Medical Blog

1) EXTERNAL OTITIS:infection by staphylococcus aureus is the usual cause of localised inflammation (boils) in the external auditory meatus.when more generalised ,the inflammation may be caused by bacteria or fungi or by an allergic reaction to,e.g.,daddruff,saops,hairs sprays hair dyes.2) OTOSCLEROSIS:this is a common cause of progressive conductive hearing loss in loss in young adults that may affects one ear but is more commonly bilateral.it is usually hereditary,more common in females than in males and often worsens during pregancy.abnormal bone develops around the footplate of the stapes fusing it to the oval window,reducing the ability to transmit sound waves across the tympanic cavity.3) PRESBYCUSIS:this form of hearing impairment commonly accompainies the ageing process.degenrative changes in the sensory cells of the spinal organ (of corti) results in sensorineural (perceptive)deafness.perception of high-frequency sound is impaired first and later low frequency sound may also be affected.the individual develops difficulty in discrimmination,e.g.following a concervation,especially in the presence of background noise.4) LABYRINTHIS:this may be caused by development of a fistula from a cholesteatoma or rarely by spread of infection from the middle ear.in some cases the spiral organ is destroyed ,causing sudden total nerve deafness in the affected ear.5) MOTION SICKNESS:repetitive motion causes excessive stimulation of the semilunar canals and vestibular apparatus and results in nausea and vomiting in some people.6) DEAFNESS:hearing impairment can be classified in two main categories CONDUCTIVE and SENSORINEURAL.hearing impairment can also be mixed when there is a combination of conductive and sensorineural deafness in one ear. a) Conductive deafness:this is due to impaired transmmision of sound waves from the outside to oval window ,i.e.an abnormality of the outer or middle ear b) Sensorineural(perceptive)deafness:this is the result of diseases of the cochlea,the cochlear branch of the vestibular nerve or hearing area of the brain .the indiviual usually perceives noise but cannot discriminate between sounds,i.e.hears but cannot understand.    risk factors for congenital deafness  include:1) family history of hereditary deafness2) viruses,e.g.maternal rubella during the first 3months of pregancy 3) acute hypoxia at birth

INFECTIONS1)VIRAL INFECTION:a)Human papilloma virus(HPV)this causes WARTS or VERUCCAS that are spread by direct contact,e.g.from another lesions ,or another infected indiviual.there is proliferation of the epidermis and development of a small firm growth.common sites are  the hands,the face and soles of the feet.b)Herpes viruseschicken pox and shinges are caused by the herpes zoster viruses.other herpes viruses causes cold sores (HSV1) and genital herpes (HSV2).the latter causes gential warts affecting the genitilia and/or anus and are spread by direct contact during sexual intercourse.2)BACTERIAL INFECTIONA)Impetigo:this is a highly infectious condition commonly caused by STAPHYLOCOCCUS AUREUS.superfical pustules  develop,usually around the nose and mouth.it is spread by direct contact and affects mainly childrens and immunosuppressed indivuals. when caused by strepococcus pyopgenes (group A beta-heamolytic streptococcus)the infection may be complicated ,a few weeks later ,by an immune reaction causing glomerulonephritisB)Cellulitis:this is a spreading infection caused by some anaerobic microbes or by STREPTOCOCCUS PYOGENES or CLOSTRIDIUM PERFRINGENS.the spread of infection is facilitated by the formation of enzymes that break down the connective tissue that normally isolates an area of inflammation.the microbes enter the body through a break in the skin.if untreated,the products of inflammation may enter the blood causing septicaemia.in severe cases nectrotising fasciitis may occur,there is oedema and necrosis of subcutaneous tissue that usually includes the fascia in the affected area.FUNGAL INFECTIONS1)Ringworm and tinea pedis:these are superficial infections of the skin.in ringworm there is an outward spreading ring of inflammation.it most commonly affects the scalp and is found in cattle from which infection is spread .            tinea pedis(athletes foot)affects the area between the toes.both infections are spread by direct contact. 

ACNE VULGARIS:this is a common condition in adolescent that is thought to be caused by incresed levels of male sex hormones after puberty.it occurs  when sebaceous glands in hair follicles become blocked and then infected leading to inflammation and pustule formation.in serve cases permanent scarring may result.the most common sites are the face,chest and upper back.

A)MYASTHENIA GRAVIS:
this autoimmune condition of unknow origin affects more women than men,and usually those between 20 and 40 years.antibodies are produced that bind to and block the acetylcholine receptors of neuromuscular juncations.the transmision of nerve impluses to muscle fibres is therefore blocked.this causes progressive and extensive muscle weakness,although the muscles are normal.extraocular and eyelids muscles are affected first,causing PTOSIS(droping of eye)or diplopia (double vision),followed by thoseof the neck (possibly affecting chewing,swallowing and speech) and limbs.there are periods of remmision,relapes being precipitated by,for example,strenuous exercise,infection or pregancy.
B)MYOPATHIES:
in this group of inherited diseases there is progressive degeneration of groups of muscles.the main differences in the types are:
1)age onset
2)rate of progression
3)groups of muscles involved.

OSTEOPOROSIS:in this condition bone mass(amount of bone tissue) is reduced because its depostion does not keep pace with resorption .peak bone mass occurs around 35years and then gradually declines in the both sexes.lowered oestrogen levels after menopause are associated with a period of accelerated bone loss in women.thereafter bone densisty in women is less than in men for any given age.bone progressively weakened with cancellous bone affected first by thinning and loss of trabeculae .in the post menopausal period an imbalance of hormones probly cause bone weakening ,i.e,between anabolic steriods (oestrogen and androgens) and antianabolic steriods (glucocorticiods).common features of osteoporesis are :1)skeletal deformity gradual loss of height with age,which is caused by decomposstion of vertebrae.2)bone pain.3)fractures especially of the hip(neck of femur),wrist and vertebrae.CAUSES OF DECRESED BONE MASS:1`)RISK FACTORS:female gender,increasing age,white ethnic origin,family history,lack of exercise/immobility,diet(low calcium),smoking,excess alcohol intake,early menopause/oophorectomy,thin build(small bones)2)DRUGS:corticosteriods3)DISEASES:cushings syndrome,hyperparathyroidism,type 1 diabetes mellitus,rheumoid arthiritis,chronic renal failure,chronic liver diseases,anorexia nervosa,neoplasia.

