between high-salt intake and an increase in blood pressure in certain people who are considered "salt sensitive."

High blood pressure is a major risk factor for cardiovascular disease. That's important information for the nearly one in three American adults who have high blood pressure, according to the American Heart Association (AHA).

Studies have shown that cutting back on salt can lower blood pressure in people with and without high blood pressure, according to a statement from the AHA.

"Reduced salt intake can blunt the rise in blood pressure that occurs with age and reduce the risk of atherosclerotic cardiovascular disease events and congestive heart failure," according to the January 2006 statement.

Here's something baby boomers need to know: People tend to become more sensitive to sodium as they get older. Likewise, their blood pressure is more likely to drop when they cut back on salt in their later years.

Further, sodium may increase the risk for stroke even beyond its affect on blood pressure, according to research reported at the 2005 American Stroke Association International Conference.

The risk of stroke was higher in people who ate more sodium, regardless of their blood pressure, reported researchers. Their results also showed that people who took in more than 4,000 milligrams of sodium a day almost doubled their stroke risk compared with those getting 2,400 milligrams or less.

Are You Salt-Sensitive?

The reason salt-sensitive people's blood pressure responds strongly to salt intake is through sodium's effect on blood volume. When you eat more salt, your blood pressure tends to rise and when you eat less salt, your blood pressure lowers.

What portion of the population is salt-sensitive? Some researchers have estimated that about a quarter of the American population with normal blood pressure is salt-sensitive, while about half of the people with high blood pressure seem to be salt-sensitive. The black population has demonstrated a greater susceptibility to salt sensitivity than the white population, adds Thierry-Palmer.

5 Steps to Less Salt

1. Pass Up Processed Foods

The Food Standards Agency of the United Kingdom estimates that 75% of salt intake comes from processed food. Some food companies are developing products with less sodium, so keep an eye out for sodium listed on food labels. Only small amounts of sodium occur naturally in foods, eating mostly natural, whole foods will help keep levels of sodium down.

2. Cut Back on Condiments

Always dress your sandwiches and burgers yourself. This way, you can not only control the amounts of condiments used, you can choose those that are lower in calories, fat, and sodium, such as:

Balsamic vinegar. 2 teaspoons has 14 calories, 0 grams fat, and 2 milligrams sodium
Mustard. 1 teaspoon has 10 calories, 0 grams fat, and 100 milligrams sodium
Pickle relish. 1 tablespoon has 21 calories, 0 grams fat, and 109 milligrams sodium
Horseradish. 2 teaspoons has 4 calories, 0 grams fat, and 10 milligrams sodium
Low-sodium light mayonnaise. 17 calories, 1.3 grams fat, and 27 milligrams sodium (the numbers may vary depending on brand).
Lemon juice (from 1/2 lemon). 8 calories, 0 grams fat, and 1 milligram sodium

Feel free to load on all the lettuce, tomato, and onion your heart desires. Each adds 5 calories or less per serving, and is mostly sodium-free.

3. Beware of Dressings and Sauces

If you think a little bit of dressing or sauce won't add that much sodium to your meal, think again. Take a gander at some of the dressing offered at the Jack in the Box fast-food restaurant:

Creamy Southwest Dressing (71-gram serving): 1,060 milligrams sodium
Bacon Ranch Dressing (71-gram serving): 810 milligrams sodium
Asian Sesame Dressing (71-gram serving): 780 milligrams sodium

4. Opt for Alternatives

Purchase a battery-operated pepper grinder and your favorite flavor of salt-free herb and spice blend (like Mrs. Dash). Then keep them front and center on your kitchen table to help you break the habit of salting your food.

5. Forgo Fast Food

Eating at fast-food chains may be fast and cheap, but you pay the price in calories, fat, and sodium. Many fast-food items are big on sodium. The following items, at a few top chains, topped the sodium scale:

Jack in the Box

Bacon Ultimate Cheeseburger: 2,040 milligrams sodium
Chipotle Chicken Ciabatta with Grilled Chicken: 1,850 milligrams
Bruschetta Chicken Ciabatta Sandwich: 1,810 milligrams
Ciabatta Breakfast Sandwich: 1,770 milligrams
Ultimate Breakfast Sandwich: 1,700 milligrams
Bacon Cheese Ciabatta Burger: 1,670 milligrams
Chipotle Chicken Ciabatta with Spicy Crispy Chicken: 1,650 milligrams
Sausage, Egg, & Cheese Biscuit: 1,430 milligrams

Wendy's

Homestyle Chicken Strips (3) with dipping sauce: 1,690-1,890 milligrams sodium, depending on sauce
Frescata Club Sandwich: 1,610 milligrams
Frescata Italiana Sandwich: 1,530 milligrams
Roasted Turkey & Swiss Frescata Sandwich: 1,520 milligrams
Big Bacon Classic Sandwich: 1,510 milligrams

McDonald's

Deluxe Breakfast: 1,920 milligrams sodium
Premium Crispy Chicken Club Sandwich: 1,830 milligrams
Premium Crispy Chicken Ranch BLT Sandwich: 1,750 milligrams
Premium Grilled Chicken Club Sandwich: 1,690 milligrams
Big Breakfast: 1,470 milligrams
Sausage, Egg, & Cheese McGriddle: 1,300 milligrams

Published October 2006.

Reference Link:

http://www.webmd.com/diet/features/5-easy-ways-to-cut-back-on-salt

13 Food Gifts NOT to Give

2008-01-09T17:54:00.001+02:00

Considering an edible holiday present? Before you hit the mall, check out this list of food gifts it's best to avoid.

By Elaine Magee, MPH, RD
WebMD Weight Loss Clinic - Expert Column

We've all gotten them at one time or another: gifts of food that were disappointing or misguided, even comical. Sometimes it isn't the gift itself that doesn't work so much as the match between the gift and the recipient.

For example, I was the goofball who, with all the best of intentions, gave a Starbucks gift card to a music teacher at my daughter's school. It didn't occur to me that he might be a Mormon (see No. 7 in the list below).

Here's another example: I was once given dark chocolate as a gift, when anyone who knows me well knows that I prefer milk chocolate. (The giver in this instance happened to be my mother.)

So, with some personal experience and some tongue-in-cheek reflections on gifts from Christmases past, here is my list of 13 food gifts NOT to give:

Don't give sugar-free candies or chocolates to someone with IBS (irritable bowel syndrome) or other intestinal issues. The sugar replacement often used in these products is maltitol, which is only partially digested and absorbed. The part that isn't digested tends to ferment in the intestinal tract and attract water. To someone with diarrhea-predominant IBS, having a few pieces of these sugar-free goodies can cause some "intestinal issues". (As someone who has IBS, I can speak from sad experience.) We'll leave it at that.
Pay attention that you don't give tea with special properties to someone whom it might offend. The Republic of Tea, for example, makes "Get Lost" tea, described as "herb tea for weight control"; "Get it Going" tea (for regularity); and "Get Gorgeous" tea (for clear skin).
Be sure you don't give alcohol to someone who doesn't (or shouldn't) drink. Even if someone has consumed alcohol in the past, they may now be avoiding it for a number of possible reasons.
Don't give those tins of stale popcorn to pretty much anyone. If it isn't fresh, it isn't worth the calories.
Don't give fruitcake as a food gift, because all the fruitcake jokes known to man are bound to ensue moments after it is unwrapped.
Don't give a gift assortment of dark chocolates to someone who is passionate about milk chocolate (or vice versa). The same goes for giving cream-filled chocolates to someone who is wild about nuts and chews.
Don't give alcohol or anything with caffeine to a member of the Church of Jesus Christ of Latter-Day Saints. These items are not in line with their beliefs.
If you don't know the gift recipient all that well, avoid holiday processed meat gift packs (from gourmet catalogue companies) or other foods containing meat, in case your giftee is a vegetarian.
Don't give food gifts that include chocolate, peppermint or spearmint, garlic and onions, coffee, caffeinated tea, citrus, tomato products, or chili peppers, to someone who suffers from acid reflux.
Don't give any food containing pork or pork products, or that combines dairy with meat products, to someone who keeps kosher or observes Muslim dietary laws.
Don't give peanut brittle, caramel apples, or candy canes to people with braces. According to H. Dixon Taylor, DDS, an orthodontist in Concord, Calif., these are the three worst food gifts for someone with orthodontics. (And about 20% of Taylor's clients happen to be grown-ups.)
To that friend of yours who is working hard to lose extra pounds, don't give a gift card to The Cheesecake Factory.
Don't give chocolate-covered insects to people who might be "bugged" by it. I'm serious -- this actually happened to an acquaintance's mom, and she was definitely not amused!
Reference Link:
http://www.webmd.com/diet/features/13-food-gifts-not-to-give

New Weight Loss Drug Shows Promise

2008-01-09T17:53:00.001+02:00

Modest Weight Loss Seen in Some Patients Taking Taranabant

By Salynn Boyles
WebMD Medical News

Reviewed by Louise Chang, MD

Jan. 8, 2008 -- An experimental weight loss medication in the same class as the drug Acomplia helped patients lose weight in a 12-week, phase II study, but side effects were common at higher doses.

Like Acomplia (rimonabant), which is approved for sale in Europe but not in the U.S., the Merck & Co. drug taranabant targets receptors in the brain linked to appetite.

Concerns about reports of anxiety and depression in rimonabant users have kept the drug off the market in the U.S.

Based on these reports, an FDA advisory panel voted against recommending its approval last June, prompting manufacturer Sanofi-Aventis to withdraw its application to the agency.

Depression and anxiety were also reported in the taranabant study, but these side effects were most common at the highest doses given, researcher Steven Heymsfield, MD, of Merck Research Laboratories, tells WebMD.

Based on these findings, an ongoing phase III trial of taranabant does not include the highest doses used in phase II study.

Taranabant Trial

The double-blind study included 533 obese people randomly assigned to treatment with either placebo or 0.5 milligrams, 2 milligrams, 4 milligrams, or 6 milligrams of taranabant. All the participants received counseling on diet and exercise throughout the trial.

At the end of 12 weeks, the placebo-treated participants had lost the least weight and those treated with the highest dose of taranabant had lost the most.

Patients treated with 0.5 milligrams of the drug lost an average of 3.5 pounds, compared with 5 pounds among people treated with 2 milligrams of the drug and almost 9 pounds among those treated with 6 milligrams.

A total of 27% of patients who took 0.5 milligrams of taranabant lost 5% or more of their body weight, compared with 61% in the 6-milligram group.

But patients taking the higher dosages of the drug also had higher rates of side effects, including anxiety, nausea, and vomiting.

The study drop-out rate due to side effects was also twice as high among patients treated with the highest dosage of the drug, compared with the lowest dose (10.2% vs. 4.7%). But no patients dropped out because of serious events.

The study appears in the January issue of the journal Cell Metabolism.

Heymsfield says he was surprised to find that patients treated with the lowest dose of the drug lost weight.

"We didn't expect weight loss at all doses," he says.

Seeking FDA Approval

The ongoing phase III trial includes roughly 2,000 people being treated with taranabant at doses ranging from 0.5 milligrams to 2 milligrams, a Merck spokeswoman tells WebMD.

She adds that the plan is to petition the FDA for approval in the second half of this year if the phase III results prove promising.

A spokeswoman for Sanofi-Aventis says several phase III trials of rimonabant are also under way, and the findings could help address the FDA advisory panel's safety concerns about the drug.

Julissa Viana tells WebMD that the company will likely petition the FDA once again to approve the drug for sale in the United States.

"I can't speculate on when we will submit or what those indications [for use] will be," she says. "We are looking forward to the results of our ongoing trials."

Weight loss specialist Louis Aronne, MD, says the FDA may be more likely to approve the drug the second time around as safety issues are addressed.

Aronne directs the comprehensive weight control program at New York-Presbyterian/Weill Cornell Medical Center.

"Rimonabant is now approved in 51 countries, and it is being actively sold in 20," he says. "I think as time goes on and the evidence builds that this class of drugs has a manageable side effect profile, the FDA will become more comfortable with it."

Reference Link:

http://www.webmd.com/diet/news/20080108/new-weight-loss-drug-shows-promise

BRCA Breast Cancer Gene Risk Varies

2008-01-09T17:51:00.001+02:00

Odds of Breast Cancer Vary for Relatives of Breast Cancer Patients With BRCA1 and BRCA2 Gene Mutations

By Miranda Hitti
WebMD Medical News

Reviewed by Louise Chang, MD

Jan. 8, 2008 -- Scientists have some new clues about breast cancer risk among the sisters, daughters, and mothers ofsome breast cancer patients.

Those clues center on the BRCA1 and BRCA2 gene mutations, which make breast cancer and ovarian cancer more likely.

In a new study, nearly 1,400 women diagnosed with breast cancer before age 55 got BRCA1 and BRCA2 genetic tests. They were also asked if their mother, daughters, or sisters had ever been diagnosed with breast cancer.

The vast majority of the breast cancer patients had no BRCA1 or BRCA2 gene mutations.

But 5% of the patients who had had breast cancer in one breast and 15% of those who had had breast cancer in both breasts had BRCA1 or BRCA2 gene mutations. Their close female relatives were more likely to have had breast cancer than the relatives of patients without BRCA1 or BRCA2 gene mutations.

Age also mattered. Younger breast cancer patients were more likely to have a mother, daughter, or sister with a history of breast cancer.

Besides BRCA1 and BRCA2, other genes likely "play a major role" in the study's breast cancer risk variation, and environmental and lifestyle factors may also have been involved, write the researchers.

They included Colin Begg, PhD, of New York's Memorial Sloan-Kettering Cancer Center. Their study appears in the Jan. 9/16 issue of The Journal of the American Medical Association.

Reference Link:

http://www.webmd.com/breast-cancer/news/20080108/brca-breast-cancer-gene-risk-varies

Get to the Bottom of Your Sore Throat

2008-01-09T17:49:00.001+02:00

A scratchy throat can be more than just an annoyance. Experts offer tips for assessing your sore throat “threat level.”

By Tom Valeo
WebMD Feature

Reviewed by Louise Chang, MD

As a symptom of illness, sore throat rivals fatigue for being both commonplace and a potential sign of catastrophe. Usually, having a sore throat is nothing to worry about -- most are caused by cold and flu germs. In rare cases, however, a sore throat can signal something much more serious. One of the first symptoms of infection caused by the dreaded ebola virus, for example, is a sore throat.

And strep bacteria, a common cause of sore throat, especially in children, can spread like wildfire if it gets into the blood, damaging the liver, brain, kidneys, and other organs.

Jim Henson, creator of the Muppets, came down with a sore throat caused by a strep infection late Sunday, May 13, 1990. He was admitted to the hospital with pneumonia on Tuesday and died 20 hours later of septic shock, a life-threatening response to a severe infection.

"In the preantibiotic era, people died from sore throats all the time," says Robert T. Sataloff, MD, associate dean for clinical academic specialties at Drexel University College of Medicine in Philadelphia. "They'd end up with general toxicity and seed infections in the brain or lungs, and they'd die."

So how do you know the difference between a scratchy throat that will disappear on its own and the start of a potentially deadly infection?

Sore Throat Threat Level: Always "Guarded"

When it comes to sore throat, forget the "low" threat level. The symptom always merits "guarded" or even "elevated" alertness. Pay attention, but don't panic.

If you were talking loudly at a noisy, smoky bar, you may have strained your vocal cords, resulting in throat soreness. If you have hay fever, or if your allergies are acting up, that can make your throat feel scratchy. Even sleeping with your mouth open in the winter, when the air can get as dry as the Sahara, can cause a sore throat.

Even if your sore throat is caused by a viral infection, such as a cold or the flu, you probably can wait it out while drinking hot tea with honey and sucking on throat lozenges to ease the discomfort. Because most sore throats are caused by viruses that don't respond to antibiotics, there's not much you can do about them outside of resting so your immune system is strong and ready to fight the invaders.

"Wait a day, drink plenty of fluids, take pain medication if you'd like," Sataloff tells WebMD. "You might as well try vitamin C. The data are controversial, but vitamin C doesn't do any harm, and there's some suggestion that vitamin C and antioxidants may have some efficacy. These are not unreasonable things to do when helping your body fight off an infection, and that's what it has to do since we don't treat viral infections with antibiotics."

Some people with gastroesophageal reflux disease (GERD) may experience hoarseness with a sore throat, but this will probably be accompanied by other symptoms, such as heartburn or the sour reflux of stomach contents.

(Do you have a favorite sort throat remedy? Tell us about it on the Health Cafe message board.)

When Sore Throat Hits "High" Threat

If your sore throat is accompanied by an achy feeling all over and you have a fever, you should elevate your threat level to "high." You might want to go to the doctor for a throat culture to see if you have a strep infection, especially if you have been around children, who frequently harbor strep bacteria.

"A strep infection can be dangerous for adults or kids," Sataloff says. "The greatest dangers are local inflammation and rapid spread to the throat and adjacent structures like the tonsils and lymph tissues. They can swell and obstruct the airway, and the bacteria can get into the bloodstream and cause infections elsewhere, such as the heart valves."

Inflammation is what makes a sore throat sore, and the greater the inflammation, the greater the danger, Sataloff explains.

"Extreme" Sore Throat Threat: Know the Symptoms

Raise your threat level to "extreme" if you are having difficulty swallowing or breathing, or if you develop a high fever with painful swelling of your lymph nodes. That could indicate tonsillitis, mononucleosis, or some other potentially dangerous infection. These symptoms can also signal strep throat.

"A simple sore throat can cause lots of problems," Sataloff says.

Lemierre's syndrome, for example, is a rare disorder that begins with a fever and sore throat. Soon blood clots form in the jugular vein, and when these infected clots break away, they carry the infection to other parts of the body.

The good news is that prompt treatment can forestall almost all the serious consequences of sore throat.

"We don't see them very often because people get treated," Sataloff says of the life-threatening complications of sore throat. "And if they don't get treated and the sore throat gets worse, then they get treated."

Reference Link:

http://www.webmd.com/cold-and-flu/features/get-to-the-bottom-of-your-sore-throat

Children's Nightmares Less Common

2008-01-03T22:22:00.001+02:00

Nightmares Among Preschoolers Linked to Their Personality

By Jennifer Warner
WebMD Medical News

Reviewed by Louise Chang, MD

Jan. 3, 2008 -- Nightmares among young children may be less common than thought. A new study suggests most children's nightmares may be linked to the child's personality traits.

Researchers found most parents of preschoolers reported that their children had nightmares "never" or "sometimes," with less than 4% having nightmares "often" or "always."

The survey also showed that children with frequent nightmares were more likely to be considered anxious by their parents or to have a difficult temperament.

Researchers say the results show that young children with frequent nightmares are a lot like adults with frequent nightmares, who generally suffer from distress and other emotional problems.

Nightmares Tied to Personality Traits

In the study, published in the journal Sleep, researchers surveyed parents of 987 children in the Canadian Province of Quebec at ages 29 months, 41 months, 50 months, 5 years, and 6 years. Parents were asked about the frequency of their child's nightmares without having to assess whether the nightmares caused them to wake up during the night.

The results showed that less than 4% had nightmares often or always.

Researchers found children with risk factors for nightmares shared common traits that emerged as early as 5 months of age. For example, children with risk factors for nightmares:

Were more likely to have a difficult temperament as rated by their mother at 5 and 17 months old
Were more likely to be restless during the day at 5 and 17 months old
Were more likely to be anxious and difficult to calm at 17 months old

Protective factors included parents who provided emotional nurturing after children awoke from nightmares.

Researcher Valerie Simard, MSc,of the University of Montreal says the results suggest that carefully targeting early anxiety symptoms in young children may help prevent nightmares and other emotional issues.

reference link:

http://children.webmd.com/news/20080103/childrens-nightmares-less-common?src=RSS_PUBLIC

Hormones Delay Prostate Cancer Growth

2008-01-03T22:20:00.001+02:00

Short-Term Androgen Deprivation Therapy Has Long-Term Benefits

By Salynn Boyles
WebMD Medical News

Reviewed by Louise Chang, MD

Jan. 2, 2008 -- Short-term hormone therapy to lower testosterone levels can significantly delay the progression of prostate cancer in some patients treated with radiation, a study shows.

Just four months of androgen deprivation therapy (ADT) before and during radiation was found to slow cancer growth by as much as eight years in patients with high-risk, locally advanced disease. The patients had either declined or were not considered candidates for longer-term hormonal treatment, researcher Mack Roach III, MD, of the University of California San Francisco, tells WebMD.

The findings were reported today in the American Society of Clinical Oncology (ASCO) publication Journal of Clinical Oncology.

ADT and Heart Risk

The researchers also found no evidence of an increase in heart risk among the hormone-treated patients, compared with patients treated with radiation alone.

This finding should allay concerns about the treatment raised by a recent study, Roach tells WebMD.

In mid-October, Harvard researchers reported that short-term ADT prior to prostate cancer surgery was associated with a more than twofold increase in death from cardiovascular causes in men with localized disease.

That study did not include patients treated with ADT and radiation, and there is no clinical evidence of an increase in cardiovascular risk in these patients, Roach says.

"Our findings clearly show that the benefits [of short-term hormone treatment] outweigh the risks in this group of patients," Roach tells WebMD. "If there is an increase in heart attack risk, we didn't see it in this long-term follow-up."

8-Year Delay in Progression

The goal of ADT is to lower levels of the male sex hormones, which fuel the growth of prostate cancer.

Long-term hormone suppression of two years or more has been shown to improve survival in prostate cancer patients treated with radiation who are considered high risk due to high tumor burden, high prostate-specific antigen (PSA) scores, or other prognostic indicators.

But long-term ADT is also associated with an increased risk for osteoporosis, diabetes, and other health problems.

In an effort to assess the risks vs. benefits of shorter-term ATD, Roach and colleagues followed 456 older men with high-risk prostate cancer for 13 years.

Roughly half the men were treated with ADT for four months, immediately before and during radiation treatment. The rest of the patients were treated with radiation alone.

After about five years of follow-up, 40% of patients treated with radiation alone had cancer that had spread to the bones. It took an additional eight years for the same percentage of patients treated with ADT and radiation to develop bone metastases, says Roach.

Fewer prostate cancer deaths were reported in ADT-treated patients over 10 years of follow-up, and these men were also more likely to show no evidence of disease after 10 years.

Fatal cardiac events occurred in 12.5% of the ADT-treated patients, compared with 9.1% of the patients treated with radiation alone -- a difference that could have been due to chance.

"Men who took hormone therapy were 25% more likely to be alive after 10 years," Roach tells WebMD.

The findings confirm the long-term benefits of short-term ADT when combined with radiation, University of Michigan radiation oncology professor Howard Sandler, MD, tells WebMD.

"Even when hormone therapy is used for only four months, the benefits of hormones and radiation can last for many years," he says.

Sandler recommends two to three years of ADT for his highest-risk patients, but he says short-term hormone therapy appears adequate for patients at the higher end of the intermediate-risk scale.

reference link:

http://www.webmd.com/prostate-cancer/news/20080102/hormones-delay-prostate-cancer-growth?src=RSS_PUBLIC

Eye Health: LASIK Laser Eye Surgery

2007-12-30T09:10:00.001+02:00

Laser in-situ keratomileusis, or LASIK, is a popular surgical approach used to correct vision in people who are nearsighted, farsighted, or have astigmatism.

All laser vision correction surgeries work by reshaping the cornea, or clear front part of the eye, so that light traveling through it is properly focused onto the retina located in the back of the eye. LASIK laser eye surgery (laser in-situ keratomileusis) is one of a number of different surgical techniques used to reshape the cornea.

What Are the Advantages of LASIK Laser Eye Surgery?

LASIK laser eye surgery has many benefits, including:

It works! It corrects vision. Around 80% of patients will have their desired vision after LASIK laser eye surgery. An enhancement can further increase this number.
LASIK laser eye surgery is associated with very little pain.
Vision is corrected nearly immediately or by the next day after LASIK laser eye surgery.
Recovery is quick and usually no bandages or stitches are required after LASIK laser eye surgery.
Adjustments can be made years after LASIK laser eye surgery to further correct vision.
After having LASIK laser eye surgery, most patients no longer need corrective eyewear.

What Are the Disadvantages of LASIK Laser Eye Surgery?

Despite the pluses, there are some disadvantages:

Changes made to the cornea cannot be reversed after LASIK laser eye surgery.
Corrections can only be made by additional LASIK laser eye surgeries.
LASIK laser eye surgery is expensive, typically costing $2,200 to $2,250 per eye; though compared to the cost of glasses and contact lenses, the price is reasonable.
LASIK laser eye surgery is technically complex. Problems may occur when the doctor cuts the flap, which can permanently affect vision.
LASIK laser eye surgery can cause a loss of "best" vision with or without glasses at 1 year after surgery. Your best vision is the highest degree of vision that you achieved while wearing your contacts or eyeglasses.

What Are the Potential Side Effects of LASIK Laser Eye Surgery?

Some patients experience discomfort in the first 24-48 hours after surgery. Other side effects, although rare, may include:

Glare
Seeing halos around images
Difficulty driving at night
Fluctuating vision
Dry eyes

The FDA has found no long-term side effects from LASIK laser eye surgery.

How Should I Prepare for LASIK Laser Eye Surgery?

Before your LASIK laser eye surgery, you will meet with a coordinator who will discuss what you should expect during and after the surgery. During this session, your medical history will be evaluated and your eyes will be tested. Likely tests include measuring corneal thickness, refraction, and pupil dilation. Once you have gone through your evaluation, you will meet the surgeon, who will answer any further questions you may have. Afterwards, you can schedule an appointment for the procedure.

If you wear rigid gas permeable contact lenses, you should not wear them for three weeks before your surgery. Other types of contact lenses shouldn't be worn for at least three days prior to surgery. Be sure to bring your eyeglasses to the surgeon so your prescription can be reviewed.

On the day of your surgery, eat a light meal before going to the doctor, and take all of your prescribed medications. Do not wear eye makeup or have any bulky accessories in your hair that will interfere with positioning your head under the laser. If you are not feeling well that morning, call the doctor's office to determine whether the procedure needs to be postponed.

What Happens During LASIK Laser Eye Surgery?

During LASIK laser eye surgery, an instrument called a microkeratome is used to cut a thin flap in the cornea. The cornea is then peeled back and the underlying cornea tissue is reshaped using an excimer laser. After the cornea is reshaped so that it can properly focus light into the eye and onto the retina, the cornea flap is put back in place and the laser eye surgery is complete.

LASIK laser eye surgery is performed while the patient is under a local anesthesia and usually takes about 10 minutes to complete.

What Should I Expect After LASIK Laser Eye Surgery?

Healing after LASIK laser eye surgery usually occurs very rapidly. Most patients notice improved vision within a few days after LASIK laser eye surgery. However, your vision may be blurry and hazy for the first day. You should plan to have someone drive you home after LASIK laser eye surgery.

Your eyes will be dry even though they do not feel that way. Your doctor will give you prescription eye drops to prevent infection and keep your eyes moist. These eye drops may cause a momentary slight burn or blurring of your vision when you use them. Do not use any eye drops not approved by your ophthalmologist. Specific follow-up after the surgery varies from one surgeon to another. You will revisit the doctor for an evaluation 24-48 hours after LASIK laser eye surgery, as well as at regular intervals within the first six months after surgery.

Reviewed by the doctors at The Cleveland Clinic Cole Eye Institute (2005).

Reference Link:

http://www.webmd.com/eye-health/lasik-laser-eye-surgery

Peanut Allergies Striking Sooner

2007-12-30T09:07:00.001+02:00

Despite Warnings, Kids Being Exposed to Peanuts at Earlier Age

By Jennifer Warner
WebMD Medical News

Reviewed by Louise Chang, MD

Dec. 3, 2007 -- Children are developing potentially dangerous peanut allergies at a much younger age, according to a new study.

And that's not all: The study researchers found more parents are feeding their children peanuts at an earlier age.

"This should be a wake-up call to all parents of young children," says researcher Wesley Burks, MD, chief of pediatric allergy and immunology at Duke University Medical Center, in a news release. "Kids are being exposed to peanuts and having allergic reactions much earlier than they did five or 10 years ago."