ARTHRITIS                                  —————-THRE ARE TWO MAIN TYPES OF ARTHRITIS THEY ARE 1)OSTEOARTHRITIS:type if disease is degenrative,tissue affected is articular cartilage,age of onsetis late middle age,joints affected are weight bearing .e.g,hip,knee,often only a single joint.OSTEOARTHIRITIS OF SPINE:this condition is relatively common in the elderly.degenerative changes cause narrowing of intervertebral disc and osteophytes may develop round the margins of joints of the vertebral column,commonly in the cervcial region (cervical spondylosis).they may causes damage to the nervous system,varyng from compression of indiviual spinal nerves to spinal cord injury.  2)RHEUMAIOD ARTHIRITIS:type of disease is inflammatory and auto immune,tissue affected are synovial membrane,age of onset is any age ,mainly 30 to 53 years,occasionally childrens,joints affected are small,e.g,hands,feet;often many joints.

1)INFECTION OF PENIS:inflammation of glans and prepuce may be caused by a specific or non-specific infection in non-specific infection ,or balanitis,lack of personal hygiene is an important predisposing factor,especially PHIMOSIS is present ,i.e,the orifice in the foreskin(prepuse) is too small to allow for its normal retraction .if the infection becomes chronic there may be fibrosis of the foreskin,which increases the phimosis2)INFECTION OF URETHRA :gonococcal urethrites is the most common specific infection .non-specific infection may be spread from the bladder(cystitis).or be introduced dyring catherisation,cystosscopy or surgery.both types may spread throughout the system to the prostate,seminal vesicles,epididymis and testes.if infection becomes chronic,fibrosis may causes urethral structure or obstrucation,leading to retention of urine3)INFECTION OF TESTES A)ORCHITIS :(inflammation of the testis):this is more commonly caused by mumps viruses,blood dorne from the parotid glands.acute inflammationwith oedema occurs about 1 week after apperance of parotid swelling the infection is ussually unilateral but,if bilateral,severe damage to germinal epithelium of the seminiferous tubules may  result in sterilityB)UNDESENDED TESTIS(CRYPTORCHIDISM)during embronic life the testes develop with the abdominal cavity,but desends into the scrotum prior to birth .if they fail to do this and the condition is not corected ,infertilty is like to follow and the risk of testicular cancer is increased.C)HYDROCELE:this is the most common from of scrotal swelling and is accumulation of serous  fluid in the tunica vaginalis.the onset may be acute and painfull or chronic,it may be congenital or be secondary to another disorder of the testis or epididymis          

1)PELVIC INFLAMATORY DISEASES(PID)          this infection may be specific or non-specific .it usually begins as vulvovaginitis,including the vulvar glands,then it may spread to the cervix,uterus,uterine tube and spread is most common when microbes are present in the vagina before a surgical procedure,child birth or absorption,especially if some of produtcs of conception2)VULVAR DYSTROPHIESA)ATROPHIC DYSTROPHY:this is thining of vulvar epithelium and the formation of fibrous tissues occuring after the menopause due to oestrogen withdrawal.it predisposes to infection,especially in debilated women and to malignant epithelium neoplasiaDISORDERS OF UTERINE TUBE AND OVARIESA)ACUTE SALPINGITES:salpingitis is inflammation of the uterine tubes & is usually due to infection spreading from the uterus,and only occasionally from the peritoneal cavity.the out come may be 1)uneventful recovery.2)chronic inflammation leading to fibrous tubal.obstrucation & infertility.3)pus formation(pyosalpinx)FEMALE INFERTILITYmay be due to 1)blocakage of uterine tube,often the consequence of pelvic inflammatory diseases.2)anatomical problems,e.g,retroversion(tiliting backwards)of the uterus3)endocrine factors,any abnormalities of glands & hormones governing the menstural cycle can interfere.for example ovulation or the uterine cycle.4)endo metriosis.5)low body weight or severve malnourishment.DISORDERS OF THE BREAST1)MASTITIS(inflamation of breast) A)ACUTE NON-SUPPURATIVE MASTITISthis occurs during lactation and is associated with painful congenstion & oedema of the breast B)ACUTE SUPPURATIVE(PYOGENIC) MASTITISthe microbes enter through a nipple abrasion caused by the infant sucking.the most common causative microbes the STAPHYLOCOCCUS AUREUS and STREPTOCOCCUS  PYOGENES usually acquired by infants which in hospital.the infection spreads along,the mammary ducts of alobe causing localised swelling & redness.if it does not resolve it can become chronic and an abseen may form.

Kidney stones, one of the most painful of the urologic disorders, are not a product of modern life. Scientists have found evidence of kidney stones in a 7,000-year-old Egyptian mummy. Unfortunately, kidney stones are one of the most common disorders of the urinary tract. In 2000, patients made 2.7 million visits to health care providers and more than 600,000 patients went to emergency rooms for kidney stone problems. Men tend to be affected more frequently than women.

Most kidney stones pass out of the body without any intervention by a physician. Stones that cause lasting symptoms or other complications may be treated by various techniques, most of which do not involve major surgery. Also, research advances have led to a better understanding of the many factors that promote stone formation.

[Top]

Introduction to the Urinary Tract

The urinary tract

The urinary tract, or system, consists of the kidneys, ureters, bladder, and urethra. The kidneys are two bean-shaped organs located below the ribs toward the middle of the back. The kidneys remove extra water and wastes from the blood, converting it to urine. They also keep a stable balance of salts and other substances in the blood. The kidneys produce hormones that help build strong bones and help form red blood cells.

Narrow tubes called ureters carry urine from the kidneys to the bladder, an oval-shaped chamber in the lower abdomen. Like a balloon, the bladder’s elastic walls stretch and expand to store urine. They flatten together when urine is emptied through the urethra to outside the body.

[Top]

What is a kidney stone?

A kidney stone is a hard mass developed from crystals that separate from the urine and build up on the inner surfaces of the kidney. Normally, urine contains chemicals that prevent or inhibit the crystals from forming. These inhibitors do not seem to work for everyone, however, so some people form stones. If the crystals remain tiny enough, they will travel through the urinary tract and pass out of the body in the urine without being noticed.

Kidney stones may contain various combinations of chemicals. The most common type of stone contains calcium in combination with either oxalate or phosphate. These chemicals are part of a person’s normal diet and make up important parts of the body, such as bones and muscles.

A less common type of stone is caused by infection in the urinary tract. This type of stone is called a struvite or infection stone. A bit less common is the uric acid stone. Cystine stones are rare.

Urolithiasis is the medical term used to describe stones occurring in the urinary tract. Other frequently used terms are urinary tract stone disease and nephrolithiasis. Doctors also use terms that describe the location of the stone in the urinary tract. For example, a ureteral stone (or ureterolithiasis) is a kidney stone found in the ureter. To keep things simple, however, the term “kidney stones” is used throughout this fact sheet.

Gallstones and kidney stones are not related. They form in different areas of the body. If you have a gallstone, you are not necessarily more likely to develop kidney stones.

[Top]

Who gets kidney stones?

For unknown reasons, the number of people in the United States with kidney stones has been increasing over the past 30 years. The prevalence of stone-forming disease rose from 3.8 percent in the late 1970s to 5.2 percent in the late 1980s and early 1990s. White Americans are more prone to develop kidney stones than African Americans. Stones occur more frequently in men. The prevalence of kidney stones rises dramatically as men enter their 40s and continues to rise into their 70s. For women, the prevalence of kidney stones peaks in their 50s. Once a person gets more than one stone, others are likely to develop.

[Top]

What causes kidney stones?

Doctors do not always know what causes a stone to form. While certain foods may promote stone formation in people who are susceptible, scientists do not believe that eating any specific food causes stones to form in people who are not susceptible.

A person with a family history of kidney stones may be more likely to develop stones. Urinary tract infections, kidney disorders such as cystic kidney diseases, and certain metabolic disorders such as hyperparathyroidism are also linked to stone formation.

In addition, more than 70 percent of people with a rare hereditary disease called renal tubular acidosis develop kidney stones.

Cystinuria and hyperoxaluria are two other rare, inherited metabolic disorders that often cause kidney stones. In cystinuria, too much of the amino acid cystine, which does not dissolve in urine, is voided. This can lead to the formation of stones made of cystine. In patients with hyperoxaluria, the body produces too much of the salt oxalate. When there is more oxalate than can be dissolved in the urine, the crystals settle out and form stones.

Shapes of various stones. Sizes are usually smaller than shown here.

Hypercalciuria is inherited. It is the cause of stones in more than half of patients. Calcium is absorbed from food in excess and is lost into the urine. This high level of calcium in the urine causes crystals of calcium oxalate or calcium phosphate to form in the kidneys or urinary tract.

Other causes of kidney stones are hyperuricosuria which is a disorder of uric acid metabolism, gout, excess intake of vitamin D, urinary tract infections, and blockage of the urinary tract. Certain diuretics which are commonly called water pills or calcium-based antacids may increase the risk of forming kidney stones by increasing the amount of calcium in the urine.

Calcium oxalate stones may also form in people who have a chronic inflammation of the bowel or who have had an intestinal bypass operation, or ostomy surgery. As mentioned above, struvite stones can form in people who have had a urinary tract infection. People who take the protease inhibitor indinavir, a drug used to treat HIV infection, are at risk of developing kidney stones.

[Top]

What are the symptoms?

Kidney stones often do not cause any symptoms. Usually, the first symptom of a kidney stone is extreme pain, which occurs when a stone acutely blocks the flow of urine. The pain often begins suddenly when a stone moves in the urinary tract, causing irritation or blockage. Typically, a person feels a sharp, cramping pain in the back and side in the area of the kidney or in the lower abdomen. Sometimes nausea and vomiting occur. Later, pain may spread to the groin.

If the stone is too large to pass easily, pain continues as the muscles in the wall of the tiny ureter try to squeeze the stone along into the bladder. As a stone grows or moves, blood may appear in the urine. As the stone moves down the ureter closer to the bladder, you may feel the need to urinate more often or feel a burning sensation during urination.

If fever and chills accompany any of these symptoms, an infection may be present. In this case, you should contact a doctor immediately.

[Top]

How are kidney stones diagnosed?

Sometimes “silent” stones—those that do not cause symptoms—are found on x rays taken during a general health exam. If they are small, these stones would likely pass out of the body unnoticed.

More often, kidney stones are found on an x ray or sonogram taken on someone who complains of blood in the urine or sudden pain. These diagnostic images give the doctor valuable information about the stone’s size and location. Blood and urine tests help detect any abnormal substance that might promote stone formation.

The doctor may decide to scan the urinary system using a special test called a CT (computed tomography) scan or an IVP (intravenous pyelogram). The results of all these tests help determine the proper treatment.

[Top]

How are kidney stones treated?

Fortunately, surgery is not usually necessary. Most kidney stones can pass through the urinary system with plenty of water (2 to 3 quarts a day) to help move the stone along. Often, you can stay home during this process, drinking fluids and taking pain medication as needed. The doctor usually asks you to save the passed stone(s) for testing. (You can catch it in a cup or tea strainer used only for this purpose.)

[Top]

The First Step: Prevention

If you’ve had more than one kidney stone, you are likely to form another; so prevention is very important. To prevent stones from forming, your doctor must determine their cause. He or she will order laboratory tests, including urine and blood tests. Your doctor will also ask about your medical history, occupation, and eating habits. If a stone has been removed, or if you’ve passed a stone and saved it, the laboratory should analyze it because its composition helps in planning treatment.

You may be asked to collect your urine for 24 hours after a stone has passed or been removed. The sample is used to measure urine volume and levels of acidity, calcium, sodium, uric acid, oxalate, citrate, and creatinine (a product of muscle metabolism). Your doctor will use this information to determine the cause of the stone. A second 24-hour urine collection may be needed to determine whether the prescribed treatment is working.