About 1.8 million Americans are allergic to peanuts, and researchers say the number of peanut allergies diagnosed in children has doubled in the last decade. They say these results suggest earlier exposure to peanuts may be a major factor behind that rapid increase.

"There's a valid reason to delay introduction to products containing peanuts," says researcher Todd D. Green, MD, assistant professor of pediatrics at Children's Hospital of Pittsburgh, in the release. "When kids are older, it can be easier to manage bad reactions. They can tell you right away if their mouths feel funny. For that reason alone, it's worth delaying exposing your child to a peanut product, especially if a child is at high risk."

The American Academy of Pediatrics recommends that parents not give peanuts to children until age 3 if there is a strong history of allergies in the family.

Peanut Allergies Showing Up Earlier

Researchers compared statistics on children diagnosed with peanut allergies at a Duke University clinic between July 2000 and April 2006 with similar-age children diagnosed between 1995 and 1997.

The results, published in Pediatrics, showed the average age of first exposure to peanuts was 14 months in 2000-2006 compared with 22 months five to 10 years earlier.

The age of first peanut allergy reaction also decreased from about 24 months in 1995-1997 to 18 months in 2000-2006. Many of the children with peanut allergy also had other food allergies such as allergies to eggs, cow's milk, nuts, fish, soy, wheat, and sesame seeds.

Researchers say as many as one-third of people with peanut allergies have severe reactions that can be fatal.

Reference Link:

http://www.webmd.com/allergies/news/20071203/peanut-allergies-striking-sooner

Skin Conditions: Cysts, Lumps and Bumps

2007-12-30T09:05:00.001+02:00

There are a number skin conditions that cause lumps and bumps to appear on the surface of the skin or just below the skin. This article covers some of the most common ones, and includes the following:

Skin cysts
Cherry angioma
Dermatofibromas
Epidermoid cysts
Folliculitis
Keratoacanthoma
Keratosis pilaris
Lipomas
Neurofibromas

Skin Cysts

Cysts are noncancerous, closed pockets of tissue that can be filled with fluid, pus, or other material.

Cysts are common on the skin and can appear anywhere. They feel like small peas under the surface of the skin. Cysts can develop as a result of infection, clogging of sebaceous glands (oil glands), or around foreign bodies, such as earrings.

What Are the Symptoms of Skin Cysts?

Skin cysts usually are:

Slow-growing
Painless
Smooth to the touch when they are rolled under the skin

How Are Skin Cysts Treated?

Cysts usually do not cause pain unless they rupture or become infected or inflamed. Some cysts disappear on their own without treatment. Other cysts may need to be drained. That involves piercing the cyst with a sharp object and draining it. Some inflamed cysts can be treated with an injection of cortisone medication to cause it to shrink. Cysts that do not respond to other treatments or reoccur can be removed surgically.

Cherry Angioma

A cherry angioma is a smooth, cherry-red bump on the skin.

Although cherry angiomas usually appear on the trunk of the body, they can occur nearly anywhere. The cause of cherry angiomas is not known and the growths usually appear on people over the age of 40.

What Are the Symptoms of Cherry Angiomas?

Cherry angiomas are small, bright red growths that are smooth. The size of the growths can vary from the size of a pinhead to about a quarter inch in diameter.

How Is a Cherry Angioma Treated?

In most cases, cherry angiomas do not require treatment. If they are cosmetically unappealing or are subject to bleeding, angiomas may be removed by lasers or electrocautery -- the process of burning or destroying tissue by use of a small probe with an electric current running through it. Removal may cause scarring.

Dermatofibromas

Dermatofibromas are harmless round, red-brownish skin growths that are most commonly found on the arms and legs. Dermatofibromas contains scar tissue and feel like hard lumps in the skin.

The cause of dermatofibromas is not known.

What Are the Symptoms of Dermatofibromas?

The symptoms of dermatofibromas include:

A red, brown or purple growth that can change colors over time
A growth that is as small as a BB pellet
Tenderness, pain and itching; however, growths also can be painless
A dimple that appears when the growth is pinched

How Are Dermatofibromas Treated?

In most cases, there is no need to treat dermatofibromas. However, the growths can be removed surgically or can be flattened by being frozen with liquid nitrogen.

Epidermoid Cysts

Epidermoid cysts, also called sebaceous cysts, are benign (non-cancerous) skin cysts formed from blocked oil glands in the skin. Most commonly, epidermoid cysts are found on the genitals, trunk and back; but, they also can occur in other areas of the skin.

What Are the Symptoms of Epidermoid Cysts?

In general, epidermoid cysts have a round appearance. A dark portion of the cyst is visible on the skin. If the cysts become infected, they will become red and tender. When the cysts are squeezed, they can produce a cheesy white discharge.

How Are Epidermoid Cysts Treated?

The effective treatment of epidermoid cysts requires that the sac of the cyst be completely removed. If the cyst is squeezed and the discharge is forced out, the cyst will reappear in the skin. Usually, a doctor will be able to remove the cyst by making only a small incision in the skin. Antibiotics may be prescribed to treat infected cysts.

Folliculitis

Folliculitis is an inflammation of the hair follicles. It can be caused by an infection in the hair follicles, by chemical irritation or by physical irritation (for example, shaving or friction from clothing). Typical body sites that are involved in folliculitis include the face, thighs and scalp.

Folliculitis is more common in people who have diabetes mellitus. It also is more common in people who are obese or have compromised immune systems.

What Are the Symptoms of Folliculitis?

The main lesion in folliculitis is a papule or pustule with a central hair. The hair shaft in the middle of the lesion may not be seen.

Other symptoms include:

Multiple red pimples and/or pustules on hair-bearing areas of the body
A rash
Itching skin

How Is Folliculitis Treated?

Topical antibiotics, oral antibiotics or antifungal medications may be used to treat infections associated with folliculitis. Treatment also involves preventing further damage to the hair follicles. Steps that can help achieve this goal include:

Minimizing friction from clothing
Not shaving in the affected area, if possible. If shaving is necessary, use a clean new razor blade or an electric razor each time.
Keeping the area clean

Keratoacanthoma

A keratoancanthoma occurs when cells in a hair follicle do not grow normally. The growth apparently is triggered by a minor skin injury in an area that previously had suffered sun damage. Ultraviolet radiation from sun exposure is the biggest risk factor in keratoacanthomas.

A keratoacanthoma usually will appear on sun-damaged skin as a thick growth that has a central crusted plug.

Keratoacanthomas appear most often in people who are over the age of 60.

What Are the Symptoms of a Keratoacanthoma?

Keratoacanthomas are rapidly growing, red, dome-shaped bumps with central craters. Some keratoacanthomas can grow to extremely large sizes, occasionally 3 to 6 inches in diameter.

How Are Keratoacanthomas Treated?

Keratoacanthomas can be removed by:

Cryotherapy (freezing the growth with liquid nitrogen)
Curettage (cutting out or scraping off the growth)

Keratosis Pilaris

Keratosis pilaris (commonly called KP) appears as "chicken skin bumps" on the skin. These bumps usually appear on the upper arms and thighs. They also can appear on the cheeks, back and buttocks. Keratosis pilaris, while unattractive, is harmless.

What Are the Symptoms of Keratosis Pilaris?

This disorder appears as small, rough bumps. The bumps are usually white or red, but do not itch or hurt. Keratosis pilaris is usually worse during the winter months or other times of low humidity when skin becomes dry. It also may worsen during pregnancy or after childbirth.

How Is Keratosis Pilaris Treated?

Although the condition may remain for years, it gradually disappears before age 30 in most cases. Treatment of keratosis pilaris is not medically necessary; but, individuals with this condition may want to seek treatment for cosmetic reasons.

The initial treatment of keratosis pilaris should be intensive moisturizing. A cream such as Acid Mantle, Vaseline or Complex 15 can be applied after bathing, and then re-applied several times a day. Other treatments may include:

Medicated creams containing urea (Carmol-20) or alpha-hydroxy acids (Aqua Glycolic, Lacticare) applied twice daily
Efforts to unplug pores by taking long, hot soaking tub baths and then rubbing the areas with a coarse washcloth or stiff brush

Lipomas

Lipomas are subcutaneous soft tissue tumors or nodules that usually are slow-growing and are considered benign (not harmful). They have a firm, rubbery consistency. Lipomas tend to form on the trunk, shoulders, neck, but can appear elsewhere on the body.

What Are the Symptoms of Lipomas?

Lipomas can appear as solitary nodules or in groups. Most lipomas are less than 5 cm in diameter and are asymptomatic, but they can cause pain when they compress nerves.

How Are Lipomas Treated?

Lipomas are not removed unless there is a cosmetic concern, a compression of surrounding structures, or an uncertain diagnosis. Lipomas generally do not infiltrate into surrounding tissue so they can be removed easily during excision.

An alternative to standard excision is to manually squeeze the lipoma through a small incision. This technique is useful in areas with thin dermis, such as the face and extremities. Liposuction-assisted lipectomy also can be used to remove large lipomas with minimal scarring.

Neurofibromas

Neurofibromas are soft, fleshy growths that occur on or under the skin, sometimes even deep within the body. These are benign (harmless) tumors; however, they can turn malignant or cancerous in rare cases.

What Are the Symptoms of Neurofibromas?

The symptoms of neurofibromas may vary, depending on the locations and the sizes of the tumors. Symptoms can include:

A painless, slow-growing mass
Occasional pain
Electric-like "shock" when the affected area is touched
Neurological problems if the tumor involves a major motor or sensory nerve or a nerve that is compressed between the tumor and a hard structure

How Are Neurofibromas Treated?

If the tumor is not causing any symptoms, no treatment may be necessary. However, doctors may choose to surgically remove the neurofibroma if it is affecting a major nerve. In most cases, neurofibromas are treated successfully and do not recur.

Reviewed by doctors at The Cleveland Clinic Department of Dermatology.

Reference Link:

http://www.webmd.com/skin-problems-and-treatments/guide/cysts-lumps-bumps

Cosmetic Procedures: Laser Tattoo Removal

2007-12-30T09:02:00.001+02:00

It is estimated that close to 10% of the U.S. population has some sort of tattoo. Eventually, as many as 50% of them want to have laser tattoo removal.

There is good news for those who have an unwanted body design. Newer laser tattoo removal techniques can eliminate your tattoo with minimal side effects. Here's how it works: lasers remove tattoos by breaking up the pigment colors of the tattoo with a high-intensity light beam.

Black tattoo pigment absorbs all laser wavelengths, making it the easiest to treat. Other colors can only be treated by selected lasers based upon the pigment color.

Who Can Benefit From Laser Tattoo Removal?

Because each tattoo is unique, removal techniques must be tailored to suit each individual case. In the past, tattoos could be removed by a wide variety of methods but, in many cases, the scars were more unsightly than the tattoo itself.

Patients with previously treated tattoos may also be candidates for laser therapy. Tattoos that have not been effectively removed by other treatments or through home remedies may respond well to laser therapy providing the prior treatments did not result in excessive scarring.

How Do I Find a Reputable Doctor to Do Laser Tattoo Removal?

You want to make sure you find a reputable dermatologist or cosmetic surgery center to ensure proper treatment and care. If possible, you should obtain a recommendation from your family physician for a dermatologist or skin surgery center that specializes in tattoo removal.

What Can I Expect During the Laser Tattoo Removal?

Depending on the size and color of your tattoo, the number of treatments will vary. Your tattoo may be removed in two to four visits, though many more sessions may be necessary. You should schedule a consultation, during which time a trained professional will evaluate your personal situation and advise you on the process.

Treatment with the laser varies from patient to patient depending on the age, size and type of tattoo (amateur or professional). The color of the patient's skin, as well as the depth to which the tattoo pigment extends, will also affect the removal technique.

In general, this is what will happen during an office visit for tattoo removal using the newer lasers:

Protective eye shields are placed on the patient.
The skin's reaction to the laser is tested to determine the most effective energy for treatment.
The treatment itself consists of placing a hand piece against the surface of the skin and activating the laser light. As many patients describe it, each pulse feels like a grease splatter or the snapping of a rubber band against the skin.
Smaller tattoos require fewer pulses while larger ones require more. In either case, the tattoo requires several treatments and multiple visits. At each treatment, the tattoo should become progressively lighter.
Immediately following treatment, an ice pack is applied to soothe the treated area. The patient will then be asked to apply a topical antibiotic cream or ointment. A bandage or patch will be used to protect the site and it should likewise be covered with a sun block when out in the sun.

Most patients do not require any anesthesia. However, depending on the location of the tattoo and the pain threshold for the patient, the physician may elect to use some form of anesthesia (topical anesthesia cream, painkiller injections at the site of the procedure).

What Are The Possible Side Effects?

There are minimal side effects to tattoo removal by lasers. However, you should consider these factors in your decision:

The tattoo removal site is at risk for infection. You may also risk lack of complete pigment removal, and there is a slight chance that the treatment can leave you with a permanent scar.
You may also risk hypopigmentation, where the treated skin is paler than surrounding skin, or hyperpigmentation, where the treated skin is darker than surrounding skin.
Cosmetic tattoos like lip liner, eyeliner and eyebrows may darken following treatment with tattoo removal lasers. Further treatment of the darkened tattoos usually results in fading.

Is Laser Tattoo Removal Safe?

Thanks to newer technology, treatment of tattoos with laser systems has become much more effective with very little risk of scarring. Laser treatment is often safer than many traditional methods such as excision, dermabrasion or salabrasion (using moist gauze pads saturated with a salt solution to abrade the tattooed area) because of its unique ability to selectively treat pigment involved in the tattoo.

In many cases, certain colors may be more effectively removed than others. It is known that blue/black tattoos respond particularly well to laser treatment -- the response of other colors is under investigation.

Remember, the information provided here is designed to provide general information only and is not a replacement for a physician's advice. For details pertaining to your specific case, please arrange a consultation with a physician experienced in the use of tattoo lasers.

Does Insurance Cover Laser Tattoo Removal?

Since tattoo removal is a personal option in most cases and is considered a cosmetic procedure, most insurance carriers will not cover the process unless it is medically necessary. Physicians or surgery centers practicing tattoo removal may also require payment in full on the day of the procedure. If you are considering tattoo removal, be sure to discuss associated costs up front with the physician, and obtain all charges in writing before you undergo any treatment.

Reviewed by the doctors at The Cleveland Clinic, Department of Dermatology.

Aspirin Limits Prostate Cancer Therapy

2007-12-30T08:54:00.001+02:00

Daily Aspirin May Make Prostate Cancer Hormone Treatment Intolerable

By Daniel J. DeNoon
WebMD Medical News

Reviewed by Louise Chang, MD

Dec. 26, 2007 -- Men with prostate cancer may have to quit hormone therapy -- upping their death risk -- if they take aspirin, a small study suggests.

Regular aspirin helps many men avoid heart attacks and stroke. But it also takes a toll on the liver for some.

That's not a problem for most men. But men with prostate cancer often need hormone therapy to suppress the male hormones that speed the growth of their cancers.

The powerful drugs used to suppress male hormones include the anti-androgen drug Eulexin. Eulexin can be toxic to the liver. Doctors discontinue treatment if patients have abnormal liver-function tests.

Dana-Farber Cancer Institute researcher Anthony V. D'Amico, MD, PhD, and colleagues enrolled 206 men with high- or intermediate-risk prostate cancer in a six-month study. Half the men got hormone therapy including Eulexin, and half got radiation therapy alone.

Abnormal liver-function tests forced some of the men to quit Eulexin treatment before they could finish the six-month study. This happened to 37% of men taking aspirin, but only to 16% of the men not taking aspirin.

As it turned out, the men who got radiation therapy alone were 6.1 times more likely to die than men who finished six months of hormone therapy (and also got radiation therapy). Those who had to stop taking Eulexin were 3.5 times more likely to die than men who finished six months of hormone therapy.

It's not clear what would have happened to the men if they had stopped taking aspirin. But D'Amico and colleagues warn doctors that aspirin can make cancer treatment harder to tolerate.

The warning comes in a letter published in the Dec. 27 issue of the New England Journal of Medicine.

Reference Link:

http://www.webmd.com/prostate-cancer/news/20071226/aspirin-limits-prostate-cancer-therapy

Sinusitis: Causes and Treatments

2007-12-30T08:53:00.001+02:00

Sinusitis is an inflammation, or swelling, of the tissue lining the sinuses. Normally, sinuses are filled with air, but when sinuses become blocked and filled with fluid, germs (bacteria, viruses and fungi) can grow and cause an infection.

Conditions that can cause sinus blockage include the common cold, allergic rhinitis (swelling of the lining of the nose), nasal polyps (small growths in the lining of the nose) or a deviated septum (a shift in the nasal cavity).

There are different types of sinusitis, including:

Acute sinusitis: A sudden onset of cold-like symptoms such as runny nose, stuffy nose and facial pain that does not go away after 7-10 days. Acute sinusitis typically lasts 4 weeks or less.
Subacute sinusitis: An inflammation lasting 4 to 8 weeks.
Chronic sinusitis: A condition characterized by sinus inflammation symptoms lasting 8 weeks or longer.
Recurrent sinusitis: Several attacks within a year.

Who Gets Sinusitis?

About 37 million Americans suffer from at least one episode of sinusitis each year. People who have the following conditions have a higher risk of sinusitis:

Nasal mucous membrane swelling as from a common cold
Blockage of drainage ducts
Structure differences that narrow the drainage ducts
Conditions that result in an increased risk of infection such as immune deficiencies or taking medications that suppress the immune system.

In children, common environmental factors that contribute to sinusitis include allergies, illness from other children at day care or school, pacifiers, bottle drinking while lying on one's back, and smoke in the environment.

In adults, the contributing factors are most frequently infections and smoking.

What Are the Signs and Symptoms of Acute Sinusitis?

The primary symptoms of acute sinusitis include:

Facial pain/pressure
Nasal stuffiness
Nasal discharge
Loss of smell
Cough/congestion

Additional symptoms may include:

Fever
Bad breath
Fatigue
Dental pain

Acute sinusitis may be diagnosed when a person has two or more symptoms and/or the presence of thick, green or yellow nasal discharge.

What Are the Signs and Symptoms of Chronic Sinusitis?

People with chronic sinusitis may have the following symptoms for 8 weeks or more:

Facial congestion/fullness
A nasal obstruction/blockage
Pus in the nasal cavity
Fever
Nasal discharge/discolored postnasal drainage

Additional symptoms may include:

Headaches
Bad breath
Fatigue
Dental pain

How Is Sinusitis Diagnosed?

To diagnose sinusitis, your doctor will review your symptoms and give you a physical examination.

The exam may include the doctor feeling and pressing your sinuses for tenderness. He or she may also tap your teeth to see if you have an inflamed paranasal sinus.

Other diagnostic tests may include a study of the mucus culture, nasal endoscopy (see below), X-rays, allergy testing, CT scan of the sinuses, or bloodwor

What Is Nasal Endoscopy?

A nasal endoscope is a special tube-like instrument equipped with tiny lights and cameras used to examine the interior of the nose and sinus drainage areas.

A nasal endoscopy allows your doctor to view the accessible areas of the sinus drainage pathways. Your nasal cavity may first be numbed using a local anesthetic (some cases do not require any anesthetic). A rigid or flexible endoscope is then placed in position to view the middle bone structure of the nasal cavity.

The procedure is used to observe signs of obstruction as well as detect nasal polyps hidden from routine nasal examination. During the endoscopic examination, the doctor also looks for any structural abnormalities that would cause you to suffer from recurrent sinusitis.

How Is Sinusitis Treated?

Treatment for sinusitis depends on the severity.

Acute sinusitis. If you have a simple sinus infection, your health care provider may recommend treatment with decongestants like Sudafed and steam inhalations alone. Use of nonprescription decongestant nasal drops or sprays may also be effective in controlling symptoms. However, these medicines should not be used beyond their recommended use, usually four to five days, or they may actually increase congestion.If antibiotics are administered, they are usually given for 10 to 14 days. With treatment, the symptoms usually disappear and antibiotics are no longer required.
Chronic sinusitis. Warm moist air may alleviate sinus congestion. A vaporizer or inhaling steam from a pan of boiling water (removed from heat) may also help. Warm compresses are useful to relieve pain in the nose and sinuses. Saline nose drops are also safe for home use. Use of nonprescription decongestant nasal drops or sprays might be effective in controlling symptoms, however, they should not be used beyond their recommended use. Antibiotics may also be prescribed.

Other Treatment Options

To reduce congestion, your doctor may prescribe nasal sprays (some may contain steroid sprays), nose drops or oral decongestant medicine. If you suffer from severe chronic sinusitis, oral steroids might be prescribed to reduce inflammation -- usually only when other medications have not worked. Antibiotics will be prescribed for any bacterial infection found in the sinuses (antibiotics are not effective against a viral infection). An antihistamine may be recommended for the treatment of allergies. Antifungal medicine may be prescribed for a fungal sinus infection. Immunoglobulin (antibodies) may be given if you have certain immune deficiencies.

Will I Need to Make Lifestyle Changes?

Smoking is never recommended, but if you do smoke, you should refrain during treatment for sinus problems. No special diet is required, but drinking extra fluids helps to thin secretions.

Is Sinus Surgery Necessary?

Mucus is developed by the body to moisten the sinus walls. In the sinus walls, the mucus is moved across tissue linings toward the opening of each sinus by millions of cilia (a hair-like extension of a cell). Irritation and swelling from an allergy can narrow the opening of the sinus and block mucus movement. If antibiotics and other medicines are not effective in opening the sinus, surgery may be necessary. Also, if there is a structural abnormality of the sinus such as nasal polyps, which can obstruct sinus drainage, surgery may be needed.

Surgery is performed under local or general anesthesia using an endoscope. Most people can return to normal activities within five to seven days following surgery. Full recovery usually takes about four to six weeks.

A procedure called a "turbinectomy" may also be performed to permanently shrink the swollen membranes of the nose. This is done in the doctor's office and takes only a few minutes. The anesthetic used is very similar to that used in routine dental procedures.

What Happens If Sinusitis Is Not Treated?

Delaying treatment for sinusitis will result in suffering from unnecessary pain and discomfort. In rare circumstances, untreated sinusitis can lead to meningitis or brain abscess and infection of the bone.

Reviewed by the doctors at The Cleveland Clinic Department of Pulmonary, Allergy and Critical Care Medicine.

Reference Link:

http://www.webmd.com/allergies/guide/allergies-sinusitis

Breathe Easily: Winter Asthma Advice

2007-12-30T08:50:00.001+02:00

People with asthma need extra TLC during cold and flu season. WebMD goes to the experts for advice on staying healthy all winter long.

By Colette Bouchez
WebMD Feature

Reviewed by Louise Chang, MD

As winter weather rolls in, so do colds and flu. But for those with asthma, it can be an especially stressful time of year because even a simple cold virus can trigger a major asthma event.

"In asthma, the lungs are already irritable and more reactive. So any virus that impacts the lungs has a propensity for creating more problems, including bringing on an asthma event faster and easier than many people realize," says Jonathan Field, MD, director of the Allergy and Asthma Clinic at NYU Medical Center/Bellevue Hospital in New York City.

And that, experts tell WebMD, is more likely to happen during the fall and winter months. In one study published in the Journal of Allergy and Clinical Immunology in 2005, researchers identified what they came to call the "September epidemic," an upswing in the number of children admitted to emergency rooms for the treatment of acute asthma symptoms in the fall months.

The study concluded that one reason behind the increase was the start of the school season -- and a greater exposure to cold and flu viruses.

While you or your child may not be able to avoid these exposures, there are ways to stay safe and healthy. Among the most important: Take control of your winter asthma symptoms before other problems occur.

This simple tenet is so important that in new guidelines set down by the National Heart, Lung and Blood Institute (NHLBI) in August 2007, doctors put special emphasis on the need to encourage better day-to-day symptom control.

"Asthma affects over 22 million Americans, including 6.5 million children, but there is one truth: Asthma control is achievable for nearly every patient ... As health care providers, we should accept nothing less," NHLBI Director Elizabeth G. Nabel, MD, said when the new guidelines were introduced.

A good way to gain control is to become more vigilant about taking your regular asthma medications.

"This is especially [important] in patients who have been noncompliant with their asthma regimens in the past," says Len Horovitz, MD, a pulmonary specialist at Lenox Hill Hospital in New York City.

Because many patients feel better in warm weather, by the time fall and winter roll around they may see less of a need to take the drugs designed to control their asthma symptoms. But this, says Field, is a huge mistake.

"If there is any time of the year to be more compliant about your medication, it's certainly the start of the winter season," he says.

The new NHLBI report recommends the use of daily inhaled corticosteroid medications to prevent problems in young children during cold and flu season.

Your Winter Asthma Action Plan

Another way to avoid problems -- during the winter or anytime -- is to create and stick to an asthma action plan. This is an organized system of care that can help you triage your symptoms in the event a problem does occur.

According to the American Lung Association, your plan should include not only a list of the asthma triggers you need to avoid, but also the specific symptoms you need to be on the lookout for, such as coughing, wheezing, or shortness of breath

People with asthma need extra TLC during cold and flu season. WebMD goes to the experts for advice on staying healthy all winter long.

(continued)

Your Winter Asthma Action Plan continued...

The plan should also list your regular medications, the symptoms they control, and most important, what to do and what to take in the event of an asthma emergency.

"You should always have on hand one or more fast-acting medications, drugs you know you can take for immediate relief," says Field.

You should also make a habit of using your peak flow meter. This is a device designed to monitor how well your asthma is doing. It measures your ability to forcefully expel air from the lungs, and experts say using one regularly can help you head off a potential crisis regardless of the season.

"By remaining aware of your peak flow meter readings on a regular basis, you will know when you are headed for trouble before you get there. And that means your doctor can prescribe additional medications, such as steroids, to offset any major asthma events before a cold or flu has a chance to take hold," says Susan Zafarlotfi, PhD, clinical director of the Breath and Lung Institute, Hackensack University Medical Center in New Jersey.

The American Lung Association also advises patients to classify their peak flow meter readings and their symptoms into three zones -- and use them as a guide to determine how well your asthma is under control.

The three zones are:

Green Zone: Peak flow reading of 80%-100% of your usual "personal best" peak flow reading. The green zone indicates good asthma control.
Yellow Zone: Peak flow reading of 50%-80% of your usual peak flow reading. This indicates that your asthma control is not optimal. You may or may not notice symptoms such as cough or wheezing. Your asthma needs to be addressed according to the asthma action plan set up by you and your doctor.
Red Zone: Peak flow reading of less than 50% of your usual reading. This indicates poor asthma control needing rescue medications. Make sure to follow your asthma plan regarding use of rescue drugs and seeking medical attention.

Particularly during cold and flu season, the American Lung Association recommends that you strive to remain in the green zone and contact your doctor as soon as you begin dropping into the yellow zone.

Asthma and Cold Medicines: What You Should Know

If you do find yourself with a cold or the flu, there is an abundance of over-the-counter medications that can help. But experts advise asthma patients to take some extra precautions and talk to their doctor before deciding what treatment to use. The reason: some over-the-counter medications can be harmful.

"Decongestants, for instance, can cause palpitations when used with bronchodilators [a standard asthma medication], and even anti-inflammatory drugs other than acetaminophen may cause additional asthma symptoms," says Horovitz.

Field adds that you might want to avoid all cold medicines containing pseudoephedrine, a common ingredient in decongestants and multi-symptom products.

"There are some studies to show it may dry out the passages, and though it's still a matter of debate, there is definitely some data showing that this effect may lead to a worsening of asthma symptoms," he says.

Pharmacy professor Nick Popovitch, PhD, agrees. "When you have asthma, you don't want to use anything that could impact air passages in a negative way. You don't want to use any drug that has a drying effect, because hydration is key for controlling symptoms," says Popovitch, a professor of pharmacy administration and a department head at the University of Illinois at Chicago College of Pharmacy.

So what, if anything, can you safely use? Both Field and Popovitch suggest talking to your doctor about local treatment with a nasal spray. Field says if your doctor agrees, you can try either a decongestant nasal spray or a plain saline nasal spray for relief.