Lifestyle Changes

A simple and most important lifestyle change to prevent stones is to drink more liquids—water is best. If you tend to form stones, you should try to drink enough liquids throughout the day to produce at least 2 quarts of urine in every 24-hour period.

People who form calcium stones used to be told to avoid dairy products and other foods with high calcium content. But recent studies have shown that foods high in calcium, including dairy products, may help prevent calcium stones. Taking calcium in pill form, however, may increase the risk of developing stones.

You may be told to avoid food with added vitamin D and certain types of antacids that have a calcium base. If you have very acidic urine, you may need to eat less meat, fish, and poultry. These foods increase the amount of acid in the urine.

To prevent cystine stones, you should drink enough water each day to dilute the concentration of cystine that escapes into the urine, which may be difficult. More than a gallon of water may be needed every 24 hours, and a third of that must be drunk during the night.

Medical Therapy

The doctor may prescribe certain medications to prevent calcium and uric acid stones. These drugs control the amount of acid or alkali in the urine, key factors in crystal formation. The drug allopurinol may also be useful in some cases of hyperuricosuria.

Doctors usually try to control hypercalciuria, and thus prevent calcium stones, by prescribing certain diuretics, such as hydrochlorothiazide. These drugs decrease the amount of calcium released by the kidneys into the urine by favoring calcium retention in bone. They work best when sodium intake is low.

Very rarely, patients with hypercalciuria may be given the drug sodium cellulose phosphate, which binds calcium in the intestines and prevents it from leaking into the urine.

If cystine stones cannot be controlled by drinking more fluids, your doctor may prescribe drugs such as Thiola and Cuprimine, which help reduce the amount of cystine in the urine.

For struvite stones that have been totally removed, the first line of prevention is to keep the urine free of bacteria that can cause infection. Your urine will be tested regularly to be sure that no bacteria are present.

If struvite stones cannot be removed, your doctor may prescribe a drug called acetohydroxamic acid (AHA). AHA is used with long-term antibiotic drugs to prevent the infection that leads to stone growth.

People with hyperparathyroidism sometimes develop calcium stones. Treatment in these cases is usually surgery to remove the parathyroid glands (located in the neck). In most cases, only one of the glands is enlarged. Removing the glands cures the patient’s problem with hyperparathyroidism and with kidney stones as well.

[Top]

Surgical Treatment

Surgery should be reserved as an option for cases where other approaches have failed. Surgery may be needed to remove a kidney stone if it

• does not pass after a reasonable period of time and causes constant pain
• is too large to pass on its own or is caught in a difficult place
• blocks the flow of urine
• causes ongoing urinary tract infection
• damages kidney tissue or causes constant bleeding
• has grown larger (as seen on followup x ray studies).

Until 20 years ago, surgery was necessary to remove a stone. It was very painful and required a recovery time of 4 to 6 weeks. Today, treatment for these stones is greatly improved, and many options do not require major surgery.

Extracorporeal Shockwave Lithotripsy

Extracorporeal shockwave lithotripsy (ESWL) is the most frequently used procedure for the treatment of kidney stones. In ESWL, shock waves that are created outside the body travel through the skin and body tissues until they hit the denser stones. The stones break down into sand-like particles and are easily passed through the urinary tract in the urine.

Extracorporeal shockwave lithotripsy

There are several types of ESWL devices. In one device, the patient reclines in a water bath while the shock waves are transmitted. Other devices have a soft cushion on which the patient lies. Most devices use either x rays or ultrasound to help the surgeon pinpoint the stone during treatment. For most types of ESWL procedures, anesthesia is needed.

In most cases, ESWL may be done on an outpatient basis. Recovery time is short, and most people can resume normal activities in a few days.

Complications may occur with ESWL. Most patients have blood in their urine for a few days after treatment. Bruising and minor discomfort in the back or abdomen from the shock waves are also common. To reduce the risk of complications, doctors usually tell patients to avoid taking aspirin and other drugs that affect blood clotting for several weeks before treatment.

Another complication may occur if the shattered stone particles cause discomfort as they pass through the urinary tract. In some cases, the doctor will insert a small tube called a stent through the bladder into the ureter to help the fragments pass. Sometimes the stone is not completely shattered with one treatment, and additional treatments may be needed. ESWL is not ideal for very large stones.

Percutaneous Nephrolithotomy

Sometimes a procedure called percutaneous nephrolithotomy is recommended to remove a stone. This treatment is often used when the stone is quite large or in a location that does not allow effective use of ESWL.

Percutaneous nephrolithotomy

In this procedure, the surgeon makes a tiny incision in the back and creates a tunnel directly into the kidney. Using an instrument called a nephroscope, the surgeon locates and removes the stone. For large stones, some type of energy probe (ultrasonic or electrohydraulic) may be needed to break the stone into small pieces. Generally, patients stay in the hospital for several days and may have a small tube called a nephrostomy tube left in the kidney during the healing process.

One advantage of percutaneous nephrolithotomy over ESWL is that the surgeon removes the stone fragments instead of relying on their natural passage from the kidney.

Ureteroscopic Stone Removal

Ureteroscopic stone removal

Although some kidney stones in the ureters can be treated with ESWL, ureteroscopy may be needed for mid- and lower-ureter stones. No incision is made in this procedure. Instead, the surgeon passes a small fiberoptic instrument called a ureteroscope through the urethra and bladder into the ureter. The surgeon then locates the stone and either removes it with a cage-like device or shatters it with a special instrument that produces a form of shock wave. A small tube or stent may be left in the ureter for a few days to help the lining of the ureter heal. Before fiber optics made ureteroscopy possible, physicians used a similar “blind basket” extraction method. But this outdated technique should not be used because it may damage the ureters.