Horovitz favors home remedies like a vaporizer or humidifier to hydrate the air and help make breathing easier.

Perhaps most important: All the experts WebMD talked to warn never to depend on any cold or flu medicine to control your asthma symptoms.

"Your regularly scheduled asthma treatments remain the backbone plan for keeping symptoms under control. Think of it as wearing a seatbelt or tying your shoes. And they should not be skipped or missed, regardless of what else you may be doing to treat your cold or flu," Field says.

Winter Asthma Rescue Remedies

Even if you follow all the rules, a cold or flu can still cause asthma symptoms to spin out of control. For this reason, it's essential to be prepared with a rescue emergency kit -- and know how to use it.

"For patients with asthma, the weakest time is usually between 3 and 4 in the morning. So if you have a cold or the flu, it's essential that you keep a rescue inhaler next to your bed and know how to best use it for your symptoms," says Zafarlotfi. The inhaler can contain any number of fast-acting medications that work immediately to open up the airways and make it easier to breathe.

She also advocates talking to your doctor about other types of medications, such as corticosteroids, that can be used in an emergency, and whether or not you need to have those on hand during cold and flu season.

Field also suggests talking to your doctor about using a nebulizer treatment before bedtime. This is a device that changes liquid asthma medication into a fine mist so it can be easily inhaled. If a cough is keeping you up a night, he says a nebulizer treatment before bedtime can open the lungs and help you feel more comfortable.

Finally, experts tell WebMD, you may also find some measure of relief via natural cold and flu remedies, including hot tea with honey, a bowl or two of chicken soup, drinking plenty of fluids (non-alcoholic), and sleeping with your head elevated.

"But regardless of what you do," Field adds, "if you don't see an improvement within 48 hours, if cold symptoms worsen, or if your asthma symptoms are increasing, don't wait -- call your doctor."

Reference Link:

http://www.webmd.com/asthma/features/breathe-easy-winter-asthma-advice?

What's Ahead for Health in 2008

2007-12-30T08:47:00.001+02:00

Experts predict medical trends in the new year.

By Denise Mann
WebMD Feature

Reviewed by Louise Chang, MD

From the development of a new source of stem cells and the availability of the over-the-counter weight loss drug Alli to the emergence of a strain of drug-resistant Staphylococcus aureus bacteria, 2007 heralded some major medical advances along with its share of setbacks. We have likely not heard the end of these stories, but experts from different fields of medicine are sharing their predictions about what we will be seeing more -- or less of -- in 2008. By and large, 2008 will be a year where medicine takes baby steps toward eradicating diseases like cancer and makes a dent in burgeoning epidemics such as diabetes and obesity.

Cancer: More Targeted Therapies

Will 2008 be the year we cure cancer? "Absolutely not," says Otis Brawley, MD, the chief medical officer at the American Cancer Society in Atlanta. But that's not to say that it won't be a banner year in the war against cancer.

For example, 2008 may usher in some more targeted cancer therapies. These therapies interfere with specific molecules involved in the process by which normal cells become cancerous. "We will see more drugs like this come out that prolong life by months, but not by years," he says. "I wish I could say there will be this great study with this great drug, but we are just not there yet."

But it's not all gloom and doom. "We cure a substantial number of people who have cancer today," Brawley says. "We really need to start publishing the numbers of people whose lives have been saved. One-third of people with cancer survive long term and are technically cured and that's a far higher proportion than 25 years ago. We need to develop a little more optimism about cancer."

Other questions that should be answered definitively in 2008 are whether or not prostate cancer screening and screening for lung cancer with spiral computed tomography (CT) scans save lives, he predicts. Both tests are considered controversial because they may have inaccurate results, and it is not clear if the benefits of screening outweigh the risks of any follow-up diagnostic tests and cancer treatments.

"We are also going to learn more about how medications that treat anemia caused by chemotherapy can be appropriately used and how they should not be used," Brawley says.

Recently some research has shown that these drugs, which stimulate red blood cell production, may actually promote tumor growth and/or cause blood clots. "We are going to learn more about how to use these drugs," Brawley says. "They do have a place in oncology, but they have been overused."

Diabetes: Is the Epidemic Finally Over?

The diabetes epidemic may plateau in 2008, predicts John Buse, MD, PhD, chief of the division of endocrinology at the University of North Carolina in Chapel Hill and the president of medicine and science at the American Diabetes Association.

"We are starting to see early hints that the extremely rapid increase in the numbers of people with diabetes may have turned the corner," he says. "I do think that things are improving relatively rapidly."

As for "diabesity," the converging epidemic of obesity and diabetes, "people are individually and personally trying to make efforts, at least in segments of the population, so there is reason to hope things will be better in 2008 than in 2007."

There probably won't be any new diabetes drugs in 2008, Buse says, and fewer patients will be using a class of drugs known as glitazones. In 2007, one such drug, Avandia, was linked to an increased risk for heart attack in people with diabetes.

Inhaled insulin hit a snafu in 2007 when Pfizer announced that it would stop selling Exubera for financial reasons. But "inhaled insulin is not dead as a concept," Buse says. "Perhaps a smaller device that is easier for patients to use and is associated with reasonable expectations will have a place in the future."

Plastic Surgery: Less Is More

Less will be more in 2008, predicts Foad Nahai, MD, the president of the American Society for Aesthetic Plastic Surgery and a plastic surgeon in private practice in Atlanta.

"I think what we are going to see more of in 2008 is a continuing interest in injectables, fillers, toxins, and other noninvasive procedures [to reduce some of the visible signs of aging]," he predicts. "What we are going to see less of are the very complicated and sophisticated face-lift procedures that provide probably the best results, but also require the longest recovery."

Overall, "men and women will be opting for less in terms of the result and going with injectables because there is no downtime and no recovery time," he says.

"The other thing that we will see is growth in products to use at home," he says. "Eventually there may be an effective cream or treatment that would match the injectables and fillers."

Still, plastic surgeons won't be going out of business anytime soon. "There are still lots of things that the knife can do that needles and creams can't," he says. For example, plastic surgeons will use 2008 as time to work on refining the proper sequencing for body-contouring following weight loss surgery. When people experience such dramatic weight loss, they are often left with loose, hanging skin and opt to undergo multiple body-contouring surgeries such as tummy tucks, arm lifts, and/or breast lifts to tighten and tone. Plastic surgeons are now trying to determine the best order to perform such surgeries.

And one more thing, he adds. Just because pop star Britney Spears reportedly underwent lipodisolve, don't expect this fat-dissolving technology to become all the rage in 2008.

"We just don't have large studies looking at how effective it is and how safe it is," Buse says. "We should wait until we have studies that prove its safety and then it will rapidly become very popular." There may be some short-term results on lipodisolve published in 2008.

Rheumatology: New Drug Alert

Leslie J. Crofford, MD, the Gloria W. Singletary professor of rheumatology and the chief of rheumatology at the University of Kentucky in Lexington, has her eye on the prize in 2008. "I hope we will see another new biologic approved to treat rheumatoid arthritis (RA) in 2008," she tells WebMD. Specifically, she is referring to tocilizumab (Actemra). This drug blocks an inflammatory chemical known as interleukin-6 (Il-6), and is in final stages of clinical trials.

Crofford says she is "really excited" about this drug for people who may not respond to similar drugs. Biologic drugs block substances that cause or worsen joint inflammation in RA. They copy the effects of chemicals made by the immune system, which block inflammatory substances such as tumor necrosis factor (TNF).

"Preliminary studies look extremely promising and it seems to have a particularly good effect in pediatric patients. And we may ultimately, when approved, see studies of this agent in other rheumatic diseases."

Speaking of other rheumatic diseases, Crofford says, "I hope that we will see clinical trials looking at biologics in lupus and I hope that we will see approvals for more medications to treat fibromyalgia that target the central nervous system." In 2007, the first ever such drug to treat the chronic pain condition fibromyalgia was approved, and according to Crofford, Lyrica (pregabalin) won't be the last.

Neurology: Mixed Outlook for 2008

2008 will be a mixed bag for stroke and other neurological conditions, says Deepak L. Bhatt, MD, the associate director of the cardiovascular coordinating center and an interventional cardiologist at the Cleveland Clinic in Ohio.

"There are two warring factors," he explains. "We have better treatments and less invasive therapies on the horizon, but this has the potential to be overwhelmed by the twin epidemics of diabetes and obesity," he warns. While some researchers suggest that the diabetes epidemic may be reaching a plateau, there are still millions of Americans who have the condition and may not have it under control.

"There is trouble brewing," he says. "Even though there have been some encouraging downward trends in stroke rates, those gains could easily be reversed by epidemic of diabetes."

Cardiologists and neurologists will be working together more often in 2008 as strokes and heart disease share many of the same risk factors including high blood pressure, diabetes, and smoking, Bhatt predicts.

There has been some back and forth on the potential use of cholesterol-lowering drugs called statins in preventing future strokes among people who have had strokes due to a blockage in the brain arteries. Research has shown that such stroke survivors who took statins had a lower risk of fatal and nonfatal strokes of any kind as well as heart attacks and heart disease. That said, stroke survivors who take statins may also have an increased risk of experiencing a bleeding or hemorrhagic stroke.

"We are going to see a lot more enthusiasm among neurologists about the use of statins in patients who have had an ischemic stroke," he predicts. "The data overall in these patients show that use of a statin does reduce risk of future heart attack, stroke, and death."

Cardiology: Will HRT Make a Comeback?

Nieca Goldberg, MD, a New York City-based cardiologist and the medical director of the New York University Women's Heart Program and author of several books including the forthcoming Dr. Nieca Goldberg's Complete Guide to Women's Health, fears that 2008 may bring about some disheartening news.

"If we don't get young people to quit smoking, we will see a resurgence of heart disease in the future," she says.

Hormone replacement therapy (HRT) may make the news again in 2008, she says. The use of hormones fell from grace in the summer of 2002 when the U.S. government halted the hormone arm of the Women's Health Initiative early because of an increased risk of heart attack.

"We are going to get some more fine-tuned information about hormone therapy because of the increased numbers of women going into menopause and who have symptoms," she says. Such as? "For women who don't have heart disease risk factors or have heart disease, maybe HRT is not as harmful to the heart as we once thought," she says. Stay tuned.

Reference Link:

http://www.webmd.com/a-to-z-guides/features/whats-ahead-for-health-in-2008?

What is Ulcerative Colitis?

2007-12-30T08:41:00.001+02:00

Ulcerative colitis is a chronic inflammation of the large intestine (colon). The colon is the part of the digestive system where waste material is stored. The rectum is the end of the colon adjacent to the anus. In patients with ulcerative colitis, ulcers and inflammation of the inner lining of the colon lead to symptoms of abdominal pain, diarrhea, and rectal bleeding.

Ulcerative colitis is closely related to another condition of inflammation of the intestines called Crohn's disease. Together, they are frequently referred to as inflammatory bowel disease (IBD). Ulcerative colitis and Crohn's diseases are chronic conditions that can last years to decades. They affect approximately 500,000 to 2 million people In the United States. Men and women are affected equally. They most commonly begin during adolescence and early adulthood, but they also can begin during childhood and later in life.

It is found worldwide, but is most common in the United States, England, and northern Europe. It is especially common in people of Jewish descent. Ulcerative colitis is rarely seen in Eastern Europe, Asia, and South America, and is rare in the black population. For unknown reasons, an increased frequency of this condition has been recently observed in developing nations.

What Causes Ulcerative Colitis?

The causes of ulcerative colitis and Crohn's disease are unknown. To date, there has been no convincing evidence that these two diseases are caused by infection. Neither disease is contagious.

Ulcerative colitis and Crohn's disease are caused by abnormal activation of the immune system in the intestines. The immune system is composed of immune cells and the proteins that these cells produce. These cells and proteins serve to defend the body against harmful bacteria, viruses, fungi, and other foreign invaders. Activation of the immune system causes inflammation within the tissues where the activation occurs. (Inflammation is, in fact, an important mechanism of defense used by the immune system.) Normally, the immune system is activated only when the body is exposed to harmful invaders. In patients with Crohn's disease and ulcerative colitis, however, the immune system is abnormally and chronically activated in the absence of any known invader. The continued abnormal activation of the immune systems causes chronic inflammation and ulceration. The susceptibility to abnormal activation of the immune system is genetically inherited. First degree relatives (brothers, sisters, children, and parents) of patients with IBD are thus more likely to develop these diseases.

What are the Symptoms of Ulcerative Colitis?

Common symptoms of ulcerative colitis include rectal bleeding and diarrhea, but there is a wide range of symptoms among patients with this disease. Variability of symptoms reflects differences in the extent of disease (the amount of the colon and rectum that are inflamed) and the intensity of inflammation. Generally, patients with inflammation confined to the rectum and a short segment of the colon adjacent to the rectum have milder symptoms and a better prognosis than patients with more widespread inflammation of the colon. The different types of ulcerative colitis are classified according to the location and the extent of inflammation:

Ulcerative proctitis refers to inflammation that is limited to the rectum. In many patients with ulcerative proctitis, mild intermittent rectal bleeding may be the only symptom. Other patients with more severe rectal inflammation may, in addition, experience rectal pain, urgency (sudden feeling of having to defecate and a need to rush to the bathroom for fear of soiling), and tenesmus (ineffective, painful urge to move one's bowels).

Proctosigmoiditis involves inflammation of the rectum and the sigmoid colon (a short segment of the colon contiguous to the rectum). Symptoms of proctosigmoiditis, like that of proctitis, include rectal bleeding, urgency, and tenesmus. Some patients with proctosigmoiditis also develop bloody diarrhea and cramps.

Left–sided colitis involves inflammation that starts at the rectum and extends up the left colon (sigmoid colon and the descending colon). Symptoms of left–sided colitis include bloody diarrhea, abdominal cramps, weight loss, and left–sided abdominal pain.

Pancolitis or universal colitis refers to inflammation affecting the entire colon (right colon, left colon, transverse colon and the rectum). Symptoms of pancolitis include bloody diarrhea, abdominal pain and cramps, weight loss, fatigue, fever, and night sweats. Some patients with pancolitis have low–grade inflammation and mild symptoms that respond readily to medications. Generally, however, patients with pancolitis suffer more severe disease and are more difficult to treat than those with more limited forms of ulcerative colitis.

Fulminant colitis is a rare but severe form of pancolitis. Patients with fulminant colitis are extremely ill with dehydration, severe abdominal pain, protracted diarrhea with bleeding, and even shock. They are at risk of developing toxic megacolon (marked dilatation of the colon due to severe inflammation) and colon rupture (perforation). Patients with fulminant colitis and toxic megacolon are treated in the hospital with potent intravenous medications. Unless they respond to treatment promptly, surgical removal of the diseased colon is necessary to prevent colon rupture.

While the intensity of colon inflammation in ulcerative colitis waxes and wanes over time, the location and the extent of disease in a patient generally stays constant. Therefore, when a patient with ulcerative proctitis develops a relapse of his disease, the inflammation usually is confined to the rectum. Nevertheless, a small number of patients (less than 10%) with ulcerative proctitis or proctosigmoiditis can later develop more extensive colitis. Thus, patients who initially only have ulcerative proctitis can later develop left–sided colitis or even pancolitis.

How is the Diagnosis of Ulcerative Colitis Made?

The diagnosis of ulcerative colitis is suggested by the symptoms of abdominal pain, rectal bleeding, and diarrhea. Stool specimens are collected for analysis to exclude infection and parasites, since these conditions can cause colitis that mimics ulcerative colitis. Blood tests may show anemia and an elevated white blood cell count or sedimentation rate (commonly referred to as sed rate). An elevated white blood cell count and sed rate both reflect ongoing inflammation in the colon. Confirmation of ulcerative colitis requires a test to visualize the large intestine. Flexible tubes inserted through the rectum (sigmoidoscopes and colonoscopes) permit direct visualization of the inside of the colon to establish the diagnosis and to measure the extent of the colitis. Small tissue samples (biopsies) can be obtained during the procedure to determine the severity of the colitis.

Knowledge of the extent and severity of the colitis is important in choosing among treatment options. A barium enema x–ray may also indicate the diagnosis of ulcerative colitis. During a barium enema, a chalky substance is administered into the rectum and injected into the colon. Barium is radiopaque and can outline the colon on x–ray pictures. A barium enema is less accurate and useful than direct visualization techniques in the diagnosis of ulcerative colitis.

What are the Complications of Ulcerative Colitis?

Patients with ulcerative colitis limited to the rectum (proctitis) or colitis limited to the end of the left colon (proctosigmoiditis) usually do quite well. Brief periodic treatments using oral medications or enemas may be sufficient. Serious complications are rare in these patients. In those with more extensive disease, blood loss from the inflamed intestines can lead to anemia and may require treatment with iron supplements or even blood transfusions. Rarely, the colon can acutely dilate to a large size when the inflammation becomes very severe. This condition is called toxic megacolon. Patients with toxic megacolon are extremely ill with fever, abdominal pain and distention, dehydration, and malnutrition. Unless the patient improves rapidly with medication, surgery usually is necessary to prevent colon rupture.

Colon cancer is a recognized complication of chronic ulcerative colitis. The risk for cancer begins to rise after eight to ten years of colitis. Patients with only ulcerative proctitis probably do not have increased risk of colon cancer compared to the general population. Among patients with active pancolitis (involving the entire colon) for 10 years or longer, the risk of colon cancer is increased compared to the general population. In patients with colitis limited to the left side of the colon, the risk of colon cancer is increased but not as high as in patients with chronic pancolitis.

The current estimates for the cumulative incidence of colon cancer associated with ulcerative colitis are 2.5% at 10 years, 7.6% at 30 years, and 10.8% at 50 years. Patients at higher risk of cancer are patients with positive family histories of colon cancer, long durations of colitis, extensive colon involvement, and primary sclerosing cholangitis (PSC), another complication of ulcerative colitis.

Since these cancers have a more favorable outcome when diagnosed and treated at an earlier stage, yearly colon examinations may be recommended after eight years of known extensive disease. During these examinations, samples of tissue (biopsies) can be taken to search for precancerous changes in the lining cells of the colon. When precancerous changes are found, removal of the colon may be necessary to prevent colon cancer.

Complications of ulcerative colitis can involve other parts of the body. Ten percent of the patients can develop inflammation of the joints (arthritis). Some patients have low back pain due to arthritis of the sacroiliac joints. Rarely, patients may develop painful, red, skin nodules (erythema nodosum). Yet others can have painful, red eyes (uveitis, episcleritis). Because these particular complications can risk permanent vision impairment, eye pain or redness are symptoms that require a physician's evaluation. Diseases of the liver and bile ducts may also be associated with ulcerative colitis. For example, in rare patients with a condition called sclerosing cholangitis, repeated infections and inflammation in the bile ducts can lead to recurrent fever, yellowing of skin (jaundice), cirrhosis, and the need for a liver transplant.

What are the Treatments for Ulcerative Colitis?

Both medications and surgery have been used to treat ulcerative colitis. However, surgery is reserved for those with severe inflammation and life–threatening complications. There is no medication that can cure ulcerative colitis. Patients with ulcerative colitis will typically experience periods of relapse (worsening of inflammation) followed by periods of remission (resolution of inflammation) lasting months to years. During relapses, symptoms of abdominal pain, diarrhea, and rectal bleeding worsen. During remissions, these symptoms subside. Remissions usually occur because of treatment with medications or surgery, but occasionally they occur spontaneously, that is, without any treatment.

Medications
Since ulcerative colitis cannot be cured by medication, the goals of treatment with medication are to 1) induce remissions, 2) maintain remissions, 3) minimize side effects of treatment, and 4) improve the quality of life. Treatment of ulcerative colitis with medications is similar, though not always identical, to treatment of Crohn's disease.

Medications treating ulcerative colitis include 1) anti–inflammatory agents such as 5–ASA compounds, systemic corticosteroids, topical corticosteroids, and 2) immunomodulators.

Anti–inflammatory medications that decrease intestinal inflammation are analogous to arthritis medications that decrease joint inflammation (arthritis). The anti–inflammatory medications that are used in the treatment of ulcerative colitis are:

Topical 5–ASA compounds such as sulfasalazine (Azulfidine), olsalazine (Dipentum), and mesalamine (Pentasa, Asacol, Rowasa enema) that need direct contact with the inflamed tissue in order to be effective.
Systemic anti–inflammatory medications such as corticosteroids that decrease inflammation throughout the body without direct contact with the inflamed tissue. Systemic corticosteroids have predictable side effects with long term use.

Immunomodulators are medications that suppress the body's immune system either by reducing the cells that are responsible for immunity, or by interfering with proteins that are important in promoting inflammation. Immunomodulators increasingly are becoming important treatments for patients with severe ulcerative colitis who do not respond adequately to anti–inflammatory agents. Examples of immunomodulators include 6–mercaptopurine (6–MP), azathioprine (Imuran), methotrexate (Rheumatrex, Trexall), cyclosporine (Gengraf, Neoral).

It has long been observed that the risk of ulcerative colitis appears to be higher in nonsmokers and in ex–smokers. In certain circumstances, patients improve when treated with nicotine.

5–ASA Compounds (Azulfidine, Asacol, Pentasa, Dipentum)

5–ASA (5–aminosalicylic acid), also called mesalamine, is chemically similar to aspirin. Aspirin (acetylsalicylic acid) has been used for many years in treating arthritis, bursitis, and tendinitis (conditions of tissue inflammation). Aspirin, however, is not effective in treating ulcerative colitis. On the other hand, 5–ASA can be effective in treating ulcerative colitis if the drug can be delivered directly (topically) onto the inflamed colon lining. For example, Rowasa enema is a 5–ASA solution that is effective in treating inflammation in and near the rectum (ulcerative proctitis and ulcerative proctosigmoiditis). However, the enema solution cannot reach high enough to treat inflammation in the upper colon. Therefore, for most patients with ulcerative colitis, 5–ASA must be taken orally. When pure 5–ASA is taken orally, however, the stomach and upper small intestine absorb most of the drug before it reaches the colon. Therefore, to be effective as an oral agent for ulcerative colitis, 5–ASA has to be modified chemically to escape absorption by the stomach and the upper intestines. These modified 5–ASA compounds are sulfasalazine (Azulfidine), mesalamine (Pentasa, Rowasa, Asacol), and olsalazine (Dipentum).

Azulfidine

Sulfasalazine (Azulfidine) has been used successfully for many years in inducing remission among patients with mild to moderate ulcerative colitis. Inducing remission means decreasing intestinal inflammation and relieving symptoms of abdominal pain, diarrhea, and rectal bleeding. Sulfasalazine has also been used for prolonged periods of time to maintain remissions.

Sulfasalazine consists of a 5–ASA molecule linked chemically to a sulfapyridine molecule. (Sulfapyridine is a sulfa antibiotic). Connecting the two molecules together prevents absorption by the stomach and the upper intestines prior to reaching the colon. When sulfasalazine reaches the colon, the bacteria in the colon will break the linkage between the two molecules. After breaking away from 5–ASA, sulfapyridine is absorbed into the body and then excreted in the urine. Most of the active 5–ASA drug, however, remains in the colon to treat colitis.

Most of the side effects of sulfasalazine are due to the sulfapyridine molecule. These side effects include nausea, heartburn, headache, anemia, skin rashes, and, in rare instances, hepatitis and kidney inflammation. In men, sulfasalazine can reduce the sperm count. The reduction in sperm count is reversible, and the count usually returns to normal after discontinuing sulfasalazine or by changing to a different 5– ASA compound.

The benefits of sulfasalazine generally are dose related. Therefore, high doses of sulfasalazine may be necessary to induce remission. Some patients cannot tolerate high doses because of nausea and stomach upset. To minimize stomach upset, sulfasalazine generally is taken after or with meals. Some patients find it easier to take Azulfidine–EN (enteric–coated form of sulfasalazine). Enteric–coating helps decrease stomach upset. The newer 5–ASA compounds do not have the sulfapyridine component and have fewer side effects than sulfasalazine.

Asacol

Asacol is a tablet consisting of the 5–ASA compound, mesalamine, surrounded by an acrylic resin coating. (Asacol is sulfa free). The resin coating prevents the 5–ASA from being absorbed as it passes through the stomach and the small intestine. When the tablet reaches the terminal ileum and the colon, the resin coating dissolves, thus releasing 5–ASA into the colon.

Asacol is effective in inducing remissions in patients with mild to moderate ulcerative colitis. It also is effective when used for prolonged periods of time to maintain remissions. The recommended dose of Asacol to induce remission is two 400–mg tablets three times daily (total of 2.4 grams a day). Two tablets of Asacol twice daily (1.6 grams a day) is recommended for maintaining remission. Occasionally, the maintenance dose is higher.

As with Azulfidine, the benefits of Asacol are dose–related. If patients do not respond to 2.4 grams a day of Asacol, the dose frequently is increased to 3.6 grams a day (and sometimes even higher) to induce remission. If patients fail to respond to the higher doses of Asacol, then alternatives, such as corticosteroids, are considered.

Pentasa

Pentasa is a capsule consisting of the 5–ASA compound mesalamine inside controlled–release spheres. Like Asacol, it is sulfa free. As the capsule travels down the intestines, the 5–ASA inside the spheres is slowly released into the intestines. Unlike Asacol, the mesalamine in Pentasa is released into the small intestine as well as the colon. Therefore, Pentasa can be effective in treating inflammation in the small intestine and the colon. Pentasa is currently the most logical 5–ASA compound for treating mild to moderate Crohn's disease involving the small intestine. Pentasa also is used to induce remission and maintain remission among patients with mild to moderate ulcerative colitis.

Olsalazine (Dipentum)

Olsalazine (Dipentum) consists of two 5–ASA molecules linked together. It is sulfa free. The linked 5–ASA molecules travel through the stomach and the small intestine unabsorbed. When the drug reaches the terminal ileum and the colon, the normal bacteria in the intestine break the linkage and releases the active drug into the colon and the terminal ileum. Olsalazine has been used in treating ulcerative colitis and in maintaining remissions. A side effect unique to olsalazine is secretory diarrhea (diarrhea resulting from excessive production of fluid in the intestines). This condition occurs in 5–10% of patients, and the diarrhea sometimes can be severe.

Colazal

Colazal (balsalazide) is a capsule in which the 5–ASA is linked by a chemical bond to another molecule that is inert (without effect on the intestine) and prevents the 5–ASA from being absorbed. This drug is able to travel through the intestine unchanged until it reaches the end of the small bowel (terminal ileum) and colon. There, intestinal bacteria break apart the 5–ASA and the inert molecule, releasing the 5–ASA. Because intestinal bacteria are most abundant in the terminal ileum and colon, Colazal is used to treat inflammation predominantly localized to the colon. Colazal recently has been approved by the FDA for use in the United States.

More clinical trials are needed to compare the effectiveness of Colazal to the other mesalamine compounds such as Asacol in treating ulcerative colitis. Therefore in the United States, choosing which 5–ASA compound has to be individualized. Some doctors prescribe Colazal for patients who cannot tolerate or fail to respond to Asacol. Others prescribe Colazal for patients with predominantly left sided colitis, since some studies seem to indicate that Colazal is effective in treating left sided colitis.

Side Effects of 5–ASA Compounds

The sulfa–free 5–ASA compounds have fewer side effects than sulfasalazine and also do not impair male fertility. In general, they are safe medications for long–term use and are well–tolerated.

Patients allergic to aspirin should avoid 5–ASA compounds because they are chemically similar to aspirin.

Rare kidney inflammation has been reported with the use of 5–ASA compounds. These compounds should be used with caution in patients with known kidney disease. It also is recommended that blood tests of kidney function be obtained before starting and periodically during treatment.

Rare instances of acute worsening of diarrhea, cramps, and abdominal pain may occur which is at times may be accompanied by fever, rash, and malaise. This reaction is believed to represent an allergy to the 5–ASA compound.

Rowasa Enema

Rowasa is the 5–ASA compound mesalamine in enema form and is effective in ulcerative proctitis and ulcerative proctosigmoiditis (two conditions where active 5–ASA drugs taken as enemas can easily reach the inflamed tissues directly). Each Rowasa enema contains 4 grams of mesalamine in 60 cc of fluid. The enema usually is administered at bedtime, and patients are encouraged to retain the enema through the night.