INTRODUCTION

* Asthma is a chronic respiratory condition that affects people of all ages.
* At present there is no known cure, but it can be treated and controlled.
* It is most common in childhood but is being diagnosed more and more in adults.
* It affects twice as many boys as girls in childhood; more girls than boys develop asthma as teenagers, and in adulthood, the ratio becomes 1:1 males to females.
* Asthma affects people in varying degrees, from very mild (only during vigorous exercise) to very severe. Those with severe asthma may have symptoms every day that may cause some lifestyle restriction; in these people symptoms occur more easily and more frequently.
* There is a general trend of increased deaths and hospitalisations from asthma recorded in all the industrialised countries of the world, Canada included.
* In Canada about 3 million people are affected, and approximately 20 children and 500 adults die each year from asthma. However, with adequate treatment most deaths from asthma can be prevented.

What Is Asthma?
Asthma is a chronic lung condition characterised by difficulty in breathing.
People with asthma have extra sensitive or hyperresponsive airways. The airways react by narrowing or obstructing when they become irritated. This makes it difficult for the air to move in and out. This narrowing or obstruction can cause one or a combination of the following symptoms:

* wheezing
* coughing
* shortness of breath
* chest tightness

This narrowing or obstruction is caused by:

* Airway inflammation (meaning that the airways in the lungs become red, swollen and narrow)
* Bronchoconstriction (meaning that the muscles that encircle the airways tighten or go into spasm)

Airway Inflammation

The picture shows the opening of a normal airway on the left. In the centre is a picture of an airway which has been exposed to a certain stimuli (i.e. inhaled allergen like grass pollen). It has become swollen and plugged with mucus, thus making the airway opening considerably smaller, and therefore more restrictive to airflow. The aim of treatment is to reduce this inflammation and prevent further injury to the airway.

Bronchoconstriction
On the right is a picture of an airway which has been exposed to a certain stimulus (such as cold air or vigorous exercise). The muscle fibres surrounding the airway have contracted, thus making the airway opening considerably smaller. The aim of treatment is to reduce this constriction and prevent further injury to the airway.

PROVOKING FACTORS

Two factors provoke asthma:
1. Triggers result in tightening of the airways (bronchoconstriction).
2. Causes (or inducers) result in inflammation of the airways.

Triggers

* Triggers irritate the airways and result in bronchoconstriction.
* Triggers do not cause inflammation and therefore do not cause asthma.
* Symptoms and bronchoconstriction caused by triggers tend to be immediate, short-lived, and rapidly reversible.
* Airways will react more quickly to triggers if inflammation is already present in the airways.

Common triggers of bronchoconstriction include everyday stimuli such as:

* Cold air
* Dust
* Strong fumes
* Exercise (For more information, please refer to Exercise and Asthma).
* Inhaled irritants
* Emotional upsets
* Smoke

Smoke acts as a very strong trigger. Second-hand smoke has been shown to aggravate asthma symptoms (especially in children). The effects of one cigarette linger in the home for 7 days, and therefore it is very important to provide a SMOKE-FREE HOME.

Asthmatics should not be exposed to a polluted environment over which they have no control.

Causes or Inducers

* In contrast to triggers, inducers cause both airway inflammation and airway hyperresponsiveness and hence are recognised as causes of asthma.
* Inducers result in symptoms which may last longer, are delayed and less easily reversible than those caused by triggers.

The most common inducers are:

* Allergens
* Respiratory viral infections

Allergens

Inhaled allergens are the most important inducer or cause of inflammation and airway hyperresponsiveness. The most common inhaled allergens include:

* pollen (grasses, trees and weeds)
* animal secretions (cats and horses tend to be to the most allergen causing)
* moulds
* house dust mites

Exposure to an allergen (e.g. cat secretions) may cause immediate symptoms such as wheeze or cough. This occurs because airways are hyperresponsive and react by tightening. These symptoms can easily be relieved by a bronchodilator (such as Ventolin®). However, about 4 and 7-8 hours after exposure to the secretion, a late response occurs which is caused by the inflammation. This inflammation develops over time. Because of the late response, it is often difficult for the patient and physician to identify what is actually causing the asthma.
Respiratory Viral Infections
In some asthmatics, respiratory viral infections may cause a deterioration in their asthma. A respiratory viral infection is probably one of the most common causes of asthma in children. In some cases, the influenza vaccine is indicated. This may help to prevent respiratory complications that can occur from developing influenza. This vaccine is contraindicated for those individuals who have an allergy to eggs.

ASTHMA DIAGNOSIS

Making a correct diagnosis is extremely important: if asthma is correctly diagnosed it can be treated appropriately.
The diagnosis of asthma involves all of the following:

1. A detailed history which would include:
family history of asthma, allergies, hay fever, eczema; (children in particular will have a greater chance of developing the above if there is a family history of allergies and asthma).

2. Physical examination: i.e. listening to the lungs with a stethoscope, examination of nasal passages etc.

3. Chest x-ray may be done once to exclude the possibility of breathing problems being caused by something other than asthma.

4. Blood tests and sputum studies may be done.

5. Allergy prick skin testing: Skin tests can confirm the presence or absence of allergies; they must, however, be correlated to the history of symptoms.

6. Spirometry is a breathing test which measures the amount and rate at which air can pass through airways; if the airways are narrowed because of inflammation it will be more difficult for air to pass through the airways. This will result in changes in spirometry values. This is a very dependable method of making a diagnosis. Any difficult or troublesome asthma should be confirmed objectively by performing spirometry.

7. Challenge tests: Exercise challenge tests and methacholine inhalation tests are procedures used most frequently in clinical laboratories to evaluate airway responsiveness.

8. Differential diagnosis: Other possible causes of shortness of breath, wheeze, cough and chest tightness must be investigated in order to rule these out. i.e. such as heart disease, other lung conditions.

9. A trial use of asthma medications: If asthma medications are taken and improvement in symptoms is seen this further supports the diagnosis of asthma.

Because of the variability of symptoms (meaning symptoms can become worse and improve over time) a diagnosis cannot always be made immediately.

ASTHMA MANAGEMENT

The consensus of asthma specialists is that the best way to manage asthma is to have the individual actively involved in his or her own treatment.

Goals of Asthma Management:

1. Normalise lifestyle (taking into account environmental control): the individual should be able to participate in virtually any activity he or she wishes

2. Freedom from night/early AM symptoms: sleep should not be disturbed by asthma symptoms
3. Relief or bronchodilator medications should not be required daily (other than with vigorous exercise)
4. Normalise or optimise lung function as measured by peak flow or lung function testing

Long Term Asthma Management involves:

- Education
- Environment control
- Medications

Patient Education: Don’t let asthma manage you; you manage your asthma.
Patient education is an important area where asthma treatment can be improved. Asthma is common and controllable. Asthma is a disease that is variable, meaning that symptoms may get worse and may improve over time. Because of this variability it is often necessary to review and change the treatment. In order to enhance the patient-physician relationship, the patient must be familiar with the following:

* Nature of the disease; identifying provoking factors
* Nature of medications and side effects
* Proper technique of using devices
* Goals of treatment
* Early recognition of worsening control
* Written Action Plan

The patient with this type of knowledge can communicate to the physician in order to work out an appropriate treatment plan. The goals of treatment should be understood and agreed upon by both the physician and the patient.
Environmental Control (also see appendix)

Environmental control should always be initiated along with taking the appropriate medications. If exposure to inducers are avoided, less medication is required. It is not always easy to identify what inducer is making the asthma worse. It often means reviewing the history of symptoms carefully i.e. keeping track of the symptoms. Controlling the inside and outside environment should be considered for those people who have identified allergies. For example:

* House dust mites: Dust mites are small parasites that live off the dead skin that we shed. Decrease exposure by enclosing mattress and box spring in plastic and washing all bed sheets and blankets in hot water once a week.
* Pets: If allergic to pets, animals should not be allowed in the house; this can include animals such as dogs, cats, gerbils and birds. People with identified animal allergies should not care for the pet.
* Smoke: No smoking in the home should be allowed at any time.
* Mould: Remove the mould wherever and whenever mould is found. Bleach can be used for this. The source of mould should be eliminated.
* High humidity: Increased moisture in the home can encourage mould growth and house dust mites, which require greater than 50% humidity to survive. Humidifiers, if not cleaned properly, can grow bacteria and produce a residue which some people find irritating to their lungs.
* Pollens: It may be necessary to avoid activities outside during times of high pollen counts. Pollen counts are usually greater in hot, dry and/or windy weather and usually between 4-10 AM. Camping and raking leaves will expose the person to pollens.

Asthma Medications
This requires consideration of the drugs (anti-inflammatories, bronchodilators) as well as the devices (inhalation devices - see appendix) used in the treatment of asthma.

Principles of Medication Management:

* involves a CONTINUUM approach
* involves introduction or change in anti-inflammatory treatment
* add or increase medication - for increased symptoms
* decrease medication - when symptom free

The guiding factors to medication control includes:

1. Symptoms
2. Objective measures

Severity of symptoms may be determined by objective measures such as peak flow or spirometry.

Types of Medications: Anti-Inflammatories and Bronchodilators

1. Anti-Inflammatories - Preventers: Anti-inflammatories are used to treat the inflammation that is caused by exposure to inducers.
2. Bronchodilators - Relievers (Rescue): Bronchodilators are used to relieve the bronchoconstriction provoked by triggers.

The successful approach to asthma management, both in and out of hospital settings, is dependent upon the use of anti-inflammatory treatments with bronchodilators being prescribed for immediate and occasional relief of symptoms.

It has been shown that regular, frequent use of bronchodilator therapy may actually worsen the asthma. Again this stresses the need for adding anti-inflammatory medications if bronchodilator therapy is required often to control symptoms.

Anti-Inflammatory Medications (Preventers)

* prevent and reduce inflammation, swelling and mucus
* prevent symptoms such as cough, wheeze and breathlessness
* need to be taken on a regular basis
* are slow acting (hours or weeks)

Types of Anti-Inflammatory Drugs
There are steroidal and non-steroidal anti-inflammatory drugs. The most common ones include:
Steroids

* beclomethasone (Beclovent®, Vanceril®, Becloforte®)
* budesonide (Pulmicort®)
* flunisolide (Bronalide®)
* fluticasone (Flovent®)

Non-Steroidal

* sodium cromoglycate (Intal®)
* nedocromil (Tilade®)

Corticosteroid Inhalers
Corticosteroid drugs are the most effective preventers.
They work by reducing and preventing airway inflammation, swelling and mucus.
They must be used regularly and DO NOT have immediate effects. This means they have NO VALUE when an effect is needed in minutes.
A stepwise approach to treatment of asthma involves the introduction or change in anti-inflammatory medication.
Increased asthma symptoms indicate the need to increase the anti-inflammatory in order to achieve control. As control is achieved and the patient remains symptom free over a period of time (as specified by the physician), a decrease of medications can be initiated by the patient.

Side Effects of Corticosteroid Inhalers

* few side effects at low doses
* side effects, in general, are usually restricted to the throat:
o hoarseness and sore throat
o thrush or yeast infection
o This can be prevented by rinsing the mouth and gargling, and by using a holding chamber.

Corticosteroid Tablets
Corticosteroid tablets or Prednisone®:

* are used when inflammation becomes severe
* reduce inflammation, swelling & mucus, and help bronchodilators work better
* start to work within a few hours, but may take several days to have a full effect
* often are used for short periods of time to get the inflammation under control
* there are many side effects if used long-term, such as water retention, bruising, puffy face, increased appetite, weight gain and stomach irritation

Other Preventers - Non Steroidal
Other preventers are Intal® and Tilade®. They are non-steroidal and again, are used to reduce the inflammation.

* sodium cromoglycate (Intal®)
- for mild asthma
- can protect against the effects of cold air and exercise
- requires 4-6 weeks to be effective
- few side effects. nedocromil (Tilade®)
*

- similar to Intal®
- requires 3-4 weeks to be effective
- has a bad taste
* - fewer doses/canister; thus may need more than one canister per month. ketotifen (Zaditen®)

- used for mild asthma
- may be used for asthmatics who also have hay fever
- helps to reverse inflammation of airways
- can be used orally: comes in tablets or syrup
- requires regular use of 8-12 weeks to be effective
- side-effects include drowsiness and weight gain.

Bronchodilator Medications (Relievers)
Bronchodilators, or relievers, in general relax the muscle around the bronchi, which allows breathing to become easier.