The enema contains sulfite and should not be used by patients with sulfite allergy. Otherwise, Rowasa enemas are safe and well–tolerated.

Rowasa also comes in suppository form for treating limited proctitis. Each suppository contains 500 mg of mesalamine and usually is administered twice daily.

While some patients improve within several days of starting Rowasa, the usual course of treatment is three to six weeks. Some patients may need even longer courses of treatment for optimal benefit. In patients who do not respond to Rowasa, oral 5–ASA compounds (such as Asacol) can be added. Some studies have reported increased effectiveness in treating ulcerative proctitis and proctosigmoiditis by combining oral 5–ASA compounds with Rowasa enemas. Oral 5–ASA compounds also are used to maintain remission in ulcerative proctitis and proctosigmoiditis.

Another alternative for patients who fail to respond to Rowasa or who cannot use Rowasa is cortisone enemas (Cortenema). Cortisone is a corticosteroid that is a potent anti–inflammatory agent. Oral corticosteroids are systemic drugs with serious and predictable long–term side effects. Cortenema is a topical corticosteroid that is less absorbed into the body than oral corticosteroids, and, therefore, it has fewer and less severe side effects.

Systemic Corticosteroids (including side effects)

Corticosteroids (Prednisone, prednisolone, hydrocortisone, etc.) have been used for many years in the treatment of patients with moderate to severe Crohn's disease and ulcerative colitis or who fail to respond to optimal doses of 5–ASA compounds. Unlike the 5–ASA compounds, corticosteroids do not require direct contact with the inflamed intestinal tissues to be effective. Oral corticosteroids are potent anti–inflammatory agents. After absorption, corticosteroids exert prompt anti–inflammatory action throughout the body. Consequently, they are used in treating Crohn's enteritis, ileitis, and ileocolitis, as well as ulcerative and Crohn's colitis. In critically ill patients, intravenous corticosteroids (such as hydrocortisone) can be given in the hospital.

Corticosteroids are faster acting than the 5–ASA compounds. Patients frequently experience improvement in their symptoms within days of starting corticosteroids. Corticosteroids, however, do not appear to be useful in maintaining remissions in ulcerative colitis.

Corticosteroid side effects

Side effects of corticosteroids depend on the dose and duration of use. Short courses of prednisone, for example, usually are well tolerated with few and mild side effects. Long term, high doses of corticosteroids usually produce predictable and potentially serious side effects. Common side effects include rounding of the face (moon face), acne, increased body hair, diabetes, weight gain, high blood pressure, cataracts, glaucoma, increased susceptibility to infections, muscle weakness, depression, insomnia, mood swings, personality changes, irritability, and thinning of the bones (osteoporosis) with an accompanying increased risk of compression fractures of the spine. Children on corticosteroids can experience stunted growth.

The most serious complication from long term corticosteroid use is aseptic necrosis of the hip joints. Aseptic necrosis means death of bone tissue. It is a painful condition that can ultimately lead to the need for surgical replacement of the hips. Aseptic necrosis also has been reported in knee joints. It is unknown how corticosteroids cause aseptic necrosis. The estimated incidence of aseptic necrosis among corticosteroid users is 3–4%. Patients on corticosteroids who develop pain in the hips or knees should report the pain to their doctors promptly. Early diagnosis of aseptic necrosis with cessation of corticosteroids has been reported in some patients to decrease the severity of the condition and possibly help avoid hip replacement.

Prolonged use of corticosteroids can depress the ability of the body's adrenal glands to produce cortisol (a natural corticosteroid necessary for proper functioning of the body). Abruptly discontinuing corticosteroids can cause symptoms due to a lack of natural cortisol (a condition called adrenal insufficiency). Symptoms of adrenal insufficiency include nausea, vomiting, and even shock. Withdrawing corticosteroids too quickly also can produce symptoms of joint aches, fever, and malaise. Therefore, corticosteroids need to be gradually reduced rather than abruptly stopped.

Even after the corticosteroids are discontinued, the adrenal glands' ability to produce cortisol can remain depressed for months to two years. The depressed adrenal glands may not be able to produce enough cortisol to help the body handle stress such as accidents, surgery, and infections. These patients will need treatment with corticosteroids (prednisone, hydrocortisone, etc.) during stressful situations to avoid developing adrenal insufficiency.

Because corticosteroids are not useful in maintaining remission in ulcerative colitis and Crohn's disease and because they have predictable and potentially serious side effects, these drugs should be used for the shortest possible length of time.

Proper Use of Corticosteroids

Once the decision is made to use oral corticosteroids, treatment usually is initiated with prednisone, 40–60 mg daily. The majority of patients with ulcerative colitis respond with an improvement in symptoms. Once symptoms improve, prednisone is reduced by 5–10 mg per week until the dose of 20 mg per day is reached. The dose then is tapered at a slower rate until the prednisone ultimately is discontinued. Gradually reducing corticosteroids not only minimizes the symptoms of adrenal insufficiency, it also reduces the chances of abrupt relapse of the colitis.

Many doctors use 5–ASA compounds at the same time as corticosteroids. In patients who achieve remission with systemic corticosteroids, 5–ASA compounds such as Asacol are often continued to maintain remissions.

In patients whose symptoms return during reduction of the dose of corticosteroid, the dose of corticosteroids is increased slightly to control the symptoms. Once the symptoms are under control, the reduction can resume at a slower pace. Some patients become corticosteroid dependent. These patients consistently develop symptoms of colitis whenever the corticosteroid dose reaches below a certain level. In patients who are corticosteroid dependent or who are unresponsive to corticosteroids, other anti–inflammatory medications, immunomodulator medications or surgery are considered.

The management of patients who are corticosteroid dependent or patients with severe disease which responds poorly to medications is complex. Doctors who are experienced in treating inflammatory bowel disease and in using the immunomodulators should evaluate these patients.

Preventing Corticosteroid–induced Osteoporosis

Long–term use of corticosteroids such as prednisolone or prednisone can cause osteoporosis . Corticosteroids cause decreased calcium absorption from the intestines and increased loss of calcium from the kidneys and bones. Increasing dietary calcium intake is important but alone cannot halt corticosteroid–induced bone loss. Management of patients on long term corticosteroids should include:

Adequate calcium (1000 mg daily if premenopausal, 1500 mg daily if postmenopausal) and vitamin D (800 units daily) intake.
Periodic review with the doctor on the need for continued corticosteroid treatment and the lowest effective dose if continued treatment is necessary.
A bone density study to measure the extent of bone loss in patients taking corticosteroids for more than three months.
Regular weight–bearing exercise, and stop smoking cigarettes.
Discussion with the doctor regarding the use of alendronate (Fosamax) or risedronate (Actonel) in the prevention and the treatment of corticosteroid induced osteoporosis.

What are Immunomodulator medications?

Immunomodulators are medications that weaken the body's immune system. The immune system is composed of immune cells and the proteins that these cells produce. These cells and proteins serve to defend the body against harmful bacteria, viruses, fungi, and other foreign invaders. Activation of the immune system causes inflammation within the tissues where the activation occurs. (Inflammation is, in fact, an important mechanism to defend the body used by the immune system.) Normally, the immune system is activated only when the body is exposed to harmful invaders. In patients with Crohn's disease and ulcerative colitis, however, the immune system is abnormally and chronically activated in the absence of any known invader. Immunomodulators decrease tissue inflammation by reducing the population of immune cells and/or by interfering with their production of proteins that promote immune activation and inflammation. Generally, the benefits of controlling moderate to severe ulcerative colitis outweigh the risks of infection due to weakened immunity. Examples of immunomodulators include azathioprine (Imuran), 6–mercaptopurine (6–MP, Purinethol), cyclosporine (Sandimmune), and methotrexate (Rheumatrex, Trexall).

Azathioprine (Imuran) and 6–MP (Purinethol)

Azathioprine and 6–mercaptopurine (6–MP) are medications that weaken the body's immunity by reducing the population of a class of immune cells called lymphocytes. Azathioprine and 6–MP are related chemically. Specifically, azathioprine is converted into 6–MP inside the body. In high doses, these two drugs have been useful in preventing rejection of transplanted organs and in treating leukemia. In low doses, they have been used for many years to treat patients with moderate to severe Crohn's disease and ulcerative colitis.

Azathioprine and 6–MP are increasingly recognized by doctors as valuable drugs in treating Crohn's disease and ulcerative colitis. Some 70% of patients with moderate to severe disease will benefit from these drugs. Because of the slow onset of action and the potential for side effects, however, 6–MP and azathioprine are used mainly in the following situations:

Ulcerative colitis and Crohn's disease patients with severe disease not responding to corticosteroids.
Patients who are experiencing undesirable corticosteroid–related side effects.
Patients who are dependent on corticosteroids and are unable to discontinue them without developing relapses.

When azathioprine and 6–MP are added to corticosteroids in the treatment of ulcerative colitis patients who do not respond to corticosteroids alone, there may be an improved response or smaller doses and shorter courses of corticosteroids may be able to be used. Some patients can discontinue corticosteroids altogether without experiencing relapses. The ability to reduce corticosteroid requirements has earned 6–MP and azathioprine their reputation as "steroid–sparing" medications.

In ulcerative colitis patients with severe disease who suffer frequent relapses, 5–ASA may not be sufficient, and more potent azathioprine and 6–MP will be necessary to maintain remissions. In the doses used for treating ulcerative colitis and Crohn's disease, the long–term side effects of azathioprine and 6–MP are less serious than long–term oral corticosteroids or repeated courses of oral corticosteroids.

What Are the Side Effects of 6–MP and Azathioprine?

Side effects of 6–MP and azathioprine include increased vulnerability to infections, inflammation of the liver (hepatitis) and pancreas, (pancreatitis), and bone marrow toxicity (interfering with the formation of cells that circulate in the blood).

The goal of treatment with 6–MP and azathioprine is to weaken the body's immune system in order to decrease the intensity of inflammation in the intestines; however, weakening the immune system increases the vulnerability to infections. For example, in a group of patients with severe Crohn's disease unresponsive to standard doses of azathioprine, raising the dose of azathioprine helped to control the disease, but two patients developed cytomegalovirus (CMV) infection. (CMV usually infects individuals with weakened immune systems such as patients with AIDS or cancer, especially if they are receiving chemotherapy, which further weakens the immune system.

Azathioprine and 6–MP–induced inflammation of the liver (hepatitis) and pancreas (pancreatitis) are rare. Pancreatitis typically causes severe abdominal pain and sometimes vomiting. Pancreatitis due to 6–MP or azathioprine occurs in 3%–5% of patients, usually during the first several weeks of treatment. Patients who develop pancreatitis should not receive either of these two medications again.

Azathioprine and 6–MP also suppress the bone marrow. The bone marrow is where red blood cells, white blood cells, and platelets are made. Actually, a slight reduction in the white blood cell count during treatment is desirable since it indicates that the dose of 6–MP or azathioprine is high enough to have an effect; however, excessively low red or white blood cell counts indicates bone marrow toxicity. Therefore, patients on 6–MP and azathioprine should have periodic blood counts (usually every two weeks initially and then every 3 months during maintenance) to monitor the effect of the drugs on their bone marrow.

6–MP can reduce the sperm count in men. When the partners of male patients on 6–MP conceive, there is a higher incidence of miscarriages and vaginal bleeding. There also are respiratory difficulties in the newborn. Therefore, it is recommended that whenever feasible, male patients should stop 6–MP and azathioprine for three months before conception.

Patients on long–term, high dose azathioprine to prevent rejection of the kidney after kidney transplantation have an increased risk of developing lymphoma, a malignant disease of lymphatic cells. There is no evidence at present that long term use of azathioprine and 6–MP in the low doses used in IBD increases the risk for lymphoma, leukemia or other malignancies.

Other Issues in the Use of 6–MP

One problem with 6–MP and azathioprine is their slow onset of action. Typically, full benefit of these drugs is not realized for three months or longer. During this time, corticosteroids frequently have to be maintained at high levels to control inflammation.

The reason for this slow onset of action is partly due to the way doctors prescribe 6–MP. Typically, 6–MP is started at a dose of 50 mg daily. The blood count is then checked two weeks later. If the white blood cell count (specifically the lymphocyte count) is not reduced, the dose is increased. This cautious, stepwise approach helps prevent severe bone marrow and liver toxicity, but also delays benefit from the drug.

Studies have shown that giving higher doses of 6–MP early can speed up the benefit of 6–MP without increased toxicity in most patients, but some patients do develop severe bone marrow toxicity. Therefore, the dose of 6–MP has to be individualized. Scientists now believe that an individual's vulnerability to 6–MP toxicity is genetically inherited. Blood tests can be performed to identify those individuals with increased vulnerability to 6–MP toxicity. In these individuals, lower initial doses can be used. Blood tests can also be performed to measure the levels of certain by–products of 6–MP. The levels of these by–products in the blood help doctors more quickly determine whether the dose of 6–MP is right for the patient.

How Long Can Patients Continue on 6–MP?

Patients have been maintained on 6–MP or azathioprine for years without any important long–term side effects. Their doctors, however, should closely monitor their patients on long–term 6–MP. There is data suggesting that patients on long–term maintenance with 6–MP or azathioprine fare better than those who stop these medications. Those who stop 6–MP or azathioprine are more likely to experience relapses, more likely to need corticosteroids or undergo surgery.

Methotrexate

Methotrexate (Rheumatrex, Trexall) is an immunomodulator and anti–inflammatory medication. Methotrexate has been used for many years in the treatment of severe rheumatoid arthritis and psoriasis. It has been helpful in treating patients with moderate to severe Crohn's disease who are either not responding to 6–MP and azathioprine or are intolerant of these two medications. Methotrexate also may be effective in patients with moderate to severe ulcerative colitis who are not responding to corticosteroids or 6–MP and azathioprine. It can be given orally or by weekly injections under the skin or into the muscles. It is more reliably absorbed with the injections.

One major complication of methotrexate is the development of liver cirrhosis when the medication is given over a prolonged period of time (years). The risk of liver damage is higher in patients who also abuse alcohol or have morbid (severe) obesity. Generally, periodic liver biopsies are recommended for a patient who has received a cumulative (total) methotrexate dose of 1.5 grams and higher.

Other side effects of methotrexate include low white blood cell counts and inflammation of the lungs.

Methotrexate should not be used in pregnancy.

Cyclosporine

Cyclosporine (Sandimmune) is a potent immunosuppressant used in preventing organ rejection after transplantation, for example, of the liver. It also has been used to treat patients with severe ulcerative colitis and Crohn's disease. Because of the approval of infliximab (Remicade) for treating severe Crohn's disease, cyclosporine probably will be used primarily in severe ulcerative colitis. Cyclosporine is useful in fulminant ulcerative colitis and in severely ill patients who are not responding to systemic corticosteroids. Administered intravenously, cyclosporine can be very effective in rapidly controlling severe colitis and avoiding or delaying surgery.

Cyclosporine also is available as an oral medication, but the relapse rate with oral cyclosporine is high. Therefore, cyclosporine seems most useful when administered intravenously in acute situations.

Side effects of cyclosporine include high blood pressure, impairment of kidney function, and tingling sensations in the extremities. More serous side effects include anaphylactic shock and seizures.

Infliximab (Remicade)

Infliximab (Remicade) is an antibody that attaches to a protein called tumor necrosis factor–alpha (TNF–alpha). TNF–alpha is one of the proteins produced by immune cells during activation of the immune system. TNF–alpha, in turn, stimulates other cells of the immune system to produce and release other proteins that promote inflammation. In Crohn's disease and in ulcerative colitis, there is continued production of TNF–alpha as part of the immune activation. Infliximab, by attaching to TNF–alpha, blocks its activity and in so doing decreases the inflammation.

Infliximab, an antibody to TNF–alpha, is produced by the immune system of mice after the mice are injected with human TNF–alpha. The mouse antibody then is modified to make it look more like a human antibody, and this modified antibody is infliximab. Such modifications are necessary to decrease the likelihood of allergic reactions when the antibody is administered to humans. Infliximab is given by intravenous infusion over two hours. Patients are monitored throughout the infusion for adverse reactions.

Infliximab has been used effectively for many years for the treatment of moderate to severe Crohn's disease that was not responding to corticosteroids or immuno–modulators. In Crohn's disease patients, 65% experienced improvement in their disease after one infusion of infliximab. Some patients noticed improvement in symptoms within days of the infusion. Most patients experienced improvement within two weeks. In patients who respond to infliximab, the improvements in symptoms can be dramatic. Moreover, there can be impressively rapid healing of the ulcers and the inflammation in the intestines after just one infusion.

For many years doctors were uncertain whether infliximab could be used to treat ulcerative colitis. Only recently, have doctors begun to use infliximab as treatment for ulcerative colitis. In one randomized placebo controlled study involving more than 700 patients with moderate to severe ulcerative colitis, infliximab (5mg or 10 mg per kilogram body weight) given intravenously was more effective than placebo in inducing and maintaining remission.

Side effects of infliximab

Infliximab, generally, is well tolerated. There have been rare reports of side effects during infusions, including chest pain, shortness of breath, and nausea. These effects usually resolve spontaneously within minutes if the infusion is stopped. Other commonly reported side effects include headache and upper respiratory tract infection.

Infliximab, like immuno–modulators, increases the risk for infection. One case of salmonella colitis and several cases of pneumonia have been reported with the use of infliximab. There also have been cases of tuberculosis (TB) reported after the use of infliximab.

Because infliximab is partly a mouse protein, it may induce an immune reaction when given to humans, especially with repeated infusions. In addition to the side effects that occur while the infusion is being given, patients also may develop a "delayed allergic reaction" that occurs 7–10 days after receiving the infliximab. This type of reaction may cause flu–like symptoms with fever, joint pain and swelling, and a worsening of Crohn's disease symptoms. It can be serious, and if it occurs, a physician should be contacted. Paradoxically, those patients who have more frequent infusions of Remicade are less likely to develop this type of delayed reaction compared to those patients who receive infusions separated by long intervals (6–12 months). Although Remicade is only FDA approved for a single infusion at this time, patients should be aware that they are likely to require repeated infusions once Remicade therapy has been initiated.

There are some reports of worsening heart disease in patients who have received Remicade. The precise mechanism and role of infliximab in the development of this side effect is unclear. As a precaution, individuals with heart disease should inform their physician of this condition before receiving infliximab.

There have been rare reports of nerve damage such as optic neuritis (inflammation of the nerve of the eye) and motor neuropathy.

Precautions with infliximab

Infliximab can aggravate and cause the spread of an existing infection. Therefore, it should not be given to patients with pneumonia, urinary tract infection or abscess (localized collection of pus).

It now is recommended that patients be tested for TB prior to receiving infliximab. Patients who previously had TB should inform their physician of this before they receive infliximab.

Infliximab can cause the spread of cancer cells, therefore, it should not be given to patients with cancer.

Infliximab's effects on the fetus are not known.

Because infliximab is partly a mouse protein, some patients can develop antibodies against infliximab with repeated infusions. The development of these antibodies can decrease the effectiveness of the drug. The chances of developing these antibodies can be decreased by concomitant use of 6–MP and corticosteroids.

While infliximab represents an exciting new class of medications in the fight against Crohn's disease and ulcerative colitis, caution is warranted because of potentially serious side effects. Doctors are using infliximab in moderate to severe ulcerative colitis not responding to other medications.

Summary of Medication Treatment

Azulfidine, Asacol, Pentasa, Dipentum, Colazal, and Rowasa all contain 5–ASA compounds which are topical anti–inflammatory ingredients. These medications are effective in inducing remission among patients with mild to moderate ulcerative colitis. They also are safe and effective in maintaining remission.
Pentasa is more commonly used in treating Crohn's ileitis because the Pentasa capsules release more 5–ASA compounds into the small intestine than the Asacol tablets. Pentasa also can be used for treating mild to moderate ulcerative colitis.
Rowasa enemas are safe and effective in treating ulcerative proctitis and proctosigmoiditis.
The sulfa–free 5–ASA compounds (Asacol, Pentasa, Dipentum, Colazal, Rowasa) have fewer side effects than Azulfidine, which contains sulfa.
In ulcerative colitis patients with moderate to severe disease and in patients who fail to respond to 5–ASA compounds, systemic (oral) corticosteroids can be used. Systemic corticosteroids (prednisone, prednisolone, cortisone, etc.) are potent and fast–acting anti–inflammatory agents for treating Crohn's ileitis, ileocolitis, and ulcerative colitis.
Systemic corticosteroids are not effective in maintaining remission in patients with ulcerative colitis. Serious side effects can result from prolonged corticosteroid treatment.
To minimize side effects, corticosteroids should be gradually reduced as soon as disease remission is achieved. In patients who become corticosteroid dependent or are unresponsive to corticosteroid treatment, surgery or immunomodulator treatments are considered.
Immunomodulators used for treating severe ulcerative colitis include azathioprine/6–MP, methotrexate, and cyclosporine.
Infliximab (Remicade) may be beneficial in controlling moderate to severe ulcerative colitis and in decreasing the need for urgent removal of the colon.

Surgery

Surgery for ulcerative colitis usually involves removing the entire colon and the rectum. Removal of the colon and rectum is the only permanent cure for ulcerative colitis. This procedure also eliminates the risk of developing colon cancer. Surgery in ulcerative colitis is reserved for the following patients:

Patients with fulminant colitis and toxic megacolon who are not responding readily to medications.

Patients with long standing pancolitis or left–sided colitis who are at risk of developing colon cancers. Removal of the colon is important when precancerous changes are detected in the colon lining.

Patients who have had years of severe colitis which has responded poorly to medications.

Standard surgery involves the removal of the entire colon, including the rectum. A small opening is made in the abdominal wall. and the end of the small intestine is attached to the skin of the abdomen to form an ileostomy. Stool collects in a bag that is attached over the ileostomy. Recent improvements in the construction of ileostomies have allowed for continent ileostomies. A continent ileostomy is a pouch created from the intestine. The pouch serves as a reservoir similar to a rectum, and is emptied on a regular basis with a small tube. Patients with continent ileostomies do not need to wear collecting bags.

More recently, a surgery has been developed which allows stool to be passed normally through the anus. In an ileo–anal anastomosis, the large intestine is removed and the small intestine is attached just above the anus. Only the diseased lining of the anus is removed and the muscles of the anus remain intact. In this "pull–through" procedure, the normal route of stool elimination is maintained.

What research is being done regarding ulcerative colitis?

Infliximab (Remicade) is an antibody that attaches to a protein called tumor necrosis factor–alpha (TNF–alpha). TNF–alpha is one fo the proteins produced by immune cells that promote inflammation. By attaching to TNF–alpha, infliximab blocks its activity and in so doing decreases inflammation.

Infliximab has been used successfully in treating severe Crohn's disease patients who are not responding adequately to steroids and immunomodulators such as 6–MP/azathioprine. But for many years doctors thought infliximab would not be beneficial in treating ulcerative colitis.

Recent studies involving small numbers of patients with severe ulcerative colitis who are not responding to high dose steroids indicated infliximab may be beneficial in controlling disease and in decreasing the need for urgent removal of the colon. Placebo controlled studies involving larger number of patients will be conducted to determine the efficacy and safety of infliximab in ulcerative colitis.

Active research is also ongoing to find other anti–TNF agents that are potentially more effective with less side effects in treating ulcerative colitis.

Research in ulcerative colitis is very active, and many questions remain to be answered. The cause, mechanism of inflammation, and optimal treatments have yet to be defined. Researchers have recently identified genetic differences among patients which may allow them to select certain subgroups of patients with ulcerative colitis who may respond differently to medications. Newer and safer medications are being developed. Improvements in surgical procedures to make them safer and more effective continue to emerge.

Ulcerative Colitis At A Glance

Ulcerative colitis is an inflammation of the large intestine (colon).
The cause of ulcerative colitis is unknown.
Intermittent rectal bleeding, crampy abdominal pain and diarrhea often are symptoms of ulcerative colitis.
The diagnosis of ulcerative colitis can be made with a barium enema, but direct visualization (sigmoidoscopy or colonoscopy) is the most accurate means of diagnosis.
Long–standing ulcerative colitis is a risk factor for colon cancer.
Treatment of ulcerative colitis may involve both medications and surgery.
Ulcerative colitis also can cause inflammation in joints, spine, skin, eyes, and the liver and its bile ducts.

reference Link:

http://www.medicinenet.com/ulcerative_colitis/index.htm

What is Crohn's Disease?

2007-12-29T15:09:00.001+02:00

The esophagus, stomach, large and small intestine, aided by the liver, gallbladder and pancreas convert the nutritive components of food into energy and break down the non-nutritive components into waste to be excreted.

lower abdominal x-ray shows narrowing (stenosis) of the end of the small intestine (ileum), caused by Crohn's disease. Crohn's disease typically affects the small intestine, whereas ulcerative colitis typically affects the large intestine. A solution containing a dye (barium), was swallowed by the patient. When it passed into the small intestines, this x-ray was taken (lower GI series).

Clubbing may result from chronic low blood-oxygen levels. This can be seen with cystic fibrosis, congenital cyanotic heart disease, and several other diseases. The tips of the fingers enlarge and the nails become extremely curved from front to back.

Crohn's disease, also called regional enteritis, is a chronic inflammation of the intestines which is usually confined to the terminal portion of the small intestine, the ileum. Ulcerative colitis is a similar inflammation of the colon, or large intestine. These and other IBDs (inflammatory bowel disease) have been linked with an increased risk of colorectal cancer.

Crohn's disease is an inflammation of the intestines caused by immune response to an infection. The lining of the intestine may ulcerate and form channels of infection, called fistulas. Fistulas tunnel from the area of ulceration, creating a hole which may continue until it reaches the surface of the organ, or the surface of nearby skin. These holes typically spread the infection that creates them, and life-threatening conditions such as peritonitis (inflammation of the lining of the abdomen) may occur.

Causes

Inflammatory bowel disease has many different causes. It is due in many cases to a genetic susceptibility that enables an organism such as a virus or bacteria to trigger an abnormal immune reaction, which in turn, causes an inflammatory response in the intestines. Although Crohn's disease has features that resemble an autoimmune disease (in which the body's immune system attacks its own cells), some researchers think that it may be due to initial immune deficiencies.

The Inflammatory Response

The Immune System's Infection Fighters. The primary infection-fighting units are two types of white blood cells: lymphocytes and leukocytes.

Lymphocytes include two subtypes known as T cells and B cells. Both types of cells are designed to recognize foreign invaders (antigens) and to launch an offensive or defensive action against them:

B cells produce antibodies, which are separate substances that can either ride along with a B cell or travel on their own to attack the antigen.
T cells have special receptors attached to their surface that recognize the specific antigen.

T cells are further categorized as killer T cells or helper T cells.

Killer T cells directly attack antigens that occur in any cells that contain a nucleus.
Helper T cells also recognize antigens, but their role is two fold. They stimulate B cells and other white cells to attack the antigen. They also produce cytokines, powerful immune factors that have an important role in the inflammatory process.

Helper T cells and Inflammatory Bowel Disease. The actions of the helper T cells (TH cells) are of special interest in inflammatory bowel disease:

TH cells stimulate other white blood cells called B cells to produce antibodies. In this case, however, they appear to direct the B cells to produce autoantibodies, which are directed against the body's own cells.
TH cells also secrete or stimulate the production of powerful immune factors called cytokines. In small amounts, cytokines are indispensable for healing. If overproduced, however, they can cause serious damage, including inflammation and cellular injury. Cytokines, particularly specific ones known as tumor necrosis factor, interferon-gamma, and interleukins, cause intestinal inflammation and damage, which, in a vicious cycle, attract even more helper T cells.

Helper T cells are further categorized as TH1 and TH2. An imbalance in these two types appear to occur in IBD, although each disorder has a different balance:

Ulcerative colitis patients favor a TH2 response, which activates the interleukins IL-5, IL-6, and IL-10. These mostly affect mucosal areas in the intestine.
Research indicates that patients with Crohn's disease have increased activity in TH1 helper cells, activating interleukin-2 (IL-2) and interferon-gamma, which affect intestinal cells. Tumor necrosis factor (TNF) may be a particularly potent immune factor in Crohn's disease. It is important in properties that regulate inflammation and cell proliferation. If genetic or other factors increase production of this immune compound, it can lead to great harm.

Interleukin 6 appears to play a part in both IBDs, by inhibiting a natural mechanism called apoptosis, a process whereby cells self-destruct. In such cases, cells proliferate faster than they die, causing an excessively strong immune response.

Adhesion Molecules. Increased levels of certain molecules called E-selectin and intercellular adhesion molecule-1 (ICAM-1) also appear to play a major role in the inflammatory process by causing damaging immune factors to accumulate on intestinal cells. E-selectin may be involved in the early stages of the disease (especially ulcerative colitis) and ICAM-1 in the persistence of either inflammatory bowel disease.

Matrix Metalloproteinase. Greater activity of enzymes called matrix metalloproteinase has been detected in the colons of patients with IBD. Such increased levels tend to break down the extracellular matrix, a barrier composed of structural proteins and elastic fibers that surrounds and supports cells, in this case in the colon. Researchers suggest that this activity may cause persistent damage once the inflammatory process has triggered IBD.

Genetic Factors

Although the causes of inflammatory bowel disease are not yet known, genetic factors certainly play some role. Between 10 - 20% of people with ulcerative colitis have family members with the disease. Several candidate genes and chromosome locations have been identified that might prove to play a role in the development of ulcerative colitis, Crohn's disease, or both. Genetic factors appear to be more important in Crohn's disease, although there is evidence that they may have genetic defects in common. In either case, multiple genetic factors are likely to be responsible for susceptibility to these disorders.

Specific Genes Involved. One of the most important genetic discoveries to date was the identification of a genetic variant called NOD2, which appears to alter the immune system so that it launches an over-reaction in response to bacteria, causing inflammation. This genetic factor might be involved in 15% of Crohn's disease cases. Those with one copy of the mutated gene have twice the average risk of developing Crohn's, and those with two defective genes face 20 - 40 times the risk.

Infections

One theory suggests that viruses or bacteria within the intestine may alter properties in the lining and intestinal tract. Over time, these changes may trigger the injurious processes that lead to inflammatory bowel disease.

Measles. Some studies report that children with IBD may have had more and earlier childhood infections. The measles virus has been of particular interest. According to the U.S. Centers for Disease Control, and many studies, the measles virus does not cause Crohn’s or IBD.

Much publicity has centered on whether the vaccine for measles, mumps, and rubella (the MMR vaccine) causes conditions such as autism and Crohn’s disease. This theory has been rigorously reviewed and refuted in many well-conducted studies, including several published in 2006. The evidence clearly indicates that the MMR vaccine does not increase the risk of Crohn’s disease, other inflammatory bowel disease, or autism.

Mycobacteria. A type of bacterium associated with tuberculosis is another possible candidate for an infectious cause of Crohn’s disease.

Escherichia coli. The intestine normally harbors E. coli bacteria. In most cases, the bacteria are harmless and even protective. Some E. coli strains, however, can bind to the intestinal walls and penetrate the lining. These damaging strains may be associated with Crohn’s disease.

Cytomegalovirus. Cytomegalovirus (CMV) is a common virus that is also under suspicion as a contributor to severe cases of IBD.

Dietary Factors

Inflammatory bowel disease is much more prevalent in industrialized nations and in higher-income groups. Experts believe, then, that diet must play some role, although studies have been conflicting over its importance.

Crohn's Symptoms

Alternative Names:

Inflammatory bowel disease - Crohn's disease; Regional enteritis; Ileitis; Granulomatous ileocolitis

Symptoms:

Abdominal pain
Fever
Diarrhea
Loss of appetite
Unintentional weight loss
Abdominal mass
Abdominal sounds (borborygmus, a gurgling or splashing sound heard over the intestine)
Fatigue
Gastrointestinal bleeding
Foul-smelling stools
Tenesmus (pain with passing stool)

Additional symptoms that may be associated with this disease include the following:

Bloody stools
Joint pain
Anal Incontinence
Swollen gums
Constipation
Abdominal fullness and gas

Signs and tests:

A physical examination may reveal an abdominal mass or tenderness, skin rash, swollen joints or mouth ulcers.

Tests that show findings of Crohn's disease
- Endoscopy, colonoscopy, or sigmoidoscopy with small bowel biopsy
- Small bowel follow through
- Barium enema
- Upper GI series
Positive stool guaiac

A stool culture may be done to rule out other possible causes of the symptoms.

This disease may also alter the results of the following tests:

Fecal fat
Liver function tests
Albumin

Treatment Options for Crohn's Disease

Treatment focuses on relieving symptoms of the disease by inducing and then maintaining remission. This is accomplished by prescribing medicines that reduce the inflammation in the intestinal tract. Common drugs used to treat Crohn's disease are aminosalicylates, steroids, antibiotics, anti-TNF agents (see Infliximab below), and immunomodulators.

The cornerstone for inducing remission in severe Crohn's disease continues to be oral or intravenous corticosteroids such as prednisone. They also have a role in managing less severe disease and in treating small bowel involvement. They are used for short-term therapy and other medications are used to maintain remission following steroids. Steroids work by reducing inflammation throughout the body and thus long-term use is associated with many side effects like osteoporosis, diabetes, and hypertension. Promising results have been obtained with the use of budesonide (Entocort), a corticosteroid with high topical anti-inflammatory activity and low systemic activity (because of extensive hepatic metabolism). This medication, though costly, can reduce the intestinal inflammation while minimizing the side effects that would commonly be experienced with prednisone.

Another category of drugs often used in Crohn's disease is the topically acting 5-aminosalicylates such as mesalamine (Asacol, Pentasa), sulfasalazine (Azulfidine), and balsalazide (Colazal). These medicines are quite safe, but may require large doses. Antibiotic agents, such as metronidazole may be helpful in perianal and/or colonic Crohn's disease. How antibiotics help Crohn's disease is not well understood, but the benefit may be the result of altered concentrations of bacteria in the colon and small bowel.

Immunomodulatory drugs such as azathioprine (Imuran, Azasan), 6-mercaptopurine (Purinethol), or methotrexate are often effective in maintaining remission of Crohn's disease. These medications are used long-term and require monitoring to prevent adverse effects. They work by changing the way certain inflammatory cells in the intestinal lining respond to inflammatory triggers.

Infliximab (Remicade) is a powerful anti-inflammatory drug that blocks the action of a specific molecule called tumor necrosis factor (TNF), a key mediator of the inflammatory process in Crohn's disease. It is indicated for perianal Crohn's disease or intestinal disease not responding to the usual first-line medications. This drug is actually a synthetic antibody and is given as an intravenous infusion for both induction and maintenance of remission. Important side effects of this medication are infusion reactions (rash, fever) and, rarely, serious infections. Other medications known as biologicals, of which infliximab is one, are being studied and may emerge as viable therapies for Crohn's disease in the future.

HUMIRA® (adalimumab) is a TNF (tumor necrosis factor) blocker that was recently approved by the Food and Drug Administration (FDA) for the treatment of moderate to severe Crohn's disease in adults who have not responded well to conventional therapy. HUMIRA is also approved for those adults who have lost response to, or are unable to tolerate REMICADE (infliximab). It can work fast - many patients experienced a response (significant difference in their symptoms) in just 4 weeks. In research studies of patients with Crohn's disease, HUMIRA helped relieve many of the symptoms of Crohn's disease, including painful cramps, persistent diarrhea and fatigue. It also helped patients experience remission (stop flare-ups for long periods of time). Patients with Crohn's disease take HUMIRA as an injection once every other week. Once your doctor shows you how to take HUMIRA, the injections can be taken in the convenience of your own home.

Despite advances in the medical treatment of Crohn's disease, surgery may be necessary to remove the diseased segment of bowel. Surgery is usually reserved for those in whom medical treatment has been ineffective. Other indications for surgery may include:

permanent narrowing or an obstruction of the bowel
development of a fistula between an involved segment and the bladder, vagina or skin
infection in the area of the anus
perforation of the bowel
abscess (localized infection) within the abdomen

Surgery will result in remission but does not represent a cure of the disease. Most patients will have a recurrence of Crohn's disease after surgery and thus will require additional medical therapy.

Despite the serious nature of the disease, treatment often permits the person with Crohn's disease to lead an active and productive life with a normal lifespan. Dietary changes have not been shown to help treat Crohn's disease because diet does not appear to reduce the inflammation in the intestines. Because weight loss is common when Crohn's disease is active, it is important that patients maintain a healthy diet with adequate caloric intake. However, weight gain may only be successful after reducing the inflammation with prescription medications. If the bowel becomes narrowed (strictured) because of chronic Crohn's disease activity, then patients may be at risk of bowel obstruction. In this case, a low residue diet that eliminates non-digestible vegetables may be recommended. For all patients, stopping smoking is an important part of any therapy for this disease.

Reference Link:

http://www.healthcentral.com/chronic-pain/crohns

Laser Surgery Can Correct Nearsightedness

2007-12-29T14:52:00.001+02:00

FRIDAY, Dec. 28 (HealthDay News) -- Laser surgery effectively and safely corrects severe myopia for at least a decade, new research suggests.

People with myopia, which is caused by excessive curving of the eye's lens or cornea, are commonly referred to as nearsighted. According to the American Optometric Association, almost one in three Americans suffers from some degree of nearsightedness.

Laser surgery has been used to correct myopia since the early 1990s, although the long-term effects of the surgeries have not been documented. Writing in the January issue of the American Journal of Ophthalmology, researchers from the Miguel Hernandez University in Alicante, Spain, and the Ankara University School of Medicine in Turkey described the results of a 10-year study of 196 myopic eyes that received LASIK surgery.

The researchers gathered data from 118 patients, who originally needed 10 diopter corrections to achieve 20/20 vision. A diopter is a measure of the curve of a lens, and a 10-diopter correction indicates severe nearsightedness.

The patients were evaluated 10 years after their surgeries. After treatment, most patients showed at least some vision improvement, with 40 percent avoiding the use of glasses completely. After a decade, 61 percent of eyes operated on were within two diopters. Only 1 percent of eyes developed corneal ectasia, a weakening of the cornea that is a possible side effect of LASIK surgery.

Almost one in three (27 percent) patients had to be retreated during the 10 years, the researchers said.

"This study has allowed us to demonstrate that, in spite of the prejudices about the limits of LASIK technique, the results regarding predictability, efficacy and safety for high myopic patients are very good in the long term," lead investigator Jorge L. Ali said in a prepared statement.

Reference Link:

http://www.drkoop.com/newsdetail/93/198106-31.html

Warts and Plantar Warts - Topic Overview

2007-12-28T11:18:00.001+02:00

What are warts, and what causes them?

A wart is a harmless skin growth caused by some types of the virus called the human papillomavirus (HPV). There are more than 100 known types of HPV. HPV infects the top layer of skin, usually entering the body in an area of broken skin. The virus causes the top layer of skin to grow rapidly, forming a wart. Most warts go away on their own within months or years.

Warts can grow anywhere on the body. They are most common among children and young adults.

There are five kinds of warts. They look different and form on different parts of the body.

Common warts grow most often on the hands, but they may be anywhere on the body. They are rough, shaped like a dome, and gray-brown in color.
Plantar warts grow on the soles of the feet. They look like hard, thick patches of skin with dark specks. Plantar warts may cause pain when you walk, and you may feel like you are stepping on a pebble.
Flat warts usually grow on the face, arms, or legs. They are small (usually smaller than the eraser on the end of a pencil), have flat tops, and can be pink, light brown, or light yellow.
Filiform warts usually grow around the mouth, nose, or beard area. They are the same color as your skin and have growths that look like threads sticking out of them.
Periungual warts grow under and around the toenails and fingernails. They look like rough bumps with an uneven surface and border. They can affect nail growth.

How are warts spread?

Warts are easily spread by direct contact with a human papillomavirus. You can infect yourself again by touching the wart and then another part of your body. You can infect another person by sharing towels, razors, or other personal items. After contact with HPV, it can take 2 to 9 months of slow growth beneath the skin before you notice a wart.

It is unlikely that you will get a wart every time you come in contact with HPV. Some people are more likely to get warts than others.

What are the symptoms?

Warts come in a wide range of shapes and sizes. A wart may be a bump with a rough surface, or it may be flat and smooth. Tiny blood vessels grow into the core of the wart to supply it with blood. In both common and plantar warts, these blood vessels may look like dark dots in the wart's center. In most cases, the skin lines and creases over the wart look distorted.

Warts are usually painless. But a wart that grows in a spot where you put pressure, such as on a finger or on the bottom of the foot, can be painful.

How are warts diagnosed?

A doctor usually can tell if a skin growth is a wart just by looking at it. Your doctor may take a sample of the wart and look at it under a microscope (skin biopsy). This may be done if it is not clear that the growth is a wart. It may also be done if a skin growth is darker than the skin surrounding it, is an irregular patch on the skin, bleeds, or is large and fast-growing.

How are they treated?

Most warts don't need treatment. But if you have warts that are painful or spreading, or if you are bothered by the way they look, your treatment choices include:

Using a home treatment such as salicylic acid or adhesive tape. You can get these without a prescription.
Putting a stronger medicine on the wart, or getting a shot of medicine in it.
Freezing the wart (cryotherapy).
Removing the wart with surgery (electrosurgery, curettage, laser surgery).

Wart treatment does not always work. Even after a wart shrinks or goes away, warts may come back or spread to other parts of the body. This is because most treatments destroy the wart but do not kill the virus that causes the wart.

Reference Link:

http://www.webmd.com/skin-problems-and-treatments/tc/warts-and-plantar-warts-topic-overview

Healthy Fingernails: Clues About Your Health

2007-12-28T11:15:00.001+02:00

Fingernail color and texture can reflect a wide range of medical conditions.

By Sherry Rauh
WebMD Feature

Reviewed by Louise Chang, MD

Take a good look at your fingernails and you may notice subtle variations in the texture or color -- a touch of white here, a rosy tinge there, perhaps some rippling or bumps in the surface. These imperfections may not look like much to you, but it’s more important than you might think to maintain healthy fingernails. That’s because to the trained eye, nails can provide valuable clues about your overall health. And noticing and following up on those clues is the best way to maintain healthy fingernails.

Tips for Strong, Healthy Fingernails

To maintain healthy fingernails, avoid infections, and improve nail appearance, try the following tips:

Keep your nails clean and dry.
Avoid nail-biting or picking.
Apply moisturizer to your nails and cuticles every day. Creams with urea, phospholipids, or lactic acid can help prevent cracking.
File your nails in one direction and round the tip slightly, rather than filing to a point.
Don't remove the cuticles or clean too deeply under your nails, which can lead to infection.
Don't dig out ingrown toenails. See a dermatologist if they become bothersome.
Avoid nail polish removers that contain acetone or formaldehyde.
Bring your own instruments if you get frequent manicures.
If you have artificial nails, check regularly for green discoloration (a sign of bacterial infection).
Eat a balanced diet and take vitamins containing biotin.

Finally, to maintain your healthy fingernails over time, ask your doctor to take a look at them during your next checkup.

"Just like the eyes are the window to the soul, so are the nails," says Tamara Lior, MD, a dermatologist with Cleveland Clinic Florida. Lior says she once convinced a patient to have his lungs checked after noticing a bluish tint to his nails, a sign that he wasn't getting enough oxygen. Sure enough, he had fluid in his lungs.

Warning signs for many other conditions, from hepatitis to heart disease, may also appear when previously healthy fingernails undergo changes, according to Joshua Fox, MD, director of Advanced Dermatology and spokesman for the American Academy of Dermatology. "Changes in the nails can be a sign of a local disease like a fungus infection or a sign of a systemic disease like lupus or anemia," Fox tells WebMD.

He says he sometimes tries to guess if a person has anemia by looking at his or her nails. He explains that pale, whitish nail beds may indicate a low red blood cell count consistent with anemia.

An iron deficiency can cause the nail bed to be thin and concave and have raised ridges.

While most of Fox's patients don't come in to report nail problems, he routinely checks patients to make sure they have healthy fingernails. "The nails offer many little clues to what's going on inside you. Lupus patients get quirky, angular blood vessels in their nail folds. Psoriasis starts in the nails up to 10% of the time" and causes splitting and pitting of the nail bed.

Heart disease can turn the nail beds red. Obsessive-compulsive disorder can show up in the nails through persistent nail-biting or picking, Fox says.

Even common disorders like thyroid disease can cause abnormalities in the nail beds, producing dry, brittle nails that crack and split easily.

He lists the following 10 examples of nail changes that could indicate a serious medical condition.

A Guide to Healthy Fingernails:
10 Possible Signs of Serious Conditions

* White nails:

Liver diseases such as hepatitis

* Yellowish, thickened, slow-growing nails:

Lung diseases such as emphysema

* Yellowish nails with a slight blush at the base:

Diabetes

* Half-white, half-pink nails:

Kidney disease

* Red nail beds:

Heart disease

* Pale or white nail beds:

Anemia

* Pitting or rippling of the nail surface:

Psoriasis or inflammatory arthritis

* "Clubbing," a painless increase in tissue around the ends of the fingers, or inversion of the nail:

Lung diseases

* Irregular red lines at the base of the nail fold:

Lupus or connective tissue disease

* Dark lines beneath the nail:

Melanoma

'Rarely the First Clue'

But can a doctor truly detect undiagnosed heart disease or kidney problems by looking at your nails? American College of Physicians spokesman Christine Laine, MD, MPH, says it's not likely. She doesn't dispute the connection between nails and disease, but she cautions, "Nail changes are rarely the first clue of serious illness. In most instances, patients will manifest other signs or symptoms of disease before nail changes become evident. For example, it would be unusual that nail clubbing was the first thing a patient with emphysema noticed. Breathing difficulty probably would have been present already."

In addition, Laine, who is senior deputy editor of the Annals of Internal Medicine, notes that certain illnesses may cause nail changes in some patients but not in others. "For example, not all people with liver disease develop white nails," Laine tells WebMD. The reverse is true as well -- not everyone with white nails has liver disease. "In the absence of other signs or symptoms of disease, I would be reluctant to launch a complex, expensive work-up for systemic disease solely because of nail findings."

Fox agrees there is no need to run to the nearest cardiologist if your nail beds turn red. "It could very well be from nail polish," he says. Before assuming the worst, it's important to look at more common explanations, such as bruises, bleeding beneath the nail, and fungal infections. However, it’s worthwhile to be vigilant about maintaining healthy fingernails so that you’ll be alert to any potential problem.

When to See a Dermatologist

When healthy fingernails begin to change color or texture, one of the most common underlying causes is fingernail fungus, which can cause the nails to crack, peel, and change color and texture. These infections often prove difficult to treat and may require professional help, including prescription antifungal medications. Fox says it's best to see a dermatologist if symptoms persist, especially if the nails start to dislodge from the base or you experience pain and swelling.

Be alert to changes in texture, shape, or color that aren't due to a bruise or fungal infection, including irregular growth, pitting or holes in the nails, dark brown streaks beneath the nail and cuticle, or long-standing warts on the nail bed. Any such color change to previously healthy fingernails is cause for concern. According to Lior, such changes can indicate skin cancer. "Warts around the nails have a tendency to develop into squamous cell cancer," she tells WebMD. "If patients see a dark discoloration involving the cuticle, then we worry about melanoma," the deadliest form of skin cancer.

Fox advises reporting these types of changes to a specialist as soon as possible. "Dermatologists are well-trained in deciphering between innocuous and serious nail conditions, as well as determining when a change requires further testing."

Reference Link:

http://www.webmd.com/skin-problems-and-treatments/features/healthy-fingernails-clues-about-health

Male Enhancement: Is It Worth a Try?

2007-12-28T11:09:00.001+02:00

Nonpresciption methods of male enhancement and male enlargement range from the possibly effective to the downright dangerous.

By Richard Sine
WebMD Feature

Reviewed by Louise Chang, MD

Our email inboxes fill up every day with advertisements for pills, ointments, supplements, and contraptions aimed at enhancing penis size, sexual stamina, or libido. It’s a testimony to men’s abiding insecurities about sexual performance. The question is, do any of these “male enhancement” techniques really work?

Richard, a mechanic from upstate New York, is a muscular, athletic guy. He has a loving wife who has always enjoyed their sex life. But ever since he was a young boy, Richard couldn’t get over the feeling that his penis was too small. In public bathrooms, he’d use the handicapped stall. He felt embarrassed in gym locker rooms and when standing naked before his wife. “I didn’t feel manly enough,” he tells WebMD.

Then, in the back of a weightlifting magazine, he saw an ad for the FastSize Extender, a device that claims to make the penis longer and fatter through traction. Richard began wearing the device almost eight hours a day, every day. He was shocked to notice a difference within a few days. After four months of wearing the device, he says his flaccid penis has stretched from 3 inches to over 5 inches; erect, he has gone from less than 6 inches to over 7 inches. The device cost $298, but Richard says the effect on his self-confidence has been priceless: “It made a world of difference to me.”

The FastSize Extender, though not extensively tested, has received some validation from mainstream medical sources. But that makes it a true rarity among the nonprescription methods of male enhancement. Most are a waste of money, and some are downright dangerous, doctors say.

Instead of furtively turning to untested methods, men with persistent concerns should consider opening up about them with their doctors. That’s because performance problems sometimes act as an early warning signal for serious health problems. Your doctor might be able to prescribe something that can really help, or least provide a valuable dose of perspective about what constitutes “normal” sexual performance.

Links Between Sexual and Overall Health

Sexual performance declines naturally as men age, doctors say. But a rapid or severe decrease in performance or libido can be a red flag. Most importantly, erectile dysfunction may be an early predictor of heart disease.

Atherosclerosis, a condition in which fatty deposits build up inside arteries, may restrict blood flow to the penis and cause erection difficulties. “The small blood vessels that go to the penis can become diseased much earlier than the [larger] vessels that go to the heart,” Karen Boyle, MD, a urologist at Johns Hopkins School of Medicine, tells WebMD. “In younger or younger middle-aged men, ED is often the first sign of atherosclerosis.”

For men with ED who are at risk of heart disease, prescribing Viagra or its cousins isn’t enough, Boyle says. These men should be also be controlling their weight and cholesterol level, limiting their alcohol intake, and quitting smoking. Evidence shows that these changes in themselves can have a positive effect on sexual function, Boyle says.

Sometimes men with erection problems or a diminished libido have low levels of testosterone, Boyle says. Testosterone deficiencies can also affect mood and energy levels. Boyle tests for testosterone levels and prescribes it as a topical gel, though she warns it is only safe when prescribed and monitored by a physician. Nonprescription testosterone, such as the kind used by some bodybuilders, is dangerous, she warns.

For men with performance issues who are physically healthy, Boyle often prescribes counseling, such as marriage counseling for men with relationship issues or psychiatric help for men who are preoccupied with a problem in penile appearance. For young men with sexual performance problems and no signs of physical problems, Boyle may prescribe counseling and a low dose of Viagra as they work out issues of insecurity. “They need reassurance from a physician that everything is OK,” she says.

The Quest for a Bigger Penis

The FastSize Extender device promises results, but it’s far from quick and easy. Just ask Bob, a retail manager from New Jersey. He says he’s gained over 2 inches of erect length. All it took was 25 months and over 2,600 hours wearing the device, typically five hours a day, seven days a week. “I was afraid my girlfriend would think I was a freak, but she was supportive because she felt a difference in her satisfaction and I felt more confident in myself,” Bob tells WebMD.

Richard, the mechanic from New York, got results faster than Bob, but still wore the device under his clothes for about eight hours a day. Richard’s wife has also been supportive. “I see a more confident man in front of me from using this product,” she says. She also says the lengthening has enhanced their sex life, though she had no complaints before.

Chicago urologist Laurence A. Levine, MD, director of the male fertility program at Rush University Medical Center, tested the FastSize Extender on 10 men afflicted with Peyronie’s disease, which can cause bending and shrinkage of the penis. At the end of the six-month study, which was funded by the maker of the FastSize Extender, Levine found increased penile length and reduced curvature in every man and increased girth in seven of the men. Calling the results “remarkable,” Levine now prescribes the device to many of his Peyronie’s patients and reports no significant complications. (Levine has also worked as a paid consultant to FastSize Extender.)

Could FastSize work on men of normal penile length? Levine says it might. “If a woman can have a breast enlargement and it makes them psychologically feel better,” he reasons, “then perhaps we should have the same thing for men.”

Penis-lengthening surgery is also an option for men, but it is a highly controversial procedure. The American Urological Association says a common form of lengthening surgery (involving cutting the suspensory ligament of the penis) has not been shown to be safe or effective. The group also refuses to endorse surgeries that inject fat cells in the penis with the goal of increasing penile girth.

Many doctors question whether the benefits of lengthening surgery outweigh the risks. A 2006 study found that only 35% of men were satisfied with the outcome of surgery, which added only half an inch, on average, to length. Men who are overly preoccupied with penis length tend to have unrealistic expectations of surgery and should seek counseling instead, the authors wrote.

Herbs and Male Enhancement

Thousands of years before Viagra, men were consuming everything from horny goat weed to powdered rhino horn in hopes of boosting sexual performance. The remedies persist for men who can’t get their hands on prescription drugs like Viagra or who prefer “natural” cures.

But many doctors are wary of traditional medicines. When Boyle’s patients come to her with bottles of herbal supplements, she tells them she cannot vouch for their safety or effectiveness unless the FDA has reviewed the claims on the label.

No herbal remedy can restore erections like Viagra and its prescription counterparts, says Steven Lamm, MD, an assistant professor of medicine at New York University and author of The Hardness Factor. But Lamm says these remedies may be appropriate for men who have experienced a decline in sexual performance but do not suffer from a diagnosable sexual problem. Lamm has endorsed an herbal remedy, marketed under the Roaring Tiger label, that combines horny goat weed and other herbal extracts with the amino acid L-arginine. (The supplements are made by the same company that makes the FastSize Extender.)

The Way to Happiness in Bed

The Internet is rife with scammers who seek to prey on men’s insecurities, Levine says. “All the pills, topical creams, and gels are worthless. Many men would clearly rather spend $20, $50, $100 on the Internet than go to the doctor and get real information.”

In some cases, men are harming themselves in the pursuit of a bigger penis. Levine cites “jelqing,” a technique involving hours and hours of intense stroking. He says he has patients who have developed Peyronie’s disease due to violent stretching of the penis through jelqing.

It’s ironic that the male preoccupation with enhancement seems to be independent of the needs of women, the supposed benefactors of improved sexual performance. A recent study found that 85% of women are pleased with their partner’s penis proportions, but 45% of men say they want a larger penis. Given that the vast majority of men fall within a certain penis size -- about 5.5 to 6.2 inches long when erect -- most men fall within the normal range.

And there’s plenty of debate on whether size matters at all. The most sensitive nerves in the vagina are found close to the surface, Lamm notes, and the clitoris is found on the vagina’s outside. So there should be plenty of ways to satisfy your partner that have nothing to do with pills, creams, surgery, or devices.

Reference Link:

http://men.webmd.com/features/male-enhancement-is-it-worth-try?

Understanding Fibromyalgia

2007-12-28T11:05:00.001+02:00

What Is Fibromyalgia?

Fibromyalgia is a non-life-threatening, chronic disorder of the muscles and related soft tissue, including ligaments and tendons. Its main symptoms are muscle pain, fatigue, sleep disturbances, and tender points at certain parts of the body. Many people describe fibromyalgia as feeling like a persistent flu.

Some health care providers may use these terms to refer to fibromyalgia: fibromyositis, fibrositis, periarticular fibrositis, muscular rheumatism, chronic muscle pain syndrome, musculoskeletal pain syndrome, or tension myalgia. However, "fibromyalgia," which means "pain of the muscles and other fibrous tissue," is the accepted term and has replaced some of the others. Terms ending in "-itis," which means "inflammation," are now considered incorrect because inflammation does not play a significant role in fibromyalgia.