* are rescue medications, and therefore are used only when needed, and rarely on a regular basis (unless the asthma is under poor control)
* provide quick relief of symptoms
* relax the muscles of the airways
* useful with exercise induced bronchospasm
* usually in blue devices

Types of Bronchodilator Drugs
The most common bronchodilators are:

* B2-Agonists
* Anticholinergic Inhaler
* Theophylline

* B2-Agonists

- Salbutamol (Ventolin®, Apo-Salvent®, Novo Salmol®)

- BFenoterol (erotec®)

- Terbutaline (Bricanyl®)

- Pirbuterol (Maxair®)

B2-Agonists are rescue medications which:

* relax the muscle around the airways which allows breathing to become easier within minutes.
* are used only when needed and rarely on a regular basis, unless the asthma is under poor control.
* make the airway muscle less likely to contract.
* are usually in blue devices.

When to use B2-Agonists

* to relieve the symptoms of cough, chest tightness, wheezing and shortness of breath
* a few minutes before exercising or before exposure to any trigger you know worsens your asthma

Side effects of B2-Agonists include:

* trembling
* nervousness
* flushing
* increased heart rate

B2-Agonists are safe when used properly; for example, when you are experiencing symptoms or before exposure to a trigger.
However regular, frequent use of B2-Agonist bronchodilators may actually worsen the asthma.
Frequent use means you need to step-up your treatment plan. For example, you need to add or increase your anti-inflammatory medication.
It is safe to frequently use (every 5 minutes) your B2-Agonist bronchodilator when you are on the way to the nearest emergency department.

* Anticholinergic Inhaler

- Atrovent®

Atrovent opens the airways by blocking the signals from the nervous system which cause the airways to become narrow.
It takes one to two hours to reach its maximum effect; therefore, it should not be used as an immediate get out of trouble medication.
There are few side effects, a bad taste possibly being one.

* Theophylline

- TheoDur®, Uniphyll®, Phyllocontin®, TheoLair®.

Theophylline is an oral bronchodilator that works directly on the airway muscle to relax it.
It is used in the evening if shortness of breath disturbs sleep, or regularly if asthma is severe. Theophylline levels can be affected by other medications - ensure your physician is aware of all the medications you are taking, including over-the-counter drugs.
Side effects include:

diarrhoea, nausea, heartburn, loss of appetite, headaches, nervousness, rapid heart beat and upset stomach

The right dose is important and must be determined by your physician. Theophylline is not commonly used in the treatment of asthma.

Leukotriene Receptor Antagonists
Leukotriene receptor antagonists are a new class of oral asthma medications.
They act against one of the inflammatory components of asthma and provide protection against bronchoconstriction when taken before exercise or exposure to allergens or cold. They decrease both the early and late asthmatic response.
Because they are still so new, the actual role of leukotriene receptor antagonists in the management of asthma is not clear; i.e. it is not fully understood who exactly will benefit most when taking these medications.
Examples of leukotriene receptor antagonists available in Canada are:

* zafirlukast (Accolate®)
* montelukast (Singulair®)

What is a sexually transmitted disease (STD)?

An STD is an illness that is spread through sexual contact.

How can sexually transmitted diseases be avoided?

* The less sexual partners a person has, the lower the risk of infection.

* Most sexually transmitted diseases can be avoided to a large extent by practicing safe sex (eg using condoms).

* Most sexually transmitted diseases can be cured if they are diagnosed and treated in their early stages.

The most common diseases and their symptoms are described below.

Chlamydia

Chlamydia is the most common and fastest spreading sexually transmitted disease in the UK. It stems from a bacterium, Chlamydia trachomatis.

Women diagnosed with Chlamydia can also infect their newborn infant during delivery. Symptoms usually appear approximately 7 to 21 days after infection and differ for men, women and children.

Symptoms in men:

* inflammation of the urethra (the bladder duct within the penis)

* stinging feeling when passing water

* clear discharge from penis and possible itchiness around the opening

* pain or tenderness in the testicles.

Symptoms in women:

* stinging feeling when passing water

* unusual vaginal discharge

* pain caused by pelvic inflammation (pelvic inflammatory disease)

* pain during intercourse

* in some cases, bleeding between periods.

Symptoms in infants:

* inflammation of the eye (conjunctivitis) at birth

* problems breathing

* premature birth

* in rarer instances, pneumonia.

One of the most common ways of testing for Chlamydia is for the GP to collect a cell sample from the infected area (cervix or penis) with a cotton swab. This is then sent to a laboratory for evaluation. In the absence of a firm diagnosis, you may be referred to a specialist genitourinary clinic for further testing. Treatment consists of antibiotics, and should also be given to the patient’s partner. A further swab is recommended once treatment has ended to check whether the infection has cleared. For more information, read the factsheet on chlamydia.

Gonorrhoea

Gonorrhoea is caused by Neisseria gonorrhoeae, a bacteria that grows and multiplies quickly in moist, warm areas of the body such as the cervix, urethra, mouth, or rectum. In women, the cervix is the most common site of infection. However, the disease can also spread to the uterus (womb) and fallopian tubes, causing pelvic inflammatory disease leading to infertility. Gonorrhoea is most commonly spread during genital contact, but can also be passed from the genitals of one partner to the throat of the other during oral sex. Gonorrhoea of the rectum can occur in people who practice anal intercourse. In pregnant women, gonorrhoea can be passed from an infected woman to her newborn infant during delivery if left untreated.

The early symptoms of gonorrhoea are often mild, and many women who are infected have no visible symptoms of the disease. If symptoms of gonorrhoea develop, they usually appear within 2 to 10 days after sexual contact with an infected partner, although a small percentage of patients may be infected for several months without showing symptoms.

Symptoms in women include:

* painful, burning sensation when urinating

* yellowish or bloody discharge from the vagina

* bleeding between periods

* abdominal pain.

Men are more likely to show symptoms than women. Some of the symptoms in men include:

* burning sensation during urination

* yellowish-white discharge from the penis.

Other symptoms affecting the rectal area include itching, discharge and sometimes painful bowel movements.