Key Characteristics

Muscle pain, either throughout the body or only at certain points, is the primary symptom. It may range from mild discomfort to pain severe enough to limit work, social activities, and everyday tasks. Pain commonly occurs in the neck, shoulders, chest, rib cage, lower back and thighs and may feel like a burning, gnawing, throbbing, stabbing, or aching sensation and may develop gradually. It usually seems worse when a person is trying to relax and is less noticeable during activity.

A related, key aspect of fibromyalgia is the presence of "tender points," muscles and tendons that are tender when pressed. Typically, tender points are located in the neck, back, knee, shoulder, elbow, and hip.

People with fibromyalgia also feel moderately to severely fatigued and have sleep problems, including insomnia. This may result from restless legs and arms, which may disrupt their sleep, or they may suffer from sleep apnea or grind their teeth while they sleep.

Tender Points

According to the American Academy of Rheumatology, for a diagnosis of fibromyalgia, you must have unusual tenderness at a minimum of 11 of the 18 "tender points" associated with the condition. Some health care providers diagnose fibromyalgia in patients who have fewer tender points but who otherwise have severe, widespread (meaning upper and lower body occurring on both right and left sides) pain symptoms that are present for at least three months.

The standard tender points are located in the muscle or other soft tissue on both sides and the front and back of the body. Those who have fibromyalgia may have unusual tenderness at any of several other points on the body as well.

Who Is Affected

Experts estimate that 3 million to 6 million Americans have fibromyalgia. Of these, 80% are women. One of the main risk factors is being a woman between the age of 20 and 50. Another risk factor is having a rheumatic disease, such as rheumatoid arthritis, lupus or Sjogren's syndrome. Fibromyalgia also seems to run in families, so a gene may be at least partly responsible for the condition. Most people with fibromyalgia begin to notice symptoms between the ages of 20 and 40, but children and older adults may also develop the condition. Women with fibromyalgia typically feel pain throughout their body, while men are more likely to have facial pain or pain and stiffness in a certain part of the body as a result of a work- or recreation-related muscle strain.

What Causes It?

Experts do not know what causes fibromyalgia. There are several theories about possible causes or triggers. Inadequate sleep is a possible trigger. Another is suffering an injury or physical or emotional trauma that affects the brain, spine, and nerves. Some experts believe that a viral or bacterial infection plays a part.

Abnormal production of pain-related chemicals in the nervous system also contributes to the symptoms of fibromyalgia. It's thought that any one of these factors may bring on the symptoms of fibromyalgia in someone who is already genetically predisposed to the condition.

What Are the Symptoms?

Symptoms of fibromyalgia include:

Chronic muscle pain, muscle spasms or tightness, and leg cramps
Moderate or severe fatigue and decreased energy
Insomnia or waking up feeling just as tired as when you went to sleep
Stiffness upon waking or after staying in one position for too long
Difficulty remembering, concentrating, and performing simple mental tasks
Abdominal pain, bloating, nausea, and constipation alternating with diarrhea (irritable bowel syndrome)
Tension or migraine headaches
Jaw and facial tenderness
Sensitivity to one or more of the following: odors, noise, bright lights, medications, certain foods, and cold
Feeling anxious or depressed
Numbness or tingling in the face, arms, hands, legs, or feet
Increase in urinary urgency or frequency (irritable bladder)
Reduced tolerance for exercise and muscle pain after exercise
A feeling of swelling (without actual swelling) in the hands and feet
Painful menstrual periods
Dizziness

Symptoms may intensify depending on the time of day -- morning, late afternoon, and evening tend to be the worst times, while 11 a.m. to 3 p.m. tends to be the best time. They may also get worse with fatigue, tension, inactivity, changes in the weather, cold or drafty conditions, overexertion, hormonal fluctuations (such as just before your period or during menopause), stress, depression, or other emotional factors.

If the condition is not diagnosed and treated early, symptoms can go on indefinitely, or they may disappear for months and then recur.

Call Your Doctor If:

You have chronic muscle pain and overwhelming fatigue.

How Do I Know If I Have It?

Before fibromyalgia treatment can begin a doctor must diagnose the condition.

Some experts think that fibromyalgia is underdiagnosed. It can be difficult to diagnose because many of its symptoms are the same as those of other conditions, such as chronic fatigue syndrome, underactive thyroid, Lyme disease, lupus, and multiple chemical sensitivity. Fibromyalgia is usually diagnosed after other possible causes have been ruled out.

To diagnose fibromyalgia, your doctor will take a thorough history and do physical and neurological exams. He or she may order laboratory tests to rule out other conditions. They will also determine whether you have any tender points, the key distinguishing symptom of fibromyalgia. Some doctors use the American College of Rheumatology guidelines that require a minimum of 11 out of 18 tender points for a fibromyalgia diagnosis. Others believe that fewer than 11 tender points may indicate fibromyalgia, particularly if you also have severe fatigue and widespread pain that has lasted more than three months.

Because of the difficulty in diagnosing fibromyalgia, it is best to see a doctor who is knowledgeable about the condition, such as a rheumatologist. Diagnosis is important because the earlier fibromyalgia is detected, the sooner you can make lifestyle changes to reduce the symptoms.

What Are the Treatments?

There is no cure for fibromyalgia, and people with the condition usually have it for life. However, it is not likely to get worse as you age and it does not damage your muscles, tendons, or ligaments. Many people are able to reduce their symptoms with a combination of exercise, medication, physical therapy and relaxation.

Lifestyle Choices

A vital part of treating fibromyalgia is frequent, low-impact aerobic exercise. Examples include walking, biking, water aerobics, and swimming. Exercise tends to reduce pain and tenderness and to improve muscle fitness and sleep. Stretching is also important and may help reduce stiffness and pain.

At first, pain and fatigue may make it difficult for you to exercise. Keep in mind that persisting with an exercise routine may reduce your symptoms, while becoming unfit may make symptoms worse. If you have not exercised recently, be sure to talk with your doctor before you begin an exercise program, and start slowly. Your doctor or a physical therapist can help you work up to 20 to 30 minutes of exercise on most days of the week.

Better-quality sleep may also help reduce fibromyalgia symptoms. Low-dose tricyclic antidepressants help relieve sleep problems and pain in many people with fibromyalgia. Also, try to go to bed and wake up at the same time every day; some people notice that their symptoms get worse when they stay up just an hour or two later than usual.

Avoid alcohol and caffeine. These disrupt deep, restorative sleep and may aggravate your symptoms.

Relaxation techniques can help relieve muscle tension and reduce stress. Evaluating the causes of stress and learning new ways to cope may also lessen symptoms.

Medication

Nonsteroidal anti-inflammatory drugs (such as ibuprofen, naproxen, ketoprofen, and aspirin) or other pain medication (such as Ultram) may help relieve muscle pain. For a particularly tender area, your health care provider may inject a local anesthetic to provide relief that typically lasts about two to three month

At-Home Remedies

Applying heat or cold packs to painful areas may relieve symptoms temporarily. Staying warm and improving your posture may also help. Reducing stress may reduce symptoms and may even eliminate them in mild cases. Pace yourself with work, household chores, and social activities -- don't take on too much.

Take a proactive role in learning about fibromyalgia to help control it, and be vigilant about following your treatment plan. Emotional support is very important, too. Living with fibromyalgia may be difficult if your family, friends, or employer do not understand the condition. Seek out supportive family, friends, clergy, support groups or a mental health counselor.

Medications for Fibromyalgia

Medications

The most effective medications in the treatment of fibromyalgia are the tricyclic antidepressants, medications traditionally used in treating depression. In treating fibromyalgia, tricyclic antidepressants are taken at bedtime in doses that are a fraction of those used for treating depression. Tricyclic antidepressants appear to reduce fatigue, relieve muscle pain and spasm, and promote deep restorative sleep in patients with fibromyalgia. Scientists believe that tricyclics work by interfering with a nerve transmitter chemical in the brain called "serotonin." Examples of tricyclic antidepressants commonly used in treating fibromyalgia include amitriptyline (Elavil) and doxepin (Sinequan).

A recent study suggests that adding fluoxetine (Prozac) to low dose amitriptyline (Elavil) further reduces muscle pain, anxiety, and depression in patients with fibromyalgia. The combination is also more effective in promoting restful sleep and improving an overall sense of well-being. These two medications also tend to cancel out certain side effects each can have. Tricyclic medications can cause tiredness and fatigue, while fluoxetine can make patients more cheerful and awake. Even more recently, study of patients with resistant fibromyalgia found that lorazepam (Ativan) was helpful in relieving symptoms. Fluoxetine has also been shown to be effective when used alone for some patients with fibromyalgia. Newer antidepressants including Effexor and Cymbalta and drugs such as Lyrica may reduce pain and improve functioning.

Other Treatments

Local injections of analgesics and/or cortisone medication into the trigger point areas can also be helpful in relieving painful soft tissues, while breaking cycles of pain and muscle spasm. Some studies indicate that the pain-reliever tramadol (Ultram) and tramadol/acetaminophen (Ultracet) may be helpful for the treatment of fibromyalgia pains. The muscle relaxant cyclobenzaprine (Flexeril) has been helpful for reducing pain symptoms and improving sleep.

The nonsteroidal antiinflammatory drugs (NSAIDs), while very helpful in treating other rheumatic conditions, have only a limited value in treating fibromyalgia pain. Narcotic pain relievers and cortisone medications have not been shown to be beneficial in this condition. Narcotics and cortisone medications are avoided because they have not been shown to be beneficial and they have potential adverse side effects, including dependency, when used long-term.

Both biofeedback and electroacupuncture have been used for relief of symptoms with some success. Standard acupuncture was recently reported to be effective in treating some patients with fibromyalgia.

WebMD Guide

Reference Link:

http://www.webmd.com/fibromyalgia/guide

Severe Psoriasis May Up Risk of Death

2007-12-28T11:00:00.001+02:00

Study Shows Patients With Severe Psoriasis Die Earlier

By Salynn Boyles
WebMD Medical News

Reviewed by Louise Chang, MD

Dec. 17, 2007 -- Psoriasis is not generally thought of as life-threatening, but it just might be for those with the severest forms of the disease.

People with severe psoriasis had a 50% increased risk of death compared with people without the inflammatory skin disease in a newly reported study.

Men with severe psoriasis died an average of 3.5 years earlier than men without the condition, while women with severe psoriasis died 4.4 years earlier than women without psoriasis.

Having mild psoriasis was not associated with an increased risk of death, and the researchers did not have information on causes of death.

But researcher Joel M. Gelfand, MD, says the findings make it clear that patients with severe psoriasis are at greater risk than has been realized.

"To put this in perspective, this finding suggests that more years of life are lost related to severe psoriasis than to severe hypertension," he tells WebMD.

Psoriasis and Death

As many as 7.5 million Americans have psoriasis, according to the National Institutes of Health.

About 80% to 85% of patients have mild to moderate psoriasis, while 15% to 20% have more extensive skin involvement. These patients generally require treatment with systemic medications like the drugs methotrexate and cyclosporine or newer biologics such as Enbrel, Remicade, and Humira.

Using a national medical records database from the U.K., Gelfand and colleagues from the University of Pennsylvania School of Medicine identified 133,568 patients with mild psoriasis, defined as having a diagnosis of psoriasis but no history of treatment for the condition.

An additional 3,951 patients were identified with severe psoriasis.

For each patient, up to five people without psoriasis who visited doctors for other causes were used for comparison.

During the study period, the death rate among patients with severe psoriasis was almost twice as high as in patients without psoriasis (21.3 deaths per 1,000 individuals per year vs. 12 deaths per 1,000 individuals per year).

During the study period, patients with severe psoriasis had a 50% increased risk of death compared with those without psoriasis. Those with milder psoriasis didn't have an increased risk of death compared to those without psoriasis.

The study appears in the December issue of the Archives of Dermatology.

Is Inflammation to Blame?

Earlier research by Gelfand and others found that people with severe psoriasis are at increased risk for a wide range of chronic conditions, including heart disease.

Psoriasis is now widely believed to be an autoimmune disease involving inflammation and the accelerated growth of skin cells and blood vessels, which produce the swollen, red lesions characteristic of the condition.

"One theory is that this chronic inflammation impacts other organs and systems within the body," Elizabeth Horn, PhD, of the International Psoriasis Council tells WebMD.

Inflammation within the body is increasingly recognized as a major contributor to a host of life-threatening conditions.

"We know that chronic inflammation is bad for a variety of organs and that it is probably involved in a number of chronic diseases, including cardiovascular disease and diabetes," Gelfand says.

Horn says the latest research should serve as a wake-up call to patients and their doctors that severe psoriasis is a serious disease.

"We are learning that there is something happening in people with severe psoriasis that may not be happening with milder forms of the disease," she says.

Horn and Gelfand agree that patients with severe psoriasis need to be especially vigilant about taking care of their overall health.

"It is very important for these patients to see their internist regularly, to have age-appropriate screenings, and to have their cardiovascular risks assessed and treated, if necessary," Gelfand says.

Psoriasis Signs

The signs of psoriasis vary depending on the type you have. Some common signs for plaque psoriasis -- the most common variety of the condition -- include:

Plaques of red, inflamed skin, often covered with loose, silver-colored scales. These plaques may be itchy and painful and sometimes crack and bleed. In severe cases, the plaques of irritated skin will grow and merge into one another, covering large areas.
Disorders of the fingernails and toenails, including discoloration and pitting of the nails. The nails may also begin to crumble or detach from the nail bed.
Plaques or crust on the scalp.
Small areas of bleeding where the involved skin is scratched.

Psoriasis can also be associated with psoriatic arthritis, which causes pain and swelling in the joints. The National Psoriasis Foundation estimates that between 10% to 30% of people with psoriasis also have psoriatic arthritis.

Reference Link:

http://www.webmd.com/skin-problems-and-treatments/guide

Cigarette Smoking

2007-12-27T14:43:00.001+02:00

AUTHOR INFORMATION

Author: Steven L Bernstein, MD, Vice-Chair, Academic Affairs, Department of Emergency Medicine, Newark Beth Israel Medical Center; Assistant Professor, Department of Emergency Medicine, Mt Sinai School of Medicine

Steven L Bernstein, MD, is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Public Health Association, and Society for Academic Emergency Medicine

Editor(s): Scott H Plantz, MD, FAAEM, Research Director, Assistant Professor, Department of Emergency Medicine, Mount Sinai School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; John A Calomeni, MD, JD, Consulting Staff, Department of Emergency Medicine, Seton Medical Center; Jonathan Adler, MD, Instructor, Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital; and Anthony Anker, MD, Emergency Department, Mary Washington Hospital

INTRODUCTION

Cigarette smoking remains the leading cause of death and illness among Americans. Every year, roughly 430,000 Americans die from illnesses caused by tobacco use, accounting for one-fifth of all deaths. Tobacco use costs the nation about $100 billion each year in direct medical expense and lost productivity.

About 25% of all American adults, 46.3 million people, smoke. This number has remained constant for several years despite government efforts through Healthy People 2000 and Healthy People 2010 to lower those percentages. Slightly more men (28.1%) smoke than women (23.5%). Hispanics (20.4%) smoke less than whites (25.3%) or African Americans (26.7%).

Nevertheless, significant progress has been made since 1964, when the Surgeon General issued the first report outlining the health dangers of smoking. Since that time, the prevalence of smoking has dropped from 42.4% among adults to 25%.

Both lung cancer and emphysema would become quite rare if people would stop smoking. Compared to a nonsmoker, a smoker faces these risks:

14 times greater risk of dying from cancer of the lung, throat, or mouth
4 times greater risk of dying from cancer of the esophagus
2 times greater risk of dying from a heart attack
2 times greater risk of dying from cancer of the bladder

Use of other tobacco products such as pipes, cigars, and snuff is less common, comprising less than 10% of use of all tobacco products. But the health effects of these products are similar to those of tobacco — particularly their association with cancers of the mouth, throat, and esophagus.

Increasing attention has been devoted to publicizing the dangers of second-hand (environmental) smoke, the association between tobacco marketing and initiation of smoking among youth, and the development of strategies and medications to help smokers quit. Cigarette smoking has been linked strongly to the following illnesses:

Stroke

Other diseases of blood vessels (such as poor circulation in the legs)

Respiratory illness, including the following:
- Lung cancer
- Emphysema
- Bronchitis
- Pneumonia

Cancers, including:
- Lip or mouth
- Pharynx or larynx (voice box)
- Esophagus (food pipe)
- Pancreas
- Kidney
- Urinary bladder
- Cervix

Peptic ulcer disease
Burns

SIGNS AND SYMPTOMS

Signs and symptoms of tobacco use depend on the specific illnesses they cause.

Shortness of breath may be a sign of emphysema or heart disease.
Chest pain may signal angina pectoris caused by insufficient blood flow to the heart or a heart attack.
Difficulty swallowing, or persistent hoarseness, may signal a cancer in the mouth or larynx.
Painless bloody urination may mean bladder cancer.
Common signs and symptoms of diseases associated with tobacco use follow. The presence of any of these symptoms should prompt a visit to the doctor or hospital's Emergency Department:

Chest pain
Shortness of breath
Persistent cough
Coughing up blood
Frequent colds and upper respiratory illness
Persistent hoarseness
Difficulty or pain on swallowing
Change in exercise capacity
Sudden weakness on one side of the face or body, or difficulty speaking
Leg pain while walking that goes away when you rest
Unexplained weight loss
Persistent abdominal pain
Bloody urine

HOME CARE

Home treatment of the various conditions caused by smoking is complex and may involve many different kinds of medicines.

Treatment of respiratory diseases, for example emphysema, involves taking aerosol sprays by mouth. These medicines are called beta-agonists and are related to epinephrine (Adrenaline, Bronitin, Primatene, Vaponefrin).

The medicines may be taken by metered-dose inhalers (pumps) or through nebulizer (cloud) machines.
They dilate the air passages in your lungs known as bronchi and bronchioles.

Additional medicines that may help treat emphysema include:

Corticosteroids, which reduce swelling and airway obstruction

Leukotriene inhibitors such as zileuton (Zyflo), zafirlukast (Accolate), montelukast (Singulair), which help prevent airway narrowing

Cromolyn sodium (Crolom, Intal, Nasalcrom), another anti-inflammatory agent

Theophylline (Hydrophed, Marax, Tedral), which helps widen airways

Oxygen is available at home for people with severe emphysema.

For people with heart disease, a variety of medicines are available.

Aspirin
Antiplatelet agents
Beta-blockers
Calcium channel blockers
Angiotensin converting enzyme inhibitors
Cholesterol-lowering agents

. WHEN TO CALL THE DOCTOR

If you are interested in quitting smoking, call your doctor.

It is never too early to think about quitting.

Every encounter with a doctor, whether in the office, the hospital, the Emergency Department, or clinic, is a good time to talk about smoking and the possibility of quitting.

WHEN TO GO TO THE HOSPITAL

Anyone with unexplained or sudden onset chest pain or difficulty breathing should go to the nearest hospital's Emergency Department, probably by ambulance. These conditions may be symptoms of a heart attack, which can be life threatening if not recognized and treated promptly. Tobacco use may cause shortness of breath or chest pain that may be life threatening along with these symptoms:

Pneumonia

Acute attack of emphysema

Pulmonary embolism (blood clot in the lung)

Aortic aneurysm - A football-shaped widening of the main artery leaving the heart, caused by a weakening in the wall of the artery

Aortic dissection - A tearing of the wall of the aorta, which, if it ruptures, bleeds profusely

PHYSICIAN DIAGNOSIS

Diagnosing tobacco use or tobacco-related illness is not difficult.

Doctors should ask people about tobacco use at every visit and provide counseling about quitting.

Most people who smoke admit doing so, in part because smoking carries less social stigma than use of other substances, such as alcohol or illicit drugs.

A doctor may find various conditions associated with chronic tobacco use on physical examination.

Nicotine causes a characteristic brown staining of the hard palate, teeth, fingers, and fingernails.

A smoker's skin may wrinkle prematurely.

Smokers will have a typical odor to their hair and clothing.

People with emphysema may have a large, barrel-shaped chest and a chronic cough that brings up thick green sputum

PHYSICIAN TREATMENT

Treating specific illnesses associated with tobacco use is discussed elsewhere in this guide. Treating tobacco use requires integrated steps.

Smokers must partner with their doctors, families, spouses, friends, even employers, to make quitting successful.

Quitting is not easy. Every year, 34% of all smokers try to quit, but only about 2.5% succeed. Nonetheless, 1 million Americans quit smoking each year.

Treatment consists of 2 broad areas.

The medical conditions caused by smoking—respiratory illness, heart disease, circulatory disease, cancer, ulcers—need to be treated.

The nicotine addiction also must be addressed and generally consists of a combination of the following:
- Nicotine replacement therapy (gum, patch, inhaler, or nasal spray). Nicotine patches are available over-the-counter, under several brand names, but are best used in conjunction with a physician.
- Doctors may give you bupropion (Zyban or Wellbutrin), a prescription drug.
- Group or behavioral counseling. The most successful quitting programs use combinations of drug treatment and counseling and have success rates of 5% after 1 year.

Smokers trying to quit need lots of support and encouragement to help handle the inevitable urges to light up.

Physicians, although trained in the diagnosis and treatment of smoking-related illnesses, may be less comfortable in providing the counseling and drug treatment smokers need to quit.

They may be unfamiliar with quit-smoking clinics available in the area.

So call your local chapter of the

American Lung Association

Health insurance plans often fail to pay for smoking cessation services.

This may discourage hospitals, clinics, and other health care settings from establishing stop-smoking programs.
Your employer may reimburse you for some of the cost of a clinic. A typical stop-smoking program costs less than $500, equal to the cost of about 150 packs of cigarettes. When including the gains in productivity caused by fewer missed days of work, and decreased use of health care resources, smoking cessation programs available through your employer can be quite cost-effective.

PROGNOSIS

For smokers, quality and length of life depends on the number and severity of smoking-associated illnesses they may develop and if they have other medical conditions such as diabetes or high blood pressure. Other lifestyle factors—use of alcohol or other drugs, for example—also make a difference in long-term outcomes for smokers. For smokers who quit, projected health and life expectancy improve markedly—at any age of life.

Smokers who quit before age 50 years have half the risk of dying in the next 15 years compared with those who continue to smoke.

Quitting smoking substantially decreases the risk of lung, voice box, esophageal, oral, pancreatic, bladder, and cervical cancers. For example, 10 years after quitting, an ex-smoker has 30-50% of the risk of lung cancer compared to a continuing smoker. Continued abstinence continues to lower the risk.

Quitting lowers the risk for other major diseases including coronary heart disease (CHD) and cardiovascular disease. The increased risk of CHD halves after 1 year of abstinence. After 15 years, the risk of CHD approximates that of someone who never smoked.

Women who stop smoking before pregnancy, or during the first 3 or 4 months of pregnancy, reduce their risk of having a low birthweight baby to that of women who never smoked.

The health benefits of quitting far exceed any risks from the average 5-pound weight gain that may follow quitting.

PREVENTION

Most smokers begin to smoke as teenagers. Every day, 3,000 American youths start smoking.

Despite that fact, the American Lung Association contends that the tobacco industry "aggressively and consistently fights meaningful efforts at the federal, state, and local levels to enact and enforce laws barring sales (of cigarettes) to minors."

Parents still have the biggest impact on their children's decision whether to smoke. The best way to prevent a youngster from taking up smoking likely is to have parents who don't smoke. Children from smoking households are more likely to begin smoking than children from nonsmoking households.

Much attention has been focused in recent years on the influence of tobacco company advertising on encouraging young people to smoke.

Although cigarette commercials have been banned from television for 30 years, the tobacco industry remains the country's largest advertiser. According to the American Lung Association, the tobacco industry spent an estimated $5.7 billion on advertising in 1997, up 10.8% or $552 million from 1996. In 1982, when cigarette sales peaked, the industry spent an estimated $1.8 billion for advertising. Cigarette sales dropped from 632.5 billion in 1982 to 478.6 billion in 1997. Tobacco company ads are everywhere:

Ads are in print media and at sporting and cultural events.

Cigarette use by actors in popular films long has been a means to portray smoking as sophisticated and glamorous.

Tobacco companies sponsor automobile racing and women's tennis.

Although denied by tobacco companies, the use of cartoon animals and the like in advertising campaigns appeals to youngsters.

Counter-advertising by various antismoking advocacy groups may provide some balance, but their advertising budgets pale beside those of tobacco companies.

Schools generally provide education on the use of tobacco, alcohol, and other substances, but their impact is unclear.

Increasing the taxes on cigarettes, and hence their price, has been shown to reduce tobacco consumption, especially among adolescents

FOLLOW-UP

For additional information about the health effects of smoking, and how to quit, contact the following organizations:

National Cancer Institute

Clearing the Air: How to Quit Smoking and Quit for Keeps
(800) 4-CANCER
www.nci.nih.gov

American Lung Association
- Freedom from Smoking
- (800) LUNG-USA
- www.lungusa.org

American Cancer Society
- (800) ACS-2345
- www.cancer.org

American Heart Association
- (800) AHA-USA1
- www.americanheart.org

Reference Link

http://www.emedicine.com/AAEM/topic109.htm

Diabetes: Smoking Cessation Tips

2007-12-27T14:35:00.001+02:00

While smoking is bad for your health regardless of whether or not you have diabetes, it is especially harmful for people with diabetes. Nicotine in cigarette smoke causes large and small blood vessels to harden and narrow, resulting in reduced blood flow to the rest of your body. Because people with diabetes already have a greater risk of developing health problems like heart disease, stroke, kidney disease, nerve damage, foot problems, and many others, smoking makes the risks that much greater.

No matter how much or how long you have smoked, quitting will lower your risk of heart disease and other health problems. In addition, if you quit, you will:

Likely, prolong your life.
Improve your health.
Feel healthier. (Smoking can cause coughing, poor athletic ability, and sore throats.)
Look better. (Smoking can cause face wrinkles, stained teeth, and dull skin.)
Improve your sense of taste and smell.
Save money. (Most smokers spend nearly $100 a month on cigarettes.)

Tips for Quitting Smoking

Here are a few tips to help you quit, based on guidelines from the American Cancer Society.

Don't carry a lighter or matches; hide all ashtrays.
When the urge to smoke hits, take a deep breath. Hold it for 10 seconds and then release it slowly. Taking deep, rhythmic breaths is similar to smoking; only you'll inhale clean air, not poisonous gas.
Spend your free time in places where smoking is prohibited, such as a library, theater, or museum. Go to lunch with friends who are also trying to quit smoking and sit in the "no smoking" section.
Eat low-calorie, high-nutritional foods instead of smoking. Choose fresh fruit and crisp, crunchy vegetables. Or substitute sugarless gum for a cigarette. Other substitutes to try: lemon drops, cloves, beef jerky or popcorn (not buttered).
Exercise to help relieve tension. Climb stairs rather than take the elevator, or get off the bus before your destination and walk the rest of the way.

Drink liquids -- and lots of them. Water, decaffeinated teas, fruit juices, and certain decaffeinated soft drinks are good choices. Pass up coffee, soft drinks containing caffeine, and alcohol, as they all can increase your urge to smoke.
Keep your hands occupied. Try doodling, knitting, or other activities that keep you busy.
Change your habits connected with smoking. If you always had a cigarette on your office break, opt for a low-calorie snack and juice or tea instead.
Wrap a cigarette in a sheet of paper and then put a rubber band around it. If you must reach for a cigarette, you'll have more difficulty getting to one and you will be aware of your action. Rewrap cigarettes afterward.
Tell all your friends that you are definitely quitting smoking. Ask them to help keep you from backsliding. Ask your family and co-workers who smoke not to do so around you.
Treat your body and soul with kindness. Indulge in a bath or massage, or take a nap. Listen to your favorite music or go see a movie. Enjoying these activities in the absence of smoking will help you realize that you don't need a cigarette to have a good time.

Nicotine Replacement Therapy

Nicotine patches, gum, and nasal spray are three ways to curb cravings for nicotine. The nicotine patch is worn on the skin (between the neck and waist) and continuously supplies small amounts of nicotine. Nicotine gum allows the user to control the amount of nicotine he or she receives each day and should be used for 30 minutes at a time. Nicotine nasal spray provides fast relief from nicotine cravings but requires a prescription. Another prescription medicine available to help you stop smoking is Zyban.

Ask your doctor if nicotine replacement therapy is an option for you. When using these products, follow the directions on the package and report any side effects to your health care provider. You should not smoke while using nicotine replacement products, as doing so can cause serious side effects.

Reviewed by Certified Diabetes Educators in the Department of Patient Education and Health Information and by physicians in the Department of Endocrinology at The Cleveland Clinic.

Reference Link:

http://diabetes.webmd.com/diabetes-smoking-cessation-tips

Angina Pectoris

2007-12-27T14:32:00.001+02:00

Article Last Updated: Dec 19, 2007

AUTHOR AND EDITOR INFORMATION

Jamshid Alaeddini, MD, FACC, Clinical Cardiac Electrophysiologist, Inland Cardiology Associates
Jamshid Alaeddini is a member of the following medical societies: American College of Cardiology, American Heart Association, and Heart Rhythm Society
Coauthor(s): Jamshid Shirani, MD, FACC, FAHA, Consulting Staff, Director of Cardiovascular Fellowship Program, Department of Medicine, Division of Cardiology, Geisinger Medical Center

INTRODUCTION

Background

Angina pectoris is the result of myocardial ischemia caused by an imbalance between myocardial blood supply and oxygen demand. Angina is a common presenting symptom (typically, chest pain) among patients with coronary artery disease. A comprehensive approach to diagnosis and to medical management of angina pectoris is an integral part of the daily responsibilities of physicians.

Pathophysiology

Myocardial ischemia develops when coronary blood flow becomes inadequate to meet myocardial oxygen demand. This causes myocardial cells to switch from aerobic to anaerobic metabolism, with a progressive impairment of metabolic, mechanical, and electrical functions. Angina pectoris is the most common clinical manifestation of myocardial ischemia. It is caused by chemical and mechanical stimulation of sensory afferent nerve endings in the coronary vessels and myocardium. These nerve fibers extend from the first to fourth thoracic spinal nerves, ascending via the spinal cord to the thalamus, and from there to the cerebral cortex.

Recent studies have shown that adenosine may be the main chemical mediator of anginal pain. During ischemia, ATP is degraded to adenosine, which, after diffusion to the extracellular space, causes arteriolar dilation and anginal pain. Adenosine induces angina mainly by stimulating the A1 receptors in cardiac afferent nerve endings.

Heart rate, myocardial inotropic state, and myocardial wall tension are the major determinants of myocardial metabolic activity and myocardial oxygen demand. Increases in the heart rate and myocardial contractile state result in increased myocardial oxygen demand. Increases in both afterload (ie, aortic pressure) and preload (ie, ventricular end-diastolic volume) result in a proportional elevation of myocardial wall tension and, therefore, increased myocardial oxygen demand. Oxygen supply to any organ system is determined by blood flow and oxygen extraction. Because the resting coronary venous oxygen saturation is already at a relatively low level (approximately 30%), the myocardium has a limited ability to increase its oxygen extraction during episodes of increased demand. Thus, an increase in myocardial oxygen demand (eg, during exercise) must be met by a proportional increase in coronary blood flow.

The ability of the coronary arteries to increase blood flow in response to increased cardiac metabolic demand is referred to as coronary flow reserve (CFR). In healthy people, the maximal coronary blood flow after full dilation of the coronary arteries is roughly 4-6 times the resting coronary blood flow. CFR depends on at least 3 factors: large and small coronary artery resistance, extravascular (ie, myocardial and interstitial) resistance, and blood composition.

Myocardial ischemia can result from (1) a reduction of coronary blood flow caused by fixed and/or dynamic epicardial coronary artery (ie, conductive vessel) stenosis, (2) abnormal constriction or deficient relaxation of coronary microcirculation (ie, resistance vessels), or (3) reduced oxygen-carrying capacity of the blood.

Atherosclerosis is the most common cause of epicardial coronary artery stenosis and, hence, angina pectoris. Patients with a fixed coronary atherosclerotic lesion of at least 50% show myocardial ischemia during increased myocardial metabolic demand as the result of a significant reduction in CFR. These patients are not able to increase their coronary blood flow during stress to match the increased myocardial metabolic demand, thus they experience angina. Fixed atherosclerotic lesions of at least 90% almost completely abolish the flow reserve; patients with these lesions may experience angina at rest.

Coronary spasm can also reduce CFR significantly by causing dynamic stenosis of coronary arteries. Prinzmetal angina is defined as resting angina associated with ST-segment elevation caused by focal coronary artery spasm. Although most patients with Prinzmetal angina have underlying fixed coronary lesions, some have angiographically normal coronary arteries. Several mechanisms have been proposed for Prinzmetal angina: focal deficiency of nitric oxide production, hyperinsulinemia, low intracellular magnesium levels, smoking cigarettes, and using cocaine.

Approximately 30% of patients with chest pain referred for cardiac catheterization have normal or minimal atherosclerosis of coronary arteries. A subset of these patients demonstrates reduced CFR that is believed to be caused by functional and structural alterations of small coronary arteries and arterioles (ie, resistance vessels). Under normal conditions, resistance vessels are responsible for as much as 95% of coronary artery resistance, with the remaining 5% being from epicardial coronary arteries (ie, conductive vessels). The former is not visualized during regular coronary catheterization. Angina due to dysfunction of small coronary arteries and arterioles is called microvascular angina. Several diseases, such as diabetes mellitus, hypertension, and systemic collagen vascular diseases (eg, systemic lupus erythematosus, polyarteritis nodosa), are believed to cause microvascular abnormalities with subsequent reduction in CFR.

The syndrome that includes angina pectoris, ischemialike ST-segment changes and/or myocardial perfusion defects during stress testing, and angiographically normal coronary arteries is referred to as syndrome X. Most patients with this syndrome are postmenopausal women, and they usually have an excellent prognosis. Syndrome X is believed to be caused by microvascular angina. Multiple mechanisms may be responsible for this syndrome, including (1) impaired endothelial dysfunction, (2) increased release of local vasoconstrictors, (3) fibrosis and medial hypertrophy of the microcirculation, (4) abnormal cardiac adrenergic nerve function, and/or (5) estrogen deficiency.

A number of extravascular forces produced by contraction of adjacent myocardium and intraventricular pressures can influence coronary microcirculation resistance and thus reduce CFR. Extravascular compressive forces are highest in the subendocardium and decrease toward the subepicardium. Left ventricular (LV) hypertrophy together with a higher myocardial oxygen demand (eg, during tachycardia) cause greater susceptibility to ischemia in subendocardial layers.

Myocardial ischemia can also be the result of factors affecting blood composition, such as reduced oxygen-carrying capacity of blood, as is observed with severe anemia (hemoglobin, <8 g/dL), or elevated levels of carboxyhemoglobin. The latter may be the result of inhalation of carbon monoxide in a closed area or of long-term smoking.

Recently, ambulatory ECG monitoring has shown that silent ischemia is a common phenomenon among patients with established coronary artery disease. In one study, as many as 75% of episodes of ischemia (defined as transient ST depression of >1 mm persisting for at least 1 min) occurring in patients with stable angina were clinically silent. Silent ischemia occurs most frequently in early morning hours and may result in transient myocardial contractile dysfunction (ie, stunning). The exact mechanism(s) for silent ischemia is not known. However, autonomic dysfunction (especially in patients with diabetes), a higher pain threshold in some individuals, and the production of excessive quantities of endorphins are among the more popular hypotheses.

Frequency

United States

Approximately 6.3 million Americans are estimated to experience angina. An estimated 350,000 new cases of angina occur every year. Each year, 1.1 million new and recurrent cases of an acute coronary event occur in this country, of which more than 40% are fatal. Roughly, more than 12 million Americans had a history of myocardial infarction (MI) and/or angina pectoris in the year 2000.

Mortality/Morbidity

Coronary artery disease is the single most common cause of death in the United States, accounting for almost one death per minute. More than half of those who die suddenly from coronary artery disease have no previous symptoms.

Race

The rate of angina pectoris in women older than 20 years ranges from 3.9% in non-Hispanic white women to 6.2% in non-Hispanic black women and 5.5% in Mexican American women. The rates of angina pectoris for men in the same ethnic groups are 2.6%, 3.1%, and 4.1%, respectively. Among American Indians aged 65-74 years, the rates (per 1000 persons) of new and recurrent heart attacks are 25.1% for men and 9.1% for women.

Sex

Angina pectoris is more often the presenting symptom of coronary artery disease in women than in men, with a female-to-male ratio of 1.7:1. It has a prevalence of 3.9 million in women and 2.3 million in men. The frequency of atypical presentations is also more common among women compared with men. Women have a slightly higher rate of mortality from coronary artery disease compared with men, in part because of an older age at presentation and a frequent lack of classic anginal symptoms. The estimated age-adjusted prevalence of angina is greater in women than in men.

Age

The prevalence of angina pectoris increases with age. Age is a strong independent risk factor for mortality.

CLINICAL

History

Most patients with angina pectoris report of retrosternal chest discomfort rather than frank pain. The former is usually described as a pressure, heaviness, squeezing, burning, or choking sensation. Anginal pain may be localized primarily in the epigastrium, back, neck, jaw, or shoulders. Typical locations for radiation of pain are arms, shoulders, and neck. Typically, angina is precipitated by exertion, eating, exposure to cold, or emotional stress. It lasts for approximately 1-5 minutes and is relieved by rest or nitroglycerin. Chest pain lasting only a few seconds is not usually angina pectoris. The intensity of angina does not change with respiration, cough, or change in position. Pain above the mandible and below the epigastrium is rarely anginal in nature.

Ask patients about the frequency of angina, severity of pain, and number of nitroglycerin pills used during angina episodes.
Angina decubitus is a variant of angina pectoris that occurs at night while the patient is recumbent. Some have suggested that it is induced by an increase in myocardial oxygen demand caused by expansion of the blood volume with increased venous return during recumbency.
The Canadian Cardiovascular Society grading scale is used for classification of angina severity, as follows:
- Class I - Angina only during strenuous or prolonged physical activity
- Class II - Slight limitation, with angina only during vigorous physical activity
- Class III - Symptoms with everyday living activities, ie, moderate limitation
- Class IV - Inability to perform any activity without angina or angina at rest, ie, severe limitation
The New York Heart Association classification is also used to quantify the functional limitation imposed by patients' symptoms, as follows:
- Class I - No limitation of physical activity (Ordinary physical activity does not cause symptoms.)
- Class II - Slight limitation of physical activity (Ordinary physical activity does cause symptoms.)
- Class III - Moderate limitation of activity (Patient is comfortable at rest, but less than ordinary activities cause symptoms.)
- Class IV - Unable to perform any physical activity without discomfort, therefore severe limitation (Patient may be symptomatic even at rest.)
Unstable angina is defined as new-onset angina (ie, within 2 mo of initial presentation) of at least class III severity, significant recent increase in frequency and severity of angina, or angina at rest.

Physical

For most patients with stable angina, physical examination findings are normal. Diagnosing secondary causes of angina, such as aortic stenosis, is important.
A positive Levine sign (characterized by the patient's fist clenched over the sternum when describing the discomfort) is suggestive of angina pectoris.
Look for physical signs of abnormal lipid metabolism (eg, xanthelasma, xanthoma) or of diffuse atherosclerosis (eg, absence or diminished peripheral pulses, increased light reflexes or arteriovenous nicking upon ophthalmic examination, carotid bruit).
Examination of patients during the angina attack may be more helpful. Useful physical findings include third and/or fourth heart sounds due to LV systolic and/or diastolic dysfunction and mitral regurgitation secondary to papillary muscle dysfunction.
Pain produced by chest wall pressure is usually of chest wall origin.

Causes

Decrease in myocardial blood supply due to increased coronary resistance in large and small coronary arteries
- Significant coronary atherosclerotic lesion in the large epicardial coronary arteries (ie, conductive vessels) with at least a 50% reduction in arterial diameter
- Coronary spasm (ie, Prinzmetal angina)
- Abnormal constriction or deficient endothelial-dependent relaxation of resistant vessels associated with diffuse vascular disease (ie, microvascular angina)
- Syndrome X
- Systemic inflammatory or collagen vascular disease, such as scleroderma, systemic lupus erythematous, Kawasaki disease, polyarteritis nodosa, and Takayasu arteritis
Increased extravascular forces, such as severe LV hypertrophy caused by hypertension, aortic stenosis, or hypertrophic cardiomyopathy, or increased LV diastolic pressures
Reduction in the oxygen-carrying capacity of blood, such as elevated carboxyhemoglobin or severe anemia (hemoglobin, <8 g/dL)
Congenital anomalies of the origin and/or course of the major epicardial coronary arteries
Structural abnormalities of the coronary arteries
- Congenital coronary artery aneurysm or fistula
- Coronary artery ectasia
- Coronary artery fibrosis after chest radiation
- Coronary intimal fibrosis following cardiac transplantation
Risk factors
- Major risk factors for atherosclerosis: These include a family history of premature coronary artery disease, cigarette smoking, diabetes mellitus, hypercholesterolemia, or systemic hypertension.
- Other risk factors: These include LV hypertrophy, obesity, and elevated serum levels of homocysteine, lipoprotein (a), plasminogen activator inhibitor, fibrinogen, serum triglycerides, or low high-density lipoprotein (HDL).
- Metabolic syndrome: This has recently been characterized by the presence of hyperinsulinemia (fasting glucose level, ³110 mg/dL), abdominal obesity (waist circumference, >40 in for men or >35 in for women), decreased HDL cholesterol levels (<40 mg/dL for men or <50 mg/dL for women), hypertriglyceridemia (>150 mg/dL), and hypertension (³130/85 mm Hg). Based on data from the 2000 US census, an estimated 47 million Americans have the metabolic syndrome. Patients with the metabolic syndrome have a 3-fold increased risk for coronary atherosclerosis and stroke compared with those without this syndrome.
Precipitating factors: These include factors such as severe anemia, fever, tachyarrhythmias, catecholamines, emotional stress, and hyperthyroidism, which increase myocardial oxygen demand.
Preventive factors: Factors associated with reduced risk of atherosclerosis are a high serum HDL cholesterol level, physical activity, estrogen, and moderate alcohol intake (1-2 drinks/d).

DIFFERENTIALS

Anemia
Anxiety Disorders
Aortic Dissection
Aortic Stenosis
Biliary Colic
Cardiomyopathy, Hypertrophic
Cholecystitis
Coronary Artery Atherosclerosis
Coronary Artery Vasospasm
Diabetes Mellitus, Type 1
Diabetes Mellitus, Type 2
Gastric Ulcers
Gastritis, Acute
Gastroesophageal Reflux Disease
Hiatal Hernia
Hypercholesterolemia, Familial
Hypercholesterolemia, Polygenic
Hypertension
Hyperthyroidism
Isolated Coronary Artery Anomalies
Kawasaki Disease
Mitral Regurgitation
Mitral Valve Prolapse
Panic Disorder
Pericarditis, Acute
Pleurodynia
Pneumothorax
Polyarteritis Nodosa
Pott Disease (Tuberculous Spondylitis)
Pulmonary Embolism
Pulmonary Hypertension, Primary
Pulmonary Hypertension, Secondary
Scleroderma
Systemic Lupus Erythematosus
Takayasu Arteritis
Toxicity, Cocaine
Varicella-Zoster Virus

Imaging Studies

Chest radiograph findings are usually normal in patients with angina pectoris. However, they may show cardiomegaly in patients with previous MI, ischemic cardiomyopathy, pericardial effusion, or acute pulmonary edema. Calcification of coronary arteries frequently correlates with major coronary artery disease.
Graded exercise stress testing is the most widely used test for the evaluation of patients presenting with chest pain. In patients with established stable angina pectoris, it also can provide prognostic information about the extent of disease.
- Exercise stress testing can be performed alone and in conjunction with echocardiography or myocardial perfusion scintigraphy tests. Stress echocardiography has an overall sensitivity of 78% and specificity of 86%; myocardial perfusion scintigraphy has an overall sensitivity of 83% and specificity of 77%. Exercise stress testing alone generally has somewhat lower sensitivity and specificity, but it is cheaper and therefore is a reasonable choice in those with a low probability of disease.
- These test results must be interpreted in the context of the likelihood of the presence of coronary artery disease determined from the patient's history and physical examination findings. In a population with low prevalence, the predictive abilities of these tests are low; however, in patients with a high likelihood of coronary artery disease, the predictive value is much higher.
Stress echocardiography can be used to evaluate segmental wall motion during exercise. It detects changes in regional wall motion that occur during myocardial ischemia. Normal myocardium becomes hyperdynamic during exercise; ischemic segments become hypokinetic or akinetic.
- Stress echocardiography has the advantage of simultaneous evaluation of LV function, cardiac dimensions, and valvular disease. It is especially useful in patients with baseline ECG abnormalities and those with systolic murmurs suggestive of aortic stenosis or hypertrophic cardiomyopathy.
- It is also helpful for localizing ischemia and evaluating its severity.
- Signs of severe coronary artery disease during exercise stress echocardiography include LV dilation, a decrease in global systolic function, and new or worsening mitral regurgitation. However, with dobutamine stress echocardiography, even in patients with severe coronary artery disease, the LV cavity may not dilate and global systolic function may improve.
- A major problem with stress echocardiography is the technical difficulty with obtaining adequate images in some patients.
Thallium Tl 201 and technetium Tc 99m sestamibi are the most frequently used myocardial perfusion scintigraphy tests. These tests are especially useful in patients with baseline ECG abnormalities, to localize the region of ischemia, and as prognostic indicators. The presence of increased lung uptake upon thallium imaging is associated with a poor prognosis. Increased lung uptake, together with poststress dilation of the LV and multiple perfusion defects, is suggestive of either left main coronary artery disease or severe 3-vessel disease. The number of affected myocardial segments is predictive of long-term survival. Smaller perfusion defects are usually associated with peripheral coronary artery lesions, which are associated with a better prognosis. The absence of perfusion defects even in the presence of symptoms indicates an excellent prognosis.
The frequency of infarction or death is 1 case per 10,000 stress tests. Absolute contraindications include symptomatic cardiac arrhythmias, severe aortic stenosis, acute MI within the previous 2 days, acute myocarditis, or pericarditis. Discontinue the exercise stress test in the presence of chest pain, a drop in systolic blood pressure of more than 10 mm Hg, severe shortness of breath, fatigue, dizziness or near syncope, ST depression of more than 2 mm, ST elevation of at least 1 mm without diagnostic Q waves, or development of ventricular tachyarrhythmia.
In recent years, coronary artery calcium (CAC) scoring by fast computed tomography (CT) has become more popular in clinical practice for risk assessment of patients with chest pain. Currently, electron-beam computed tomography (EBCT) and multi-detector computed tomography (MDCT) are the primary fast CT methods for CAC measurement. However, some controversy exists about the usefulness of this test.
- In asymptomatic patients, analysis of the data from CAC scoring in patients with an intermediate Framingham risk score reveals that for a score of 400 or more, the patient's 10-year CAD risk would achieve a risk equivalent status similar to that noted with diabetes or peripheral arterial disease. Thus, finding a high CAC score in asymptomatic patients with an intermediate Framingham risk score (10-20% risk of CAD in 10 y) could be useful by resulting in a more aggressive management approach. However, unselected screening is of limited clinical value in asymptomatic patients who have a low Framingham risk score. On the other hand, assessment of CAC in asymptomatic patients with a high Framingham risk score (>20% risk of CAD in 10 y) has limited value since, based on current guidelines, these patients should be treated aggressively irrespective of their CAC scoring.
- In symptomatic patients, exclusion of measurable CAC may be an effective tool before undertaking invasive diagnostic procedures or hospital admission. Patients with CAC scores of less than 100 have a low probability (<2%) of abnormal perfusion on nuclear stress tests, and a low probability (<3%) of obstructive CAD (>50% stenosis) on cardiac catheterization. Studies of large numbers of symptomatic patients demonstrated that the absence of CAC has a high negative predictive value of 96-100%. Thus, an individual with no coronary calcium (score _ 0) can be told with a high level of confidence that he or she has no obstructive angiographic coronary disease.
- In patients with documented CAD, clinical monitoring of CAC progression through serial fast CT scanning to assess progression or regression of CAD is not recommended at this time.
- Since most of current data regarding CAC are collected from patient population of mostly Caucasian men, the guidelines suggest caution in applying these findings to women and ethnic minorities.

Other Tests

ECG is useful for evaluating persons with angina pectoris; however, findings are variable among patients.
- Approximately 50% of patients with angina pectoris have normal findings after a resting ECG. However, abnormalities such as evidence for prior MI, intraventricular conduction delay, various degrees of atrioventricular block, arrhythmias, or ST-T–wave changes may be seen.
- During an attack of angina pectoris, 50% of patients with normal findings after resting ECG show abnormalities. A 1-mm or greater depression of the ST segment below the baseline, measured 80 milliseconds from the J point, is the most characteristic change. Reversible ST-segment elevation occurs with Prinzmetal angina. Some patients with coronary artery disease may show pseudonormalization of the resting ECG ST-T–wave abnormalities during episodes of chest pain.
Exercise with ECG monitoring alone is the initial procedure of choice in patients without baseline ST-segment abnormalities or in whom anatomic localization of ischemia is not a consideration.
- Horizontal or down-sloping ST-segment depression of at least 1 mm, measured 80 milliseconds from the J point, is considered the characteristic ischemic response.
- ST-segment depression of more than 2 mm at a low workload or that persists for more than 5 minutes after termination of exercise and a failure of blood pressure to rise or an actual drop in blood pressure are signs of severe ischemic heart disease and a poor prognosis.
- Withhold beta-blockers for approximately 48 hours before the stress test, whenever possible. Patients on digoxin and those with LV hypertrophy with repolarization abnormalities more often show positive results. Exercise stress tests have lower sensitivity and specificity in women and in patients with left bundle-branch block.
- Pharmacologic agents (eg, dobutamine, dipyridamole, adenosine) can be used in patients who are unable to exercise.
Ambulatory ECG monitoring can be used for diagnostic purposes in patients with chest pain suggestive of Prinzmetal angina but is primarily used to evaluate the frequency of silent ischemia. Silent ischemia has been shown to be an independent predictor of mortality in patients with angina pectoris.

Procedures

Selective coronary angiography is the definitive diagnostic test for evaluating the anatomic extent and severity of coronary artery disease.
- Consider coronary angiography in symptomatic patients with inconclusive noninvasive study results, in survivors of sudden cardiac death, in those who are considered to have a poor prognosis based on the results of noninvasive studies, in those with occupational requirements for a definite diagnosis (eg, pilots), or in patients with coronary artery disease who are severely symptomatic despite maximal medical therapy.
- In patients in whom Prinzmetal angina is suggested, provocative testing with ergonovine maleate during coronary angiography may be useful.
Intra-aortic balloon counterpulsation can be used in patients who continue to have unstable angina pectoris despite maximal medical treatment. This procedure should be followed promptly by coronary angiography with possible coronary revascularization.
In patients whose angina is refractory to medical therapy who are not suitable candidates for either percutaneous or surgical revascularization, enhanced external counterpulsation is a safe and noninvasive alternative therapy. It increases coronary perfusion and reduces myocardial oxygen demand by diastolic augmentation of the central aortic pressure. Several studies have shown that patients treated with enhanced external counterpulsation have a significantly reduced number of anginal episodes, improved exercise tolerance, and decreased daily use of nitroglycerin tablets. Its therapeutic effects on quality of life are noted to remain at 1-year follow-up.

TREATMENT

Medical Care

The main goals of treatment in angina pectoris are to relieve the symptoms, slow the progression of disease, and reduce the possibility of future events, especially MI and premature death.