A diagnosis is made through detection of bacteria in samples taken from the urethra, cervix, throat or rectum. The condition is treated with antibiotics, and treatment should also be given to the patient’s partner. As with Chlamydia, further testing is recommended once treatment has ended to check whether the infection has cleared.

Herpes genitalis (genital herpes)

Gential herpes is a highly contagious viral condition caused by the herpes simplex virus (HSV). It principally infects the skin and mucous membranes of the genitals and rectum, but can also appear in areas such as the mouth. It is transmitted primarily through physical and sexual contact. During birth, the presence of herpes simplex virus on the genitalia or in the birth canal is a threat to the infant. Infection in the newborn infant can lead to herpetic meningitis, herpetic viremia (herpes virus particles present in the blood) and chronic skin infection.

The symptoms of herpes simplex virus usually occur a week after infection, but sometimes take longer to appear. Initially, the skin becomes reddened and multiple small blisters filled with a clear, straw-coloured fluid appear. Prior to the presence of blisters, the infected individual may also experience increased skin sensitivity, tingling, burning or pain at the site where blisters will appear. Later, the blisters burst leaving shallow, painful ulcers which eventually scab and heal over a period of 7 to 14 days.

The outbreak may be accompanied by other symptoms such as:

* swelling and tenderness of the lymph nodes in the groin area.

* in women, vaginal discharge and painful urination.

* in men, a possibility of painful urination if the lesion is near the opening of the urethra.

* fever.

In most cases, a description of the condition and the appearance of the blisters will be enough to make a diagnosis. The GP may also advise referral to a specialist genitourinary medicine (GUM) clinic for confirmation of the diagnosis.

There is no cure for the herpes simplex virus; once infected, patients will remain a carrier for the rest of their lives. Some remedies, however, can reduce the duration of the eruption. In addition, by being more aware of the initial symptoms of recurrence (skin sensitivity and tingling), timely treatment with medication such as aciclovir (Zovirax tablets/suspension) will often abort the outbreak of blisters.

The best way to avoid transmission is to avoid direct contact with an open lesion. People with herpes simplex virus should avoid sexual contact when active lesions are present.

Although the symptoms of genital herpes may not be present, it is important for those infected to inform their partner that they have the disease. This will encourage both parties to use barrier protection (condoms) to prevent the spread of the illness. Using condoms and not sharing towels are good ways of reducing the chance of infection in the first place.

HIV and AIDS

AIDS is a potentially lethal sexually transmitted disease and is caused by the HIV virus. HIV invades and destroys the immune system, which protects the body from infection. This means that a person who carries the HIV virus is prone to many different illnesses and may die from diseases that are harmless to healthy people.

AIDS is still most widespread south of the Sahara in Africa, Asia, and the Caribbean islands, and is more common among homosexual and bisexual men. However, in more developed countries the disease is becoming more frequent among heterosexuals, especially young people. In the UK, new cases of HIV are now more prevalent among heterosexuals.

Intravenous drug users and people with many different partners are particularly at risk from HIV. The virus is found in bodily fluids such as blood, sperm and vaginal secretions, and can pass through little scratches that may occur during sexual intercourse.

Although they vary considerably, the symptoms include:

* fever

* diarrhoea

* sweating at night

* loss of weight

* swollen glands

* general discomfort.

The diagnosis is made when the HIV antibody is found in the blood. The test is not usually positive until 6 to 12 weeks after infection.

There is no cure for HIV and AIDS, but the earlier the diagnosis is made, the easier it is for the doctors to help. Today, efficient treatments exist that increase quality of life and prolong life itself. Anyone who is infected with HIV should only have safe sex using barrier protection and inform all previous partners about their infection. For more information, read the factsheet on AIDS and HIV.

Genital warts

Warts, or condylomata acuminata, are caused by the human papilloma virus (HPV). Up to nine months can pass from the time of infection to the actual development of warts. In women, human papilloma virus can lead to changes in the cervix and to the development of cervical cancer. Therefore, it is important that this condition is diagnosed and treated.

The symptoms are raised, rough, wart-like growths that may occur singly or in clusters. In men, they are usually found around the head of the penis and tend to be drier. In women, they appear most often around the vaginal opening and may spread to the rectal area. It is also possible for the virus to appear on or near the cervix as whitish, flat-like lesions, usually only detectable through close visual examination of the cervix (colposcopy). In both men and women, lesions may also be present in the mouth and throat. In general, symptoms can intensify if the immune system is weakened, or during pregnancy or if the person has diabetes. The warts are very contagious so safe sex is advisable.

A diagnosis is made when a characteristic lesion is visible. By swabbing the skin with 5 per cent acetic acid, ‘invisible’ warts will emerge as white-coloured patches. A GP can treat the warts by freezing and swabbing, but if this does not help the patient may be referred to a genitourinary specialist who can offer more specialised treatment. However, it is important to note that treatment does not always offer a complete cure.

Syphilis

Syphilis is a dangerous and life-threatening bacterial disease. After infection, the bacteria is transported through the body via the bloodstream and adversely affects vital organs such as the heart, brain, nervous system and spine.

The symptoms are divided into three stages.

Up to 12 weeks after the time of infection:

* one or more red lesions will develop on the penis, labia (lips of the vagina), anus and sometimes on the mouth and lips. These lesions disappear after a week.

Up to six months after the time of infection:

* a red rash appears on the chest, back, arms, legs, hands and soles of the feet

* high fever

* sore throat

* muscular fatigue

* general feeling of discomfort.

Anyone experiencing these symptoms should contact their doctor immediately.

If the illness is not treated by the second stage, it will disappear for a while. However, the disease can lie dormant in the body and return up to 20 years later. At this more advanced stage the symptoms will be:

* heart failure

* paralysis

* insanity

* possible death.

The diagnosis is made through the detection of the micro-organism or the detection of antibodies in the blood. In its early stages, syphilis can easily be treated with antibiotics.

How to avoid sexually transmitted diseases (STDs)

Avoid high-risk behaviours and practise safe sex.

* Though not necessarily practical or desirable, abstinence is the only way to completely prevent STDs.

* Avoid sex with many different partners.

* Always use condoms.