General measures
- Smoking cessation results in a significant reduction of acute adverse effects on the heart and may reverse, or at least slow, atherosclerosis. Strongly encourage patients to quit smoking, and take an active role in helping them to achieve this goal.
- Treat risk factors, including hypertension, diabetes mellitus, obesity, and hyperlipidemia.
- Several clinical trials have shown that in patients with established coronary artery disease, reduction of low-density lipoprotein (LDL) level with a beta-hydroxy-beta-methylglutaryl coenzyme A reductase inhibitor (ie, statin) is associated with significant reductions in both mortality rate and major cardiac events.
- - These benefits are present even in patients with mild-to-moderate elevations of LDL cholesterol level.
  - Recent trials with cholesterol-lowering agents have confirmed the benefits of the therapeutic LDL lowering in older persons.
  - Angiographic studies demonstrate that a reduction of the LDL level in patients with coronary artery disease could cause slowing of progression, stabilization, or even regression of coronary artery lesions.
  - A recent study demonstrates a significant reduction of symptomatic myocardial ischemia in patients with unstable angina or non–Q-wave infarction with the administration of a statin during the early acute phase.
  - In a study of 10,001 patients with stable coronary artery disease, an aggressive cholesterol-lowering approach with atorvastatin 80 mg daily (mean cholesterol level of 77 mg/dL) compared to a less-aggressive approach with atorvastatin 10 mg daily (mean cholesterol level of 101 mg/dL) resulted in a 2.2% absolute reduction and a 22% relative reduction in the occurrence of a first major cardiovascular event (defined as death from coronary heart disease; nonfatal, non–procedure-related myocardial infarction; resuscitation from cardiac arrest; or fatal or nonfatal stroke).¹ This occurred with a greater incidence of elevated aminotransferase levels with the aggressive cholesterol-lowering approach (1.2% vs 0.2%, p <0.001).
- Based on several recent studies that have demonstrated the benefits of more aggressive LDL-lowering therapies in high-risk patients with coronary artery disease, the Committee of the National Cholesterol Education Program recently made the following modifications to the Adult Treatment Panel III (ATP III) guidelines.
- - In high-risk patients, a serum LDL cholesterol level of less than 100 mg/dL is the goal.
  - In very high-risk patients, an LDL cholesterol level goal of less than 70 mg/dL is a therapeutic option. Patients in the category of very high risk are those with established coronary artery disease with one of the following: multiple major risk factors (especially diabetes), severe and poorly controlled risk factors (especially continued cigarette smoking), multiple risk factors of the metabolic syndrome (especially high triglyceride levels [³200 mg/dL] plus non-HDL cholesterol level [³130 mg/dL] with low HDL cholesterol level [<40 mg/dL]), and patients with acute coronary syndromes.
  - For moderately high-risk persons (2+ risk factors), the recommended LDL cholesterol level is less than130 mg/dL, but an LDL cholesterol level of 100 mg/dL is a therapeutic option.
- Some triglyceride-rich lipoproteins, including partially degraded very LDL levels, are believed to be independent risk factors for coronary artery disease. In daily practice, non-HDL cholesterol level (ie, LDL + very LDL cholesterol [total cholesterol - HDL cholesterol]) is the most readily available measure of the total pool of these atherogenic lipoproteins. Thus, the ATP III has identified non-HDL cholesterol level as a secondary target of therapy in persons with high triglyceride levels (>200 mg/dL). The goal for non-HDL cholesterol level (for persons with serum triglyceride levels >200 mg/dL) is 30 mg/dL higher than the identified LDL cholesterol level goal.
- Patients with established coronary disease and low HDL cholesterol levels are at high risk for recurrent events and should be targeted for aggressive nonpharmacological (ie, dietary modification, weight loss, physical exercise) and pharmacological treatment.
- Several large epidemiologic studies demonstrated that HDL cholesterol levels are inversely related to cardiovascular risk. Thus, developing pharmaceutical agents to increase the HDL level has been an attractive target for prevention and treatment of CAD. Cholesteryl ester transfer protein (CETP) inhibitors have been shown to have the effect of increasing HDL cholesterol levels by blocking this CETP. Torcetrapib has been one of CETP agents that has been used in large randomized trials.
- - Investigation of Lipid Level management using coronary UltraSound To assess Reduction of Atherosclerosis by CETP inhibition and HDL Elevation (ILLUSTRATE) was a randomized study that looked at the effect of torecetrapib in 1188 patients with CAD who underwent intravascular ultrasonography at baseline.² After treatment with atorvastatin to reduce levels of LDL cholesterol to less than 100 mg/dL, patients were randomly assigned to receive atorvastatin monotherapy or atorvastatin plus 60 mg of torcetrapib daily.
    Intravascular ultrasonography was repeated in 910 of these patients (77%) after 24 months of treatment to evaluate the disease progression. Compared with atorvastatin monotherapy, torcetrapib–atorvastatin therapy was associated with an impressive 61% relative increase in HDL levels and a 20% relative decrease in LDL levels resulting in an LDL to HDL ratio of less than 1.0 in this group of patients. Despite this favorable change in the HDL and LDL levels, among patients who underwent repeat intravascular ultrasonography, the percent atheroma volume between the 2 groups was not different. Torcetrapib did not result in significant decrease in the progression of coronary atherosclerosis, but it was associated with an increase in blood pressure.
  - Rating Atherosclerotic Disease change by Imaging with A New Cholesteryl-Ester-transfer protein inhibitor (RADIANCE) 2, a more recent trial, looked into the effect of torcetrapib on carotid atherosclerosis progression in patients with mixed dyslipidaemia.³ Although similar to the ILLUSTRATE trial, torcetrapib also substantially raised HDL levels and lowered LDL levels in this study; it did not affect the progression of carotid atherosclerosis. Similar to the ILLUSTRATE trial, torcetrapib also significantly increased systolic blood pressure.
  - Investigation of Lipid Level management to Understand its iMpact IN ATherosclerotic Events (ILLUMINATE), an international phase 3 study of 15,000 patients, was terminated early because it had already recorded 82 deaths in the patients taking torcetrapib-atorvastatin compared with 51 deaths in patients taking atorvastatin alone. In addition, the rates of MI, revascularization, angina, and heart failure were higher in the torcetrapib-atorvastatin arm. Due to the disappointing results of these studies, torcetrapib will not be developed further. Whether this failure represents a problem unique to torcetrapib or is common among the entire class of CETP inhibitors remains to be determined.
- A recent study demonstrated that in patients with established coronary artery disease who have low HDL levels and low-risk LDL levels, drug therapy with medications that raise HDL levels and lower triglyceride levels but have no effect on LDL levels (eg, gemfibrozil) could significantly reduce the risk of major cardiac events.
- Currently, the accepted approach to the management of patients with coronary artery disease and low HDL levels is as follows:
- - In all persons with low HDL cholesterol levels, the primary target of therapy is to achieve the ATP III guideline LDL cholesterol level goals with diet, exercise, and drug therapy as needed.
  - After reaching the targeted LDL level goal, emphasis shifts to other issues. That is, in patients with low HDL cholesterol levels who have associated high triglyceride levels (>200 mg/dL), the secondary priority is to achieve the non-HDL cholesterol level goal of 30 mg/dL higher than the identified LDL cholesterol level goal. In patients with isolated low HDL cholesterol levels (triglycerides <200 mg/dL), drugs to raise the HDL cholesterol level (eg, gemfibrozil, nicotinic acid) can be considered.
- Exercise training results in improvement of symptoms, increase in the threshold of ischemia, and improvement of patients' sense of well-being. However, before enrolling a patient in an exercise-training program, perform an exercise tolerance test to establish the safety of such a program.
- Consider enteric-coated aspirin at a dose of 80-325 mg/d for all patients with stable angina who have no contraindications to its use. In patients in whom aspirin cannot be used because of allergy or gastrointestinal complications, consider clopidogrel.
- Although early observational studies suggested a cardiovascular protective effect with the use of hormone replacement therapy, recent large randomized trials failed to demonstrate any benefit with hormone replacement therapy in the primary or secondary prevention of cardiovascular disease.
- - In fact, these studies even demonstrated an increased risk of coronary artery disease and stroke in patients on hormone replacement therapy.
  - The Women's Health Initiative study demonstrated that the use of hormone replacement therapy for 1 year in 10,000 healthy postmenopausal women is associated with 7 more instances of coronary artery disease, 8 more strokes, 8 more pulmonary emboli, 8 more invasive breast cancers, 5 fewer hip fractures, and 6 fewer colorectal cancers.
  - Based on these data, the risks and benefits of hormone replacement therapy must be assessed on an individual basis for each patient.
Sublingual nitroglycerin has been the mainstay of treatment for angina pectoris. Sublingual nitroglycerin can be used for acute relief of angina and prophylactically before activities that may precipitate angina. No evidence indicates that long-acting nitrates improve survival in patients with coronary artery disease.
Beta-blockers are also used for symptomatic relief of angina and prevention of ischemic events. They work by reducing myocardial oxygen demand and by decreasing the heart rate and myocardial contractility. Beta-blockers have been shown to reduce the rates of mortality and morbidity following acute MI.
Long-acting heart rate–slowing calcium channel blockers can be used to control anginal symptoms in patients with a contraindication to beta-blockers and in those in whom symptomatic relief of angina cannot be achieved with the use of beta-blockers, nitrates, or both. Avoid short-acting dihydropyridine calcium channel blockers because they have been shown to increase the risk of adverse cardiac events.
Anginal symptoms in patients with Prinzmetal angina can be treated with calcium channel blockers with or without nitrates. In one study, supplemental vitamin E added to a calcium channel blocker significantly reduced anginal symptoms among such patients.
In patients with syndrome X and hypertension, ACE inhibitors may normalize thallium perfusion defects and increase exercise capacity.

Surgical Care

Revascularization therapy (ie, coronary revascularization) can be considered in patients with left main artery stenosis greater than 50%, 2- or 3-vessel disease and LV dysfunction (ejection fraction, <45%), poor prognostic signs during noninvasive studies, or severe symptoms despite maximum medical therapy. The 2 main coronary revascularization procedures are percutaneous transluminal coronary angioplasty, with or without coronary stenting, and coronary artery bypass grafting.
Patients with 1- or 2-vessel disease and normal LV function who have anatomically suitable lesions are candidates for percutaneous transluminal coronary angioplasty and coronary stenting. Restenosis is the major complication, with symptomatic restenosis occurring in 20-25% of patients. Restenosis mostly occurs during the first 6 months after the procedure and can be managed by repeat angioplasty. Several trials have demonstrated that the use of drug-eluting stents (eg, sirolimus-eluting stents, paclitaxel-coated stents) can remarkably reduce the rate of in-stent restenosis. With the introduction of these drug-coated stents, patients with multivessel coronary artery disease are more frequently treated with percutaneous revascularization as opposed to the surgical revascularization.
More recently, some concerns have arisen that instead of improving the long-term prognosis, drug-eluting stents might actually worsen it. In addition, stent thrombosis is a major concern with the use of drug-eluting stents. A meta-analysis of individual data on 4958 patients enrolled in 14 randomized trials comparing sirolimus-eluting stents with bare-metal stents looked at the long-term effect of these stents.⁴ The mean follow-up interval was 12.1-58.9 months. The primary end point was death from any cause. The secondary end points were stent thrombosis, the composite end point of death or myocardial infarction, and the composite of death, MI, or a revascularization. The overall risk of death and the combined risk of death or MI were not significantly different for patients receiving sirolimus-eluting stents versus bare-metal stents. A sustained reduction in the need for revascularization occurred after the use of sirolimus-eluting stents compared with bare-metal stents. The overall risk ofstentthrombosis with sirolimus-eluting stents was not significantly higher than bare-metal stents. However, evidence showed an increase in the risk of stent thrombosis associated with sirolimus-eluting stents after the first year.
Patients with single-vessel disease and normal ventricular function treated with percutaneous transluminal coronary angioplasty show improved exercise tolerance and fewer episodes of angina compared with those who receive medical treatment. However, no difference in the frequency of MI or death has been shown between these two groups.
The Clinical Outcomes Utilizing Revascularization and AGgressive Drug Evaluation (COURAGE) trial looked at the benefits of PCI as an initial management strategy in patients with stable CAD. This trial was a randomized and involved 2287 patients who had objective evidence of myocardial ischemia and significant CAD.⁵ Of these, 1149 patients were randomized to undergo PCI with optimal medical therapy (PCI group) and 1138 were to receive optimal medical therapy alone (medical-therapy group). They were observed for 2.5-7 years (median, 4.6 y). During the follow-up, no difference was reported in the primary outcome of death from any cause and nonfatal MI between the PCI group and the medical-therapy group. In addition, no significant differences were noted between the 2 groups in the secondary end points of the composite of death, MI, and stroke; hospitalization for acute coronary syndrome; or MI.
Patients with significant left main coronary artery disease, 2- or 3-vessel disease and LV dysfunction, diabetes mellitus, or lesions anatomically unsuitable for percutaneous transluminal coronary angioplasty have better results with coronary artery bypass grafting. The overall operative mortality rate for coronary artery bypass grafting is approximately 1.3%. The rate of graft patency 10 years after surgery is less than 50% for vein grafting, although more than 90% of grafts using internal mammary arteries are patent at 10 years. In recent years, interest has increased regarding surgery without cardiopulmonary bypass (ie, off-pump) in an attempt to avoid the morbidity associated with cardiopulmonary bypass. A recent randomized study demonstrated that off-pump coronary surgery was as safe as on-pump surgery and caused less myocardial damage. However, the graft-patency rate was lower at 3 months in the off-pump group than in the on-pump group.
Recently, laser transmyocardial revascularization has been used as an experimental therapy for the treatment of severe, chronic, stable angina refractory to medical or other therapies. This technique has been performed with either an epicardial surgical technique or by a percutaneous approach. In both approaches, a series of transmural endomyocardial channels are created to improve myocardial perfusion. The surgical transmyocardial revascularization technique has been associated with symptomatic relief for end-stage chronic angina in the short term. However, no published data address the long-term efficacy of surgical transmyocardial revascularization. Nonetheless, this technique appears to provide at least symptomatic relief for end-stage chronic angina in the short term.

Diet

A diet low in saturated fat and dietary cholesterol is the mainstay of the Step I and Step II diet from the American Heart Association.

Activity

The level of activity that aggravates anginal symptoms is different for each patient. However, most patients with stable angina can avoid symptoms during daily activities simply by reducing the speed of activity.

MEDICATION

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Drug Category: Antiplatelet agents

Prevent thrombus formation by inhibiting platelet aggregation. Aspirin is proven beneficial in primary and secondary prevention of coronary artery disease. In patients with aspirin intolerance, use clopidogrel. Clopidogrel is also used in combination with aspirin after coronary stent placement. Recently, clopidogrel use in addition to aspirin has been shown to be significantly superior to aspirin alone in patients with acute coronary syndrome without ST-segment elevation MI.

Drug Name
Aspirin (Bayer, Empirin, Anacin)

Description
Prevents platelet aggregation by irreversible cyclooxygenase inhibition with subsequent suppression of thromboxane A2. Antiplatelet effect can last as long as 7 d.

Adult Dose
81-325 mg PO qd

Pediatric Dose
Not established

Contraindications
Documented hypersensitivity; liver damage; hypoprothrombinemia; vitamin K deficiency; bleeding disorders; asthma
Because of association with Reye syndrome, do not use in children ( <16 y) with flu

Interactions
Antacids and urinary alkalinizers may decrease effects; corticosteroids decrease salicylate serum levels; anticoagulants may cause additive hypoprothrombinemic effects and increased bleeding time; may antagonize uricosuric effects of probenecid and increase toxicity of phenytoin and valproic acid; doses > 2 g/d may potentiate glucose-lowering effect of sulfonylurea drugs

Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions
May cause transient decrease in renal function and aggravate chronic kidney disease; avoid use in patients with severe anemia, history of blood coagulation defects, or taking anticoagulants; adverse effects include prolonged bleeding time, rhinitis, asthma, urticaria, and exacerbation of gout; monitor BP, BUN, and uric acid level; consider discontinuing 7 d before surgery

Drug Name
Clopidogrel (Plavix)

Description
Selectively inhibits ADP binding to platelet receptor and subsequent ADP-mediated activation of GPIIb/IIIa complex, thereby inhibiting platelet aggregation. Consider in patients with contraindication to aspirin.

Adult Dose
75 mg PO qd

Pediatric Dose
Not established

Contraindications
Documented hypersensitivity; active pathological bleeding

Interactions
Naproxen associated with increased occult GI blood loss; prolongs bleeding time; safety of coadministration with warfarin not established

Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions
Caution in patients at increased risk of bleeding from trauma, surgery, or other pathological conditions; caution in patients with lesions with propensity to bleed (eg, ulcers); adverse effects include rash, diarrhea, purpura, GI ulcers, neutropenia, and rare cases of agranulocytosis; consider discontinuing 7 d before surgery

Drug Category: Beta-adrenergic blocking agents

Work by competing with endogenous catecholamines for beta-adrenergic receptors. Reduce myocardial oxygen consumption via several effects, including decrease in resting and exercise heart rates and reductions in myocardial contractility and afterload. Classified as nonselective, beta-1 selective, and having intrinsic sympathomimetic effects.

Drug Name
Metoprolol (Lopressor, Toprol XL)

Description
Selective beta1-adrenergic receptor blocker that decreases automaticity of contractions. Is lipophilic and penetrates CNS.

Adult Dose
50-200 mg PO bid

Pediatric Dose
Not established

Contraindications
Documented hypersensitivity; uncompensated CHF; bradycardia; asthma; cardiogenic shock; AV conduction abnormalities

Interactions
Aluminum salts, barbiturates, NSAIDs, penicillins, calcium salts, cholestyramine, and rifampin may decrease bioavailability and plasma levels, possibly resulting in decreased pharmacologic effects; sparfloxacin, phenothiazines, astemizole, calcium channel blockers, quinidine, flecainide, and contraceptives may increase toxicity; may increase toxicity of digoxin, flecainide, clonidine, epinephrine, nifedipine, prazosin, verapamil, and lidocaine

Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions
Beta-adrenergic blockade may mask signs and symptoms of acute hypoglycemia and may decrease clinical signs of hyperthyroidism; abrupt withdrawal may exacerbate symptoms of hyperthyroidism, including thyroid storm; monitor patient closely and withdraw drug slowly; during IV administration, carefully monitor BP, heart rate, and ECG; adverse effects include hypotension, decreased libido, impotence, lethargy, depression, and decreased HDL; may cause less bronchial tree and arterial smooth muscle constriction

Drug Name
Atenolol (Tenormin)

Description
Selectively blocks beta-1 receptors with little or no effect on beta-2 receptors. Is hydrophilic and does not penetrate CNS.

Adult Dose
50-200 mg PO qd

Pediatric Dose
Not established

Contraindications
Documented hypersensitivity; CHF; pulmonary edema; cardiogenic shock; AV conduction abnormalities; heart block (without pacemaker)

Interactions
Aluminum salts, barbiturates, calcium salts, cholestyramine, NSAIDs, penicillins, and rifampin may decrease effects; haloperidol, hydralazine, loop diuretics, and MAOIs may increase toxicity

Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions
Beta-adrenergic blockade may hide symptoms of acute hypoglycemia and mask signs of hyperthyroidism; abrupt withdrawal may exacerbate symptoms of hyperthyroidism and cause thyroid storm; monitor patients closely and withdraw drug slowly; adverse effects include bradycardia, hypotension, decreased libido, impotence, and decreased HDL; beta1-selective blockers may cause less bronchial tree and arterial smooth muscle constriction; titrate dose carefully to level of patient tolerance and effectiveness

Drug Name
Propranolol (Inderal)

Description
Nonselective beta-blocker that is lipophilic (penetrates CNS). Although generally short-acting agent, long-acting preparations also available.

Adult Dose
IR: 40-160 mg PO bid
SR: 60-320 mg PO qd

Pediatric Dose
Not established

Contraindications
Documented hypersensitivity; history of bronchospasm; uncompensated CHF; bradycardia; cardiogenic shock; AV conduction abnormalities

Interactions
Aluminum salts, barbiturates, NSAIDs, penicillins, calcium salts, cholestyramine, and rifampin may decrease effects; calcium channel blockers, cimetidine, loop diuretics, and MAOIs may increase toxicity; may increase toxicity of hydralazine, haloperidol, benzodiazepines, and phenothiazines

Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions
Beta-adrenergic blockade may mask signs of acute hypoglycemia and hyperthyroidism; abrupt withdrawal may exacerbate symptoms of hyperthyroidism, including thyroid storm; withdraw drug slowly and monitor closely; adverse effects include bronchial constriction, Raynaud phenomenon, hypotension, decreased libido, impotence, lethargy, depression, and decreased HDL; caution in Wolff-Parkinson-White syndrome and renal or hepatic dysfunction

Drug Category: Calcium channel blockers

Reduce transmembrane flux of calcium via calcium channels. Cause smooth muscle relaxation, resulting in peripheral arterial vasodilation and afterload reduction. Indicated when symptoms persist despite treatment with beta-blockers or when beta-blockers are contraindicated. Also indicated in patients with Prinzmetal angina with or without nitrates.

Drug Name
Amlodipine (Norvasc)

Description
During depolarization, inhibits calcium ions from entering slow channels and voltage-sensitive areas of vascular smooth muscle and myocardium.

Adult Dose
5-10 mg PO qd

Pediatric Dose
Not established

Contraindications
Documented hypersensitivity; severe CHF; sick sinus syndrome; second- or third-degree AV block; hypotension (<90 mm Hg systolic)

Interactions
Fentanyl may increase hypotensive effects; may increase cyclosporine levels; H2 blockers (eg, cimetidine) may increase toxic effects

Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions
Severe aortic stenosis, CHF, hepatic dysfunction; adverse effects include headache, edema, flushing, palpitation, drowsiness, and fatigue

Drug Name
Diltiazem (Cardizem CD, Dilacor)

Description
During depolarization, inhibits calcium ions from entering slow channels and voltage-sensitive areas of vascular smooth muscle and myocardium.

Adult Dose
IR: 120-360 mg PO divided tid/qid
SR: 120-480 mg PO qd

Pediatric Dose
Not established

Contraindications
Documented hypersensitivity; severe CHF; sick sinus syndrome; second- or third-degree AV block; hypotension (<90 mm Hg systolic)

Interactions
May increase carbamazepine, digoxin, cyclosporine, and theophylline levels; when administered with amiodarone, may cause bradycardia and decrease in cardiac output; when given with beta-blockers may increase cardiac depression; cimetidine may increase levels

Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions
Caution in impaired renal or hepatic function; may increase LFT levels, and hepatic injury may occur; adverse effects include constipation, AV conduction block, worsening of heart failure, peripheral edema, bradycardia, and AV dissociation

Drug Name
Verapamil (Calan, Covera)

Description
During depolarization, inhibits calcium ion from entering slow channels or voltage-sensitive areas of vascular smooth muscle and myocardium.

Adult Dose
IR: 80-120 mg PO tid/qid
SR: 120-240 mg PO qd/bid

Pediatric Dose
Not established

Contraindications
Documented hypersensitivity; severe CHF; sick sinus syndrome; second- or third-degree AV block; hypotension (<90 mm Hg systolic)

Interactions
May increase carbamazepine, digoxin, theophylline, and cyclosporine levels; amiodarone can cause bradycardia and decrease in cardiac output; when administered concurrently with beta-blockers may increase cardiac depression; cimetidine may increase levels

Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions
Hepatocellular injury may occur; transient elevations of transaminases with and without concomitant elevations in alkaline phosphatase and bilirubin have occurred (elevations have been transient and may disappear with continued treatment); monitor liver function periodically; adverse effects include constipation, AV dissociation, worsening heart failure, bradycardia, negative inotropism, and hypotension

Drug Category: Short-acting nitroglycerins

Suitable for immediate relief of exertional or rest angina. Can also be used for prophylaxis several minutes before planned exercise to avoid angina. Reduce myocardial oxygen demand by reduction of LV and arterial pressure, primarily by reducing preload.

Drug Name
Nitroglycerin (Nitrostat, Nitro-bid, Nitrol)

Description
Causes relaxation of vascular smooth muscle by stimulating intracellular cyclic GMP production. Result is decrease in BP.

Adult Dose
0.3-0.6 mg SL prn
0.4 mg metered-dose spray PO prn
0.1-0.8 mg/h patch TD qd

Pediatric Dose
Not established

Contraindications
Documented hypersensitivity; severe anemia; shock; postural hypotension; head trauma; closed-angle glaucoma; cerebral hemorrhage; hypertrophic obstructive cardiomyopathy

Interactions
Concurrent sildenafil (Viagra) may cause severe hypotension and death; aspirin may increase serum concentrations; calcium channel blockers may cause markedly symptomatic orthostatic hypotension (dose adjustment of either agent may be necessary)

Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions
Caution in coronary artery disease and low systolic BP; adverse effects include hypotension, flushing, headache, light-headedness, and tolerance (8- to 12-h nitrate-free interval is most effective method to prevent development of tolerance); high IV doses may cause methemoglobinemia, heparin resistance, and ethanol intoxication; ischemia may worsen upon withdrawal

Drug Category: Long-acting nitroglycerins

Reduce LV preload and afterload by venous and arterial dilation, which subsequently reduces myocardial oxygen consumption and relieves angina. Also cause dilation of epicardial coronary arteries, which is beneficial in patients with coronary spasm. In addition, nitroglycerin has antithrombotic and antiplatelet effects in patients with angina pectoris. No evidence suggests that nitrates improve survival or slow progression of coronary artery disease.

Drug Name
Isosorbide (Isordil, ISMO)

Description
Relaxes vascular smooth muscle by stimulating intracellular cyclic GMP. Decreases LV pressure (ie, preload) and arterial resistance (ie, afterload). Reduces cardiac oxygen demand by decreasing LV pressure and dilating arteries.

Adult Dose
Isosorbide dinitrate:
2.5-10 mg SL prn IR
10-30 mg PO bid/tid SR
80-120 mg PO qd IR
Isosorbide mononitrate:
10-20 mg PO bid SR
30-120 mg PO qd

Pediatric Dose
Not established

Contraindications
Documented hypersensitivity; severe anemia; closed-angle glaucoma; postural hypotension; head trauma; cerebral hemorrhage

Interactions
Alcohol may cause severe hypotension and cardiovascular collapse; aspirin may increase serum concentrations and actions; calcium channel blockers may increase symptomatic orthostatic hypotension (adjust dose of either agent); may decrease effects of heparin

Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions
Tolerance to vascular and antianginal effects of nitrates may develop; minimize tolerance by using smallest effective dose or pulse therapy (intermittent dosing) or by alternating with other coronary vasodilators (take last daily dose of short-acting agent no later than 7 pm); caution when administering to patients with glaucoma

Drug Category: Angiotensin-converting enzyme inhibitors

Recently shown to reduce rates of death, MI, stroke, and need for revascularization procedures in patients with coronary artery disease or diabetes mellitus and at least one other cardiovascular risk factor, irrespective of the presence of hypertension or heart failure.

Drug Name
Ramipril (Altace)

Description
Prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, resulting in lower aldosterone secretion.

Adult Dose
2.5-5 mg PO qd; not to exceed 20 mg/d

Pediatric Dose
Not established

Contraindications
Documented hypersensitivity; history of angioedema

Interactions
May increase digoxin, lithium, and allopurinol levels; probenecid may increase levels; coadministration with diuretics increases hypotensive effects; NSAIDs may reduce hypotensive effects

Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions
Adverse effects include persistent cough, angioedema, hypotension, and prerenal azotemia; caution in renal impairment, valvular stenosis, or severe CHF

Drug Category: Anti-ischemic agents, miscellaneous

Ranolazine elicits action unlike beta-blockers, calcium antagonists, or nitrates. It does not affect hemodynamics or contractile and conduction parameters.

Drug Name
Ranolazine (Ranexa)

Description
Cardioselective anti-ischemic agent (piperazine derivative) that partially inhibits fatty acid oxidation. Also inhibits late sodium current into myocardial cells and prolongs QTc interval. Indicated for chronic angina unresponsive to other antianginal treatments. Used in combination with amlodipine, beta-blockers, or nitrates. Unlike beta-blockers, calcium channel blockers, and nitrates, does not reduce blood pressure or heart rate. Effect on angina rate or exercise tolerance appears to be smaller in women than in men. Absorption is highly variable but unaffected by food.

Adult Dose
500 mg PO bid initially; if necessary, may increase to 1000 mg PO bid

Pediatric Dose
Not established

Contraindications
Documented hypersensitivity; preexisting QT prolongation; hepatic impairment (Child-Pugh class A [mild], B [moderate], or C [severe]); QT-prolonging drugs (see Interactions); potent or moderate CYP4503A inhibitors (eg, ketoconazole, diltiazem)

Interactions
CYP4503A and P-gp substrate; potent CYP3A inhibitors (eg, ketoconazole at 200 mg bid) increase levels approximately 3.2-fold, moderate CYP3A inhibitors (eg, diltiazem at 180-360 mg/d) increase levels approximately 1.8- to 2.3-fold, and verapamil (a CYP3A and P-gp inhibitor) increases levels approximately 2-fold; caution with other P-gp inhibitors (eg, ritonavir, cyclosporine); toxicity may occur when coadministered with other drugs that increase QTc interval (eg, class I and III antiarrhythmic agents, certain macrolide and quinolone antibiotics, phenothiazines, TCAs)
Inhibits CYP4503A, CYP 4502D6, and P-gp; may increase plasma levels of digoxin, simvastatin, dextromethorphan, TCAs, and antipsychotics

Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions
Causes dose-related QTc-interval prolongation (obtain baseline and follow-up ECGs to monitor for torsades de pointes and potential for sudden death; mild and moderate hepatic impairment increases QTc interval compared with normal hepatic function at same plasma level; increases blood pressure by approximately 15 mm Hg in persons with severe renal impairment; common adverse effects include dizziness, headache, constipation, and nausea

FOLLOW-UP

Deterrence/Prevention:

Coronary atherosclerosis is the main preventable cause of mortality in the United States. A rigorous effort to address correctable risk factors is the mainstay of preventive cardiovascular medicine.
Smoking cessation is the single most effective preventive intervention to reduce coronary atherosclerosis prevalence. It has been associated with a coronary artery disease reduction of 7-47% in primary prevention settings.
Aggressive treatment of diabetes mellitus, hypertension, LV hypertrophy, hyperlipidemia, and obesity has an important role in the prevention of coronary artery disease.
The most important recent development in coronary atherosclerosis risk modification is the introduction of inhibitors of beta-hydroxy-beta-methylglutaryl coenzyme A reductase. Reductions of total and LDL cholesterol levels by 25% and 35%, respectively, can achieve a similar reduction in rates of total and coronary mortality, MI, and need for coronary revascularization.

Complications:

Complications of angina pectoris include unstable angina, MI, and death.

Prognosis:

Important prognostic indicators in patients with angina pectoris include LV function, severity and location of atherosclerotic lesions, and response of symptoms to medical treatment.
- LV function is the strongest predictor of long-term survival. Elevated LV end-diastolic pressure and volume along with reduced LV ejection fraction ( <40%) are poor prognostic signs.
- Critical lesions of left main and proximal left anterior descending coronary arteries are associated with a greater risk. Mortality rates are also directly associated with the number of epicardial arteries involved.
- Unstable angina, recent MI, or both is a sign of atherosclerotic plaque instability, which is a strong predictor of increased risk of short-term coronary events.
A number of signs during noninvasive testing are predictive of a higher risk of coronary events, including ST-segment depression of more than 2 mm at a low workload, ST-segment depression that persists for more than 5 minutes after termination of exercise, and failure of blood pressure to rise or an actual drop in blood pressure.
Patients who continue to smoke after an MI have a 22-47% increased risk of reinfarction and death.
In general, Prinzmetal angina and syndrome X are associated with excellent long-term prognoses.

Patient Education:

Educating patients about the benefits of smoking cessation, a low-cholesterol diet, physical activity, and periodic screening for diabetes mellitus and hypertension is the prime component of a long-term management plan.
For excellent patient education resources, visit eMedicine's Circulatory Problems Center, Cholesterol Center, Heart Center, and Statins Center. Also, see eMedicine's patient education articles Angina Pectoris, High Cholesterol, Understanding Your Cholesterol Level, Lifestyle Cholesterol Management, Understanding Cholesterol-Lowering Medications, Chest Pain, Coronary Heart Disease, and Heart Attack.

REFERENCES

http://www.emedicine.com/med/topic133.htm